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FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022
EXHIBIT C
FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022
OJ\1PREHENSIVE
EHABILITATION
ONSULTANTS,rNc.
Assistance to Individuals with
Special Needs and
Their Families
Case Management/
Advocacy
Guardianship Planning &
Support
(Serve as Guardian/Trustee)
Advocacy at Individualized THE FOLLOWING REPORT ON KELLEY ANN PHILLIPS IS BASED
Education Plan (IEP) and
Section 504 Plan Meetings ON THE INFORMATION AVAILABLE TO COMPREHENSIVE
Continuum of Care &
Cost Assessment
REHABILITATION CONSULTANTS, INC. AS OF JULY 28, 2021.
Vocational Evaluations & ANY ADDITIONAL INFORMATION OR DOCUMENTATION
Job Placement
Assistance
RECEIVED THAT IS NOT CURRENTLY AVAILABLE MAY ALTER
Special Needs Research
THE REPORT.
Assessment of Home/Work
Modifications & Accommodations
Rehabilitation & Habilitation
Counseling
Disabil ity Management
Habilitation & Rehabilitation
Administration
Diagnostic & Evaluation
Services
Medicar e Set-Aside
Adminis tration and Reports
Into the Future Planning
www.int o-the-future.com
• Miami: 10250 SW 56th Street D-203 • Miami, Florida 33165-3148 • Tel: (305) 595-8232 • Fax: (305) 598-1 073 • email: rehab@crcmiami.com
• New York: 275 Madison Avenue • Suite 1916 • New York, New York 10016-1101 • Tel: (212) 370-5544 • Fax: (212) 986-2757 • email: crcny@aol.com
• Buffalo: 85 Sterling Avenue · Buffalo, New York 14 216-2807 • Tel: (716) 836-5631 • Fax: (716) 836-5681 • email: crcbuffalo@verizon.net
www.crcmiami.com
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OJ\1PREHENSIVE
EHABILITATION
ONSULTANTS,rNc.
July 28, 2021
Michael A. Rose, Esq.
Hach & Rose
112 Madison Avenue, 10th Floor
Assistance to Individuals with
Special Needs and
New York, NY 10016
Their Families
Case Management/
Advocacy
Guardianship Planning &
Support Re: Phillips, Kelley Ann
(Serve as Guardian/Trustee)
Advocacy at Individualized
Education Plan (IEP) and
Section 504 Plan Meetings
Dear Mr. Rose:
Continuum of Care &
Cost Assessment
Vocational Evaluations &
Job Placement Kelley Ann Phillips, a 42-year-old woman, was contacted by telephone on
Assistance
Special Needs Research August 24, 2020. In addition to the interview, Dr. Phillips was administered the
Assessment of Home/Work
Modifications & Accommodations Reynolds Intellectual Assessment Scales-2 Verbal Index. Dr. Phillips was
Rehabilitation & Habilitation
Counseling referred to assess her current status with particular emphasis on the effect of her
Disabil ity Management
condition upon her future vocational potential, rehabilitation needs, and quality of
Habilitation & Rehabilitation
Administration
life. Dr. Phillips was also mailed multiple inventories (Ruff Neurobehavioral
Diagnostic & Evaluation
Services
Inventory, Pain Patient Profile, and Quality of Life Inventory), which were
Medicar e Set-Aside
Adminis tration and Reports
completed under separate cover and mailed to the examiner. The evaluation,
Into the Future Planning
www.int o-the-future.com
independent of the extensive inventories, encompassed approximately two hours.
Records from the following were additionally received:
• Miami: 10250 SW 56th Street D-203 • Miami, Florida 33165-3148 • Tel: (305) 595-8232 • Fax: (305) 598-1 073 • email: rehab@crcmiami.com
• New York: 275 Madison Avenue • Suite 1916 • New York, New York 10016-1101 • Tel: (212) 370-5544 • Fax: (212) 986-2757 • email: crcny@aol.com
• Buffalo: 85 Sterling Avenue · Buffalo, New York 14 216-2807 • Tel: (716) 836-5631 • Fax: (716) 836-5681 • email: crcbuffalo@verizon.net
www.crcmiami.com
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• FDNY
• Coney Island Hospital
• Montefiore Medical Center—The Center for Orthopaedic Specialties at Montefiore
• New York Spine & Sport Rehabilitation Medicine, PC
• Holmes Regional Medical Center
• Brevard Health Alliance—Melbourne
• MIMA Malabar Internal Medicine
• Weiss & Neberry Medical Associates/Weiss, Lombardo and Vliegenthart Medical
Associates
• Advanced Pain and Neuromuscular Consultants of Brevard
• The B.A.C.K. Center
• Jacobi Medical Center
• HFMG--Health First Medical Group
• Crane Creek Surgery Center
• Integrated Medical Professions, PLLC
• Advanced Behavioral Care, LLC
• Apollo Medical Message, Inc.
• Community Psychological Services
• NeuroSkeletal Imaging
• Florida Institute of Technology—The Scott Center for Autism Treatment
• Julio Westerband, MD
• Kuldip K. Sachdev, MD
• Andrew R. Miller, MD
• Solomon Miskin, MD
• Miguel Rivera, MD
• CVS Pharmacy
• Verified Bill of Particulars [03/27/2014]
• Supplemental Verified Bill of Particulars [04/22/2014]
• Supplemental Verified Bill of Particulars [05/16/2014]
• Supplemental Verified Bill of Particulars [05/20/2014]
• Supplemental Verified Bill of Particulars [10/17/2014]
• Supplemental Verified Bill of Particulars [11/12/2015]
• Supplemental Verified Bill of Particulars [06/20/2019]
Medical Summary
On 06/14/2009 Dr. Phillips was seen at Coney Island Hospital Emergency Department.
She was a surgical resident at Montefiore Hospital and had been exposed to someone with the flu
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four days previously. Subsequently, she developed generalized malaise. Last night she had very
weak chills; she believed she had a fever, but did not take her temperature. She was very weak
and very uncomfortable and so called an ambulance. In the ER she complained of epigastric
pain and nausea. There was no significant past medical or surgical history. Primary diagnosis
was influenza with other respiratory manifestations (George Gandev, M.D.).
On 07/01/2010 a note from Soniya Gandhi, M.D. indicated that Dr. Phillips was admitted
to MMC from 06/30 to 07/01 for an ongoing medical condition. This condition limited her
mobility and hence she would be unable to participate in personal training. Consequently, it
should be considered to void her previously made contract due to an unforeseen injury.
On 07/02/2010 Dr. Phillips was seen in consultation with a chief complaint of neck and
back pain. Dr. Phillips was a 32-year-old surgery resident who had symptoms intermittently
since an automobile accident in 2008. She recently had a new accident in June 2010. Prior to
this latter accident, she was asymptomatic. Since the time of the accident, she had severe neck
and back pain with headaches and severe muscle spasms. She had intermittent leg pain, but at
this point there was minimal leg pain. There was some buttock pain. There was numbness in her
hands at times. Her pain had been stable but continuous. She had difficulty walking and was
unable to exercise. She never had spine surgery. There was some urinary hesitancy and trouble
voiding, which she attributed to narcotics. She was currently taking multiple medications
including Valium, Percocet, cyclobenzaprine, Advil and Tylenol. Past medical history was
notable for mitral valve prolapse, asthma, anxiety disorder and migraine headaches. Past
surgical history was notable for breast augmentation and skin grafts. When seen, medications
included Percocet, diazepam, NuvaRing, Flexeril, Lyrica, Advil, Tylenol, Ambien and Xanax.
An examination followed as well as review of studies. Adam Wollowick, M.D. concluded that
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Dr. Phillips had cervical and lumbar strains. She was quite symptomatic and had a severe acute
change in symptoms since the car accident. She had not responded to multiple medications.
MRI was recommended. She was also given a referral for physical therapy as well as
prescriptions for medications.
On 08/12/2010 Karen Morice, M.D. noted that Dr. Phillips was seen in consultation
regarding diffuse back pain after a recent car accident. After the accident, she worked for four
days at Jacobi Hospital in the surgical residency with pain somewhat controlled with 60 mg of
Toradol as needed. After that time she was admitted to the hospital with severe pain at which
time there was a question of T5-T9 old fractures on CT scan. However, Schmorl’s nodes were
indicated and she was treated with a TLSO. She then had about eight months of PT. Pain
essentially resolved as of last July or August except for intermittent upper extremity numbness
and tingling, which was treated with Lyrica until the last two months. Nerve conduction studies
ruled out carpal tunnel syndrome. Last summer, she then started going to the gym and working
with a personal trainer. In April of this year, she had a cervical spine MRI due to the upper
extremity numbness and tingling. On June 3 she had another motor vehicle accident. Pain began
two hours later in her neck down to her back with migraines. She went to the emergency room.
She received medications. She treated herself with a TENS unit she had from the last MVA,
heat and pain medication. On 06/30 she developed an acute exacerbation of pain. She went to
the hospital and was kept overnight. She was given medications including extended release
morphine. She felt “goofy” from the medications and even fell once inside her apartment. The
next day pain recurred after the medications wore off. She then consulted Dr. Wollowick.
Cervical and lumbosacral MRIs showed a slight L5-S1 disc bulge. She initiated physical
therapy. However, she developed, after new exercises, sudden severe bilateral thoracolumbar
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back pain, which resolved with conservative treatment and then during exercise and PT, she
again had right severe thoracolumbar pain. Her physical therapist recommended a steroid
injection. She consulted Dr. Wollowick’s colleague, Dr. Sharan. She was told she did not need
an injection. Pain was described as “lying on a bed of steak knives,” worse on the right side of
her back in the thoracolumbar area. She also had spasm pain in the upper trapezius area. Back
pain radiated distally as far as the buttocks. Neck pain was not very bothersome. The only upper
extremity symptom was stiffness. Past medical history was notable for asthma as a child and
right knee pes anserine bursitis as well as a polycystic ovarian syndrome. She continued on
multiple medications. A physical examination followed. She was a resident in surgery with
plans to pursue plastic surgery and was currently doing two years for research and a Master’s in
Public Health classes. The mid-term examination was rescheduled due to the severity of her pain.
The assessment was a 32-year-old woman with upper and lower back pain after MVA on
06/03/2010 secondary to muscle strain with acute exacerbation from intensive physical therapy.
She received an injection of lidocaine. Medication adjustments followed. She would continue
with physical therapy with more gentle progression of intensity of exercises.
Sireen Gopal, M.D. was consulted on 09/28/2010. She complained of pain in the neck
area radiating to both of her shoulders and the lower back. Pain was constant on an 8/10 in
severity. The history was noted. Pain was now aggravated by prolonged sitting, bending, lifting,
getting up from a seated position and climbing stairs with difficulty performing duties. She was
acknowledging some memory loss, confusion and insomnia as well as depression. Medications
now included fentanyl, famotidine, Colace, Lyrica, diazepam, senna, among multiple other
medications. The assessment was lumbar spine HNP; backache NOS; cervical neck disorder
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symptom NOS. Dilaudid and other medications were refilled. Physical therapy and electrical
stimulation were recommended.
On 09/29/2010 Julio Westerband, M.D., an orthopedic surgeon, evaluated Dr. Phillips.
The history was generated. She had not returned to work as a surgical resident since the
accident. Her complaints persisted: pain in the neck, mid back, low back and both shoulders,
occasional pain in both hips, short-term memory impairment and confusion. An orthopedic
examination followed. Review of records was noted. The diagnosis was cervical spine sprain
and strain; thoracic spine sprain and strain; lumbar spine sprain and strain; and bilateral shoulder
sprain and strain, all resolving. There was evidence of a moderate orthopedic disability. She
could work with restrictions of no heavy lifting over 15 pounds, no bending and no prolonged
standing or walking. She could carry on all activities of daily living she was doing prior to the
accident. She was currently not working. Physical therapy was recommended. There was no
indication for surgery. A prior history of fibromyalgia was also noted.
On 12/13/2010 Dr. Phillips returned to Dr. Gopal. Her condition persisted. Pain was still
aggravated by prolonged sitting, bending, lifting, getting up from a seated position and climbing
stairs with difficulty performing duties. Treatments now included pain medications, physical
therapy and epidural steroid injections. The assessment was lumbar radiculopathy; unspecified
myalgia or myositis; lumbar spine HNP; cervical neck disorder. Continued conservative care
and medications were recommended.
By 12/13/2010 Dr. Gopal noted that Dr. Phillips was unable to perform her duties as a
surgical resident for an undetermined period of time. She had a lumbar disc herniation, multiple
cervical disc bulges, severe low back pain and neck pain with spasms.
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By 01/17/2011 Dr. Gopal indicated that she was still unable to perform her duties as a
surgical resident for an undetermined period of time.
On 01/27/2011 a neurology consult followed given headache, neck pain and back pain
status post fall. She came to the ER hours after falling out of bed during sleep with intractable
neck and back pain as well as worsening of headaches. She hit her right hip, her lip and her chin.
Pain was resistant to all of her home medications, so she came to the emergency department.
She required occasional straight catheterization secondary to medication induced urinary
retention. Since the fall with head trauma in November 2010, she had slowed cognitive
processing, unsteady gait and slurred speech. In the hospital she required significant doses of
Dilaudid for continued pain control. After an examination, the impression was chronic pain
syndrome exacerbated by an acute fall; no clear anatomic dysfunction. Patient appeared quite
depressed. There may be a component of a post-concussive syndrome after a fall in November,
but the doctor suspected a great deal of her non-pain symptoms were related to multiple
medications, which could lead to fatigue and poor concentration (Mark Milstein, M.D.).
On 03/16/2011 Dr. Milstein noted that Dr. Phillips was being followed by neurology
given complaints of cognitive impairment since her traumatic brain injury last year. She was
currently undergoing a battery of tests.
By 03/17/2011 Dr. Gopal indicated that Dr. Phillips had a diagnosis of lumbar
radiculopathy; lumbar disc herniation; myalgias; neck pain; and upper back pain. The prognosis
was fair. She was still unable to perform her full duties. The expected return to work was
07/01/2011.
On 04/13, 05/03, 05/10 and 05/17/2011 a neuropsychological evaluation was generated
by Ronda Facchini, Ph.D. and David Masur, Ph.D. There were concerns of memory and
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concentration difficulties subsequent to her head injury in October 2010 and January 2011. She
reported memory loss, daily headaches, word finding difficulty, photophobia, sensitivity to loud
noise, sleeping difficulty, concentration difficulty, “tunnel” or blurry vision, inability to read
more than a sentence or two and overall foggy or “hazy” feelings and fatigue. She was at the end
of her second year as a surgical resident on medical leave due to her injury. She reported that in
October 2010, she reported taking a muscle relaxant prescribed for pain along with Xanax. She
did not remember what happened but indicated that she lost consciousness in the bathroom and
fell, hitting her head on the bathtub. She experienced severe back and neck pain and then a
concussion was diagnosed. She was put on different pain medications. In mid January of 2011,
while asleep, she rolled out of bed and hit her head again. She reported that she found it very
difficult to stay awake and avoided driving because of fear of falling asleep at the wheel.
Review of an MRI from November 2010 was unremarkable. CAT scan of the head and spine
from January 2011 indicated no evidence of acute fracture, subluxation or intracranial
hemorrhage with tiny disc protrusions at C4-C5 and C5-C6. Medications included Lyrica for
fibromyalgia, Opana for pain, Nortriptiline for headaches, Cymbalta for pain, Fioricet for pain,
Ambien for sleeplessness, Imitrex for migraines, Reglan for nausea as needed, Xanax for anxiety
and ibuprofen for pain as needed. She had discontinued Fioricet. She had attended the
University of Florida for undergraduate and Master’s degree and the University of Miami for
medical school. She was valedictorian in her high school class and in the top eight of her
medical school class. Multiple difficulties were reported in areas such as problem-solving,
speech and language, nonverbal skills, concentration, memory difficulties, motor and
coordination difficulties, sensory difficulties and physical symptoms including headaches,
dizziness and tiredness. There was also a history of severe anxiety attacks, shortness of breath,
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chest pain and radiation of pain down her arms at which point she took Xanax to halt the attack.
There was a family history of heart disease, bipolar disorder and major depression in her father.
When seen she had been let go from her position as a surgical resident as she was unable to
perform the activities required. She was seeking long-term disability benefits and a legal
response to her injuries. On the Word Memory Test, her performance was complicated by
factors other than her memory ability and should not be considered a definitive assessment of her
present memory functioning. Memory difficulties could not be ruled out, though the extent or
features of memory function issues were unclear. On the WAIS-IV her score was in the average
range. Verbal skills standard score 98; working memory standard score 89; perceptual reasoning
standard score 92; and processing speed standard score 86. These scores were considerably
lower than expected given her past history. Her performance on verbal tests was variable,
ranging from borderline to high average. Nonverbal functioning was overall average.
Processing speed was low average and working memory was also low average overall. Memory
functions were quite weak. Language functions were variable. Motor speed was deficient under
single-handed conditions and average for bilateral performance. Visual search and set shifting
was quite slow, in the deficient range for simple search and in the low average range for more
complex set shifting components (Trails A and B, respectively). The Tower of London Test was
standard score 120, but in the deficient range for the amount of time it took her to do so. Speed
of processing and the ability to inhibit automatic output was quite weak as seen on the Stroop
Color and Word Test. Thus, there was evidence of some areas of sustained functioning with
inconsistent performance in other areas of attention and executive functioning. The MMPI-II
was valid, highlighting physical and depressive symptomatology. The findings raised some
questions of the interpretability of the current findings. It was likely that factors other than
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neurological impairment had influenced her performance. Test results should therefore be
assessed with extreme caution. In conclusion, her overall ability fluctuated from the bottom of
the average range with average verbal skills and average visual/perceptual skills. Processing
speed and working memory were low average. Performances were markedly variable, ranging
from borderline to high average. Language functions were variable with impaired word finding
and repetition, but intact reasoning, comprehension and fluency. Visual motor integration was
intact. Fine motor speed was slow on unilateral functions but better for bilateral coordinated
functions. Attention and executive functions varied remarkably. Memory assessments could not
be reported with any certainty. The personality inventory yielded a valid profile demonstrating
elevations in areas of hysteria and hypochondriasis as well as mild elevation in the area of
depression. These factors likely influenced her performance somewhat and should be further
explored. Discomfort and fatigue may also have impacted her performance. A complete
neurologic examination was recommended as well as an evaluation by a psychiatrist.
A note from Dr. Milstein (05/18/2011) indicated that Dr. Phillips was continuing to make
gradual progress and had become progressively more functional. She was referred to Dr. Lado
for additional treatment options.
Subsequently on 05/23/2011 Dr. Lado was consulted in connection with Dr. Phillips’
pain and headaches. The history was generated. Complaints that were most disabling included
photophobia (which had improved), word-finding difficulties, memory loss, poor sleep, poor
concentration, an inability to read secondary to pain, tunnel vision (now resolved), daily
headaches, slurring (better) and numbness and tingling in both hands, left worse than right up to
the forearm. An examination and review of studies followed. Dr. Phillips thus presented with
numerous pain-related complaints as well as symptoms of poor concentration, difficulty reading
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and overall decline in her intellectual functioning that had produced significant impairment. Pre-
existing diagnoses of fibromyalgia and an anxiety disorder with panic attacks was noted. She
had been treated by numerous physicians as well as a large number of medications. Review of
numerous radiographic studies did not reveal any significant anatomical pathology consistent
with the level of pain she experienced. This finding, taken with the level of subjective pain and
functional disability, was consistent with a prior diagnosis of fibromyalgia and suggested a
central pain syndrome that was affected by mood and her affective state. Recommendations for
reducing and tapering sedating medications followed.
On 05/24/2011 Dr. Phillips returned to Dr. Gopal. She still had complaints of pain in the
neck area radiating to the bilateral posterior shoulders, pain in the upper mid back and pain in the
lower back radiating to the left leg and foot with numbness in the left medial forearm/digits 3-5.
Pain was sharp and dull with spasms. Timing of the pain was constant, worse in the neck. Pain
was 7/10 in the back and 9/10 in the neck. Multiple treatments had been applied. Pain improved
with rest, standing, walking, heat and medications and was aggravated by prolonged sitting,
bending, lifting, getting up from a seated position and climbing stairs with difficulty performing
duties. Pain was associated with headaches. The assessment was lumbar radiculopathy;
chondromalacia of the patella; lumbar spine HNP; cervical neck disorder symptoms; and cervical
spondylosis without myelopathy. Medications were refilled. A cervical facet joint medial
branch block was recommended.
On 05/27/2011 Dr. Gopal indicated that Dr. Phillips was still unable to perform her duties
with an expected return to work date of 10/01/2011. He recommended a loan deferment as she
was unable to work because of her current severe disability.
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On 06/11/2011 Dr. Gopal also indicated that Dr. Phillips was unable to perform her
duties as a surgical resident. She was unable to stand, sit or walk for greater than 30 minutes nor
lift, bend or twist. She was undergoing a process of being placed on disability, which was
recommended.
By 07/22/2011 Mark Fulton, M.D. was consulted at Holmes Regional Medical Center
given a chief complaint of chronic neck and back pain with recent exacerbation. Her condition
was most consistent with chronic myofascial pain and given its severity, a followup MRI was
reasonable.
On 07/23/2011 an additional consultation at Holmes Regional Medical Center was
negotiated by Jay E. Olsson, D.O. in connection with pain management. The chief complaint
was severe neck and back pain. Medications had controlled her pain prior to her moving to
Florida. After an examination and review of studies, the impression was chronic pain syndrome
related to neck and back pain as a result of motor vehicle accidents; chronic neck pain; chronic
back pain with possible radiculopathy; history of motor vehicle accidents; history of
postconcussion syndrome. Medications were adjusted.
On 07/23/2011 an additional consultation at Holmes Regional Medical Center followed
by Dr. Dandapani. Dr. Phillips was a 33-year-old female with a history of motor vehicle
accident, fibromyalgia and chronic pain syndrome. Dr. Dandapani recommended a
rheumatologist to address the fibromyalgia. Dr. Phillips wished to see a neurologist to deal with
accident-related cognitive limitations.
On 08/05/2011 given the reason for consultation being headache and neck pain, Dr.
Phillips was again seen at Holmes Medical Center. Dr. Unger’s impression was headaches; neck
pain; cervical disc disease and lumbar disc disease with herniated nucleus pulposus L5-S1 to the
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left; chronic pain; short-term memory loss, questionably secondary to pseudodementia based on
previous neurologic and psychiatric testing. Review of neuropsychiatric testing was pending; an
atonic bladder was also noted. Her acute symptoms were probably secondary to cervicogenic
headaches and cervical strain. He prescribed Robaxin, Dilaudid and a patient-controlled
analgesia pump. He recommended to check the MRI of the brain and the cervical and thoracic
regions as well as check the MRA of the brain. There would be a consultation with physical
therapy as well.
On 08/06/2011 given the reason for the consultation being urinary retention, Dr. Phillips
was seen by Dr. Littlejohn. She had a neurogenic voiding dysfunction resulting in urinary
retention. She currently managed her situation with clean and intermittent self-catheterization.
The plan was for an indwelling Foley catheter until pain resolved enough for the patient to
resume clean intermittent self-catheterization. She could follow up for further discussion of
treatment of her urinary retention with a sacral nerve stimulation.
On 08/06/2011 Dr. Phillips consulted Brian Dowdell, M.D. His impression was chronic
pain syndrome, focal mostly to the neck and related cervicogenic/posttraumatic headaches;
chronic back pain, no evidence of radiculopathy; history of head concussion with probable mild
postconcussive syndrome; opioid dependence. She had been put on a patient-controlled
analgesia pump. The pump would be discontinued. She could supplement medication by an as
needed intravenous Dilaudid. Oral medications would be reinstituted. Pain had been well
controlled. She had anticipated a rhizotomy, but this had not been accomplished prior to her
move.
On 08/15/2011 Dr. Jasperse with an amended report on 08/30/2011 evaluated the patient
in connection with a somatoform disorder. She presented to Holmes Regional with a chief
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complaint of neck pain as well as headaches, back pain and urinary retention. The history was
noted. Depression, decreased concentration, sleep disturbance, appetite disturbance, anhedonia,
increased anxiety and stress, irritability, fatigue and increasing pain were noted. Dr. Jasperse
concluded that it was unlikely that she had a somatoform disorder as her signs and symptoms did
not fit the definition of a somatoform disorder. However, she certainly had a pain disorder,
which had caused psychological as well as financial distress. There was no inpatient psychiatric
history. She had only seen a psychiatrist in relationship to multiple medical issues to determine
if there was any psychological distress associated with the patient’s injuries. The DSM-IV
diagnosis was pain disorder associated with psychological factors and general medical condition;
opiate dependence (pain disorder); substance-induced mood disorder. She should continue on
Cymbalta. Outpatient counseling was recommended as well as treatment for opioid addiction.
On 08/15/2011 Dr. Phillips was discharged from Holmes Regional Medical Center. The
discharge diagnosis was cervicalgia/cervicogenic headache secondary to the motor vehicle
accident x2; multiple cervical herniation; L5-S1 herniated disc; chronic pain secondary to the
above; vaginal yeast infection, resolved; urinary retention secondary to an acontractile bladder
diagnosed by urodynamic studies. She was discharged home on oxycodone, Valium, Cymbalta,
and Lyrica. She would continue to followup with multiple physicians.
On 09/26/2011 Lynette Graff, M.D. was consulted. Medications were prescribed. The
impression was depressive disorder, not elsewhere classified; fibromyalgia; back pain, thoracic
region chronic; back pain lumbosacral, chronic; and neck pain, chronic.
On 10/04/2011 Dr. Phillips returned to Dr. Graff with a complaint of bilateral breast pain.
There was a history of bilateral breast implants in 2006.
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On 10/10/2011 given urinary retention issues, chronic; DDD; neck pain; low back pain;
and dizziness, medications were prescribed (MIMA Malabar Internal Medicine).
By 10/17/2011 Dr. Phillips consulted Gary Weiss, M.D. The history was again
generated. She was receiving massage therapy with benefit. She was seen for a neurologic
evaluation and treatment. She reported daily headaches, decreased short and long-term memory,
sensitive to bright lights and sound, blurred vision and diplopia. Her handwriting was poor. She
could not remember how to spell. Constant pain in the neck, shoulders, arms, right greater than
left with numbness and tingling in the arms, more on the left than the right was reported. She
had decreased range of motion in the neck and severe pain and constant pain in the middle back,
radiating to the ribcages and chest with almost constant muscle spasms. She complained of
constant pain across the low back with varying severity. Current pain when seen was severe.
Medications included Aleve, Ambien, Cymbalta and Lyrica. Her past medical and surgical
history additionally noted benign essential hypertension with severe pain. A neurologic
examination followed. Review of studies was noted. The assessment was motor vehicle
accident 06/03/2010 with fall with loss of consciousness on 11/01/2010 and second closed head
injury on 01/25/2011 with closed head injury with posttraumatic headaches and cognitive loss;
neck pain with some radicular symptoms; thoracic spine pain; lower back pain with radicular
symptoms.
By 10/19/2011 Miguel Rivera, M.D. was consulted. Dr. Phillips presented with low back
pain and neck pain. Medications additionally included Lidoderm adhesive patch, Nucynta and
Opana. The assessment was neck pain; cervical spondylarthritis; bilateral hand paresthesia; low
back pain. A facet joint injection was recommended, consider PRF for long-lasting relief.
Lumbar spondylarthritis was also noted.
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On 11/14/2011 Dr. Weiss conducted a quantitative electroencephalogram. The
impression was an abnormal study with a brain injury analysis positive for CHI with a 95%
probability.
On 11/14/2011 an EEG report was also generated by Dr. Weiss. This was within normal
limits.
On 01/10/2012 Dr. Weiss noted that Dr. Phillips’ condition had worsened with increased
joint pain. She could not get out of bed without medication. She could barely walk. She was
seen at HRMC due to a severe anxiety attack and had severe shortness of breath (“I felt like I
was dying”). The assessment now included chronic pain with narcotic dependence and new joint
pain everywhere after an infection. She requested an inpatient pain program. The
recommendation was also for rheumatology to evaluate the new joint pains.
On 01/16/2012 Dr. Rivera was again consulted. Neck pain was addressed. She was
being referred to the University of Miami for further investigation of her condition. She would
also see a rheumatologist.
By 02/06/2012 Dr. Weiss reiterated the diagnosis and highlighted that it was highly
unlikely that she would be able to pursue her career in any type of surgical field. However,
physically she should be able to pursue a career in radiology.
On 02/15/2012 a narrative report was generated by Kuldip Sachdev, M.D., a neurologist.
He performed an Independent Neurologic Evaluation. The history was gathered. When seen,
complaints included daily generalized throbbing headaches with photophobia, phonophobia and
dizziness. Headaches were preceded by visual scotomas. She had tried Pamelor for several
months; it did not help and was discontinued. Rest in a dark quiet room and sleep helped the
headaches. She had pain in her neck, which was constant, associated with spasms radiating to
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both shoulders and aggravated by neck bending and turning as well as sitting. She had constant
upper and mid back pain with variable intensity and constant low back pain with radiation to her
hips and buttocks increased with walking and sitting. Standing helped the pain. She could sit for
20 to 30 minutes. She had intermittent tingling and numbness in both hands, but it did not wake
her from sleep. Memory and concentration were slowly improving. She had suffered migraine
headaches off and on since her teenage years with visual scotomas and pain in her eyes. She had
anxiety attacks in medical school that worsened since the accident on 06/03/2010. She had not
worked since August 2010. Medical records were reviewed and an examination followed. The
impression and diagnosis was posttraumatic headaches; cervical spine sprain and strain; thoracic
spine sprain and strain; lumbosacral spine sprain and strain superimposed upon pre-existing age-
related degenerative disc disease at L5-S1; posttraumatic vertigo precipitated by the use of
Zanaflex and most likely iatrogenic rather than posttraumatic. The anxiety disorder was referred
to the appropriate specialist. There was no permanency to the cervical, thoracic and lumbar
spine sprains and strains. The sensory loss over the entire right arm was not consistent with a
radiculopathy, myelopathy or neuropathy. It was not consistent with a carpal tunnel syndrome.
There was no clinical evidence of a cervical or lumbosacral radiculopathy or myelopathy. Dr.
Sachdev recommended weaning her from narcotic pain medications. The mini mental
examination was normal. There was no need for further treatment. There was no neurological
disability. She was thus not disabled neurologically from working or from activities of daily
living.
On 02/16/2012 Andrew Miller, M.D., an orthopedic surgeon, performed an Independent
Orthopedic Evaluation. Medical records were reviewed. Dr. Phillips did not provide
background material or her current complaints. An examination followed. The diagnosis was
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cervical spine, thoracic spine and lumbar spine sprain. There was evidence of a disability based
upon available medical documentation.
On 03/15/2012 a Psychological Intake was generated at Community Psychological
Services in Melbourne, Florida. The clinician was Laurel McHone, M.S. Dr. Phillips was seen
in connection with severe anxiety and posttraumatic stress. At that point she was 33 years of
age. The background was noted. When seen she experienced poor self-esteem and fear of social
contact with people outside her family. Medication let her sleep eight hours at night, but she still
had difficulty falling asleep each night. She had constant feelings of guilt for talking back to her
verbally abusive father, who had died the day before she left her residency. Since the car
accident, she had difficulty concentrating and with low energy. She was irritable and tense, but
reported no change in appetite. She resided with her mother in Melbourne, Florida due to
financial difficulty. She did not drive due to anxiety. Her mother drove her everywhere. She
did not leave the house most days and shared her mother’s social circle. She was not sexually
active and was experiencing low sex drive. She was currently engaged in a civil lawsuit. Her
physician told her not to work at present and the lack of income had caused financial difficulties.
In terms of her psychiatric history, she reported in 2007 she received therapy for test taking
anxiety and it helped. Since 2010, she had seen Dr. Schreber in the Bronx, New York and Dr.
Bunt in Melbourne for psychiatric services related to her distress after the accident. She received
neuropsychological testing from Dr. Fatini in 2011 while living in the Bronx. She was currently
prescribed Cymbalta, Xanax and Ambien. She had had several incidents of blackouts after
taking her sleep medications. After a mental status examination and interview, the diagnostic
impression was adjustment disorder with mixed anxiety and depressed mood; nicotine
dependence; traumatic brain injury, herniated disc, polycystic ovarian syndrome, low-grade
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cervical dysplasia per client. Weekly psychotherapy was recommended (Barbara Paulillo,
Psy.D. supervised Ms. McHone).
On 03/29/2012 Solomon Miskin, M.D., a psychiatrist, examined Dr. Phillips. He
reviewed records and generated the history as well as her current complaints and conducted a
mental status examination. A cognitive status screening examination revealed no evidence of
deficit. The diagnostic impression was panic disorder predating the incident, dated 06/03/2010,
chronic not otherwise specified; adjustment disorder with mixed emotional features, mild
severity, not otherwise specified; anxiety disorder predating the incident dated 06/03/2010, not
otherwise specified; status post motor vehicle accident with no loss of consciousness; status post
closed head injury with associated loss of consciousness; status post closed head injury with no
reported loss of consciousness; mitral valve prolapse, asthma and migraine headaches; breast
augmentation, skin graft; postconcussion syndrome associated with the closed head injury of
11/01/2010 and a second closed head injury of 01/25/2011. She was not currently wo
Preview
FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 EXHIBIT C FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 OJ\1PREHENSIVE EHABILITATION ONSULTANTS,rNc. Assistance to Individuals with Special Needs and Their Families Case Management/ Advocacy Guardianship Planning & Support (Serve as Guardian/Trustee) Advocacy at Individualized THE FOLLOWING REPORT ON KELLEY ANN PHILLIPS IS BASED Education Plan (IEP) and Section 504 Plan Meetings ON THE INFORMATION AVAILABLE TO COMPREHENSIVE Continuum of Care & Cost Assessment REHABILITATION CONSULTANTS, INC. AS OF JULY 28, 2021. Vocational Evaluations & ANY ADDITIONAL INFORMATION OR DOCUMENTATION Job Placement Assistance RECEIVED THAT IS NOT CURRENTLY AVAILABLE MAY ALTER Special Needs Research THE REPORT. Assessment of Home/Work Modifications & Accommodations Rehabilitation & Habilitation Counseling Disabil ity Management Habilitation & Rehabilitation Administration Diagnostic & Evaluation Services Medicar e Set-Aside Adminis tration and Reports Into the Future Planning www.int o-the-future.com • Miami: 10250 SW 56th Street D-203 • Miami, Florida 33165-3148 • Tel: (305) 595-8232 • Fax: (305) 598-1 073 • email: rehab@crcmiami.com • New York: 275 Madison Avenue • Suite 1916 • New York, New York 10016-1101 • Tel: (212) 370-5544 • Fax: (212) 986-2757 • email: crcny@aol.com • Buffalo: 85 Sterling Avenue · Buffalo, New York 14 216-2807 • Tel: (716) 836-5631 • Fax: (716) 836-5681 • email: crcbuffalo@verizon.net www.crcmiami.com FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 OJ\1PREHENSIVE EHABILITATION ONSULTANTS,rNc. July 28, 2021 Michael A. Rose, Esq. Hach & Rose 112 Madison Avenue, 10th Floor Assistance to Individuals with Special Needs and New York, NY 10016 Their Families Case Management/ Advocacy Guardianship Planning & Support Re: Phillips, Kelley Ann (Serve as Guardian/Trustee) Advocacy at Individualized Education Plan (IEP) and Section 504 Plan Meetings Dear Mr. Rose: Continuum of Care & Cost Assessment Vocational Evaluations & Job Placement Kelley Ann Phillips, a 42-year-old woman, was contacted by telephone on Assistance Special Needs Research August 24, 2020. In addition to the interview, Dr. Phillips was administered the Assessment of Home/Work Modifications & Accommodations Reynolds Intellectual Assessment Scales-2 Verbal Index. Dr. Phillips was Rehabilitation & Habilitation Counseling referred to assess her current status with particular emphasis on the effect of her Disabil ity Management condition upon her future vocational potential, rehabilitation needs, and quality of Habilitation & Rehabilitation Administration life. Dr. Phillips was also mailed multiple inventories (Ruff Neurobehavioral Diagnostic & Evaluation Services Inventory, Pain Patient Profile, and Quality of Life Inventory), which were Medicar e Set-Aside Adminis tration and Reports completed under separate cover and mailed to the examiner. The evaluation, Into the Future Planning www.int o-the-future.com independent of the extensive inventories, encompassed approximately two hours. Records from the following were additionally received: • Miami: 10250 SW 56th Street D-203 • Miami, Florida 33165-3148 • Tel: (305) 595-8232 • Fax: (305) 598-1 073 • email: rehab@crcmiami.com • New York: 275 Madison Avenue • Suite 1916 • New York, New York 10016-1101 • Tel: (212) 370-5544 • Fax: (212) 986-2757 • email: crcny@aol.com • Buffalo: 85 Sterling Avenue · Buffalo, New York 14 216-2807 • Tel: (716) 836-5631 • Fax: (716) 836-5681 • email: crcbuffalo@verizon.net www.crcmiami.com FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 • FDNY • Coney Island Hospital • Montefiore Medical Center—The Center for Orthopaedic Specialties at Montefiore • New York Spine & Sport Rehabilitation Medicine, PC • Holmes Regional Medical Center • Brevard Health Alliance—Melbourne • MIMA Malabar Internal Medicine • Weiss & Neberry Medical Associates/Weiss, Lombardo and Vliegenthart Medical Associates • Advanced Pain and Neuromuscular Consultants of Brevard • The B.A.C.K. Center • Jacobi Medical Center • HFMG--Health First Medical Group • Crane Creek Surgery Center • Integrated Medical Professions, PLLC • Advanced Behavioral Care, LLC • Apollo Medical Message, Inc. • Community Psychological Services • NeuroSkeletal Imaging • Florida Institute of Technology—The Scott Center for Autism Treatment • Julio Westerband, MD • Kuldip K. Sachdev, MD • Andrew R. Miller, MD • Solomon Miskin, MD • Miguel Rivera, MD • CVS Pharmacy • Verified Bill of Particulars [03/27/2014] • Supplemental Verified Bill of Particulars [04/22/2014] • Supplemental Verified Bill of Particulars [05/16/2014] • Supplemental Verified Bill of Particulars [05/20/2014] • Supplemental Verified Bill of Particulars [10/17/2014] • Supplemental Verified Bill of Particulars [11/12/2015] • Supplemental Verified Bill of Particulars [06/20/2019] Medical Summary On 06/14/2009 Dr. Phillips was seen at Coney Island Hospital Emergency Department. She was a surgical resident at Montefiore Hospital and had been exposed to someone with the flu 2 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 four days previously. Subsequently, she developed generalized malaise. Last night she had very weak chills; she believed she had a fever, but did not take her temperature. She was very weak and very uncomfortable and so called an ambulance. In the ER she complained of epigastric pain and nausea. There was no significant past medical or surgical history. Primary diagnosis was influenza with other respiratory manifestations (George Gandev, M.D.). On 07/01/2010 a note from Soniya Gandhi, M.D. indicated that Dr. Phillips was admitted to MMC from 06/30 to 07/01 for an ongoing medical condition. This condition limited her mobility and hence she would be unable to participate in personal training. Consequently, it should be considered to void her previously made contract due to an unforeseen injury. On 07/02/2010 Dr. Phillips was seen in consultation with a chief complaint of neck and back pain. Dr. Phillips was a 32-year-old surgery resident who had symptoms intermittently since an automobile accident in 2008. She recently had a new accident in June 2010. Prior to this latter accident, she was asymptomatic. Since the time of the accident, she had severe neck and back pain with headaches and severe muscle spasms. She had intermittent leg pain, but at this point there was minimal leg pain. There was some buttock pain. There was numbness in her hands at times. Her pain had been stable but continuous. She had difficulty walking and was unable to exercise. She never had spine surgery. There was some urinary hesitancy and trouble voiding, which she attributed to narcotics. She was currently taking multiple medications including Valium, Percocet, cyclobenzaprine, Advil and Tylenol. Past medical history was notable for mitral valve prolapse, asthma, anxiety disorder and migraine headaches. Past surgical history was notable for breast augmentation and skin grafts. When seen, medications included Percocet, diazepam, NuvaRing, Flexeril, Lyrica, Advil, Tylenol, Ambien and Xanax. An examination followed as well as review of studies. Adam Wollowick, M.D. concluded that 3 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 Dr. Phillips had cervical and lumbar strains. She was quite symptomatic and had a severe acute change in symptoms since the car accident. She had not responded to multiple medications. MRI was recommended. She was also given a referral for physical therapy as well as prescriptions for medications. On 08/12/2010 Karen Morice, M.D. noted that Dr. Phillips was seen in consultation regarding diffuse back pain after a recent car accident. After the accident, she worked for four days at Jacobi Hospital in the surgical residency with pain somewhat controlled with 60 mg of Toradol as needed. After that time she was admitted to the hospital with severe pain at which time there was a question of T5-T9 old fractures on CT scan. However, Schmorl’s nodes were indicated and she was treated with a TLSO. She then had about eight months of PT. Pain essentially resolved as of last July or August except for intermittent upper extremity numbness and tingling, which was treated with Lyrica until the last two months. Nerve conduction studies ruled out carpal tunnel syndrome. Last summer, she then started going to the gym and working with a personal trainer. In April of this year, she had a cervical spine MRI due to the upper extremity numbness and tingling. On June 3 she had another motor vehicle accident. Pain began two hours later in her neck down to her back with migraines. She went to the emergency room. She received medications. She treated herself with a TENS unit she had from the last MVA, heat and pain medication. On 06/30 she developed an acute exacerbation of pain. She went to the hospital and was kept overnight. She was given medications including extended release morphine. She felt “goofy” from the medications and even fell once inside her apartment. The next day pain recurred after the medications wore off. She then consulted Dr. Wollowick. Cervical and lumbosacral MRIs showed a slight L5-S1 disc bulge. She initiated physical therapy. However, she developed, after new exercises, sudden severe bilateral thoracolumbar 4 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 back pain, which resolved with conservative treatment and then during exercise and PT, she again had right severe thoracolumbar pain. Her physical therapist recommended a steroid injection. She consulted Dr. Wollowick’s colleague, Dr. Sharan. She was told she did not need an injection. Pain was described as “lying on a bed of steak knives,” worse on the right side of her back in the thoracolumbar area. She also had spasm pain in the upper trapezius area. Back pain radiated distally as far as the buttocks. Neck pain was not very bothersome. The only upper extremity symptom was stiffness. Past medical history was notable for asthma as a child and right knee pes anserine bursitis as well as a polycystic ovarian syndrome. She continued on multiple medications. A physical examination followed. She was a resident in surgery with plans to pursue plastic surgery and was currently doing two years for research and a Master’s in Public Health classes. The mid-term examination was rescheduled due to the severity of her pain. The assessment was a 32-year-old woman with upper and lower back pain after MVA on 06/03/2010 secondary to muscle strain with acute exacerbation from intensive physical therapy. She received an injection of lidocaine. Medication adjustments followed. She would continue with physical therapy with more gentle progression of intensity of exercises. Sireen Gopal, M.D. was consulted on 09/28/2010. She complained of pain in the neck area radiating to both of her shoulders and the lower back. Pain was constant on an 8/10 in severity. The history was noted. Pain was now aggravated by prolonged sitting, bending, lifting, getting up from a seated position and climbing stairs with difficulty performing duties. She was acknowledging some memory loss, confusion and insomnia as well as depression. Medications now included fentanyl, famotidine, Colace, Lyrica, diazepam, senna, among multiple other medications. The assessment was lumbar spine HNP; backache NOS; cervical neck disorder 5 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 symptom NOS. Dilaudid and other medications were refilled. Physical therapy and electrical stimulation were recommended. On 09/29/2010 Julio Westerband, M.D., an orthopedic surgeon, evaluated Dr. Phillips. The history was generated. She had not returned to work as a surgical resident since the accident. Her complaints persisted: pain in the neck, mid back, low back and both shoulders, occasional pain in both hips, short-term memory impairment and confusion. An orthopedic examination followed. Review of records was noted. The diagnosis was cervical spine sprain and strain; thoracic spine sprain and strain; lumbar spine sprain and strain; and bilateral shoulder sprain and strain, all resolving. There was evidence of a moderate orthopedic disability. She could work with restrictions of no heavy lifting over 15 pounds, no bending and no prolonged standing or walking. She could carry on all activities of daily living she was doing prior to the accident. She was currently not working. Physical therapy was recommended. There was no indication for surgery. A prior history of fibromyalgia was also noted. On 12/13/2010 Dr. Phillips returned to Dr. Gopal. Her condition persisted. Pain was still aggravated by prolonged sitting, bending, lifting, getting up from a seated position and climbing stairs with difficulty performing duties. Treatments now included pain medications, physical therapy and epidural steroid injections. The assessment was lumbar radiculopathy; unspecified myalgia or myositis; lumbar spine HNP; cervical neck disorder. Continued conservative care and medications were recommended. By 12/13/2010 Dr. Gopal noted that Dr. Phillips was unable to perform her duties as a surgical resident for an undetermined period of time. She had a lumbar disc herniation, multiple cervical disc bulges, severe low back pain and neck pain with spasms. 6 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 By 01/17/2011 Dr. Gopal indicated that she was still unable to perform her duties as a surgical resident for an undetermined period of time. On 01/27/2011 a neurology consult followed given headache, neck pain and back pain status post fall. She came to the ER hours after falling out of bed during sleep with intractable neck and back pain as well as worsening of headaches. She hit her right hip, her lip and her chin. Pain was resistant to all of her home medications, so she came to the emergency department. She required occasional straight catheterization secondary to medication induced urinary retention. Since the fall with head trauma in November 2010, she had slowed cognitive processing, unsteady gait and slurred speech. In the hospital she required significant doses of Dilaudid for continued pain control. After an examination, the impression was chronic pain syndrome exacerbated by an acute fall; no clear anatomic dysfunction. Patient appeared quite depressed. There may be a component of a post-concussive syndrome after a fall in November, but the doctor suspected a great deal of her non-pain symptoms were related to multiple medications, which could lead to fatigue and poor concentration (Mark Milstein, M.D.). On 03/16/2011 Dr. Milstein noted that Dr. Phillips was being followed by neurology given complaints of cognitive impairment since her traumatic brain injury last year. She was currently undergoing a battery of tests. By 03/17/2011 Dr. Gopal indicated that Dr. Phillips had a diagnosis of lumbar radiculopathy; lumbar disc herniation; myalgias; neck pain; and upper back pain. The prognosis was fair. She was still unable to perform her full duties. The expected return to work was 07/01/2011. On 04/13, 05/03, 05/10 and 05/17/2011 a neuropsychological evaluation was generated by Ronda Facchini, Ph.D. and David Masur, Ph.D. There were concerns of memory and 7 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 concentration difficulties subsequent to her head injury in October 2010 and January 2011. She reported memory loss, daily headaches, word finding difficulty, photophobia, sensitivity to loud noise, sleeping difficulty, concentration difficulty, “tunnel” or blurry vision, inability to read more than a sentence or two and overall foggy or “hazy” feelings and fatigue. She was at the end of her second year as a surgical resident on medical leave due to her injury. She reported that in October 2010, she reported taking a muscle relaxant prescribed for pain along with Xanax. She did not remember what happened but indicated that she lost consciousness in the bathroom and fell, hitting her head on the bathtub. She experienced severe back and neck pain and then a concussion was diagnosed. She was put on different pain medications. In mid January of 2011, while asleep, she rolled out of bed and hit her head again. She reported that she found it very difficult to stay awake and avoided driving because of fear of falling asleep at the wheel. Review of an MRI from November 2010 was unremarkable. CAT scan of the head and spine from January 2011 indicated no evidence of acute fracture, subluxation or intracranial hemorrhage with tiny disc protrusions at C4-C5 and C5-C6. Medications included Lyrica for fibromyalgia, Opana for pain, Nortriptiline for headaches, Cymbalta for pain, Fioricet for pain, Ambien for sleeplessness, Imitrex for migraines, Reglan for nausea as needed, Xanax for anxiety and ibuprofen for pain as needed. She had discontinued Fioricet. She had attended the University of Florida for undergraduate and Master’s degree and the University of Miami for medical school. She was valedictorian in her high school class and in the top eight of her medical school class. Multiple difficulties were reported in areas such as problem-solving, speech and language, nonverbal skills, concentration, memory difficulties, motor and coordination difficulties, sensory difficulties and physical symptoms including headaches, dizziness and tiredness. There was also a history of severe anxiety attacks, shortness of breath, 8 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 chest pain and radiation of pain down her arms at which point she took Xanax to halt the attack. There was a family history of heart disease, bipolar disorder and major depression in her father. When seen she had been let go from her position as a surgical resident as she was unable to perform the activities required. She was seeking long-term disability benefits and a legal response to her injuries. On the Word Memory Test, her performance was complicated by factors other than her memory ability and should not be considered a definitive assessment of her present memory functioning. Memory difficulties could not be ruled out, though the extent or features of memory function issues were unclear. On the WAIS-IV her score was in the average range. Verbal skills standard score 98; working memory standard score 89; perceptual reasoning standard score 92; and processing speed standard score 86. These scores were considerably lower than expected given her past history. Her performance on verbal tests was variable, ranging from borderline to high average. Nonverbal functioning was overall average. Processing speed was low average and working memory was also low average overall. Memory functions were quite weak. Language functions were variable. Motor speed was deficient under single-handed conditions and average for bilateral performance. Visual search and set shifting was quite slow, in the deficient range for simple search and in the low average range for more complex set shifting components (Trails A and B, respectively). The Tower of London Test was standard score 120, but in the deficient range for the amount of time it took her to do so. Speed of processing and the ability to inhibit automatic output was quite weak as seen on the Stroop Color and Word Test. Thus, there was evidence of some areas of sustained functioning with inconsistent performance in other areas of attention and executive functioning. The MMPI-II was valid, highlighting physical and depressive symptomatology. The findings raised some questions of the interpretability of the current findings. It was likely that factors other than 9 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 neurological impairment had influenced her performance. Test results should therefore be assessed with extreme caution. In conclusion, her overall ability fluctuated from the bottom of the average range with average verbal skills and average visual/perceptual skills. Processing speed and working memory were low average. Performances were markedly variable, ranging from borderline to high average. Language functions were variable with impaired word finding and repetition, but intact reasoning, comprehension and fluency. Visual motor integration was intact. Fine motor speed was slow on unilateral functions but better for bilateral coordinated functions. Attention and executive functions varied remarkably. Memory assessments could not be reported with any certainty. The personality inventory yielded a valid profile demonstrating elevations in areas of hysteria and hypochondriasis as well as mild elevation in the area of depression. These factors likely influenced her performance somewhat and should be further explored. Discomfort and fatigue may also have impacted her performance. A complete neurologic examination was recommended as well as an evaluation by a psychiatrist. A note from Dr. Milstein (05/18/2011) indicated that Dr. Phillips was continuing to make gradual progress and had become progressively more functional. She was referred to Dr. Lado for additional treatment options. Subsequently on 05/23/2011 Dr. Lado was consulted in connection with Dr. Phillips’ pain and headaches. The history was generated. Complaints that were most disabling included photophobia (which had improved), word-finding difficulties, memory loss, poor sleep, poor concentration, an inability to read secondary to pain, tunnel vision (now resolved), daily headaches, slurring (better) and numbness and tingling in both hands, left worse than right up to the forearm. An examination and review of studies followed. Dr. Phillips thus presented with numerous pain-related complaints as well as symptoms of poor concentration, difficulty reading 10 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 and overall decline in her intellectual functioning that had produced significant impairment. Pre- existing diagnoses of fibromyalgia and an anxiety disorder with panic attacks was noted. She had been treated by numerous physicians as well as a large number of medications. Review of numerous radiographic studies did not reveal any significant anatomical pathology consistent with the level of pain she experienced. This finding, taken with the level of subjective pain and functional disability, was consistent with a prior diagnosis of fibromyalgia and suggested a central pain syndrome that was affected by mood and her affective state. Recommendations for reducing and tapering sedating medications followed. On 05/24/2011 Dr. Phillips returned to Dr. Gopal. She still had complaints of pain in the neck area radiating to the bilateral posterior shoulders, pain in the upper mid back and pain in the lower back radiating to the left leg and foot with numbness in the left medial forearm/digits 3-5. Pain was sharp and dull with spasms. Timing of the pain was constant, worse in the neck. Pain was 7/10 in the back and 9/10 in the neck. Multiple treatments had been applied. Pain improved with rest, standing, walking, heat and medications and was aggravated by prolonged sitting, bending, lifting, getting up from a seated position and climbing stairs with difficulty performing duties. Pain was associated with headaches. The assessment was lumbar radiculopathy; chondromalacia of the patella; lumbar spine HNP; cervical neck disorder symptoms; and cervical spondylosis without myelopathy. Medications were refilled. A cervical facet joint medial branch block was recommended. On 05/27/2011 Dr. Gopal indicated that Dr. Phillips was still unable to perform her duties with an expected return to work date of 10/01/2011. He recommended a loan deferment as she was unable to work because of her current severe disability. 11 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 On 06/11/2011 Dr. Gopal also indicated that Dr. Phillips was unable to perform her duties as a surgical resident. She was unable to stand, sit or walk for greater than 30 minutes nor lift, bend or twist. She was undergoing a process of being placed on disability, which was recommended. By 07/22/2011 Mark Fulton, M.D. was consulted at Holmes Regional Medical Center given a chief complaint of chronic neck and back pain with recent exacerbation. Her condition was most consistent with chronic myofascial pain and given its severity, a followup MRI was reasonable. On 07/23/2011 an additional consultation at Holmes Regional Medical Center was negotiated by Jay E. Olsson, D.O. in connection with pain management. The chief complaint was severe neck and back pain. Medications had controlled her pain prior to her moving to Florida. After an examination and review of studies, the impression was chronic pain syndrome related to neck and back pain as a result of motor vehicle accidents; chronic neck pain; chronic back pain with possible radiculopathy; history of motor vehicle accidents; history of postconcussion syndrome. Medications were adjusted. On 07/23/2011 an additional consultation at Holmes Regional Medical Center followed by Dr. Dandapani. Dr. Phillips was a 33-year-old female with a history of motor vehicle accident, fibromyalgia and chronic pain syndrome. Dr. Dandapani recommended a rheumatologist to address the fibromyalgia. Dr. Phillips wished to see a neurologist to deal with accident-related cognitive limitations. On 08/05/2011 given the reason for consultation being headache and neck pain, Dr. Phillips was again seen at Holmes Medical Center. Dr. Unger’s impression was headaches; neck pain; cervical disc disease and lumbar disc disease with herniated nucleus pulposus L5-S1 to the 12 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 left; chronic pain; short-term memory loss, questionably secondary to pseudodementia based on previous neurologic and psychiatric testing. Review of neuropsychiatric testing was pending; an atonic bladder was also noted. Her acute symptoms were probably secondary to cervicogenic headaches and cervical strain. He prescribed Robaxin, Dilaudid and a patient-controlled analgesia pump. He recommended to check the MRI of the brain and the cervical and thoracic regions as well as check the MRA of the brain. There would be a consultation with physical therapy as well. On 08/06/2011 given the reason for the consultation being urinary retention, Dr. Phillips was seen by Dr. Littlejohn. She had a neurogenic voiding dysfunction resulting in urinary retention. She currently managed her situation with clean and intermittent self-catheterization. The plan was for an indwelling Foley catheter until pain resolved enough for the patient to resume clean intermittent self-catheterization. She could follow up for further discussion of treatment of her urinary retention with a sacral nerve stimulation. On 08/06/2011 Dr. Phillips consulted Brian Dowdell, M.D. His impression was chronic pain syndrome, focal mostly to the neck and related cervicogenic/posttraumatic headaches; chronic back pain, no evidence of radiculopathy; history of head concussion with probable mild postconcussive syndrome; opioid dependence. She had been put on a patient-controlled analgesia pump. The pump would be discontinued. She could supplement medication by an as needed intravenous Dilaudid. Oral medications would be reinstituted. Pain had been well controlled. She had anticipated a rhizotomy, but this had not been accomplished prior to her move. On 08/15/2011 Dr. Jasperse with an amended report on 08/30/2011 evaluated the patient in connection with a somatoform disorder. She presented to Holmes Regional with a chief 13 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 complaint of neck pain as well as headaches, back pain and urinary retention. The history was noted. Depression, decreased concentration, sleep disturbance, appetite disturbance, anhedonia, increased anxiety and stress, irritability, fatigue and increasing pain were noted. Dr. Jasperse concluded that it was unlikely that she had a somatoform disorder as her signs and symptoms did not fit the definition of a somatoform disorder. However, she certainly had a pain disorder, which had caused psychological as well as financial distress. There was no inpatient psychiatric history. She had only seen a psychiatrist in relationship to multiple medical issues to determine if there was any psychological distress associated with the patient’s injuries. The DSM-IV diagnosis was pain disorder associated with psychological factors and general medical condition; opiate dependence (pain disorder); substance-induced mood disorder. She should continue on Cymbalta. Outpatient counseling was recommended as well as treatment for opioid addiction. On 08/15/2011 Dr. Phillips was discharged from Holmes Regional Medical Center. The discharge diagnosis was cervicalgia/cervicogenic headache secondary to the motor vehicle accident x2; multiple cervical herniation; L5-S1 herniated disc; chronic pain secondary to the above; vaginal yeast infection, resolved; urinary retention secondary to an acontractile bladder diagnosed by urodynamic studies. She was discharged home on oxycodone, Valium, Cymbalta, and Lyrica. She would continue to followup with multiple physicians. On 09/26/2011 Lynette Graff, M.D. was consulted. Medications were prescribed. The impression was depressive disorder, not elsewhere classified; fibromyalgia; back pain, thoracic region chronic; back pain lumbosacral, chronic; and neck pain, chronic. On 10/04/2011 Dr. Phillips returned to Dr. Graff with a complaint of bilateral breast pain. There was a history of bilateral breast implants in 2006. 14 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 On 10/10/2011 given urinary retention issues, chronic; DDD; neck pain; low back pain; and dizziness, medications were prescribed (MIMA Malabar Internal Medicine). By 10/17/2011 Dr. Phillips consulted Gary Weiss, M.D. The history was again generated. She was receiving massage therapy with benefit. She was seen for a neurologic evaluation and treatment. She reported daily headaches, decreased short and long-term memory, sensitive to bright lights and sound, blurred vision and diplopia. Her handwriting was poor. She could not remember how to spell. Constant pain in the neck, shoulders, arms, right greater than left with numbness and tingling in the arms, more on the left than the right was reported. She had decreased range of motion in the neck and severe pain and constant pain in the middle back, radiating to the ribcages and chest with almost constant muscle spasms. She complained of constant pain across the low back with varying severity. Current pain when seen was severe. Medications included Aleve, Ambien, Cymbalta and Lyrica. Her past medical and surgical history additionally noted benign essential hypertension with severe pain. A neurologic examination followed. Review of studies was noted. The assessment was motor vehicle accident 06/03/2010 with fall with loss of consciousness on 11/01/2010 and second closed head injury on 01/25/2011 with closed head injury with posttraumatic headaches and cognitive loss; neck pain with some radicular symptoms; thoracic spine pain; lower back pain with radicular symptoms. By 10/19/2011 Miguel Rivera, M.D. was consulted. Dr. Phillips presented with low back pain and neck pain. Medications additionally included Lidoderm adhesive patch, Nucynta and Opana. The assessment was neck pain; cervical spondylarthritis; bilateral hand paresthesia; low back pain. A facet joint injection was recommended, consider PRF for long-lasting relief. Lumbar spondylarthritis was also noted. 15 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 On 11/14/2011 Dr. Weiss conducted a quantitative electroencephalogram. The impression was an abnormal study with a brain injury analysis positive for CHI with a 95% probability. On 11/14/2011 an EEG report was also generated by Dr. Weiss. This was within normal limits. On 01/10/2012 Dr. Weiss noted that Dr. Phillips’ condition had worsened with increased joint pain. She could not get out of bed without medication. She could barely walk. She was seen at HRMC due to a severe anxiety attack and had severe shortness of breath (“I felt like I was dying”). The assessment now included chronic pain with narcotic dependence and new joint pain everywhere after an infection. She requested an inpatient pain program. The recommendation was also for rheumatology to evaluate the new joint pains. On 01/16/2012 Dr. Rivera was again consulted. Neck pain was addressed. She was being referred to the University of Miami for further investigation of her condition. She would also see a rheumatologist. By 02/06/2012 Dr. Weiss reiterated the diagnosis and highlighted that it was highly unlikely that she would be able to pursue her career in any type of surgical field. However, physically she should be able to pursue a career in radiology. On 02/15/2012 a narrative report was generated by Kuldip Sachdev, M.D., a neurologist. He performed an Independent Neurologic Evaluation. The history was gathered. When seen, complaints included daily generalized throbbing headaches with photophobia, phonophobia and dizziness. Headaches were preceded by visual scotomas. She had tried Pamelor for several months; it did not help and was discontinued. Rest in a dark quiet room and sleep helped the headaches. She had pain in her neck, which was constant, associated with spasms radiating to 16 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 both shoulders and aggravated by neck bending and turning as well as sitting. She had constant upper and mid back pain with variable intensity and constant low back pain with radiation to her hips and buttocks increased with walking and sitting. Standing helped the pain. She could sit for 20 to 30 minutes. She had intermittent tingling and numbness in both hands, but it did not wake her from sleep. Memory and concentration were slowly improving. She had suffered migraine headaches off and on since her teenage years with visual scotomas and pain in her eyes. She had anxiety attacks in medical school that worsened since the accident on 06/03/2010. She had not worked since August 2010. Medical records were reviewed and an examination followed. The impression and diagnosis was posttraumatic headaches; cervical spine sprain and strain; thoracic spine sprain and strain; lumbosacral spine sprain and strain superimposed upon pre-existing age- related degenerative disc disease at L5-S1; posttraumatic vertigo precipitated by the use of Zanaflex and most likely iatrogenic rather than posttraumatic. The anxiety disorder was referred to the appropriate specialist. There was no permanency to the cervical, thoracic and lumbar spine sprains and strains. The sensory loss over the entire right arm was not consistent with a radiculopathy, myelopathy or neuropathy. It was not consistent with a carpal tunnel syndrome. There was no clinical evidence of a cervical or lumbosacral radiculopathy or myelopathy. Dr. Sachdev recommended weaning her from narcotic pain medications. The mini mental examination was normal. There was no need for further treatment. There was no neurological disability. She was thus not disabled neurologically from working or from activities of daily living. On 02/16/2012 Andrew Miller, M.D., an orthopedic surgeon, performed an Independent Orthopedic Evaluation. Medical records were reviewed. Dr. Phillips did not provide background material or her current complaints. An examination followed. The diagnosis was 17 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 cervical spine, thoracic spine and lumbar spine sprain. There was evidence of a disability based upon available medical documentation. On 03/15/2012 a Psychological Intake was generated at Community Psychological Services in Melbourne, Florida. The clinician was Laurel McHone, M.S. Dr. Phillips was seen in connection with severe anxiety and posttraumatic stress. At that point she was 33 years of age. The background was noted. When seen she experienced poor self-esteem and fear of social contact with people outside her family. Medication let her sleep eight hours at night, but she still had difficulty falling asleep each night. She had constant feelings of guilt for talking back to her verbally abusive father, who had died the day before she left her residency. Since the car accident, she had difficulty concentrating and with low energy. She was irritable and tense, but reported no change in appetite. She resided with her mother in Melbourne, Florida due to financial difficulty. She did not drive due to anxiety. Her mother drove her everywhere. She did not leave the house most days and shared her mother’s social circle. She was not sexually active and was experiencing low sex drive. She was currently engaged in a civil lawsuit. Her physician told her not to work at present and the lack of income had caused financial difficulties. In terms of her psychiatric history, she reported in 2007 she received therapy for test taking anxiety and it helped. Since 2010, she had seen Dr. Schreber in the Bronx, New York and Dr. Bunt in Melbourne for psychiatric services related to her distress after the accident. She received neuropsychological testing from Dr. Fatini in 2011 while living in the Bronx. She was currently prescribed Cymbalta, Xanax and Ambien. She had had several incidents of blackouts after taking her sleep medications. After a mental status examination and interview, the diagnostic impression was adjustment disorder with mixed anxiety and depressed mood; nicotine dependence; traumatic brain injury, herniated disc, polycystic ovarian syndrome, low-grade 18 FILED: BRONX COUNTY CLERK 02/03/2022 03:39 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 268 RECEIVED NYSCEF: 02/03/2022 cervical dysplasia per client. Weekly psychotherapy was recommended (Barbara Paulillo, Psy.D. supervised Ms. McHone). On 03/29/2012 Solomon Miskin, M.D., a psychiatrist, examined Dr. Phillips. He reviewed records and generated the history as well as her current complaints and conducted a mental status examination. A cognitive status screening examination revealed no evidence of deficit. The diagnostic impression was panic disorder predating the incident, dated 06/03/2010, chronic not otherwise specified; adjustment disorder with mixed emotional features, mild severity, not otherwise specified; anxiety disorder predating the incident dated 06/03/2010, not otherwise specified; status post motor vehicle accident with no loss of consciousness; status post closed head injury with associated loss of consciousness; status post closed head injury with no reported loss of consciousness; mitral valve prolapse, asthma and migraine headaches; breast augmentation, skin graft; postconcussion syndrome associated with the closed head injury of 11/01/2010 and a second closed head injury of 01/25/2011. She was not currently wo