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Document DOJ-OGR-00026123

AI Analysis

Summary: This clinical encounter document details a medical evaluation of Jeffrey Epstein on July 12, 2019, while he was incarcerated. It covers his medical history, current complaints, and treatment plans for issues including high triglycerides and back pain. The evaluation was conducted at the NYM facility.
Significance: This document provides insight into Jeffrey Epstein's health conditions and medical treatment while incarcerated, potentially relevant to understanding his overall health status and any claims or concerns raised about his care.
Key Topics: Jeffrey Epstein's medical evaluation Health issues including hypertriglyceridemia and back pain Treatment and medication prescribed during incarceration
Key People:
  • Jeffrey Edward Epstein - Inmate being evaluated
  • [redacted] MD - Provider/Doctor conducting the evaluation
Document Type
Medical Record
Date
July 12, 2019
Pages
1
Folder
IMAGES010

Full Text

Page 2447 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10 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 434. 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 PBL 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): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology 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 07/12/2019 14:20 by [redacted] MD Bureau of Prisons - NYM Page 1 of 3 DOJ-OGR-00026123