EFTA00134737

# 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 | Provider: RN | Unit: H01 |

Nursing - Follow up encounter performed at Health Services.

<table><tr><td colspan="3">SUBJECTIVE:</td></tr><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>

<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>

<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></td></tr></tbody></table>

<table><thead><tr><th colspan="5">SaO2:</th></tr><tr><th>Date</th><th>Time</th><th>Value(%)</th><th>Air</th><th>Provider</th></tr></thead><tbody><tr><td>07/28/2019</td><td>20:28 NYM</td><td>98</td><td></td><td>RN</td></tr></tbody></table>

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 RN

Bureau of Prisons - NYM

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SDNY_00000994


| EFTA_00000203 |
| :--- | :--- |

This is a simple text representation of a table with two columns. The first column contains the label "EFTA_00000203", and the second column contains the corresponding data. No formatting or special characters are present.

EFTA00134738

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/28/2019 20:25

Follow-up in 12-24 Hours

Patient Education Topics:
Date Initiated Format: Counseling
Handout/Topic: Plan of Care
Provider: H01
Outcome: 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:
Cosign documentation will be displayed on the following page.

Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM

EFTA00134739

Bureau of Prisons
Health Services
Cosign/Review

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

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

# 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 | Provider: RN | 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></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: , Extraocular Movements Intact

## Eyes

## Face

Bureau of Prisons - NYM

Page 1 of 3



SDNY_00000997




EFTA_00000206



EFTA00134741

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Reg #: 76318-054 |
| :--- | :--- |
| Date of Birth: 01/20/1953 | Facility: NYM |
| Encounter Date: 07/28/2019 06:51 | Unit: H01 |

**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 payo obs through the slot. V/S noted WNL, RR even and unlabored, no neurological deficits noted, no facial droop slur, which or dysphagia, Inmate with Full ROM to all extremities with 4/4 strength bilaterally, slight swelling noted to the palms when compared to left, no edema, erythema or ecchymosis noted. Denies any pain numbness or tingling. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes MD on Call notif. evaluate intubation or cage if S/S persist.

## ASSESSMENT:

Alteration in comfort

## PLAN:

## Disposition:

**Position:**

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

RN

Bureau of Prisons - NYM



Provider

Columbo, Joseph



# Outcome

Verbalizes

Understanding

Page 2 of 3



SDNY_00000998

EFTA_00000207



EFTA00134742

| Date Initiated Format | Handout/Topic | Provider | Outcome |
| :--- | :--- | :--- | :--- |
| Copay Required: No | Cosign Required: Yes | | |
| Telephone/Verbal Order: No | RN on 07/28/2019 07:22 | | |
| Requested to be cosigned by | Cosign documentation will be displayed on the following page. | | |

Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM

Page 3 of 3
SDNY_00000999
EFTA_0000208

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Sex: M
Encounter Date: 07/28/2019 08:51
Provider: RN
Reg #: 76318-054
Race: WHITE
Facility: NYM

Cosigned by on 07/28/2019 20:51.

# Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note

<table><thead><tr><th>Inmate Name:</th><th colspan="4">EPSTEIN, JEFFREY EDWARD</th><th>Reg #:</th><th>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><td>Facility:</td><td>NYM</td></tr><tr><td>Note Date:</td><td>07/26/2019 08:57</td><td>Provider:</td><td></td><td></td><td>Unit:</td><td>H01</td></tr></tbody></table>

Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.

Administrative Notes:

ADMINISTRATIVE NOTE 1 Provider:

THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO.

New Medication Orders:

<table><thead><tr><th colspan="2">New Medication Orders:</th></tr></thead><tbody><tr><td>Rx#</td><td>Medication</td></tr><tr><td></td><td>Docusate Sodium Capsule</td></tr></tbody></table>

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/26/2019 08:57</td></tr></tbody></table>

Indication: Constipation, unspecified

Prescriber Order

Copay Required: No



TAKE ONE 100 MG CAP Orally

- Two Times a Day x 180 day(s)



Cosign Required: No

Telephone/Verbal Order: No

Completed by on 07/26/2019 08:58

Generated 07/26/2019 08:58 by

Page 1 of 1

Bureau of Prisons - NYM



SDNY_00001001


EFTA_00000210