EFTA00138991.pdf

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Bole RN Team/Code Leader Code Events: IYRe Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/2019 06:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15 L 08/10/2019 06:47 IV Access Peripheral IV 08/10/2019 06:48 18 g Left AC Airway Endotracheal Tube 08/10/2019 07:08 ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions 08/10/2019 07:11 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:11 IV Fluids Normal Saline 0.9% 1000 ml 08/10/2019 07:12 Medications Epinephrine 1mg IV 08/10/2019 07:13 CPR Compressions 08/10/2019 07:14 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:14 Medications Epinephrine 1mg IV 08/10/2019 07:16 CPR Compressions 08/10/2019 07:17 Comments: Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Placed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered, Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 08/1012019 08:10 by RN Bureau of Prisons - NYM SDNY_0001:74564 1 of 2 EFTA00138991 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Date Scheduled Target Date Priority Translator Language Emergency Room 08/10/2019 08/10/2019 Emergent No Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 08/10/2019 08:10 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 08,10,2019 08:10 by RN Bureau of Prisons - NYM SDNY_0001-71.55 rage 201 2 EFTA00138992  Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 08/10/2019 07:25 Provider: RN Facility: NYM Cosigned by MD on 08/12x2019 08:09. SDNV_00017356 Bureau of Pesons NYM EFTA00138993  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 15:58 Provider: MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07/30/2019 16:12 by MD Bureau of Prisons - NYM SONY_0001-7257 raga 1 of 2 EFTA00138994 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Encounter Date: 07/30/2019 15:58 Provider: MD Unit: Z01 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Eta Medication Order Date Prescriber Order INsulin REG - Human 07/30/2019 15:58 SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Indication: Prediabetes Discontinued Medication Orders: Eta Medication Order Date Prescriber Order 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML lnj 07/30/2019 15:58 Inject regular insulin subcutaneously per sliding scale: twice daily —*pill linen* for 7 days Discontinue Type: When Pharmacy Processes Discontinue Reason:new order written Indication: Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by MD on 07/30/2019 16:12 Generated 071302019 16:12 by MD Bureau of Prisons - NYM SDNY_0001102 of 2 EFTA00138995  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT REFERRED BY THE WARDEN FOR EVALUATION. PATIE RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALS S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DEN SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME ES. STATES HE FEELS OTHERWISE Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology,4 )1 Respiratory OBJECTIVE: Pulse: Date Time Rate Per Minute Location 07/30/2019 13:02 94 07/30/2019 09:40 88 Via Machine D 07/30/2019 09:30 87 Via Machine Respirations: Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing MD 07/30/2019 09:40 NYM 125/60 Right Arm Standing MD 07/30/2019 09:30 NYM 108/86 Left Arm Sitting MD SaO2: Date Time Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air MD Weight: Date Time Lim Kg Waist Circum Provider Generated 07/30/2019 14:05 by MD Bureau of Prisons - NYM SDNY_0001/01 of 3 EFTA00138996 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 Date lime Lbs Kg Waist Circum. Provider 07/30/2019 09:30 NYM 194.2 88.1 MD Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0.27.9, adult. Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: BXg Medication Order Date Prescriber Order Generated 07)30,2019 14:05 by MD Bureau of Prisons - NYM SDNY_OOOWN2 of 3 EFTA00138997 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 New Medication Orders: fiat Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally • Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously • Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: Medication Order Date Prescriber Order 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff one Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Time 08/29/2019 Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NU R 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Outcome 07/30/2019 Counseling Access to Care Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by MD on 07/30/2019 14:05 Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_00011613 of 3 EFTA00138998  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT REFERRED BY THE WARDEN FOR EVALUATION. PATIE RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALS S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DEN SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME ES. STATES HE FEELS OTHERWISE Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology0 Respiratory OBJECTIVE: 0 Pulse: Date lime Rate Per Minute Location 07/30/2019 13:02 94 MD 07/30/2019 09:40 88 Via Machine MD 07/30/2019 09:30 87 Via Machine MD Respirations: Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Data lime Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing MD 07/30/2019 09:40 NYM 125/60 Right Arm Standing MD 07/30/2019 09:30 NYM 108/86 Left Arm Sitting MD SaO2: Data lima Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air MD Weight: Date Time Lin Kg Waist Circum. Provider Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7382 rage-1 of 3 EFTA00138999 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 Date Time Lbs Kg Waist Circum. Provider 07/30/2019 09:30 NYM 194.2 88.1 MD Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0.27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Hxg Medication Order Date Prescriber Order Generated 07/3012019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7383 rage 2 of 3 EFTA00139000 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 New Medication Orders: fiat Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally • Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously • Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: 13att Medication Order Date Prescriber Order 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff one Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Time 08/29/2019 Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NU R 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Outcome 07/30/2019 Counseling Access to Care Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by MD on 07/30/2019 14:05 Generated 072302019 14:05 by MD Bureau of Prisons - NYM SDNY_000a3 of 3 EFTA00139001  Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by MD on 07 30 2019 16:12. Bureau of Prisons • NYM SDNY_00017365 EFTA00139002  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: RN Unit: H01 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats " My R hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date lime Rate Per Minute Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Dale Time Rate Per Minute Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 20:28 NYM 157/91 RN SaO2: Dale BEM Valuer/O1 Air Provider 07/28/2019 20:28 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Nutrition Yes: Within Normal Limits Skin General Yes: Within Normal Limits, Dry, Skin Intact ASSESSMENT: No Significant Findings/No Apparent Distress PLAN: Disposition: To be Evaluated by Provider Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM SDNY_000W1 of 2 EFTA00139003 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 07'28'2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 0712&201920:30 by RN Bureau of Prisons - NYM SDNY_0001-7387 rage 2 of 2 EFTA00139004  Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by MD on 07 28 2019 20:50. SDNV_00017368 ' Pr ',or , NYt! EFTA00139005  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: " I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do" Pain: No OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 06:57 82 RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 RN SaO2: Date Time Valuerkl Air provider 07/28/2019 06:57 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact Head General Yes: Symmetry of Motor Function, Atraumatic/Normocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: PERRLA, Extraocular Movements Intact Face General Yes: Symmetric Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_00011491 of 3 EFTA00139006 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Exam: No: Ecchymosis, Numbness, Swelling, Periorbital Edema Neck General Yes: Abrasion(s) Pulmonary Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation Cardiovascular Observation Yes: Normal Rate Musculoskeletal Shoulder Yes: Full Range of Motion R, Symmetric R No: Swelling R, Inflammation R Humerus Yes: Within Normal Limits R Elbow Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R Radius / Ulna Yes: Normal Exam R, Full Range of Motion R WrisVHand/Fingers Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) R, Contusion(s) R ROS Comments Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently CIO Right arm numbness after waking up from "sleeping on my side" that has since subsided. inmate interviewed in psyc obs through the slot. V/S noted WNL, RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or dysphagia, Inmate with Full ROM to all extremities with 4/4 strength bilaterally, slight swelling noted to right phalanges when compared to left, no edema, erythema or ecchymosis noted. Denies any pain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes PERRLA. MD on Call notified, Re-evaluate this evening or sooner if S/S persist. ASSESSMENT: Alteration in comfort PLAN: Disposition: Follow-up at Sick Call as Needed Notify Medical Duty Officer Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_0001:7422 of 3 EFTA00139007 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Date Initiated Format HandouUTqpic Provider Outcome Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_000'1:7413 of 3 EFTA00139008  Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by MD on 07.28.2019 20:51. SDNV_00017372 ' Pr sae; NYt.' EFTA00139009  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/26/2019 08:57 Provider: M MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: SX Medication Order Date Prescriber Order Docusate Sodium Capsule 07/26/2019 08:57 TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) Indication: Constipation, unspecified Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by MD on 07/26/2019 08:58 Generated 07.262019 08:58 by MD Bureau of Prisons - NYM SDNY_OOPOW1)3°I EFTA00139010  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: • Facility: NYM Note Date: 07/24/2019 16:10 Provider: MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Cosign Required: No Telephone/Verbal Order: Completed by 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM soNcooPoiVe EFTA00139011  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Rarp.WHITF Facility: NYM Note Date: 07/24/2019 16:10 Provider: MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Cosign Required: No TelephoneNerbal Order: Completed by I 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM SDNY_OOP OWe f 1 EFTA00139012  Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 08:57 Facility: NYM Amendment made to this note by MD on 07 26 2019 08:58. Bureau of Prisons • Nym SDNY_00017376 EFTA00139013  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/24/2019 15:10 Provider: 1WISM MD Unit: H01 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/24/2019 15:17 Generated 07/24/2919 15:17 by MD Bureau of Prisons - NYM SDNY_OOP OWV7°f 1 EFTA00139014  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: MLP Unit: H01 Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: . MLP Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Date Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral MLP Pulse: Dale Time Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular . MLP Blood Pressure: Date Time Maim Location Position Cuff Size Provider 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%) Ai_► Provider 07/24/2019 13:12 NYM 96 Room Ai