EFTA00121336 # Bureau of Prisons Health Services History & Physical

Inmate Name:	EPSTEIN, JEFFREY EDWARD	Sex:	M Race:	WHITE MLP	Reg #:	76318-054
Date of Birth:	01/20/1953	Provider:			Facility:	NYM
Encounter Date:	07/09/2019 12:35				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 High school diploma Banker Traveled to Paris x 3 weeks up until arrest
No tattoos

Generated 07/09/2019 13:03 by Page 1 of 13 MLP Bureau of Prisons - NYM EFTA00121337 ## 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 Page 2 of 13 MLP Bureau of Prisons - NYM EFTA00121338 | 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 | ## 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:

Pregnant:	N/A

Dental Condition: Denied Generated 07/09/2019 13:03 by MLP Page 3 of 13 Bureau of Prisons - NYM EFTA00121339 | 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 | 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 Comments: Generated 07/09/2019 13:03 by Page 4 of 13 MLP Bureau of Prisons - NYM EFTA00121340 | 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 Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM Page 5 of 13 EFTA00121341 | 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 | Temperature:

Date	Time	Fahrenheit	Celsius	Location	Provider
07/09/2019	12:49 NYM	97.3	36.3	Oral	.MLP

## Pulse:

Date	Time	Rate Per Minute	Location	Rhythm	Provider
07/09/2019	12:49	82	Via Machine	Regular	. MLP

Respirations:

Date	Time	Rate Per Minute	Provider
07/09/2019	12:49 NYM	16	.MLP

Blood Pressure:

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

SaO2:

Date	Time	Value(%)	Air	Provider
07/09/2019	12:49 NYM	97	Room Air	. MLP

## Height:

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 EFTA00121342

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			Location	When
Acute Appendicitis			Mount Sinai Hospital	1990
Complications: None
Comments:
Head:
Normal: Yes
Comments:

Generated 07/09/2019 13:03 by Bureau of Prisons - NYM MLP Page 7 of 13 EFTA00121343 | 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 MLP Page 8 of 13 Bureau of Prisons - NYM EFTA00121344

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

Instructions for Self Breast Exam Given: No Comments: Generated 07/09/2019 13:03 by MLP Page 9 of 13 Bureau of Prisons - NYM EFTA00121345 | 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 | ## 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:	Right	Left
Radial:
Femoral:
Dorsalis Pedis:
Post. Tibialis:

## Comments: Generated 07/09/2019 13:03 by MLP Page 10 of 13 Bureau of Prisons - NYM EFTA00121346 | 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 | ## 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:

Comments: Generated 07/09/2019 13:03 by Page 11 of 13 MLP Bureau of Prisons - NYM EFTA00121347 | 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 |

	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 EFTA00121348

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
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. Cosign documentation will be displayed on the following page. Generated 07/09/2019 13:03 by MLP Page 13 of 13 Bureau of Prisons - NYM EFTA00121349 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