EFTA00058507.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. MLP Unit: H01 Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: MLP Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room male had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Data Time Fahrenheit Celsius .Locatiort Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral MLP Pulse: Data lima Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular MLP Blood Pressure: Date Time Value Location position Cuff Size provider 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular . MLP SaO2: Data lima Valuef%). Aft provider 07/24/2019 13:12 NYM 96 Room Air MLP 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: Generated 07/24/201913:24 by MLP Bureau of Prisons • NYM Page 1 of 2 CONFIDENTIAL SDNY_00009410 EFTA00058507 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: MLP 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 MLP on 07/24/2019 13:24 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/24/2019 13:24 by MLP Bureau of Prisons • NYM Page 2 of 2 CONFIDENTIAL SDNY_00009411 EFTA00058508  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: MLP Facility: NYM Cosigned with New Encounter Note by MD on 07/24/2019 16:10. &mmmoHNisorm-NYM CONFIDENTIAL SDNY_00009412 EFTA00058509