Prison medical record of Epstein's July 2019 neck injury and suicide watch

Bureau of Prisons Health Services Clinical Encounter¶

Inmate Name: Date of Birth: Encounter Date: 07/23/2019 06:20	EPSTEIN JEFFREY EDWARD			Sex: M Provider: Joaquin, Y. MLP		Race: WHITE	Reg #: Facility: NYM Unit:	76318-054 H01
Injury Assessment - Non-work related encounter performed at Health Services.
SUBJECTIVE:
INJURY 1	Provider:		Joaquin, Y. MLP
	Date of Injury:	07/23/2019 01:27				Date Reported for Treatment:		07/23/2019 08:25
	Work Related:	No		Work Assignment:		UNASSG
	Pain Location:
Pain Scale:	0
Pain Qualities:
	Where Did Injury Happen (Be specific as to location):
Special Housing Unit Z05-Cell 124 L
Cause of Injury (Inmate’s Statement of how injury occurred):
“I do not know. Just went to drink a little water and wake up snorting”.
	Symptoms (as reported by inmate):
	None
OBJECTIVE: Temperature: Date 07/23/2019	Time 06:30 NYM	Fahrenheit	Celsius 97.5	Location 36.4 Oral		Provider Joaquin, Y. MLP
Pulse:
Date 07/23/2019 06:30	Time	Rate Per Minute	92	Location Via Machine		Rhythm Regular	Provider Joaquin, Y. MLP
Respirations:
Date	Time		Rate Per Minute	Provider
07/23/2019	06:30 NYM			16 Joaquin, Y. MLP
Blood Pressure:
Date	Time	Value	Location	Position		Cuff Size	Provider
	07/23/2019 06:30 NYM 140/85		Right Arm	Sitting		Adult-regular Joaquin, Y. MLP
SaO2:
Air Value(%) Date Time					Provider
07/23/2019	06:30 NYM		96 Room Air			Joaquin, Y. MLP
Exam:
General
Affect
	Yes: Cooperative
Appearance
	Yes: Appears Well, Alert and Oriented x 3
								No: Appears Distressed, Lethargic. Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled,
Generated 07/23/2019 09:05 by Joaquin. Y. MLP				Bureau of Prisons - NYM				Page 1 of 2

CONFIDENTIAL SDNY_00008777¶

EFTA00033588¶

Exam:¶

Acutely III¶

Pulmonary¶

Auscultation¶

Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally¶

No: Crackles, Rhonchi, Wheezing¶

Exam Comments¶

Inmate for injury report as requested by Operational Lt.¶

He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not know what happened. Can not explain the marks on his neck. Responded: ‘I don’t know”.¶

He does not want to talk of the events leading to the marks on his neck.¶

He does not look in any distress or pain.¶

Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction.¶

No inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem.¶

Has another small erythema on left knee about 2cm in diameter(mild).¶

As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor.¶

Inmate is currently placed on suicide watch.¶

ASSESSMENT:¶

Injury, unspecified, T1490 - Current - FUO self inflicted injuries.¶

PLAN:¶

Disposition:¶

Follow-up at Sick Call as Needed Placed on Suicide Watch Follow-up in 2-4 Hours¶

Other:¶

For follow up with psychology service.¶

Patient Education Topics:¶

Date Initiated 07/23/2019	Format Counseling	Handout/Topic Access to Care	Provider Joaquin, Y.	Outcome Verbalizes Understanding
07/23/2019	Counseling	Plan of Care	Joaquin, Y.	Verbalizes Understanding
Copay Required: No		Cosign Required: Yes
TelephoneNerbal Order:	No
	Completed by Joaquin, Y. MLP on 07/23/2019 09:05
	Requested to be cosigned by Beaudouin, Robert MD.

Cosign documentation will be displayed on the following page.¶