| Inmate Name: Date of Birth: Encounter Date: 07/28/2019 20:25 | EPSTEIN, JEFFREY EDWARD 01/20/1953 | M Sex: Provider: | Race: WHITE | Reg #: RN Unit: | 76318-054 Facility: NYM H01 | |||
|---|---|---|---|---|---|---|---|---|
| Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: | ||||||||
| COMPLAINT 1 Subjective: Pain: | Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) No | Provider: | appearance from previous exam. | RN | Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats ” My R hand still has pins and needles sometimes’ No change in | |||
| OBJECTIVE: | ||||||||
| Pulse: | ||||||||
| Qata 07/28/2019 20:28 | Time | Rate Per Minute 81 | j•ocation | Rhythm | Provider | RN | ||
| Respirations: | ||||||||
| Rate 07/28/2019 | Time | 20:28 NYM | Rate Per Minute, provider 14 | RN | ||||
| Blood Pressure: | ||||||||
| Data | lima 07/28/2019 20:28 NYM | Value 157/91 | iscation | position | Cuff Size | Provider | RN | |
| SaO2: | ||||||||
| Dale 07/28/2019 | lime 20:28 NYM | Valuef%), ALE 98 | Provider | RN | ||||
| Exam: General Affect | Yes: Cooperative | |||||||
| Appearance | ||||||||
| Yes: Appears Well, Alert and Oriented x 3 | ||||||||
| Nutrition | Yes: Within Normal Limits | |||||||
| Skin General | Yes: Within Normal Limits, Dry, Skin Intact | |||||||
| ASSESSMENT: | ||||||||
| No Significant Findings/No Apparent Distress | ||||||||
| PLAN: | ||||||||
| Disposition: Generated 07/2812019 20:30 by | To be Evaluated by Provider | RN | Bureau of Prisons - NYM | Page 1 of 2 |
CONFIDENTIAL SDNY_00009398¶
| EPSTEIN, JEFFREY EDWARD Inmate Name: Date of Birth: 01/20/1953 Encounter Date: 07/28/2019 20:25 | M Sex: Provider: | Race: WHITE RN | Reg #: 76318-054 Facility: NYM Unit: H01 | |
|---|---|---|---|---|
| Follow-up in 12-24 Hours | ||||
| Patient Education Topics: | ||||
| format Pate Initiated | Handout/Took | Provider | Outcome | |
| Counseling 07/28/2019 | Plan of Care | Verbalizes Understanding | ||
| Copay Required: No | Cosign Required: Yes | |||
| TelephoneNerbal Order: No | ||||
| Completed by | RN on 07/28/2019 20:30 | |||
| Requested to be cosigned by | MD. |
Cosign documentation will be displayed on the following page.¶
Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM¶
Page 2 of 2¶
CONFIDENTIAL SDNY_00009399 EFTA00033805¶
Bureau of Prisons Health Services Cosign/Review¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD | Reg #: | 76318-054 | |||
|---|---|---|---|---|---|---|
| Date of Birth: | 01/20/1953 | Sex: | M | Race: | WHITE | |
| Encounter Dale: 07/28/2019 20:25 | Provider: | RN | Facility: | NYM |
Cosigned by MD on 07/28/2019 20:50.¶
Bureau of Prisons • NYM¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD | Reg #: | 76318-054 | |||
|---|---|---|---|---|---|---|
| Date of Birth: | 01/20/1953 | Sex: | M | Race: WHITE | Facility: NYM | |
| Encounter Date: 07/28/2019 06:51 | Provider: | RN | Unit: | H01 | ||
| Nursing - Triage Note encounter performed at Health Services. | ||||||
| SUBJECTIVE: | ||||||
| COMPLAINT 1 | Provider: | RN | ||||
| Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) | ||||||
| Subjective: | I woke up and I had no control over my Right arm for a few minutes it was just doing what it | |||||
| Pain: | wanted to do’ No | |||||
| OBJECTIVE: | ||||||
| Pulse: | ||||||
| QM& | Time | Rate Per Minute | j.ocatioo | Rhythm | provider | |
| 07/28/2019 06:57 | 82 | RN | ||||
| Respirations: | ||||||
| Qat | lima | Rate Per Minute Provider | ||||
| 07/28/2019 | 06:57 NYM | 14 | RN | |||
| Blood Pressure: | ||||||
| git~ | Time Value | Location | Position | Cuff Size | Provider | |
| 07/28/2019 06:57 NYM 138/80 | RN | |||||
| SaO2: | ||||||
| Dais | Time | vaiueem Am | Provider | |||
| 07/28/2019 | 06:57 NYM | 98 | RN | |||
| Exam: | ||||||
| General | ||||||
| Affect | ||||||
| Yes: Cooperative | ||||||
| Appearance | ||||||
| Yes: Appears Well, Alert and Oriented x 3 | ||||||
| Skin | ||||||
| General | Yes: Within Normal Limits, Dry, Skin Intact | |||||
| Head | ||||||
| General | ||||||
| Yes: Symmetry of Motor Function, Atraumatic/Normocephalic | ||||||
| No: Facial Asymmetry, Battle’s Sign, Raccoon Eyes, Deformity | ||||||
| Eyes | ||||||
| General | ||||||
| Yes: PERRLA, Extraocular Movements Intact | ||||||
| Face | ||||||
| General | Yes: Symmetric | |||||
| Generaled 07/2/M2019 07:22 by | RN | Bureau of Prisons - NYM | Page tol3 | |||
CONFIDENTIAL SDNY_00009401¶
Exam:¶
No: Ecchymosis, Numbness, Swelling, Periorbital Edema¶
Neck¶
General¶
Yes: Abrasion(s)¶
Pulmonary¶
Observation/Inspection¶
Yes: Within Normal Limits¶
No: Respiratory Distress, Tachypnea, Hyperventilation¶
Cardiovascular¶
Observation¶
Yes: Normal Rate¶
Musculoskeletal¶
Shoulder¶
Yes: Full Range of Motion R, Symmetric R¶
No: Swelling R, Inflammation R¶
Humerus¶
Yes: Within Normal Limits R¶
Elbow¶
Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R¶
Radius / Ulna¶
Yes: Normal Exam R, Full Range of Motion R¶
Wrist/Hand/Fingers¶
Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R¶
No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) R, Contusion(s) R¶
ROS Comments.¶
Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently C/O Right arm numbness after waking up from “sleeping on my side” that has since subsided. inmate interviewed in psyc obs through the slot. V/S noted WNL, RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or dysphagia, Inmate with Full ROM to all extremities with 4/4 strength bilaterally, slight swelling noted to right phalanges when compared to left, no edema, erythema or ecchymosis noted. Denies any pain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes PERRLA. MD on Call notified, Re-evaluate this evening or sooner if S/S persist.¶
ASSESSMENT:¶
Alteration in comfort¶
PLAN:¶
Disposition:¶
Follow-up at Sick Call as Needed Notify Medical Duty Officer¶
Patient Education Topics:¶
Pate Initiated Format Handout/Tonic 07/28/2019 Counseling Plan of Care¶
Outcome Verbalizes Understanding¶
Page 2 of 3¶
CONFIDENTIAL SDNY_00009402¶
| EPSTEIN, JEFFREY EDWARD Inmate Name: 01/20/1953 Date of Birth: Encounter Date: 07/28/2019 06:51 | Sex: Provider: | ilm lif i | NHITE RN | Reg #: Facility: NYM Unit: | 76318.054 H01 | |
|---|---|---|---|---|---|---|
| pate Initiated Format | Handout/Topic | Provider | Outcome | |||
| Copay Required: No | Cosign Required: Yes | |||||
| TelephoneNerbal Order: No | ||||||
| Completed by | RN on 07/28/2019 07:22 | |||||
| Requested to be cosigned by | MD. | |||||
Cosign documentation will be displayed on the following page.¶
Generated 07/28/2019 07:22 by Columbo Joseph RN Bureau of Prisons - NYM Page 3 of 3¶
CONFIDENTIAL SDNY_00009403¶
Bureau of Prisons Health Services Cosign/Review¶
| Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: M 01/20/1953 Sex: Encounter Date: 07/28/2019 06:51 Provider: | Reg #: 76318-054 WHITE Race: RN Facility: NYM |
|---|---|
| --------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------- |
Cosigned by MD on 07/28/2019 20:51.¶
Bureau of Prisons • NYM¶
| Inmate Name: Date of Birth: Note Date: | EPSTEIN, JEFFREY EDWARD 01/20/1953 07/26/2019 08:57 | Sex: Provider: | 1.101. | MD | Reg #: Facility: Unit: | 76318-054 NYM H01 | ||
|---|---|---|---|---|---|---|---|---|
| Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. | ||||||||
| Administrative Notes: THE | ADMINISTRATIVE NOTE 1 | Provider: | MD | NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM | ||||
| 2 NI | AGO. | |||||||
| New Medication Orders: | ||||||||
| RisE | Medication | Order Date | Prescriber Order | |||||
| Docusate Sodium Capsule | 07/26/2019 08:57 | TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) | ||||||
| Indication: Constipation, unspecified | ||||||||
| Copay Required: No | Cosign Required: No | |||||||
| TelephoneNerbal Order No | ||||||||
| Completed by | MD on 07/26/2019 08:58 |
Generated 0726/2019 08.58 by¶
CONFIDENTIAL SDNY_00009405¶