EFTA00139002

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

| Date of Birth: | 01/20/1953 |

| Encounter Date: | 07/28/2019 20:25 |

Sex:

Provider:

<table border="1"><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>H01</td></tr></table>

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>

## 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>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:

Disposition:

To be Evaluated by Provider

Generated 07/28/2019 20:30 by



SDNY_00017366
Page


Bureau of Prisons - NYM

RN

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EFTA00139003


| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

| Date of Birth: | 01/20/1953 |

| Encounter Date: | 07/28/2019 20:25 |

Follow-up in 12-24 Hours

<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

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.

<table><thead><tr><th>Outcome</th></tr></thead><tbody><tr><td>Verbalizes</td></tr><tr><td>Understanding</td></tr></tbody></table>

Generated 07/28/2019 20:30 by

RN

Bureau of Prisons - NYM



SDNY_00017367
Page 2 of 2


EFTA00139004

Bureau of Prisons
Health Services
Cosign/Review

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

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

Bureau of Prisons - NYM



SDNY_00017368