Preview
Filing # 127217959 E-Filed 05/20/2021 02:30:36 PM
IN THE CIRCUIT COURT OF THE
19™ JUDICIAL CIRCUIT IN AND FOR
MARTIN COUNTY, FLORIDA
CASE NO.: 2019CA000015
FREDERIC CHARLES GREER, III and
MELISSA ANNE GREER, as Husband
and Wife, and FREDERIC CHARLES
GREER, Il and MELISSA ANNE
GREER, individually,
Plaintiffs,
VS.
MARTIN MEMORIAL MEDICAL
CENTER, _ INC., D/B/A MARTIN
MEDICAL CENTER, a Florida
Corporation, KUNAL CHAUDHRY,
MD, and CARDIOLOGY
ASSOCIATES OF STUART, P.A., a
Florida Profit Corporation,
Defendants.
/
PLAINTIFFS' FIFTH REQUEST FOR PRODUCTION
The Plaintiffs, FREDERIC CHARLES GREER, III] and MELISSA ANNE GREER, as
Husband and Wife, and FREDERIC CHARLES GREER, III] and MELISSA ANNE GREER,
individually, by and through their undersigned counsel, and hereby propounds this their Request
for Production to Defendant, MARTIN MEMORIAL MEDICAL CENTER, INC., D/B/A
MARTIN MEDICAL CENTER. The Defendant is to respond to said Fifth Request for
Production on or before thirty (30) days of receipt of service.
1 The Onsite Computer Inspection as ordered by ordered Judge Sweet occurred on
April 21, 2021 at Martin Memorial Medical Center.
Electronically Filed Martin 05/20/2021 02:30 PM
2 In the transcribed proceedings Stephani Grace, HIM supervisor stated that the
version of Dr. Chaudhry’s Interventional Cardiac results missing one sentence describing the
wall motion of the left ventricle could not be produced because of the Epic Contract. See
Exhibit “A”.
3 Produce the electronic medical records of Frederic Greer in existence in
September 2017 as labeled in Exhibit “G”, the Cardiac result in its final version and not the
chart view version.
4 Produce the contract between Epic and Martin Medical Center for the production
of Protected Health Information of Patients in 2017, including chart view format.
5 Produce the contract between Epie and Martin Medical Center that states that the
print group of the electronic medical records for Frederic Greer in Exhibit ‘G” is confidential
and not part of the electronic medical record of Frederic Greer in 2017.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing was sent via
electronic mail on this a
Z day of i , 2021 to: SEE ATTACHED SERVICE LIST.
Somera & Silva, LLP
One Boca Place
2255 Glades Road, Suite 232W
Boca Raton, FL 33431
Phone: (561) 981-8881
Fax: (561) 981-8887
Primary Email: pleadings@somerasilva.com
Secondary Email: litigation@somerasilva.com
Attorneys for Plaintif
By:
PETER J. SOMERA JR., ESQ.
FBN: 0034267
PAUL M SILVA, M.D., ESQ.
FBN: 0319820
SERVICE LIST
Geoffrey Fieger, Esq. Dinah Stein, Esq.
Fieger, Fieger, Kenney & Harrington, PC Hicks, Porter, Ebenfeld & Stein, PA
19390 West Ten Mile Road 799 Brickell Plaza, 9"" Floor
Southfield, MI 48075 Miami, FL 33131
Primary E-mail: G.Fieger@Fiegerlaw.com Primary Emails: dstein@mhickslaw.com
Secondary E-mail: eal@Fiegerlaw.com akozub@mhickslaw.com
(Co-Counsel
for Plaintiffs) Secondary Email: eclerk@mhickslaw.com
(Counsel for Defendants, Kunal Chaudhry,
M_D. and Cardiology Associates of Stuart,
Thomas G. Aubin, Esq. P.A.)
Stearns Weaver Mille Weissler Alhadeff &
Sitterson, P.A.
200 East Las Olas Boulevard, Suite 2100 Adam J. Richardson, Esq.
Fort Lauderdale, FL 33301 Bard Rockenbach, Esq.
Primary Email: taubin@stearnsweaver.com Burlington & Rockenbach, P.A.
mpodolnick@stearnsweaver.com Courthouse Commons/Suite 350
Secondary Email: nrodrigues@stearnsweaver.com 444 West Railroad Avenue
mpetruk@stearnsweaver.com West Palm Beach, FL 33401
knetto@stearnsweaver.com Primary Email: ajr@FLAppellateLaw.com
(Counsels for Defendant, Martin Memorial bdr@FLAppellateLaw.com
Medical Center, Inc. d/b/a Martin Secondary Email:
Memorial Medical Center) fa@FLAppellateLaw.com
(Appellate Counsel for Plaintiffs)
Keith J. Puya, Esq.
Hector R. Buigas, Esq.
Law Offices of Keith J. Puya, P.A.
4880 Donald Ross Road, Suite 225
Palm Beach Gardens, FL 33418
Primary Email: eservice@puyalaw.com
Secondary Email: kpuya@puyalaw.com
(Counsels for Defendants, Kunal Chaudhry,
M.D. and Cardiology Associates of Stuart,
PA)
PROCEEDINGS April
21, 2021
GREER V MMMC
MR. GARRETT: So in chart rearview, like this
is printed, there's two sentences there and here is one.
Can you pull it up like this that has the one sentence
in it?
MS. GRACE: This is what we have. This is
What can. pulel up, I can't pull up stuff from -- I
can't pull up something from 2017
MR. SILVA: I just want to be clear for the
record. Exhibit G, which has one sentence, cannot be
10 pulled up today. Exhibit. F, that has two sentences, can
11 be.
12 MR. GARRETT: Do you have any auditing data?
13 MS. KURISH: That's because the print group
14 was fixed between both of those exhibits so that's why
15 we can pull it up today.
16 MS BRANDENBURG: Jamie, what if we put the
17 broken print group back in there and then print?
18 MS GRACE: I mean, that was produced from
19 chart review A caregiver printed it out the wrong way.
20 MS BRANDENBURG: Right.
21 MS GRACE: They're not supposed to be
22 printing it out that way, anyway, so.
23 MS. BRANDENBURG: So in sup, I wonder if we
24 put the broken print group into the chart review report
25 and then show them that it was broken back then.
Z ESQUIRE DEPositioN SOLUTIONS,
800.211.DEPO (3376) | EXHIBIT
EsquireSolutions.com
PROCEEDINGS April
21, 2021
GREER
V MMMC 34
eae
Because --
MR. AUBIN: Give us a minute and we'll see if
there's a way to do that.
MR. SOMERA: Take a two-minute bathroom break
(A recess was taken.)
MR. GARRETT: Before we went on our little
break, you said, I guess there was some discussion to
look up something or something you |wanted to maybe show
us.
10 MS. GRACE: The answer is, can you ask me what
11 your question is.again?
12 MR. GARRETT: I asked if there's any way to
13 see the print group that would show why a sentence
14 exists or doesn't exist in the printed record?
15 MS. GRACE: The answer is no. Unfortunately,
16 because of our Epic agreement, those print groups are
17 confidential so we are not able to share that
18 information with you.
19 MR. SILVA: Guess what. For the record, put
20 on the record that the representatives at the hospital
21 are not giving us the data in regards to the print
22 group. Is that what it's called?
23 MR. GARRETT: Yes.
24 MR. SILVA: The print group for the cardiac
25 cath report authored by Dr. Kunal Chaudhry on
Z ESQUIRE 800.211.DEPO (3376)
EsquireSolutions.com
PROCEEDINGS eee
GREER V MMMC
September lst, 2017.
peneUse ices
MR. AUBIN: Okay. So we have 11 exhibits,
screenshots that were taken.
MS GRACE Yes.
MR AUBIN Is that it?
MR SILVA Yep.
MR AUBIN All you guys wanted.
MR SILVA Yep.
10 And you're going to have those to us within
11 seven days?
12 MR. AUBIN: Whatever the order is, yeah. I
13 think it's seven days, Paul.
14 MR. SILVA: All right. Okay. Thank you.
tS MR. AUBIN: Okay, thanks.
16 We'll get a copy of the transcript,
17 Ms. Reporter.
18 MR. SILVA: We're going to order. Big hard
19 copy, mini hard copy, and an E-Tran to depos, D-E-P-O-S,
20 at somerasilva dot com.
21 (The On-site Hospital Computer Inspection was
22 concluded 1:13 p.m.)
23
24
25)
ZESQ UIRE
DEPOSITION SOLUTIONS
800.211.DEPO (3376)
EsquireSolutions.com
* 1
Cardiology Associate POTSmodem1 (15792) 0/12/2018 02:53:34 PM -0400
Chart}[Frederick Greer)[39940]
— a _ —— a)
“Greet, Fréderick (MR # ee 6)
EXHIBIT
MARTIN HEALTH SYSTEM 15-/7)
Interventional Services Department
MC CARDIAC CATH
P.O Box 9010
Stuart, Florida 34995,
772-223-5919
Cardiac Result sf
—
Name:
Greer, Frederick
Pracedure(s) Performed:
(
MRM
MS90736
~~-AGGORSiOn:
) Dow
2/20/1965
Exam Date
Cardiac‘catheterization 006774699 09/04/2037
Péricardiocantesis 006775054 09/02/2017
‘Sex: Mate Patient Class: Inpatient
Ord Prov and CC Recipients Reason for Exam: STEMI
Kunal Chaudhry STEMI
Kunal-Chaudhry
Procedures Performed
Impella Insertion
Perciituinedtis coronary Intervention
Perlcardiacentasts:
Cardiac Alatt
LHC/CORONARIES/GRAFTS WIWO LV GRAM
Physicians
Painat Physi ns Rete Physician Canc Ad oning Phys
Kune Chaudhry -MD (Primary)
Indications
NSTEMI{non-8T elevated myocardial infarction) (*) {121.4 (ICD-10-CM)}
‘Cardiogeni¢ shack (*) (R570 ((CD-40-CM)]
Pe e:procedure Diagnosis
NSTEM!
Gatdiagedlc Shock
Cleat History
‘The patients @ $2-year-old male with past mental history significant for insulin-dependant diabetes and hyperlipidemia who
prosonted to the em: ancy Foor with complaints of savers dyspnea along with.rest chest discomfort which had been ongoing far
4 daya, H18 tnilla! Gardiae blomarkers Wore markedly. elevated with a traponin | graater than 20. His electrocardiogrant
demonstrated evidence7 af Gaadwaves actoas the inferalateral leads consistent with an inferior posteriat lateral myocardial Infarction
which is age Indeterminate likely 4 days prior to presentation. He was brought with.the diaghosls.of a hon-ST elevation
myscardial infarctisn with ofigoing symptoms In the setting of cardiogeiic shack,
Piocedure detail
A2% WdOCsIAG olution was used to anesthelize the right wrist, and a 5/6 French sheath wea insarted into the right radial artery
without Issue.A.§ French:
TIG diagnostic catheter
was used to engage the left main and multiple angiographic ews were
‘obtained: Th same cathaler was used to ehgage the right coronary artery, and multiple anglographic views were obtalned.A SF
Pigtad catheter was Used to-traneduce LV hemodynamics. Let ventdculography was performed with the Same tatheter,
‘Alter Gagnbatle cardiac cathatarization, a 6 F: ranch XB LAD 3.8 guide gathoter was used to engage the lek main cdcofiaty ostium,
Th ‘o:palient Was anticoagulated with Intavenous bivelinudia. A run-ihrough wire was used to attempt to cfoss the proximal left:
‘eit fiifSx lesion but this veds Not possible givén the longevity of the occlusion and the fkelitood that the infarction occurred: 4 days:
aga. The pallerit’s siectrocardiogtem raftected Q waves-across. the Infatolat eral laads, He did have ongoing 'ayriptoms which
Srothiled arrettentpt at intervention. A Corsair catheter was Used along with a pilot 150 wire to cross'the lesion and. wai left inthe’
Greer Brederick (MR # M520730) Printed by Karen Lara [KLARA] at 9/7/17 10:42 AM of 6
EXHIBIT
(Page 14 of 91]
1G
1
‘Cardiology Associate POTSmodemt (16/92) 10/12/2018 02:54:45 PM -0400
‘Chart][Frederick Greer]{89940}
— _ —— -
SS
Greer, Frederick (MR #M590736)
distal portion of the OM1, The Corsair catheter was t hen passed inte the distal portion of the marginal and the pilot 150 wire was
exchanged for a long run-through wire. The proximal portion of the left circumflex was dilated several times with a 2.5mmwas
compiiant ballocn followed by a 3.0 mm compliant balloon with no fiow in the vessel despite this. A surgical consultation
oblained at he bedside and the patient was not felt to be a suitable candidate balloon at this time for coronary bypass grafting given
‘ongoing infarction In a passibla nonviable distributh lon: The 2.5 mm compliant was also usad to pradilate the proximal
fortlan of the OM1: Subsequent angiography reveal lad improvement ia flow In the circumflex distribution but with evidence of frank
parforation of the caronary veaeal in the mid segment of f the OM1. The patient's blood prassure subsequently dropped and in
intravenous bivalirudin was discontinued. The patient received multiple boluses af Neo-Synephrine with some improvement
blood pressute, An emerge’ ncy pericardiocentesis tray was opened and multipleDespite attempts were Used to perform pericardiacentesis
unsuccessfully given the dey pt th from the chest wall to the actual pericardium. use of an ultrasound, we were unsuccessful
in entering the pericardium pereutaneousty, At thi is fime, | had Dr. Crouch from cardiothoracic surgeryTheparformed a pericarcial
remaval of bicady fluld,
windaw in the cath tab with successful Irnprovement in hi lemosynamics andand sedation patient was alse intubated
for airway protection during this period of time and recaived paralytic for the procadure. Repest angiography
demonstrated closure of tha proximal left circumfiax with no further bleeding Into tha pericardium. The pallent however developed
worsening cardiogenic shock which was present initially as his opening left ventricular leftend-diastolic prosaura was 40 mmHg in the
setting af multivessel coronary disease. At this time, the decision was made tosheath. obti common femoral arterial access and the
6 French sheath which was insarted with serial dilatations up to a 14 French Successful and uncomplicated placement of
in homedynaraica. During this period of ime, the patientAfter
an inpalla CP device was t then performed with significant improvement compression
did sustain 2 episodes of a PEA arrest which required CPR with chest s and medications as outlined by nursing.
placement of the devics, the 7: fatlant atarted to improve olinioally. His overall hemodynamic s were significanty improved but he was
maintained on high dose norepinephrine and phenylephrine. Right common femoral arterial acoess was then obtained to
reavaluate the coronary arteries which ware unchi angad. Loft common femoral | venouscareaccess sites was obtained and exchanged
unit. The case was discussed in detail
for @ triple lumen csthatar which was left in place for transfer to the cardiac intenalve
with the patient's wife and family members were aware of his oriticat condition.
During this procedure, Or, Chaudhry admin! Kstered moderate conscious sedation using varsed and fentanyl, Dr. Chaudhry was
assisted in monitoring the patient's level of consclousness , blaod pressure, heartrate, arterial saturation, and respiratory rate by an
independent, critical cara nurse as documented in th 1¢ chart. Pre-and post: sessment and monitoring was Dr.performed. Br,
Chaudhry exited the
Chaudhry documented intraservice time (continuous: face to face time after administration of sedation unt!
room) was 279 minutes.
Contrast
Visipaque 320 was used during the procedure, total contrast used was 200 ml.
Left Heart
Left Ventricle to be 44
LV and diastollc pressure is severely slevated. The jo: ction fraction Is calculated to be 18%, The EDM Is calculated
Wall Motion
Aortic
aa
al
& My
2 os
Qea ce
“oy Tn. < Bey
ae
:
fey
a
g oom
seya
th
a treet
i
2 eu
‘Akinesis of the mid inferior wall with overall savers hypokinesis of the remaining segments with LV
ejection fraction estimated at 15%
Aneurysmal
@® wormai BD Hypokinesis @® rxinesis GB) ovskinesis
Coronary Findings
Dominance: Right
Left Main vessel originates from the left coronary
The vessel was visualized by angiography, is large and is angiographically normal. The
simis.
Lett Anterior Descending
— mek
ie
A] at 9/7/17 10:42 AM Page 2 of 6
Greer, Frederick (MR # M590736) Printed by Karen Lara [KLAR
(Page 15 of 91}
Cardiology Associate POTSmodem1 (17792) 10/12/2018 02:55:57 PM ~0400
Chan]{Frederick Greer][89940}
—— -
Greer, Frederick (MR # M590736)
‘The vessel is moderate in size. The vessel is moderately calcified
+ Prox LAD lesion, 30% stenosis.
+ Mid LAD lesion, 80% stenosis,
+ Dist LAD tasion, 70% stenosis.
Loft Circumtiex
‘The vessatis moderate in size.
+ Prox Cx leston, 100% stenosis, Culprit lesion. The lesion is C - 20mm or greater. The lasion was not praviously treated.
+ PCI: Lesion tengtn: 30 mm. The guidewire crossed lesion. alAngioplasty atone was performed, There is no pre-Interventional
antegrade distal flow CFIM{ '0). There is no post-intervention antegrade distal flaw (TIMI 0), The intervention was
unsuccessful, No reflow dui @ to non viable myocardium Al this lesion, a perforation of the vesset occurred. Pressure
witeJFFR was not performed on the lesion. 'VUS was not performed on the lesion, No optical coherence tomography
{OCT) was parfarmed. The intervention wasn't successful,
There is a 100% residual stenosis post intervention.
Right Coronary Attary
‘The vessel was visualized by angiography and is moderate in size. The vessel originates from the right coronary sinus. The
vessel ig maderately calcified
+ Mid RCA lesion, 95% stenosis
+ Dist RCA-1 lesion, 80% stenosis.
+ Dist RCA-2 lasion, 70% stenosis.
Condition
Gardiae Output Sysiemig Arteria!
Condition HR BSA Hernaglobin kOe Batimarag 02
02 REST 106 bpm 2.42 m2 13.1 gf 133 321.86
Pressures O2 REST
Blood G
Data Time Syatotic Diastotie EOP Means wave: V Wave SAT
AO 6:55 AM 4113 mmHg 84 mmtg 96 mmHg
7:10AM 107 mmHg 80 mmHg 91 mmtg
7:29 AM 100 mmHg. 74 mmHg 83 mmHg
2 AM 62 mmbg 48 mmbig 52 mmHg
7:56 AM 63 mmHg 50 mmHg 55 mmHg
8:02 AM 132 mmHg 88 mmHg 102 mmHg
8:07 AM 426 mmHg 94 mmitg 105 mmbig
8:10 AM 124 mmdg 91 mmtig 102 mmitg
812 AM 145 mmeig 85 mmig 96 mmtHg
8:20 AM 24 mmHg 69 mmHg 78 mmig
8:23 AM 117 mmtg, 99 mmHg 107 mmtig
8:24 AM 73 mmHg 67 mmHg 74 mmHg
8:27 AM 125 mmlg 116 mmHg 121 mmHg
8:42 AM 87 mmtig 81 mmig 64 mmHg
8:42 AM 92 mmHg 47 mmHg 65 mmHg
8:45 AM 122 mmtg 70 mmHg 88 mmHg
8:47 AM 101 mmMtg 87 mmg 73 mmHg
8:48 AM 133 mmHg 77 mmHg 97 mmHg
8:55 AM 105 mmHg 62 mmHg 77 mmHg
9:05 AM 108 mmHg @1 mmig 78 mmHg
O10 AM 70 mmHg 39 mmHg 50 mmtig
9:12 AM 69 mmHg 4t mmHg, 81 mmHg
uv 7:00 AM 24 metg +8 mmHg 44 comiig
AOp 7:00 AM 419 mmHg 48 mmitg 6 mmHg
Lp 7:00 AM 421 mmHg 17 meng 39 mmiig
Blood Oximetry 9/1/17 0639--9/1/17 1057
Date/Time Pulse Resp BP sp02
9/0: 06:45: 87 20 128/86 i %
ogia 10:16:32 103 a 112/64
Greer, Frederick (MR # M590736) Printed by Karen Lara {KLARA] at 9/7/17
10:42 AM Page 3 of 6
{Page 16 of 91}
7
Card io logy Associate POTSmodem|! (48/92) 10/12/2018 02:56:57 PM -0400
Chart][Frederick G 2189940)
eee _ —_ —
=
Greer, Prederick (MR # 1590736)
Gs/Ot/? 10:25:08 102 18 194/70
““Impalla Insertion
Impolta Insertion
‘The catheter was inserted lo the left famoral artery. The performance evel was P9. The Impolta was nat repositioned. Cardiag
Output was 3 Limin,
Pericardiscentesis
Portcardium with ultrasound, Unsuccessful attempt at
Pesicaddiocetitesie performed by the apical and.parastemal approach with flyoro andwindow performed by Dr, Crouch.
Bericardiocentesis given depth from chest ‘wall {6 "pericardium. Bedskte pericardial
ouinmary
Conclusion:
of Q waves across the
4) ‘Otéltision of the proximal left circumflex arter ry which is likely 4 days old in the settingangioplasty with no
inférotateral leads (pre-TIMLO flow, "100% .occlusi ‘on, culprit vessel) status post balloon
Significant impror wement in flow and unfortunate coronary perforatl ionmedleading te pericardial tarripanade ‘requiring
balloon inflation was perfor of the proximal left-clreumfex to limit
badside patigardi
: ial window. Prolténged
bléeding ani final i angiography revealed post-TIMI 0 flow with 100% occlusion of the préxifnal
tefl circumttex.
2) Severe disease in thé mid and distal LAO.
3): Sevaré disease in the mid and distat RCA.
4) Successful placement of an‘impella C device with cardiac output of 3.2 L/m via the device in the
setting of diogsnio shock.
5). Severely elevated LV filling pressures with LV end-diastolic pressure 44 mmHg.
of the mid inferior wall with overall severe hypokinesis of the remaining segmer
nits with LV
6) Akinasis
ejection fraction astiniated at 15%,
site,
7). Manual compression was achieved of the rig ht common femoral arterial access
8) TR band Was used to achieve heriostasis at the right radial atcess site,
site.
9): A tiple iumen catheter was left in’ placein the left common femoral venous access access
10) The impélla’ GP device and sheath was su tured in place at the left common-femdral arterial
site,
+1) Case was discussed in detail with the patient's wi ife who understands his
critical situation.
12) The patient recéived intravenous bivalirudin at the beginning of the procedure and this
was
subsequefitly discontinued. during the procedure.
43) The patient was transferred to:the CVICU in critical condition
Recommendations:
and overall hamadynamic status and respiratory status,
1) Maintain [mpella support with close monitating closely
2) Trend lactates closely: “Monitor rena! function along with urine output
3) Hopeful bridgeto potential revascutarization of the LAD and RGA with coronary artery bypass grat fting depending
‘on clinigat situation.
4) .Origoing ctitical care monitoring.
status.
5) "Pulmonary constiltation has been requested to help manage his resplratory
Complications the procedure with pericardial tap and not
Other complications: The patient did develop frank perforation of the OM1 duringcatheteriza tion lab by Or. Crouch.
reguiring an-emergent pericardial wi iindow which was performed in the cardiac
” Staff
Type Tene tn View a
Jacob Bennett, ROIS VAR Documenter 91/2017 0618 9/1/2017 2087
Brian roll, RN, GUAR Circulator arv2017 0618 99/2017 1057
Kafteriiia Glkeau, RT(R) VAR Scrub Tech 9/1/2017 0618 9/1/2017 1087,
{tot assigned) _ CVAR Pre RN
(Nat, 9), VAR Post RN
CVAR Nurse 9/1/2017 0639 9/1/2017 1057
Katelyn Tilley, RN
“Radiation Exposure Detalles Use
Event
10:42 AM Page 4: of 6 oe
-, Greer, Frederick (MR # M590736) Printed by Karen Lara [KLARA] at 9/7/17
(Page17 of 91]
.
cardidlogy Associate POTSmodem! (19/92) 10/12/2018 02:58:12 PM -0400
(Char[Erederie Greer][89940]
Greer, Frederick (MR # M590736)
[0:49AM Radiation Tracking DLP: Total Dose (mGy) = §701,000 JB
Physician: Kunal Chaudhry, MO
Dose (mGy) = 701.000
Fluoro Time (mins) = 42.1
DAP (Gy-em2) = 45817.000
Implants
Name 10 Temporary Type Supply
No information to-display
Coronary Diagrams
Diagnostic Diagram
oo co
S028) BI
a
(7S
a
Sasa
12 fo™N
L = - |
Post-Intervention Diagram
: Greet, Frederick (MR #590736) foe by Karen Lara [KLARA] . 9/TIVT 10:42 AM Page 5 Ce
- Le
[Page 18
of 91]
cardiology Associate POTSmodemt (20/92) 10/12/2018 02:59:07 PM -0400
Chit] [Frederick Greer (89940)
= oe ee a,
Greer, Frederick (MR # 590736)
oO
fo a,
Cu ee
cst,
eens, ceie —
ROY
een
ten
{THRE
te
a
iG
oo Teri
—
Pen
tneanctemie name
nremerrnanes
{8 [— tines
Gael
soca
nd
on |
pene"
a
error ee
ony —
ee
t ~
Signed
Electronically signed by Kunal Chaudhry, MD on 9/1/17 at 1208 EOT
Grect, Frederick (MR 4 M590736) Printed by Karen Lara [KLARA] at O/T/AT 10:42 AM
Page 6 of 6
{Page 19 of 91]
Preview
Filing # 127217959 E-Filed 05/20/2021 02:30:36 PM IN THE CIRCUIT COURT OF THE 19™ JUDICIAL CIRCUIT IN AND FOR MARTIN COUNTY, FLORIDA CASE NO.: 2019CA000015 FREDERIC CHARLES GREER, III and MELISSA ANNE GREER, as Husband and Wife, and FREDERIC CHARLES GREER, Il and MELISSA ANNE GREER, individually, Plaintiffs, VS. MARTIN MEMORIAL MEDICAL CENTER, _ INC., D/B/A MARTIN MEDICAL CENTER, a Florida Corporation, KUNAL CHAUDHRY, MD, and CARDIOLOGY ASSOCIATES OF STUART, P.A., a Florida Profit Corporation, Defendants. / PLAINTIFFS' FIFTH REQUEST FOR PRODUCTION The Plaintiffs, FREDERIC CHARLES GREER, III] and MELISSA ANNE GREER, as Husband and Wife, and FREDERIC CHARLES GREER, III] and MELISSA ANNE GREER, individually, by and through their undersigned counsel, and hereby propounds this their Request for Production to Defendant, MARTIN MEMORIAL MEDICAL CENTER, INC., D/B/A MARTIN MEDICAL CENTER. The Defendant is to respond to said Fifth Request for Production on or before thirty (30) days of receipt of service. 1 The Onsite Computer Inspection as ordered by ordered Judge Sweet occurred on April 21, 2021 at Martin Memorial Medical Center. Electronically Filed Martin 05/20/2021 02:30 PM 2 In the transcribed proceedings Stephani Grace, HIM supervisor stated that the version of Dr. Chaudhry’s Interventional Cardiac results missing one sentence describing the wall motion of the left ventricle could not be produced because of the Epic Contract. See Exhibit “A”. 3 Produce the electronic medical records of Frederic Greer in existence in September 2017 as labeled in Exhibit “G”, the Cardiac result in its final version and not the chart view version. 4 Produce the contract between Epic and Martin Medical Center for the production of Protected Health Information of Patients in 2017, including chart view format. 5 Produce the contract between Epie and Martin Medical Center that states that the print group of the electronic medical records for Frederic Greer in Exhibit ‘G” is confidential and not part of the electronic medical record of Frederic Greer in 2017. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing was sent via electronic mail on this a Z day of i , 2021 to: SEE ATTACHED SERVICE LIST. Somera & Silva, LLP One Boca Place 2255 Glades Road, Suite 232W Boca Raton, FL 33431 Phone: (561) 981-8881 Fax: (561) 981-8887 Primary Email: pleadings@somerasilva.com Secondary Email: litigation@somerasilva.com Attorneys for Plaintif By: PETER J. SOMERA JR., ESQ. FBN: 0034267 PAUL M SILVA, M.D., ESQ. FBN: 0319820 SERVICE LIST Geoffrey Fieger, Esq. Dinah Stein, Esq. Fieger, Fieger, Kenney & Harrington, PC Hicks, Porter, Ebenfeld & Stein, PA 19390 West Ten Mile Road 799 Brickell Plaza, 9"" Floor Southfield, MI 48075 Miami, FL 33131 Primary E-mail: G.Fieger@Fiegerlaw.com Primary Emails: dstein@mhickslaw.com Secondary E-mail: eal@Fiegerlaw.com akozub@mhickslaw.com (Co-Counsel for Plaintiffs) Secondary Email: eclerk@mhickslaw.com (Counsel for Defendants, Kunal Chaudhry, M_D. and Cardiology Associates of Stuart, Thomas G. Aubin, Esq. P.A.) Stearns Weaver Mille Weissler Alhadeff & Sitterson, P.A. 200 East Las Olas Boulevard, Suite 2100 Adam J. Richardson, Esq. Fort Lauderdale, FL 33301 Bard Rockenbach, Esq. Primary Email: taubin@stearnsweaver.com Burlington & Rockenbach, P.A. mpodolnick@stearnsweaver.com Courthouse Commons/Suite 350 Secondary Email: nrodrigues@stearnsweaver.com 444 West Railroad Avenue mpetruk@stearnsweaver.com West Palm Beach, FL 33401 knetto@stearnsweaver.com Primary Email: ajr@FLAppellateLaw.com (Counsels for Defendant, Martin Memorial bdr@FLAppellateLaw.com Medical Center, Inc. d/b/a Martin Secondary Email: Memorial Medical Center) fa@FLAppellateLaw.com (Appellate Counsel for Plaintiffs) Keith J. Puya, Esq. Hector R. Buigas, Esq. Law Offices of Keith J. Puya, P.A. 4880 Donald Ross Road, Suite 225 Palm Beach Gardens, FL 33418 Primary Email: eservice@puyalaw.com Secondary Email: kpuya@puyalaw.com (Counsels for Defendants, Kunal Chaudhry, M.D. and Cardiology Associates of Stuart, PA) PROCEEDINGS April 21, 2021 GREER V MMMC MR. GARRETT: So in chart rearview, like this is printed, there's two sentences there and here is one. Can you pull it up like this that has the one sentence in it? MS. GRACE: This is what we have. This is What can. pulel up, I can't pull up stuff from -- I can't pull up something from 2017 MR. SILVA: I just want to be clear for the record. Exhibit G, which has one sentence, cannot be 10 pulled up today. Exhibit. F, that has two sentences, can 11 be. 12 MR. GARRETT: Do you have any auditing data? 13 MS. KURISH: That's because the print group 14 was fixed between both of those exhibits so that's why 15 we can pull it up today. 16 MS BRANDENBURG: Jamie, what if we put the 17 broken print group back in there and then print? 18 MS GRACE: I mean, that was produced from 19 chart review A caregiver printed it out the wrong way. 20 MS BRANDENBURG: Right. 21 MS GRACE: They're not supposed to be 22 printing it out that way, anyway, so. 23 MS. BRANDENBURG: So in sup, I wonder if we 24 put the broken print group into the chart review report 25 and then show them that it was broken back then. Z ESQUIRE DEPositioN SOLUTIONS, 800.211.DEPO (3376) | EXHIBIT EsquireSolutions.com PROCEEDINGS April 21, 2021 GREER V MMMC 34 eae Because -- MR. AUBIN: Give us a minute and we'll see if there's a way to do that. MR. SOMERA: Take a two-minute bathroom break (A recess was taken.) MR. GARRETT: Before we went on our little break, you said, I guess there was some discussion to look up something or something you |wanted to maybe show us. 10 MS. GRACE: The answer is, can you ask me what 11 your question is.again? 12 MR. GARRETT: I asked if there's any way to 13 see the print group that would show why a sentence 14 exists or doesn't exist in the printed record? 15 MS. GRACE: The answer is no. Unfortunately, 16 because of our Epic agreement, those print groups are 17 confidential so we are not able to share that 18 information with you. 19 MR. SILVA: Guess what. For the record, put 20 on the record that the representatives at the hospital 21 are not giving us the data in regards to the print 22 group. Is that what it's called? 23 MR. GARRETT: Yes. 24 MR. SILVA: The print group for the cardiac 25 cath report authored by Dr. Kunal Chaudhry on Z ESQUIRE 800.211.DEPO (3376) EsquireSolutions.com PROCEEDINGS eee GREER V MMMC September lst, 2017. peneUse ices MR. AUBIN: Okay. So we have 11 exhibits, screenshots that were taken. MS GRACE Yes. MR AUBIN Is that it? MR SILVA Yep. MR AUBIN All you guys wanted. MR SILVA Yep. 10 And you're going to have those to us within 11 seven days? 12 MR. AUBIN: Whatever the order is, yeah. I 13 think it's seven days, Paul. 14 MR. SILVA: All right. Okay. Thank you. tS MR. AUBIN: Okay, thanks. 16 We'll get a copy of the transcript, 17 Ms. Reporter. 18 MR. SILVA: We're going to order. Big hard 19 copy, mini hard copy, and an E-Tran to depos, D-E-P-O-S, 20 at somerasilva dot com. 21 (The On-site Hospital Computer Inspection was 22 concluded 1:13 p.m.) 23 24 25) ZESQ UIRE DEPOSITION SOLUTIONS 800.211.DEPO (3376) EsquireSolutions.com * 1 Cardiology Associate POTSmodem1 (15792) 0/12/2018 02:53:34 PM -0400 Chart}[Frederick Greer)[39940] — a _ —— a) “Greet, Fréderick (MR # ee 6) EXHIBIT MARTIN HEALTH SYSTEM 15-/7) Interventional Services Department MC CARDIAC CATH P.O Box 9010 Stuart, Florida 34995, 772-223-5919 Cardiac Result sf — Name: Greer, Frederick Pracedure(s) Performed: ( MRM MS90736 ~~-AGGORSiOn: ) Dow 2/20/1965 Exam Date Cardiac‘catheterization 006774699 09/04/2037 Péricardiocantesis 006775054 09/02/2017 ‘Sex: Mate Patient Class: Inpatient Ord Prov and CC Recipients Reason for Exam: STEMI Kunal Chaudhry STEMI Kunal-Chaudhry Procedures Performed Impella Insertion Perciituinedtis coronary Intervention Perlcardiacentasts: Cardiac Alatt LHC/CORONARIES/GRAFTS WIWO LV GRAM Physicians Painat Physi ns Rete Physician Canc Ad oning Phys Kune Chaudhry -MD (Primary) Indications NSTEMI{non-8T elevated myocardial infarction) (*) {121.4 (ICD-10-CM)} ‘Cardiogeni¢ shack (*) (R570 ((CD-40-CM)] Pe e:procedure Diagnosis NSTEM! Gatdiagedlc Shock Cleat History ‘The patients @ $2-year-old male with past mental history significant for insulin-dependant diabetes and hyperlipidemia who prosonted to the em: ancy Foor with complaints of savers dyspnea along with.rest chest discomfort which had been ongoing far 4 daya, H18 tnilla! Gardiae blomarkers Wore markedly. elevated with a traponin | graater than 20. His electrocardiogrant demonstrated evidence7 af Gaadwaves actoas the inferalateral leads consistent with an inferior posteriat lateral myocardial Infarction which is age Indeterminate likely 4 days prior to presentation. He was brought with.the diaghosls.of a hon-ST elevation myscardial infarctisn with ofigoing symptoms In the setting of cardiogeiic shack, Piocedure detail A2% WdOCsIAG olution was used to anesthelize the right wrist, and a 5/6 French sheath wea insarted into the right radial artery without Issue.A.§ French: TIG diagnostic catheter was used to engage the left main and multiple angiographic ews were ‘obtained: Th same cathaler was used to ehgage the right coronary artery, and multiple anglographic views were obtalned.A SF Pigtad catheter was Used to-traneduce LV hemodynamics. Let ventdculography was performed with the Same tatheter, ‘Alter Gagnbatle cardiac cathatarization, a 6 F: ranch XB LAD 3.8 guide gathoter was used to engage the lek main cdcofiaty ostium, Th ‘o:palient Was anticoagulated with Intavenous bivelinudia. A run-ihrough wire was used to attempt to cfoss the proximal left: ‘eit fiifSx lesion but this veds Not possible givén the longevity of the occlusion and the fkelitood that the infarction occurred: 4 days: aga. The pallerit’s siectrocardiogtem raftected Q waves-across. the Infatolat eral laads, He did have ongoing 'ayriptoms which Srothiled arrettentpt at intervention. A Corsair catheter was Used along with a pilot 150 wire to cross'the lesion and. wai left inthe’ Greer Brederick (MR # M520730) Printed by Karen Lara [KLARA] at 9/7/17 10:42 AM of 6 EXHIBIT (Page 14 of 91] 1G 1 ‘Cardiology Associate POTSmodemt (16/92) 10/12/2018 02:54:45 PM -0400 ‘Chart][Frederick Greer]{89940} — _ —— - SS Greer, Frederick (MR #M590736) distal portion of the OM1, The Corsair catheter was t hen passed inte the distal portion of the marginal and the pilot 150 wire was exchanged for a long run-through wire. The proximal portion of the left circumflex was dilated several times with a 2.5mmwas compiiant ballocn followed by a 3.0 mm compliant balloon with no fiow in the vessel despite this. A surgical consultation oblained at he bedside and the patient was not felt to be a suitable candidate balloon at this time for coronary bypass grafting given ‘ongoing infarction In a passibla nonviable distributh lon: The 2.5 mm compliant was also usad to pradilate the proximal fortlan of the OM1: Subsequent angiography reveal lad improvement ia flow In the circumflex distribution but with evidence of frank parforation of the caronary veaeal in the mid segment of f the OM1. The patient's blood prassure subsequently dropped and in intravenous bivalirudin was discontinued. The patient received multiple boluses af Neo-Synephrine with some improvement blood pressute, An emerge’ ncy pericardiocentesis tray was opened and multipleDespite attempts were Used to perform pericardiacentesis unsuccessfully given the dey pt th from the chest wall to the actual pericardium. use of an ultrasound, we were unsuccessful in entering the pericardium pereutaneousty, At thi is fime, | had Dr. Crouch from cardiothoracic surgeryTheparformed a pericarcial remaval of bicady fluld, windaw in the cath tab with successful Irnprovement in hi lemosynamics andand sedation patient was alse intubated for airway protection during this period of time and recaived paralytic for the procadure. Repest angiography demonstrated closure of tha proximal left circumfiax with no further bleeding Into tha pericardium. The pallent however developed worsening cardiogenic shock which was present initially as his opening left ventricular leftend-diastolic prosaura was 40 mmHg in the setting af multivessel coronary disease. At this time, the decision was made tosheath. obti common femoral arterial access and the 6 French sheath which was insarted with serial dilatations up to a 14 French Successful and uncomplicated placement of in homedynaraica. During this period of ime, the patientAfter an inpalla CP device was t then performed with significant improvement compression did sustain 2 episodes of a PEA arrest which required CPR with chest s and medications as outlined by nursing. placement of the devics, the 7: fatlant atarted to improve olinioally. His overall hemodynamic s were significanty improved but he was maintained on high dose norepinephrine and phenylephrine. Right common femoral arterial acoess was then obtained to reavaluate the coronary arteries which ware unchi angad. Loft common femoral | venouscareaccess sites was obtained and exchanged unit. The case was discussed in detail for @ triple lumen csthatar which was left in place for transfer to the cardiac intenalve with the patient's wife and family members were aware of his oriticat condition. During this procedure, Or, Chaudhry admin! Kstered moderate conscious sedation using varsed and fentanyl, Dr. Chaudhry was assisted in monitoring the patient's level of consclousness , blaod pressure, heartrate, arterial saturation, and respiratory rate by an independent, critical cara nurse as documented in th 1¢ chart. Pre-and post: sessment and monitoring was Dr.performed. Br, Chaudhry exited the Chaudhry documented intraservice time (continuous: face to face time after administration of sedation unt! room) was 279 minutes. Contrast Visipaque 320 was used during the procedure, total contrast used was 200 ml. Left Heart Left Ventricle to be 44 LV and diastollc pressure is severely slevated. The jo: ction fraction Is calculated to be 18%, The EDM Is calculated Wall Motion Aortic aa al & My 2 os Qea ce “oy Tn. < Bey ae : fey a g oom seya th a treet i 2 eu ‘Akinesis of the mid inferior wall with overall savers hypokinesis of the remaining segments with LV ejection fraction estimated at 15% Aneurysmal @® wormai BD Hypokinesis @® rxinesis GB) ovskinesis Coronary Findings Dominance: Right Left Main vessel originates from the left coronary The vessel was visualized by angiography, is large and is angiographically normal. The simis. Lett Anterior Descending — mek ie A] at 9/7/17 10:42 AM Page 2 of 6 Greer, Frederick (MR # M590736) Printed by Karen Lara [KLAR (Page 15 of 91} Cardiology Associate POTSmodem1 (17792) 10/12/2018 02:55:57 PM ~0400 Chan]{Frederick Greer][89940} —— - Greer, Frederick (MR # M590736) ‘The vessel is moderate in size. The vessel is moderately calcified + Prox LAD lesion, 30% stenosis. + Mid LAD lesion, 80% stenosis, + Dist LAD tasion, 70% stenosis. Loft Circumtiex ‘The vessatis moderate in size. + Prox Cx leston, 100% stenosis, Culprit lesion. The lesion is C - 20mm or greater. The lasion was not praviously treated. + PCI: Lesion tengtn: 30 mm. The guidewire crossed lesion. alAngioplasty atone was performed, There is no pre-Interventional antegrade distal flow CFIM{ '0). There is no post-intervention antegrade distal flaw (TIMI 0), The intervention was unsuccessful, No reflow dui @ to non viable myocardium Al this lesion, a perforation of the vesset occurred. Pressure witeJFFR was not performed on the lesion. 'VUS was not performed on the lesion, No optical coherence tomography {OCT) was parfarmed. The intervention wasn't successful, There is a 100% residual stenosis post intervention. Right Coronary Attary ‘The vessel was visualized by angiography and is moderate in size. The vessel originates from the right coronary sinus. The vessel ig maderately calcified + Mid RCA lesion, 95% stenosis + Dist RCA-1 lesion, 80% stenosis. + Dist RCA-2 lasion, 70% stenosis. Condition Gardiae Output Sysiemig Arteria! Condition HR BSA Hernaglobin kOe Batimarag 02 02 REST 106 bpm 2.42 m2 13.1 gf 133 321.86 Pressures O2 REST Blood G Data Time Syatotic Diastotie EOP Means wave: V Wave SAT AO 6:55 AM 4113 mmHg 84 mmtg 96 mmHg 7:10AM 107 mmHg 80 mmHg 91 mmtg 7:29 AM 100 mmHg. 74 mmHg 83 mmHg 2 AM 62 mmbg 48 mmbig 52 mmHg 7:56 AM 63 mmHg 50 mmHg 55 mmHg 8:02 AM 132 mmHg 88 mmHg 102 mmHg 8:07 AM 426 mmHg 94 mmitg 105 mmbig 8:10 AM 124 mmdg 91 mmtig 102 mmitg 812 AM 145 mmeig 85 mmig 96 mmtHg 8:20 AM 24 mmHg 69 mmHg 78 mmig 8:23 AM 117 mmtg, 99 mmHg 107 mmtig 8:24 AM 73 mmHg 67 mmHg 74 mmHg 8:27 AM 125 mmlg 116 mmHg 121 mmHg 8:42 AM 87 mmtig 81 mmig 64 mmHg 8:42 AM 92 mmHg 47 mmHg 65 mmHg 8:45 AM 122 mmtg 70 mmHg 88 mmHg 8:47 AM 101 mmMtg 87 mmg 73 mmHg 8:48 AM 133 mmHg 77 mmHg 97 mmHg 8:55 AM 105 mmHg 62 mmHg 77 mmHg 9:05 AM 108 mmHg @1 mmig 78 mmHg O10 AM 70 mmHg 39 mmHg 50 mmtig 9:12 AM 69 mmHg 4t mmHg, 81 mmHg uv 7:00 AM 24 metg +8 mmHg 44 comiig AOp 7:00 AM 419 mmHg 48 mmitg 6 mmHg Lp 7:00 AM 421 mmHg 17 meng 39 mmiig Blood Oximetry 9/1/17 0639--9/1/17 1057 Date/Time Pulse Resp BP sp02 9/0: 06:45: 87 20 128/86 i % ogia 10:16:32 103 a 112/64 Greer, Frederick (MR # M590736) Printed by Karen Lara {KLARA] at 9/7/17 10:42 AM Page 3 of 6 {Page 16 of 91} 7 Card io logy Associate POTSmodem|! (48/92) 10/12/2018 02:56:57 PM -0400 Chart][Frederick G 2189940) eee _ —_ — = Greer, Prederick (MR # 1590736) Gs/Ot/? 10:25:08 102 18 194/70 ““Impalla Insertion Impolta Insertion ‘The catheter was inserted lo the left famoral artery. The performance evel was P9. The Impolta was nat repositioned. Cardiag Output was 3 Limin, Pericardiscentesis Portcardium with ultrasound, Unsuccessful attempt at Pesicaddiocetitesie performed by the apical and.parastemal approach with flyoro andwindow performed by Dr, Crouch. Bericardiocentesis given depth from chest ‘wall {6 "pericardium. Bedskte pericardial ouinmary Conclusion: of Q waves across the 4) ‘Otéltision of the proximal left circumflex arter ry which is likely 4 days old in the settingangioplasty with no inférotateral leads (pre-TIMLO flow, "100% .occlusi ‘on, culprit vessel) status post balloon Significant impror wement in flow and unfortunate coronary perforatl ionmedleading te pericardial tarripanade ‘requiring balloon inflation was perfor of the proximal left-clreumfex to limit badside patigardi : ial window. Prolténged bléeding ani final i angiography revealed post-TIMI 0 flow with 100% occlusion of the préxifnal tefl circumttex. 2) Severe disease in thé mid and distal LAO. 3): Sevaré disease in the mid and distat RCA. 4) Successful placement of an‘impella C device with cardiac output of 3.2 L/m via the device in the setting of diogsnio shock. 5). Severely elevated LV filling pressures with LV end-diastolic pressure 44 mmHg. of the mid inferior wall with overall severe hypokinesis of the remaining segmer nits with LV 6) Akinasis ejection fraction astiniated at 15%, site, 7). Manual compression was achieved of the rig ht common femoral arterial access 8) TR band Was used to achieve heriostasis at the right radial atcess site, site. 9): A tiple iumen catheter was left in’ placein the left common femoral venous access access 10) The impélla’ GP device and sheath was su tured in place at the left common-femdral arterial site, +1) Case was discussed in detail with the patient's wi ife who understands his critical situation. 12) The patient recéived intravenous bivalirudin at the beginning of the procedure and this was subsequefitly discontinued. during the procedure. 43) The patient was transferred to:the CVICU in critical condition Recommendations: and overall hamadynamic status and respiratory status, 1) Maintain [mpella support with close monitating closely 2) Trend lactates closely: “Monitor rena! function along with urine output 3) Hopeful bridgeto potential revascutarization of the LAD and RGA with coronary artery bypass grat fting depending ‘on clinigat situation. 4) .Origoing ctitical care monitoring. status. 5) "Pulmonary constiltation has been requested to help manage his resplratory Complications the procedure with pericardial tap and not Other complications: The patient did develop frank perforation of the OM1 duringcatheteriza tion lab by Or. Crouch. reguiring an-emergent pericardial wi iindow which was performed in the cardiac ” Staff Type Tene tn View a Jacob Bennett, ROIS VAR Documenter 91/2017 0618 9/1/2017 2087 Brian roll, RN, GUAR Circulator arv2017 0618 99/2017 1057 Kafteriiia Glkeau, RT(R) VAR Scrub Tech 9/1/2017 0618 9/1/2017 1087, {tot assigned) _ CVAR Pre RN (Nat, 9), VAR Post RN CVAR Nurse 9/1/2017 0639 9/1/2017 1057 Katelyn Tilley, RN “Radiation Exposure Detalles Use Event 10:42 AM Page 4: of 6 oe -, Greer, Frederick (MR # M590736) Printed by Karen Lara [KLARA] at 9/7/17 (Page17 of 91] . cardidlogy Associate POTSmodem! (19/92) 10/12/2018 02:58:12 PM -0400 (Char[Erederie Greer][89940] Greer, Frederick (MR # M590736) [0:49AM Radiation Tracking DLP: Total Dose (mGy) = §701,000 JB Physician: Kunal Chaudhry, MO Dose (mGy) = 701.000 Fluoro Time (mins) = 42.1 DAP (Gy-em2) = 45817.000 Implants Name 10 Temporary Type Supply No information to-display Coronary Diagrams Diagnostic Diagram oo co S028) BI a (7S a Sasa 12 fo™N L = - | Post-Intervention Diagram : Greet, Frederick (MR #590736) foe by Karen Lara [KLARA] . 9/TIVT 10:42 AM Page 5 Ce - Le [Page 18 of 91] cardiology Associate POTSmodemt (20/92) 10/12/2018 02:59:07 PM -0400 Chit] [Frederick Greer (89940) = oe ee a, Greer, Frederick (MR # 590736) oO fo a, Cu ee cst, eens, ceie — ROY een ten {THRE te a iG oo Teri — Pen tneanctemie name nremerrnanes {8 [— tines Gael soca nd on | pene" a error ee ony — ee t ~ Signed Electronically signed by Kunal Chaudhry, MD on 9/1/17 at 1208 EOT Grect, Frederick (MR 4 M590736) Printed by Karen Lara [KLARA] at O/T/AT 10:42 AM Page 6 of 6 {Page 19 of 91]