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.¶
| 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:¶
| 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 | |
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 07/24/2019 | 13:12 NYM | 132/89 | Right Arm | Sitting | Adult-regular |
| Date | Time | Value(%) | Air | Provider |
|---|---|---|---|---|
| 07/24/2019 | 13:12 NYM | 96 | Room Air |
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¶
Page 1 of 2¶
SDNY_00001006¶
EFTA_00000215¶
EFTA00134750¶
| 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¶
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¶
| EFTA_00000221 |¶
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