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¶