# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Facility: NYM |
| Encounter Date: 07/24/2019 13:08 | Unit: H01 |

Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge.

## SUBJECTIVE:

<table><tr><td>COMPLAINT 1</td><td>Provider:</td></tr><tr><td colspan="2">Chief Complaint: Other Problem</td></tr><tr><td>Subjective:</td><td>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.</td></tr><tr><td>Pain:</td><td>No</td></tr></table>

## OBJECTIVE:

## Temperature:

<table><thead><tr><th>Date</th><th>Time</th><th>Fahrenheit</th><th>Celsius</th><th>Location</th><th>Provider</th></tr></thead><tbody><tr><td>07/24/2019</td><td>13:12 NYM</td><td>97.8</td><td>36.6</td><td>Oral</td><td></td></tr></tbody></table>

## Pulse:

<table border="1"><tr><td>Date</td><td>Time</td><td>Rate Per Minute</td><td>Location</td><td>Rhythm</td><td>Provider</td></tr><tr><td>07/24/2019</td><td>13:12</td><td>83</td><td>Via Machine</td><td>Regular</td><td></td></tr></table>

## Blood Pressure:

<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>07/24/2019</td><td>13:12 NYM</td><td>132/89</td><td>Right Arm</td><td>Sitting</td><td>Adult-regular</td><td></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>07/24/2019</td><td>13:12 NYM</td><td>96</td><td>Room Air</td><td></td></tr></tbody></table>

## Exam:

## General

Affect

Yes: Cooperative

<table><tr><td>Appearance</td></tr><tr><td>Yes: Appears Well, Alert and Oriented x 3</td></tr><tr><td>No: Appears Distressed, Appears in Pain</td></tr></table>

## 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

Page 1 of 2

CONFIDENTIAL



SDNY_00009410
EFTA00123141


| Inmate Name: EPSTEIN, JEFFREY EDWARD | Date of Birth: 01/20/1953 | Sex: M | Race: WHITE | Reg #: 76318-054 | Facility: NYM |
| :--- | :--- | :--- | :--- | :--- | :--- |
| Encounter Date: 07/24/2019 13:08 | Provider: | | | Unit: H01 | |

Follow-up at Sick Call as Needed

Patient Education Topics:

| Date Initiated | Format | Handout/Topic | Provider | Outcome |
| :--- | :--- | :--- | :--- | :--- |
| 07/24/2019 | Counseling | Access to Care | | Verbalizes Understanding |
| 07/24/2019 | Counseling | Preventive Health | | Verbalizes Understanding |

Copay Required: No Cosign Required: Yes

Telephone/Verbal Order: No

Completed by on 07/24/2019 13:24

Requested to be cosigned by

Cosign documentation will be displayed on the following page.

Generated 07/24/2019 13:24 by

Page 2 of 2

Bureau of Prisons - NYM

CONFIDENTIAL



SDNY_00009411
EFTA00123142


Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/24/2019 13:08
Sex: M
Provider:

Reg #: 76318-054
Race: WHITE
Facility: NYM

Cosigned with New Encounter Note by on 07/24/2019 16:10.

Bureau of Prisons - NYM

CONFIDENTIAL



SDNY_00009412
EFTA00123143