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¶