mirror-epstein-docs/results/IMAGES010/DOJ-OGR-00026088.json

{
  "document_metadata": {
    "page_number": "2412",
    "document_number": "76318-054",
    "date": "07/30/2019",
    "document_type": "Clinical Encounter",
    "has_handwriting": false,
    "has_stamps": false
  },
  "full_text": "Page 2412\n\nBureau of Prisons\nHealth Services\nClinical Encounter\n\nInmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nEncounter Date: 07/30/2019 15:58\nSex: M\nRace: WHITE\nReg #: 76318-054\nProvider: [b(6); (b)(7)(C)] MD\nFacility: NYM\nUnit: Z01\n\nChronic Care - Chronic Care Clinic encounter performed at Health Services.\n\nSUBJECTIVE:\n\nCOMPLAINT 1\nProvider: [b(6); (b)(7)(C)] MD\nChief Complaint: Other Problem\nSubjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION.\nPATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE\nALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.\nSTATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.\nHE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY\nSPEAKING OR SWALLOWING.\nHE REPORTS NOCTURIA OF ABOUT 5 TIMES., HE DENIES DYSURIA.\nHE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING\nTOPROL.\nHE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS\nISNCE HE HASBEEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I\nINFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO\nHIM TONIGHT..\nHE REPORT OTHER NON-MEDICAL ISSUES.\nSTATES HE FEELS OTHERWISE FINE.\nPain: Not Applicable\n\nSeen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/I\n\nOBJECTIVE:\n\nExam:\nGeneral\nAffect\nYes: Cooperative\nAppearance\nYes: Appears Well, Alert and Oriented x 3\nNo: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,\nDisheveled, Unkempt, Acutely Ill\nNutrition\nNo: Appears Obese\nPulmonary\nAuscultation\nYes: Clear to Auscultation\nCardiovascular\nAuscultation\nYes: Regular Rate and Rhythm (RRR), Normal S1 and S2\nNo: M/R/G\nMusculoskeletal\nTibia / Fibula\nNo: Edema\nNeurologic\n\nGenerated 07/30/2019 16:12 by [b(6); (b)(7)(C)] MD\nBureau of Prisons - NYM\nPage 1 of 2\n\nDOJ-OGR-00026088",
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      "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: 07/30/2019 15:58\nSex: M\nRace: WHITE\nReg #: 76318-054\nProvider: [b(6); (b)(7)(C)] MD\nFacility: NYM\nUnit: Z01",
      "position": "top"
    },
    {
      "type": "printed",
      "content": "Chronic Care - Chronic Care Clinic encounter performed at Health Services.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "SUBJECTIVE:\n\nCOMPLAINT 1\nProvider: [b(6); (b)(7)(C)] MD\nChief Complaint: Other Problem\nSubjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION.\nPATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE\nALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.\nSTATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.\nHE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY\nSPEAKING OR SWALLOWING.\nHE REPORTS NOCTURIA OF ABOUT 5 TIMES., HE DENIES DYSURIA.\nHE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING\nTOPROL.\nHE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS\nISNCE HE HASBEEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I\nINFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO\nHIM TONIGHT..\nHE REPORT OTHER NON-MEDICAL ISSUES.\nSTATES HE FEELS OTHERWISE FINE.\nPain: Not Applicable",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/I",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "OBJECTIVE:\n\nExam:\nGeneral\nAffect\nYes: Cooperative\nAppearance\nYes: Appears Well, Alert and Oriented x 3\nNo: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic,\nDisheveled, Unkempt, Acutely Ill\nNutrition\nNo: Appears Obese\nPulmonary\nAuscultation\nYes: Clear to Auscultation\nCardiovascular\nAuscultation\nYes: Regular Rate and Rhythm (RRR), Normal S1 and S2\nNo: M/R/G\nMusculoskeletal\nTibia / Fibula\nNo: Edema\nNeurologic",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Generated 07/30/2019 16:12 by [b(6); (b)(7)(C)] MD\nBureau of Prisons - NYM\nPage 1 of 2",
      "position": "footer"
    }
  ],
  "entities": {
    "people": [
      "JEFFREY EDWARD EPSTEIN"
    ],
    "organizations": [
      "Bureau of Prisons"
    ],
    "locations": [
      "NYM"
    ],
    "dates": [
      "01/20/1953",
      "07/30/2019"
    ],
    "reference_numbers": [
      "76318-054",
      "DOJ-OGR-00026088"
    ]
  },
  "additional_notes": "The document appears to be a clinical encounter report for Jeffrey Epstein, an inmate at a Bureau of Prisons facility. The report details his medical complaints and examination results. Some personal identifiable information is redacted."
}