mirror-epstein-docs/results/IMAGES009/DOJ-OGR-00024114.json

{
  "document_metadata": {
    "page_number": "1",
    "document_number": "76318-054",
    "date": "07/14/2019",
    "document_type": "Clinical Encounter",
    "has_handwriting": false,
    "has_stamps": false
  },
  "full_text": "Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/14/2019 17:36 Sex: M Race: WHITE Reg #: 76318-054 Provider: [redacted] MD Facility: NYM Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: [redacted] MD Chief Complaint: ENDO/LIPID Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX 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. STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid OBJECTIVE: Exam: General 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 Generated 07/14/2019 18:11 by [redacted] MD Bureau of Prisons - NYM Page 1 of 3 DOJ-OGR-00024114",
  "text_blocks": [
    {
      "type": "printed",
      "content": "Bureau of Prisons Health Services Clinical Encounter",
      "position": "header"
    },
    {
      "type": "printed",
      "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/14/2019 17:36 Sex: M Race: WHITE Reg #: 76318-054 Provider: [redacted] MD Facility: NYM Unit: Z05",
      "position": "top"
    },
    {
      "type": "printed",
      "content": "Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: [redacted] MD Chief Complaint: ENDO/LIPID Subjective: ...",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK ...",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid OBJECTIVE: Exam: General Appearance ...",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Generated 07/14/2019 18:11 by [redacted] MD Bureau of Prisons - NYM Page 1 of 3 DOJ-OGR-00024114",
      "position": "footer"
    }
  ],
  "entities": {
    "people": [
      "JEFFREY EDWARD EPSTEIN"
    ],
    "organizations": [
      "Bureau of Prisons",
      "FBI"
    ],
    "locations": [
      "NYM"
    ],
    "dates": [
      "01/20/1953",
      "07/14/2019",
      "07/12/2019"
    ],
    "reference_numbers": [
      "76318-054",
      "DOJ-OGR-00024114"
    ]
  },
  "additional_notes": "The document contains redacted information, likely for privacy or security reasons. The document is a clinical encounter report from the Bureau of Prisons Health Services."
}