EFTA00033804.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: 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 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 RN
Blood Pressure:
Date Time Value Location Position Cuff Size Provider
07/28/2019 20:28 NYM 157/91 RN
SaO2:
Date Time Value(%) 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 Page 1 of 2
CONFIDENTIAL SDNY_00009398
EFTA00033804

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:
Date Initiated Format Handout/Topic Provider Outcome
07/28/2019 Counseling Plan of Care Verbalizes Understanding
Copay Required: No
Telephone/Verbal 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.
Cosign Required: Yes
Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM Page 2 of 2
CONFIDENTIAL SDNY_00009399
EFTA00033805

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.
Bureau of Prisons - NYM
CONFIDENTIAL SDNY_00009400
EFTA00033806

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:
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 Time Value Location Position Cuff Size Provider
07/28/2019 06:57 NYM 138/80 RN
SaO2:
Date Time Value(%) 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 Page 1 of 3
CONFIDENTIAL SDNY_00009401
EFTA00033807

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 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
Wrist/Hand/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 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. 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 Page 2 of 3
CONFIDENTIAL SDNY_00009402
EFTA00033808

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 Handout/Topic 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 Columbo, Joseph RN Bureau of Prisons - NYM Page 3 of 3
CONFIDENTIAL SDNY_00009403
EFTA00033809

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.
Bureau of Prisons - NYM
CONFIDENTIAL SDNY_00009404
EFTA00033810

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 Race: WHITE Facility: NYM
Note Date: 07/26/2019 08:57 Provider: MD Unit: H01
Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1 Provider: MD
THE [REDACTED] NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO.
New Medication Orders:
Rx# 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 07/26/2019 08:58 by MD Bureau of Prisons - NYM Page 1 of 1
CONFIDENTIAL SDNY_00009405
EFTA00033811

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 Race: WHITE 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 [REDACTED] 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: No
Completed by Beaudouin, Robert MD on 07/24/2019 16:12
(Watermark: See Amendment)
Generated 07/24/2019 16:12 by MD Bureau of Prisons - NYM Page 1 of 1
CONFIDENTIAL SDNY_00009406
EFTA00033812

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 Race: WHITE 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 [REDACTED] 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: No
Completed by Beaudouin, Robert MD on 07/24/2019 16:12
(Watermark: See Amendment)
Generated 07/24/2019 16:12 by MD Bureau of Prisons - NYM Page 1 of 1
CONFIDENTIAL SDNY_00009407
EFTA00033813

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
CONFIDENTIAL SDNY_00009408
EFTA00033814

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 Race: WHITE Facility: NYM
Note Date: 07/24/2019 15:10 Provider: 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
Telephone/Verbal Order: No
Completed by MD on 07/24/2019 15:17
Generated 07/24/2019 15:17 by MD Bureau of Prisons - NYM Page 1 of 1
CONFIDENTIAL SDNY_00009409
EFTA00033815

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: [REDACTED] Unit: H01
Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge.
SUBJECTIVE:
COMPLAINT 1 Provider: [REDACTED]
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
Pulse:
Date Time Rate Per Minute Location Rhythm Provider
07/24/2019 13:12 83 Via Machine Regular
Blood Pressure:
Date Time Value Location Position Cuff Size Provider
07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular
SaO2:
Date Time Value(%) Air Provider
07/24/2019 13:12 NYM 96 Room Air
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed, Appears in Pain
Exam Comments
Follow up evaluation done for inmate Epstein.
He does not look in any pain or distress.
He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. he insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it.
ASSESSMENT:
Injury, unspecified, T1490 - Current
PLAN:
Disposition:
Generated 07/24/2019 13:24 by Bureau of Prisons - NYM Page 1 of 2
CONFIDENTIAL SDNY_00009410
EFTA00033816

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: [REDACTED] Unit: H01
Follow-up at Sick Call as Needed
Patient Education Topics:
Date Initiated Format Handout/Topic Provider Outcome
07/24/2019 Counseling Access to Care Verbalizes Understanding
07/24/2019 Counseling Preventive Health Verbalizes Understanding
Copay Required: No
Cosign Required: Yes
Telephone/Verbal Order: No
Completed by [REDACTED] on 07/24/2019 13:24
Requested to be cosigned by [REDACTED] MD.
Cosign documentation will be displayed on the following page.
Generated 07/24/2019 13:24 by Bureau of Prisons - NYM Page 2 of 2
CONFIDENTIAL SDNY_00009411
EFTA00033817

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: 07/24/2019 13:08 Provider: [REDACTED] Facility: NYM
Cosigned with New Encounter Note by [REDACTED] MD on 07/24/2019 16:10.
Bureau of Prisons - NYM
CONFIDENTIAL SDNY_00009412
EFTA00033818

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: 07/23/2019 06:20 Provider: [REDACTED] Unit: H01
Injury Assessment - Non-work related encounter performed at Health Services.
SUBJECTIVE:
INJURY 1 Provider: [REDACTED]
Date of Injury: 07/23/2019 01:27 Date Reported for Treatment: 07/23/2019 08:25
Work Related: No Work Assignment: UNASSG
Pain Location:
Pain Scale: 0
Pain Qualities:
Where Did Injury Happen (Be specific as to location):
Special Housing Unit Z05-Cell 124 L
Cause of Injury (Inmate's Statement of how injury occurred):
"I do not know. Just went to drink a little water and wake up snorting".
Symptoms (as reported by inmate):
None
OBJECTIVE:
Temperature:
Date Time Fahrenheit Celsius Location Provider
07/23/2019 06:30 NYM 97.5 36.4 Oral
Pulse:
Date Time Rate Per Minute Location Rhythm Provider
07/23/2019 06:30 92 Via Machine Regular
Respirations:
Date Time Rate Per Minute Provider
07/23/2019 06:30 NYM 16
Blood Pressure:
Date Time Value Location Position Cuff Size Provider
07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular
SaO2:
Date Time Value(%) Air Provider
07/23/2019 06:30 NYM 96 Room Air
Exam:
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed, Lethargic, Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled,
Generated 07/23/2019 09:05 by [REDACTED] Bureau of Prisons - NYM Page 1 of 2
CONFIDENTIAL SDNY_00009413
EFTA00033819

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054
Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM
Encounter Date: 07/23/2019 06:20 Provider: [REDACTED] Unit: H01
Exam:
Acutely III
Pulmonary
Auscultation
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally
No: Crackles, Rhonchi, Wheezing
Exam Comments
Inmate for injury report as requested by Operational Lt.
He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not know what happened. Can not explain the marks on his neck. Responded: "I don't know".
He does not want to talk of the events leading to the marks on his neck.
He does not look in any distress or pain.
Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction.
No inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem.
Has another small erythema on left knee about 2cm in diameter(mild).
As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor.
Inmate is currently placed on suicide watch.
ASSESSMENT:
Injury, unspecified, T1490 - Current - R/O self inflicted injuries.
PLAN:
Disposition:
Follow-up at Sick Call as Needed
Placed on Suicide Watch
Follow-up in 2-4 Hours
Other:
For follow up with psychology service.
Patient Education Topics:
Date Initiated Format Handout/Topic Provider Outcome
07/23/2019 Counseling Access to Care Verbalizes Understanding
07/23/2019 Counseling Plan of Care Verbalizes Understanding
Copay Required: No
Cosign Required: Yes
Telephone/Verbal Order: No
Completed by [REDACTED] on 07/23/2019 09:05
Requested to be cosigned by [REDACTED] MD.
Cosign documentation will be displayed on the following page.
Generated 07/23/2019 09:05 by [REDACTED] Bureau of Prisons - NYM Page 2 of 2
CONFIDENTIAL SDNY_00009414
EFTA00033820

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: 07/23/2019 06:20 Provider: [REDACTED] Facility: NYM
Cosigned by [REDACTED] MD on 07/23/2019 15:44.
Bureau of Prisons - NYM
CONFIDENTIAL SDNY_00009415
EFTA00033821

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: 07/14/2019 17:36 Provider: [REDACTED] MD Unit: Z05
Chronic Care - 14 Day Physician Eval encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1 Provider: [REDACTED] MD
Chief Complaint: ENDO/LIPID
Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS.
HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS
L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES.
SURGICAL HX: NONE
MENTAL HEALTH HX: NONE
Pain: Yes
Pain Assessment
Date: 07/12/2019 13:25
Location: Back-Middle
Quality of Pain: Shooting
Pain Scale: 5
Intervention: MEDROL DOSE PACK
Trauma Date/Year:
Injury:
Mechanism:
Onset: 5+ Years
Duration: 5+ Years
Exacerbating Factors: NO EXERCISE
Relieving Factors: MEDROL DOSE PACK
Reason Not Done:
Comments:
Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid
Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid
OBJECTIVE:
Exam:
General
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
Generated 07/14/2019 18:11 by [REDACTED] MD Bureau of Prisons - NYM Page 1 of 3
CONFIDENTIAL SDNY_00009416
EFTA00033822

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054
Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM
Encounter Date: 07/14/2019 17:36 Provider: [REDACTED] MD Unit: Z05
Exam:
Eyes
General
Yes: PERRLA, Extraocular Movements Intact
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: M/R/G
Abdomen
Auscultation
Yes: Normo-Active Bowel Sounds
Palpation
Yes: Within Normal Limits
Musculoskeletal
Tibia / Fibula
No: Edema
Back
Yes: Tenderness
Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
ASSESSMENT:
Constipation, unspecified, K5900 - Current
Hyperlipidemia, unspecified, E785 - Current
Low back pain, M545 - Current
Neuralgia and neuritis, unspecified, M792 - Current
Sleep apnea, G4730 - Current
PLAN:
New Medication Orders:
Rx# Medication Order Date Prescriber Order
Omega 3 ( Vascepa) 1 GM Capsule 07/14/2019 17:36 TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) – TAKE WITH FOOD.
Indication: Hyperlipidemia, unspecified
New Laboratory Requests:
Details Frequency Due Date Priority
Lab Tests-H-Hemoglobin A1C One Time 10/10/2019 00:00 Routine
Lab Tests-L-Lipid Profile
Additional Information:
Generated 07/14/2019 18:11 by [REDACTED] MD Bureau of Prisons - NYM Page 2 of 3
CONFIDENTIAL SDNY_00009417
EFTA00033823

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054
Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM
Encounter Date: 07/14/2019 17:36 Provider: [REDACTED] MD Unit: Z05
FASTING.
Lab Tests-H-Hep B surface Ab One Time 08/08/2019 00:00 Routine
Lab Tests-H-Hep B surface Ag
Lab Tests-H-Hep C Ab
Lab Tests-H-Hepatic Profile
Schedule:
Activity Date Scheduled Scheduled Provider
Clinical Encounter 07/24/2019 00:00 Optometrist
66 YR OLD MALE FOR ROUTINE SCREENING.
Chronic Care Visit 01/07/2020 00:00 Mid-Level Provider
6 MONTH F/U.
Chronic Care Visit 07/01/2020 00:00 Physician 01
Other:
PENDING EKG AND FOBT. CXR WAS REFUSED.
Patient Education Topics:
Date Initiated Format Handout/Topic Provider Outcome
07/14/2019 Counseling Diagnosis Verbalizes Understanding
Copay Required: No
Cosign Required: No
Telephone/Verbal Order: No
Completed by [REDACTED] MD on 07/14/2019 18:11
Generated 07/14/2019 18:11 by [REDACTED] MD Bureau of Prisons - NYM Page 3 of 3
CONFIDENTIAL SDNY_00009418
EFTA00033824