Bureau of Prisons medical triage note for Jeffrey Epstein, July 28, 2019

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:¶

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				RN

SaO2:¶

Date	Time	Value(%)	Air
07/28/2019	06:57 NYM	98

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¶

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Bureau of Prisons - NYM¶

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Inmate Name:	EPSTEIN, JEFFREY EDWARD		Reg #:	76318-054
Date of Birth:	01/20/1953	Sex:	M	Race: WHITE
Encounter Date:	07/28/2019 06:51	Provider:	RN
Exam:
No: Ecchymosis, Numbness, Swelling, Periorbital 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: Inflammation R, Ecchymosis 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 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:¶

Date Initiated	Format
07/28/2019	Counseling

Handout/Topic¶

Plan of Care¶

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Bureau of Prisons - NYM¶

Outcome¶

Verbalizes¶

Understanding¶

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Inmate Name: EPSTEIN, JEFFREY EDWARD				Reg #: 76318-054
Date of Birth: 01/20/1953	Sex: M	Race: WHITE		Facility: NYM
Encounter Date: 07/28/2019 06:51	Provider:		RN	Unit: H01
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¶

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Bureau of Prisons - NYM¶

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