EFTA00034701.pdf

Type: pdf
Source set: data-set-8
Extracted text

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: 
MLP 
Unit: 
H01 
Injury Assessment - Non-work related encounter performed at Health Services. 
SUBJECTIVE: 
INJURY 1 
Provider: 
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 
MLP 
Pulse: 
Date 
Time 
Rate Per Minute 
Location 
Rhythm 
Provider 
07/23/2019 06:30 
92 
Via Machine 
Regular 
. MLP 
Respirations: 
Date 
lime 
Rate Per Minute Provider
07/23/2019 
06:30 NYM 
16 
MLP 
Blood Pressure: 
Date 
Time 
Value 
Location 
Position 
Cuff Size 
Provider 
07/23/2019 06:30 NYM 140/85 
Right Arm 
Sitting 
Adult-regular 
MLP 
SaO2: 
Date 
Time 
Value(%) Alf 
Provider
07/23/2019 
06:30 NYM 
96 Room Air 
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 
MLP 
Bureau of Prisons - NYM 
Page 1 of 2 
CONFIDENTIAL 
SDNY_00012086 
EFTA00034701


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: 
MLP 
Unit: 
H01 
Exam: 
Acutely III 
Pulmonary 
Auscultation 
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally 
No: Crackles, Rhonchi, Wheezing …
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