# 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 | Facility: NYM |
| Encounter Date: 07/28/2019 20:25 | Unit: H01 |

Nursing - Follow up encounter performed at Health Services.

## SUBJECTIVE:

<table border="1"><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">Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats &quot;My R hand still has pins and needles sometimes&quot; No change in appearance from previous exam.</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>20:28</td><td>81</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>20:28 NYM</td><td>14</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>RN</td></tr></tbody></table>



SaO2:


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

## 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:

To be Evaluated by Provider

Generated 07/28/2019 20:30 by

Page 1 of 2

RN

Bureau of Prisons - NYM

EFTA00110361

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

Follow-up in 12-24 Hours

Patient Education Topics:

| Date Initiated Format | Handout/Topic | Provider | Outcome |
| :--- | :--- | :--- | :--- |
| 07/28/2019 Counseling | Plan of Care | | 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.

Cosign documentation will be displayed on the following page.

Generated 07/28/2019 20:30 by

Page 2 of 2

RN

Bureau of Prisons - NYM

EFTA00110362

Bureau of Prisons
Health Services
Cosign/Review

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

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

Bureau of Prisons - NYM