Preview
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Exhibit 8
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
F NONE NONE BHIX Consent:Y
Y WTCKOFFREIGIFTCMEDICALCENTER EMERGENCT ROOMRegistrationForm ENG
ER
ACCTS: WO0503693700 Admit Date: 05/06/10 Mat:WDO2157352 A D? NCNE
ROOm/Bed: Adnut Timr: 0324 F/C: HCDEMO HPA? Y
Type: EMERGENCT(T Loc/Serv:NSEDA SSf:xxx-xx-9999 BMP?
ADMSRC: SED EMER
PATIENTADDRESSINFo: IPATIENTDD400RAPHICS
SANTILLAN,RAUL I008: /63 LTDSC:
33-05 90TH ST 4B IAas: 54 ADMSC:SED
JACKSONHEIGHTS,NY11372 Isexa M NTLNG:ENGLISH
HomePhone: IRace:0TH INTRP: N
IReis ORDNR:
CNTY: QUEENS IM/S: S EPANEX
SER:
TATIENT EMPLOYER 1 PERSON70 WMIFY - EMERGENCYofNTACT
EMPLOTERATTD4PTEDUNENOVN
UNKNOWNUNKNOWN I
UNKNOWN,UU99999
(999)999-9999 IH: W:
Procedure:HVA NECKPAIN/WYCKOFF
Accident Date/time:05/06/18 ISANTILLAN,MARIZA SI ST
Arrived 8V:W)0W- AMBULANCE I 33-0590TH 5T 4B
Prim Care MD: BAE2,DAYSIX IJACKSONHEIGHTS,NY11372
AdmND: IG• N
AT." MD: UDEH,NGOZIHD I
,wn ii.., m. ,uaaw .. .4 4 ,u,u w1,w. m,i
l-Lw Im -. .,
GUARANTOR IGUABANTOR DtPLOYER
SANTILLAN,RAUL SELF IEMPloYERATTEMPTED UNKNOWN
33-05 90TR ST 4B IUNKNOWN UNKNOWN
JACKSONREIGHTS,NY11372 IUNKNOWN,UU 99999
xxx-xx-9999 I (999)999-9999
PRIHARYINSURANCE POL1CTNUMBER SUBSCRIBER
FIDELIS M30 CARENY MCD RK562717 SANTILLAN,RAUL 5EL
P.O.BOX 806
AMMERST NY 1422G-0006
GRP SUBSSN:
COVERAGE5: AUTBI:
SECONDARY INSURANCE POL1CYNUMBER SUBS;RI8ER
NO FAULTMISCELLANEQUS 999999999 SANTILLAN,RAUL SEL
GEICO
UNAVAILAELE NY 00000
(716)006-8000 GRP SUB5SN:
COVERAGEf: AUTH4:
TERTIARYI NSURANCE POLICTNUHBER SUBSCR1BER
GRP SURSSN:
COVERAGEf: AUTBf:
COMtENTS/ NOTES
ALL LOCATIONS:NSEDA
SVC/PVT: LANG:
RM/BEDLOC: NSEDA
ACCTDENTPLACE:
ETHNIC: HIPPA DT: 04 .1/12
HMO:HMO IJtP:
HIPPA: N acp:
FA*1IER: CCC: ONSETMEDSYMPTOMS/ILLNESS 05/06c18
DIS BY: SIGNEDBY:
SNT: N
AD DIR: NCNE HIPFA: Y BP: ORGAN: LANG: ENGLI INT: N
ALERGYi
REVRT.A:
COP9{ENT: MONE
HOP9tAID: ADMDX: MVANECKPAIN/WTCKOFF
4th INSURANCE POLI SURSCR1BER
GRP
AUTN
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
RUN DATE: 05/08/18 Uyckoff Heights EDH **LIVE** PAGE 1
RUN TIME: 0201 ED CHART
RUN USER: HEDITECH
Patient: SANTILIAN.RAUL Age/Sex: 54/M Acet No: V00503693700
ED Provider: UDEH,NG0ZI HD, ATTPHYS Unit No: V002157352
Demographics
33-05 90TH ST
4B
JACKSON HEIGHTS. NY 11372
Insurance: FIDELIS HGD CARE NY - HCD PCP. BAEZ.DAYSI X
Next of Kin:'SANTILLAN.MARIZA Family Doctor. BAEZ.DAYSI X
Relation: SISTER Referring:
Phone:
General
ED Physician: UDEH.NGOZI HD. AT1PHYS Arrival Date/Time: 06/06/18 - 0017
Practitioner: Triage Date/Time·
Nurse: Date of Birth. 963
Stated Complaint: HVA NECK PAIN/VYCKOFF
Chief Ccaplaint: Priority:
Chief Complaint History:
Staff History:
ED Physician
05/06/18 0422 UDEH.NGOZI HD. ATTPHYS
0024 UNASSIGNED PHYSICIAN, ATTPHYS
Practitioner
Nurse
Orders
prWred Order Ordering Provider E-Signed
05/06 18 0109 CT-CERVICAL SPINE V/O CONTRAST UDEH.NG0ZI HD N/A
05/06/18 0109 DILAUDID 0.5 HG/0.5 HL UDEH.NGOZI HD N/A
05/06/18 0109 CT HEAD V/O CONTRAST UDEH.NG0ZI HD N/A
05/06/18 0111 SHOULDER RT -HIN 2 VIEUS UDEILNG0ZI HD N/A
05/06/18 0111 RIBS UNILAT RIGHT V/PA CHEST UDEH.NG0ZI HD N/A
05/06/18 0112 SPINE LUMBROSACRAL 2 OR 3 VIEW UDEH.NGOZI HD N/A
Depature Information
Primary Impression: HVA (motor vehicle accident)
Disposition: HOME - ROUTINE 01 Departure Date/Time: 05/06/18 - 0420
cmw-t:
Candition:
Referrals:
Pt Instructions.
Additional Instructions.
Departure Forms:
Patient. SANTILLAN.RAUL
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Wyckoff Heights Medical Center
374 STOCKHOLM STREET BROOKLYN, NY 11237
(718) 963-7373
Department of MedicalImaging
Patient:SANTILLAN,RAUL Unit #: W002157352 Acct#: W00503693700
DOB: 63 Age: 54 Sex: M
Report #: 0506-0138 Service Date: 05/06/18 Service Time: 0109
Order #: 0506-0005 Location: NSEDA Admit Source:
Attending MD UDEH NGOZI MD Ordering MD: UDEH,NGOZI MD Room/Bed:
CAT SCAN REPORT
Procedure: CT HEAD W/O CONTRAST
Signed
HEAD
EXAM
CT Head Without Intravenous Contrast
CLINICAL HISTORY
54 years old,male 920 contusIon head x eye MVA with headache
x0a
TECHNIQUE:
Axialcomputed tomography images of thehead/brain without
intravenous
contrast.
Coronal and sagittalreformattedimages were created and
reviewed.
COMPARISON:
No relevant priorstudies available.
FINDINGS:
Brain:Asymmetric CSF density is seen In theanteromedial left
temporal
fossa measuring approximately 9 x 26mm In size
suggesting
arachnold cyst.No
hemorrhage. No signNicant white matter disease.
Ventricles:Unremarkable. No ventriculomegaly.
Bonestfoints: Unremarkable. No acute fracture.
Soft tissues:Unremarkable.
Sinuses: There Is a smallcyst orpolyp In theleftmaxillary
sinus.
Mastoid air cells:
Unremarkable as visualized.
No mastold
effusion.
IMPRESSION:
No acute findings.
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Name SANTILLAN,RAUL Report Number 0506-0138
Unit# WD02157352 Locatbn: NSEDA
This reportwas signed
electronically by
Christopher Lawton MD
«Signature on Flie>>
DictatingMD: LAWTON,CHRISTOPHER MD
Signing MD: LAWTON.CHRISTOPHER MD
Dictation D/T:05/06/18 0554
Transcription DIT. 05/06/180554
Transcribed By
Report #. 0506-0138
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Wyckoff Heights Medical Center
374 STOCKHOLM STREET BROOKLYN, NY 11237
(718) 963-7373
Department of Medical Imaging
Patient: SANTILLAN,RAUL Unit #: W002157352 Acet#: W00503693700
DOB: 63 Age: 54 Sex: M
Report #: 0506-0139 Service Date: 05/06/18 Service Time: 0109
Order #: 0506-0004 Location:NSEDA Admit Source:
Attending MD: UDEH,NGOZI MD Ordering MD: UDEH,NGOZl MD Room/Bed:
CAT SCAN REPORT
Procedure: CT-CERVICAL SP)NE W/O CONTRAST
Signed
CSPINE_
EXAM
CT Cervical Spine Without Intravenous Contrast
CLINICAL HISTORY
54 years old,male, 959.9 Injurynec nos-site nos MVA with neck
pain
TECHNIQUE:
Axialcomputed tomography Images of thecervical
spine without
Intravenous
contrast.
Coronal and sagittalreformattedImages were created and
reviewed.
COMPARISON:
No relevant priorstudies available.
FINDINGS:
Vertebrae: Right laminectomy defectsare demonstrated at
C7-T1-T2 from
previous laminectomy surgeries.Associated softtissue
postsurgicalscarring is
seen in thisarea.No acute fracture.
Discs/spinal canal/neuralforamina: No acute findings.No
spinalcanal
stenosis.
Lung apIces: Unremarkable as visualized.
IMPRESSION:
Statuspost rightlaminectomy surgely invoMng C7-T1-T2
This reportwas electronicallysigned by:
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Name SANTILLAN,RAUL Report Number 0506-0139
Unit# WOO2157352 Location: NSEDA
Christopher Lawton MD
«Signature on File>>
DIctating MD: LAWTON,CHRISTOPHER MD
Signing MD: LAWTON,CHRISTOPHER MD
Dictation D/T: 05/06/180559
Transcription D/T: 05/06/18 0559
Transcribed By
Report #: 0506-0139
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Wyckoff Heights Medical Center
374 STOCKHOLM STREET BROOKLYN, NY 11237
(718) 963-7373
Department of Medical Imaging
. .
Patient:SANTILLAN,RAUL Unit #: WOO2157352 Acct#: W00503693700
DOB 63 Age: 54 Sex: M
Report #: 0506-0143 Service Date: 05m6/18 Service Time: 0111
Order #: 0506-0009 Location: NSEDA Admit Source:
Attending MD: UDEH,NGOZI MD Ordering MD: UDEH,NGOZI MD Room/Bed:
RADIOLOGY REPORT
Procedure: SHOULDER RT -MIN 2 VIEWS
Signed
SHLDRRT2
EXAM
XR Right Shoulder Complete, 2 orMore Views
CLINICAL HISTORY
54 years old,male; 719.81 Jointdis nec-shoulder S/P MVA
TECHNIQUE:
Two ormore views ofthe rightshoulder
COMPARISON:
No relevantpriorstudies available
FINDINGS:
Bones/Joints:The patientis statuspost rightlaminectomy as
invoMng at
leastT1 and T2. No acute fracture.
No dislocation.
Soft Unremarkable.
tissues:
IMPRESSION:
No acute findings.
This reportwas electronicallysigned by
Christopher Lawton MD
«Signature on File»
Dictating MD: LAWTON,CHRISTOPHER MD
Signing MD: LAWTON,CHRISTOPHER MD
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Name SANTILLAN,RAUL Report Number 0506-0143
Unit # WD02157352 Locatbn NSEDA
Dictation D/T: 0506/18 0640
Transcription D/T: 05/06/18 0640
Transcribed By
Report #: 0506-0143
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Wyckoff Heights Medical Center
374 STOCKHOLM STREET BROOKLYN, NY 11237
(718) 963-7373
Department of MedicalImaging
. ._.. ..
Patient:SANTILLAN,RAUL Unit #: WDO2157352 Acct#: W00503693700
DOB: 63 Age: 54 Sex: M
Report #: 0506-0144 Service Date: 05A)6/18 Service Time: 0112
Order #: 0506-0011 Location: NSEDA Admit Source:
Attending MD. UDEH,NGOZI MD Ordering MD: UDEH,NGOZI MD Room/Bed:
RADIOLOGY REPORT
Procedure: SPINE LUMBROSACRAL 2 OR 3 VIEW
Signed
LSPINE2V
EXAM
XR Lumbar Sphe, 2 or 3 Views
CLINICAL HISTORY
54 years old,male, 724.2 lumbago lower back pain S/P MVA
TECHNIQUE:
Frontaland lateralviews ofthe lumbar spine
COMPARISON:
No relevantpriorstudies available.
FINDINGS:
Vertebrae:There Is minimaldextrocurvature of thelumbar
spine.Anterior
osteophytes are demonstrated at L3 and L4. No acute fracture
Disc spaces: There is mildnarrowing of theintervertebral
disc
space at
L3-4.
Soft tissues:
Surgical clipsare noted in therightupper
quadrant of the
abdomen.
IMPRESSION:
Mild narrowing ofthe intervertebral
disc space at L3-4with
anterior
osteophytes.
Minimal dextrocurvature of thelumbar spine
Cholecystectomy.
This reportwas electronicallysigned by:
Christopher Lawton MD
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Name. SANTILLAN,RAUL Report Number: 0506-0144
Unit* W002157352 Location: NSEDA
<
Printed By George Squires on 5/N/2018
3 26 PM
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 2 of I I
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTILLAN DOB: M963
MR #: W002157352 Age/Gender: 54y M
DOS: 5/6/2018 00:17 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZl UDEH, MD
Reviewed By: NGOZi UDEH, MD 5/6/2018 10:36
Home Medications
Wedication Name Last Dose
Instructions Taken Date
abapentin oral (Strength Unknown/Unconfirmed)
Active TN May 6 2018 12:18AM>
Reviewed By: NGOZI UDEH, MD 5/6/2018 10:36
Problem List
roblem ded Problem Nource t Date 15tatus status Date hpdated
pack disorder 53.9 (ICD10-CM) )ED IEroblem ctive i/6/2018 GN May 6 2018 12:19AM>
PAST HISTORY
Immunizations: Tetanus: unknown ; Pneumonia: unknown ; Flu:unknown
MEDICATIONS: Nurse notes reviewed and confirmed.
ALLERGIES/lNTOLERANCES: Nurse notes reviewed and confirmed.
IMMUNIZATIONS: Nurse notes reviewed and confirmed.
MEDICAL HISTORY: No significantmedical history.
SOCIAL HISTORY: No significantsocial history.
SURGICAL HISTORY: cervical Laminectomy
FLOWSHEETS
Medication Administration
DILAUDID 0.5 MG/0.5 ML IM 0.5 MG NGOZl UDEH, MD 5/6/2018 01:05
Given right deltoid Shani Roberts, RN 5/6/2018 01:22
PROVIDER NOTES
HISTORY OF PRESENT ILLNESS
Vitalsigns reviewed.
Historian:patient.
The patientpresents with a complaint of motor vehiclecollision.The patientreports pain tothe rightneck. There is/arealso painon the
rightextremity shoulder and pain on the rightmid chest.There are no foreignbodies present.minute(s) ago. The pain is characterizedas:
sharp, The symptom severity ismoderate. The context and/or mechanism of injury was: carcollision,The patientwas adriver. The type
and/or siteof impact was: high speed, The patient was restrained by a lapbelt only.Associated symptoms: (-)bleeding,(-) lossof
consciousness, PriorTreatment: OTC medication(s), neck collarThe patienthas the following risk factors:pthad a cervical laminectomy
few months ago
Printed By George Squires on 5 142018 3 26 PM
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 3 of I 1
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTILLAN DOB: 1963
MR #: W002I57352 Age/Gender: 54y M
DOS: 5/6/2018 00:l7 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZI UDEH, MD
REVIEW OF SYSTEMS
Except as noted elsewhere in therecord, allother systems are negative.
EXAM
CONSTITUTIONAL: Distress:Moderate. Patient appears WDWN. Patientisalert.
INTEGUMENTARY: Color normal forrace, warm and dry, no rash.
MUSCULOSKELETAL/EXTREMITIES: (+) localized spinaltenderness, Tenderness Over: chest,neck, other:right shoulder
NEURO: Oriented x3. Cranial nerves II-XII within normal limits.No motor or sensory deficits.
EYES: PERRL, lidsand conjunctivae are normal on exam, no acute pathological process.
ENT: External inspectionnormal, TM's clear,pharnyx normal, teeth normal.
CARDIOVASCULAR: Regular rate and rhythm, heart sounds normal, no gallops,rubs or murmurs, no edema present.
GI/ABDOMEN: Soft, non-tender, no organomegly, no pulsatilemass. Normal bowel sounds.
GENITOURINARY: External genitalianormal, no tenderness or swelling.No testicularor inguinal pain.
NECK: The neck is supple,no JVD, thyromegaly, or Iymphadenopathy.
RESPIRATORY: Breath sounds clear,no distresspresent, no wheezing rales,rhonchi or tachypnea. Normal rateand effort.
HEME/LYMPH: No adenopathy, no palpable or tender nodes.
ORDERS
Medicine
DILAUDID 0.5 MG/0.5 ML IM 0.5 MG < NGOZl UDEH. MD 5/6/201B01DS>
Radiology
CT CERVICAL SPINE W/O CONTRAST ; REASON: INJURY NEC&NOS-SITE NOS ; VENTILATOR: NO ; OXYGEN: NO ;
PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZl UDEH MD
[Reference: 13310313.00I]
< NGOZl UDEll,MD 5/6/2018 01:06>
Special Instructions
MVA with neck pain
CT HEAD W/O CONTRAST ; REASON: CONTUSION HEAD X EYE ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ;
TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZI UDEH MD [Reference:
13310316.001]
< NGOZI UDEH, MD 5/6/2018 01:07>
Special Instructions
MVA with headache
SHOULDER RT -MIN 2 VIEWS ; REASON:.IOINT DIS NEC-SHOULDER ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO
; TRANSPORT: STRETCHER ; Order type:V.O. (Read back verified) ; Orderingphysician: NGOZl UDEH MD [Reference:
13310320.001]
< NGOZl UDEH, MD 5/6/2018 0l:08>
Special instructions
s/p mva
RIBS UNILAT RIGHT W/PA CHEST ; REASON: CHEST WALL INJURY NEC ; VENTILATOR: NO ; OXYGEN: NO ;PREGNANT:
NO ; TRANSPORT: STRETCHER ; Order type:V.O. (Read back verified); Ordering physician: NGOZI UDEH MD [Reference:
Printed By George Squires on S.14.2018 3 26 PAf
ClinicalChart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 4 of 1I
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTILLAN DOB: 963
MR #: W002157352 Age/Gender: 54y M
DOS: 5/6/2018 00:I7 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZl UDEH, MD
1331032I.00I]
Special Instructions
R/O FRACTURE
SPINE LUMBROSACRAL 2 OR 3 VIEW ; REASON: LUMBAGO ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ;
TRANSPORT: STRETCHER ; Ordertype:V.O. (Read back verified) ; Ordering physician: NGOZI UDEH MD [Reference:
13310324.00l]
Special Instructions
LOWER BACK PAIN S/P mva
Prescriptions
Ibuprofen 600 MG OralTablet TAKE 1 TABLET EVERY 6 TO 8 HOURS AS NEEDED FOR PAIN. Dispense: 30
Robaxin 500 MG Oral Tablet TAKE I TABLET 3 TIMES DAILY. Dispense: 30
RESULTS
Radiology
CT CERVICAL SPINE W/O CONTRAST ; REASON: INJURY NEC&NOS-SITE NOS ; VENTILATOR: NO ; OXYGEN: NO ;
PREGNANT: NO ; TRANSPORT: STRETCHER ;Order type:V.O. (Read back verified); Ordering physician: NGOZl UDEH MD
Interfacedresult received:5/6/2018 12:58
Interfacedresult completed: 5/6/2018 01:09
CT CERVICAL SPINE W/O CONTRAST : REASON: INJrJRY NEC&NOS-SITE NOS : VENTILATOR: NO ; OXYGEN: NO : PE
CSPINE_
EXAM:
CT Cervical Spine Without Intravenous Contrast
CLINICAL HISTORY:
54 years old, male; 959. 9 injury nec nos-site nos MVA with neck
pain
TECHNIQUE:
Axial computed tomography images of the cervical spine without
intravenous
contrast.
Coronal and sagittal reformatted images were created and
reviewed.
COMPARISON:
No relevant prior studies available.
FINDINGS:
Vertebrae: Right laminectomy defects are demonstrated at
C7-T1-T2 from
Printed By George Squires on SIN/2018
3 26 PM
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 5 of I I
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTILLAN DOB: 963
MR #: W002157352 Age/Gender: 54y M
DOS: 5/6/2018 00:I7 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZI UDEH, MD
previous laminectomy surgeries. Associated soft tissue
postsurgical scarring is
seen in this area. No acute fracture.
Discs/spinal canal/neural foramina: No acute findings. No
spinal canal
stenosis.
Lung apices: Unremarkable as visualized.
IMPRESSION:
Status post right laminectomy surgery involving C7-T1-T2.
This report was electronically signed by:
Christopher Lawton MD
Dictated on 05/06/18 0559 by LAWTON,CHRISTOPHER MD
Transcribed on 05/06/18 0559 by MEDITECH
Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258
Sign by:
LAWTON ,CHRISTOPHER MD
CT HEAD W/O CONTRAST ; REASON: CONTUSION HEAD X EYE ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ;
TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZI UDEH MD
Interfaced resultreceived: 5/6/2018 12:58
Interfaced resultcompleted: 5/6/2018 01:09
CT HEAD W/O CONTRAST ; REA5ON : CONTUSION READ X EYE ; VENTILATOR: NO / OXYGEN : NO ; PREGNANT : NO ;
HEAD
EXAM:
CT Head Without Intravenous Contrast
CLINICAL HISTORY:
54 years old, male; 920 contusion head x eye MVA with headache
x0a
TECHNIQUE:
Axial computed tomography images of the head/brain without
intravenous
contrast .
Coronal and sagittal reformatted images were created and
reviewed.
COMPARISON:
No relevant prior studies available.
FIN DINGS:
Brain: Asymmetric CSF density is seen in the anteromedial left
---- .
Printed ByGeorge
Squires on S/I4/2018
3 26 PM
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 6 of I I
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTILLAN DOB: 963
MR #: W002157352 Age/Gender: 54y M
DOS: 5/6/2018 00:17 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZI UDEH, MD
temporal
fossa measuring approximately 9 x 26 mm in size sugges ting
arachnoid cyst. No
hemorrhage. No significant white matter disease.
Ventricles: Unremarkable. No ventriculomegaly.
Bones/joints: Unremarkable. No acute fracture.
Soft tissues: Unremarkable.
Sinuses: There is a small cyst or polyp in the left maxillary
sinus.
Mastoid air cells: Unremarkable as visualized. No mastoid
effusion.
IMPRESSION:
No acute findings.
This report was electronically signed by:
Christopher Lawton MD
Dictated on 05/06/18 0554 by LAWTON,CHRISTOPHER MD
Transcribed on 05/06/18 0554 by MEDITECH
Sign by LANTON,CHRISTOPHER MD on 05/06/18 1258
Sign by:
LAWTON,CHRISTOPHER MD
SHOULDER RT -MIN 2 VIEWS ; REASON: JOINT DIS NEC-SHOULDER ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO
; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZI UDEH MD
Interfaced resuh received: 5/6/2018 12:59
Interfaced resultcompleted: 5/6/2018 01:11
SHOULDER RT -MTN 2 VZEWS ; REASON: JOINT DIS NEC-SHOULDER ; VENTILATOR; NO ; OXYGEN: NO ; PREGNANT:
SHLDRRT2
EXAM:
XR Right Shoulder Complete, 2 or More Views
CLINICAL HISTORY:
54 years old, ma le; 719.81 joint dis nec-shoulder S/F MVA
TECHNIQUE:
Two or more views of the right shoulder.
COMPARISON:
No relevant prior studies available.
FINDINGS:
Bones/joints: The patient is status post right laminectomy as
involving at
PrimedByGeorgeSquireson5/N2018326PM
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 7 of I I
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
IIhlI -
Patient: RAUL SANTILLAN DOB: 963
MR #: W002157352 Age/Gender: 54y M
DOS: 5/6/2018 00:17 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZI UDEH, MD
least T1 and T2. No acute fracture. No dislocation.
Soft tissues: Unremarkable.
IMPRESSION:
No acute findings.
This report was electronically signed by:
Christopher Lawton MD
Dictated on 05/06/18 0640 by LAWTON,CHRISTOPHER MD
Transcribed on 05/06/18 064 0 by MEDITECH
Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258
Sign by:
LAWTON,CHRTSTCPHER MD
RIBS UNILAT RIGHT W/PA CHEST ; REASON: CHEST WALL INJURY NEC ; VENTILATOR: NO ; OXYGEN: NO : PREGNANT:
NO ; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified) ; Ordering physician:NGOZI UDEH MD
Interfacedresult received:5/6/2018 12:59
interfacedresult completed: 5/6/20I8 01:1I
RIBS UNZLAT RZGHT W/PA CHEST ; REASON: CHSST WALL ZNJR1RY NEC ; VENTZLATOR: NO ; OXYGEN: NO ; PREGN)
CXR1RIB R
EXAM:
XR Right Ribs and AP Chest, 3 or More Views
CLINICAL HISTORY:
54 years old, male; 959. 11 chest wall injury nec R/O fracture
TECHNIQUE:
Frontal and oblique views of the right ribs and frontal view of
the chest.
COMPARISON:
No relevant prior studies available.
FINDINGS:
Lungs: Unremarkable. No consolidation.
Pleural space: Unremarkable. No pneumothorax.
Heart: Unremarkable. No cardiomegaly.
Mediastinum: Unremarkable.
Bones/joints: Unremarkable. No acute fracture.
Upper abdomen: Surgical clips are noted in the right upper
quadrant of the
abdomen.
Other findings: The patient is status post right laminectomies
involving at
- ... ..... .. . .
PrintedByGeorgeSquiresonS/I40018326PM
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 8 of I I
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTlLLAN DOB: 963
MR #: W002157352 Age/Gender: 54y M
DOS: 5/6/2018 00:17 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZI UDEH, MD
least L1-L2.
IMPRESSION:
No acute findings.
This report was electronically signed by:
Christopher Lawton MD
Dictated on 05/06/18 0645 by LAWTON,CHRISTOPHER MD
Transcribed on 05/06/18 0645 by MEDITECH
Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258
Sign by:
LAWTON,CHRISTOPHER MD
SPINE LUMBROSACRAL 2 OR 3 VIEW ; REASON: LUMBAGO ; VENTlLATOR: NO ; OXYGEN: NO ; PREGNANT: NO ,
TRANSPORT: STRETCHER ; Ordertype: V.O. (Read back verified) ; Ordering physician: NGOZl UDEH MD
Interfaced resultreceived: 5/6/2018 12:59
Interfacedresult completed: 5/6/2018 01:12
SPINS LUMBROSACRAL 2 OR 3 VIEW ; REASON: LDHBAGO ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TF
LSPINE2V
EXAM:
XR Lumbar Spine, 2 or 3 Views
CLINICAL HISTORY:
54 years old, male; 724 .2 lumbago lower back pain S/P MVA
TECHNIQUE:
Frontal and lateral views of the lumbar spine.
COMPARISON:
No relevant prior studies available.
FINDINGS:
Vertebrae: There is minimal dextrocurvature of the lumbar
spine. Anterior
asteophytes are demonstrated at L3 and L4. No acute fracture.
Disc spaces: There is mild narrowing of the intervertebral disc
space at
L3-4.
Soft tissues: Surgical clips are noted in the right upper
quadrant of the
abdomen.
IMPRESSION:
Mild narrowing of the intervertebral disc space at L3-4 with
PrimedBy George Squires on 5 It2018
3 26PA/
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 9 of II
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTILLAN DOB: M963
MR #: W002157352 Age/Gender: 54y M
DOS: 5/6/2018 00:17 Acet #: W00503693700
Private Phys: BAEZ ED Phys: NGOZl UDEH, MD
anterior
osteophytes.
Minimal dextrocurvature of the lumber spine.
Cholecystectomy.
This report was electronically signed by:
Christopher Lawton MD
Dictated on 05/06/18 0641 by LAWTON,CHRISTOPHER MD
Transcribed on 05/06/18 0641 by MEDITECH
Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258
Sign by:
LAWTON,CHRISTOPHER MD
PROGRESS NOTES
Progress: 54y/o male with MVA presenting with headache.neck pain ,rightshoulder pain ,rightchest wallpain and lower back pain
allimaging studies arenegative forfracture ordislocation
discharge home on motrin and robaxin NU 05/06/l8 04:16
DIAGNOSIS
MVA (motor vehicle accident)
Neck muscle spasm
Chest wall contusion
Sprain ofshoulder, right
DISPOSITION
Nursing
Disposition isHome - Routine
The patientwas discharged to home. The patientis alert
and oriented and is inno respiratory distress. Patient's
condition: good .
Discharge mode is ambulatory . Patientaccompanied by self. The patient'sdiagnosis,condition and treatment were explained topatient
or parent/guardian. The patient/responsible party expressed understanding. Extended patienteducation given to patient/guardian.A
discharge plan has been developed. Aftercare instructions were givento thepatient.
Discharge done
Physician
Discharge from ED: The patientis discharged to home. Patient'scondition is stable. The patientis tofollow-up with Follow up with
your private medical doctor.3 day(s) from today as needed
MANAGEMENTOPTIONS: No additional work-up planned.
Prmted By George Squires on 3 14 2018 3 26 PM
Clinical Chart
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022
Page 10 of 1I
Wyckoff Heights Medical Center -
Brooklyn, NY 11237
Patient: RAUL SANTILLAN DOB:
Preview
FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Exhibit 8 FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 F NONE NONE BHIX Consent:Y Y WTCKOFFREIGIFTCMEDICALCENTER EMERGENCT ROOMRegistrationForm ENG ER ACCTS: WO0503693700 Admit Date: 05/06/10 Mat:WDO2157352 A D? NCNE ROOm/Bed: Adnut Timr: 0324 F/C: HCDEMO HPA? Y Type: EMERGENCT(T Loc/Serv:NSEDA SSf:xxx-xx-9999 BMP? ADMSRC: SED EMER PATIENTADDRESSINFo: IPATIENTDD400RAPHICS SANTILLAN,RAUL I008: /63 LTDSC: 33-05 90TH ST 4B IAas: 54 ADMSC:SED JACKSONHEIGHTS,NY11372 Isexa M NTLNG:ENGLISH HomePhone: IRace:0TH INTRP: N IReis ORDNR: CNTY: QUEENS IM/S: S EPANEX SER: TATIENT EMPLOYER 1 PERSON70 WMIFY - EMERGENCYofNTACT EMPLOTERATTD4PTEDUNENOVN UNKNOWNUNKNOWN I UNKNOWN,UU99999 (999)999-9999 IH: W: Procedure:HVA NECKPAIN/WYCKOFF Accident Date/time:05/06/18 ISANTILLAN,MARIZA SI ST Arrived 8V:W)0W- AMBULANCE I 33-0590TH 5T 4B Prim Care MD: BAE2,DAYSIX IJACKSONHEIGHTS,NY11372 AdmND: IG• N AT." MD: UDEH,NGOZIHD I ,wn ii.., m. ,uaaw .. .4 4 ,u,u w1,w. m,i l-Lw Im -. ., GUARANTOR IGUABANTOR DtPLOYER SANTILLAN,RAUL SELF IEMPloYERATTEMPTED UNKNOWN 33-05 90TR ST 4B IUNKNOWN UNKNOWN JACKSONREIGHTS,NY11372 IUNKNOWN,UU 99999 xxx-xx-9999 I (999)999-9999 PRIHARYINSURANCE POL1CTNUMBER SUBSCRIBER FIDELIS M30 CARENY MCD RK562717 SANTILLAN,RAUL 5EL P.O.BOX 806 AMMERST NY 1422G-0006 GRP SUBSSN: COVERAGE5: AUTBI: SECONDARY INSURANCE POL1CYNUMBER SUBS;RI8ER NO FAULTMISCELLANEQUS 999999999 SANTILLAN,RAUL SEL GEICO UNAVAILAELE NY 00000 (716)006-8000 GRP SUB5SN: COVERAGEf: AUTH4: TERTIARYI NSURANCE POLICTNUHBER SUBSCR1BER GRP SURSSN: COVERAGEf: AUTBf: COMtENTS/ NOTES ALL LOCATIONS:NSEDA SVC/PVT: LANG: RM/BEDLOC: NSEDA ACCTDENTPLACE: ETHNIC: HIPPA DT: 04 .1/12 HMO:HMO IJtP: HIPPA: N acp: FA*1IER: CCC: ONSETMEDSYMPTOMS/ILLNESS 05/06c18 DIS BY: SIGNEDBY: SNT: N AD DIR: NCNE HIPFA: Y BP: ORGAN: LANG: ENGLI INT: N ALERGYi REVRT.A: COP9{ENT: MONE HOP9tAID: ADMDX: MVANECKPAIN/WTCKOFF 4th INSURANCE POLI SURSCR1BER GRP AUTN FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 RUN DATE: 05/08/18 Uyckoff Heights EDH **LIVE** PAGE 1 RUN TIME: 0201 ED CHART RUN USER: HEDITECH Patient: SANTILIAN.RAUL Age/Sex: 54/M Acet No: V00503693700 ED Provider: UDEH,NG0ZI HD, ATTPHYS Unit No: V002157352 Demographics 33-05 90TH ST 4B JACKSON HEIGHTS. NY 11372 Insurance: FIDELIS HGD CARE NY - HCD PCP. BAEZ.DAYSI X Next of Kin:'SANTILLAN.MARIZA Family Doctor. BAEZ.DAYSI X Relation: SISTER Referring: Phone: General ED Physician: UDEH.NGOZI HD. AT1PHYS Arrival Date/Time: 06/06/18 - 0017 Practitioner: Triage Date/Time· Nurse: Date of Birth. 963 Stated Complaint: HVA NECK PAIN/VYCKOFF Chief Ccaplaint: Priority: Chief Complaint History: Staff History: ED Physician 05/06/18 0422 UDEH.NGOZI HD. ATTPHYS 0024 UNASSIGNED PHYSICIAN, ATTPHYS Practitioner Nurse Orders prWred Order Ordering Provider E-Signed 05/06 18 0109 CT-CERVICAL SPINE V/O CONTRAST UDEH.NG0ZI HD N/A 05/06/18 0109 DILAUDID 0.5 HG/0.5 HL UDEH.NGOZI HD N/A 05/06/18 0109 CT HEAD V/O CONTRAST UDEH.NG0ZI HD N/A 05/06/18 0111 SHOULDER RT -HIN 2 VIEUS UDEILNG0ZI HD N/A 05/06/18 0111 RIBS UNILAT RIGHT V/PA CHEST UDEH.NG0ZI HD N/A 05/06/18 0112 SPINE LUMBROSACRAL 2 OR 3 VIEW UDEH.NGOZI HD N/A Depature Information Primary Impression: HVA (motor vehicle accident) Disposition: HOME - ROUTINE 01 Departure Date/Time: 05/06/18 - 0420 cmw-t: Candition: Referrals: Pt Instructions. Additional Instructions. Departure Forms: Patient. SANTILLAN.RAUL FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Wyckoff Heights Medical Center 374 STOCKHOLM STREET BROOKLYN, NY 11237 (718) 963-7373 Department of MedicalImaging Patient:SANTILLAN,RAUL Unit #: W002157352 Acct#: W00503693700 DOB: 63 Age: 54 Sex: M Report #: 0506-0138 Service Date: 05/06/18 Service Time: 0109 Order #: 0506-0005 Location: NSEDA Admit Source: Attending MD UDEH NGOZI MD Ordering MD: UDEH,NGOZI MD Room/Bed: CAT SCAN REPORT Procedure: CT HEAD W/O CONTRAST Signed HEAD EXAM CT Head Without Intravenous Contrast CLINICAL HISTORY 54 years old,male 920 contusIon head x eye MVA with headache x0a TECHNIQUE: Axialcomputed tomography images of thehead/brain without intravenous contrast. Coronal and sagittalreformattedimages were created and reviewed. COMPARISON: No relevant priorstudies available. FINDINGS: Brain:Asymmetric CSF density is seen In theanteromedial left temporal fossa measuring approximately 9 x 26mm In size suggesting arachnold cyst.No hemorrhage. No signNicant white matter disease. Ventricles:Unremarkable. No ventriculomegaly. Bonestfoints: Unremarkable. No acute fracture. Soft tissues:Unremarkable. Sinuses: There Is a smallcyst orpolyp In theleftmaxillary sinus. Mastoid air cells: Unremarkable as visualized. No mastold effusion. IMPRESSION: No acute findings. FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Name SANTILLAN,RAUL Report Number 0506-0138 Unit# WD02157352 Locatbn: NSEDA This reportwas signed electronically by Christopher Lawton MD «Signature on Flie>> DictatingMD: LAWTON,CHRISTOPHER MD Signing MD: LAWTON.CHRISTOPHER MD Dictation D/T:05/06/18 0554 Transcription DIT. 05/06/180554 Transcribed By Report #. 0506-0138 FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Wyckoff Heights Medical Center 374 STOCKHOLM STREET BROOKLYN, NY 11237 (718) 963-7373 Department of Medical Imaging Patient: SANTILLAN,RAUL Unit #: W002157352 Acet#: W00503693700 DOB: 63 Age: 54 Sex: M Report #: 0506-0139 Service Date: 05/06/18 Service Time: 0109 Order #: 0506-0004 Location:NSEDA Admit Source: Attending MD: UDEH,NGOZI MD Ordering MD: UDEH,NGOZl MD Room/Bed: CAT SCAN REPORT Procedure: CT-CERVICAL SP)NE W/O CONTRAST Signed CSPINE_ EXAM CT Cervical Spine Without Intravenous Contrast CLINICAL HISTORY 54 years old,male, 959.9 Injurynec nos-site nos MVA with neck pain TECHNIQUE: Axialcomputed tomography Images of thecervical spine without Intravenous contrast. Coronal and sagittalreformattedImages were created and reviewed. COMPARISON: No relevant priorstudies available. FINDINGS: Vertebrae: Right laminectomy defectsare demonstrated at C7-T1-T2 from previous laminectomy surgeries.Associated softtissue postsurgicalscarring is seen in thisarea.No acute fracture. Discs/spinal canal/neuralforamina: No acute findings.No spinalcanal stenosis. Lung apIces: Unremarkable as visualized. IMPRESSION: Statuspost rightlaminectomy surgely invoMng C7-T1-T2 This reportwas electronicallysigned by: FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Name SANTILLAN,RAUL Report Number 0506-0139 Unit# WOO2157352 Location: NSEDA Christopher Lawton MD «Signature on File>> DIctating MD: LAWTON,CHRISTOPHER MD Signing MD: LAWTON,CHRISTOPHER MD Dictation D/T: 05/06/180559 Transcription D/T: 05/06/18 0559 Transcribed By Report #: 0506-0139 FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Wyckoff Heights Medical Center 374 STOCKHOLM STREET BROOKLYN, NY 11237 (718) 963-7373 Department of Medical Imaging . . Patient:SANTILLAN,RAUL Unit #: WOO2157352 Acct#: W00503693700 DOB 63 Age: 54 Sex: M Report #: 0506-0143 Service Date: 05m6/18 Service Time: 0111 Order #: 0506-0009 Location: NSEDA Admit Source: Attending MD: UDEH,NGOZI MD Ordering MD: UDEH,NGOZI MD Room/Bed: RADIOLOGY REPORT Procedure: SHOULDER RT -MIN 2 VIEWS Signed SHLDRRT2 EXAM XR Right Shoulder Complete, 2 orMore Views CLINICAL HISTORY 54 years old,male; 719.81 Jointdis nec-shoulder S/P MVA TECHNIQUE: Two ormore views ofthe rightshoulder COMPARISON: No relevantpriorstudies available FINDINGS: Bones/Joints:The patientis statuspost rightlaminectomy as invoMng at leastT1 and T2. No acute fracture. No dislocation. Soft Unremarkable. tissues: IMPRESSION: No acute findings. This reportwas electronicallysigned by Christopher Lawton MD «Signature on File» Dictating MD: LAWTON,CHRISTOPHER MD Signing MD: LAWTON,CHRISTOPHER MD FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Name SANTILLAN,RAUL Report Number 0506-0143 Unit # WD02157352 Locatbn NSEDA Dictation D/T: 0506/18 0640 Transcription D/T: 05/06/18 0640 Transcribed By Report #: 0506-0143 FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Wyckoff Heights Medical Center 374 STOCKHOLM STREET BROOKLYN, NY 11237 (718) 963-7373 Department of MedicalImaging . ._.. .. Patient:SANTILLAN,RAUL Unit #: WDO2157352 Acct#: W00503693700 DOB: 63 Age: 54 Sex: M Report #: 0506-0144 Service Date: 05A)6/18 Service Time: 0112 Order #: 0506-0011 Location: NSEDA Admit Source: Attending MD. UDEH,NGOZI MD Ordering MD: UDEH,NGOZI MD Room/Bed: RADIOLOGY REPORT Procedure: SPINE LUMBROSACRAL 2 OR 3 VIEW Signed LSPINE2V EXAM XR Lumbar Sphe, 2 or 3 Views CLINICAL HISTORY 54 years old,male, 724.2 lumbago lower back pain S/P MVA TECHNIQUE: Frontaland lateralviews ofthe lumbar spine COMPARISON: No relevantpriorstudies available. FINDINGS: Vertebrae:There Is minimaldextrocurvature of thelumbar spine.Anterior osteophytes are demonstrated at L3 and L4. No acute fracture Disc spaces: There is mildnarrowing of theintervertebral disc space at L3-4. Soft tissues: Surgical clipsare noted in therightupper quadrant of the abdomen. IMPRESSION: Mild narrowing ofthe intervertebral disc space at L3-4with anterior osteophytes. Minimal dextrocurvature of thelumbar spine Cholecystectomy. This reportwas electronicallysigned by: Christopher Lawton MD FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Name. SANTILLAN,RAUL Report Number: 0506-0144 Unit* W002157352 Location: NSEDA < Printed By George Squires on 5/N/2018 3 26 PM Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 2 of I I Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTILLAN DOB: M963 MR #: W002157352 Age/Gender: 54y M DOS: 5/6/2018 00:17 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZl UDEH, MD Reviewed By: NGOZi UDEH, MD 5/6/2018 10:36 Home Medications Wedication Name Last Dose Instructions Taken Date abapentin oral (Strength Unknown/Unconfirmed) Active TN May 6 2018 12:18AM> Reviewed By: NGOZI UDEH, MD 5/6/2018 10:36 Problem List roblem ded Problem Nource t Date 15tatus status Date hpdated pack disorder 53.9 (ICD10-CM) )ED IEroblem ctive i/6/2018 GN May 6 2018 12:19AM> PAST HISTORY Immunizations: Tetanus: unknown ; Pneumonia: unknown ; Flu:unknown MEDICATIONS: Nurse notes reviewed and confirmed. ALLERGIES/lNTOLERANCES: Nurse notes reviewed and confirmed. IMMUNIZATIONS: Nurse notes reviewed and confirmed. MEDICAL HISTORY: No significantmedical history. SOCIAL HISTORY: No significantsocial history. SURGICAL HISTORY: cervical Laminectomy FLOWSHEETS Medication Administration DILAUDID 0.5 MG/0.5 ML IM 0.5 MG NGOZl UDEH, MD 5/6/2018 01:05 Given right deltoid Shani Roberts, RN 5/6/2018 01:22 PROVIDER NOTES HISTORY OF PRESENT ILLNESS Vitalsigns reviewed. Historian:patient. The patientpresents with a complaint of motor vehiclecollision.The patientreports pain tothe rightneck. There is/arealso painon the rightextremity shoulder and pain on the rightmid chest.There are no foreignbodies present.minute(s) ago. The pain is characterizedas: sharp, The symptom severity ismoderate. The context and/or mechanism of injury was: carcollision,The patientwas adriver. The type and/or siteof impact was: high speed, The patient was restrained by a lapbelt only.Associated symptoms: (-)bleeding,(-) lossof consciousness, PriorTreatment: OTC medication(s), neck collarThe patienthas the following risk factors:pthad a cervical laminectomy few months ago Printed By George Squires on 5 142018 3 26 PM Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 3 of I 1 Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTILLAN DOB: 1963 MR #: W002I57352 Age/Gender: 54y M DOS: 5/6/2018 00:l7 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZI UDEH, MD REVIEW OF SYSTEMS Except as noted elsewhere in therecord, allother systems are negative. EXAM CONSTITUTIONAL: Distress:Moderate. Patient appears WDWN. Patientisalert. INTEGUMENTARY: Color normal forrace, warm and dry, no rash. MUSCULOSKELETAL/EXTREMITIES: (+) localized spinaltenderness, Tenderness Over: chest,neck, other:right shoulder NEURO: Oriented x3. Cranial nerves II-XII within normal limits.No motor or sensory deficits. EYES: PERRL, lidsand conjunctivae are normal on exam, no acute pathological process. ENT: External inspectionnormal, TM's clear,pharnyx normal, teeth normal. CARDIOVASCULAR: Regular rate and rhythm, heart sounds normal, no gallops,rubs or murmurs, no edema present. GI/ABDOMEN: Soft, non-tender, no organomegly, no pulsatilemass. Normal bowel sounds. GENITOURINARY: External genitalianormal, no tenderness or swelling.No testicularor inguinal pain. NECK: The neck is supple,no JVD, thyromegaly, or Iymphadenopathy. RESPIRATORY: Breath sounds clear,no distresspresent, no wheezing rales,rhonchi or tachypnea. Normal rateand effort. HEME/LYMPH: No adenopathy, no palpable or tender nodes. ORDERS Medicine DILAUDID 0.5 MG/0.5 ML IM 0.5 MG < NGOZl UDEH. MD 5/6/201B01DS> Radiology CT CERVICAL SPINE W/O CONTRAST ; REASON: INJURY NEC&NOS-SITE NOS ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZl UDEH MD [Reference: 13310313.00I] < NGOZl UDEll,MD 5/6/2018 01:06> Special Instructions MVA with neck pain CT HEAD W/O CONTRAST ; REASON: CONTUSION HEAD X EYE ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZI UDEH MD [Reference: 13310316.001] < NGOZI UDEH, MD 5/6/2018 01:07> Special Instructions MVA with headache SHOULDER RT -MIN 2 VIEWS ; REASON:.IOINT DIS NEC-SHOULDER ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type:V.O. (Read back verified) ; Orderingphysician: NGOZl UDEH MD [Reference: 13310320.001] < NGOZl UDEH, MD 5/6/2018 0l:08> Special instructions s/p mva RIBS UNILAT RIGHT W/PA CHEST ; REASON: CHEST WALL INJURY NEC ; VENTILATOR: NO ; OXYGEN: NO ;PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type:V.O. (Read back verified); Ordering physician: NGOZI UDEH MD [Reference: Printed By George Squires on S.14.2018 3 26 PAf ClinicalChart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 4 of 1I Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTILLAN DOB: 963 MR #: W002157352 Age/Gender: 54y M DOS: 5/6/2018 00:I7 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZl UDEH, MD 1331032I.00I] Special Instructions R/O FRACTURE SPINE LUMBROSACRAL 2 OR 3 VIEW ; REASON: LUMBAGO ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TRANSPORT: STRETCHER ; Ordertype:V.O. (Read back verified) ; Ordering physician: NGOZI UDEH MD [Reference: 13310324.00l] Special Instructions LOWER BACK PAIN S/P mva Prescriptions Ibuprofen 600 MG OralTablet TAKE 1 TABLET EVERY 6 TO 8 HOURS AS NEEDED FOR PAIN. Dispense: 30 Robaxin 500 MG Oral Tablet TAKE I TABLET 3 TIMES DAILY. Dispense: 30 RESULTS Radiology CT CERVICAL SPINE W/O CONTRAST ; REASON: INJURY NEC&NOS-SITE NOS ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TRANSPORT: STRETCHER ;Order type:V.O. (Read back verified); Ordering physician: NGOZl UDEH MD Interfacedresult received:5/6/2018 12:58 Interfacedresult completed: 5/6/2018 01:09 CT CERVICAL SPINE W/O CONTRAST : REASON: INJrJRY NEC&NOS-SITE NOS : VENTILATOR: NO ; OXYGEN: NO : PE CSPINE_ EXAM: CT Cervical Spine Without Intravenous Contrast CLINICAL HISTORY: 54 years old, male; 959. 9 injury nec nos-site nos MVA with neck pain TECHNIQUE: Axial computed tomography images of the cervical spine without intravenous contrast. Coronal and sagittal reformatted images were created and reviewed. COMPARISON: No relevant prior studies available. FINDINGS: Vertebrae: Right laminectomy defects are demonstrated at C7-T1-T2 from Printed By George Squires on SIN/2018 3 26 PM Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 5 of I I Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTILLAN DOB: 963 MR #: W002157352 Age/Gender: 54y M DOS: 5/6/2018 00:I7 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZI UDEH, MD previous laminectomy surgeries. Associated soft tissue postsurgical scarring is seen in this area. No acute fracture. Discs/spinal canal/neural foramina: No acute findings. No spinal canal stenosis. Lung apices: Unremarkable as visualized. IMPRESSION: Status post right laminectomy surgery involving C7-T1-T2. This report was electronically signed by: Christopher Lawton MD Dictated on 05/06/18 0559 by LAWTON,CHRISTOPHER MD Transcribed on 05/06/18 0559 by MEDITECH Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258 Sign by: LAWTON ,CHRISTOPHER MD CT HEAD W/O CONTRAST ; REASON: CONTUSION HEAD X EYE ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZI UDEH MD Interfaced resultreceived: 5/6/2018 12:58 Interfaced resultcompleted: 5/6/2018 01:09 CT HEAD W/O CONTRAST ; REA5ON : CONTUSION READ X EYE ; VENTILATOR: NO / OXYGEN : NO ; PREGNANT : NO ; HEAD EXAM: CT Head Without Intravenous Contrast CLINICAL HISTORY: 54 years old, male; 920 contusion head x eye MVA with headache x0a TECHNIQUE: Axial computed tomography images of the head/brain without intravenous contrast . Coronal and sagittal reformatted images were created and reviewed. COMPARISON: No relevant prior studies available. FIN DINGS: Brain: Asymmetric CSF density is seen in the anteromedial left ---- . Printed ByGeorge Squires on S/I4/2018 3 26 PM Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 6 of I I Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTILLAN DOB: 963 MR #: W002157352 Age/Gender: 54y M DOS: 5/6/2018 00:17 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZI UDEH, MD temporal fossa measuring approximately 9 x 26 mm in size sugges ting arachnoid cyst. No hemorrhage. No significant white matter disease. Ventricles: Unremarkable. No ventriculomegaly. Bones/joints: Unremarkable. No acute fracture. Soft tissues: Unremarkable. Sinuses: There is a small cyst or polyp in the left maxillary sinus. Mastoid air cells: Unremarkable as visualized. No mastoid effusion. IMPRESSION: No acute findings. This report was electronically signed by: Christopher Lawton MD Dictated on 05/06/18 0554 by LAWTON,CHRISTOPHER MD Transcribed on 05/06/18 0554 by MEDITECH Sign by LANTON,CHRISTOPHER MD on 05/06/18 1258 Sign by: LAWTON,CHRISTOPHER MD SHOULDER RT -MIN 2 VIEWS ; REASON: JOINT DIS NEC-SHOULDER ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified); Ordering physician: NGOZI UDEH MD Interfaced resuh received: 5/6/2018 12:59 Interfaced resultcompleted: 5/6/2018 01:11 SHOULDER RT -MTN 2 VZEWS ; REASON: JOINT DIS NEC-SHOULDER ; VENTILATOR; NO ; OXYGEN: NO ; PREGNANT: SHLDRRT2 EXAM: XR Right Shoulder Complete, 2 or More Views CLINICAL HISTORY: 54 years old, ma le; 719.81 joint dis nec-shoulder S/F MVA TECHNIQUE: Two or more views of the right shoulder. COMPARISON: No relevant prior studies available. FINDINGS: Bones/joints: The patient is status post right laminectomy as involving at PrimedByGeorgeSquireson5/N2018326PM Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 7 of I I Wyckoff Heights Medical Center - Brooklyn, NY 11237 IIhlI - Patient: RAUL SANTILLAN DOB: 963 MR #: W002157352 Age/Gender: 54y M DOS: 5/6/2018 00:17 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZI UDEH, MD least T1 and T2. No acute fracture. No dislocation. Soft tissues: Unremarkable. IMPRESSION: No acute findings. This report was electronically signed by: Christopher Lawton MD Dictated on 05/06/18 0640 by LAWTON,CHRISTOPHER MD Transcribed on 05/06/18 064 0 by MEDITECH Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258 Sign by: LAWTON,CHRTSTCPHER MD RIBS UNILAT RIGHT W/PA CHEST ; REASON: CHEST WALL INJURY NEC ; VENTILATOR: NO ; OXYGEN: NO : PREGNANT: NO ; TRANSPORT: STRETCHER ; Order type: V.O. (Read back verified) ; Ordering physician:NGOZI UDEH MD Interfacedresult received:5/6/2018 12:59 interfacedresult completed: 5/6/20I8 01:1I RIBS UNZLAT RZGHT W/PA CHEST ; REASON: CHSST WALL ZNJR1RY NEC ; VENTZLATOR: NO ; OXYGEN: NO ; PREGN) CXR1RIB R EXAM: XR Right Ribs and AP Chest, 3 or More Views CLINICAL HISTORY: 54 years old, male; 959. 11 chest wall injury nec R/O fracture TECHNIQUE: Frontal and oblique views of the right ribs and frontal view of the chest. COMPARISON: No relevant prior studies available. FINDINGS: Lungs: Unremarkable. No consolidation. Pleural space: Unremarkable. No pneumothorax. Heart: Unremarkable. No cardiomegaly. Mediastinum: Unremarkable. Bones/joints: Unremarkable. No acute fracture. Upper abdomen: Surgical clips are noted in the right upper quadrant of the abdomen. Other findings: The patient is status post right laminectomies involving at - ... ..... .. . . PrintedByGeorgeSquiresonS/I40018326PM Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 8 of I I Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTlLLAN DOB: 963 MR #: W002157352 Age/Gender: 54y M DOS: 5/6/2018 00:17 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZI UDEH, MD least L1-L2. IMPRESSION: No acute findings. This report was electronically signed by: Christopher Lawton MD Dictated on 05/06/18 0645 by LAWTON,CHRISTOPHER MD Transcribed on 05/06/18 0645 by MEDITECH Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258 Sign by: LAWTON,CHRISTOPHER MD SPINE LUMBROSACRAL 2 OR 3 VIEW ; REASON: LUMBAGO ; VENTlLATOR: NO ; OXYGEN: NO ; PREGNANT: NO , TRANSPORT: STRETCHER ; Ordertype: V.O. (Read back verified) ; Ordering physician: NGOZl UDEH MD Interfaced resultreceived: 5/6/2018 12:59 Interfacedresult completed: 5/6/2018 01:12 SPINS LUMBROSACRAL 2 OR 3 VIEW ; REASON: LDHBAGO ; VENTILATOR: NO ; OXYGEN: NO ; PREGNANT: NO ; TF LSPINE2V EXAM: XR Lumbar Spine, 2 or 3 Views CLINICAL HISTORY: 54 years old, male; 724 .2 lumbago lower back pain S/P MVA TECHNIQUE: Frontal and lateral views of the lumbar spine. COMPARISON: No relevant prior studies available. FINDINGS: Vertebrae: There is minimal dextrocurvature of the lumbar spine. Anterior asteophytes are demonstrated at L3 and L4. No acute fracture. Disc spaces: There is mild narrowing of the intervertebral disc space at L3-4. Soft tissues: Surgical clips are noted in the right upper quadrant of the abdomen. IMPRESSION: Mild narrowing of the intervertebral disc space at L3-4 with PrimedBy George Squires on 5 It2018 3 26PA/ Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 9 of II Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTILLAN DOB: M963 MR #: W002157352 Age/Gender: 54y M DOS: 5/6/2018 00:17 Acet #: W00503693700 Private Phys: BAEZ ED Phys: NGOZl UDEH, MD anterior osteophytes. Minimal dextrocurvature of the lumber spine. Cholecystectomy. This report was electronically signed by: Christopher Lawton MD Dictated on 05/06/18 0641 by LAWTON,CHRISTOPHER MD Transcribed on 05/06/18 0641 by MEDITECH Sign by LAWTON,CHRISTOPHER MD on 05/06/18 1258 Sign by: LAWTON,CHRISTOPHER MD PROGRESS NOTES Progress: 54y/o male with MVA presenting with headache.neck pain ,rightshoulder pain ,rightchest wallpain and lower back pain allimaging studies arenegative forfracture ordislocation discharge home on motrin and robaxin NU 05/06/l8 04:16 DIAGNOSIS MVA (motor vehicle accident) Neck muscle spasm Chest wall contusion Sprain ofshoulder, right DISPOSITION Nursing Disposition isHome - Routine The patientwas discharged to home. The patientis alert and oriented and is inno respiratory distress. Patient's condition: good . Discharge mode is ambulatory . Patientaccompanied by self. The patient'sdiagnosis,condition and treatment were explained topatient or parent/guardian. The patient/responsible party expressed understanding. Extended patienteducation given to patient/guardian.A discharge plan has been developed. Aftercare instructions were givento thepatient. Discharge done Physician Discharge from ED: The patientis discharged to home. Patient'scondition is stable. The patientis tofollow-up with Follow up with your private medical doctor.3 day(s) from today as needed MANAGEMENTOPTIONS: No additional work-up planned. Prmted By George Squires on 3 14 2018 3 26 PM Clinical Chart FILED: KINGS COUNTY CLERK 02/15/2022 03:53 PM INDEX NO. 519867/2018 NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 02/15/2022 Page 10 of 1I Wyckoff Heights Medical Center - Brooklyn, NY 11237 Patient: RAUL SANTILLAN DOB: