# Bureau of Prisons

# Health Services

# Clinical Encounter

| Inmate Name:    | EPSTEIN, JEFFREY   | EDWARD   |           |    |       |       | Reg #:    | 76318-054<br />NYM   |
|-|-|-|-|-|-|-|-|-|
| Date of Birth:  | 01/20/1953         |          | Sex:      | M  | Race: | WHITE | Facility: |                      |
| Encounter Date: | 07/12/2019 13:10   |          | Provider: |    |       |       | Unit:     | Z05                  |

Chronic Care - 14 Day Physician Eval encounter performed at Health Services.

## SUBJECTIVE:

| COMPLAINT   | 1   | Provider:   |
|-|-|-|

<table><tr><th colspan="2">Chief Complaint: ENDO/LIPID</th></tr><tr><td>Subjective: 66 YR OLD

800, NOW
MEDS DUE
HX OF
MACHINE.
STATES THE
L4-L5
LOWER
SURGICAL
MENTAL</td><td>WHITE MALE WITH HX OF
HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
434. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
TO THEIR GI SIDE EFFECTS.
OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
FBI LOKELY HAS
SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
EXTREMITIES.
HX: NONE
HEALTH HX: NONE</td></tr><tr><td>Pain: Yes</td><td></td></tr><tr><td colspan="2">Pain Assessment

Amendment</td></tr><tr><td>Date:</td><td>07/12/2019 13:25</td></tr><tr><td>Location:</td><td>Back-Middle</td></tr><tr><td>Quality of Pain:</td><td>Shooting</td></tr><tr><td>Pain Scale:</td><td>5</td></tr><tr><td>Intervention:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Trauma Date/Year:</td><td></td></tr><tr><td>Injury:</td><td></td></tr><tr><td>Mechanism:</td><td></td></tr><tr><td>Onset:</td><td>5+ Years</td></tr><tr><td>Duration:</td><td>5+ Years</td></tr><tr><td>Exacerbating Factors:</td><td>NO EXERCISE</td></tr><tr><td>Relieving Factors:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Reason Not Done:</td><td></td></tr><tr><td>Comments:</td><td></td></tr></table>

Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

OBJECTIVE:

Exam:
General
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,
Disheveled, Unkempt, Acutely Ill

Nutrition
No: Appears Obese

Generated 07/12/2019 14:20 by <empty>
Bureau of Prisons - NYM
Page 1 of 3

CONFIDENTIAL

SDNY 00009419

EFTA00034142

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Reg #: 76318-054

M Race: WHITE

Sex:
Provider:

Facility: NYM
Unit: Z05

## Exam:

Eyes
General
Yes: PERRLA, Extraocular Movements Intact

Pulmonary
Auscultation
Yes: Clear to Auscultation

Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: M/R/G
Abdomen
Auscultation
Yes: Normo-Active Bowel Sounds

Palpation
Yes: Within Normal Limits

Musculoskeletal
Tibia / Fibula

No: Edema
Back
Yes: Tenderness See Amendment
Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits

Motor System-General
Yes: Normal Exam

ASSESSMENT:

Constipation, unspecified, K5900 - Current

Hyperlipidemia, unspecified, E785 - Current

Low back pain, M545- Current

Neuralgia and neuritis, unspecified, M792 - Current

Sleep apnea, G4730 - Current

## PLAN:

New Medication Orders:

| Rx#                                             | Medication                                          | Order Date                                      | Prescriber Order                                 |
|-|-|-|-|
|                                                 | Magnesium Hydroxide Susp                            | 07/12/2019 13:10                                | 30 CC Orally Two Times a<br />Day PRN x 2 day(s) |
|                                                 | Indication: Constipation, unspecified               |                                                 |                                                  |
|                                                 | MethylPREDNISolone Tab 4 MG (Dose<br />Pack 21 tab) | 07/12/2019 13:10                                | AS DIRECTED Orally - daily x<br />6 day(s)       |
| Indication: Neuralgia and neuritis, unspecified | Indication: Neuralgia and neuritis, unspecified     | Indication: Neuralgia and neuritis, unspecified | Indication: Neuralgia and neuritis, unspecified  |

## Disposition:

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SDNY 00009420
EFTA00034143

Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054
Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM
Encounter Date: 07/12/2019 13:10 Provider: I Unit: Z05

Follow-up at Sick Call as Needed

## Other:

WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.

Patient Education Topics:

| Date Initiated   | Format     | Handout/Topic   |
|-|-|-|
| 07/12/2019       | Counseling | Diagnosis       |

Provider

Outcome
Verbalizes
Understanding

Cosign Required: No
See Amendment

Copay Required: No

Telephone/Verbal Order: No

Completed by Beaudouin, Robert MD on 07/12/2019 14:20

Generated 07/12/2019 14 20 by

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SDNY 00009421
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# Bureau of Prisons
Health Services
Clinical Encounter

| Inmate Name:    | EPSTEIN. JEFFREY EDWARD   |           |    |       |       | Reg tit:   | 76318.054   |
|-|-|-|-|-|-|-|-|
| Date of Birth:  | 01/20/1953                | Sex:      | M  | Race: | WHITE | Facility:  | NYM         |
| Encounter Date: | 07/12/2019 13:10          | Provider: |    |       |       | Unit:      | Z05         |

Chronic Care - 14 Day Physician Eval encounter performed at Health Services.

## SUBJECTIVE:

| COMPLAINT   | 1   | Provider:   |
|-|-|-|

Chief Complaint: ENDO/LIPID

<table><tr><th>Chief Complaint: ENDO/LIPID</th><th></th></tr><tr><td>Subjective: 66 YR OLD

800, NOW
MEDS DUE
HX OF
MACHINE.
STATES THE
L4-L5 SEVERE
LOWER
SURGICAL
MENTAL
Pain: Yes</td><td>WHITE MALE WITH HX OF
HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
434. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
TO THEIR GI SIDE EFFECTS.
OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
FBI LOKELY HAS
STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
EXTREMITIES.
HX: NONE
HEALTH HX: NONE

Amendment</td></tr><tr><td>Pain Assessment</td><td></td></tr><tr><td>Date:</td><td>07/12/2019 13:25</td></tr><tr><td>Location:</td><td>Back-Middle</td></tr><tr><td>Quality of Pain:</td><td>Shooting</td></tr><tr><td>Pain Scale:</td><td>5</td></tr><tr><td>Intervention:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Trauma Date/Year:</td><td></td></tr><tr><td>Injury:</td><td></td></tr><tr><td>Mechanism:</td><td></td></tr><tr><td>Onset:</td><td>5+ Years</td></tr><tr><td>Duration:</td><td>5+ Years</td></tr><tr><td>Exacerbating Factors:</td><td>NO EXERCISE</td></tr><tr><td>Relieving Factors:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Reason Not Done:</td><td></td></tr><tr><td>Comments:</td><td></td></tr></table>

Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

## OBJECTIVE:

Exam:
General Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,
Disheveled, Unkempt, Acutely Ill

## Nutrition

No: Appears Obese
Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 1 of 3

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SDNY 00009422

EFTA00034145

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
Provider:

M Race: WHITE

Reg #: 76318-054

Facility: NYM
Unit: 205

## Exam:

Eyes

General

Yes: PERRLA, Extraocular Movements Intact

Pulmonary
Auscultation 
Yes: Clear to Auscultation

Cardiovascular

Auscultation

Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 See Amendment

No: M/R/G

Abdomen

Auscultation

Yes: Normo-Active Bowel Sounds

Palpation

Yes: Within Normal Limits

Musculoskeletal

Tibia / Fibula

No: Edema

Back

Yes: Tenderness

Neurologic

Cranial Nerves (CN)

Yes: Within Normal Limits

## Motor System-General

Yes: Normal Exam

## ASSESSMENT:

Constipation, unspecified, K5900 - Current

Hyperlipidemia, unspecified, E785 - Current

Low back pain, M545 - Current

Neuralgia and neuritis, unspecified, M792 - Current

Sleep apnea, G4730 - Current

## PLAN:

New Medication Orders:

| Rx#                                             | Medication                                          | Order Date                                      | Prescriber Order                                 |
|-|-|-|-|
|                                                 | Magnesium Hydroxide Susp                            | 07/12/2019 13:10                                | 30 CC Orally Two Times a<br />Day PRN x 2 day(s) |
|                                                 | Indication: Constipation, unspecified               |                                                 |                                                  |
|                                                 | MethylPREDNISolone Tab 4 MG (Dose<br />Pack 21 tab) | 07/12/2019 13:10                                | AS DIRECTED Orally daily x<br />6 day(s)         |
| Indication: Neuralgia and neuritis, unspecified | Indication: Neuralgia and neuritis, unspecified     | Indication: Neuralgia and neuritis, unspecified | Indication: Neuralgia and neuritis, unspecified  |

## Disposition:

Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

Page 2 of 3

CONFIDENTIAL  SDNY 00009423

EFTA00034146

Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318.054
Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM
Encounter Date: 07/12/2019 13:10 Provider: El Unit: Z05

Follow-up at Sick Call as Needed

## Other:

WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.

## Patient Education Topics:

| Date Initiated   | Format     | Handout/Tonic    |
|-|-|-|
| 07/12/2019       | Counseling | Diagnosis        |

Provider

Outcome
Verbalizes
Understanding

Copay Required: No

Cosign Required: No

Telephone/Verbal Order: No

Completed by

n 07/12/2019 14:20
ee Amendment

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Bureau of Prisons - NYM

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SDNY 00009424
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# Bureau of Prisons
Health Services
See Amendment

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054
Date of Birth: 01/20/1953 
Sex: M
Race: WHITE
Encounter Date: 07/14/2019 17:36
Facility: NYM

Amendment made to this note by: <empty>
on 07/14/2019 18:11.

Bureau of Prisons - NYM

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SDNY 00009425
EFTA00034148

# Bureau of Prisons

# Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M
Race: WHITE
Facility: NYM

Note Date: 07/12/2019 09:06
Provider: <empty>
Unit: Z05

Admin Note - Orders encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1 
Provider: <empty>
PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION.

New Medication Orders:
Rx#: <empty>
Medication: Docusate Sodium Capsule
Order Date: 07/12/2019 09:06
Prescriber Order: TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s)
Indication: Constipation, unspecified

Discontinued Medication Orders:
Rx#: 121757-NYM
Medication: Bisacodyl E.C. 5 MG TAB
Order Date: 07/12/2019 09:06
Prescriber Order: Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days
Discontinue Type: When Pharmacy Processes
Discontinue Reason:discontinue
Indication:<empty>

Copay Required:No
Cosign Required: No
Telephone/Verbal Order: No
Completed by <empty> on 07/12/2019 09:10

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SONY 00009426
EFTA00034149

# Bureau of Prisons

# Health Services Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Note Date: 07/07/2019 00:17
Provider: <empty>
Unit: E06

Cosign Note - Intake Cosign encounter performed at Health Services.

Administrative Notes:

ADMINISTRATIVE NOTE 1
Provider: <empty>
MED CL:1
NO CCC APPT.

## Discontinued Laboratory Requests:

Details
Lab Tests-H-Hemoglobin A1C
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:

| Frequency   | Due Date         | Priority   |
|-|-|-|
| One Time    | 08/05/2019 00:00 | Routine    |

New Laboratory Requests:

## Details

Chronic Care Clinics-Diabetic-CBC w/diff
Chronic Care Clinics-Diabetic-Lipid Profile
Chronic Care Clinics-Diabetic-Hemoglobin A1C
Lab Tests-H-HIV 1/2
Lab Tests-R-RPR
Chronic Care Clinics-Diabetic-Comprehensive
Metabolic Profile (CMP)

| Frequency   | Due Date         | Priority   |
|-|-|-|
| One Time    | 07/25/2019 00:00 | Routine    |

New Radiology Request Orders:

Details: General Radiology-Chest-2 Views
Frequency: One Time
End Date: <empty>
Due Date: 07/25/2019
Priority: Routine

Specific reason(s) for request (Complaints and findings):
66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUTINE CXR.

Copay Required:No
Cosign Required: No
Telephone/Verbal Order: No
Completed by <empty> on 07/07/2019 00:30

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EFTA00034150

Bureau of Prisons

# Health Services
History & Physical

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: <empty>
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

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CONFIDENTIAL

SDNY 00009428
EFTA00034151

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: <empty>
Unit: H01

<table><tr><th colspan="2">HIV History:</th></tr><tr><td>When Tested:</td><td>2019</td></tr><tr><td>Test Result:</td><td>Negative</td></tr><tr><td>When Diagnosed AIDS:</td><td></td></tr><tr><td>Last CD4:</td><td></td></tr><tr><td colspan="2">Comments:</td></tr><tr><td>Hepatitis:</td><td>Denied</td></tr><tr><td>Other Infectious Diseases:</td><td></td></tr><tr><td>Syphilis:</td><td>No</td></tr><tr><td>Syphilis Last Treatment:</td><td>N/A</td></tr><tr><td>Genital Warts:</td><td>No</td></tr><tr><td>Chlamydia:</td><td>Yes</td></tr><tr><td>Gonorrhea:</td><td>No</td></tr><tr><td>Herpes:</td><td>No</td></tr><tr><td>Chicken Pox:</td><td>Yes</td></tr><tr><td>Other:</td><td>No</td></tr><tr><td colspan="2">Comments: Chlamydia in 2015, treated
Chicken pox in childhood</td></tr><tr><td colspan="2">Abuse History: Denied</td></tr><tr><td>Physical: No</td><td></td></tr><tr><td>Emotional: No</td><td></td></tr><tr><td>Sexual: No</td><td></td></tr><tr><td>Comments: Denies</td><td></td></tr></table>

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SDNY 00009429
EFTA00034152

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: <empty>
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



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CONFIDENTIAL

SDNY 00009430

EFTA00034153

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: <empty>
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:<empty>

Generated 07/09/2019 13:03 by Generated 07/09/2019 13:03 by

Bureau of Prisons - NYM Bureau of Prisons - NYM

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CONFIDENTIAL

SDNY 00009431
EFTA00034154

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: Unit: H01

## Immunizations:

Hepatitis A and B (TwinRx) Series Administration:
History Unknown, Not Administered

Documented Date: 07/09/2019 12:51 EST
Immunization Date: <empty>
Provider: <empty>
Location: <empty>
Drug Mfg: <empty>
Lot Number: <empty>
Dosage: <empty>
Route: <empty>
Exp Dt: <empty>
Comments: <empty>

Measles/Mumps/Rubella Series Administration:
History Unknown, Not Administered

Documented Date: 07/09/2019 12:51 EST
Immunization Date: <empty>
Provider: <empty>
Location: <empty>
Drug Mfg: <empty>
Lot Number: <empty>
Dosage: <empty>
Route: <empty>
Exp Dt: <empty>
Comments: <empty>

Smallpox Series Administration:
History Unknown, Not Administered

Documented Date: 07/09/2019 12:51 EST
Immunization Date: <empty>
Provider: <empty>
Location: <empty>
Drug Mfg: <empty>
Lot Number: <empty>
Dosage: <empty>
Route: <empty>
Exp Dt: <empty>
Comments: <empty>

Tetanus Administration:
History Unknown, Not Administered

Documented Date: 07/09/2019 12:51 EST

Generated 07/09f2019 13:03 by

Bureau of Prisons - NYM

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SDNY 00009432
EFTA00034155

| Category        | Date           | Time       | Value/Details     |
|-----------------|----------------|------------|---------------------|
| Temperature      | 07/09/2019     | 12:49 NYM  | 97.3 F, 36.3 C, Oral |
| Pulse            | 07/09/2019     | 12:49      | 82 Rate per Minute, Via Machine, Regular Rhythm |
| Respirations     | 07/09/2019     | 12:49 NYM  | 16 Rate per Minute |
| Blood Pressure   | 07/09/2019     | 12:49 NYM  | 117/66, Right Arm, Sitting, Adult-regular Cuff Size |
| SaO2             | 07/09/2019     | 12:49 NYM  | 97%, Room Air        |
| Height           | 07/09/2019     | 12:49 NYM  | 70.0 Inches, 177.8 Cm|
| Inmate Name      |                |            | JEFFREY EDWARD EPSTEIN |
| Date of Birth    |                |            | 01/20/1953          |
| Encounter Date   |                |            | 07/09/2019 12:35   |
| Registration Number |                |            | 76318-054          |
| Facility         |                |            | NYM                 |
| Unit             |                |            | H01                 |
| Varicella Series |                |            | History Unknown, Not Administered |
| Varicella Series Doc. Date  | 07/09/2019 | 12:51 EST  |                      |

CONFIDENTIAL

SDNY 00009433
EFTA00034156

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: <empty>
Unit: H01

Weight:
Date Time Lbs Kg Waist Circum. Provider
07/09/2019 12:49 NYM 194.4 88.2 <empty>

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/Listing 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 <empty>
Bureau of Prisons - NYM
Page 7 of 13

CONFIDENTIAL

SDNY 00009434
EFTA00034157

| 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: |    |       |       | Unit:     | H01         |

## Eyes:

Eyes:

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:

| Vision Screen<br />Blindness:   | 07/09/2019   |     | 12:52   |        |     | With Corrective   | With Corrective   | With Corrective   |
|-|-|-|-|-|-|-|-|-|
| Distance Vision:                | OD:          | 100 |         | OS: 70 | OU: | OD:               | OS                | OU:               |
| Near Vision:                    | OD:          |     |         | OS:    | OU: | OD:               | OS:               | OU:               |

## lshihara Color Test:

Tonometry: L: R:

Comments: Needs evaluation with optometrist.

## 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:

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EFTA00034158

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex:
Provider:

M Race: WHITE

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 07/092019 13:03 by

Bureau of Prisons - NYM

Page 9 of 13

CONFIDENTIAL

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