EFTA00049118

# 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 |

<table border="1"><tr><td>Sex:</td><td>M</td><td>Race:</td><td>WHITE</td></tr><tr><td>Provider:</td><td colspan="3">Joaquin, Y. MLP</td></tr></table>

<table border="1"><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>H01</td></tr></table>

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:

<table border="1"><tr><td colspan="6">Temperature:</td></tr><tr><td>Date</td><td>Time</td><td>Fahrenheit</td><td>Celsius</td><td>Location</td><td>Provider</td></tr><tr><td>07/23/2019</td><td>06:30 NYM</td><td>97.5</td><td>36.4</td><td>Oral</td><td>Joaquin, Y. MLP</td></tr></table>

<table border="1"><tr><td colspan="6">Pulse:</td></tr><tr><td>Date</td><td>Time</td><td>Rate Per Minute</td><td>Location</td><td>Rhythm</td><td>Provider</td></tr><tr><td>07/23/2019</td><td>06:30</td><td>92</td><td>Via Machine</td><td>Regular</td><td>Joaquin, Y. MLP</td></tr></table>

<table border="1"><tr><td colspan="4">Respirations:</td></tr><tr><td>Date</td><td>Time</td><td>Rate Per Minute</td><td>Provider</td></tr><tr><td>07/23/2019</td><td>06:30 NYM</td><td>16</td><td>Joaquin, Y. MLP</td></tr></table>

<table><thead><tr><th>Date</th><th>Time</th><th>Value</th><th>Location</th><th>Position</th><th>Cuff Size</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30 NYM</td><td>140/85</td><td>Right Arm</td><td>Sitting</td><td>Adult-regular</td><td>Joaquin, Y. MLP</td></tr></tbody></table>



SaO2:


<table><thead><tr><th>Date</th><th>Time</th><th>Value(%)</th><th>Air</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30 NYM</td><td>96</td><td>Room Air</td><td>Joaquin, Y. MLP</td></tr></tbody></table>

## Exam:

## General

Affect

Yes: Cooperative

## Appearance

<table><tr><td>Appearance</td></tr><tr><td>Yes: Appears Well, Alert and Oriented x 3</td></tr><tr><td>No: Appears Distressed, Lethargic, Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled,</td></tr></table>

Generated 07/23/2019 09:05 by Joaquin, Y. MLP

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Bureau of Prisons - NYM

EFTA00049119

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/23/2019 06:20 |

<table border="1"><tr><td>Sex:</td><td>M</td><td>Race:</td><td>WHITE</td></tr><tr><td>Provider:</td><td colspan="3">Joaquin, Y. MLP</td></tr></table>

<table border="1"><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>H01</td></tr></table>

## Exam:

Acutely III

## Pulmonary

## Auscultation

## Exam Comments

<table border="1"><tr><td>Inmate for injury report as requested by Operational Lt.</td></tr><tr><td>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:&quot;I don&#x27;t know&quot;</td></tr><tr><td>He does not want to talk of the events leading to the marks on his neck.</td></tr><tr><td>He does not look in any distress or pain.</td></tr><tr><td>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.</td></tr><tr><td>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.</td></tr><tr><td>Has another small erythema on left knee about 2cm in diameter(mild)</td></tr><tr><td>As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor.</td></tr><tr><td>Inmate is currently placed on suicide watch.</td></tr></table>

Inmate is currently placed on suicide watch.

## ASSESSMENT:

Injury, unspecified, T1490 - Current - R/O self inflicted injuries.

## PLAN:

## Disposition:

## Other:



Follow-up at Sick Call as Needed

Placed on Suicide Watch

Follow-up in 2-4 Hours



For follow up with psychology service.

## Patient Education Topics:

<table border="1"><tr><td>Date Initiated</td><td>Format</td><td>Handout/Topic</td><td>Provider</td><td>Outcome</td></tr><tr><td>07/23/2019</td><td>Counseling</td><td>Access to Care</td><td>Joaquin, Y.</td><td>Verbalizes Understanding</td></tr><tr><td>07/23/2019</td><td>Counseling</td><td>Plan of Care</td><td>Joaquin, Y.</td><td>Verbalizes Understanding</td></tr></table>

<table><tr><td>Sopay Required: No</td><td>Cosign Required: Yes</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td colspan="2">Completed by Joaquin, Y. MLP on 07/23/2019 09:05</td></tr><tr><td colspan="2">Requested to be cosigned by Beaudouin, Robert MD.</td></tr><tr><td colspan="2">Cosign documentation will be displayed on the following page.</td></tr></table>



Generated 07/23/2019 09:05 by Joaquin, Y. MLP

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Bureau of Prisons - NYM