DOJ-OGR-00026210.jpg
Extracted Text (OCR)
Page 2550
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953 Sex: M Race: WHITE
Encounter Date: 07/28/2019 06:51 Provider; PO"! (re)
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
Reg #: 76318-054
Facility: NYM
Unit: HO1
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
07/28/2019 Counseling
Handout/Topic
Plan of Care
Generated 07/28/2019 07:22 bi Bureau of Prisons - NYM
Outcome
Verbalizes
Understanding
(b)6}, (oF HC}
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DOJ-OGR-00026210
Extracted Information
Document Details
| Filename | DOJ-OGR-00026210.jpg |
| File Size | 593.7 KB |
| OCR Confidence | 92.6% |
| Has Readable Text | Yes |
| Text Length | 2,000 characters |
| Indexed | 2026-02-03 21:03:29.645579 |