{ "document_metadata": { "page_number": "2418", "document_number": "76318-054", "date": "07/30/2019", "document_type": "Medical Examination Report", "has_handwriting": false, "has_stamps": true }, "full_text": "Page 2418 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/30/2019 11:12 Sex: M Race: WHITE Reg #: 76318-054 Provider: (b)(6); (b)(7)(C) MD Facility: NYM Unit: Z01 Date Time Lbs Kg Waist Circum. Provider 07/30/2019 09:30 NYM 194.2 88.1 (b)(6); (b)(7)(C) MD Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, I10 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Rx# Medication Order Date Prescriber Order Generated 07/30/2019 14:05 by (b)(6); (b)(7)(C) MD Bureau of Prisons - NYM Page 2 of 3 DOJ-OGR-00026094", "text_blocks": [ { "type": "printed", "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/30/2019 11:12 Sex: M Race: WHITE Reg #: 76318-054 Provider: (b)(6); (b)(7)(C) MD Facility: NYM Unit: Z01", "position": "top" }, { "type": "printed", "content": "Date Time Lbs Kg Waist Circum. Provider 07/30/2019 09:30 NYM 194.2 88.1 (b)(6); (b)(7)(C) MD", "position": "middle" }, { "type": "printed", "content": "Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength", "position": "middle" }, { "type": "printed", "content": "ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, I10 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current", "position": "middle" }, { "type": "printed", "content": "PLAN: New Medication Orders: Rx# Medication Order Date Prescriber Order", "position": "middle" }, { "type": "stamp", "content": "See Amendment", "position": "middle" }, { "type": "printed", "content": "Generated 07/30/2019 14:05 by (b)(6); (b)(7)(C) MD Bureau of Prisons - NYM Page 2 of 3 DOJ-OGR-00026094", "position": "bottom" } ], "entities": { "people": [ "JEFFREY EDWARD EPSTEIN" ], "organizations": [ "Bureau of Prisons" ], "locations": [ "NYM" ], "dates": [ "01/20/1953", "07/30/2019" ], "reference_numbers": [ "76318-054", "DOJ-OGR-00026094" ] }, "additional_notes": "The document contains redacted information and a 'See Amendment' stamp, indicating potential changes or corrections to the original content." }