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 |¶
| :--- | :--- | :--- |¶
| Reg #: | 76318-054 |
| Facility: | NYM |
| Unit: | H01 |
Nursing - Triage Note encounter performed at Health Services.¶
SUBJECTIVE:¶
| LAINT 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 |
Blood Pressure:¶
| Date | Time | Value | Location | Position | Cuff Size | Provider |
|---|---|---|---|---|---|---|
| 07/28/2019 | 06:57 NYM | 138/80 | (b)(6); (b)(7)(A); (b)(7)(C) | RN |
SaO2:¶
| of the Freedom of Information and Privacy Act | ||||
| Date | Time | Value(%) | Air | 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¶
Page 1 of 3¶
EFTA00073847¶
Inmate Name: EPSTEIN, JEFFREY EDWARD¶
Date of Birth: 01/20/1953¶
Encounter Date: 07/28/2019 06:51¶
| Reg #: | 76318-054 |
| Facility: | NYM |
| Unit: | H01 |
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¶
Page 2 of 3¶