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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: HO1 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 Peon | Verbalizes Understanding Generated 07/28/2019 07:22 byfPN@) OXMC) RN Bureau of Prisons - NYM Page 2 of 3 DOJ-OGR-00024107