EFTA00073831.pdf

2019-05665 Item 9, 13, 17 (partial), 18 (partial) EFTA00073831  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: Type 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 Page 001 of 148 Airway Endotracheal Tube 08/10/2019 07:08 Withheld pursuant to exemption ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV (b)(6) (b)(7)(A); (b)(7)(C) 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions of the Freedom of Information and Privacy Act, cro/10/2019 07:11 Medications Sodium Bicarbonate 1 mEaikg 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 mEaikg 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 10 2019 08.10 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073832 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 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 Cosign documentation will be displayed on the following page. Page 002 of 148 Withheld pursuant to exemption (b)(6) : (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 08/1012019 08:10 by RN Bureau of Prisons NYM Page 2 of 2 EFTA00073833  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 on 08/12/2019 08:09. Page 003 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073834  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 Unit: Z01 Chronic Care Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: 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 ISSUE rage uu4 of 148 STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Withheld pursuant to exemption Seen for clinic(s): Pulmonary/Respiratory. Orthopedic,Rheumatology, Endocrine/Lipid (b)(6), (b)(7)(C) OBJECTIVE: of the Freedom of Information and Privacy Act 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 SI and S2 No: MITG Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07 302019 16.12 by Bureau of Prisons - NYM Page 1 of 2 EFTA00073835 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 Unit: 701 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: Page 005 of 148 New Medication Orders: Withheld pursuant to exemption Rxtl Medication Order Date Prescriber Order INsulin REG - Human (b)(8); (b)(dXM10;/0)(g)11%)58 SLIDING SCALE Subcutaneously each morning x of the Freedom of Information and Privacy Act 7 day(s) Pill Line Only Indication: Prediabetes Discontinued Medication Orders: Rx# Medication Order Date Prescriber Order 122148-NYM Insulin Reg (10 ML) 100 UNITSML lnj 07/30/2019 15:58 Inject regular insulin subcutaneously per sliding scale: twice daily — *pill line"' 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 on 07/30/2019 16:12 Generated 0730:2019 16:12 by Bureau of Prisons - NYM Page 2 of 2 EFTA00073836  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: Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: 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 €W8 of 148 STATES HE FEELS OTHERWISEPIN Pain: Not Applicable Withheld o exemption Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology' Respiratory (b)(6) (b)( XC) OBJECTIVE: of the Freedom of Information Pulse: &Quin. Dale lime Rate Per Minute Location Provider 07/30/2019 13:02 94 eaudouin, Robert MD 07/30/2019 09:40 88 Via Machine Robert MD 07/30/2019 09:30 87 Via Machine Robert MD Respirations: pate Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Date limes Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Dale lime Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time Lbs Kg Waist Circum. Provider Generated 07/30/2019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073837 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: Unit: Z01 Date Time Lba Kg Waist Circum, Provider 07/30/2019 09:30 NYM 194.2 88.1 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: Mil(G Musculoskeletal e 007 of 148 Tibia / Fibula Withheld exemption No: Edema Neurologic (b)(8). (b)(7) ( )(C) Cranial Nerves (CN) of the Freedom of Information 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 Prediabeles, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: R x# Medication Order Date Prescriber Order Generated 07/30.2019 14.05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073838 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 Unit: Z01 New Medication Orders: Rx# Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally - Two Times a MG15ML 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: Rxff 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 ane 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 008 of 148 New Radiology Request Orders: Withheld e emption Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Ti(ix)(6); (b)( )(C) 08/29/2019 Routine General Specific reason(s) for request (ttfififtSiffigraei6 InfRnalje 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI 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 Pipit l Outcome 07/30/2019 Counseling Access to Care Beaudo Robert Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No Telephone, Verbal Order: No Completed by on 07/30/2019 14:05 Generated 07 30'2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073839  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: Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: 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 E 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 HI 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 CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE EBED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISEPIN Pain: Not Applicable Withhelddi o exemption Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, Respiratory (b)(6) (b)( )(C) OBJECTIVE: of the Freedom of Information Pulse: Date Time Rate Per Minute Location Provider 07/30/2019 13:02 07/30/2019 09:40 07/30/2019 09:30 94 88 87 Via Machine Via Machine e ouin. eaudouin, Robed MD Robed MD Robert MD Respirations: Date lime Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Data Time Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Date Time Value(%) Alt Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Pale Time Lin Kg Waist Circum. Provider Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073840 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: Unit: Z01 Dale Time LIM Kg Waist Circum Provider 07/30/2019 09:30 NYM 194.2 88.1 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•IG Musculoskeletal e 010 of 148 Tibia / Fibula exemption No: Edema Neurologic (b)( ) • (• (b)(6):le )(C) Cranial Nerves (CN) of the Freedom of Information 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: Exit Medication Order Date Prescriber Order Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073841 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: Unit: Z01 New Medication Orders: BLit( 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: &ft 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 ane 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 e 011 of 148 New Radiology Request Orders: e emption Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Ti0b)(6); (b )(C) 08/29/2019 Routine General Specific reason(s) for request ft 8ffirfffeftliekilfliRMISP 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI 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 Prov Outcome 07/30/2019 Counseling Access to Care Beaudo Robert Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 14:05 Generated 07130/2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073842  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 on 07/30/2019 16:12. Page 012 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073843  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, hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 20:28 NYM 14 Blood Pressure: Withheld pursuant to exemption Date Time Value Location (b)WPO:jR9)(A): (b)Filk-PiZe Provider 07/28/2019 20:28 NYM 157/91 RN of the Freedom of Information and Privacy Act SaO2: Date Time yatue(%) 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 0712812019 20:30 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073844 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 Follow-up in 12-24 Hours Patient Education Topics: ttate_lnitiated Formal Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 20:30 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 014 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM Page 2 of 2 EFTA00073845  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 on 07/28/2019 20:50. Page 015 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073846  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 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: Dale Time Rate Per Minute location Rhythm Provider 07/28/2019 06:57 82 RN Respirations: DAM lime Rate Per Minute Pr vider 07/28/2019 06:57 NYM 14 Blood Pressure: LocationWithhe0cPtlif8iint to extaidni(gize Dale Time Value Provider 07/28/2019 06:57 NYM 138/80 (b)(6) : (b)(7)(A): (b)(7)(C) RN SaO2: of the Freedom of Information and Privacy Act DAM Time ValuerY41 Alt 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, AtraumaticlNormocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: , Extraocular Movements Intact Face General Yes: Symmetric Generated 07128;2019 07:22 by■ RN Bureau of Prisons - NYM Page 1 of 3 EFTA00073847 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 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 Symmetric, No: Swelling I, Inflammation' Humerus Yes: Within Normal Limits, Elbow Yes: Normal Exam I, Full Range of Motion', Nikkfie0tnicibrlifeilpation I Radius / Ulna Withhdd pursuant to exemption Yes: Normal Exam Full Range of Motion I Wrist/Hand/Fingers (b)(6); (b)(7)(A) ; (b)(7)(C) Yes: Full Range of Motion RoNtitio*HefRAAtigoog•Awitleiviic9 Act No: Inflammation I. Ecchymosis Erythema'. Tenderness Laceration(s) I, Abrasion(s) I, Contusion(s) I ROS Comments Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently C/O Right arm numbness after waking up from "sleeping on my side" that has since subsided. inmate interviewed in psyc obs through the slot. ViS 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 an ain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes . 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: Pate 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 Page 2 of 3 EFTA00073848 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 Randoutagpic 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 Cosign documentation will be displayed on the following page. Page 018 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM Page 3 of 3 EFTA00073849  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 on 07/28/2019 20:51. Page 019 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073850  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Parr WHITE Facility: NYM Note Date: 07/26/2019 08:57 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: That 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 on 07/26/2019 08:58 Page 020 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07126,2019 08:58 by Bureau of Prisons NYM Page I of I EFTA00073851  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Rate WHITE Facility: NYM Note Date: 07/24/2019 16:10 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: 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 1 Withheld i.co e 021 of 148 exemption (b)(6) ; (b) ) ,( )(C) of the Freedom of Information Generated 07/24/2019 16:12 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073852  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY