{ "document_metadata": { "page_number": "2447", "document_number": "DOJ-OGR-00026123", "date": "07/12/2019", "document_type": "Clinical Encounter", "has_handwriting": false, "has_stamps": false }, "full_text": "Page 2447\n\nBureau of Prisons\nHealth Services\nClinical Encounter\n\nInmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nEncounter Date: 07/12/2019 13:10\nSex: M\nRace: WHITE\nReg #: 76318-054\nProvider: [redacted] MD\nFacility: NYM\nUnit: Z05\n\nChronic Care - 14 Day Physician Eval encounter performed at Health Services.\n\nSUBJECTIVE:\n\nCOMPLAINT 1 Provider: [redacted] MD\nChief Complaint: ENDO/LIPID\nSubjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800, NOW 434. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS.\nHX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.\nSTATES THE PBL HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES.\nSURGICAL HX: NONE\nMENTAL HEALTH HX: NONE\n\nPain: Yes\nPain Assessment\nDate: 07/12/2019 13:25\nLocation: Back-Middle\nQuality of Pain: Shooting\nPain Scale: 5\nIntervention: MEDROL DOSE PACK\nTrauma Date/Year:\nInjury:\nMechanism:\nOnset: 5+ Years\nDuration: 5+ Years\nExacerbating Factors: NO EXERCISE\nRelieving Factors: MEDROL DOSE PACK\nReason Not Done:\nComments:\n\nSeen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology\nAdded to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology\n\nOBJECTIVE:\n\nExam:\nGeneral\nAppearance\nYes: Appears Well, Alert and Oriented x 3\nNo: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill\nNutrition\nNo: Appears Obese\n\nGenerated 07/12/2019 14:20 by [redacted] MD Bureau of Prisons - NYM\nPage 1 of 3\n\nDOJ-OGR-00026123", "text_blocks": [ { "type": "printed", "content": "Bureau of Prisons\nHealth Services\nClinical Encounter", "position": "header" }, { "type": "printed", "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nEncounter Date: 07/12/2019 13:10\nSex: M\nRace: WHITE\nReg #: 76318-054\nProvider: [redacted] MD\nFacility: NYM\nUnit: Z05", "position": "top" }, { "type": "printed", "content": "Chronic Care - 14 Day Physician Eval encounter performed at Health Services.", "position": "middle" }, { "type": "printed", "content": "SUBJECTIVE:\n\nCOMPLAINT 1 Provider: [redacted] MD\nChief Complaint: ENDO/LIPID\nSubjective: ...", "position": "middle" }, { "type": "printed", "content": "Pain: Yes\nPain Assessment\nDate: 07/12/2019 13:25\nLocation: Back-Middle\nQuality of Pain: Shooting\nPain Scale: 5\nIntervention: MEDROL DOSE PACK", "position": "middle" }, { "type": "printed", "content": "OBJECTIVE:\n\nExam:\nGeneral\nAppearance\nYes: Appears Well, Alert and Oriented x 3\nNo: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill\nNutrition\nNo: Appears Obese", "position": "middle" }, { "type": "printed", "content": "Generated 07/12/2019 14:20 by [redacted] MD Bureau of Prisons - NYM\nPage 1 of 3", "position": "footer" }, { "type": "stamp", "content": "Amendment", "position": "middle" } ], "entities": { "people": [ "JEFFREY EDWARD EPSTEIN" ], "organizations": [ "Bureau of Prisons" ], "locations": [ "NYM" ], "dates": [ "01/20/1953", "07/12/2019" ], "reference_numbers": [ "76318-054", "DOJ-OGR-00026123" ] }, "additional_notes": "The document contains redacted information, indicated by '[redacted]'." }