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¶