EFTA00123141.pdf

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider. 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: Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral Pulse: pig lima Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular Blood Pressure: lE ate lime value Location position Cuff Size provider 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular SaO2: bate lima Valuef%). Aft 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 happed. 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: Genecaled 07/24/201913:24 by Bureau of Prisons - NYM Page 1 of 2 CONFIDENTIAL SDNY_00009410 EFTA00123141 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: Unit: H01 Follow-up at Sick Call as Needed Patient Education Topics: Pate 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 TelephoneNerbal 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 CONFIDENTIAL SDNY_00009411 EFTA00123142  Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: Facility: NYM Cosigned with New Encounter Note by on 07/24/2019 16:10. Bureau of Prisons - NYM CONFIDENTIAL SDNY_00009412 EFTA00123143