# 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: 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

SDNY 00008777
EFTA00033905

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 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 - FUO self inflictedinjuries.

## 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<br />Understanding |
| 07/23/2019       | Counseling | Plan of Care    | Joaquin, Y. | Verbalizes<br />Understanding |

| Copay Required: No                                            |                                                               | Cosign Required: Yes                                          |
|-|-|-|
| TelephoneNerbal Order:                                        | No                                                            |                                                               |
| Completed by Joaquin, Y. MLP on 07/23/2019 09:05              | Completed by Joaquin, Y. MLP on 07/23/2019 09:05              | 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. | Cosign documentation will be displayed on the following page. | 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
EFTA00033906