EFTA00059468 ## Health Services History & Physical **Immate Name:** EPSTEIN, JEFFREY EDWARD **Date of Birth:** 01/20/1953 **Encounter Date:** 07/09/2019 12:35 | 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: | | Travel Outside US: Yes | | Tattoos: No | | Comments: Born in US | | High school diploma | | Banker | | Traveled to Paris x 3 weeks up until arrest | | No tattoos | EFTA00059469

Inmate Name:	EPSTEIN, JEFFREY EDWARD			Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:	M	Race: WHITE	Facility:	NYNM
Encounter Date:	07/09/2019 12:35	Provider:	MLP		Unit:	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

Generated 07/09/2019 13:03 by MLP Page 2 of 13 Bureau of Prisons - NYM EFTA00059470 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Sex: M Race: WHITE Facility: NVM 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 Page 3 of 13 Bureau of Prisons - NYM EFTA00059471

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
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 MLP Page 4 of 13 Bureau of Prisons - NYM EFTA00059472 ## Immunizations: ### Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered - Documented Date: 07/09/2019 12:51 EST - Immunization Date: - Provider: [MLP] - 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: [MLP] - 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: [MLP] - 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 on 07/09/2019 13:03 by [MLP] Bureau of Prisons - NYM EFTA00059473 ## Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 ### Immunization Date: Provider: MLP 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: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: ## Temperature: | Date | Time | Fahrenheit | Celsius | Location | Provider | | :--- | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 97.3 | 36.3 | Oral | MLP | ## Pulse: | Date | Time | Rate Per Minute | Location | Rhythm | Provider | | :--- | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 | 82 | Via Machine | Regular | MLP | ## Respirations: | Date | Time | Rate Per Minute | Provider | | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 16 | MLP | ## Blood Pressure: | Date | Time | Value | Location | Position | Cuff Size | Provider | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 117/66 | Right Arm | Sitting | Adult-regular | MLP | ## SaO2: | Date | Time | Value(%) | Air | Provider | | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 97 | Room Air | MLP | ## Height: | Date | Time | Inches | Cm | Provider | | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12:49 NYM | 70.0 | 177.8 | MLP | Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM EFTA00059474 | Date | Time | Inches | Cm | Provider | | :--- | :--- | :--- | :--- | :--- | | Date 07/09/2019 | 12:49 NYM | 194.4 | 88.2 | MLP, MLP | **Prosthetic Devices/Equipment:** Denied **Tobacco Usage:** Denied **General Social History:** - Foreign Travel: - Born in USA: Yes - Country of Birth: USA **Patient Education Assessments:** | Date | Ed Yrs | Occupation | Learns Best By | Primary Language | Barriers to Education | | :--- | :--- | :--- | :--- | :--- | :--- | | 07/09/2019 | 12 | Banker | Speaking/Listening | English | None | **Family History - Father:** - Age at Death: 74 - Cause of Death: Diabetes complications - Significant Illnesses: - Diabetes - Heart Disease **Comments:** **Family History - Mother:** - Age at Death: 81 - Cause of Death: Kidney Failure - Significant Illnesses: - Heart Disease **Comments:** **Family History - Sibling:** - Number of Siblings: 1 - Significant Illnesses: **Comments:** **Past Hospitalization:** | Reason | Location | When | | :--- | :--- | :--- | | Acute Appendicitis | Mount Sinai Hospital | 1990 | | Complications: None | | | | Comments: | | | **Head:** - Normal: Yes - Comments: | EFTA00059475 | Inmate Name: EPSTEIN, JEFFREY EDWARD | Date of Birth: 01/20/1953 | Sex: M | Race: WHITE | Reg #: 76318-054 | | :--- | :--- | :--- | :--- | :--- | | Encounter Date: 07/09/2019 12:35 | Provider: | MLP | Unit: NYM | H01 | **Eyes:** - EOMI: Yes - Icterus: No - Conjunctival Inflammation: No - Pupils PERRLA: Yes - Pupil Size Rt: - Pupil Size Lt: - Pupils Comments: - Fundi Vessels Nicking: No - Fundi Vessels Discs Flat: Yes - Fundi Vessels Discs Sharp Margins: Yes - Fundi Vessels Grounds Abnormal: No - Eyes Comments: **Vision Screen** 07/09/2019 12:52 **Blindness:** With Corrective **Distance Vision:** OD: 100 OS: 70 OU: OD: OS OU: **Near Vision:** OD: OS: OU: OD: OS: OU: **Ishihara 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 MLP Page 8 of 13 Bureau of Prisons - NYM EFTA00059476 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | | | | | Reg #: | 76318-054 | | :--- | :--- | :--- | :--- | :--- | :--- | | | Sex: | M | Race: WHITE | Facility: NYM | | | Provider: | Y. MLP | | 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 II-XII: 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 07/09/2019 13:03 by MLP Page 9 of 13 Bureau of Prisons - NYM EFTA00059477 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Sex: M Race: WHITE Facility: NYM Unit: H01 Thorax: Contour Normal: Yes Increased AP Diameter: No Asymmetrical Expansion: No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rales: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM: Yes Tenderness: No Cardiovascular: RRR: Yes Normal S1/S2: Yes Murmurs: No Carotid Bruits: No JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Pedis: Post. Tibialis: Comments: EFTA00059478 ## 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: Nalis Clubbing: No Nalis 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: Right Left Arm: Leg: Full ROM: Right Left Arm: Yes Yes Leg: Yes Yes Comments: Generated 07/09/2019 13:03 by EFTA00059479 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Reflexes: Right Left 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: Item 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. EFTA00059480 Inmate Name: EPSTEIN, JEFFREY EDWARD 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: Rx# 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 Telephone/Verbal 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