EFTA00073888

Inmate Name:	EPSTEIN, JEFFREY EDWARD
Date of Birth:	01/20/1953
Encounter Date:	07/09/2019 12:35

Sex: Provider:

Reg #:	76318-054
Facility:	NYM
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:

Page 058 of 148 Breasts: Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Normal: Yes Masses: No Tenderness: No Scars: No

Dimpling:No

Nipple Discharge:No

Nipple Retraction:No

Comments: Instructions for Self Breast Exam Given: No Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 9 of 13 EFTA00073889

Inmate Name:	EPSTEIN, JEFFREY EDWARD
Date of Birth:	01/20/1953
Encounter Date:	07/09/2019 12:35

Sex: Provider:

Reg #:	76318-054
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

Comments:

## Cardiovascular:

RRR: Yes

Normal S1/S2: Yes

Murmurs: No

Carotid Bruits: No

JVD: No

Arteries:

Radial:

Femoral:

Dorsalis Pedis:

Post. Tibialis:

## Page 059 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Right Left Comments: Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 10 of 13 EFTA00073890

Inmate Name:	EPSTEIN, JEFFREY EDWARD
Date of Birth:	01/20/1953
Encounter Date:	07/09/2019 12:35

Sex: Provider:

Reg #:	76318-054
Facility:	NYM
Unit:	H01

## Abdomen:

Normal Contour:Yes

Scaphoid:No

Obese:No

Gravid:No

Hernias:No

Bruits:No

Masses:No

Scars:No

Tenderness:No

Organomegaly:No

Active Bowel Sounds:Yes

Comments:

## Extremities: Page 060 of 148 Withheld pursuant to exemption (b) (6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act

Strength:	Right	Left
Arm:
Leg:
Full ROM:	Right	Left
Arm:	Yes	Yes
Leg:	Yes	Yes
Comments:

Comments: Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 11 of 13 EFTA00073891

Inmate Name:	EPSTEIN, JEFFREY EDWARD
Date of Birth:	01/20/1953
Encounter Date:	07/09/2019 12:35

Sex: Provider:

Reg #:	76318-054
Facility:	NYM
Unit:	H01

Reflexes:

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. Page 061 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C)

Normal: Yes

Rash: No

Redness: No

Abnormal Pigmentation: No

Abnormal Lesions/Growths: No

Comments:

of the Freedom of Information and Privacy Act Lymphatics: Adenopathy: No Comments: # 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 Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 12 of 13 EFTA00073892 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | Sex: | M | Race: WHITE | | :--- | :--- | :--- | | Provider: | | | | Reg #: | 76318-054 | | :--- | :--- | | Facility: | NYM | | Unit: | H01 | Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current -

New Medication Orders:
Rx#	Medication
	Bisacodyl E.C. Tablet

Order Date
07/09/2019 12:35

Indication: Constipation, unspecified Prescriber Order 5 mg Orally at bedtime PRN x 10 day(s) 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 on 07/09/2019 13:03 Requested to be cosigned by Cosign documentation will be displayed on the following page. 062 of 148 Withheld pursuant to exemption (b) (6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 13 of 13 EFTA00073893 # Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Provider: Reg #: 76318-054 Encounter Date: 07/09/2019 12:35 Cosigned by Race: WHITE on 07/11/2019 22:41. Facility: NYM Withheld pursuant to exemption (b) (6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM