EFTA00139017

# 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:

Provider:

M Race: WHITE MLP

<table><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>H01</td></tr></table>

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

## SUBJECTIVE:

# NJURY 1 Provider: 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 | MLP |

## Pulse:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Location</th><th>Rhythm</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30</td><td>92</td><td>Via Machine</td><td>Regular</td><td>.MLP</td></tr></tbody></table>

## Respirations:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30 NYM</td><td>16</td><td>. MLP</td></tr></tbody></table>

## Blood Pressure:



SaO2:


<table><thead><tr><th>Date</th><th>Time</th><th>Value(%)</th><th>Air</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30 NYM</td><td>96</td><td>Room Air</td><td>.MLP</td></tr></tbody></table>

## Exam:

## General

Affect

Yes: Cooperative

## Appearance

<table border="1"><tr><td>Yes: Appears Well, Alert and Oriented x 3</td></tr><tr><td>No: Appears Distressed,Lethargic,Dyspneic,Appears in Pain,Pallor,Cyanotic,Diaphoretic,Disheveled,</td></tr></table>

Generated 07/23/2019 09:05 by

MLP

EFTA00139018

### 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 MLP on 07/23/2019 09:05







<table><tr><td>Copay Required: No</td><td>Cosign Required: Yes</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td>Completed by</td><td>.MLP on 07/23/2019 09:05</td></tr><tr><td>Requested to be cosigned by</td><td>MD.</td></tr><tr><td colspan="2">Cosign documentation will be displayed on the following page.</td></tr></table>

Generated 07/23/2019 09:05 by

MLP



SDNY_00017382
Page 2 of 2


Bureau of Prisons - NYM

EFTA00139019

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/23/2019 06:20
Sex: M
Provider: MLP
Reg #: 76318-054
Race: WHITE
Facility: NYM

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

Bureau of Prisons - NYM



SDNY_00017383