EFTA00073855¶
Bureau of Prisons Health Services Clinical Encounter¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
|---|---|
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/24/2019 13:08 |
| Sex: | M | Race: WHITE |
|---|---|---|
| Provider: |
Reg #: 76318-054 Facility: NYM Unit: H01¶
Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge.¶
SUBJECTIVE:¶
COMPLAINT 1 Provider:¶
Chief Complaint: Other Problem¶
| Subjective: | I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. |
| Pain: | No |
OBJECTIVE:¶
Temperature:¶
| Date | Time | Fahrenheit | Celsius | Location | Provider |
|---|---|---|---|---|---|
| 07/24/2019 | 13:12 NYM | 97.8 | 36.6 | Oral |
Pulse:¶
| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
|---|---|---|---|---|---|
| 07/24/2019 | 13:12 | 83 | Via Machine | Regular |
Blood Pressure:¶
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 07/24/2019 | 13:12 NYM | 132/89 | Right Arm | (b)(6);(9)(7)(A);(b)(7)(U) | Adult regular |
SaO2:¶
| Date | Time | Value(%) | Air | Provider |
| 07/24/2019 | 13:12 NYM | 96 | Room Air |
Exam:¶
General¶
Affect¶
Yes: Cooperative¶
Appearance¶
Yes: Appears Well, Alert and Oriented x 3¶
No: Appears Distressed, Appears in Pain¶
Exam Comments¶
Follow up evaluation done for inmate Epstein.¶
He does not look in any pain or distress.¶
He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happened. he insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it.¶
ASSESSMENT:¶
Injury, unspecified, T1490 - Current¶
PLAN:¶
Disposition:¶
Generated 07/24/2019 13:24 by¶
Bureau of Prisons - NYM¶
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