EFTA00110390 # Bureau of Prisons Health Services History & Physical

Inmate Name:

EPSTEIN, JEFFREY EDWARD

Reg #:

76318-054

Date of Birth:

01/20/1953

Sex:

Race: WHITE

Facility:

NYM

Encounter Date:

07/09/2019 12:35

Provider:

MLP

Unit:

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

Page 1 of 13 Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM EFTA00110391 | Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 | | :--- | :--- | :--- | :--- | | Date of Birth: 01/20/1953 | Provider: | MLP | Facility: NYM | | Encounter Date: 07/09/2019 12:35 | | | 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 Comments: Denies Generated 07/09/2019 13:03 by MLP Page 2 of 13 Bureau of Prisons - NYM EFTA00110392 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | | | | :--- | :--- | | Sex: | M Race: WHITE | | Provider: | Y. MLP | | Reg #: | 76318-054 | | Facility: | NYM | | Unit: | H01 |

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 MLP Page 3 of 13 Bureau of Prisons - NYM EFTA00110393

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
Creaturing: No
ts:

Generated 07/09/2019 13:03 by MLP Page 4 of 13 Bureau of Prisons - NYM EFTA00110394 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | Sex: | M Race: WHITE | | :--- | :--- | | Provider: | MLP | | Reg #: | 76318-054 | | :--- | :--- | | Facility: | NYM | | Unit: | H01 | # 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 Page 5 of 13 EFTA00110395 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | Sex: | M | Race: WHITE | | :--- | :--- | :--- | | Provider: | MLP | Unit: H01 |

Date	Time	Value	Location	Position	Cuff Size	Provider
07/09/2019	12:49 NYM	117/66	Right Arm	Sitting	Adult-regular	MLP

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

Page 6 of 13 EFTA00110396 | 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: | .MLP | | Unit: | H01 |

Date	Time	Inches	Cm	Provider
Weight:
Date	Time	Lbs	Kg	Waist Circum.	Provider
07/09/2019	12:49 NYM	194.4	88.2		.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 Acute Appendicitis **Complications:** None **Comments:** ## Head: Normal: Yes Comments: Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM Page 7 of 13 EFTA00110397 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | Sex: | M Race: WHITE | | :--- | :--- | | Provider: | MLP | | Reg #: | 76318-054 | | :--- | :--- | | Facility: | NYM | | Unit: | H01 |

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:

# 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 Page 8 of 13 MLP Bureau of Prisons - NYM EFTA00110398 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | Sex: | M Race: WHITE | | :--- | :--- | | Provider: | MLP | | 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:

## Breasts:

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 MLP Page 9 of 13 Bureau of Prisons - NYM EFTA00110399 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/09/2019 12:35 | | Sex: | M Race: WHITE | | :--- | :--- | | Provider: | MLP | | 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

Arteries:	Right	Left
Radial:
Femoral:
Dorsalis Pedis:
Post.Tibialis:

## Comments: Generated 07/09/2019 13:03 by Page 10 of 13 MLP Bureau of Prisons - NYM EFTA00110400 | 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: | MLP | | 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:

Nails Clubbing: No

Nails 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 Page 11 of 13 MLP Bureau of Prisons - NYM EFTA00110401 | 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: | .MLP | | Unit: H01 |

Date of Birth:	01/20/1953	Sex:	M	Race: WHITE	Facility:	NYM
Encounter Date:	07/09/2019 12:35	Provider:	MLP		Unit:	H01
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.

Generated 07/09/2019 13:03 by Page 12 of 13 MLP Bureau of Prisons - NYM EFTA00110402 | Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 | | :--- | :--- | :--- | :--- | | Date of Birth: 01/20/1953 | | | 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. the following page. Generated 07/09/2019 13:03 by MLP Page 13 of 13 Bureau of Prisons - NYM EFTA00110403 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Sex: M Provider: .MLP Reg #: 76318-054 Race: WHITE Facility: NYM Cosigned by MD on 07/11/2019 22:41. Bureau of Prisons - NYM