EFTA00033588.pdf

Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054
Date of Birth: [REDACTED] Sex: M Race: WHITE Facility: NYM
Encounter Date: 07/23/2019 06:20 Provider: Joaquin, Y. MLP Unit: H01

Injury Assessment - Non-work related encounter performed at Health Services.
SUBJECTIVE:
INJURY 1 Provider: Joaquin, Y. 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 Joaquin, Y. MLP
Pulse:
Date Time Rate Per Minute Location Rhythm Provider
07/23/2019 06:30 92 Via Machine Regular Joaquin, Y. MLP
Respirations:
Date Time Rate Per Minute Provider
07/23/2019 06:30 NYM 16 Joaquin, Y. MLP
Blood Pressure:
Date Time Value Location Position Cuff Size Provider
07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular Joaquin, Y. MLP
SaO2:
Date Time Value(%) Air Provider
07/23/2019 06:30 NYM 96 Room Air Joaquin, Y. 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 07/23/2019 09:05 by Joaquin, Y. MLP Bureau of Prisons - NYM Page 1 of 2
CONFIDENTIAL
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Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054
Date of Birth: [REDACTED] Sex: M Race: WHITE Facility: NYM
Encounter Date: 07/23/2019 06:20 Provider: Joaquin, Y. MLP Unit: H01
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 Joaquin, Y. Verbalizes Understanding
07/23/2019 Counseling Plan of Care Joaquin, Y. Verbalizes Understanding

Copay Required: No Cosign Required: Yes
Telephone/Verbal Order: No
Completed by Joaquin, Y. MLP on 07/23/2019 09:05
Requested to be cosigned by Beaudouin, Robert MD.
Cosign documentation will be displayed on the following page.
Generated 07/23/2019 09:05 by Joaquin, Y. MLP Bureau of Prisons - NYM Page 2 of 2
CONFIDENTIAL
SDNY_00008778
EFTA00033589