EFTA00110363

# 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 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>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>06:57 NYM</td><td>98</td><td></td></tr></tbody></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

**General**

Yes: PERRLA, Extraocular Movements Intact

## Eyes

## Face

General

Yes: Symmetric

Generated 07/28/2019 07:22 by

Page 1 of 3

Bureau of Prisons - NYM

EFTA00110364

<table><thead><tr><th>Inmate Name:</th><td>EPSTEIN, JEFFREY EDWARD</td><th></th><th>Reg #:</th><td>76318-054</th></tr></thead><tbody><tr><td>Date of Birth:</td><td>01/20/1953</td><td>Sex:</td><td>M</td><td>Race: WHITE</td></tr><tr><td>Encounter Date:</td><td>07/28/2019 06:51</td><td>Provider:</td><td colspan="2">RN</td></tr><tr><td colspan="5">Exam:</td></tr><tr><td colspan="5">No: Ecchymosis, Numbness, Swelling, Periorbital Edema</td></tr><tr><td colspan="5">Neck</td></tr><tr><td colspan="5">General</td></tr><tr><td colspan="5">Yes: Abrasion(s)</td></tr><tr><td colspan="5">Pulmonary</td></tr><tr><td colspan="5">Observation/Inspection</td></tr><tr><td colspan="5">Yes: Within Normal Limits</td></tr><tr><td colspan="5">No: Respiratory Distress, Tachypnea, Hyperventilation</td></tr><tr><td colspan="5">Cardiovascular</td></tr><tr><td colspan="5">Observation</td></tr><tr><td colspan="5">Yes: Normal Rate</td></tr><tr><td colspan="5">Musculoskeletal</td></tr><tr><td colspan="5">Shoulder</td></tr><tr><td colspan="5">Yes: Full Range of Motion R, Symmetric R</td></tr><tr><td colspan="5">No: Swelling R, Inflammation R</td></tr><tr><td colspan="5">Humerus</td></tr><tr><td colspan="5">Yes: Within Normal Limits R</td></tr><tr><td colspan="5">Elbow</td></tr><tr><td colspan="5">Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R</td></tr><tr><td colspan="5">Radius / Ulna</td></tr><tr><td colspan="5">Yes: Normal Exam R, Full Range of Motion R</td></tr><tr><td colspan="5">Wrist/Hand/Fingers</td></tr><tr><td colspan="5">Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R</td></tr><tr><td colspan="5">No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) R, Contusion(s) R</td></tr></tbody></table>



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 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:

<table><thead><tr><th>Date Initiated</th><th>Format</th></tr></thead><tbody><tr><td>07/28/2019</td><td>Counseling</td></tr></tbody></table>

Handout/Topic

Plan of Care

Generated 07/28/2019 07:22 by

Bureau of Prisons - NYM

# Outcome

Verbalizes

Understanding

Page 2 of 3

EFTA00110365

<table><thead><tr><th>Inmate Name: EPSTEIN, JEFFREY EDWARD</th><th></th><th></th><th></th><th>Reg #: 76318-054</th><th></th></tr></thead><tbody><tr><td>Date of Birth: 01/20/1953</td><td>Sex: M</td><td>Race: WHITE</td><td></td><td>Facility: NYM</td><td></td></tr><tr><td>Encounter Date: 07/28/2019 06:51</td><td colspan="2">Provider:</td><td>RN</td><td>Unit: H01</td><td></td></tr><tr><th>Date Initiated Format</th><th colspan="3">Handout/Topic</th><th>Provider</th><th>Outcome</th></tr><tr><td>Copay Required: No</td><td colspan="3">Cosign Required: Yes</td><td></td><td></td></tr><tr><td>Telephone/Verbal Order: No</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Completed by</td><td colspan="3">RN on 07/28/2019 07:22</td><td></td><td></td></tr><tr><td>Requested to be cosigned by</td><td colspan="3">MD.</td><td></td><td></td></tr><tr><td colspan="6">Cosign documentation will be displayed on the following page.</td></tr></tbody></table>

Generated 07/28/2019 07:22 by

RN

Page 3 of 3

Bureau of Prisons - NYM

EFTA00110366

# Bureau of Prisons
Health Services
Cosign/Review

<table><tr><td>Inmate Name:</td><td colspan="4">EPSTEIN, JEFFREY EDWARD</td><td>Reg #:</td><td>76318-054</td></tr><tr><td>Date of Birth:</td><td>01/20/1953</td><td>Sex:</td><td colspan="2">M</td><td>Race:</td><td>WHITE</td></tr><tr><td>Encounter Date:</td><td>07/28/2019 06:51</td><td>Provider:</td><td colspan="2"></td><td>Facility:</td><td>NYM</td></tr></table>

Bureau of Prisons - NYM