Bureau of Prisons Health Services Clinical Encounter¶
| Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/23/2019 06:20 | M Sex: Provider: | Reg #: 76318-054 Facility: NYM Race: WHITE Unit: H01 | ||||
|---|---|---|---|---|---|---|
| Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: 1 Provider: INJURY | ||||||
| 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: Time Date Fahrenheit | Location Celsius | Provider | ||||
| 07/23/2019 06:30 NYM 97.5 | 36.4 Oral | |||||
| Pulse: | ||||||
| Time Rate Per Minute Date | Location | Rhythm Provider | ||||
| 07/23/2019 06:30 92 | Via Machine | Regular | ||||
| Respirations: | ||||||
| Rate Per Minute Time Date | Provider | |||||
| 06:30 NYM 07/23/2019 | 16 | |||||
| Blood Pressure: | ||||||
| Location Date Time Value | Position | Provider Cuff Size | ||||
| 07/23/2019 06:30 NYM 140/85 Right Arm | Sitting | Adult-regular | ||||
| SaO2: | ||||||
| Air Date Time Value(%) 06:30 NYM 96 Room Air 07/23/2019 | Provider | |||||
| 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 | Bureau of Prisons - NYM | Page I of 2 |
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 - RIO 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 | Format | Handout/Topic | Provider | Outcome |
|---|---|---|---|---|
| 07/23/2019 | Counseling | Access to Care | Verbalizes Understanding | |
| 07/23/2019 | Counseling | Plan of Care | Verbalizes Understanding | |
| Copay Required:No | Cosign Required: Yes | |||
| TelephoneNerbal Order: | No | |||
| Completed by | on 07/23/2019 09:05 | |||
| Requested to be cosigned by | MD. | |||
| Cosign documentation will be displayed on the following page. |