EFTA00121329 # Bureau of Prisons Health Services Health Screen

Inmate Name:	EPSTEIN, JEFFREY EDWARD			Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:	M	Race:	WHITE
Encounter Date:	07/06/2019 21:38	Provider:	PA-C	Facility:	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 EFTA00121330 ### 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 High school diploma Banker Traveled to Paris x 3 weeks up until arrest No 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, treated Chicken 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 EFTA00121331 | 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: --- Dental Condition: Denied Generated 07/06/2019 21:56 by PA-C Page 3 of 6 Bureau of Prisons - NYM EFTA00121332 | 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:

Date	Time	Rate Per Minute	Location	Rhythm	Provider
07/06/2019	21:43	90	Via Machine		PA-C

Date	Time	Rate Per Minute	Provider
07/06/2019	21:43 NYM	15	PA-C

Date	Time	Value	Location	Position	Cuff Size	Provider
07/06/2019	21:45 NYM	164/90	Right Arm	Sitting	Adult-regular	PA-C
07/06/2019	21:43 NYM	155/83	Left Arm	Sitting	Adult-regular	PA-C

Date	Time	Value(%)	Air	Provider
07/06/2019	21:43 NYM	95	Room Air	PA-C

Date	Time	Inches	Cm	Provider
07/06/2019	21:43 NYM	72.0	182.9	PA-C

Date	Time	Lbs	Kg	Waist Circum.	Provider
07/06/2019	21:43 NYM	200.0	90.7		PA-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 EFTA00121333 | 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: ## Medication Reconciliation. The patient's known medication list including OTC items was compiled and compared to new and changed BOP orders. ## Reconciled Medications:

Source	Action	Type	Rx#	Medication	Order Detail
		OTC		No known OTCs

## New Laboratory Requests:

Details	Frequency	Due Date	Priority
Lab Tests-H-Hemoglobin A1C	One Time	08/05/2019 00:00	Routine
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:

Activity	Date Scheduled	Scheduled Provider
Vision Screen66 y/o male	07/06/2019 00:00	Optometrist
PPD Reading	07/08/2019 00:00	Nurse
Follow-upBP check	07/09/2019 00:00	Mid-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 EFTA00121334 | 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 EFTA00121335

Bureau of Prisons Health Services Cosign/Review
Inmate Name:	EPSTEIN, JEFFREY EDWARD			Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:	M	Race:	WHITE
Encounter Date:	07/06/2019 21:38	Provider:	PA-C	Facility:	NYM

MD on 07/07/2019 00:17. Bureau of Prisons - NYM