Preview
FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF SUFFOLK
-----------------------------------------------------------------------X
ALICIA M. ARUNDEL; SUZANNE SCHULMAN, AS Index No.: 611214/2015
ADMINISTRATRIX OF THE ESTATE OF BRITTNEY
M. SCHULMAN, DECEASED; OLGA LIPETS; MINDY
GRABINA, AS ADMINSTRATRIX OF THE ESTATE
OF AMY GRABINA, AND MINDY GRABINA,
INDIVIDUALLY; STEVEN BARUCH, AS ADMINISTRATOR
OF THE ESTATE OF LAUREN BARUCH, DECEASED,
AND STEVEN BARUCH, INDIVIDUALLY; JOELLE
DIMONTE; AND MELISSA A. CRAI, NOTICE OF EXPERT
WITNESS DISCLOSURE
Plaintiffs, PURSUANT TO § 3101(d)
-against-
ULTIMATE CLASS LIMOUSINE, INC., CARLOS PINO,
ROMEO DIMON MARINE SERVICE, INC., STEVEN
ROMEO, TOWN OF SOUTHOLD and COUNTY OF
SUFFOLK, CABOT COACH BUILDERS, INC., d/b/a
1-5"
ROYALE LIMOUSINE and "XYZ COMPANIES
name being fictitious but intended to be the remanufacturers,
distributors and/or sellers of the 2007 Lincoln Town Car
stretch limousine involved in the collision,
Defendants.
-----------------------------------------------------------------------X
TO: Plaintiff, MELISSA A. CRAI
PLEASE TAKE NOTICE, that pursuant to CPLR §3101(d) the defendant,
CABOT COACH BUILDERS, INC., intends to call Dr. Suzanne L. Tuzel, M.D., to testify as an
expert witness at the time of trial in the above-captioned matter. Dr. Tuzel is a Diplomate American
Board of Psychiatry & Neurology and a licensed medical practitioner in the State of New York. Dr.
Tuzel will testify based upon, but not limited to, a review of the plaintiff, Melissa A. Crai's medical
records, and examinations of the plaintiff.
A copy of Dr. Tuzel's report and curriculum vitae are annexed hereto.
1
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PLEASE TAKE FURTHER NOTICE, that the undersigned reserves all rights
to supplement and/or alter any or all of the foregoing if and when additional and/or different
information becomes available and/ or known up to and including the time of trial.
PLEASE TAKE FURTHER NOTICE, that pursuant to Section 130.01 of the
Rules of the Chief Administrator (22NYCRR), I certify to the best of my knowledge,
information and belief, formed after an inquiry reasonable under the circumstances, that the
within Response to 3101 Notice is not frivolous.
Dated: April 14, 2021
Melville, New York
Yours, etc.
LAW OFFICE OF VICTOR J. NATALE
_________________________________
STEVEN A. STEIGERWALD
Attorneys for Defendant
CABOT COACH BUILDERS, INC., d/b/a
ROYALE LIMOUSINE
Mailing address:
P.O. Box 2903
Hartford, CT 06104-2903
(631) 501-3100
TO:
Joseph J. Tock, Esq.
Attorney for Plaintiff
Melissa A. Crai
963 Route 6
Mahopac, NY 10541
(845) 628-8080
2
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NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022
SUZANNEL. TUZEL, M.D.
222 MIDDLE COUNTRY RD.
SUITE 210
SMITHTOWN,NEW YORK 11787
Telephone(631) 265-6868
Fux (631) 265-6890
PSYCHIATRIC INDEPENDENT MEDICAL EXAMINATION
March 1, 2020
Law offices of Andrea G. Sawyers
Attn.: Steven A. Steigerwald
3 Huntington Quadrangle, Suite 1025
Melville, NY 11747
CLAIMANT: Melissa Crai
DATE OF BIRTH: 06/02/1992
CLAIM#: E3R8872
DAiE OF INJURY: 07/18/2015
DATE OF EXAM: 02/25/2020, 4:00 p.m.
To Whom It May concern:
A psychiatric examination of Ms. Melissa Crai was performed at
this examining physician's office, North Shore Psychiatric
Consultants, 222 Middle Country Road, Suite 210, Smithtown, New
York, on February 25, 2020. Ms. Crai arrived 15 minutes late for
her appointment scheduled at 4:00 p.m. A thorough evaluation in
the form of her New York State Driver's License was reviewed. It
was explained to the examinee that this appointment was for the
purpose of evaluation only and therefore no doctor-patient
relationship would be established.
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REVIEW OF MEDICAL RECORDS
TABLE OF CONTENTS
Legal Documents
Suffolk County Supreme Court response to
interrogatories, index # 611214/2015.
10/05/2017 Stony Brook University Hospital Medical Records
07/18/2015 Daniel - diagnosis splenic
Rutigliano, D.O., admitting
laceration.
07/19/2015 Advance - none.
Directive information
07/18/2015 Edvard Skripochnik, M.D. / Jerry Rubano, M.D.,
- discharge with - motor
summary final diagnoses vehicle
07/24/2015 collision with multiple facial and skull fractures
with two epidural hematomas and a grade II splenic
laceration.
07/18/2015 Inpatient clinical summary. Attending physician Daniel
- D.O.
Rutigliano,
07/24/2015
07/18/2015 History and physical. Daniel Rutigliano, D.O.,
- M.D.
attending Brian Wright,
07/24/2015
07/18/2015 Neurosurgery consultation.
07/24/2015
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07/18/2015 Raphael Davis, M.D. Impression: Left temporal
epidural hematoma, sinus and orbital fractures with
pneumocephalus.
07/20/2015 Samuel Kri vit, PA.
07/18/2015 Progress Notes
07/24/2015
Trauma Surgery Daniel Rutigliano, signed
07/15/2015.
Psychiatry -
Christa Sinha, RN, signed 07/23/2015 and
07/24/2015.
Neurology -
discharge medications: Keppra 500 mg
b.i.d., oxycodone 5 mg q.6h. p.r.n.
Neurologie: Total Glasgow Coma Scale -
15.
Documentation of vital signs, hematology and
chemistry lab results.
Radiology Results -
Steven West, D.O.
07/20/2015 -
Head CT
(1) Stable left middle cranial fossa epidural
hematoma with mass effect on temporal lobe.
(2) Stable subdural hematoma with associated orbital
fractures.
(3) Stable subarachnoid hemorrhage in the left
inferior frontal foci.
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Cardiology Progress Notes -
no evidence of acute deep
vein thrombosis, signed on 07/23/2015 by Frederick
Gutman, M.O.
Oromaxillofacial Surgery Progress Notes -
no acute
OMFS surgical intervention indicated with
recommendation for sinus precautions and
ophthalmology consult, signed on 07/20/2015 by Robert
Lynn, DMD, and Mark Gelfand, M.O.
Surgical ICU Progress Notes cervical collar
discontinued, signed on 07/20/2015 by Steven
Sandoval, M.O., and Brian Wright, M. D. I on
07/19/2015.
07/23/2015 -
Jerry Rubano, M.D., downgraded from SICU
to ICR.
Nutrition consult/note -
poor appetite signed on
07/21/2015 by Thomas Dominguez.
Skin assessment notes with illegible signature dated
07/18/2015 and 07/20/2015.
Discharge Note dated 07/24/2015.
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Clinical flow sheets including cardiovascular flow
sheets, falls information flow sheet,
gastrointestinal flow sheets, genitourinary flow
sheet, head/neck flow sheets, integumentary flow
sheets, and neurological and neurovascular flow
sheets.
Orders/Actions/Interventions flow sheets, chemistry
flow sheets, hematology flow sheets
Molecular Genetics -
MRSA PCR negative on 07/18/2015.
Diagnostic Radiology
07/18/2015 Chest Al? with impression: no acute cardiopulmonary
and process, signed by radiologist Almas Abbasi, M. D,,
07/19/2015 and Cliff Bernstein.
07/18/2015 Pelvic AP with impression: No pelvic fracture1 signed
by radiologist William Moore, M.D.
07/18/2015 CT facial bone, mandible without IV contrast with
impression: Bilateral nasal bone, left frontal bone,
left orbital roof, and left cribriform plate
fractures. Hemorrhage in ethmoid air cells and
sphenoid sinuses. Signed by radiologist William
Moore, M.D.
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07/18/2015 CT abdomen and pelvis with IV contrast, impression:
Grade II laceration of spleen with laceration depth
of 2 cm extending to the splenic hilum, perisplenic
hematoma and hemoperitoneum. Signed by radiologist
Matthew Barish, M,D.
CT chest with IV contrast on 07/18/2015 with
impression same as above.
07/18/2015 CT head routine without IV contrast with impression:
X 2, (1) Stable left middle cranial fossa epidural
07/19/2015 hematoma with mass effect on temporal lobe.
and (2) Stable subdural hematoma along left frontal
07/20/2015 convexity with associated orbital fractures.
(3) Stable subarachnoid hemorrhage in left inferior
frontal sulci.
Signed by radiologist Steven West, M.D,, on
07/20/2015 and Luboslav Woroch, D.O., on 07/18/2015.
07/18/2015 CT spine cervical without IV contrast with
impression: No fracture or subluxation. Signed by
radiologist William Moore, M.O.
07/18/2015 CT spine lumbar without IV contrast with impression:
No defini ti ve acute compression fracture. Signed by
·
radiologist Jared Dunkin, M,D.
07/18/2015 CT spine, thoracic without IV contrast with
impression: No definitive acute compression fracture.
Signed by radiologist Jared Dunkin1 M.O.
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07/21/2015 Lower limb venous duplex with impression: Venous
duplex of right and left lower extremity showed no
evidence of acute deep vein thrombosis.
07/19/2015 EKG report and interpretation with impression of
sinus tachycardia, otherwise normal ECG.
07/18/2015 Immunizations: Tdap administered IM to left arm.
Assessment Documentation
07/19/2015: sepsis -
none.
07/18/2015 to 07/24/2015: p.r.n. medication
effectiveness -
yes.
07/18/2015 to 07/24/2015: Early Warning Scores Form -
green-yellow score.
07/18/2015 to 07/19/2015: Patient Factors Form -
height 5'4", weight 114.6 pounds.
07/19/2015: Home Medication Form.
07/19/2015: Adult Nursing History Form.
07/24/2015: Nursing Discharge Summary.
07/19/2015 to 07/23/2015: Turning and positioning -
the patient repositions self and on 07/23/2015 out of
bed.
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07/22/2015: Inpatient occupational therapy evaluation
-
ADL independent with no interventions needed.
07/19/2015 to 07/20/2015: SICU daily goals and plan
of care.
07/18/2015 to 07/21/2015: Interdisciplinary plan of
care, problem list and goals.
07/22/2015: ADL evaluation.
07/19/2015 to 07/24/2015: Hygiene ADLs.
07/20/2015 to 07/23/2015: Nutrition ADLs.
07/18/2015 to 07/24/2015: Activity ADLs.
07/19/2015 to 07/24/2015: Assessment prior to
admission.
07/18/2015: Education skills and needs -
inpatient
care management/social work documents.
07/20/2015: Care management initial assessment.
Care management progress notes: 07/18/2015,
07/20/2015, and 07/24/2015.
07/21/2015: Care management inpatient comprehensive
assessment.
Care management discharge plan with no post-acute
services listed.
07/19/2015 to 07/21/2015: Admission information.
07/22/2015: Orientation assessment with findings of
orientated x 4.
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07/18/2015 to 07/22/2015: Physician VTE assessment.
07/18/2015 to 07/21/2015: Assessment review.
07/18/2015 to 07/20/2015: Body position information.
07/24/2015: Discharge information.
07/18/2015 to 07/24/2015: Musculoskeletal
information.
07/19/2015 to 07/22/2015: System assessment.
07/19/2015 to 07/24/2015: Nutritional assessments.
07/19/2015: Blood transfusion with banked blood -
no.
07/18/2015 to 07/24/2015: Psychosocial -
essentially
unremarkable.
07/19/2015 to 07/24/2015: Restraints -
unremarkable.
07/18/2015 to 07/24/2015: Respiratory therapy
essentially unremarkable.
07/19/2015 to 07/24/2015: Risk scores -
agitation
risk factor score consistently zero.
07/22/2015: OT evaluation/treatment -
no therapy
needs.
07/18/2015 to 07/24/2015: Vascular assessment -
no
complications.
07/18/2015 to 07/24/2015: Vital signs, vital
measurements -
essentially unremarkable.
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Diagnostic Testing
07/19/2015 ECG - sinus tachycardia, otherwise normal ECG.
07/18/2015 record - unremarkable.
Daily telemetry essentially
to
07/24/2015
07/18/2015 ED Triage Note - arrived from the scene of accident
by helicopter with the patient unable to give name.
......
07/18/2015 ED Physician Note - Impression & Plan: Splenic
laceration, closed fracture of orbital wall, epidural
hematoma, subdural hematoma, hemoperitoneum,
condition disposition - admission to ICU.
guarded,
Signed by Asher Baer, M.D.
07/18/2015 New York State Department of Health EMS.
Trauma - Prehospital Care Report with chief
die."
complaint: "Everything hurts, I want to
Signature was illegible.
07/18/2015 Stony Brook final report: CT facial bone mandible
without IV contrast - bilateral nasal left
bone,
frontal bone, left orbital roof, and left cribriform
plate fracture. Signed by radiologist William Moore,
M.D.
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07/18/2015 Noncontrast head CT -
fractures of bilateral nasal
bone extending into the frontal sinuses, left frontal
bone fracture, fractures of the cribriform plates and
roof of the left orbit with probable subdural
hematoma along left frontal lobe and epidural
hematoma along left middle cranial fossa. Signed by
radiologist William Moore, M.O.
07/18/2015 CT of abdomen and pelvis with IV contrast.
Impression: Grade II laceration of spleen with
laceration depth of 2 cm extending to the splenic
hilurn. Signed by radiologist Matthew Barish, M.O.
07/18/2015 CT spine thoracic and lumbar without contrast.
Impression: No definitive acute compression
fractures. Signed by radiologist Jared Dunkin, M.O.
07 /18 /20Í5 Final Report -
CT head without contrast. Impression:
Stable left middle cranial fossa epidural hematoma,
and left frontal subdural hemorrhage with left
frontal bone fracture. Signed by radiologist Michael
Reiter, D.O.
07/19/2015 final Report -
CT head without contrast. Impression:
Stable left middle cranial fossa epidural hematoma
with underlying mass effect. Signed by radiologist
Luboslav Woroch, D.O.
Stony Brook University Hospital consultations with
07/19/2015 OMFS consultation with impression:
Multiple facial and skull fractures, no acute OMFS
surgical intervention indicated. Signed by attending
Mark Gelfand, M.O.
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07/20/2015 Ophthalmology Consult -
Impression:
(1) Stable left middle cranial fossa epidural
hematoma with mass effect on temporal lobe.
(2) Stable subdural hematoma along the left frontal
convexity with associated orbital fractures.
(3) Stable subarachnoid hemorrhage in the left
inferior frontal sulci.
Recommendation: Lubrication OS with artificial tears
and followup with ophthalmologist upon discharge.
Signed by attending Timothy Chou, M.D.
07/20/2015 Final Report -
CT head without contrast. Impression:
Left middle cranial fossa epidural hematoma with mass
effect upon the temporal lobe. Signed by attending
radiologist Steven West, D.O.
Ledger Itemized View Report: 07/13/2015 to
01/09/2017.
CiOx Health Invoice dated 11/27/2017.
IOD Invoice dated 12/21/2017.
07 /31/20f5 NYOMIS Gary Orentlicher, DMD. Followup from
discharge report. Assessment & Plan: No treatment
indicated with followup as needed.
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west Chester Medical Center
08/02/2015: Final consult: CT abdomen/pelvis with
impression; Large splenic laceration in interior
spleen grade II; hemoperitoneum.
08/02/2015: Final report: Outside CT head.
Impression: No acute intracranial hemorrhage, mass
effect, midline shift, or hydrocephalus. Signed by
Shalabh Bobra, M.O.
08/02/2015 to 08/06/2015: Discharge summary: Status
post traumatic splenic injury/re-bleed. Discharge
home. Signed by Gary Lombardo, M.D.
08/02/2015: Hospital documentation notes signed by
Donald McKnight, M.D. Admitted to ICU with grade III
splenic laceration.
08/02/2015: Express Ambulance final patient care
report.
08/02/2015: Trauma surgery history and physical and
flow sheets with admit to TICU, signature illegible.
08/02/2015 to 08/06/2015: Progress notes signed by
Prem Patel, M.D.
08/02/2015 to 08/06/2015: Daily cumulative
hematology, coagulation, chemistry, and miscellaneous
lab results, signed by John T. Fallon, M.D., Ph.D.,
Director of Laboratory Services.
08/02/2015: Vital signs report signed by Lucy
Cheevers, RN.
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08/02/2015 -
08/03/2015: IV administration record
with attending Gary Lombardo, M.D.
08/02/2015 -
08/05/2015: Medication administration
record, attending Gary Lombardo, M.D.
08/02/2015 -
08/06/2015: Nursing assessment record,
electronically signed by various nurses.
08/02/2015: Nursing administration database signed by
Lucy Cheevers, RN, signature illegible.
08/02/2015 -
08/05/2015: Braden Scale by attending
Gary Lombardo, M.D.
08/02/2015: Mobility profile records by attending
Gary Lombardo, M.D.
08/02/2015 -
08/06/2015: Fain assessment records
electronically signed by various nurses.
08/03/2015 08/04/2015: TICO patient flow
sheets/nurses' notes and initial assessment dated
08/03/2015.
08/04/2015 -
08/05/2015: Intake and output record
with no signature recorded.
08/04/2015 08/06/2015: Vital sign records
electronically signed by various nurses.
08/02/2015 08/04/2015: Initial consult
ophthalmology with impression: Subconj une ti val heme
left eye, by attending Kenneth Juechter, M.D.
08/03/2015 -
08/06/2015: Patient care flow sheet
electronically signed by various nurses.
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Preview
FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF SUFFOLK -----------------------------------------------------------------------X ALICIA M. ARUNDEL; SUZANNE SCHULMAN, AS Index No.: 611214/2015 ADMINISTRATRIX OF THE ESTATE OF BRITTNEY M. SCHULMAN, DECEASED; OLGA LIPETS; MINDY GRABINA, AS ADMINSTRATRIX OF THE ESTATE OF AMY GRABINA, AND MINDY GRABINA, INDIVIDUALLY; STEVEN BARUCH, AS ADMINISTRATOR OF THE ESTATE OF LAUREN BARUCH, DECEASED, AND STEVEN BARUCH, INDIVIDUALLY; JOELLE DIMONTE; AND MELISSA A. CRAI, NOTICE OF EXPERT WITNESS DISCLOSURE Plaintiffs, PURSUANT TO § 3101(d) -against- ULTIMATE CLASS LIMOUSINE, INC., CARLOS PINO, ROMEO DIMON MARINE SERVICE, INC., STEVEN ROMEO, TOWN OF SOUTHOLD and COUNTY OF SUFFOLK, CABOT COACH BUILDERS, INC., d/b/a 1-5" ROYALE LIMOUSINE and "XYZ COMPANIES name being fictitious but intended to be the remanufacturers, distributors and/or sellers of the 2007 Lincoln Town Car stretch limousine involved in the collision, Defendants. -----------------------------------------------------------------------X TO: Plaintiff, MELISSA A. CRAI PLEASE TAKE NOTICE, that pursuant to CPLR §3101(d) the defendant, CABOT COACH BUILDERS, INC., intends to call Dr. Suzanne L. Tuzel, M.D., to testify as an expert witness at the time of trial in the above-captioned matter. Dr. Tuzel is a Diplomate American Board of Psychiatry & Neurology and a licensed medical practitioner in the State of New York. Dr. Tuzel will testify based upon, but not limited to, a review of the plaintiff, Melissa A. Crai's medical records, and examinations of the plaintiff. A copy of Dr. Tuzel's report and curriculum vitae are annexed hereto. 1 1 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 PLEASE TAKE FURTHER NOTICE, that the undersigned reserves all rights to supplement and/or alter any or all of the foregoing if and when additional and/or different information becomes available and/ or known up to and including the time of trial. PLEASE TAKE FURTHER NOTICE, that pursuant to Section 130.01 of the Rules of the Chief Administrator (22NYCRR), I certify to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the within Response to 3101 Notice is not frivolous. Dated: April 14, 2021 Melville, New York Yours, etc. LAW OFFICE OF VICTOR J. NATALE _________________________________ STEVEN A. STEIGERWALD Attorneys for Defendant CABOT COACH BUILDERS, INC., d/b/a ROYALE LIMOUSINE Mailing address: P.O. Box 2903 Hartford, CT 06104-2903 (631) 501-3100 TO: Joseph J. Tock, Esq. Attorney for Plaintiff Melissa A. Crai 963 Route 6 Mahopac, NY 10541 (845) 628-8080 2 2 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 SUZANNEL. TUZEL, M.D. 222 MIDDLE COUNTRY RD. SUITE 210 SMITHTOWN,NEW YORK 11787 Telephone(631) 265-6868 Fux (631) 265-6890 PSYCHIATRIC INDEPENDENT MEDICAL EXAMINATION March 1, 2020 Law offices of Andrea G. Sawyers Attn.: Steven A. Steigerwald 3 Huntington Quadrangle, Suite 1025 Melville, NY 11747 CLAIMANT: Melissa Crai DATE OF BIRTH: 06/02/1992 CLAIM#: E3R8872 DAiE OF INJURY: 07/18/2015 DATE OF EXAM: 02/25/2020, 4:00 p.m. To Whom It May concern: A psychiatric examination of Ms. Melissa Crai was performed at this examining physician's office, North Shore Psychiatric Consultants, 222 Middle Country Road, Suite 210, Smithtown, New York, on February 25, 2020. Ms. Crai arrived 15 minutes late for her appointment scheduled at 4:00 p.m. A thorough evaluation in the form of her New York State Driver's License was reviewed. It was explained to the examinee that this appointment was for the purpose of evaluation only and therefore no doctor-patient relationship would be established. 3 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 2 REVIEW OF MEDICAL RECORDS TABLE OF CONTENTS Legal Documents Suffolk County Supreme Court response to interrogatories, index # 611214/2015. 10/05/2017 Stony Brook University Hospital Medical Records 07/18/2015 Daniel - diagnosis splenic Rutigliano, D.O., admitting laceration. 07/19/2015 Advance - none. Directive information 07/18/2015 Edvard Skripochnik, M.D. / Jerry Rubano, M.D., - discharge with - motor summary final diagnoses vehicle 07/24/2015 collision with multiple facial and skull fractures with two epidural hematomas and a grade II splenic laceration. 07/18/2015 Inpatient clinical summary. Attending physician Daniel - D.O. Rutigliano, 07/24/2015 07/18/2015 History and physical. Daniel Rutigliano, D.O., - M.D. attending Brian Wright, 07/24/2015 07/18/2015 Neurosurgery consultation. 07/24/2015 4 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 3 07/18/2015 Raphael Davis, M.D. Impression: Left temporal epidural hematoma, sinus and orbital fractures with pneumocephalus. 07/20/2015 Samuel Kri vit, PA. 07/18/2015 Progress Notes 07/24/2015 Trauma Surgery Daniel Rutigliano, signed 07/15/2015. Psychiatry - Christa Sinha, RN, signed 07/23/2015 and 07/24/2015. Neurology - discharge medications: Keppra 500 mg b.i.d., oxycodone 5 mg q.6h. p.r.n. Neurologie: Total Glasgow Coma Scale - 15. Documentation of vital signs, hematology and chemistry lab results. Radiology Results - Steven West, D.O. 07/20/2015 - Head CT (1) Stable left middle cranial fossa epidural hematoma with mass effect on temporal lobe. (2) Stable subdural hematoma with associated orbital fractures. (3) Stable subarachnoid hemorrhage in the left inferior frontal foci. 5 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 4 Cardiology Progress Notes - no evidence of acute deep vein thrombosis, signed on 07/23/2015 by Frederick Gutman, M.O. Oromaxillofacial Surgery Progress Notes - no acute OMFS surgical intervention indicated with recommendation for sinus precautions and ophthalmology consult, signed on 07/20/2015 by Robert Lynn, DMD, and Mark Gelfand, M.O. Surgical ICU Progress Notes cervical collar discontinued, signed on 07/20/2015 by Steven Sandoval, M.O., and Brian Wright, M. D. I on 07/19/2015. 07/23/2015 - Jerry Rubano, M.D., downgraded from SICU to ICR. Nutrition consult/note - poor appetite signed on 07/21/2015 by Thomas Dominguez. Skin assessment notes with illegible signature dated 07/18/2015 and 07/20/2015. Discharge Note dated 07/24/2015. 6 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 5 Clinical flow sheets including cardiovascular flow sheets, falls information flow sheet, gastrointestinal flow sheets, genitourinary flow sheet, head/neck flow sheets, integumentary flow sheets, and neurological and neurovascular flow sheets. Orders/Actions/Interventions flow sheets, chemistry flow sheets, hematology flow sheets Molecular Genetics - MRSA PCR negative on 07/18/2015. Diagnostic Radiology 07/18/2015 Chest Al? with impression: no acute cardiopulmonary and process, signed by radiologist Almas Abbasi, M. D,, 07/19/2015 and Cliff Bernstein. 07/18/2015 Pelvic AP with impression: No pelvic fracture1 signed by radiologist William Moore, M.D. 07/18/2015 CT facial bone, mandible without IV contrast with impression: Bilateral nasal bone, left frontal bone, left orbital roof, and left cribriform plate fractures. Hemorrhage in ethmoid air cells and sphenoid sinuses. Signed by radiologist William Moore, M.D. 7 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 6 07/18/2015 CT abdomen and pelvis with IV contrast, impression: Grade II laceration of spleen with laceration depth of 2 cm extending to the splenic hilum, perisplenic hematoma and hemoperitoneum. Signed by radiologist Matthew Barish, M,D. CT chest with IV contrast on 07/18/2015 with impression same as above. 07/18/2015 CT head routine without IV contrast with impression: X 2, (1) Stable left middle cranial fossa epidural 07/19/2015 hematoma with mass effect on temporal lobe. and (2) Stable subdural hematoma along left frontal 07/20/2015 convexity with associated orbital fractures. (3) Stable subarachnoid hemorrhage in left inferior frontal sulci. Signed by radiologist Steven West, M.D,, on 07/20/2015 and Luboslav Woroch, D.O., on 07/18/2015. 07/18/2015 CT spine cervical without IV contrast with impression: No fracture or subluxation. Signed by radiologist William Moore, M.O. 07/18/2015 CT spine lumbar without IV contrast with impression: No defini ti ve acute compression fracture. Signed by · radiologist Jared Dunkin, M,D. 07/18/2015 CT spine, thoracic without IV contrast with impression: No definitive acute compression fracture. Signed by radiologist Jared Dunkin1 M.O. 8 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 7 07/21/2015 Lower limb venous duplex with impression: Venous duplex of right and left lower extremity showed no evidence of acute deep vein thrombosis. 07/19/2015 EKG report and interpretation with impression of sinus tachycardia, otherwise normal ECG. 07/18/2015 Immunizations: Tdap administered IM to left arm. Assessment Documentation 07/19/2015: sepsis - none. 07/18/2015 to 07/24/2015: p.r.n. medication effectiveness - yes. 07/18/2015 to 07/24/2015: Early Warning Scores Form - green-yellow score. 07/18/2015 to 07/19/2015: Patient Factors Form - height 5'4", weight 114.6 pounds. 07/19/2015: Home Medication Form. 07/19/2015: Adult Nursing History Form. 07/24/2015: Nursing Discharge Summary. 07/19/2015 to 07/23/2015: Turning and positioning - the patient repositions self and on 07/23/2015 out of bed. 9 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 8 07/22/2015: Inpatient occupational therapy evaluation - ADL independent with no interventions needed. 07/19/2015 to 07/20/2015: SICU daily goals and plan of care. 07/18/2015 to 07/21/2015: Interdisciplinary plan of care, problem list and goals. 07/22/2015: ADL evaluation. 07/19/2015 to 07/24/2015: Hygiene ADLs. 07/20/2015 to 07/23/2015: Nutrition ADLs. 07/18/2015 to 07/24/2015: Activity ADLs. 07/19/2015 to 07/24/2015: Assessment prior to admission. 07/18/2015: Education skills and needs - inpatient care management/social work documents. 07/20/2015: Care management initial assessment. Care management progress notes: 07/18/2015, 07/20/2015, and 07/24/2015. 07/21/2015: Care management inpatient comprehensive assessment. Care management discharge plan with no post-acute services listed. 07/19/2015 to 07/21/2015: Admission information. 07/22/2015: Orientation assessment with findings of orientated x 4. 10 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 9 07/18/2015 to 07/22/2015: Physician VTE assessment. 07/18/2015 to 07/21/2015: Assessment review. 07/18/2015 to 07/20/2015: Body position information. 07/24/2015: Discharge information. 07/18/2015 to 07/24/2015: Musculoskeletal information. 07/19/2015 to 07/22/2015: System assessment. 07/19/2015 to 07/24/2015: Nutritional assessments. 07/19/2015: Blood transfusion with banked blood - no. 07/18/2015 to 07/24/2015: Psychosocial - essentially unremarkable. 07/19/2015 to 07/24/2015: Restraints - unremarkable. 07/18/2015 to 07/24/2015: Respiratory therapy essentially unremarkable. 07/19/2015 to 07/24/2015: Risk scores - agitation risk factor score consistently zero. 07/22/2015: OT evaluation/treatment - no therapy needs. 07/18/2015 to 07/24/2015: Vascular assessment - no complications. 07/18/2015 to 07/24/2015: Vital signs, vital measurements - essentially unremarkable. 11 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 10 Diagnostic Testing 07/19/2015 ECG - sinus tachycardia, otherwise normal ECG. 07/18/2015 record - unremarkable. Daily telemetry essentially to 07/24/2015 07/18/2015 ED Triage Note - arrived from the scene of accident by helicopter with the patient unable to give name. ...... 07/18/2015 ED Physician Note - Impression & Plan: Splenic laceration, closed fracture of orbital wall, epidural hematoma, subdural hematoma, hemoperitoneum, condition disposition - admission to ICU. guarded, Signed by Asher Baer, M.D. 07/18/2015 New York State Department of Health EMS. Trauma - Prehospital Care Report with chief die." complaint: "Everything hurts, I want to Signature was illegible. 07/18/2015 Stony Brook final report: CT facial bone mandible without IV contrast - bilateral nasal left bone, frontal bone, left orbital roof, and left cribriform plate fracture. Signed by radiologist William Moore, M.D. 12 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 11 07/18/2015 Noncontrast head CT - fractures of bilateral nasal bone extending into the frontal sinuses, left frontal bone fracture, fractures of the cribriform plates and roof of the left orbit with probable subdural hematoma along left frontal lobe and epidural hematoma along left middle cranial fossa. Signed by radiologist William Moore, M.O. 07/18/2015 CT of abdomen and pelvis with IV contrast. Impression: Grade II laceration of spleen with laceration depth of 2 cm extending to the splenic hilurn. Signed by radiologist Matthew Barish, M.O. 07/18/2015 CT spine thoracic and lumbar without contrast. Impression: No definitive acute compression fractures. Signed by radiologist Jared Dunkin, M.O. 07 /18 /20Í5 Final Report - CT head without contrast. Impression: Stable left middle cranial fossa epidural hematoma, and left frontal subdural hemorrhage with left frontal bone fracture. Signed by radiologist Michael Reiter, D.O. 07/19/2015 final Report - CT head without contrast. Impression: Stable left middle cranial fossa epidural hematoma with underlying mass effect. Signed by radiologist Luboslav Woroch, D.O. Stony Brook University Hospital consultations with 07/19/2015 OMFS consultation with impression: Multiple facial and skull fractures, no acute OMFS surgical intervention indicated. Signed by attending Mark Gelfand, M.O. 13 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 12 07/20/2015 Ophthalmology Consult - Impression: (1) Stable left middle cranial fossa epidural hematoma with mass effect on temporal lobe. (2) Stable subdural hematoma along the left frontal convexity with associated orbital fractures. (3) Stable subarachnoid hemorrhage in the left inferior frontal sulci. Recommendation: Lubrication OS with artificial tears and followup with ophthalmologist upon discharge. Signed by attending Timothy Chou, M.D. 07/20/2015 Final Report - CT head without contrast. Impression: Left middle cranial fossa epidural hematoma with mass effect upon the temporal lobe. Signed by attending radiologist Steven West, D.O. Ledger Itemized View Report: 07/13/2015 to 01/09/2017. CiOx Health Invoice dated 11/27/2017. IOD Invoice dated 12/21/2017. 07 /31/20f5 NYOMIS Gary Orentlicher, DMD. Followup from discharge report. Assessment & Plan: No treatment indicated with followup as needed. 14 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 13 west Chester Medical Center 08/02/2015: Final consult: CT abdomen/pelvis with impression; Large splenic laceration in interior spleen grade II; hemoperitoneum. 08/02/2015: Final report: Outside CT head. Impression: No acute intracranial hemorrhage, mass effect, midline shift, or hydrocephalus. Signed by Shalabh Bobra, M.O. 08/02/2015 to 08/06/2015: Discharge summary: Status post traumatic splenic injury/re-bleed. Discharge home. Signed by Gary Lombardo, M.D. 08/02/2015: Hospital documentation notes signed by Donald McKnight, M.D. Admitted to ICU with grade III splenic laceration. 08/02/2015: Express Ambulance final patient care report. 08/02/2015: Trauma surgery history and physical and flow sheets with admit to TICU, signature illegible. 08/02/2015 to 08/06/2015: Progress notes signed by Prem Patel, M.D. 08/02/2015 to 08/06/2015: Daily cumulative hematology, coagulation, chemistry, and miscellaneous lab results, signed by John T. Fallon, M.D., Ph.D., Director of Laboratory Services. 08/02/2015: Vital signs report signed by Lucy Cheevers, RN. 15 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022 12:36 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 926 RECEIVED NYSCEF: 08/03/2022 Melissa Crai Page 14 08/02/2015 - 08/03/2015: IV administration record with attending Gary Lombardo, M.D. 08/02/2015 - 08/05/2015: Medication administration record, attending Gary Lombardo, M.D. 08/02/2015 - 08/06/2015: Nursing assessment record, electronically signed by various nurses. 08/02/2015: Nursing administration database signed by Lucy Cheevers, RN, signature illegible. 08/02/2015 - 08/05/2015: Braden Scale by attending Gary Lombardo, M.D. 08/02/2015: Mobility profile records by attending Gary Lombardo, M.D. 08/02/2015 - 08/06/2015: Fain assessment records electronically signed by various nurses. 08/03/2015 08/04/2015: TICO patient flow sheets/nurses' notes and initial assessment dated 08/03/2015. 08/04/2015 - 08/05/2015: Intake and output record with no signature recorded. 08/04/2015 08/06/2015: Vital sign records electronically signed by various nurses. 08/02/2015 08/04/2015: Initial consult ophthalmology with impression: Subconj une ti val heme left eye, by attending Kenneth Juechter, M.D. 08/03/2015 - 08/06/2015: Patient care flow sheet electronically signed by various nurses. 16 of 30 FILED: SUFFOLK COUNTY CLERK 08/03/2022