EFTA00059498


# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Provider: RN | Facility: NYM |
| Encounter Date: 07/28/2019 20:25 | | Unit: H01 |

Nursing - Follow up encounter performed at Health Services.

<table><thead><tr><th colspan="7">Pulse:</th></tr><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Location</th><th>Rhythm</th><th>Provider</th><th></th></tr></thead><tbody><tr><td>07/28/2019</td><td>20:28</td><td>81</td><td></td><td></td><td></td><td>RN</td></tr></tbody></table>

<table><thead><tr><th colspan="5">Respirations:</th></tr><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Provider</th><th></th></tr></thead><tbody><tr><td>07/28/2019</td><td>20:28 NYM</td><td>14</td><td></td><td>RN</td></tr></tbody></table>

<table><thead><tr><th>Date</th><th>Time</th><th>Value</th><th>Location</th><th>Position</th><th>Cuff Size</th><th>Provider</th></tr></thead><tbody><tr><td>07/28/2019</td><td>20:28 NYM</td><td>157/91</td><td></td><td></td><td></td><td></td></tr></tbody></table>

<table><thead><tr><th>Date</th><th>Time</th><th>Value(%)</th><th>Air</th><th>Provider</th></tr></thead><tbody><tr><td>07/28/2019</td><td>20:28 NYM</td><td>98</td><td></td><td>RN</td></tr></tbody></table>

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:

To be Evaluated by Provider

Generated 07/28/2019 20:30 by RN

Bureau of Prisons - NYM

Page 1 of 2



EFTA00059499


Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/28/2019 20:25

Follow-up in 12-24 Hours

Patient Education Topics:
Date Initiated Format: Counseling
Handout/Topic: Plan of Care
Provider: H01
Outcome: Verbalizes Understanding

Copay Required: No
Cosign Required: Yes

Telephone/Verbal 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.

EFTA00059500

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Sex: M
Provider: RN
Reg #: 76019-054
Race: WHITE
Facility: NYM

Cosigned by MD on 07/28/2019 20:50.

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Provider: RN | Facility: NYM |
| Encounter Date: 07/28/2019 06:51 | | Unit: H01 |

Nursing - Triage Note encounter performed at Health Services.

## SUBJECTIVE:

<table><tr><td>COMPLAINT 1</td><td>Provider:</td><td>RN</td></tr><tr><td colspan="3">Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies)</td></tr><tr><td>Subjective:</td><td colspan="2">&quot;I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do&quot;</td></tr><tr><td>Pain:</td><td colspan="2">No</td></tr></table>

## OBJECTIVE:

## Pulse:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Location</th><th>Rhythm</th><th>Provider</th></tr></thead><tbody><tr><td>07/28/2019</td><td>06:57</td><td>82</td><td></td><td></td><td>RN</td></tr></tbody></table>

## Respirations:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Provider</th></tr></thead><tbody><tr><td>07/28/2019</td><td>06:57 NYM</td><td>14</td><td>RN</td></tr></tbody></table>

## Blood Pressure:

<table><thead><tr><th>Date</th><th>Time</th><th>Value</th><th>Location</th><th>Position</th><th>Cuff Size</th><th>Provider</th></tr></thead><tbody><tr><td>07/28/2019</td><td>06:57 NYM</td><td>138/80</td><td></td><td></td><td></td><td></td></tr></tbody></table>



SaO2:


## 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

Generated 07/28/2019 07:22 by RN

Bureau of Prisons - NYM

Page 1 of 3

EFTA00059502

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/28/2019 08:51

Exam:
No: Echymosis, Numbness, Swelling, Perforbital 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: Infractionation R, Echymosis 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 pajo obs through the slot. V/S noted WNL, RR even and unilabored, no neurological deficits noted, no facial droop sturred 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 echymosis 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:

Date Initiated Format
Counseling
07/28/2019

Handout/Topic
Plan of Care

Provider

Outcome
Verbalizes
Understands

Generated 07/28/2019 07:22 by RN
Bureau of Prisons - NYM

EFTA00059503

| Date Initiated Format | Handout/Topic | Provider | Outcome |
| :--- | :--- | :--- | :--- |
| Copay Required: No | Cosign Required: Yes | | |
| Telephone/Verbal 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 RN Bureau of Prisons - NYM