Full Text
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 Reg #: 76318-054 Provider: (b)(6); (b)(7)(C) RN Facility: NYM Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: (b)(6); (b)(7)(C) 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 (b)(6); (b)(7)(C) RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 (b)(6); (b)(7)(C) RN Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 (b)(6); (b)(7)(C) RN SaO2: Date Time Value(%) Air Provider 07/28/2019 06:57 NYM 98 (b)(6); (b)(7)(C) 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 (b)(6); (b)(7)(C) RN Bureau of Prisons - NYM Page 1 of 3