EFTA00033804.pdf

Bureau of Prisons Health Services Clinical Encounter 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 20:25 Provider: RN Unit: H01 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats " My R hand still has pins and needles sometimes' No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Qata Time Rate Per Minute j•ocation Rhythm Provider 07/28/2019 20:28 Respirations: Rate Time 07/28/2019 20:28 NYM Blood Pressure: Data lima Value 07/28/2019 20:28 NYM 81 RN Rate Per Minute, provider 14 RN iscation position Cuff Size Provider 157/91 RN SaO2: Dale lime Valuef%), ALE 07/28/2019 20:28 NYM 98 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: To be Evaluated by Provider Generated 07/2812019 20:30 by RN Provider RN Bureau of Prisons - NYM Page 1 of 2 CONFIDENTIAL SDNY_00009398 EFTA00033804 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 20:25 Provider: RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: Pate Initiated format Handout/Took 07/28/2019 Counseling Plan of Care Copay Required: No TelephoneNerbal Order: No Completed by RN on 07/28/2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Cosign Required: Yes Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM Provider Outcome Verbalizes Understanding Page 2 of 2 CONFIDENTIAL SDNY_00009399 EFTA00033805 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Dale: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by MD on 07/28/2019 20:50. Bureau of Prisons • NYM CONFIDENTIAL SDNY_00009400 EFTA00033806 Bureau of Prisons Health Services Clinical Encounter 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 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: QM& Time Rate Per Minute j.ocatioo Rhythm provider 07/28/2019 06:57 82 RN Respirations: Qat lima Rate Per Minute Provider 07/28/2019 06:57 NYM 14 RN Blood Pressure: git~ Time Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 RN SaO2: Dais Time vaiueem Am 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 Eyes General Yes: PERRLA, Extraocular Movements Intact Provider Face General Yes: Symmetric Generaled 07/2/M2019 07:22 by RN Bureau of Prisons - NYM RN Page tol3 CONFIDENTIAL SDNY_00009401 EFTA00033807 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 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: Pate Initiated Format Handout/Tonic 07/28/2019 Counseling Plan of Care Generated 07728/2019 07:22 by RN Bureau of Prisons - NYM Outcome Verbalizes Understanding Page 2 of 3 CONFIDENTIAL SDNY_00009402 EFTA00033808 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: ilmlifi NHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 pate Initiated Format Handout/Topic Provider Outcome Copay Required: No TelephoneNerbal 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. Cosign Required: Yes Generated 07/28/2019 07:22 by Columbo Joseph RN Bureau of Prisons - NYM Page 3 of 3 CONFIDENTIAL SDNY_00009403 EFTA00033809 Bureau of Prisons Health Services Cosign/Review 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 Facility: NYM Cosigned by MD on 07/28/2019 20:51. Bureau of Prisons • NYM CONFIDENTIAL SDNY_00009404 EFTA00033810 Copay Required: No TelephoneNerbal Order No Completed by Generated 0726/2019 08. 58 by Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: 07/26/2019 08:57 1.101. Provider: MD Reg #: Facility: Unit: 76318-054 NYM H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NI AGO. New Medication Orders: RisE Medication Docusate Sodium Capsule Indication: Constipation, unspecified Cosign Required: No MD on 07/26/2019 08:58 Order Date 07/26/2019 08:57 MD Bureau of Prisons - NYM Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) Page 1 of 1 CONFIDENTIAL SDNY_00009405 EFTA00033811 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/24/2019 16:10 Provider: MD Unit: H0