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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
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
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DOJ-OGR-00026123