EFTA00135004.pdf

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: MLP Unit: H01 Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 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 205-Cell 124 L Cause of Injury (Inmate's Statement of how injury occurred): CCO t "I do not know. Just went to drink a little water and wake up snorting". /lel Symptoms (as reported by inmate): 4 1 CP None OBJECTIVE: Temperature: Data Time Fahrenheit Celsius Location Provider 07/23/2019 06:30 NYM 97.5 36.4 Oral MLP Pulse: Date Time sate Per Minute Location Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular MLP Respirations: Date Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 MLP Blood Pressure: Delft Time Value Location Position Cuff Size Provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular MLP SaO2: Date Time Valuer/ol AIL Provider 07/23/2019 06:30 NYM 96 Room Air MLP 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 072312019 09:05 by MLP Bureau of Prisons - NYM Page 1 of 2 SONY 00006507 EFTA_00000592 EFTA00135004 SDNY_00006508 EFTA_00000593 EFTA00135005 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: MLP Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comment% 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 Handoutfropic 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 TelephoneNerbal Order: No Completed by MLP on 07/23/2019 09:05 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/2312019 09:05 by MLP Bureau of Prisons • NYM Page 2 of 2 SON Y_00006509 EFTA_00000594 EFTA00135006