EFTA00134749

# 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 | Provider: | Facility: NYM |
| Encounter Date: 07/24/2019 13:08 | | Unit: H01 |

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

<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:

<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>

<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>07/24/2019</td><td>13:12</td><td>83</td><td>Via Machine</td><td>Regular</td><td></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>07/24/2019</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>

<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>

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



SDNY_00001006


EFTA_00000215

EFTA00134750

<table><thead><tr><th colspan="5">Follow-up at Sick Call as Needed</th></tr></thead><tbody><tr><td colspan="5">Patient Education Topics:</td></tr><tr><td>Date Initiated</td><td>Format</td><td>Handout/Topic</td><td>Provider</td><td>Outcome</td></tr><tr><td>07/24/2019</td><td>Counseling</td><td>Access to Care</td><td></td><td>Verbalizes Understanding</td></tr><tr><td>07/24/2019</td><td>Counseling</td><td>Preventive Health</td><td></td><td>Verbalizes Understanding</td></tr><tr><td colspan="5">Copay Required: No Cosign Required: Yes</td></tr><tr><td colspan="5">Telephone/Verbal Order: No</td></tr><tr><td colspan="5">Completed by on 07/24/2019 13:24</td></tr><tr><td colspan="5">Requested to be cosigned by .</td></tr><tr><td colspan="5">Cosign documentation will be displayed on the following page.</td></tr></tbody></table>

Generated 07/24/2019 13:24 by

Bureau of Prisons - NYM

Page 2 of 2



SDNY_00001007


EFTA_00000216

EFTA00134751

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Sex: M
Provider: NYM

Reg #: 76318-064
Race: WHITE
Facility: NYM

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

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
Provider: H01

Injury Assessment - Non-work related encounter performed at Health Services.

SUBJECTIVE:

INJURY 1 Provider:
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 snoring".
Symptoms (as reported by inmate):
None

OBJECTIVE:

Temperature:
Date 07/23/2019 08:30 NYM
Time 97.5
Fahrenheit 36.4
Celsius 14.4
Location Oral
Provider

Pulse:
Date 07/23/2019 08:30
Time 92
Rate Per Minute Via Machine
Location Rhythm Regular
Provider

Respirations:
Date 07/23/2019 08:30 NYM
Time 16
Rate Per Minute Provider

Blood Pressure:
Date 07/23/2019 08:30 NYM
Time 140/65
Value Location Right Arm Sitting
Cuff Size Adult-regular
Provider

SaO2:
Date 07/23/2019 08:30 NYM
Value(%) Air
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 08:05 by Bureau of Prisons - NYM

SDNY_00001009
EFTA_000002

EFTA00134753

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/23/2019 08:20
Provider:

Exam:
Acutely ill

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 - R/O 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
Telephone/Verbal Order: No
Completed by on 07/23/2019 09:05
Requested to be cosigned by
Cosign documentation will be displayed on the following page.

EFTA00134754

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Sex: M
Encounter Date: 07/23/2019 08:20
Provider: NYM

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

Cosigned by on 07/23/2019 15:44.

Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1983
Encounter Date: 07/14/2019 17:36
Provider: Z05

Chronic Care - 14 Day Physician Eval encounter performed at Health Services.

SUBJECTIVE:

COMPLAINT 1 Provider:

Chief Complaint: ENDO/LIPID
Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDE MIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800, NOW 431. STATES HE COULD NOT TOLERATE OTHER ANT-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS.
HX OF OBSTRUCTIVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD MY CPAP MACHINE WITH HIM WHEN HE ARRESTED.
STATES THE FBI LONELY HAS
L4 + L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES.
SURGICAL HX: NONE
MENTAL HEALTH HX: NONE

Pain Assessment
Date: 07/12/2019 13:25
Location: Back-Middle
Quality of Pain: Shooting
Pain Scale: 5
Intervention: MEDROL DOSE PACK

Trauma Date/Year:
Injury:
Mechanism:
Onset: 5+ Years
Duration: 5+ Years
Exacerbating Factors: NO EXERCISE
Relieving Factors: MEDROL DOSE PACK
Reason Not Done:
Comments:

Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid
Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid

OBJECTIVE:

Exam:
General

Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed, Dysnecic, Appears In Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely ill

Nutrition
No: Appears Obese

Generated 07/14/2019 18:11 by Bureau of Prisons - NYM

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