Bureau of Prisons

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: 07/23/2019 06:20 Provider: Unit: 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: Work Related: Pain Location: No Work Assignment: UNASSG 07/23/2019 08:25 Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Be specific as to location): Special Housing Unit 205-Cell 124 L "I do not know. Just went to drink a little water and wake up snorting". 6)), Cause of Injury (Inmate's Statement of how injury occurred): Symptoms (as reported by inmate): None OBJECTIVE: Temperature: Data Time Fahrenheit Celsius Location 07/23/2019 06:30 NYM 97.5 36.4 Oral Provider Pulse: Dais Time Rate Per Minute Location Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular Respirations: Data Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 Blood Pressure: Data. Time Value Location position Cuff Size provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular SaO2: Date Time Value%) AIL Provider 07/23/2019 06:30 NYM 96 Room Air 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 09:05 by Bureau of Prisons - NYM Page 1 of 2 SONY 00001039 EFTA_00000248 EFTA00134783 SDNY_00001040 EFTA_00000249 EFTA00134784 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: Unit: H01 Exam: Acutely Ill 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: 1 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 stall 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 RandoutfTopic 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 on 07/23/2019 09:05 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 07/2312019 09:05 by Bureau of Prisons • NYM Page 2 of 2 SDNY_00001041 EFTA_00000250 EFTA00134785