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FILED: ONONDAGA COUNTY CLERK 03/08/2022 12:39 PM INDEX NO. 007476/2018
James Square Health & Rehabilitation Centre
NYSCEF DOC. NO. 83 RECEIVED NYSCEF: 03/08/2022
PROGRESS NOTE
Resident Name: Room#: Medical Record#: Physician Name:
AUSTIN, LARRY 347D JEANNE BISHOP
SUBSEQUENT MEDICAL CARE
6/14/2016
Mr. Austin is with us from St. Joseph’s Hospital 3/20-3/29/2016 with shortness of breath due to pulmonary
edema, managed with hemodialysis as he has end stage renal disease. He was treated for bi-basilar pneumonia
and hypertension out of control. All these medical problems are compensated. During that hospitalization he
was found to have oropharyngeal dysphagia and a consistency adjusted diet was recommended. He continues to
be on a ground mechanical soft diet with pureed fruits and vegetables and thin liquids. He has had no
aspirations that I have been made aware of. Here he has been diagnosed with a right radial nerve palsy and he
has peripheral neuropathy, the causation of which is not clearly specified, questionable uremic diabetic or
alcoholic. At any rate today he denies any neuropathic pain. He continues to receive dialysis Mondays,
Wednesdays and Fridays at the Seneca Dialysis Unit.
PAST MEDICAL HISTORY/MEDICAL ILLNESSES:
1. End stage renal disease on hemodialysis at Seneca Dialysis Unit through right AV fistula.
2. Anemia of chronic disease and secondary hyperparathyroidism due to end stage renal disease.
3. Hypertension.
4. Hyperlipidemia.
5. Diabetes mellitus, Type 2, diet controlled.
6. Coronary artery disease, status post myocardial infarction.
7. Atrial fibrillation, detail unspecified.
8. Peripheral arterial disease, detail unspecified.
9. Venous insufficiency with history of bilateral lower extremity cellulitis.
10. One quarter pack per day smoker for 33 years.
11. Left femur fracture between previous left Gamma nail fixation device and distal femur, nonsurgical.
12. Peripheral neuropathy and radial nerve palsy, questionable uremic, diabetic, ? alcoholic.
13. Dementia with ataxia spasticity.
14. Oropharyngeal dysphagia requiring consistency-adjusted diet.
PAST SURGICAL HISTORY:
1. Right AV fistula, 04/2011.
2. Bilateral inguinal hernia repair.
3. Excision of left perirectal abscess, 10/09/2014.
4. Right greater trochanteric hip fracture, status post ORIF/Gamma nail fixation 10/21/2014.
5. Left pleural effusion thoracentesis, 4/15/2016 with 1.5 L of fluid, nonmalignant.
MEDICATIONS ON TRANSFER FROM THE HOSPITAL: Are reviewed as entered in the electronic
record.
ALLERGIES: Tetracycline and Tetracaine.
FAMILY HISTORY: Not obtained here.
FILED: ONONDAGA COUNTY CLERK 03/08/2022 12:39 PM INDEX NO. 007476/2018
AUSTIN, LARRY
NYSCEF DOC. NO. 83 RECEIVED NYSCEF: 03/08/2022
SUBSEQUENT MEDICAL CARE
PAGE 2 OF 3
RM# 347D
6/14/2016
SOCIAL HISTORY: He lives at home with his wife. Primary contact is his wife, Valerie Austin,who also
has Power of Attorney. She is at . Secondary contact is daughter, Amanda Dillon, at
. THERE IS NO MOLST FORM. HIS ADVANCE DIRECTIVE IS CPR. THERE IS NO COPY
OF A HEALTH CARE PROXY.
REVIEW OF SYSTEMS: See HPI. In general he denies any discomforts.
PHYSICAL EXAMINATION: His weight is not recorded, b/p 140/74, temperature is 97.8, pulse is 76,
respirations in inaccurately recorded, oxygen SAT is 95%. In general he is a quiet gentleman, clean groomed
and dressed, sitting up in his wheelchair at bedside. He smiles and engages. He is not acutely, physically or
emotionally distressed. HEENT: Hair is graying, scalp is balding. Pupils are reactive. He is edentulous. He
has no thrush. NECK: No masses. LUNGS: Clear on good effort, no rhonchi, wheezes or rales. HEART:
S1, S2. Rhythm is regular and rate is controlled. ABDOMEN: Soft, nontender. Bowel sounds are active.
EXTREMITIES: Reveal slender calves they are non tender. There is no edema. His right AV fistula has a
palpable thrill and audible bruit. It is covered with a Kerlix. NEUROLOGIC: He has some cognitive
strength sufficient to engage in bedside conversation. Cranial nerves are normal. He can move extremities.
Gait and Babinski’s not tested.
IMPRESSION:
1. Peripheral neuropathy and improving right radial nerve palsy.
2. Hypertension.
3. Oropharyngeal dysphagia on consistency adjusted diet.
4. Questionable cognitive frailty.
5. End stage renal disease on hemodialysis at Seneca Dialysis Unit through right AV fistula, anemia of
chronic renal disease, secondary hyperparathyroidism.
6. Hyperlipidemia.
7. Diabetes mellitus, Type 2, diet controlled.
8. Coronary artery disease, status post myocardial infarction.
9. History of atrial fibrillation, detail unspecified.
10. Peripheral arterial disease, detail unspecified.
11. Venous insufficiency with history of bilateral lower extremity cellulitis.
12. One quarter pack per day smoker for 33 years.
13. Previous left femur fracture, 1/13/2015, between previous left Gamma nail fixation and distal femur,
nonsurgical.
14. Previous other surgeries.
15. ADVANCE DIRECTIVE IS CPR. THERE IS NO MOLST FORM. QUESTIONABLE
STATUS OF HEALTH CARE PROXY.
16. Left pleural effusion, status post thoracentesis of 1.5 L of fluid.
FILED: ONONDAGA COUNTY CLERK 03/08/2022 12:39 PM INDEX NO. 007476/2018
AUSTIN, LARRY
NYSCEF DOC. NO. 83 RECEIVED NYSCEF: 03/08/2022
SUBSEQUENT MEDICAL CARE
PAGE 3 OF 3
RM# 347D
6/14/2016
PLAN:
1. Continue all medications and treatments as reflected in the Physician Orders and Comprehensive
Care Plan which I have reviewed.
2. UPHOLD ADVANCE DIRECTIVE OF CPR.
3. Continue hemodialysis three times weekly.
4. Nephrology follow up with Dr. Rao.
5. Further management based on his course.
D: 6/14/2016
T: 6/15/2016
JB/mb Jeanne Bishop, M.D.
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FILED: ONONDAGA COUNTY CLERK 03/08/2022 12:39 PM INDEX NO. 007476/2018 James Square Health & Rehabilitation Centre NYSCEF DOC. NO. 83 RECEIVED NYSCEF: 03/08/2022 PROGRESS NOTE Resident Name: Room#: Medical Record#: Physician Name: AUSTIN, LARRY 347D JEANNE BISHOP SUBSEQUENT MEDICAL CARE 6/14/2016 Mr. Austin is with us from St. Joseph’s Hospital 3/20-3/29/2016 with shortness of breath due to pulmonary edema, managed with hemodialysis as he has end stage renal disease. He was treated for bi-basilar pneumonia and hypertension out of control. All these medical problems are compensated. During that hospitalization he was found to have oropharyngeal dysphagia and a consistency adjusted diet was recommended. He continues to be on a ground mechanical soft diet with pureed fruits and vegetables and thin liquids. He has had no aspirations that I have been made aware of. Here he has been diagnosed with a right radial nerve palsy and he has peripheral neuropathy, the causation of which is not clearly specified, questionable uremic diabetic or alcoholic. At any rate today he denies any neuropathic pain. He continues to receive dialysis Mondays, Wednesdays and Fridays at the Seneca Dialysis Unit. PAST MEDICAL HISTORY/MEDICAL ILLNESSES: 1. End stage renal disease on hemodialysis at Seneca Dialysis Unit through right AV fistula. 2. Anemia of chronic disease and secondary hyperparathyroidism due to end stage renal disease. 3. Hypertension. 4. Hyperlipidemia. 5. Diabetes mellitus, Type 2, diet controlled. 6. Coronary artery disease, status post myocardial infarction. 7. Atrial fibrillation, detail unspecified. 8. Peripheral arterial disease, detail unspecified. 9. Venous insufficiency with history of bilateral lower extremity cellulitis. 10. One quarter pack per day smoker for 33 years. 11. Left femur fracture between previous left Gamma nail fixation device and distal femur, nonsurgical. 12. Peripheral neuropathy and radial nerve palsy, questionable uremic, diabetic, ? alcoholic. 13. Dementia with ataxia spasticity. 14. Oropharyngeal dysphagia requiring consistency-adjusted diet. PAST SURGICAL HISTORY: 1. Right AV fistula, 04/2011. 2. Bilateral inguinal hernia repair. 3. Excision of left perirectal abscess, 10/09/2014. 4. Right greater trochanteric hip fracture, status post ORIF/Gamma nail fixation 10/21/2014. 5. Left pleural effusion thoracentesis, 4/15/2016 with 1.5 L of fluid, nonmalignant. MEDICATIONS ON TRANSFER FROM THE HOSPITAL: Are reviewed as entered in the electronic record. ALLERGIES: Tetracycline and Tetracaine. FAMILY HISTORY: Not obtained here. FILED: ONONDAGA COUNTY CLERK 03/08/2022 12:39 PM INDEX NO. 007476/2018 AUSTIN, LARRY NYSCEF DOC. NO. 83 RECEIVED NYSCEF: 03/08/2022 SUBSEQUENT MEDICAL CARE PAGE 2 OF 3 RM# 347D 6/14/2016 SOCIAL HISTORY: He lives at home with his wife. Primary contact is his wife, Valerie Austin,who also has Power of Attorney. She is at . Secondary contact is daughter, Amanda Dillon, at . THERE IS NO MOLST FORM. HIS ADVANCE DIRECTIVE IS CPR. THERE IS NO COPY OF A HEALTH CARE PROXY. REVIEW OF SYSTEMS: See HPI. In general he denies any discomforts. PHYSICAL EXAMINATION: His weight is not recorded, b/p 140/74, temperature is 97.8, pulse is 76, respirations in inaccurately recorded, oxygen SAT is 95%. In general he is a quiet gentleman, clean groomed and dressed, sitting up in his wheelchair at bedside. He smiles and engages. He is not acutely, physically or emotionally distressed. HEENT: Hair is graying, scalp is balding. Pupils are reactive. He is edentulous. He has no thrush. NECK: No masses. LUNGS: Clear on good effort, no rhonchi, wheezes or rales. HEART: S1, S2. Rhythm is regular and rate is controlled. ABDOMEN: Soft, nontender. Bowel sounds are active. EXTREMITIES: Reveal slender calves they are non tender. There is no edema. His right AV fistula has a palpable thrill and audible bruit. It is covered with a Kerlix. NEUROLOGIC: He has some cognitive strength sufficient to engage in bedside conversation. Cranial nerves are normal. He can move extremities. Gait and Babinski’s not tested. IMPRESSION: 1. Peripheral neuropathy and improving right radial nerve palsy. 2. Hypertension. 3. Oropharyngeal dysphagia on consistency adjusted diet. 4. Questionable cognitive frailty. 5. End stage renal disease on hemodialysis at Seneca Dialysis Unit through right AV fistula, anemia of chronic renal disease, secondary hyperparathyroidism. 6. Hyperlipidemia. 7. Diabetes mellitus, Type 2, diet controlled. 8. Coronary artery disease, status post myocardial infarction. 9. History of atrial fibrillation, detail unspecified. 10. Peripheral arterial disease, detail unspecified. 11. Venous insufficiency with history of bilateral lower extremity cellulitis. 12. One quarter pack per day smoker for 33 years. 13. Previous left femur fracture, 1/13/2015, between previous left Gamma nail fixation and distal femur, nonsurgical. 14. Previous other surgeries. 15. ADVANCE DIRECTIVE IS CPR. THERE IS NO MOLST FORM. QUESTIONABLE STATUS OF HEALTH CARE PROXY. 16. Left pleural effusion, status post thoracentesis of 1.5 L of fluid. FILED: ONONDAGA COUNTY CLERK 03/08/2022 12:39 PM INDEX NO. 007476/2018 AUSTIN, LARRY NYSCEF DOC. NO. 83 RECEIVED NYSCEF: 03/08/2022 SUBSEQUENT MEDICAL CARE PAGE 3 OF 3 RM# 347D 6/14/2016 PLAN: 1. Continue all medications and treatments as reflected in the Physician Orders and Comprehensive Care Plan which I have reviewed. 2. UPHOLD ADVANCE DIRECTIVE OF CPR. 3. Continue hemodialysis three times weekly. 4. Nephrology follow up with Dr. Rao. 5. Further management based on his course. D: 6/14/2016 T: 6/15/2016 JB/mb Jeanne Bishop, M.D.