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Document DOJ-OGR-00026331

AI Analysis

Summary: This clinical encounter document from the Bureau of Prisons details a medical evaluation of Jeffrey Epstein on July 14, 2019. It covers his medical history, current complaints, and treatment for conditions including hypertension, obstructive sleep apnea, and lower back pain. The document provides a snapshot of Epstein's health status and the care he received while incarcerated.
Significance: This document provides insight into Jeffrey Epstein's health conditions and medical treatment while in prison, which could be relevant to understanding his overall health and potential claims or issues related to his care.
Key Topics: Jeffrey Epstein's medical history and current health issues His treatment and medication for various health conditions Specific complaints and symptoms reported during the clinical encounter
Key People:
  • Jeffrey Edward Epstein - Inmate being treated
  • [b](6); (b)(7)(C) MD - Provider/Doctor conducting the clinical encounter
Document Type
Medical Record
Date
July 14, 2019
Pages
1
Folder
IMAGES010

Full Text

Page 2675 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/14/2019 17:36 Sex: M Race: WHITE Reg #: 76318-054 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 FBI 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