EFTA00110400.pdf

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness: No Comments: Cardiovascular. RRR: Yes Normal S1/52: Yes Murmurs: No Carotid Bruits:No JVD: No Arteries: Rlaht. 1st Radial: Femoral: Dorsalis Pedis: Post Tibialis: Comments: Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM Page 10 ol 13 EFTA00110400 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Abdomen: Normal Contour:Yes Scaphold: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomegaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness: No Pulse Deficit: No Strength: Eight Left Ann: Leg: Full ROM: Right Lett Arm: Yes Yes Leg: Yes Yes Comments: Generated 07/0912019 13O3 by MLP Bureau of Prisons • NYM Par 11 01 13 EFTA00110401 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Reflexes: Right S LA Biceps: Patellar: Brachioradialis: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: GU: Chaperoned By: Rectum: Not Done Comments: Refused. Male Genitalia: Not Done Comments: Refused. Skin: Normal:Yes Rash: No Redness:No Abnormal Pigmentation: No Abnormal Lesions/Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: Lim Travel Outside US Other Infectious Disease History Rectum Not Done Male Genitalia Not Done PPD Administration Not Performed Comments: Patient has a history of constipation. Generated 07.092019 13.03 by Bureau of Prisons • NYM Page 12 of 13 EFTA00110402 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - New Medication Orders: Rd Medication Order Date Prescriber Order Bisacodyl E.C. Tablet 07/09/2019 12:35 5 mg Orally at bedtime PRN x 10 day(s) Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Instructed inmate how to obtain medical, dental, and mental health care. Copay Required: No Cosign Required: Yes TelephoneNerbal Order: No Completed by MLP on 07/09/2019 13:03 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/09/2019 13.03 by MLP Bureau of Prisons NYM Page 13 of 13 EFTA00110403  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: 07/09/2019 12:35 Provider: . MLP Facility: NYM Cosigned by MD on 07/11/2019 22:41. Bureau of Prisons - NYM EFTA00110404  Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current R/O self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult Current Medications: All medications to be continued until evaluated by a physician unless otherwise indicated. Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments Data Time Activity Provider 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Date freouency Duration Details EKG 07/06/2019 One Time 66 y/o male Fecal Occult Blood 07/06/2019 One Time 3 different stools TB Clearance: Yes Last PPD Date: 07/09/2019 Induration: 0mm Last Chest X-Ray Date: Results: TB Treatment: Sx free for 30 days: Yes TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Generated 08/10/2019 07:00 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00110405 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Llmitations/Restrictions/Diets: Cell: lower bunk — 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. - 07/30/2020 Comments: Allergies No Known Allergies Devices / Equipment C-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number. Address 1: Address 2: City/State/Zip: NEW YORK, New York 10007 Name/ Title of Person Completing Form: RN Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ft: 76318-054 DOB: 01/20/1953 Sex: M Generated 08/1072019 07:00 by RN Bureau or Prisons - NYM Page 2 01 2 EFTA00110406  Bureau of Prisons Health Services Vitals All Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Temperature: Rata Ilms Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral MLP Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 97.5 36.4 Oral MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97.3 36.3 Oral MLP Orig Entered: 07/09/2019 12:51 EST MLP Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/30/2019 13:02 94 MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:40 88 Via Machine MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:30 87 Via Machine MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 81 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 82 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 83 Via Machine Regular MLP Orig Entered: 07/24/2019 13:14 EST . MLP 07/23/2019 06:30 92 Via Machine Regular MLP Orig Entered: 07/23/2019 08:33 EST . MLP 07/09/2019 12:49 82 Via Machine Regular MLP Orig Entered: 07/09/2019 12:51 EST MLP Respirations: Rate Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 14 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 14 RN Orig Entered: 07/28/2019 06:58 EST RN 07/23/2019 06:30 NYM 16 MLP Orig Entered: 07/23/2019 08:33 EST . MLP 07/09/2019 12:49 NYM 16 MLP Orig Entered: 07/09/2019 12:51 EST . MLP Generated 00/10/2019 11:02 by Bureau of Prisons - NYM Page I of 3 EFTA00110407 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Blood Pressure: galg Time Value Location Position Cuff Sin Provider 07/30/2019 13:02 NYM 114/84 Loft Arm Standing MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:40 NYM 125/60 Right Arm Standing MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:30 NYM 108/86 Left Arm Sitting MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 157/91 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 138/80 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MLP Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular MLP Orig Entered: 07/09/2019 12:51 EST MLP Blood Glucose: nate It Maktalak11) bee Regular Insulin Provider 08/04/2019 08:30 156 Non-Fasting RN Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 97 Non-Fasting MLP Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 103 Non-Fasting MLP Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 06:15 108 Non-Fasting MLP Orig Entered: 07/31/2019 08:36 EST MLP SaO2: Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 98 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 98 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 96 Room Air . MLP Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 96 Room Air . MLP Orig Entered: 07/23/2019 08:33 EST MLP 07109/2019 12:49 NYM 97 Room Air . MLP Orig Entered: 07/09/2019 12:51 EST MLP Height: Generaled 08110/2019 11 02 by Bureau of Prisons • NYM Page 2 of 3 EFTA00110408 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Inches Cm Provider 07/09/2019 12:49 NYM 70.0 . 177.8 MLP Orig Entered: 07/09/2019 12:51 EST MLP Weight: Date Time kke hg Waist Circum, provider 07/30/2019 09:30 NYM 194.2 88.1 MD Orig Entered: 07/30/2019 12:59 EST MD 07/09/2019 12:49 NYM 194.4 88.2 MLP Orig Entered: 07/09/2019 12:51 EST MLP Generated 00110/2019 11.02 by Bureau of Prisons - NYM Page 3 of 3 EFTA00110409  Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Minim Legalism Provider Reading: Jnduration Provider 07/06/2019 21:39 Right Forearm PA-C 07/09/2019 12:47 0 mm . MLP Orig Entered: 07/06/2019 21:43 EST PA-C Orig Entered: 07/09/2019 12:47 EST MLP Total: 1 Generated 0811012019 11:02 by RNAOP/IDC Bureau of Prisons • NYM Page 1 of 1 EFTA00110410 76318-054 EPSTEIN. JEFFREY Medication Administration Record JULY 2019 Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Dee MD 07/30119 PRN .4 o 1421 Inject regular Insulin subcutaneously per Esp. Dane sliding scale: twice daily "'pin line" for 7 07(31/19 Pays 10 01 NYM 112148- NYM frauitn Reg (10 kr4.1100 UNITS/SAL IN Ord. Date MC 0701/19 PRN 10.00 Inject regular Insulin subcutaneously per Exp. Date sliding seal*: each morning for 7 days "'pill 08107/19 boe••• 09:59 NYM 112160- NYM Ineutn Reg (10 MLI 100 UNITSAIL inj Providers: YJ = Documentation Codes. ORD = Order I NI = Dose Not Indicated Registration 4: 76318-054 Pt. Name: EPSTEIN. JE'FFREY DOW 0120/53 Report information is current as of the date and time of printing: 08/10/2019 11:02 EST EFTA00110411 76318-054 EPSTEIN. JEFFREY Medication Administration Record AUGUST 2019 Medication Ordors Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Oase M3 07/31/19 PON 1000 Injocl-egular insu:In subcutaneously per Exp. Dow sliding into: posh monolog tor 7 days — pill 08/07119 09 59 NYM 122160- NYM Insulin Reg (10 ML) 100 UNITS/ML Phi Providers: YJ = Documenta5on Codes ORD = Order I NI = Dose Nol indicated Registration 76318-054 Pt. Name: EPSTEIN. JEST REY DOB: 01/20153 Report information Is current as of tho dato and lime of prinling: 08/10/2019 11 02 EST EFTA00110412  Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Device/Equipment Start Date Stop Date pate Returned Obtained From Comments C•Pap 07/30/2019 14:05 EST MD 07/30/2019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Generated 08/10/2019 II:02 by RN/IOP/IDC Bureau of Prisons • NMI Page 1 of EFTA00110413  Bureau of Prisons Health Services Pain Management Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Data Jntervention Pain Quality Location pa post Provider 07/12/2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 MD Orig Entered: 07/12/2019 13:28 EST MD Generated 08/10/201911:02 by FtN/1OPADC Bureau of Prisons - NYM Page 1 or 1 EFTA00110414  Bureau of Prisons Health Services Modified Diet Request Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: Full Liquid Exp Date: Sodium Controlled Exp Date: Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other: FISH ALLERGIES. Exp Date: 07/30/2020 Comments: MD Health Service Staff EPSTEIN, JEFFREY EDWARD 76318-054 07/3012019 Inmate Name Reg# Date Generate0 07/30/2019 14:57 by MD Bureau ot Prisons • NYM Page 1 ol 1 EFTA00110415  Bureau of Prisons Health Services Allergies Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Moray Date Noted Reaction No Known Allergies 07/06/2019 Orig Entered: 07/06/2019 21:40 EST PA-C Total: 1 Generated 08/10/2019 11:02 by Bureau of Prisons - NYM Page 1 of 1 EFTA00110416  Bureau of Prisons Health Services Patient Education Assessments & Topics Reg N: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessments Assessment Learns Best By Primary Language Years of Education Flarriers To Education Provider 07/09/2019 Speaking/Listening English 12 None Orig Entered: 07/09/2019 12:52 EST Total: 1 Topics Date Initiated Format fiandout/Toplc Outcome Provider 07/30/2019 Counseling Access to Care Verbalizes Understanding Ode Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Verbalizes Understanding Odg Entered: 07/30/2019 13:34 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Odg Entered: 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Odg Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Verbalizes Understanding Odg Entered: 07/24/2019 13:23 EST 07/24/2019 Counseling Preventive Health Verbalizes Understanding Ode Entered: 07/24/2019 13:23 EST 07/23/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/23/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling Diagnosis Verbalizes Understanding Odg Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Verbalizes Understanding Generated 08/1012019 11:02 by RNAORIDC Bureau of Prisons • NY1A Page 1 at 2 EFTA00110417  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics Date Initiated format Handout/700c. outcona Provider Orig Entered: 07/12/2019 13:33 EST Total: 10 Generated 0B.10/2319 11 02 by RNfl0P/IDC Bureau o' Prisons • tdrili Page 2 c' 2 EFTA00110418  Bureau of Prisons Health Services Blood Glucose Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) Date Time Value Tvoe Comment% 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MLP Total: 4 Generated 08110/2019 11:02 by RN/IOP/IDC Bureau of Pitons - NYM Page 1 of 1 EFTA00110419  Bureau of Prisons Health Services Health Problems Reg it 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description &i a Coda Tynp Cada Nag Date Status Current Hyperlipidemia, unspecified 07/12/2019 13:48 EST MD ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST MD ICD-10 G4730 07/12/2019 Current Essential (primary) hypertension 07/30/2019 13:13 EST MD ICD-10 110 07/30/2019 Current BY HX. Constipation, unspecified 07/09/2019 12:58 EST MLP ICD-10 K5900 07/09/2019 Current Low back pain 07/12/2019 13:30 EST MD ICD-10 M545 07/12/2019 Current Neuralgia and neuritis, unspecified 07/12/2019 13:30 EST MD ICD-10 M792 07/12/2019 Current No Diagnosis 07/09/2019 10:28 EST PhD/Chief I DSM-IV No Dx 07/09/2019 Current sychologist Prediabetes 07/30/2019 13:26 EST MD ICD-10 R7303 07/30/2019 Current Injury, unspecified 07/23/2019 09:04 EST MLP ICD-10 T1490 07/23/2019 Current R/O self inflicted injuries. Body mass Index (BMI) 27.0-27.9, adult 07/30/2019 13:14 EST MD ICD-10 Z6827 07/30/2019 Current Total: 10 Generated 09/10/2019 11:02 by RNOOPADC Bureau of Prisons - NYM Page 1 of 1 EFTA00110420