mirror-epstein-docs/results/IMAGES010/DOJ-OGR-00026331.json

{
  "document_metadata": {
    "page_number": "2675",
    "document_number": "DOJ-OGR-00026331",
    "date": "07/14/2019",
    "document_type": "Clinical Encounter",
    "has_handwriting": false,
    "has_stamps": false
  },
  "full_text": "Page 2675\nBureau of Prisons\nHealth Services\nClinical Encounter\nInmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nEncounter Date: 07/14/2019 17:36\nSex: M\nRace: WHITE\nReg #: 76318-054\nProvider: [b](6); (b)(7)(C)\nMD\nFacility: NYM\nUnit: Z05\nChronic Care - 14 Day Physician Eval encounter performed at Health Services.\nSUBJECTIVE:\nCOMPLAINT 1\nProvider: [b](6); (b)(7)(C)\nMD\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 431. 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 FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES.\nSURGICAL HX: NONE\nMENTAL HEALTH HX: NONE\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:\nSeen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid\nAdded to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid\nOBJECTIVE:\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\nGenerated 07/14/2019 18:11 by [b](6); (b)(7)(C)\nMD\nBureau of Prisons - NYM\nPage 1 of 3",
  "text_blocks": [
    {
      "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: 07/14/2019 17:36\nSex: M\nRace: WHITE\nReg #: 76318-054\nProvider: [b](6); (b)(7)(C)\nMD\nFacility: NYM\nUnit: Z05",
      "position": "top"
    },
    {
      "type": "printed",
      "content": "Chronic Care - 14 Day Physician Eval encounter performed at Health Services.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "SUBJECTIVE:\nCOMPLAINT 1\nProvider: [b](6); (b)(7)(C)\nMD\nChief Complaint: ENDO/LIPID\nSubjective: ...",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "OBJECTIVE:\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",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Generated 07/14/2019 18:11 by [b](6); (b)(7)(C)\nMD\nBureau of Prisons - NYM\nPage 1 of 3",
      "position": "footer"
    }
  ],
  "entities": {
    "people": [
      "JEFFREY EDWARD EPSTEIN",
      "[b](6); (b)(7)(C)"
    ],
    "organizations": [
      "Bureau of Prisons",
      "FBI"
    ],
    "locations": [
      "NYM"
    ],
    "dates": [
      "01/20/1953",
      "07/14/2019",
      "07/12/2019"
    ],
    "reference_numbers": [
      "76318-054",
      "DOJ-OGR-00026331"
    ]
  },
  "additional_notes": "The document appears to be a clinical encounter report for Jeffrey Epstein, an inmate at NYM facility. The report includes his medical history, current complaints, and physical examination results. Some personal identifiable information is redacted."
}