Full Text
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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: [redacted] RN
Facility: NYM
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:
Date Initiated Format Handout/Topic Provider Outcome
07/28/2019 Counseling Plan of Care [redacted] Verbalizes Understanding
Generated 07/28/2019 07:22 by [redacted] RN Bureau of Prisons - NYM Page 2 of 3
DOJ-OGR-00026210