Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Sex: M Race: WHITE 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¶
Cardiovascular: RRR: Yes Normal S1/S2: Yes Murmurs: No Carotid Bruits: No JVD: No¶
Arteries: Right Left Radial: Femoral: Dorsalis Pedis: Post. Tibialis:¶
Comments:¶
Page 10 of 13¶
SDNY_00000938¶
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EFTA00134682¶
Abdomen:¶
Normal Contour: Yes¶
Scaphold: No¶
Obese: No¶
Gravid: No¶
Hernias: No¶
Bruits: No¶
Masses: No¶
Scars: No¶
Tenderness: No¶
Organomegaly: No¶
Active Bowel Sounds: Yes¶
Comments:¶
Extremities:¶
Nalis Clubbing: No¶
Nalis 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¶
Bureau of Prisons - NYM¶
SDNY_00000939¶
EFTA_00000148¶
EFTA00134683¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35¶
Sex: M Race: WHITE Facility: NYM Unit: HQ1¶
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.¶
EFTA00134684¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Unit: H01 Encounter Date: 07/09/2019 12:35 Provider:¶
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 on 07/09/2019 13:03 Requested to be cosigned by¶
Cosign documentation will be displayed on the following page.¶
Generated 07/09/2019 13:03 by Bureau of Prisons - NYM¶
EFTA00134685¶
Bureau of Prisons Health Services Cosign/Review¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Encounter Date: 07/09/2019 12:35 Provider: NYM¶
Reg #: 76818-054 Race: WHITE Facility: NYM¶
Cosigned by on 07/11/2019 22:41.¶
Bureau of Prisons Health Services Inmate Local Hospital¶
Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD¶
ENSITIVE BUT UNCLASSIFIED – This information is confidential and must be appropriately safeguarded.¶
Transfer To: Transfer Date: 08/10/2019¶
Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current R/O self inflicted Injuries. Body mass Index (BMI) 27.0-27.9, adult Current¶
Medications: All medications to be continued until evaluated by a physician unless otherwise indicated. Bolded drugs required for transport: Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food¶
OTCs: Listing of all known OTCs this inmate is currently taking. None¶
Pending Appointments Date Time Activity Provider 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse¶
Pending Non-Medication Orders: Order Order Date Frequency Duration Details EKG 07/06/2019 One Time 66 y/o male Fecal Occult Blood 07/06/2019 One Time 3 different stools¶
TB Clearance: Yes Last PPD Date: 07/09/2019 Induration: 0mm Last Chest X-Ray Date: Results: TB Treatment: Sx free for 30 days: Yes TB Follow-up Recommended: No¶
Sickle Cell: Sickle Cell Trait/Disease: No¶
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EFTA00134687¶
SENSITIVE BUT UNCLASSIFIED – This information is confidential and must be appropriately safeguarded.¶
Limitations/Restrictions/Diets: Cell: lower bunk — 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. — 07/30/2020¶
Comments:¶
Allergies No Known Allergies¶
Devices / Equipment C-Pap¶
Travel: Direct Travel: No Travel Restrictions: None¶
UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE:¶
Transfer From Institution: NEW YORK MCC Address 1: 150 PARK ROW Address 2: NEW YORK, New York 10007¶
Name/Title of Person Completing Form: RN Date: 08/10/2019¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Sex: M¶
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