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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: HO1 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: POON) 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: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 20:28 NYM 14 Prema RN Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/28/2019 20:28NYM 157/91 ear. SaQ2: Date Time Value(%) Air Provider 07/28/2019 20:28 NYM 98 ee 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 07/28/2019 20:30 byfPX6) XN) |RN Bureau of Prisons - NYM Page 1 of 2 DOJ-OGR-00024103