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.¶
| Pulse: | ||||||
|---|---|---|---|---|---|---|
| Date | Time | Rate Per Minute | Location | Rhythm | Provider | |
| 07/28/2019 | 20:28 | 81 | RN | |||
| Respirations: | ||||
|---|---|---|---|---|
| Date | Time | Rate Per Minute | Provider | |
| 07/28/2019 | 20:28 NYM | 14 | RN | |
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 07/28/2019 | 20:28 NYM | 157/91 |
| Date | Time | Value(%) | Air | Provider |
|---|---|---|---|---|
| 07/28/2019 | 20:28 NYM | 98 | RN |
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:¶
| 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 wanted to do" | |
| Pain: | No | |
OBJECTIVE:¶
Pulse:¶
| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
|---|---|---|---|---|---|
| 07/28/2019 | 06:57 | 82 | RN |
Respirations:¶
| Date | Time | Rate Per Minute | Provider |
|---|---|---|---|
| 07/28/2019 | 06:57 NYM | 14 | RN |
Blood Pressure:¶
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 07/28/2019 | 06:57 NYM | 138/80 |
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¶