EFTA00139005 # Bureau of Prisons Health Services Clinical Encounter | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/28/2019 06:51 | | Sex: | M | Race: WHITE | | :--- | :--- | :--- | | Provider: | | RN | | Reg #: | 76318-054 | | :--- | :--- | | Facility: | NYM | | 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	Provider
07/28/2019	06:57 NYM	98		RN

## 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 ## Eyes **General** Yes: PERRLA, Extraocular Movements Intact ## Face General Yes: Symmetric generated 07/28/2019 07:22 by SDNY_00017369 Page 1 of 3 EFTA00139006

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

Outcome
Verbalizes
Understanding

RN SDNY_00017370 Page 2 of 3 EFTA00139007

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:			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 SDNY_00017371 Page RN Bureau of Prisons - NYM 3 of 3 EFTA00139008 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 06:51 Provider: RN Facility: NYM Cosigned by MD on 07/28/2019 20:51. Bureau of Prisons - NYM SDNY_00017372