U.S, Public Health Service tant ssaecur EFTA00061607

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Bureau of Prisons Health Services Clinical Encounter Inmate Name: ee Regs: Date of Birth: Sex: M_ Race: Facility: NYM Encounter Date: 9 15:01 Provider: Unit: Z05 eee 3 injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 14 Provide: Date of Injury: 08/09/2019 14:30 Date Reported for Treatment: 08/09/2019 15:01 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Be specific as to location): No injuries, Pt. is being placed on Dry cell. Medical assessment requested by the LT. Cause of Injury (Inmate's Statement of how injury occurred): "| have no injuries” Symptoms (as reported by inmate): “Tt have no injuries” OBJECTIVE: Pulse: Date Iime Rate Per Minute Location Bhythm Provider 08/09/2019 15:00 64 Via Machine fF Blood Pressure: Date Time Value Location Position CuffSize Provider 08/09/2019 15:00NYM 130/74 Left Arm Sitting Adult-reguiar $a02: Date Time Value(%) Air Provider 08/09/2019 15:00 NYM 99 Room Air Po Exam Comments Injury- Neg objective findings. FACE: no erythema, no edema, no opening into skin, no abrasions, no laceration, no ecchymosis, non tender to palpation, no signs of acute trauma, old healing ecchymosis on the right periorbital area noted from zygomatic fx. TORSO (front and back) no erythema, no edema, no laceration, no ecchymosis, ni, rom, non tender to palpation UPPER EXT: no erythema, no edema, no opening into skin, no abrasions, no laceration, no ecchymosis, no signs of acute trauma, no bony deformity noted, non tender to palpation LOWER EXT; no erythema, no edema, no opening into skin, no abrasions, no laceration, no ecchymosis, no signs of acute trauma, no bony deformity noted, non tender to palpation Mouth/inner Mucosa, no abrasions, no lacerations, no edema, no bleeding gums or loose teeth noted Generated 08/09/2019 15:09 by [A Bureau of Prisons - NYM Page 1 of 2 EFTA00061608

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Inmate Name: Reg #: Date of Birth: Sex: 4 Facility: NYM Encounter Date: 0 2019 15:01 Provider: Unit 205 ASSESSMENT: Constipation, unspecified, K5900 - Current Unspecified place or not applicable of injury/occurrence, Y929 - Current PLAN: New Medication Orders: Ret Medication Order Date Prescriber Order Docusate Sodium Capsule 08/09/2019 15:01 100mg Orally - daily x 10 day(s) — 1 refill Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Return Immediately if Condition Worsens Other: Neg subjective and objective findings. pt. states he is constipated and he goes <3x/week. will rx laxative. Patient Education Topics: Date Initiated Format Handout/Topic Outcome 08/09/2019 Counseling Access to Care Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by EEE on 08/09/2019 15:09 Requested to be cosigned by Casign documentation will be displayed on the following page. Generated 08/09/2019 15:09 by [A Bureau of Prisons - NYM Page 2 of 2 EFTA00061609