# Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
Encounter Date: 07/23/2019 06:20

Sex: M Race: WHITE
Provider: Joaquin, Y. MLP

Reg #: 76318-054
Facility: NYM
Unit: H01

Injury Assessment - Non-work related encounter performed at Health Services.

SUBJECTIVE:

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

<table><tr><th>INJURY</th><th colspan="5">1 Provider: Joaquin, Y. MLP</th></tr><tr><td>Date of</td><td>Injury:</td><td>07/23/2019 01:27</td><td></td><td>Date Reported for Treatment:</td><td>07/23/2019 08:25</td></tr><tr><td>Work</td><td>Related:</td><td>No</td><td>Work</td><td>Assignment: UNASSG</td><td></td></tr><tr><td>Pain</td><td>Location:</td><td></td><td></td><td></td><td></td></tr><tr><td>Pain</td><td>Scale: 0</td><td></td><td></td><td></td><td></td></tr><tr><td>Pain</td><td>Qualities:</td><td></td><td></td><td></td><td></td></tr><tr><td>Where</td><td>Did Injury</td><td>Happen (Be specific</td><td>as to</td><td>location):</td><td></td></tr><tr><td colspan="6">Special Housing Unit Z05-Cell 124 L</td></tr><tr><td>Cause</td><td>of Injury</td><td>(Inmate's Statement</td><td>of how</td><td>injury occurred):</td><td></td></tr><tr><td>"I</td><td>do not know.</td><td>Just went to drink</td><td>a little water</td><td>and wake up snorting".</td><td></td></tr><tr><td>Symptoms</td><td>(as</td><td>reported by inmate):</td><td></td><td></td><td></td></tr><tr><td>None</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>OBJECTIVE:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Temperature:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Fahrenheit</td><td>Celsius</td><td>Location Provider</td><td></td></tr><tr><td>07/23/2019</td><td>06:30 NYM</td><td>97.5</td><td>36.4</td><td>Oral Joaquin, Y.</td><td>MLP</td></tr><tr><td>Pulse:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td colspan="2">Rate Per Minute Location</td><td>Rhythm</td><td>Provider</td></tr><tr><td>07/23/2019</td><td>06:30</td><td></td><td>92 Via</td><td>Machine Regular</td><td>Joaquin, Y. MLP</td></tr><tr><td>Respirations:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Rate</td><td>Per Minute</td><td>Provider</td><td></td></tr><tr><td>07/23/2019</td><td>06:30</td><td>NYM</td><td>16</td><td>Joaquin, Y. MLP</td><td></td></tr><tr><td>Blood Pressure:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Value</td><td>Location</td><td>Position Cuff Size</td><td>Provider</td></tr><tr><td>07/23/2019</td><td>06:30 NYM</td><td>140/85 Right</td><td>Arm</td><td>Sitting Adult-regular</td><td>Joaquin, Y. MLP</td></tr><tr><td>SaO2:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Value(%)</td><td>Air</td><td>Provider</td><td></td></tr><tr><td>07/23/2019</td><td>06:30 NYM</td><td>96</td><td>Room Air</td><td>Joaquin, Y. MLP</td><td></td></tr><tr><td>Exam:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>General</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Affect</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes:</td><td>Cooperative</td><td></td><td></td><td></td><td></td></tr><tr><td>Appearance</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Yes: Appears Well, Alert and Oriented x 3</td></tr><tr><td>No:</td><td colspan="5">Appears Distressed, Lethargic, Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled,</td></tr></table>

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

Generated 07/23/2019 09:05 by Joaquin, Y. MLP

Bureau of Prisons - NYM

Page 1 of 2

CONFIDENTIAL

SDNY 00008777
EFTA00034713

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth:
Encounter Date: 07/23/2019 06:20

Sex: M Race: WHITE
Provider: Joaquin, Y. MLP

Reg #: 76318-054
Facility: NYM
Unit: H01

Exam:

Acutely III

Pulmonary

Auscultation
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally
No: Crackles, Rhonchi, Wheezing

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

## 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:

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

## 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:

<table><tr><th>Date Initiated Format</th><th></th><th>Handout/Topic</th><th>Provider</th><th>Outcome</th></tr><tr><td>07/23/2019 Counseling</td><td></td><td>Access to Care</td><td>Joaquin, Y.</td><td>Verbalizes
Understanding</td></tr><tr><td>07/23/2019 Counseling</td><td></td><td>Plan of Care</td><td>Joaquin, Y.</td><td>Verbalizes
Understanding</td></tr><tr><td>Copay Required: No</td><td></td><td>Cosign Required: Yes</td><td></td><td></td></tr><tr><td>Telephone/Verbal Order: No</td><td></td><td></td><td></td><td></td></tr><tr><td>Completed by Joaquin, Y. MLP</td><td>on</td><td>07/23/2019 09:05</td><td></td><td></td></tr><tr><td colspan="3">Requested to be cosigned by Beaudouin, Robert MD.</td><td></td><td></td></tr><tr><td colspan="3">Cosign documentation will be displayed on the following page.</td><td></td><td></td></tr></table>

Generated 07/23/2019 09:05 by Joaquin, Y. MLP

Bureau of Prisons - NYM

Page 2 of 2

CONFIDENTIAL

SDNY 00008778
EFTA00034714