On August 01, 2018 a
Exhibit,Appendix
was filed
involving a dispute between
Amanda Dillon,
Valerie Austin,
and
Brian Changlai Md,
Jeanne Bishop Md,
Ovid Neulander Md,
Pawan K Rao Md,
for Torts - Medical, Dental, or Podiatrist Malpractice
in the District Court of Onondaga County.
Preview
FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022
EXHIBIT “N”
FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022
James Square Health & Rehabilitation Centre
PROGRESS NOTE
Resident Name: Room#: Medical Record#: Physician Name:
AUSTIN, LARRY 347D 19360 JEANNE BISHOP
SUBSEQUENT MEDICAL CARE
5/21/2016
Since last evaluation Mr. Austin has been reasonably medically stable. He did sustain a roll out of bed fall on
5/13/2016 without major injury. He is recovering from his right radial nerve palsy and peripheral neuropathy.
He continues to receive dialysis for his end stage renal disease.
From a functional perspective he is alert. He engages appropriately. His mood is good. Today he is happy and
requires no psychotropics. He has no pain. He sleeps well and sees well with his glasses. Hearing and speech
are good. He can make his needs known. He requires limited assist for bathing, grooming and dressing. He is
edentulous. He takes a pureed renal diet. His appetite is fair. His weight is 123.2 lbs versus 128.7 lbs one month
ago. He is on a 1500 cc fluid restriction. He has good skin integrity with no pressure ulcers and no edema. He is
continent of bowel. Nurses report that his dialysis sessions are Monday, Wednesday and Friday.
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.
EXHIBIT
FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022
AUSTIN, LARRY
SUBSEQUENT MEDICAL CARE
PAGE 2 OF 3
RM# 347D MR# 19360
5/21/2016
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: He denies any discomforts at all.
PHYSICAL EXAMINATION: Weight is 123.2 Ibs, b/p 153/64, pulse is 63, respirations am 18,
temperature is 97.9. In general he lies comfortably in bed. He is happy and pleasant. HEENT: Hair is graying,
scalp is balding. Pupils reactive. He has no teeth. His mucosa is clean. NECK: Supple. LUNGS: Clear.
HEART: Sl, S2. ABDOMEN: Soft, nontender. Bowel sounds are active. EXTREMITIES: Reveal no calf
swelling, tenderness or edema. He has a right arm AV fistula with palpable thrill and audible bruit.
NEUROLOGIC: He has some cognitive strength. He engages appropriately. Cranial nerves are normal. He
can move extremities. His right radial palsy is improved. He can extend his wrist. Gait and Babinski's not
tested.
IMPRESSION:
1. Right arm and leg weakness due to radial nerve palsy and peripheral neuropathy, causation uremic
versus diabetic. His arm seems to be improved.
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.
1 1. 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.
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.
FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018
NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022
AUSTIN, LARRY
SUBSEQUENT MEDICAL CARE
PAGE 3 OF 3
RM# 347D MR# 19360
5/21/2016
PLAN: (Con't)
4. follow up with Dr. Pawan Rao.
Nephrology
5. Further management based on his course.
D: 5/21/2016
T: 5/24/2016
JB/mb Jeanne Bishop, M.D.
Document Filed Date
August 11, 2022
Case Filing Date
August 01, 2018
Category
Torts - Medical, Dental, or Podiatrist Malpractice
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Preview
FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022 EXHIBIT “N” FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022 James Square Health & Rehabilitation Centre PROGRESS NOTE Resident Name: Room#: Medical Record#: Physician Name: AUSTIN, LARRY 347D 19360 JEANNE BISHOP SUBSEQUENT MEDICAL CARE 5/21/2016 Since last evaluation Mr. Austin has been reasonably medically stable. He did sustain a roll out of bed fall on 5/13/2016 without major injury. He is recovering from his right radial nerve palsy and peripheral neuropathy. He continues to receive dialysis for his end stage renal disease. From a functional perspective he is alert. He engages appropriately. His mood is good. Today he is happy and requires no psychotropics. He has no pain. He sleeps well and sees well with his glasses. Hearing and speech are good. He can make his needs known. He requires limited assist for bathing, grooming and dressing. He is edentulous. He takes a pureed renal diet. His appetite is fair. His weight is 123.2 lbs versus 128.7 lbs one month ago. He is on a 1500 cc fluid restriction. He has good skin integrity with no pressure ulcers and no edema. He is continent of bowel. Nurses report that his dialysis sessions are Monday, Wednesday and Friday. 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. EXHIBIT FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022 AUSTIN, LARRY SUBSEQUENT MEDICAL CARE PAGE 2 OF 3 RM# 347D MR# 19360 5/21/2016 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: He denies any discomforts at all. PHYSICAL EXAMINATION: Weight is 123.2 Ibs, b/p 153/64, pulse is 63, respirations am 18, temperature is 97.9. In general he lies comfortably in bed. He is happy and pleasant. HEENT: Hair is graying, scalp is balding. Pupils reactive. He has no teeth. His mucosa is clean. NECK: Supple. LUNGS: Clear. HEART: Sl, S2. ABDOMEN: Soft, nontender. Bowel sounds are active. EXTREMITIES: Reveal no calf swelling, tenderness or edema. He has a right arm AV fistula with palpable thrill and audible bruit. NEUROLOGIC: He has some cognitive strength. He engages appropriately. Cranial nerves are normal. He can move extremities. His right radial palsy is improved. He can extend his wrist. Gait and Babinski's not tested. IMPRESSION: 1. Right arm and leg weakness due to radial nerve palsy and peripheral neuropathy, causation uremic versus diabetic. His arm seems to be improved. 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. 1 1. 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. 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. FILED: ONONDAGA COUNTY CLERK 08/11/2022 02:58 PM INDEX NO. 007476/2018 NYSCEF DOC. NO. 168 RECEIVED NYSCEF: 08/11/2022 AUSTIN, LARRY SUBSEQUENT MEDICAL CARE PAGE 3 OF 3 RM# 347D MR# 19360 5/21/2016 PLAN: (Con't) 4. follow up with Dr. Pawan Rao. Nephrology 5. Further management based on his course. D: 5/21/2016 T: 5/24/2016 JB/mb Jeanne Bishop, M.D.