mirror-epstein-docs/results/IMAGES010/DOJ-OGR-00026123.json

{
  "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",
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      "content": "Bureau of Prisons\nHealth Services\nClinical Encounter",
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      "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",
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    {
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      "content": "Chronic Care - 14 Day Physician Eval encounter performed at Health Services.",
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      "type": "printed",
      "content": "SUBJECTIVE:\n\nCOMPLAINT 1 Provider: [redacted] MD\nChief Complaint: ENDO/LIPID\nSubjective: ...",
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    {
      "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",
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    {
      "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",
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  ],
  "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]'."
}