Preview
FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020
EXHIBIT E
FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020
DHD Medical, P.C.
2132 Ralph Avenue
Brooldyn, NY 11234
718-.763-1400
FOLLOW UP PHYSIATRIC EVALUATION . .
PATIENT NAME: Lorenzo Gabriel
BVALUATION DATE: January 23, 2017
DATE OF ACClDENT: October 29, 2016
HISTORY OF PRESENT ILLNESS
This is a 29-year-cid-right-handed rnale, who returns for follow up evaluation aRer being injured in a
motor vehicle accident, which occurred on October 29, 2016.
The patient denies any new eceMents or injuries since his initial
evalanca on November 7, 2016.
CHIEF COMPLAINT:
The patient statesthat hisneck, leA shoulder, leftknee, lefthip, leftleg and thigh and leftribpain has
improved since his lastvisit.He statesthat he has occasional stiffness;however, his pain level is
much improved.
PHYSICAL TI-lERAPY:
The patientattended 19 sessions of physical therapy and he participates in a home exercise program.
MEDICATIONS: .
. None for pain atthis time.
DIAGNOSTIC STUDIES:
The patientunderwent CT scan ofthe cervical spine, left hip and leftknee. The finding were
reviewed and were discussed with the patient.All questions were answerest.
CONSULTATIONS:
The patientwas referred to Dr. Katzman, or±epedie surgeon, forevaluation of his leftshcalder, left
hip and leftknee pain. The patient statesthat he was seen by Dr. Katzman. He states that
Dr. Katzman referred him for an MRI. However, he has bene unable to obtain the MRI study. The
patient statesthat he was advised by Dr. Ketme to return to clinicstatus post the MRI study.
VOCATIONAL HISTORY:
The patient isa construction worker. The patient statesthat he has planned to returnto work on
January 24, 2017.
REVIEW OF SYSTEMS:
The patient denies any chaus- in hisbowel or bladder habits.He denies any fallsor loss ofbalance
in the interim visit.He denies headaches, nausea, vomiting, blurred vision or double vision.
PHYSICAL EXAMINATION:
General: The patient isa 29-year-old well-developed male. He is alertand oriersed x3. He
ambulates independently.
FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020
PATIENT NAME: Lorenzo Gabriel
EVALUATION DATE: January 23, 2017
MUSCULOSKELETAL EXAMINATION
Cervical spine: There is no tenderness on palpation of the cervical paraspinal musculare.
Range of motion: Flexion is 50 degrees, normal 50 degrees. Extension is 60 degrees, normal 60
degrees. Rotation to the right is 75 degrees and tothe left is 80 degrees, normal 80 degrees.
Left Shoulder There is no tenderness on palpation of the joint. Range of motion: Abduction is
180 degrees, normal 180 degrees. Forward flexion is 180 degrees, normal 180 degrees.
Left Hip: There is no tenderness on palpation of the joint Flexion is 0-120 normal 0-
degrees,
120 degrees.
Left Knee: There isno tenderness on palpation on the joint. Range of motion: Flexion is 0-130
degrees, normal 0-130 degrees.
Left thigh and left leg/pretibial area: examination is unremarkable.
MOTOR SYSTEM:
Motor strength is 5/5 in the upper and lower extremities.
MUSCLE STRETCH REFLEXES:
Deep tendon reflexes are 1+ in the upper extremities.
SBNSORY EXAM: . .
There is nonnel sensation to fine touch in the upper extremities.
All range of motion data was obtained objectively through the use of a handheld goniometer.
Normal ranges of motion are based on published values by the NYS Division of Disability
Workers'
Dete÷*is, NYS Compensation Board and the Manual of Structural Kinesiology,
2012.
ASSESSMENT:
1. Status post motor vehicle accident on October 29, 2016.
2. Cervical spine hemiated discs, bulging discs,myofascial derangement
3. Left shoulder internal derangement.
4. Left hip internal derangement with labral tear.
5. Left knee tear of the medial collateral ligamcat, internal derañgamêñt
6. Left thigh and legcontusion, clinicallyresolved.
7. Left rib strain/sprain/contusion.
RECOMMENDATIONS:
At this point, we will discontinue the patient's physical therapy program since he is
asymptomatic at thistime. The patient has reached maximal medical benefit from formal
physical therapy program.
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FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020
PATIENT NAME: Lorenzo Gabriel
EVALUATION DATE: January 23, 2017
BECOMMENDATIONS: (continued)
The patient isadvised that this of course does not mean that he is cured. I have explened to him
thatdue tothe nature of his hüuries that I would expect that he would continue to suffer from
periodic exacerbations in his pain and limitations in his abUities.
The patient was advised to ce*='nue gentle stretching and low impact exercises at home in an
effort to help slow the inevitably accelerated progression of his dissbñines due tothese injuries.
I have advised the patient to fouaw-up with Dr. Katzman, orthopcdie surgeon, with or without
the MRI studies. I have advised him to notify Dr. Katzman's oilice that he has had difficulty
obtaining the MRI study, per his referral. I again explained to the patient that in view of his
injuries, with regards to the lefthip and leftknee that he should follow-up with Dr. Katzman.
I have advised the patient to follow up with his regular medical doctor or clinic forany other
medical canditions or concerns.
I will re-evaluate the patient on an as needed basis.
CAUSALITY: .
There is a direct causal relationship betweeñ the patient's motor vehicle accident of
October 29, 2016 and his above complaints, disabilitiesand injuries.
DISABILITY:
The patient has not retamed to work since the eceident. He feels that he is now able to retum to
work and will retum to work on 1/24/2017. The patient previcasty complained of difficulty with
walking, heading, pmlonged standing. These activitieswere not a problem prior to the accident.
I have advised the patient to be vigiltst and notdo any activities that would further exacerbate
his injuries.
I helieve that his injuries and disabilities from thisaccident are significant, partial and
permanent.
This document serves as a letterof medical necessity for the above stated diagnostic testmg,
physical therapy, and referrals.
I,Yolande Bernard, M.D., being a physiciaa duly licensed to practice in the State of New York,
under the pccaltics of perjury, pursuant to CPLR, section 2106; do hereby affinn the cantents of
the foregoing.
Y andÉemard .D.
Physical Medicine and Rehabilitation
ilw
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Preview
FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020 EXHIBIT E FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020 DHD Medical, P.C. 2132 Ralph Avenue Brooldyn, NY 11234 718-.763-1400 FOLLOW UP PHYSIATRIC EVALUATION . . PATIENT NAME: Lorenzo Gabriel BVALUATION DATE: January 23, 2017 DATE OF ACClDENT: October 29, 2016 HISTORY OF PRESENT ILLNESS This is a 29-year-cid-right-handed rnale, who returns for follow up evaluation aRer being injured in a motor vehicle accident, which occurred on October 29, 2016. The patient denies any new eceMents or injuries since his initial evalanca on November 7, 2016. CHIEF COMPLAINT: The patient statesthat hisneck, leA shoulder, leftknee, lefthip, leftleg and thigh and leftribpain has improved since his lastvisit.He statesthat he has occasional stiffness;however, his pain level is much improved. PHYSICAL TI-lERAPY: The patientattended 19 sessions of physical therapy and he participates in a home exercise program. MEDICATIONS: . . None for pain atthis time. DIAGNOSTIC STUDIES: The patientunderwent CT scan ofthe cervical spine, left hip and leftknee. The finding were reviewed and were discussed with the patient.All questions were answerest. CONSULTATIONS: The patientwas referred to Dr. Katzman, or±epedie surgeon, forevaluation of his leftshcalder, left hip and leftknee pain. The patient statesthat he was seen by Dr. Katzman. He states that Dr. Katzman referred him for an MRI. However, he has bene unable to obtain the MRI study. The patient statesthat he was advised by Dr. Ketme to return to clinicstatus post the MRI study. VOCATIONAL HISTORY: The patient isa construction worker. The patient statesthat he has planned to returnto work on January 24, 2017. REVIEW OF SYSTEMS: The patient denies any chaus- in hisbowel or bladder habits.He denies any fallsor loss ofbalance in the interim visit.He denies headaches, nausea, vomiting, blurred vision or double vision. PHYSICAL EXAMINATION: General: The patient isa 29-year-old well-developed male. He is alertand oriersed x3. He ambulates independently. FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020 PATIENT NAME: Lorenzo Gabriel EVALUATION DATE: January 23, 2017 MUSCULOSKELETAL EXAMINATION Cervical spine: There is no tenderness on palpation of the cervical paraspinal musculare. Range of motion: Flexion is 50 degrees, normal 50 degrees. Extension is 60 degrees, normal 60 degrees. Rotation to the right is 75 degrees and tothe left is 80 degrees, normal 80 degrees. Left Shoulder There is no tenderness on palpation of the joint. Range of motion: Abduction is 180 degrees, normal 180 degrees. Forward flexion is 180 degrees, normal 180 degrees. Left Hip: There is no tenderness on palpation of the joint Flexion is 0-120 normal 0- degrees, 120 degrees. Left Knee: There isno tenderness on palpation on the joint. Range of motion: Flexion is 0-130 degrees, normal 0-130 degrees. Left thigh and left leg/pretibial area: examination is unremarkable. MOTOR SYSTEM: Motor strength is 5/5 in the upper and lower extremities. MUSCLE STRETCH REFLEXES: Deep tendon reflexes are 1+ in the upper extremities. SBNSORY EXAM: . . There is nonnel sensation to fine touch in the upper extremities. All range of motion data was obtained objectively through the use of a handheld goniometer. Normal ranges of motion are based on published values by the NYS Division of Disability Workers' Dete÷*is, NYS Compensation Board and the Manual of Structural Kinesiology, 2012. ASSESSMENT: 1. Status post motor vehicle accident on October 29, 2016. 2. Cervical spine hemiated discs, bulging discs,myofascial derangement 3. Left shoulder internal derangement. 4. Left hip internal derangement with labral tear. 5. Left knee tear of the medial collateral ligamcat, internal derañgamêñt 6. Left thigh and legcontusion, clinicallyresolved. 7. Left rib strain/sprain/contusion. RECOMMENDATIONS: At this point, we will discontinue the patient's physical therapy program since he is asymptomatic at thistime. The patient has reached maximal medical benefit from formal physical therapy program. 2 FILED: KINGS COUNTY CLERK 01/10/2020 03:02 PM INDEX NO. 519700/2018 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 01/10/2020 PATIENT NAME: Lorenzo Gabriel EVALUATION DATE: January 23, 2017 BECOMMENDATIONS: (continued) The patient isadvised that this of course does not mean that he is cured. I have explened to him thatdue tothe nature of his hüuries that I would expect that he would continue to suffer from periodic exacerbations in his pain and limitations in his abUities. The patient was advised to ce*='nue gentle stretching and low impact exercises at home in an effort to help slow the inevitably accelerated progression of his dissbñines due tothese injuries. I have advised the patient to fouaw-up with Dr. Katzman, orthopcdie surgeon, with or without the MRI studies. I have advised him to notify Dr. Katzman's oilice that he has had difficulty obtaining the MRI study, per his referral. I again explained to the patient that in view of his injuries, with regards to the lefthip and leftknee that he should follow-up with Dr. Katzman. I have advised the patient to follow up with his regular medical doctor or clinic forany other medical canditions or concerns. I will re-evaluate the patient on an as needed basis. CAUSALITY: . There is a direct causal relationship betweeñ the patient's motor vehicle accident of October 29, 2016 and his above complaints, disabilitiesand injuries. DISABILITY: The patient has not retamed to work since the eceident. He feels that he is now able to retum to work and will retum to work on 1/24/2017. The patient previcasty complained of difficulty with walking, heading, pmlonged standing. These activitieswere not a problem prior to the accident. I have advised the patient to be vigiltst and notdo any activities that would further exacerbate his injuries. I helieve that his injuries and disabilities from thisaccident are significant, partial and permanent. This document serves as a letterof medical necessity for the above stated diagnostic testmg, physical therapy, and referrals. I,Yolande Bernard, M.D., being a physiciaa duly licensed to practice in the State of New York, under the pccaltics of perjury, pursuant to CPLR, section 2106; do hereby affinn the cantents of the foregoing. Y andÉemard .D. Physical Medicine and Rehabilitation ilw 3