Preview
FILED: NEW YORK COUNTY CLERK 06/02/2021 12:33 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146 RECEIVED NYSCEF: 06/02/2021
Exhibit B3
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( Location: GO?S-7244-A
- Fib two VBACs
3. IUFD, current pregnancy
- presented to NYPH-LM 9/8 with 2d of decreased FM, in setting of T38.1
4. cHTN
- first noted in 1993 pregnancy c/b PEC and HTN since
5. History of PEC
- no baseline 24hr urine protein, labs available
6. FUO
- 2wk history of chills and fevers, T38.1 on admission to NYPH-LM
- workup in progress
7. Asthma
- dx 6mos ago
- Dulera BID, Albuterol PRN
- self d/c'd Dulera 1wk ago, albuterol >2x/wk
8. History of preterm delivery x2
- 1993 iatrogenic for PEC
- 2007 32wks, PPROM and subsequent PTO
0:
VITALS (last 24h) [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 07:53]:
Tc: 36.4 Tmax: 37.5@ 12 Sep 17:00
HR: 95 (95 - 107)
BP: 126/82 (126/82 - 149/96)
RR: 18 (18 - 18) I Sp02: 96% (96% - 99%)
UOP: 2500/4500
General: no acute distress
Abdom: soft, appropriately tender, nondistended, no rebound/guarding, tympanic; staples intact; no
erythema, oozing, induration
Ext: venodynes in place, no edema
Labs: AM labs pending
Assessment & Plan: 37 yo POD#4 sip hysterectomy with placenta and fetus en bloc for IUFD and placenta
percreta. Post-op course c/b elevated BPs and elevated Cr, possibly due to volume depletion. Cr to be be
repeat this AM, has remained high. Low suspicion for PEG. BPs is normal to mild range, asymptomatic.
Psych and Rheum consults appreciated.
Post-op:
- Management as per GYN team, excellent care appreciated - Regular, Percocet
- Maintain foley until day of discharge
- Physical therapy and IS
cHTN: r/o superimposed PEG
- Continue home dose nifidipine
- Normal to mild range BPs currently
- Creatinine uptrending, continue to monitor, has had excellent UOP
- No Mg gtt indicated
IUFD: ID vs Rheum
- Lupus AC negative, ANA negative, dsDNA negative, B2glycoprotein neg, anti- CL neg
- f/u anti-centromere, anti-Scl-70, anti-Jo, anti-RNApolymerase, CK, aldoase
- Add anti Ro, Anti-La
- per Rheum, obtain CXR, b/1 hip and pelvis XR
- Parvo neg, Measles immune
Psych/Social:
- per Psych: no meds now, will continue to follow
- SW following
Misc:
- Autopsy form dropped off
89
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
- Wants private burial
Electronic Signatures:
Setton, Robert (MD) (Signed on 13-Sep-2014 07:55)
Authored
Last Updated: 13-Sep-2014 07:55 by Setton, Robert (MD)
****************************************************************************************************
OB/GYN Miscellaneous [Date of Service: 13-Sep-2014 07:48, Authored: 13-Sep-2014
08:05]- for Visit: 000414138 983, Complete, Appended Only, Signed in Full, General
Gyn Resident Prag ress Note
OE: None
S: Patient reports pain is well controlled on PO pain meds. Has not still not passed flatus yet, and
notes feeling distended.Pt has not been OOB with PT to chair and in the shower with PT. Notes
joint pain at baseline, very uncomfortale in bed and desires PT to come again today to help OOB.
Tolerating reg diet Denies fevers, chills, nausea, vomiting. Patient denies headache,
disturbances, scotoma, epigastric pain, RUQ pain.
0:
VITALS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 07:50]:
Tc: 36.4 Tmax: 37.5@ 12 Sep 17:00
HR: 95 (95 - 107)
BP: 126/82 (126/82-149/96)
RR: 18 (18 - 18) I Sp02: 96% (96% - 99%)
UOP: 2000cc shi11/4000cc over 24h
General: no acute distress
CV: regular rate
Pulm: clear to auscultation bilaterally
Abdom: soft, appropriately tender, nondistended, no rebound/guarding. Incision: staples intact
area of skin irritation 1x1 cm above left aspect of incision with silvadeine cream applied,
approved. no erythema, oozing, induration.
Pelv: Foley in place draining clear yellow urine
Ext: venodynes in place, no edema, no calf-tenderness bilaterally, 2+ patellar DTRs
Labs: AM labs pending
Assessment & Plan: 37 yo POD#4 sip hysterectomy with placenta and fetus en bloc for IUFD and
placenta percreta. Overnight, patient w/ adequate uop. on POD#2, Cr elevated to 1.21, likely
hypovolemia/pre-renal etiology given FeNa < .2 and large EBL, POD# Cr 1 .24, will follow up
today's Cr (these levels are within patient's baseline). Per MFM consult, defer Mg gtt for now, low
suspicion for preeclampsia. Blood pressures remain in mild range overnight, apparently at
patient's baseline and controlled on home dose Nifedipine. Pain well controlled on PO pain meds.
Pt tolerating regular diet Will continue foley for now to monitor urine output closely. Rheum left
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FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
further recommendations as below, with a working diagnosis of dermatomyositis. Overall, patient
doing well post-operatively. Will defer IUFD w/u to OB. Appreciate OB/MFM recommendations
and involvement Encouraged patient strongly to ambulate today, PT aware will ask them to
return today. Encourage PO intake.
FEN/GI:
-Reg diet
-LR@ 125cc/hr
-Zofran prn
Pain/Neuro:
- Percocet 1-2 tabs q4h prn
CV:
- BP range 11 0-1 30/90
- continue home dose nifidipine
Heme:
- intraop Hct 28, 22, post-op/post transfusion 32.4, (9/11) 29.2 hct-->26.2 (9/12)
-VSS
GU:
-continue Foley until discharge
ID:
-follow up pending labs (ID)
MSK:
-Labs ordered per rheum suggestions; appreciate recs
PPX:
-Encourage IS & OOB
-venodynes
-SQH
-PT consult
Psych:
appreciate psych recs as below:
- Restart SSRI when pt is ready, especially if sx persist after 3-4 weeks, pt currently considering
medication
- We will provide outpatient psych referral list for pt to reconnect with outpatient care after
discharge.
Rheum:
appreciate recs as below, but need clarification on details of myositis panel and MRI
Presentation most consistent with dermatomyositis, CK elevated. Additional work up
recommended as below. Treatment consistent with steroids, but patient is now postsurgical and
high dose steroids can complicate wound healing.
- A secondary HTN work up and evaluation by nephrology/HTN is also recommended in this
patient with difficult to control BP and many HTN complications, can be done as outpatient
- Follow up anti-centromere, Anti-Scl-70, anti-RNP, Anti-Jo-1, anti-RNA polymerase, and aldolase
- Follow up anti-DNA, B2GP and anti-cardiolipin
- Please obtain daily CK
;. Please consult..de.rmatology.to. help.w.i.th. a. skin.b.x.of c.he.st. rash...
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FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
- Follow up CXR PNLA and bilateral hip and pelvis xrays
- obtain daily myositis panel (not ordered)
- Please obtain thigh MRI to assess for myositis. Imaging will help guide muscle bx if this was
needed in the future (not ordered)
Electronic Signatures for Addendum Section:
Kim, Julia G (MD, MPH) (Signed Addendum 13-Sep-2014 12:08)
LABORATORY ADDENDUM
LABS (last 24h) [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 12:08]:
t 36 1106 I 8
--------------------< 94 Ca: 8.3 Mg: 1 A Anion Gap: 5.0 [09/13@07:13]
3.9 I 25 11 .22
WBC: 7.9 I Hb: 8.9 (MCV: 86.9) I Hct: 24.9 / Pit: 424 [09/13@ 07:13]
-- Diff: N:68.9% L:23.2% Mo:6.8% Eo:0.6% Baso:0.5%
Hematocrit stable. Platelets appropriate. Cr stable at pt's baseline
- Continue to monitor patient closely
Electronic Signatures:
Hancock, Kolbe Larson (MD) (Signed on 13-Sep-2014 08:05)
Authored
Last Updated: 13-Sep-2014 12:08 by Kim, Julia G (MO, MPH)
****************************************************************************************************
,,J Rheumatology Fellow Follow-up Free Text Note [Date of Service: 13-Sep-2014 09:55,
Authored: 13-Sep-2014 10:23]- for Visit: 000414138 983, Complete, Revised, Signed in Full,
General
RHEUMATOLOGY FELLOW FU NOTE
S:
No acute events overnight Slightly depressed at times, overall feels OK. Abd pain is improving
and well controlled on current pain regimen. Joint pain in hips, wrists stable without any new
swelling, rash still pruritic over chest Pt still feels weak especially in LE, needing assistance
getting out of bed and difficulty raising her arms above the bed but not worse than in the past few
days.
Meds:
DRIPS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 10:20]:
Lactated Ringers
STANDING MEDS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 201410:20]:
NIFEdipine Sustained Release Oral 60 mg Oral daily 9am
Heparin lnj 5000 Unit Subcutaneous qt 2h-(9,21)
Silver Sulfadiazine Cream 1 application Topical q8hr
92
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
PRN MEDS [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 10:20]:
Albuterol MDI 2 PUFFS INHALATION q4h
Ondansetron lnj 4 mg IV PUSH q6hr
Ondansetron lnj 4 mg IV PUSH q6hr
Ondansetron Tab 4 mg Oral q6hr
Simethicone Oral 80 mg Oral qt 2hr
oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 1 tablet Oral q4h
oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 2 tablet Oral q4h
VITALS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 201410:20]:
Tc: 36.8 Tmax: 37.5@ 12 Sep 17:00
HR: 102 (95 - 107)
BP: 144/86 (126/82-144/86)
RR: 20 (18 - 20) I Sp02: 100% (96% - 100%)
PE:
Gen: NAO, slightly flat affect, AOX3
HEENT: OP clear without ulcers, no appreciale LAD
CV: RRR, soft systolic murmur
Lungs CTA BL
Abdomen: Distended, diffusely tender to palpation, soft, lowr abd incision C/D/1, staples in place,
one area of small skin breakdown
Ext: no LE edema, warm, well perfused
Neuro: Strength - prox UE 5-/5 BL, biceps triceps, 5-/5, hand grip 4/5 BL; 3/5 hip flexors; distal LE
- 5-/5 BL.
MSK: Left wrist w mild swelling and TTP, R wrist with TTP. Hips without pain on logrolling; dee
hip flexion, internal and external rotation (limited by abd incision). no other synovitis
Skin: Bilateral violaceous and plaque/papular rash on medial upper and lower eyelids;
plaques/papules on anterior chest and some on posterior ears.
Labs:
LABS (last 24h) [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 10:14]:
t 36 1106 I 8
--------------------< 94 Ca: 8.3 Mg: 1 A Anion Gap: 5.0 [09/13@07:13]
3.9 I 25 11 .22
WBC: 7.9 / Hb: 8.9 (MCV: 86.9) I Hct: 24.9 / Pit: 424 [09/13@ 07:13]
-- Diff: N:68.9% L:23.2% Mo:6.8% Eo:0.6% Baso:0.5%
CK 1422--> 729
Mgt.4
TSH 1 .2
T4 14.34
ANA negative
LAC negative
B2GP lgG/M/A negative
Anti-Cardiolipin negative
C3174 C444
PT 12, INR 1.1 PTT 34.8
UA with no blood or protein
93
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
Imaging: MRI pelvis (9/9/2014): Placental previa
CXR clear
XR pelvis and hips - no evidence of arthritis
Echo (9/9/2014):
Normal left ventricular size and function.
Normal right ventricular size and function.
Normal valvular function by Doppler.
Abnormal left ventricular relaxation.
Imp:
37yo AA F with PMH of HTN, gestational OM one fist trimester miscarriage,PEC who was
transferred to NYP on 9/8 with IUFD and placenta previa, possible accreta, s/p hysterectomy.
Rheumatology consulted to r/o connective tissue disease in the setting of arthralgias, skin rash,
alopecia and muscle weakness (prox>distal). Work up thus far significant for skin rash over chest
and eyelids, subtle arthritis and prox muscle weakness. Labs with normal inflammatory markers,
C3/4, negative ANA, dsDNA, APS serologies (no hx of thrombosis). DDx includes SLE (less likely
with neg ANA and normal complements), dermatomyositis (elevated CK although trending down
on own, muscle weakness, rash), MCTD. Await further work up. Today, pt clinically stable.
Plan:
--holding off on steroid treatment at this time given concern of recent abdominal surgery and
wound healing, Close monitoring of clinical status - currently stable.
--Follow up pending serologies including anti-centromere, Anti-Scl-70, anti-RNP, Anti-Jo-1,
anti-RNA polymerase, and aldolase. Would also check anti-Ro, La, RNP antibodies
--continue to trend CK daily and LFTs for now
--monitor creatinine
--please order MRI I-spine and BL thighs to assess for muscle inflammation to better define
etiology of weakness and guide potential bx as well as lower back pathology as cause of LE
weakness
--rec derm consult for possible biopsy of chest skin rash
- We will continue to follow with you, please call with any questions
Cased/wand pt seen with Dr. Fields
Elizabeth Schulman MD
HSS Rheumatolgy Fellow
phone 646-714-6119, pager 212-606-1000*76726
Electronic Signatures:
Schulman, Elizabeth Robin Weiner (MD) (Signed on 13-Sep-2014 10:23)
Authored
Last Updated: 13-Sep-2014 12:04 by Schulman, Elizabeth Robin Weiner (MD)
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)ct;2Q15 16 37 page 27gf7Q
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FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
****************************************************************************************************
Physical Therapy [Date of Service: 13-Sep-2014 12:33, Authored: 13-Sep-2014 12:33]- for
Visit: 000414138 983, Complete, Entered, Signed in Full, General
Physical Therapy:
• Time of Treatment and Number of 60 min at 11 am
Minutes
• Acute Care Treatment Note
• Diagnosis Hysterectomy
History and Precautions:
• Chart Review The patient's medical record has been reviewed.
Chart reviewed to date. RN Daisy made aware prior
to tx session.
Subjective/Objective:
Subjective/Objective:
• Patient Report/ Complaints: Pt reports feeling "very tired" today. Continues to
report inability to "pass gas."
• Pain: Present pt does not quantify pain level. Moderate to
lower abdomin/ perineum
• General Observation: Pt received supine in bed, NAO +IV
• Mentation: Assessed
• Findings: Alert Oriented to person, place, time Able to follow
directions
• Vital Signs: BP: 138/88 HR: 83bpm Sa02: 96% RA
post supine to sit with subject report of dizziness
BP:143/89 HR: 85bpm
post ambulation: BP: 155/100 pt diaphoretic with c/o
dizziness
pt returned supine. RN made aware.
• Sensation: pt reports decreased sensation to light touch to
L4-L5 dermatomes on R compared to L. (as per pt
chronic issue)
Balance:
Balance Tests:
• Sitting Balance: Within functional limits.
• Standing Balance: Limited
• Comments: static standing balance with close supervision with
bilateral UE support
dynamic standing with contact guard with bilateral
UE support
Mobility/Function:
• Bed Mobility Rolling with minimum assist, Scooting with minimum
assist, Supine to sit with moderate assist, via log roll
without HOB elevated, Sit to supine with minimum
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FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
assist with bed rails, with log roll
• Transfer- Sit to Stand Contact guard with rolling walker
• Ambulation Patient ambulated 25' x1 with standing rest breaks
Minimum assist using a rolling walker
• Gait Description Ambulates with a wide base of support
• Additional Comments on Mobility decreased gait speed, decreased step length with
and Gait flat foot initial contact, decreased foot clearance
during swing, mild lateral trunk sway bilaterally
Patient Education:
Learner: Patient.
Barriers To Learning: No Barriers/Ready to learn.
General Topic: Benefits of exercise and PT intervention.
Mobility/Functional Training Topic: Ambulation-Use of assistive device. Bed mobility techniques.
Transfer techniques.
Exercise Techniques/Home Program/Protocols Topic: Body mechanics. Breathing exercises.
Exercise program. Posture re-education.
AOL/Self Care/Equipment Topic: Use of call bell.
Methods/Resource Used: Demonstration. Verbal Discussion. Written.
Evaluation: Able to repeat /verbalize key points (Teach back). Return demo (Teach back).
Interventions:
Interventions and Treatment provided:
• Therapeutic Exercise supine: ankle pumps, heel slides, hook lying fall
outs, glut squeeze
• Therapeutic Activities See mobility/function section of note above.
• Gait Training See mobility/function section of note above.
• Neuromuscular Re-education static and dynamic standing balance
• Breathing Exercises diaphragmatic breathing to increase motility and gas
movement, paced breathing with movement to avoid
valsalva maneuver
Assessment and Plan:
• Response to Intervention Pt with signs of diaphoresis including cold sweat,
pallor, and complaints of dizziness after ambulation.
Pt's BP did not drop with positional change or
activity, became elevated with activity to 155/1 DO-
RN made aware. Pt returned to supine, NAO, VSS
+call bell. Pt educated on importance of getting OOB
multiple times per day with nursing and negative
effects of bedrest Pt continues to require assistance
with bed mobility, transfers and ambulation. Pt left
supine in bed, NAO all needs in reach +call bell.
• Pain Re-Assessment: Unchanged
• Plan Continue goal oriented physical therapy.,
5-7x/week., Patient and family education. Gait
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FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( • Location: GO?S-7244-A
training. Therapeutic activities. Therapeutic exercise.
Neuromuscular re-education
• Response to Plan PatienVcaregiver in agreement with goals and plan
• Interdisciplinary Communication: Resident, Nursing staff
Plan of care discussed with
• Interdisciplinary Communication Spoke with RN prior to and post session. RN made
Discussion Details aware of increased BP and aware of patient's
tolerance for PT session.
SW made aware of the die recommendation above.
Team paged about possible order for abdominal
binder for pain and stabilization.
• Discharge Recommendations Home PT services. Home care referral
• Equipment Recommendations: Rolling walker.
• Additional Comments and Anticipate pt will continue to make steady progress
Recommendations with therapy and will not require rehab. Pt states that
20 yo son and husband are not home during the
day. Pt at this time requires assistance as above
and thus would benefit from max# of HHA hours.
Team made aware to continue to advise pt to sit
OOB as tolerated over the weekend. RW left in pt's
room however pt should not ambulate without
assistance from family/ staff.
• Therapist Phone/Beeper Susan Roessler PT, DPT xt 3079
Electronic Signatures:
Roessler, Susan (Physical Therapist) (Signed 13-Sep-2014 13:07)
Authored: Physical Therapy, History and Precautions, Subjective/Objective, Balance,
Mobility/Function, Patient Education, Interventions, Assessment and Plan
Last Updated: 13-Sep-2014 13:07 by Roessler, Susan (Physical Therapist)
****************************************************************************************************
GYN Attending Follow-Up Note [Date of Service: 13-Sep-2014 13:43, Authored:
13-Sep-2014 13:43]- for Visit: 000414138 983, Complete, Entered, Signed in Full, General
Attestation:
Attestation:
I have seen the patient with the resident and agree with the resident's findings and plan ..
Pt feels overall better today. She still complains of lower and upper extremity weakness. Also
feels tired. Attempted to get out of bed today; sat in the chair.
appreciate rheumatology consult Will await test results. Will go ahead with MRI
appreciate derm consult Pt will get skin bx today
will try rectal suppository
cont heparin sq for DVT prophylaxis
PO pain control
regular diet
All questions were answered. PT agrees with the plan.
97
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( Location: GO?S-7244-A
Electronic Signatures:
Havryliuk, Yelena (MD) (Signed 13-Sep-2014 13:46)
Authored: Attestation
Last Updated: 13-Sep-2014 13:46 by Havryliuk, Yelena (MD)
****************************************************************************************************
.,
/j Dermatology Resident Consult Note [Date of Service: 13-Sep-2014 13:59, Authored:
13-Sep-2014 14:00]- for Visit: 000414138 983, Complete, Revised, Signed in Full, General
Dermatology Resident New Pafient Consult
Consulted By: T aubel, Gyn
Chief Complaint: rash
HPI: 37 yo F with PMHx of HTN an gestational OM transfered to NYP on 918 with IUFD adn placenta praevia,
possibly acccreta. Dermatology consulted was possibly skin biopsy 2/2 to concerns of dermatomysosifis. The
patient repor1s that appoximately three months ago she starfing having difficulty gelling of bed and the sitting
position. At ttie same time she started having some joint pain, primarily in her hips. Denies any joint swelling but
did complain of painful bumps overlying her finger joints which went away one week ago. About two weeks ago
she developed a pruritic rash on her chest and around her eyes. She reports the rash started two days before she
underwent oral surgery for a tooth infection. She was started on Amoxicillin after ttie procedure. She notes a
history of rashes when she is out in ttie sun on her neck and forearms. Reports some "hair ttlinning and breakage"
that has been occurring for ttie last several monttls. Reports her fingers turn "white" in the cold. + occasional oral
ulcers. Denies n/v/d. Is having some abdominal pain 2/2 to hysterectomy. Reports history of allergy to "jewelry" -
gets rashes around the neck.
ROS: See above, ottierwise negative
PMHx/SHx
HTN
Gestational diabetes
Asttlam
C-Secfion
left shoulder surgery
Medications:
DRIPS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]:
Lactated Ringers
STANDING MEDS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]:
NIFEdipine Sustained Release Oral 60 mg Oral daily 9am
Heparin lnj 5000 Unit Subcutaneous q12h-(9,21)
Docusate Sodium Cap 100 mg Oral tid-(9,13,17)
Glycerin Supp Adult Rectal 1 suppository RECTAL q24h
Silver Sulfadiazine Cream 1 application Topical q8hr
PRN MEDS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]:
Albuterol MDI 2 PUFFS INHALATION q4h
Ondansetron lnj 4 mg IV PUSH q6hr
Ondansetron lnj 4 mg IV PUSH q6hr
................ 9~~~~~~~.C?.r:1..~~~.~.~~.9~.1.q~·~·~··
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)c1;2Q15 16 37 page 31 gf7Q
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FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y( Location: GO?S-7244-A
Simethicone Oral 80 mg Oral q12hr
oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 1 tablet Oral q4h
oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 2 tablet Oral q4h
Allergies: NKDA
FHx: No history of connective tissue disease
SHx: lives with husband and three children. Denies smoking, alcohol or drugs
Physical Exam
VITALS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]:
Tc:36.7Tmax:37.1@12Sep 21:00
HR: 89 (89 - 107)
BP: 139/95 (126/82-139/95)
RR: 19 (18 - 20) I Sp02: 98% (96% - 100%)
General: NAO
Skin: A complete skin exma was performed induding face, scalp, neck, back, chest, RUE, LUE, RLE, LLE, palms,
soles and oral mucosa. Pertinent exam findings include:
-reddish purple scaly thin patches on ttie bilateral upper cutaneous eyelids. Faint violaceous color of ttie lower
cutaneous eyelids.
-erythematous slightly edematous eczematous patches on the anterior chest ex1ending to the periphery of the
axilla on ttie anterior and lateral neck. Spares the submental area.
-no evidence of dilated periungual telangiectasias
-diffuse scale throughout the scalp. Broken hairs near ttie base of ttie braids.
-no oral involvement
Associated Organ Systems:
Conjunctiva and lids: see above
Neck/Thyroid: supple
Cardiovasrular: no LE edema
GI: see above
Labs:
LABS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]:
13611061 8
--------< 94 Ca: 8.3 Mg: 1 A Anion Gap: 5.0 [09/13@ 07:13]
3.91 2511.22
WBC: 7.9 / Hb: 8.9 (MCV: 86.9) I Hct: 24.9 / Pit: 424 [09/13@ 07:13]
- Diff: N:68.9% L:23.2% Mo:6.8% Eo:0.6% Baso:0.5%
Assessment and Plan
37 yo F with 3 months of progressive weakness during pregnacy admitted on 9/8 for IUFD, placental previa
possibly placenta accreta sip hysterectomy presents witt, heliotrope rash along with eczematous erythematous
rash on the chest Constellation of symptoms concerning for dermatomyosifis. CK 700's, ANA negaive, B2Gp
pening, anti-cardiolipin pending, C3/C4 WNL. Also must consider allergic contact dermatitis considering
distribution and pruritus.
-3 mm punch biopsy sent for H&E and DIF
-triamcinolone 0.1% cream BID pm pruritus (chest and body)
-recommend regular photoprotection
-agree with plan per rheumatology
99
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
Please call witt, any additional questions/concerns
Ashley Decker, MD
Dermatology Resident, PGY3
pgr 30035
Electronic Signatures:
Decker, Ashley B (MD) (Signed on 13-Sep-2014 14:00)
Authored
Last Updated: 13-Sep-2014 18:25 by Decker, Ashley B (MD)
****************************************************************************************************
Rheumatology Attending Follow-up Free Text Note [Date of Service: 13-Sep-2014 14:09,
Authored: 13-Sep-2014 14:10]- for Visit: 000414138 983, Complete, Entered, Signed in Full,
General
37 year old woman sip hysterectomy with muscle weakness, especially of hip flexion, and
recent-onset rash.
She has a shawl-distribution erythematous raised rash below the neck She has papules behind
the ears. Purple rash on eyelids. She has weakness of hip flexion bilaterally. Left hand strength
appears normal, but right hand strength seems decreased (right -handed). Shoulder abduction
strength seems normal. Straight leg raise negative bilaterally.
Her CPK was elevated but this was post-op so difficult to interpret
Impression:
1 . Proximal muscle weakness which seems to go back a few months
2. Joint pain in hips, shoulders and wrists, without synovitis on exam
3. Skin rash that suggests possible dermatomyositis. Has proximal thigh flexion weakness.
Has increased CPK but hard to interpret this since post-op.
Plan:
1 . Hold off on steroids now since post-op.
2. Flu on pending serology- see details in Dr. Schuhuan' s note- please add anti-Ro, La, Sm
and RNP antibodies.
3. FluCPK
4. MRI of thighs can help evaluate for inflanunation to help decide necessity and location of
biopsy. Also, MRI of lumbar spine important here since she has prior history of
scoliosis and disc problem (by her recollection, from another hospital)- and some of her
leg symptoms could relate to nerve compression in the spine.
5. Dermatology evaluation important-skin biopsy may help.
100
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 146
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y Location: GO?S-7244-A
Theodore R Fields, MD
FI030
Electronic Signatures:
Fields, Theodore R (MD) (Signed on 13-Sep-2014 14:10)
Authored
Last Updated: 13-Sep-2014 14:10 by Fields, Theodore R (MD)
****************************************************************************************************
Miscellaneous Nursing Note. [Date of Service: 13-Sep-2014 14:22, Authored: 13-Sep-2014
14:28]- for Visit: 000414138 983, Complete, Entered, Signed in Full, General
Received patient alert and oriented x3. IVRL in right
forearm within normal limits via sigma pump. venodyne boots
on. foley draining clear yellow urine. abdominal incision
with steristrips clean, dry and intact. small open blister
above incision noted. silvadine applied. patient feels
weakness and joint pain in hips when ambulating. instructed
to call nurse for assistance. Physical Therapy in to see
patient assisted patient out of bed. patient with
complaint of lightheadedness and calminess. patient
assisted patient back to bed. blood pressure elevated as
per patient. Dr. Kim notified. patient ordered for MRI.
patient with rash noted on chest and face. dermatology in
to see patien
Preview
FILED: NEW YORK COUNTY CLERK 06/02/2021 12:33 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 RECEIVED NYSCEF: 06/02/2021 Exhibit B3 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( Location: GO?S-7244-A - Fib two VBACs 3. IUFD, current pregnancy - presented to NYPH-LM 9/8 with 2d of decreased FM, in setting of T38.1 4. cHTN - first noted in 1993 pregnancy c/b PEC and HTN since 5. History of PEC - no baseline 24hr urine protein, labs available 6. FUO - 2wk history of chills and fevers, T38.1 on admission to NYPH-LM - workup in progress 7. Asthma - dx 6mos ago - Dulera BID, Albuterol PRN - self d/c'd Dulera 1wk ago, albuterol >2x/wk 8. History of preterm delivery x2 - 1993 iatrogenic for PEC - 2007 32wks, PPROM and subsequent PTO 0: VITALS (last 24h) [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 07:53]: Tc: 36.4 Tmax: 37.5@ 12 Sep 17:00 HR: 95 (95 - 107) BP: 126/82 (126/82 - 149/96) RR: 18 (18 - 18) I Sp02: 96% (96% - 99%) UOP: 2500/4500 General: no acute distress Abdom: soft, appropriately tender, nondistended, no rebound/guarding, tympanic; staples intact; no erythema, oozing, induration Ext: venodynes in place, no edema Labs: AM labs pending Assessment & Plan: 37 yo POD#4 sip hysterectomy with placenta and fetus en bloc for IUFD and placenta percreta. Post-op course c/b elevated BPs and elevated Cr, possibly due to volume depletion. Cr to be be repeat this AM, has remained high. Low suspicion for PEG. BPs is normal to mild range, asymptomatic. Psych and Rheum consults appreciated. Post-op: - Management as per GYN team, excellent care appreciated - Regular, Percocet - Maintain foley until day of discharge - Physical therapy and IS cHTN: r/o superimposed PEG - Continue home dose nifidipine - Normal to mild range BPs currently - Creatinine uptrending, continue to monitor, has had excellent UOP - No Mg gtt indicated IUFD: ID vs Rheum - Lupus AC negative, ANA negative, dsDNA negative, B2glycoprotein neg, anti- CL neg - f/u anti-centromere, anti-Scl-70, anti-Jo, anti-RNApolymerase, CK, aldoase - Add anti Ro, Anti-La - per Rheum, obtain CXR, b/1 hip and pelvis XR - Parvo neg, Measles immune Psych/Social: - per Psych: no meds now, will continue to follow - SW following Misc: - Autopsy form dropped off 89 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A - Wants private burial Electronic Signatures: Setton, Robert (MD) (Signed on 13-Sep-2014 07:55) Authored Last Updated: 13-Sep-2014 07:55 by Setton, Robert (MD) **************************************************************************************************** OB/GYN Miscellaneous [Date of Service: 13-Sep-2014 07:48, Authored: 13-Sep-2014 08:05]- for Visit: 000414138 983, Complete, Appended Only, Signed in Full, General Gyn Resident Prag ress Note OE: None S: Patient reports pain is well controlled on PO pain meds. Has not still not passed flatus yet, and notes feeling distended.Pt has not been OOB with PT to chair and in the shower with PT. Notes joint pain at baseline, very uncomfortale in bed and desires PT to come again today to help OOB. Tolerating reg diet Denies fevers, chills, nausea, vomiting. Patient denies headache, disturbances, scotoma, epigastric pain, RUQ pain. 0: VITALS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 07:50]: Tc: 36.4 Tmax: 37.5@ 12 Sep 17:00 HR: 95 (95 - 107) BP: 126/82 (126/82-149/96) RR: 18 (18 - 18) I Sp02: 96% (96% - 99%) UOP: 2000cc shi11/4000cc over 24h General: no acute distress CV: regular rate Pulm: clear to auscultation bilaterally Abdom: soft, appropriately tender, nondistended, no rebound/guarding. Incision: staples intact area of skin irritation 1x1 cm above left aspect of incision with silvadeine cream applied, approved. no erythema, oozing, induration. Pelv: Foley in place draining clear yellow urine Ext: venodynes in place, no edema, no calf-tenderness bilaterally, 2+ patellar DTRs Labs: AM labs pending Assessment & Plan: 37 yo POD#4 sip hysterectomy with placenta and fetus en bloc for IUFD and placenta percreta. Overnight, patient w/ adequate uop. on POD#2, Cr elevated to 1.21, likely hypovolemia/pre-renal etiology given FeNa < .2 and large EBL, POD# Cr 1 .24, will follow up today's Cr (these levels are within patient's baseline). Per MFM consult, defer Mg gtt for now, low suspicion for preeclampsia. Blood pressures remain in mild range overnight, apparently at patient's baseline and controlled on home dose Nifedipine. Pain well controlled on PO pain meds. Pt tolerating regular diet Will continue foley for now to monitor urine output closely. Rheum left Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)ct;2Q15 16 37 page 23gf7Q 90 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A further recommendations as below, with a working diagnosis of dermatomyositis. Overall, patient doing well post-operatively. Will defer IUFD w/u to OB. Appreciate OB/MFM recommendations and involvement Encouraged patient strongly to ambulate today, PT aware will ask them to return today. Encourage PO intake. FEN/GI: -Reg diet -LR@ 125cc/hr -Zofran prn Pain/Neuro: - Percocet 1-2 tabs q4h prn CV: - BP range 11 0-1 30/90 - continue home dose nifidipine Heme: - intraop Hct 28, 22, post-op/post transfusion 32.4, (9/11) 29.2 hct-->26.2 (9/12) -VSS GU: -continue Foley until discharge ID: -follow up pending labs (ID) MSK: -Labs ordered per rheum suggestions; appreciate recs PPX: -Encourage IS & OOB -venodynes -SQH -PT consult Psych: appreciate psych recs as below: - Restart SSRI when pt is ready, especially if sx persist after 3-4 weeks, pt currently considering medication - We will provide outpatient psych referral list for pt to reconnect with outpatient care after discharge. Rheum: appreciate recs as below, but need clarification on details of myositis panel and MRI Presentation most consistent with dermatomyositis, CK elevated. Additional work up recommended as below. Treatment consistent with steroids, but patient is now postsurgical and high dose steroids can complicate wound healing. - A secondary HTN work up and evaluation by nephrology/HTN is also recommended in this patient with difficult to control BP and many HTN complications, can be done as outpatient - Follow up anti-centromere, Anti-Scl-70, anti-RNP, Anti-Jo-1, anti-RNA polymerase, and aldolase - Follow up anti-DNA, B2GP and anti-cardiolipin - Please obtain daily CK ;. Please consult..de.rmatology.to. help.w.i.th. a. skin.b.x.of c.he.st. rash... Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)ct;2Q15 16 37 page 24gf7Q 91 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A - Follow up CXR PNLA and bilateral hip and pelvis xrays - obtain daily myositis panel (not ordered) - Please obtain thigh MRI to assess for myositis. Imaging will help guide muscle bx if this was needed in the future (not ordered) Electronic Signatures for Addendum Section: Kim, Julia G (MD, MPH) (Signed Addendum 13-Sep-2014 12:08) LABORATORY ADDENDUM LABS (last 24h) [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 12:08]: t 36 1106 I 8 --------------------< 94 Ca: 8.3 Mg: 1 A Anion Gap: 5.0 [09/13@07:13] 3.9 I 25 11 .22 WBC: 7.9 I Hb: 8.9 (MCV: 86.9) I Hct: 24.9 / Pit: 424 [09/13@ 07:13] -- Diff: N:68.9% L:23.2% Mo:6.8% Eo:0.6% Baso:0.5% Hematocrit stable. Platelets appropriate. Cr stable at pt's baseline - Continue to monitor patient closely Electronic Signatures: Hancock, Kolbe Larson (MD) (Signed on 13-Sep-2014 08:05) Authored Last Updated: 13-Sep-2014 12:08 by Kim, Julia G (MO, MPH) **************************************************************************************************** ,,J Rheumatology Fellow Follow-up Free Text Note [Date of Service: 13-Sep-2014 09:55, Authored: 13-Sep-2014 10:23]- for Visit: 000414138 983, Complete, Revised, Signed in Full, General RHEUMATOLOGY FELLOW FU NOTE S: No acute events overnight Slightly depressed at times, overall feels OK. Abd pain is improving and well controlled on current pain regimen. Joint pain in hips, wrists stable without any new swelling, rash still pruritic over chest Pt still feels weak especially in LE, needing assistance getting out of bed and difficulty raising her arms above the bed but not worse than in the past few days. Meds: DRIPS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 10:20]: Lactated Ringers STANDING MEDS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 201410:20]: NIFEdipine Sustained Release Oral 60 mg Oral daily 9am Heparin lnj 5000 Unit Subcutaneous qt 2h-(9,21) Silver Sulfadiazine Cream 1 application Topical q8hr 92 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A PRN MEDS [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 10:20]: Albuterol MDI 2 PUFFS INHALATION q4h Ondansetron lnj 4 mg IV PUSH q6hr Ondansetron lnj 4 mg IV PUSH q6hr Ondansetron Tab 4 mg Oral q6hr Simethicone Oral 80 mg Oral qt 2hr oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 1 tablet Oral q4h oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 2 tablet Oral q4h VITALS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 201410:20]: Tc: 36.8 Tmax: 37.5@ 12 Sep 17:00 HR: 102 (95 - 107) BP: 144/86 (126/82-144/86) RR: 20 (18 - 20) I Sp02: 100% (96% - 100%) PE: Gen: NAO, slightly flat affect, AOX3 HEENT: OP clear without ulcers, no appreciale LAD CV: RRR, soft systolic murmur Lungs CTA BL Abdomen: Distended, diffusely tender to palpation, soft, lowr abd incision C/D/1, staples in place, one area of small skin breakdown Ext: no LE edema, warm, well perfused Neuro: Strength - prox UE 5-/5 BL, biceps triceps, 5-/5, hand grip 4/5 BL; 3/5 hip flexors; distal LE - 5-/5 BL. MSK: Left wrist w mild swelling and TTP, R wrist with TTP. Hips without pain on logrolling; dee hip flexion, internal and external rotation (limited by abd incision). no other synovitis Skin: Bilateral violaceous and plaque/papular rash on medial upper and lower eyelids; plaques/papules on anterior chest and some on posterior ears. Labs: LABS (last 24h) [retrieved for HOFFMAN, SHELL YANN at 13 Sep 2014 10:14]: t 36 1106 I 8 --------------------< 94 Ca: 8.3 Mg: 1 A Anion Gap: 5.0 [09/13@07:13] 3.9 I 25 11 .22 WBC: 7.9 / Hb: 8.9 (MCV: 86.9) I Hct: 24.9 / Pit: 424 [09/13@ 07:13] -- Diff: N:68.9% L:23.2% Mo:6.8% Eo:0.6% Baso:0.5% CK 1422--> 729 Mgt.4 TSH 1 .2 T4 14.34 ANA negative LAC negative B2GP lgG/M/A negative Anti-Cardiolipin negative C3174 C444 PT 12, INR 1.1 PTT 34.8 UA with no blood or protein 93 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A Imaging: MRI pelvis (9/9/2014): Placental previa CXR clear XR pelvis and hips - no evidence of arthritis Echo (9/9/2014): Normal left ventricular size and function. Normal right ventricular size and function. Normal valvular function by Doppler. Abnormal left ventricular relaxation. Imp: 37yo AA F with PMH of HTN, gestational OM one fist trimester miscarriage,PEC who was transferred to NYP on 9/8 with IUFD and placenta previa, possible accreta, s/p hysterectomy. Rheumatology consulted to r/o connective tissue disease in the setting of arthralgias, skin rash, alopecia and muscle weakness (prox>distal). Work up thus far significant for skin rash over chest and eyelids, subtle arthritis and prox muscle weakness. Labs with normal inflammatory markers, C3/4, negative ANA, dsDNA, APS serologies (no hx of thrombosis). DDx includes SLE (less likely with neg ANA and normal complements), dermatomyositis (elevated CK although trending down on own, muscle weakness, rash), MCTD. Await further work up. Today, pt clinically stable. Plan: --holding off on steroid treatment at this time given concern of recent abdominal surgery and wound healing, Close monitoring of clinical status - currently stable. --Follow up pending serologies including anti-centromere, Anti-Scl-70, anti-RNP, Anti-Jo-1, anti-RNA polymerase, and aldolase. Would also check anti-Ro, La, RNP antibodies --continue to trend CK daily and LFTs for now --monitor creatinine --please order MRI I-spine and BL thighs to assess for muscle inflammation to better define etiology of weakness and guide potential bx as well as lower back pathology as cause of LE weakness --rec derm consult for possible biopsy of chest skin rash - We will continue to follow with you, please call with any questions Cased/wand pt seen with Dr. Fields Elizabeth Schulman MD HSS Rheumatolgy Fellow phone 646-714-6119, pager 212-606-1000*76726 Electronic Signatures: Schulman, Elizabeth Robin Weiner (MD) (Signed on 13-Sep-2014 10:23) Authored Last Updated: 13-Sep-2014 12:04 by Schulman, Elizabeth Robin Weiner (MD) Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)ct;2Q15 16 37 page 27gf7Q 94 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A **************************************************************************************************** Physical Therapy [Date of Service: 13-Sep-2014 12:33, Authored: 13-Sep-2014 12:33]- for Visit: 000414138 983, Complete, Entered, Signed in Full, General Physical Therapy: • Time of Treatment and Number of 60 min at 11 am Minutes • Acute Care Treatment Note • Diagnosis Hysterectomy History and Precautions: • Chart Review The patient's medical record has been reviewed. Chart reviewed to date. RN Daisy made aware prior to tx session. Subjective/Objective: Subjective/Objective: • Patient Report/ Complaints: Pt reports feeling "very tired" today. Continues to report inability to "pass gas." • Pain: Present pt does not quantify pain level. Moderate to lower abdomin/ perineum • General Observation: Pt received supine in bed, NAO +IV • Mentation: Assessed • Findings: Alert Oriented to person, place, time Able to follow directions • Vital Signs: BP: 138/88 HR: 83bpm Sa02: 96% RA post supine to sit with subject report of dizziness BP:143/89 HR: 85bpm post ambulation: BP: 155/100 pt diaphoretic with c/o dizziness pt returned supine. RN made aware. • Sensation: pt reports decreased sensation to light touch to L4-L5 dermatomes on R compared to L. (as per pt chronic issue) Balance: Balance Tests: • Sitting Balance: Within functional limits. • Standing Balance: Limited • Comments: static standing balance with close supervision with bilateral UE support dynamic standing with contact guard with bilateral UE support Mobility/Function: • Bed Mobility Rolling with minimum assist, Scooting with minimum assist, Supine to sit with moderate assist, via log roll without HOB elevated, Sit to supine with minimum Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)ct;2Q15 16 37 page 28gf7Q 95 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A assist with bed rails, with log roll • Transfer- Sit to Stand Contact guard with rolling walker • Ambulation Patient ambulated 25' x1 with standing rest breaks Minimum assist using a rolling walker • Gait Description Ambulates with a wide base of support • Additional Comments on Mobility decreased gait speed, decreased step length with and Gait flat foot initial contact, decreased foot clearance during swing, mild lateral trunk sway bilaterally Patient Education: Learner: Patient. Barriers To Learning: No Barriers/Ready to learn. General Topic: Benefits of exercise and PT intervention. Mobility/Functional Training Topic: Ambulation-Use of assistive device. Bed mobility techniques. Transfer techniques. Exercise Techniques/Home Program/Protocols Topic: Body mechanics. Breathing exercises. Exercise program. Posture re-education. AOL/Self Care/Equipment Topic: Use of call bell. Methods/Resource Used: Demonstration. Verbal Discussion. Written. Evaluation: Able to repeat /verbalize key points (Teach back). Return demo (Teach back). Interventions: Interventions and Treatment provided: • Therapeutic Exercise supine: ankle pumps, heel slides, hook lying fall outs, glut squeeze • Therapeutic Activities See mobility/function section of note above. • Gait Training See mobility/function section of note above. • Neuromuscular Re-education static and dynamic standing balance • Breathing Exercises diaphragmatic breathing to increase motility and gas movement, paced breathing with movement to avoid valsalva maneuver Assessment and Plan: • Response to Intervention Pt with signs of diaphoresis including cold sweat, pallor, and complaints of dizziness after ambulation. Pt's BP did not drop with positional change or activity, became elevated with activity to 155/1 DO- RN made aware. Pt returned to supine, NAO, VSS +call bell. Pt educated on importance of getting OOB multiple times per day with nursing and negative effects of bedrest Pt continues to require assistance with bed mobility, transfers and ambulation. Pt left supine in bed, NAO all needs in reach +call bell. • Pain Re-Assessment: Unchanged • Plan Continue goal oriented physical therapy., 5-7x/week., Patient and family education. Gait Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)ct;2Q15 16 37 page 29gf7Q 96 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( • Location: GO?S-7244-A training. Therapeutic activities. Therapeutic exercise. Neuromuscular re-education • Response to Plan PatienVcaregiver in agreement with goals and plan • Interdisciplinary Communication: Resident, Nursing staff Plan of care discussed with • Interdisciplinary Communication Spoke with RN prior to and post session. RN made Discussion Details aware of increased BP and aware of patient's tolerance for PT session. SW made aware of the die recommendation above. Team paged about possible order for abdominal binder for pain and stabilization. • Discharge Recommendations Home PT services. Home care referral • Equipment Recommendations: Rolling walker. • Additional Comments and Anticipate pt will continue to make steady progress Recommendations with therapy and will not require rehab. Pt states that 20 yo son and husband are not home during the day. Pt at this time requires assistance as above and thus would benefit from max# of HHA hours. Team made aware to continue to advise pt to sit OOB as tolerated over the weekend. RW left in pt's room however pt should not ambulate without assistance from family/ staff. • Therapist Phone/Beeper Susan Roessler PT, DPT xt 3079 Electronic Signatures: Roessler, Susan (Physical Therapist) (Signed 13-Sep-2014 13:07) Authored: Physical Therapy, History and Precautions, Subjective/Objective, Balance, Mobility/Function, Patient Education, Interventions, Assessment and Plan Last Updated: 13-Sep-2014 13:07 by Roessler, Susan (Physical Therapist) **************************************************************************************************** GYN Attending Follow-Up Note [Date of Service: 13-Sep-2014 13:43, Authored: 13-Sep-2014 13:43]- for Visit: 000414138 983, Complete, Entered, Signed in Full, General Attestation: Attestation: I have seen the patient with the resident and agree with the resident's findings and plan .. Pt feels overall better today. She still complains of lower and upper extremity weakness. Also feels tired. Attempted to get out of bed today; sat in the chair. appreciate rheumatology consult Will await test results. Will go ahead with MRI appreciate derm consult Pt will get skin bx today will try rectal suppository cont heparin sq for DVT prophylaxis PO pain control regular diet All questions were answered. PT agrees with the plan. 97 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( Location: GO?S-7244-A Electronic Signatures: Havryliuk, Yelena (MD) (Signed 13-Sep-2014 13:46) Authored: Attestation Last Updated: 13-Sep-2014 13:46 by Havryliuk, Yelena (MD) **************************************************************************************************** ., /j Dermatology Resident Consult Note [Date of Service: 13-Sep-2014 13:59, Authored: 13-Sep-2014 14:00]- for Visit: 000414138 983, Complete, Revised, Signed in Full, General Dermatology Resident New Pafient Consult Consulted By: T aubel, Gyn Chief Complaint: rash HPI: 37 yo F with PMHx of HTN an gestational OM transfered to NYP on 918 with IUFD adn placenta praevia, possibly acccreta. Dermatology consulted was possibly skin biopsy 2/2 to concerns of dermatomysosifis. The patient repor1s that appoximately three months ago she starfing having difficulty gelling of bed and the sitting position. At ttie same time she started having some joint pain, primarily in her hips. Denies any joint swelling but did complain of painful bumps overlying her finger joints which went away one week ago. About two weeks ago she developed a pruritic rash on her chest and around her eyes. She reports the rash started two days before she underwent oral surgery for a tooth infection. She was started on Amoxicillin after ttie procedure. She notes a history of rashes when she is out in ttie sun on her neck and forearms. Reports some "hair ttlinning and breakage" that has been occurring for ttie last several monttls. Reports her fingers turn "white" in the cold. + occasional oral ulcers. Denies n/v/d. Is having some abdominal pain 2/2 to hysterectomy. Reports history of allergy to "jewelry" - gets rashes around the neck. ROS: See above, ottierwise negative PMHx/SHx HTN Gestational diabetes Asttlam C-Secfion left shoulder surgery Medications: DRIPS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]: Lactated Ringers STANDING MEDS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]: NIFEdipine Sustained Release Oral 60 mg Oral daily 9am Heparin lnj 5000 Unit Subcutaneous q12h-(9,21) Docusate Sodium Cap 100 mg Oral tid-(9,13,17) Glycerin Supp Adult Rectal 1 suppository RECTAL q24h Silver Sulfadiazine Cream 1 application Topical q8hr PRN MEDS [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]: Albuterol MDI 2 PUFFS INHALATION q4h Ondansetron lnj 4 mg IV PUSH q6hr Ondansetron lnj 4 mg IV PUSH q6hr ................ 9~~~~~~~.C?.r:1..~~~.~.~~.9~.1.q~·~·~·· Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 26;C)c1;2Q15 16 37 page 31 gf7Q 98 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y( Location: GO?S-7244-A Simethicone Oral 80 mg Oral q12hr oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 1 tablet Oral q4h oxyCODONE/Acetaminophen 5/325 mg Tab (Percocet) 2 tablet Oral q4h Allergies: NKDA FHx: No history of connective tissue disease SHx: lives with husband and three children. Denies smoking, alcohol or drugs Physical Exam VITALS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]: Tc:36.7Tmax:37.1@12Sep 21:00 HR: 89 (89 - 107) BP: 139/95 (126/82-139/95) RR: 19 (18 - 20) I Sp02: 98% (96% - 100%) General: NAO Skin: A complete skin exma was performed induding face, scalp, neck, back, chest, RUE, LUE, RLE, LLE, palms, soles and oral mucosa. Pertinent exam findings include: -reddish purple scaly thin patches on ttie bilateral upper cutaneous eyelids. Faint violaceous color of ttie lower cutaneous eyelids. -erythematous slightly edematous eczematous patches on the anterior chest ex1ending to the periphery of the axilla on ttie anterior and lateral neck. Spares the submental area. -no evidence of dilated periungual telangiectasias -diffuse scale throughout the scalp. Broken hairs near ttie base of ttie braids. -no oral involvement Associated Organ Systems: Conjunctiva and lids: see above Neck/Thyroid: supple Cardiovasrular: no LE edema GI: see above Labs: LABS (last 24h) [retrieved for HOFFMAN, SHELLYANN at 13 Sep 2014 18:25]: 13611061 8 --------< 94 Ca: 8.3 Mg: 1 A Anion Gap: 5.0 [09/13@ 07:13] 3.91 2511.22 WBC: 7.9 / Hb: 8.9 (MCV: 86.9) I Hct: 24.9 / Pit: 424 [09/13@ 07:13] - Diff: N:68.9% L:23.2% Mo:6.8% Eo:0.6% Baso:0.5% Assessment and Plan 37 yo F with 3 months of progressive weakness during pregnacy admitted on 9/8 for IUFD, placental previa possibly placenta accreta sip hysterectomy presents witt, heliotrope rash along with eczematous erythematous rash on the chest Constellation of symptoms concerning for dermatomyosifis. CK 700's, ANA negaive, B2Gp pening, anti-cardiolipin pending, C3/C4 WNL. Also must consider allergic contact dermatitis considering distribution and pruritus. -3 mm punch biopsy sent for H&E and DIF -triamcinolone 0.1% cream BID pm pruritus (chest and body) -recommend regular photoprotection -agree with plan per rheumatology 99 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A Please call witt, any additional questions/concerns Ashley Decker, MD Dermatology Resident, PGY3 pgr 30035 Electronic Signatures: Decker, Ashley B (MD) (Signed on 13-Sep-2014 14:00) Authored Last Updated: 13-Sep-2014 18:25 by Decker, Ashley B (MD) **************************************************************************************************** Rheumatology Attending Follow-up Free Text Note [Date of Service: 13-Sep-2014 14:09, Authored: 13-Sep-2014 14:10]- for Visit: 000414138 983, Complete, Entered, Signed in Full, General 37 year old woman sip hysterectomy with muscle weakness, especially of hip flexion, and recent-onset rash. She has a shawl-distribution erythematous raised rash below the neck She has papules behind the ears. Purple rash on eyelids. She has weakness of hip flexion bilaterally. Left hand strength appears normal, but right hand strength seems decreased (right -handed). Shoulder abduction strength seems normal. Straight leg raise negative bilaterally. Her CPK was elevated but this was post-op so difficult to interpret Impression: 1 . Proximal muscle weakness which seems to go back a few months 2. Joint pain in hips, shoulders and wrists, without synovitis on exam 3. Skin rash that suggests possible dermatomyositis. Has proximal thigh flexion weakness. Has increased CPK but hard to interpret this since post-op. Plan: 1 . Hold off on steroids now since post-op. 2. Flu on pending serology- see details in Dr. Schuhuan' s note- please add anti-Ro, La, Sm and RNP antibodies. 3. FluCPK 4. MRI of thighs can help evaluate for inflanunation to help decide necessity and location of biopsy. Also, MRI of lumbar spine important here since she has prior history of scoliosis and disc problem (by her recollection, from another hospital)- and some of her leg symptoms could relate to nerve compression in the spine. 5. Dermatology evaluation important-skin biopsy may help. 100 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 146 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y Location: GO?S-7244-A Theodore R Fields, MD FI030 Electronic Signatures: Fields, Theodore R (MD) (Signed on 13-Sep-2014 14:10) Authored Last Updated: 13-Sep-2014 14:10 by Fields, Theodore R (MD) **************************************************************************************************** Miscellaneous Nursing Note. [Date of Service: 13-Sep-2014 14:22, Authored: 13-Sep-2014 14:28]- for Visit: 000414138 983, Complete, Entered, Signed in Full, General Received patient alert and oriented x3. IVRL in right forearm within normal limits via sigma pump. venodyne boots on. foley draining clear yellow urine. abdominal incision with steristrips clean, dry and intact. small open blister above incision noted. silvadine applied. patient feels weakness and joint pain in hips when ambulating. instructed to call nurse for assistance. Physical Therapy in to see patient assisted patient out of bed. patient with complaint of lightheadedness and calminess. patient assisted patient back to bed. blood pressure elevated as per patient. Dr. Kim notified. patient ordered for MRI. patient with rash noted on chest and face. dermatology in to see patien