mirror-epstein-docs/results/IMAGES010/DOJ-OGR-00026116.json

{
  "document_metadata": {
    "page_number": "2440",
    "document_number": "DOJ-OGR-00026116",
    "date": "07/14/2019",
    "document_type": "Clinical Encounter",
    "has_handwriting": false,
    "has_stamps": false
  },
  "full_text": "Page 2440 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: M Race: WHITE Reg #: 76318-054 Date of Birth: 01/20/1953 Encounter Date: 07/14/2019 17:36 Provider: (b)(6); (b)(7)(C) MD Facility: NYM Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: (b)(6); (b)(7)(C) 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 FB1 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 (b)(6); (b)(7)(C) MD Bureau of Prisons - NYM Page 1 of 3",
  "text_blocks": [
    {
      "type": "printed",
      "content": "Bureau of Prisons Health Services Clinical Encounter",
      "position": "header"
    },
    {
      "type": "printed",
      "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: M Race: WHITE Reg #: 76318-054 Date of Birth: 01/20/1953 Encounter Date: 07/14/2019 17:36 Provider: (b)(6); (b)(7)(C) 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: (b)(6); (b)(7)(C) MD Chief Complaint: ENDO/LIPID Subjective: ...",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "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",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Generated 07/14/2019 18:11 by (b)(6); (b)(7)(C) MD Bureau of Prisons - NYM Page 1 of 3",
      "position": "footer"
    }
  ],
  "entities": {
    "people": [
      "JEFFREY EDWARD EPSTEIN"
    ],
    "organizations": [
      "Bureau of Prisons"
    ],
    "locations": [
      "NYM"
    ],
    "dates": [
      "01/20/1953",
      "07/14/2019",
      "07/12/2019"
    ],
    "reference_numbers": [
      "76318-054",
      "DOJ-OGR-00026116"
    ]
  },
  "additional_notes": "The document appears to be a clinical encounter report for Jeffrey Epstein, an inmate at a Bureau of Prisons facility. The report includes subjective and objective information about Epstein's medical condition, including his chief complaint, pain assessment, and examination results. Some personal identifiable information is redacted."
}