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 |¶
| Sex: | M | Race: | WHITE |
| Provider: | Joaquin, Y. MLP | ||
| Reg #: | 76318-054 |
| Facility: | NYM |
| Unit: | 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 | Time | Fahrenheit | Celsius | Location | Provider |
| 07/23/2019 | 06:30 NYM | 97.5 | 36.4 | Oral | Joaquin, Y. MLP |
| Pulse: | |||||
| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
| 07/23/2019 | 06:30 | 92 | Via Machine | Regular | Joaquin, Y. MLP |
| Respirations: | |||
| Date | Time | Rate Per Minute | Provider |
| 07/23/2019 | 06:30 NYM | 16 | Joaquin, Y. MLP |
| 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:¶
| Date | Time | Value(%) | Air | Provider |
|---|---|---|---|---|
| 07/23/2019 | 06:30 NYM | 96 | Room Air | Joaquin, Y. MLP |
Exam:¶
General¶
Affect¶
Yes: Cooperative¶
Appearance¶
| 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¶
Page 1 of 2¶
Bureau of Prisons - NYM¶
EFTA00049119¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
|---|---|
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/23/2019 06:20 |
| Sex: | M | Race: | WHITE |
| Provider: | Joaquin, Y. MLP | ||
| Reg #: | 76318-054 |
| Facility: | NYM |
| Unit: | H01 |
Exam:¶
Acutely III¶
Pulmonary¶
Auscultation¶
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. |
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:¶
| Date Initiated | Format | Handout/Topic | Provider | Outcome |
| 07/23/2019 | Counseling | Access to Care | Joaquin, Y. | Verbalizes Understanding |
| 07/23/2019 | Counseling | Plan of Care | Joaquin, Y. | Verbalizes Understanding |
| Sopay Required: No | Cosign Required: Yes |
| Telephone/Verbal 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. | |
Generated 07/23/2019 09:05 by Joaquin, Y. MLP¶
Page 2 of 2¶
Bureau of Prisons - NYM¶