EFTA00073846

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

| Date of Birth: | 01/20/1953 |

| Encounter Date: | 07/28/2019 06:51 |

Sex:

Provider:

| M | Race: WHITE | RN |

| :--- | :--- | :--- |

<table border="1"><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>H01</td></tr></table>

Nursing - Triage Note encounter performed at Health Services.

## SUBJECTIVE:

<table><tr><td>LAINT 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></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>(b)(6); (b)(7)(A); (b)(7)(C)</td><td></td><td>RN</td></tr></tbody></table>



SaO2:


<table border="1"><tr><td colspan="5">of the Freedom of Information and Privacy Act</td></tr><tr><td>Date</td><td>Time</td><td>Value(%)</td><td>Air</td><td>Provider</td></tr><tr><td>07/28/2019</td><td>06:57 NYM</td><td>98</td><td></td><td>RN</td></tr></table>

## 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

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EFTA00073847

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Encounter Date: 07/28/2019 06:51

<table><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>H01</td></tr></table>

## Exam:

# Humerus

Yes: Within Normal Limits

Elbow

Yes: Normal Exam ■, Full Range of Motion ■, No Tendonal Palpation ■

Radius / U1na Withheld pursuant to exemption

Yes: Normal Exam □, Full Range of Motion □

# Wrist/Hand/Fingers

Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R

No: Inflammation ■, Ecchymosis ■, Erythema ■, Tenderness ■, Laceration(s) ■, Abrasion(s) ■, Contusion(s) ■



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 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 |

| :--- | :--- |

| 07/28/2019 | Counseling |

Generated 07/28/2019 07:22 by

Handout/Topic

Plan of Care



Bureau of Prisons - NYM

# Outcome

Verbalizes

Understanding

RN

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