# Bureau of Prisons Health Services Health Screen
Inmate Name:EPSTEIN, JEFFREY EDWARDSex:MReg #:76318-054
Date of Birth:01/20/1953Provider:PA-CRace:WHITE
Encounter Date:07/06/2019 21:38Facility:NYM
Seizures:Denied
Diabetes:Denied
Cardiovascular:Denied
CVA:Denied
Hypertension:Denied
Respiratory:Denied
Sickle Cell Anemia:Denied
Carcinoma/Lymphoma:Denied
Allergies:Denied
PPD Administration:
  Date/Time:07/06/2019 21:39
  Provider:PA-C
  Location:Right Forearm
  Drug Mfg:Sanofi Pasteur
  Lot Number:C5474BA
  Dosage:0.1mL
  Route:ID
  Exp Dt:10/2020
  Comments:
Tuberculosis:
  Hx of Previous Disease:No
  Blood-tinged Sputum:No
  Night Sweats:No
  Weight Loss:No
  Fever:No
  Cough:No
  Comments:
Generated 07/06/2019 21:56 by Page 1 of 6 PA-C Bureau of Prisons - NYM EFTA00121308
Inmate Name:EPSTEIN, JEFFREY EDWARDReg #:76318-054
Date of Birth:01/20/1953Sex: MRace:WHITE
Encounter Date:07/06/2019 21:38Provider: PA-CFacility:NYM
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 USHigh school diplomaBankerTraveled to Paris x 3 weeks up until arrestNo tattoos
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,treatedChicken pox in childhood
Abuse History:Denied
Physical:No
Emotional:No
Sexual:No
Comments:Denies
Generated 07/06/2019 21:56 by Page 2 of 6 PA-C Bureau of Prisons - NYM EFTA00121309 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/06/2019 21:38 | **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: *N/A* Dental Condition: Denied Generated 07/06/2019 21:56 by PA-C Page 3 of 6 Bureau of Prisons - NYM EFTA00121310 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/06/2019 21:38 | | | | | | Reg #: | 76318-054 | | :--- | :--- | :--- | :--- | :--- | :--- | | | Sex: | M | | Race: | WHITE | | | Provider: | PA-C | | Facility: | NYM | ## 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
## Pulse:
DateTimeRate Per MinuteLocationRhythmProvider
07/06/201921:4390Via MachinePA-C
Respirations:
DateTimeRate Per MinuteProvider
07/06/201921:43 NYM15PA-C
DateTimeValueLocationPositionCuff SizeProvider
07/06/201921:45 NYM164/90Right ArmSittingAdult-regularPA-C
07/06/201921:43 NYM155/83Left ArmSittingAdult-regularPA-C
DateTimeValue(%)AirProvider
07/06/201921:43 NYM95Room AirPA-C
DateTimeInchesCmProvider
07/06/201921:43 NYM72.0182.9PA-C
DateTimeLbsKgWaist Circum.Provider
07/06/201921:43 NYM200.090.7PA-C
Prosthetic Devices/Equipment: Denied Item Potential Items For Follow-up: Travel Outside US Other Infectious Disease History Comments: I have reviewed 0 pages of intake paperworks Page 4 of 6 EFTA00121311 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/06/2019 21:38 | | | | | :--- | :--- | | Sex: | M | | Provider: | PA-C | | Reg #: | 76318-054 | | :--- | :--- | | Race: | WHITE | | Facility: | NYM | Health Problems Newly Identified During This Encounter: Health Problem ## Medication Reconciliation. The patient's known medication list including OTC items was compiled and compared to new and changed BOP orders. ## Reconciled Medications:
SourceActionTypeRx#MedicationOrder Detail
OTCNo known OTCs
## New Laboratory Requests:
DetailsFrequencyDue DatePriority
Lab Tests-H-Hemoglobin A1COne Time08/05/2019 00:00Routine
Lab Tests-C-CBC w/diff
Lab Tests-L-Lipid Profile
Lab Tests-C-Comprehensive Metabolic Profile(CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
Additional Information:66 y/o male, elevated BP
Labs requested to be reviewed by:MD
## New Non-Medication Orders: ## Schedule:
ActivityDate ScheduledScheduled Provider
Vision Screen66 y/o male07/06/2019 00:00Optometrist
PPD Reading07/08/2019 00:00Nurse
Follow-upPD check07/09/2019 00:00Mid-Level Provider
## Other: BP noticed to be elevated. IM denies Hx of HTN or any significant chronic medical conditions. He is currently asymptomatic and denies any bodily complaints at this time. Will recheck BP in 2-3 days. ## Disposition: Follow-up at Sick Call as Needed To be Evaluated by Provider Instructed inmate how to obtain medical, dental, and mental health care. Telephone/Verbal Order: No Generated 07/06/2019 21:56 by Page 5 of 6 PA-C Bureau of Prisons - NYM EFTA00121312 | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/06/2019 21:38 | | | | | | Reg #: | 76318-054 | | :--- | :--- | :--- | :--- | :--- | :--- | | | Sex: | M | | Race: | WHITE | | | Provider: | PA-C | | Facility: | NYM | Completed by PA-C on 07/06/2019 21:56 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/06/2019 21:56 by PA-C Page 6 of 6 Bureau of Prisons - NYM EFTA00121313
Bureau of Prisons Health Services Cosign/Review
Inmate Name:EPSTEIN, JEFFREY EDWARDReg #:76318-054
Date of Birth:01/20/1953Sex:MRace:WHITE
Encounter Date:07/06/2019 21:38Provider:PA-CFacility:NYM
MD on 07/07/2019 00:17. Bureau of Prisons - NYM EFTA00121314