DOJ-OGR-00026094.json 4.0 KB

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  1. {
  2. "document_metadata": {
  3. "page_number": "2418",
  4. "document_number": "76318-054",
  5. "date": "07/30/2019",
  6. "document_type": "Medical Examination Report",
  7. "has_handwriting": false,
  8. "has_stamps": true
  9. },
  10. "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",
  11. "text_blocks": [
  12. {
  13. "type": "printed",
  14. "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",
  15. "position": "top"
  16. },
  17. {
  18. "type": "printed",
  19. "content": "Date Time Lbs Kg Waist Circum. Provider 07/30/2019 09:30 NYM 194.2 88.1 (b)(6); (b)(7)(C) MD",
  20. "position": "middle"
  21. },
  22. {
  23. "type": "printed",
  24. "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",
  25. "position": "middle"
  26. },
  27. {
  28. "type": "printed",
  29. "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",
  30. "position": "middle"
  31. },
  32. {
  33. "type": "printed",
  34. "content": "PLAN: New Medication Orders: Rx# Medication Order Date Prescriber Order",
  35. "position": "middle"
  36. },
  37. {
  38. "type": "stamp",
  39. "content": "See Amendment",
  40. "position": "middle"
  41. },
  42. {
  43. "type": "printed",
  44. "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",
  45. "position": "bottom"
  46. }
  47. ],
  48. "entities": {
  49. "people": [
  50. "JEFFREY EDWARD EPSTEIN"
  51. ],
  52. "organizations": [
  53. "Bureau of Prisons"
  54. ],
  55. "locations": [
  56. "NYM"
  57. ],
  58. "dates": [
  59. "01/20/1953",
  60. "07/30/2019"
  61. ],
  62. "reference_numbers": [
  63. "76318-054",
  64. "DOJ-OGR-00026094"
  65. ]
  66. },
  67. "additional_notes": "The document contains redacted information and a 'See Amendment' stamp, indicating potential changes or corrections to the original content."
  68. }