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 | 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¶