EFTA00033830 ## Bureau of Prisons Health Services See Amendment | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/14/2019 17:36 | Sex: | M | Reg #:
Race:
Facility: | 76318-054
WHITE
NYM | |--------------------------------|---------------------------------------------------------------------------|------|---|------------------------------|---------------------------| | | | | | | | Amendment made to this note by on 07114/2019 18:11. &mftwoflhiumis.NYM ### Bureau of Prisons Health Services Clinical Encounter - Administrative Note | Inmate Name:
Date of Birth:
Note Date: | EPSTEIN, JEFFREY EDWARD
01/20/1953
07/12/2019 09:06 | Sex:
Provider: | | Reg #:
Facility:
Unit: | 76318-054
NYM
205 | |----------------------------------------------|--------------------------------------------------------------------------------------|-------------------------|------------------|------------------------------|----------------------------------------------------------------| | Administrative Notes: | Admin Note - Orders encounter performed at Health Services.
ADMINISTRATIVE NOTE 1 | Provider: | | | | | | PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. | | | | | | New Medication Orders: | | | | | | | B.24 | Medication | | Order Date | Prescriber Order | | | | Docusate Sodium Capsule | | 07/12/2019 09:06 | | TAKE ONE 100 MG CAP Orally
- Two Times a Day x 30 day(s) | | | Indication: Constipation, unspecified | | | | | | | Discontinued Medication Orders: | | | | | | Bit# | Medication. | | Order Data | prescriber Order | | | 121757-NYM | Bisacodyl E.C. 5 MG TAB | | 07/12/2019 09:06 | days | Take one tablet (5 MG) by mouth
at bedtime AS NEEDED for 10 | | | Discontinue Type: | When Pharmacy Processes | | | | | | Discontinue Reason:discontinue | | | | | | | Indication: | | | | | | Copay Required: No
TelephoneNerbal Order: | No | Cosign Required: No | | | | | Completed by | on 07/12/2019 09:10 | | | | | Generated 07/12/2019 09:10 by Bureau of Prisons • NYM ### Bureau of Prisons Health Services Clinical Encounter - Administrative Note | Inmate Name:
Date of Birth:
Note Date: | EPSTEIN, JEFFREY EDWARD
01/20/1953
07/07/2019 00:17 | Provider: Sex: | | Reg #:
Facility:
Unit: | 76318-054
NYM
E06 | |---------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------|----------|------------------------------|-------------------------| | Administrative Notes: | Cosign Note - Intake Cosign encounter performed at Health Services. | | | | | | | ADMINISTRATIVE NOTE 1
MED CL:1
NO CCC APPT. | Provider: | | | | | | Discontinued Laboratory Requests: | | | | | | Details
(CMP) | Lab Tests-H-Hemoglobin A1C
Lab Tests-C-CBC w/diff
Lab Tests-L-Lipid Profile
Lab Tests-C-Comprehensive Metabolic Profile
Lab Tests-U-Urinalysis w/Rellex to Microscopic
Additional Information: | Frequency
One Time | | Due Date
08/05/2019 00:00 | Priority
Routine | | | 66 y/o male, elevated BP | | | | | | | Labs requested to be reviewed by: | | | | | | New Laboratory Requests: | | | | | | | Details
Lab Tests-H-HIV 1/2
Lab Tests-R-RPR | Chronic Care Clinics-Diabetic-CBC w/diff
Chronic Care Clinics-Diabetic-Lipid Profile
Chronic Care Clinics-Diabetic-Hemoglobin A1C
Chronic Care Clinics-Diabetic-Comprehensive
Metabolic Profile (CMP)
New Radiology Request Orders: | Freauency
One Time | | DUG Date
07/25/2019 00:00 | Priority
Routine | | Details | | Frequency | End Date | Due Date | Priority | | General Radiology-Chest-2 Views | | One Time | | 07/25/2019 | Routine | | | Specific reason(s) for request (Complaints and findings): | | | | | | | 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. | | | | | | Copay Required: No | | Cosign Required: No | | | | | | TelephoneNerbal Order: No | | | | | | Completed by | | on 07/07/2019 00:30 | | | | Generated 07/07/2019 00:30 by ## CONFIDENTIAL SDNY_00009427 ### Bureau of Prisons Health Services History & Physical | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | | Sex:
Provider: | M | Race: WHITE | Reg #:
Facility:
Unit: | 76318-054
NYM
H01 | |--------------------------------|-----------------------------------------------------------------------------|--------|-------------------|---|-------------|------------------------------|-------------------------| | | | | | | | | | | Seizures: | | Denied | | | | | | | Diabetes: | | Denied | | | | | | | Cardiovascular: | | Denied | | | | | | | CVA: | | Denied | | | | | | | Hypertension: | | Denied | | | | | | | Respiratory: | | Denied | | | | | | | Sickle Cell Anemia: | | Denied | | | | | | | Carcinoma/Lymphoma: | | Denied | | | | | | | Allergies: | | Denied | | | | | | | Tuberculosis: | | | | | | | | | | Hx of Previous Disease: No | | | | | | | | | Blood-tinged Sputum: No | | | | | | | | Night Sweats: No | | | | | | | | | Weight Loss: No | | | | | | | | | Fever: No | | | | | | | | | Cough:No | | | | | | | | | Comments: | | | | | | | | | | Infectious Disease Risk Factors: | | | | | | | | IV Drug Use: No | | | | | | | | | IV Drug Use Needles: | | | | | | | | | | Sexual Partner IV Drug Use: No | | | | | | | | | Sexual Partner IV Drug Use Needles: | | | | | | | | | Female Sexual Partners (Last 5 Yrs): 10+ | | | | | | | | | Male Sexual Partners (Last 5 Yrs): 0 | | | | | | | | Condom Use: Sometimes | | | | | | | | | | Sexual Contact With HIV+ Individual: No | | | | | | | | | Blood Product Transfusion: No | | | | | | | | Travel Outside US: Yes | | | | | | | | | Tattoos: No | | | | | | | | | Comments: Born in US | High school diploma
Banker
Traveled to Pans x 3 weeks up until arrest | | | | | | | | | No tattoos | | | | | | | Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 1 of 13 CONFIDENTIAL SDNY_00009428 | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | | Sex:
Provider: | i m | ilfaHITS | Reg #:
Facility:
Unit: | 76318-054
NYM
H01 | |--------------------------------|---------------------------------------------------------------------------|----------|-------------------|-----|----------|------------------------------|-------------------------| | HIV History: | | | | | | | | | When Tested: | | 2019 | | | | | | | Test Result: | | Negative | | | | | | | When Diagnosed AIDS: | | | | | | | | | Last CD4: | | | | | | | | | Comments: | | | | | | | | | Hepatitis: | | Denied | | | | | | | Other Infectious Diseases: | | | | | | | | | Syphilis: | | No | | | | | | | | Syphilis Last Treatment: | N/A | | | | | | | Genital Warts: | | No | | | | | | | Chlamydia: | | Yes | | | | | | | Gonorrhea: | | No | | | | | | | Herpes: | | No | | | | | | | Chicken Pox: | | Yes | | | | | | | Other: | | No | | | | | | | | Comments: Chlamydia in 2015, treated
Chicken pox in childhood | | | | | | | | Abuse History: Denied | | | | | | | | | Physical: No | | | | | | | | | Emotional: No | | | | | | | | | Sexual: No
Comments: Denies | | | | | | | | | Inmate Name: | EPSTEIN. JEFFREY EDWARD | | | Reg #: | 76318-054 | |----------------|----------------------------------|-----------|--|-----------|-----------| | Date of Birth: | 01/20/1953 | Sex: | | Facility: | NYM | | | Encounter Date: 07/09/2019 12:35 | Provider: | | Unit: | H01 | #### Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No - Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Comments: Substance Use History: Denied Current Painful Condition: Denied Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: N/A Dental Condition: Denied Generated 07/09/2019 13:03 by Bureau of Prisons • NYM Page 3 of 13 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | | Reg #: | 76318-054 | |----------------|----------------------------------|-----------|----------|-----------|-----------| | Date of Birth: | 01/20/1953 | Sex: | 1.1/HITS | Facility: | NYM | | | Encounter Date: 07/09/2019 12:35 | Provider: | | Unit | H01 | #### Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Pardo( 13 # CONFIDENTIAL SDNY_00009431 | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/09/2019 12:35 | Sex:
Provider: | | Race: WHITE | | Reg #:
Facility:
Unit: | 76318-054
NYM
H01 | | |-------------------------------------------------------------------------------------------------------------|-------------------|--|-------------|--|------------------------------|-------------------------|--| |-------------------------------------------------------------------------------------------------------------|-------------------|--|-------------|--|------------------------------|-------------------------|--| #### Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Measles/Mumps/Rubella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number Dosage: Route: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Generated 07/09f2019 13:03 by Bureau of Prisons - NYM Page 5 of 13 ## CONFIDENTIAL SDNY_00009432 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | | ITE | Reg #: | 76318-054
NYM | |----------------|------------------------------------------------|-------------------|---|-----|--------------------|------------------| | Date of Birth: | 07/09/2019
Encounter Date: 07/09/2019 12:35 | Sex:
Provider. | • | | Facility:
Unit: | H01 | | | Immunization Date: | | | | | | | | |-----------------------|---------------------------------------|-----------|-----------------|-----------------|--------------------------------------------------------------------|---------------|----------|--------------| | | Provider: | | | | | | | | | | Location: | | | | | | | | | | Drug Mfg: | | | | | | | | | | Lot Number: | | | | | | | | | | Dosage: | | | | | | | | | | Route: | | | | | | | | | | Exp Dt: | | | | | | | | | | Comments: | | | | | | | | | | | | | | Varicella Series Administration: History Unknown, Not Administered | | | | | | Documented Date: 07/09/2019 12:51 EST | | | | | | | | | | Immunization Date: | | | | | | | | | | Provider: | | | | | | | | | | Location: | | | | | | | | | | Drug Mfg: | | | | | | | | | | Lot Number: | | | | | | | | | | Dosage: | | | | | | | | | | Route: | | | | | | | | | | Exp Dt: | | | | | | | | | | Comments: | | | | | | | | | Temperature: | | | | | | | | | | pate | | Time | Fahrenheit | Celsius | Location | provider | | | | | 07/09/2019 | 12:49 NYM | 97.3 | | 36.3 Oral | | | | | Pulse: | | | | | | | | | | DAM | Time | | Rate Per Minute | | Location | Rhythm | Provider | | | | 07/09/2019 12:49 | | | 82 | Via Machine | Regular | | | | Respirations:
Date | | Time | | Rate Per Minute | Provider | | | | | | 07/09/2019 | 12:49 NYM | | | 16 | | | | | Blood Pressure: | | | | | | | | | | DAM | Time | | Yarn | Location | Position | Cuff Slut | Provider | | | | 07/09/2019 12:49 NYM 117/66 | | | Right Arm | Sitting | Adult-regular | | | | SaO2: | | | | | | | | | | Data | | Time | Valuee4). Air | | Provider | | | | | | 07/09/2019 | 12:49 NYM | | 97 Room Air | | | | | | Height:
DatS | lima | | Inches | fa | Provider | | | | | | 07/09/2019 12:49 NYM | | 70.0 | 177.8 | | | | | | | Generated 07,09/2019 13:03 by | | | | Bureau of Prisons • NYM | | | Page a of 13 | | | | | | | | | | | CONFIDENTIAL SDNY_00009433 | Inmate Name:
Date of Birth:
Encounter Date: 07/09/2019 12:35 | EPSTEIN, JEFFREY EDWARD
01/20/1953 | | Sex: | Provider: | M | Race: WHITE | Reg #:
Facility:
Unit: | 76318-054
NYM
H01 | | |-------------------------------------------------------------------------------------------------------|--------------------------------------------------------|----------------|----------------|------------------------------|---|----------------------------------------|------------------------------|-------------------------|--| | Date
Weight:
Mt | Time
Int | inches
Lbs. | Cm | Provider
hg Waist Circum. | | Provider | | | | | 07/09/2019 | 12:49 NYM | 194.4 | 88.2 | | | | | | | | Prosthetic Devices/Equipment: Denied
Tobacco Usage: Denied | | | | | | | | | | | General Social History: | | | | | | | | | | | Foreign Travel:
Born in USA:
Country of Birth: USA | Yes | | | | | | | | | | Patient Education Assessments: | | | | | | | | | | | Date
07/09/2019 | Ed Yrs Occupation
12 Banker | | Learns Best By | Speaking/Listening English | | Primary Language Barriers to Education | None | | | | Family History - Father: | | | | | | | | | | | Age at Death: 74
Significant Illnesses:
Diabetes
Heart Disease | Cause of Death: Diabetes complications | | | | | | | | | | Comments: | | | | | | | | | | | Family History - Mother: | | | | | | | | | | | Age at Death: 81
Significant Illnesses:
Heart Disease
Comments:
Family History - Sibling: | Cause of Death: Kidney Failure | | | | | | | | | | Number of Siblings: 1
Significant Illnesses: | | | | | | | | | | | Comments:
Past Hospitalization: | | | | | | | | | | | Reason | | | | Location | | | When | | | | | Acute Appendicitis
Complications: None
Comments: | | | Mount Sinai Hospital | | | 1990 | | | | Head: | | | | | | | | | | | Normal:
Yes | | | | | | | | | | | Comments: | | | | | | | | | | | Generated 07/09/2019 13:03 by | | | | Bureau of Prisons NYM | | | | Page 7 of 13 | | # CONFIDENTIAL SDNY_00009434 | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | | Sex:
Provider: | M | Race.
WHITE | Reg #:
Facility:
Unit: | 76318-054
NYM
H01 | | | |-------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------|-------------------|---|----------------|------------------------------|-------------------------|--|--| | Eyes: | | | | | | | | | | | EOMI: Yes
lcterus:No
Pupils PERRLA: Yes
Pupil Size Rt:
Pupil Size Lt:
Pupils Comments:
Eyes Comments: | Conjunctival Inflammation: No
Fundi Vessels Nicking: No
Fundi Vessels Discs Flat:Yes
Fundi Vessels Discs Sharp Margins: Yes
Fundi Vessels Grounds Abnormal: No | | | | | | | | | | Vision Screen
07/09/2019 12:52
With Corrective
Blindness: | | | | | | | | | | | | Distance Vision: OD: 100 | OS: 70 | OU: | | OD: | OS | OU: | | | | Near Vision: | OD: | OS: | OU: | | OD: | OS: | OU: | | | | lshihara Color Test: | | | | | | | | | | | Tonometry: | L:
R: | | | | | | | | | | Comments: Needs evaluation with optometrist. | | | | | | | | | | | Ears: | | | | | | | | | | | Right Ear: Canal patent | | | | | | | | | | | | Left Ear:
Canal patent | | | | | | | | | | Ears Comments: | | | | | | | | | | | Nose: | | | | | | | | | | | Nares Patent: Yes | | | | | | | | | | | Septum Midline:Yes | | | | | | | | | | | Septum Intact: Yes | | | | | | | | | | | Drainage/Discharge:No
Polyps: No | | | | | | | | | | | Nose Comments: | | | | | | | | | | Generated 07/09/2019 13:03 by | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | | Reg #: | 76318-054 | |----------------|---------------------------------|-----------|--|-----------|-----------| | Date of Birth: | 01/20/1953 | Sex: | | Facility: | NYM | | | Encounter Date: 07/09/201912:35 | Provider: | | Unit: | H01 | #### Mouth Lesions:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present:Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures:No Mouth Comments: #### Cranial Nerves: Intact Yes Cranial Nerves Comments: #### Neck: Full ROM:Yes Masses/Nodes: No Trachea: Midline Thyroid: Normal Size Comments: #### Breasts: Normal: Yes Masses:No Tenderness:No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction: No Instructions for Self Breast Exam Given: No Comments: Generated 07/092019 13:03 by Bureau of Prisons - NYM Page 9 of 13 ## CONFIDENTIAL SDNY_00009436