EFTA00139032 # Bureau of Prisons Health Services Health Screen

Inmate Name:	EPSTEIN, JEFFREY EDWARD	Sex:	M	Reg #:	76318-054
Date of Birth:	01/20/1953	Provider:	PA-C	Race:	WHITE
Encounter Date:	07/06/2019 21:38		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 PA-C Bureau of Prisons - NYM SDNY 00017396 Page 1 of 6 EFTA00139033 ### 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 SDNY_00017397 Page 2 of 6 PA-C Bureau of Prisons - NYM EFTA00139034 | 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 |

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 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SDNY_00017398 Page 3 of 6 EFTA00139035 | 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

Comments: ## Pulse:

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

## Respirations:

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

Blood Pressure:

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

SaO2:

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

## Height:

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

## Weight:

Date	Time	Lbs	Kg	Waist Circum.	Provider
07/06/2019	21:43 NYM	200.0	90.7		PA-C

Prosthetic Devices/Equipment: Denied Potential Items For Follow-up: Item Travel Outside US Other Infectious Disease History # Comments: I have reviewed 0 pages of intake paperworks Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SDNY_00017399 Page 4 of 6 EFTA00139036 | 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 | ## 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:

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
Vision Screen
66 y/o male
PPD Reading
Follow-up
BP check

## 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. Cosign Required: Yes ## Copay Required: No Telephone/Verbal Order: No Generated 07/06/2019 21:56 by Bureau of Prisons - NYM PA-C EFTA00139037 | 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 Bureau of Prisons - NYM SDNY 00017401 Page 6 of 6 EFTA00139038 Bureau of Prisons Health Services Cosign/Review 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 MD on 07/07/2019 00:17. Bureau of Prisons - NYM SDNY_00017402