Preview
FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
620036/2023
SUFFOLK
JOSEPH A. ORTIZ,
JAMIE E. MULLIGAN
GOOD SAMARITAN HOSPITAL CENTER,
1000 Montauk Highway,
West Islip, NY 11795
10/4/2023
MUSCARELLA & DIRAIO,
LLP
229 Main Street, Suite 200
Huntington, NY 11743
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
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NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway
West Islip NY 11795
Patient Demographics
Name Patient ID SSN Legal Sex Birth Date
Ortiz, Joseph E1432160 xxx-xx-2387 Male 09/17/89 (33 yrs)
Address Phone Email
619 OUTLOOK AVE 631-332-3062 (M) ortizjoey0917@gmail
WEST BABYLON .com
NY 11704
Reg Status PCP
ELAPSED Nakhjavan, Jeffrey
M., DO631-242-1181
_ Ortiz, Joseph
DOB: 9/17/1989, Age 33 y.o. Male
Medical Record #E1432160 CSN: 3057502028
HAR #112321604032 Emergency
Admit Date 8/4/2023 1656
GSH EMERGENCY GER Rm STXR, Bed STXR
Patient Demographics
Address 619 OUTLOOK AVE Home Phone
West Babylon Mobile Phone 631-332-3062
New York Work Phone
11704
Religion Catholic Employment Full Time
Status
Race Other Marital Status Married
Ethnicity Hispanic or Latino Place of Birth New York,United States of America
Emergency Contacts
Name ORTIZ,MEGAN Relation Spouse Name Rivera,Nancy Relation Mother
Address Home Ph Address 33 MICHAGIN AVE; Home Ph 631-365-0437
Mobile Ph 631-871-8628 Bay Shore Mobile Ph
Work Ph New York Work Ph
11706
Guarantor
Name Ortiz, Joseph Relation Self
Address 619 OUTLOOK AVE Home Ph
West Babylon Mobile Ph 631-332-3062
NY Work Ph
11704 8/4/2023
Coverage
NO FAULT PROGRESSIVE
INS CO NF
Subscriber Name Ortiz,Joseph Claim Address Po Box 2930
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway
West Islip NY 11795
Subscriber DOB 9/17/1989 Clinton
Relationship to Subscriber Self Iowa
Policy Number 238265872 52733-2930
Insurance Phone Number 800-627-4581
Subscriber Name Claim Address
Subscriber DOB
Relationship to Subscriber
Policy Number
Insurance Phone Number
Policy Number Insurance Phone Number
Medical
Admit Dx Admit Physician
Pri Dx Unspecified injury of ri* PCP Nakhjavan, Jeffrey M., DO
Chief Complaint MVC Accident Type No-fault insurance invol*
Means of Arrival Ambulance Accident Date 8/4/2023
Admit Type Emergency Accident Location
Point of Origin NON HCR FAC/PHY REF Procedure
Patient Identifiers
CSN: 3057502028
EPIC Number: E1432160
HAR Account Number: 112321604032
Admission Information
Current Information
Attending at Discharge Admitting Provider Admission Type Admission Status
Hickey, Christine Susan, DO Emergency Confirmed Discharge
Admission Date/Time Discharge Date Hospital Service Auth/Cert Status
08/04/23 1656 08/04/23 Emergency Incomplete
Hospital Area Unit Room/Bed
GOOD SAMARITAN UNIVERSITY GSH EMERGENCY GER STXR/STXR
HOSPITAL
Discharge Disposition Discharge Destination
* DISCH 01 TO HOME OR SELF CARE
Treatment Team
Provider ED Prov Role Specialty From To
Lalos, Stavros, MD Yes Resident Resident 08/04/23 1656 —
Hickey, Christine Susan, Yes Attending Emergency Medicine 08/04/23 1756 08/04/23 1840
DO Physician
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Discharge Information
Discharge Provider Date/Time Disposition Destination
Hickey, Christine Susan, DO / 631-376- 08/04/23 1840 * DISCH 01 TO HOME OR SELF CARE (none)
4045
History
Medical as of 8/4/2023
Past Medical History
Diagnosis Date Comments Source
Hemophilia A (HCC) — — Provider
Surgical as of 8/4/2023
Past Surgical History
Procedure Laterality Date Comments Source
LIVER BIOPSY — — — Provider
Family as of 8/4/2023
None
Family Status as of 8/4/2023
None
Tobacco Use as of 8/4/2023
Smoking Status Smoking Start Date Last Attempt to Quit Smoking Frequency
Light Smoker — —
Smokeless Status Smokeless Type Smokeless Quit Date
Unknown — —
Source
Provider
Alcohol Use as of 8/4/2023
Alcohol Use Drinks/Week Alcohol/Week Comments Source
Yes — — Provider
Drug Use as of 8/4/2023
Drug Use Types Frequency Comments Source
No — — — Provider
Sexual Activity as of 8/4/2023
Sexually Active Birth Control Partners Comments Source
— — — — Provider
Activities of Daily Living as of 8/4/2023
None
Social Documentation as of 8/4/2023
None
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Occupational as of 8/4/2023
None
Socioeconomic as of 8/4/2023
Number of Years Education Preferred
Marital Status Spouse Name Children Education Level Language Ethnicity Race Source
Married — — — — English Hispanic or Other —
Latino
Birth as of 8/4/2023
None
Allergies as of 8/4/2023 Review status set to Review Complete on 8/4/2023
Noted Reaction Type Reactions
Aspridrox [aspirin Buf(alhyd-mghyd-cacar)] 10/10/2014
Prior To Admission Medication as Reported By Patient
None
Prior to Admission Meds After Reconciliation
No medications on file.
ED Arrival Information
Expected Arrival Acuity Means of arrival Escorted by Service Admission type
- 8/4/2023 16:54 Less Urgent Ambulance Self Emergency Emergency
Arrival complaint
MVC
ED Chief Complaint
Last Edited
Complaint Comment By Time Relationship ED Provider
Motor Vehicle Crash Outlaw, 8/4/2023 4:58 None No
[160395] Danielle A, PM
RN
ED Diagnoses
Diagnosis Comment Added By Time Added Team Role Associated Orders
Final diagnosis
Trauma -- Lalos, Stavros, 08/04/2023 Resident DX CHEST 2 VIEWS
MD 1815 DX SHOULDER MINIMUM 2
VIEWS RIGHT
ED Events
Date/Time Event User Comments
08/04/23 1654 Patient arrived in ED OUTLAW, DANIELLE A --
08/04/23 1656 Patient roomed in ED OUTLAW, DANIELLE A To room STXR
08/04/23 1840 Patient discharged MCFARLANE, DESTINEQUE --
ED Disposition
ED Disposition Condition User Comment
Discharge Stable Lalos, Stavros, MD Joseph Ortiz discharge to Home or Self Care
Events
ED Arrival at 8/4/2023 1654
Unit: Good Samaritan University Hospital Emergency Department
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Events (continued)
Admission at 8/4/2023 1656
Unit: Good Samaritan University Hospital Room: STXR Bed: STXR
Emergency Department
Patient class: Emergency Service: Emergency Medicine
ED Roomed at 8/4/2023 1656
Unit: Good Samaritan University Hospital Room: STXR Bed: STXR
Emergency Department
Patient class: Emergency Service: Emergency Medicine
Transfer Out at 8/4/2023 1710
Unit: Good Samaritan University Hospital Room: STXR Bed: STXR
Emergency Department
Patient class: Emergency Service: Emergency Medicine
Transfer In at 8/4/2023 1710
Unit: Good Samaritan University Hospital Room: STXR Bed: STXR
Emergency Department
Patient class: Emergency Service: Emergency Medicine
Patient Update at 8/4/2023 1756
Unit: Good Samaritan University Hospital Room: STXR Bed: STXR
Emergency Department
Patient class: Emergency Service: Emergency
Discharge at 8/4/2023 1840
Unit: Good Samaritan University Hospital Room: STXR Bed: STXR
Emergency Department
Patient class: Emergency Service: Emergency
Discharge at 8/4/2023 1840
Unit: Good Samaritan University Hospital Room: STXR Bed: STXR
Emergency Department
Patient class: Emergency Service: Emergency
Encounter Notes
ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM Version 1 of 1
Author: Lalos, Stavros, MD Service: Emergency Author Type: Resident
Filed: 8/4/2023 5:19 PM Date of Service: 8/4/2023 5:17 PM Status: Attested
Editor: Lalos, Stavros, MD (Resident) Cosigner: Hickey, Christine Susan, DO at 8/4/2023
8:06 PM
Attestation signed by Hickey, Christine Susan, DO at 8/4/2023 8:06 PM
I have personally seen, evaluated and participated in this patient’
s services and find this patient’
s
history and physical examination are consistent with Resident Physician's documentation, except
where otherwise charted by me.
Joseph Ortiz, a 33 y.o., male with past medical history of hemophilia A, who presents to the emergency
department s/p MVC. Patient was restrained front seat passenger, his car was hit from the side at very low
speed while in a parking lot, airbags did not deploy, glass did not break, he did not hit his head, no LOC. He
states that he hit his right shoulder into the door next to him and is having some mild pain in the shoulder
itself but reports no associated weakness or numbness. He otherwise has no complaints. He denies
headache, vision changes, neck or back pain, chest pain, shortness of breath, abdominal pain, nausea,
vomiting. He has otherwise been in his usual state of health prior to this occurring.
He follows with hematology through Northwell. He states that he is on a daily factor replacement and he
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Encounter Notes (continued)
ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1
took it this morning. He states in the past that he has been told to take a double dose of his factor if he has
ever had any head trauma. He adamantly denies hitting his head during this accident. He states that he
feels well overall except for some minor pain in his shoulder.
History obtained from: patient
Limitations to history taking: none
Interpreter services required: no
REVIEW OF SYSTEMS (ROS):
With exception of systems mentioned in HPI and above, all other are negative.
PHYSICAL EXAMINATION:
Vital Signs: BP 129/70 (BP Location: Left arm, BP Patient Position: Sitting) | Pulse 71 | Temp 98.6 °F (37
°C) (Oral) | Resp 16 | Wt 82 kg (180 lb 12.4 oz) | SpO2 98% | BMI 30.08 kg/m²
Constitutional: Appears in no acute distress
Head: Normal cephalic, atraumatic appearing
Eyes: PERRL, +EOMI, Pupils 3mm b/l, sclera and conjunctiva normal
Mouth: Mucous membranes moist
Neck: Supple, FROM, non tender to midline palpation, no step off deformities noted, no cervical
lymphadenopathy
Chest: Nontender to palpation, no signs of trauma
Cardiovascular: Regular rate and rhythm, no rubs, gallops, or murmurs appreciated
Respiratory: Normal respiration rate, no labored respirations, clear to auscultations bilaterally, no wheezes,
rales or rhonchi appreciated
Gastrointestinal: Soft, non-tender, non-distended, no guarding, rebound or rigidity
Musculoskeletal: No clubbing or cyanosis, no edema, normal distal pulses
Mild tenderness to palpation to the lateral aspect of the right shoulder however no obvious signs of deformity,
he has full range of motion without difficulty
Nontender to palpation to the entire midline spine with no step-off deformities noted
Pelvis stable with rocking with no tenderness to palpation of bilateral hips
Integument: No rashes, normal turgor, capillary refill < 3 seconds
Neurological: Awake and alert, answering questions appropriately, following commands well, moving all
extremities on his own with equal strength and sensation
ASSESSMENT/PLAN:
Joseph Ortiz, a 33 y.o., male with past medical history of hemophilia A, who presents to the emergency
department s/p MVC.
At this time, the patient is hemodynamically stable, neurovascular intact with no focal deficits on examination.
His x-ray imaging of the shoulder is unremarkable and shows no signs of fracture.
He has full range of motion to the extremities without difficulty.
He appears very well with no external signs of trauma.
No indication for additional factor replacement at this time.
Discussed with the patient following up with his hematologist following discharge from the emergency
department.
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Encounter Notes (continued)
ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1
Patient and his family at bedside understand very strict return precautions to the emergency department, the
patient is though feeling well and eager for discharge home.
The patient understands strict return precautions.
The patient is to follow up with PMD/heme within 24 hours following hospital discharge to arrange
appropriate follow up. Patient is to return to the ED for any persistent or worsening symptoms or if new
symptoms arise, including but not limited to new trauma or injury, worsening pain, vomiting, altered mental
status or confusion, dizziness or lightheadedness, change in color/sensation/appearance to the extremities,
chest pain or shortness of breath, abdominal pain. Patient was instructed that failure to do so could result in
worsening illness or disability.
The patient has had an opportunity to ask all questions, has verbalized an understanding of the results, plan,
and return instructions. Patient will be discharged at this time with a copy of his results and close outpatient
follow-up.
8/4/2023 5:17 PM
HPI
Joseph Ortiz is a 33 y.o. male with PMH of hemophilia A who presents to the ED today with right-sided
shoulder pain status post MVC. The patient reports he was involved in a very low impact MVC in a parking lot.
The car was T-boned in the parking lot with glass break on the right side. He was restrained. Airbags did not
deploy. He did not hit his head or lose consciousness. He was ambulatory at the scene. She denies any
numbness tingling weakness dizziness lightheadedness chest pain shortness of breath difficulty breathing
abdominal pain or back pain.
REVIEW OF SYSTEMS
All pertinent positives and negatives as noted in HPI.
PAST MEDICAL HISTORY
Past Medical History:
Diagnosis Date
•Hemophilia A
SURGICAL HISTORY
Past Surgical History:
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Encounter Notes (continued)
ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1
Procedure Laterality Date
•LIVER BIOPSY
ALLERGIES
Allergies
Allergen Reactions
•Aspridrox [Aspirin Buf(Alhyd-Mghyd-Cacar)]
FAMILY HISTORY
No family history on file.
SOCIAL HISTORY
Social History
Socioeconomic History
•Marital status: Married
Tobacco Use
•Smoking status: Light Smoker
Substance and Sexual Activity
•Alcohol use: Yes
•Drug use: No
PHYSICAL EXAM
VITAL SIGNS: BP 117/79 | Pulse 88 | Temp 98 °F (36.7 °C) | Resp 14 | Wt 82 kg (180 lb 12.4 oz) | SpO2
99% | BMI 30.08 kg/m²
CONSTITUTIONAL: Well-appearing, well-nourished, in no apparent distress,
HEAD/NECK: Normocephalic, atraumatic, full active range of motion of neck
EYES: EOMI, conjunctiva pink, sclera white
ENT: normal nose, no rhinorrhea; moist mucus membranes, oropharynx non-erythematous
CARD: RRR, no murmurs, rubs, or gallops
RESP: Normal respiratory effort, without use of accessory muscles, breath sounds clear and equal bilaterally,
no wheezes, rhonchi, or rales
ABD/GI: Non-distended, soft, non-tender, no rebound or guarding, no masses,
EXT/MS: moving all extremities, 2+ radial and posterior tibial pulses, no peripheral edema
SKIN: warm, dry, well perfused
NEURO: Alert & oriented x 3, CN II-XII grossly intact , normal motor function, normal sensory function, no focal
deficits noted
ASSESSMENT
33 y.o. male who presents with right shoulder pain and right lateral paracervical neck spasm status post MVC.
Patient is neuro intact, hemodynamically stable, comfortable appearing fully ambulatory no abdominal pain
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Encounter Notes (continued)
ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1
chest pain pelvis is stable, no head strike or LOC.
See additional note for MDM.
Lalos, Stavros, MD
Resident
08/04/23 1719
Electronically signed by Hickey, Christine Susan, DO on 8/4/2023 8:06 PM
Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM Version 3 of 3
Author: Lalos, Stavros, MD Service: — Author Type: Resident
Filed: 8/4/2023 6:34 PM Date of Service: 8/4/2023 6:15 PM Status: Edited
Editor: Lalos, Stavros, MD (Resident)
Related Notes: Original Note by Lalos, Stavros, MD (Resident) filed at 8/4/2023 6:15 PM
Follow-Up Instructions
- Follow-up with your primary care doctor. Have your doctor review your test results.
- If any medications were prescribed to you during this visit, please read the medication package insert. The
package insert includes all the adverse effects and side effects as well as warnings for these medications.
- Return to the ED for fever, vomiting, chest pain, difficulty breathing, passing out, persistent or worsening
symptoms, or any other complaints.
Results
X-Ray Shoulder Minimum of 2 Views Right
Result Date: 8/4/2023
Facility: Good Samaritan Hospital EXAMINATION: XR SHOULDER 2 OR MORE VIEWS CLINICAL
INDICATION: trauma, T14.90XA: Injury, unspecified, initial encounter TECHNIQUE: 3 view right shoulder
COMPARISON: No prior exam. FINDINGS: No fracture or dislocation. Normal alignment. Joint spaces appear
normal. Normal bone density without osseous lesion. No effusion. Soft tissues appear normal. IMPRESSION:
No acute abnormality. Electronically signed by: Peter Williams MD 08/04/2023 05:34 PM EST Workstation:
RPMXWRS2392P
X-Ray Chest 2 Views
Result Date: 8/4/2023
Facility: Good Samaritan Hospital EXAMINATION: Chest radiographs, 08/04/2023 05:33 PM EST
INDICATION: trauma, T14.90XA: Injury, unspecified, initial encounter COMPARISON(S): None.
TECHNIQUE: PA and Lateral views/2 view FINDINGS: Lungs: No consolidation, pleural effusion, or
pneumothorax. Heart and mediastinum: Cardiomediastinal silhouette has normal size and configuration. Other:
Osseous structures and soft tissues are unremarkable. IMPRESSION: No acute cardiopulmonary findings.
Electronically signed by: Peter Williams MD 08/04/2023 05:33 PM EST Workstation: RPMXWRS2392P
Results for orders placed or performed during the hospital encounter of 10/10/14
Urine culture
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Encounter Notes (continued)
Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM (continued) Version 3 of 3
Specimen: Urine Clean Catch
Result Value Ref Range
FINAL No growth
CBC and differential
Result Value Ref Range
WBC 8.25 3.50 - 10.70 x10(3)/mcL
RBC 4.61 3.90 - 5.90 x10(6)/mcL
Hgb 14.4 11.7 - 17.4 gm/dL
Hct 40.3 32.0 - 54.0 %
MCV 87 80 - 97 fL
MCH 31 27 - 32 pg
MCHC 35.7 (H) 31.0 - 35.0 gm/dL
RDW 12.6 11.9 - 15.1 %
Platelets 178 150 - 400 x10(3)/mcL
MPV 11.8 8.5 - 12.1 fL
Immature Grans % 0.1 0.0 - 0.5 %
Immature Grans (Absolute) 0.01 0.00 - 0.03 x10(3)/mcL
Basic metabolic panel
Result Value Ref Range
Glucose 128 (H) 74 - 106 mg/dL
BUN 17 7 - 18 mg/dL
Creatinine 0.7 0.6 - 1.3 mg/dL
Calcium 8.8 8.5 - 10.1 mg/dL
Sodium 141 136 - 145 mmol/L
Potassium 3.1 (L) 3.5 - 5.1 mmol/L
Chloride 107 98 - 107 mmol/L
CO2 26 21 - 32 mmol/L
Anion Gap 8 5 - 15 mEq/L
BUN/Creatinine Ratio 24 (H) 10 - 20 ratio
Hepatic function panel
Result Value Ref Range
SGPT (ALT) 41 12 - 78 unit/L
SGOT(AST) 16 15 - 37 unit/L
Alkaline Phosphatase 89 50 - 136 unit/L
Total Bilirubin 0.3 0.2 - 1.0 mg/dL
Bilirubin, Direct <0.1 0.0 - 0.2 mg/dL
Total Protein 6.9 6.4 - 8.2 gm/dL
Albumin 3.8 3.4 - 5.0 gm/dL
Lipase
Result Value Ref Range
Lipase 154 73 - 393 unit/L
Protime-INR
Result Value Ref Range
PT 10.3 9.2 - 11.6 second(s)
INR 1.0 0.8 - 1.1
APTT
Result Value Ref Range
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FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023
West Islip NY 11795
Hospital Record
Encounter Notes (continued)
Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM (continued) Version 3 of 3
PTT 51.0 (H) 21.8 - 30.9 second(s)
Urinalysis with microscopic
Result Value Ref Range
Urine Specific Gravity 1.018 1.000 - 1.025
Urine pH 6.5 4.5 - 8.0
Urine Protein Negative Negative mg/dL
Urine Appearance Clear Clear
Urine Color Yellow Yellow
Urine Glucose Negative Negative mg/dL
Urine Ketones Negative Negative mg/dL
Urine Bilirubin Negative Negative
Urine Blood Negative Negative
Urine Nitrite Negative Negative
Urine Urobilinogen Normal Normal EU/dl
Urine Leukocyte Esterase Negative Negative
Urine Microscopic Not Indicated
Auto Diff
Result Value Ref Range
Neutrophil % 51.8 46.0 - 78.0 %
Grans (Absolute) 4.3 1.4 - 7.5 x10(3)/mcL
Lymphocyte % 37.8 8.0 - 43.0 %
Lymphocyte (Absolute) 3.1 (H) 0.5 - 2.9 x10(3)/mcL
Monocyte % 8.2 5.0 - 14.0 %
Monocyte (Absolute) 0.7 0.3 - 1.0 x10(3)/mcL
Eosinophil % 1.9 0.0 - 9.0 %
Eosinophil (Absolute) 0.2 0.0 - 0.5 x10(3)/mcL
Basophil % 0.2 0.0 - 1.0 %
Basophil (Absolute) 0.0 0.0 - 0.1 x10(3)/mcL
Glomerular Filtration Rate GFR
Result Value Ref Range
eGFR Non African American >60 >=60 mL/min/1.73
eGFR African American >60 >=60 mL/min/1.73
Electronically signed by Lalos, Stavros, MD on 8/4/2023 6:34 PM
Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM Version 2 of 3
Author: Lalos, Stavros, MD Service: — Author Type: Resident
Filed: 8/4/2023 6:15 PM Date of Service: 8/4/2023 6:15 PM Status: Edited
Editor: Lalos, Stavros, MD (Resident)
Related Notes: Addendum by Lalos, Stavros, MD (Resident) filed at 8/4/2023 6:34 PM
Original Note by Lalos, Stavros, MD (Resident) filed at 8/4/2023 6:15 PM
Follow-Up Instructions
- Follow-up with your primary care doctor. Have your doctor review your test results.
- If any medications were prescribed to you during this visit, please read the medication package insert. The
package insert includes all the adverse effects and side effects as well as warnings for these medications.
- Return to the ED for fever, vomiting, chest pain, difficulty breathing, passing out, persistent or worsening
Generated on 9/15/23 8:47 AM Page 11
14 of 82
FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023
GOOD SAMARITAN Ortiz, Joseph
UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M
1000 Mon
Preview
FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 620036/2023 SUFFOLK JOSEPH A. ORTIZ, JAMIE E. MULLIGAN GOOD SAMARITAN HOSPITAL CENTER, 1000 Montauk Highway, West Islip, NY 11795 10/4/2023 MUSCARELLA & DIRAIO, LLP 229 Main Street, Suite 200 Huntington, NY 11743 1 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 2 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 3 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway West Islip NY 11795 Patient Demographics Name Patient ID SSN Legal Sex Birth Date Ortiz, Joseph E1432160 xxx-xx-2387 Male 09/17/89 (33 yrs) Address Phone Email 619 OUTLOOK AVE 631-332-3062 (M) ortizjoey0917@gmail WEST BABYLON .com NY 11704 Reg Status PCP ELAPSED Nakhjavan, Jeffrey M., DO631-242-1181 _ Ortiz, Joseph DOB: 9/17/1989, Age 33 y.o. Male Medical Record #E1432160 CSN: 3057502028 HAR #112321604032 Emergency Admit Date 8/4/2023 1656 GSH EMERGENCY GER Rm STXR, Bed STXR Patient Demographics Address 619 OUTLOOK AVE Home Phone West Babylon Mobile Phone 631-332-3062 New York Work Phone 11704 Religion Catholic Employment Full Time Status Race Other Marital Status Married Ethnicity Hispanic or Latino Place of Birth New York,United States of America Emergency Contacts Name ORTIZ,MEGAN Relation Spouse Name Rivera,Nancy Relation Mother Address Home Ph Address 33 MICHAGIN AVE; Home Ph 631-365-0437 Mobile Ph 631-871-8628 Bay Shore Mobile Ph Work Ph New York Work Ph 11706 Guarantor Name Ortiz, Joseph Relation Self Address 619 OUTLOOK AVE Home Ph West Babylon Mobile Ph 631-332-3062 NY Work Ph 11704 8/4/2023 Coverage NO FAULT PROGRESSIVE INS CO NF Subscriber Name Ortiz,Joseph Claim Address Po Box 2930 Generated on 9/15/23 8:47 AM Page 1 4 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway West Islip NY 11795 Subscriber DOB 9/17/1989 Clinton Relationship to Subscriber Self Iowa Policy Number 238265872 52733-2930 Insurance Phone Number 800-627-4581 Subscriber Name Claim Address Subscriber DOB Relationship to Subscriber Policy Number Insurance Phone Number Policy Number Insurance Phone Number Medical Admit Dx Admit Physician Pri Dx Unspecified injury of ri* PCP Nakhjavan, Jeffrey M., DO Chief Complaint MVC Accident Type No-fault insurance invol* Means of Arrival Ambulance Accident Date 8/4/2023 Admit Type Emergency Accident Location Point of Origin NON HCR FAC/PHY REF Procedure Patient Identifiers CSN: 3057502028 EPIC Number: E1432160 HAR Account Number: 112321604032 Admission Information Current Information Attending at Discharge Admitting Provider Admission Type Admission Status Hickey, Christine Susan, DO Emergency Confirmed Discharge Admission Date/Time Discharge Date Hospital Service Auth/Cert Status 08/04/23 1656 08/04/23 Emergency Incomplete Hospital Area Unit Room/Bed GOOD SAMARITAN UNIVERSITY GSH EMERGENCY GER STXR/STXR HOSPITAL Discharge Disposition Discharge Destination * DISCH 01 TO HOME OR SELF CARE Treatment Team Provider ED Prov Role Specialty From To Lalos, Stavros, MD Yes Resident Resident 08/04/23 1656 — Hickey, Christine Susan, Yes Attending Emergency Medicine 08/04/23 1756 08/04/23 1840 DO Physician Generated on 9/15/23 8:47 AM Page 2 5 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Discharge Information Discharge Provider Date/Time Disposition Destination Hickey, Christine Susan, DO / 631-376- 08/04/23 1840 * DISCH 01 TO HOME OR SELF CARE (none) 4045 History Medical as of 8/4/2023 Past Medical History Diagnosis Date Comments Source Hemophilia A (HCC) — — Provider Surgical as of 8/4/2023 Past Surgical History Procedure Laterality Date Comments Source LIVER BIOPSY — — — Provider Family as of 8/4/2023 None Family Status as of 8/4/2023 None Tobacco Use as of 8/4/2023 Smoking Status Smoking Start Date Last Attempt to Quit Smoking Frequency Light Smoker — — Smokeless Status Smokeless Type Smokeless Quit Date Unknown — — Source Provider Alcohol Use as of 8/4/2023 Alcohol Use Drinks/Week Alcohol/Week Comments Source Yes — — Provider Drug Use as of 8/4/2023 Drug Use Types Frequency Comments Source No — — — Provider Sexual Activity as of 8/4/2023 Sexually Active Birth Control Partners Comments Source — — — — Provider Activities of Daily Living as of 8/4/2023 None Social Documentation as of 8/4/2023 None Generated on 9/15/23 8:47 AM Page 3 6 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Occupational as of 8/4/2023 None Socioeconomic as of 8/4/2023 Number of Years Education Preferred Marital Status Spouse Name Children Education Level Language Ethnicity Race Source Married — — — — English Hispanic or Other — Latino Birth as of 8/4/2023 None Allergies as of 8/4/2023 Review status set to Review Complete on 8/4/2023 Noted Reaction Type Reactions Aspridrox [aspirin Buf(alhyd-mghyd-cacar)] 10/10/2014 Prior To Admission Medication as Reported By Patient None Prior to Admission Meds After Reconciliation No medications on file. ED Arrival Information Expected Arrival Acuity Means of arrival Escorted by Service Admission type - 8/4/2023 16:54 Less Urgent Ambulance Self Emergency Emergency Arrival complaint MVC ED Chief Complaint Last Edited Complaint Comment By Time Relationship ED Provider Motor Vehicle Crash Outlaw, 8/4/2023 4:58 None No [160395] Danielle A, PM RN ED Diagnoses Diagnosis Comment Added By Time Added Team Role Associated Orders Final diagnosis Trauma -- Lalos, Stavros, 08/04/2023 Resident DX CHEST 2 VIEWS MD 1815 DX SHOULDER MINIMUM 2 VIEWS RIGHT ED Events Date/Time Event User Comments 08/04/23 1654 Patient arrived in ED OUTLAW, DANIELLE A -- 08/04/23 1656 Patient roomed in ED OUTLAW, DANIELLE A To room STXR 08/04/23 1840 Patient discharged MCFARLANE, DESTINEQUE -- ED Disposition ED Disposition Condition User Comment Discharge Stable Lalos, Stavros, MD Joseph Ortiz discharge to Home or Self Care Events ED Arrival at 8/4/2023 1654 Unit: Good Samaritan University Hospital Emergency Department Generated on 9/15/23 8:47 AM Page 4 7 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Events (continued) Admission at 8/4/2023 1656 Unit: Good Samaritan University Hospital Room: STXR Bed: STXR Emergency Department Patient class: Emergency Service: Emergency Medicine ED Roomed at 8/4/2023 1656 Unit: Good Samaritan University Hospital Room: STXR Bed: STXR Emergency Department Patient class: Emergency Service: Emergency Medicine Transfer Out at 8/4/2023 1710 Unit: Good Samaritan University Hospital Room: STXR Bed: STXR Emergency Department Patient class: Emergency Service: Emergency Medicine Transfer In at 8/4/2023 1710 Unit: Good Samaritan University Hospital Room: STXR Bed: STXR Emergency Department Patient class: Emergency Service: Emergency Medicine Patient Update at 8/4/2023 1756 Unit: Good Samaritan University Hospital Room: STXR Bed: STXR Emergency Department Patient class: Emergency Service: Emergency Discharge at 8/4/2023 1840 Unit: Good Samaritan University Hospital Room: STXR Bed: STXR Emergency Department Patient class: Emergency Service: Emergency Discharge at 8/4/2023 1840 Unit: Good Samaritan University Hospital Room: STXR Bed: STXR Emergency Department Patient class: Emergency Service: Emergency Encounter Notes ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM Version 1 of 1 Author: Lalos, Stavros, MD Service: Emergency Author Type: Resident Filed: 8/4/2023 5:19 PM Date of Service: 8/4/2023 5:17 PM Status: Attested Editor: Lalos, Stavros, MD (Resident) Cosigner: Hickey, Christine Susan, DO at 8/4/2023 8:06 PM Attestation signed by Hickey, Christine Susan, DO at 8/4/2023 8:06 PM I have personally seen, evaluated and participated in this patient’ s services and find this patient’ s history and physical examination are consistent with Resident Physician's documentation, except where otherwise charted by me. Joseph Ortiz, a 33 y.o., male with past medical history of hemophilia A, who presents to the emergency department s/p MVC. Patient was restrained front seat passenger, his car was hit from the side at very low speed while in a parking lot, airbags did not deploy, glass did not break, he did not hit his head, no LOC. He states that he hit his right shoulder into the door next to him and is having some mild pain in the shoulder itself but reports no associated weakness or numbness. He otherwise has no complaints. He denies headache, vision changes, neck or back pain, chest pain, shortness of breath, abdominal pain, nausea, vomiting. He has otherwise been in his usual state of health prior to this occurring. He follows with hematology through Northwell. He states that he is on a daily factor replacement and he Generated on 9/15/23 8:47 AM Page 5 8 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Encounter Notes (continued) ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1 took it this morning. He states in the past that he has been told to take a double dose of his factor if he has ever had any head trauma. He adamantly denies hitting his head during this accident. He states that he feels well overall except for some minor pain in his shoulder. History obtained from: patient Limitations to history taking: none Interpreter services required: no REVIEW OF SYSTEMS (ROS): With exception of systems mentioned in HPI and above, all other are negative. PHYSICAL EXAMINATION: Vital Signs: BP 129/70 (BP Location: Left arm, BP Patient Position: Sitting) | Pulse 71 | Temp 98.6 °F (37 °C) (Oral) | Resp 16 | Wt 82 kg (180 lb 12.4 oz) | SpO2 98% | BMI 30.08 kg/m² Constitutional: Appears in no acute distress Head: Normal cephalic, atraumatic appearing Eyes: PERRL, +EOMI, Pupils 3mm b/l, sclera and conjunctiva normal Mouth: Mucous membranes moist Neck: Supple, FROM, non tender to midline palpation, no step off deformities noted, no cervical lymphadenopathy Chest: Nontender to palpation, no signs of trauma Cardiovascular: Regular rate and rhythm, no rubs, gallops, or murmurs appreciated Respiratory: Normal respiration rate, no labored respirations, clear to auscultations bilaterally, no wheezes, rales or rhonchi appreciated Gastrointestinal: Soft, non-tender, non-distended, no guarding, rebound or rigidity Musculoskeletal: No clubbing or cyanosis, no edema, normal distal pulses Mild tenderness to palpation to the lateral aspect of the right shoulder however no obvious signs of deformity, he has full range of motion without difficulty Nontender to palpation to the entire midline spine with no step-off deformities noted Pelvis stable with rocking with no tenderness to palpation of bilateral hips Integument: No rashes, normal turgor, capillary refill < 3 seconds Neurological: Awake and alert, answering questions appropriately, following commands well, moving all extremities on his own with equal strength and sensation ASSESSMENT/PLAN: Joseph Ortiz, a 33 y.o., male with past medical history of hemophilia A, who presents to the emergency department s/p MVC. At this time, the patient is hemodynamically stable, neurovascular intact with no focal deficits on examination. His x-ray imaging of the shoulder is unremarkable and shows no signs of fracture. He has full range of motion to the extremities without difficulty. He appears very well with no external signs of trauma. No indication for additional factor replacement at this time. Discussed with the patient following up with his hematologist following discharge from the emergency department. Generated on 9/15/23 8:47 AM Page 6 9 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Encounter Notes (continued) ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1 Patient and his family at bedside understand very strict return precautions to the emergency department, the patient is though feeling well and eager for discharge home. The patient understands strict return precautions. The patient is to follow up with PMD/heme within 24 hours following hospital discharge to arrange appropriate follow up. Patient is to return to the ED for any persistent or worsening symptoms or if new symptoms arise, including but not limited to new trauma or injury, worsening pain, vomiting, altered mental status or confusion, dizziness or lightheadedness, change in color/sensation/appearance to the extremities, chest pain or shortness of breath, abdominal pain. Patient was instructed that failure to do so could result in worsening illness or disability. The patient has had an opportunity to ask all questions, has verbalized an understanding of the results, plan, and return instructions. Patient will be discharged at this time with a copy of his results and close outpatient follow-up. 8/4/2023 5:17 PM HPI Joseph Ortiz is a 33 y.o. male with PMH of hemophilia A who presents to the ED today with right-sided shoulder pain status post MVC. The patient reports he was involved in a very low impact MVC in a parking lot. The car was T-boned in the parking lot with glass break on the right side. He was restrained. Airbags did not deploy. He did not hit his head or lose consciousness. He was ambulatory at the scene. She denies any numbness tingling weakness dizziness lightheadedness chest pain shortness of breath difficulty breathing abdominal pain or back pain. REVIEW OF SYSTEMS All pertinent positives and negatives as noted in HPI. PAST MEDICAL HISTORY Past Medical History: Diagnosis Date •Hemophilia A SURGICAL HISTORY Past Surgical History: Generated on 9/15/23 8:47 AM Page 7 10 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Encounter Notes (continued) ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1 Procedure Laterality Date •LIVER BIOPSY ALLERGIES Allergies Allergen Reactions •Aspridrox [Aspirin Buf(Alhyd-Mghyd-Cacar)] FAMILY HISTORY No family history on file. SOCIAL HISTORY Social History Socioeconomic History •Marital status: Married Tobacco Use •Smoking status: Light Smoker Substance and Sexual Activity •Alcohol use: Yes •Drug use: No PHYSICAL EXAM VITAL SIGNS: BP 117/79 | Pulse 88 | Temp 98 °F (36.7 °C) | Resp 14 | Wt 82 kg (180 lb 12.4 oz) | SpO2 99% | BMI 30.08 kg/m² CONSTITUTIONAL: Well-appearing, well-nourished, in no apparent distress, HEAD/NECK: Normocephalic, atraumatic, full active range of motion of neck EYES: EOMI, conjunctiva pink, sclera white ENT: normal nose, no rhinorrhea; moist mucus membranes, oropharynx non-erythematous CARD: RRR, no murmurs, rubs, or gallops RESP: Normal respiratory effort, without use of accessory muscles, breath sounds clear and equal bilaterally, no wheezes, rhonchi, or rales ABD/GI: Non-distended, soft, non-tender, no rebound or guarding, no masses, EXT/MS: moving all extremities, 2+ radial and posterior tibial pulses, no peripheral edema SKIN: warm, dry, well perfused NEURO: Alert & oriented x 3, CN II-XII grossly intact , normal motor function, normal sensory function, no focal deficits noted ASSESSMENT 33 y.o. male who presents with right shoulder pain and right lateral paracervical neck spasm status post MVC. Patient is neuro intact, hemodynamically stable, comfortable appearing fully ambulatory no abdominal pain Generated on 9/15/23 8:47 AM Page 8 11 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Encounter Notes (continued) ED Provider Notes by Lalos, Stavros, MD at 8/4/2023 5:17 PM (continued) Version 1 of 1 chest pain pelvis is stable, no head strike or LOC. See additional note for MDM. Lalos, Stavros, MD Resident 08/04/23 1719 Electronically signed by Hickey, Christine Susan, DO on 8/4/2023 8:06 PM Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM Version 3 of 3 Author: Lalos, Stavros, MD Service: — Author Type: Resident Filed: 8/4/2023 6:34 PM Date of Service: 8/4/2023 6:15 PM Status: Edited Editor: Lalos, Stavros, MD (Resident) Related Notes: Original Note by Lalos, Stavros, MD (Resident) filed at 8/4/2023 6:15 PM Follow-Up Instructions - Follow-up with your primary care doctor. Have your doctor review your test results. - If any medications were prescribed to you during this visit, please read the medication package insert. The package insert includes all the adverse effects and side effects as well as warnings for these medications. - Return to the ED for fever, vomiting, chest pain, difficulty breathing, passing out, persistent or worsening symptoms, or any other complaints. Results X-Ray Shoulder Minimum of 2 Views Right Result Date: 8/4/2023 Facility: Good Samaritan Hospital EXAMINATION: XR SHOULDER 2 OR MORE VIEWS CLINICAL INDICATION: trauma, T14.90XA: Injury, unspecified, initial encounter TECHNIQUE: 3 view right shoulder COMPARISON: No prior exam. FINDINGS: No fracture or dislocation. Normal alignment. Joint spaces appear normal. Normal bone density without osseous lesion. No effusion. Soft tissues appear normal. IMPRESSION: No acute abnormality. Electronically signed by: Peter Williams MD 08/04/2023 05:34 PM EST Workstation: RPMXWRS2392P X-Ray Chest 2 Views Result Date: 8/4/2023 Facility: Good Samaritan Hospital EXAMINATION: Chest radiographs, 08/04/2023 05:33 PM EST INDICATION: trauma, T14.90XA: Injury, unspecified, initial encounter COMPARISON(S): None. TECHNIQUE: PA and Lateral views/2 view FINDINGS: Lungs: No consolidation, pleural effusion, or pneumothorax. Heart and mediastinum: Cardiomediastinal silhouette has normal size and configuration. Other: Osseous structures and soft tissues are unremarkable. IMPRESSION: No acute cardiopulmonary findings. Electronically signed by: Peter Williams MD 08/04/2023 05:33 PM EST Workstation: RPMXWRS2392P Results for orders placed or performed during the hospital encounter of 10/10/14 Urine culture Generated on 9/15/23 8:47 AM Page 9 12 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Encounter Notes (continued) Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM (continued) Version 3 of 3 Specimen: Urine Clean Catch Result Value Ref Range FINAL No growth CBC and differential Result Value Ref Range WBC 8.25 3.50 - 10.70 x10(3)/mcL RBC 4.61 3.90 - 5.90 x10(6)/mcL Hgb 14.4 11.7 - 17.4 gm/dL Hct 40.3 32.0 - 54.0 % MCV 87 80 - 97 fL MCH 31 27 - 32 pg MCHC 35.7 (H) 31.0 - 35.0 gm/dL RDW 12.6 11.9 - 15.1 % Platelets 178 150 - 400 x10(3)/mcL MPV 11.8 8.5 - 12.1 fL Immature Grans % 0.1 0.0 - 0.5 % Immature Grans (Absolute) 0.01 0.00 - 0.03 x10(3)/mcL Basic metabolic panel Result Value Ref Range Glucose 128 (H) 74 - 106 mg/dL BUN 17 7 - 18 mg/dL Creatinine 0.7 0.6 - 1.3 mg/dL Calcium 8.8 8.5 - 10.1 mg/dL Sodium 141 136 - 145 mmol/L Potassium 3.1 (L) 3.5 - 5.1 mmol/L Chloride 107 98 - 107 mmol/L CO2 26 21 - 32 mmol/L Anion Gap 8 5 - 15 mEq/L BUN/Creatinine Ratio 24 (H) 10 - 20 ratio Hepatic function panel Result Value Ref Range SGPT (ALT) 41 12 - 78 unit/L SGOT(AST) 16 15 - 37 unit/L Alkaline Phosphatase 89 50 - 136 unit/L Total Bilirubin 0.3 0.2 - 1.0 mg/dL Bilirubin, Direct <0.1 0.0 - 0.2 mg/dL Total Protein 6.9 6.4 - 8.2 gm/dL Albumin 3.8 3.4 - 5.0 gm/dL Lipase Result Value Ref Range Lipase 154 73 - 393 unit/L Protime-INR Result Value Ref Range PT 10.3 9.2 - 11.6 second(s) INR 1.0 0.8 - 1.1 APTT Result Value Ref Range Generated on 9/15/23 8:47 AM Page 10 13 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Montauk Highway Adm: 8/4/2023, D/C: 8/4/2023 West Islip NY 11795 Hospital Record Encounter Notes (continued) Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM (continued) Version 3 of 3 PTT 51.0 (H) 21.8 - 30.9 second(s) Urinalysis with microscopic Result Value Ref Range Urine Specific Gravity 1.018 1.000 - 1.025 Urine pH 6.5 4.5 - 8.0 Urine Protein Negative Negative mg/dL Urine Appearance Clear Clear Urine Color Yellow Yellow Urine Glucose Negative Negative mg/dL Urine Ketones Negative Negative mg/dL Urine Bilirubin Negative Negative Urine Blood Negative Negative Urine Nitrite Negative Negative Urine Urobilinogen Normal Normal EU/dl Urine Leukocyte Esterase Negative Negative Urine Microscopic Not Indicated Auto Diff Result Value Ref Range Neutrophil % 51.8 46.0 - 78.0 % Grans (Absolute) 4.3 1.4 - 7.5 x10(3)/mcL Lymphocyte % 37.8 8.0 - 43.0 % Lymphocyte (Absolute) 3.1 (H) 0.5 - 2.9 x10(3)/mcL Monocyte % 8.2 5.0 - 14.0 % Monocyte (Absolute) 0.7 0.3 - 1.0 x10(3)/mcL Eosinophil % 1.9 0.0 - 9.0 % Eosinophil (Absolute) 0.2 0.0 - 0.5 x10(3)/mcL Basophil % 0.2 0.0 - 1.0 % Basophil (Absolute) 0.0 0.0 - 0.1 x10(3)/mcL Glomerular Filtration Rate GFR Result Value Ref Range eGFR Non African American >60 >=60 mL/min/1.73 eGFR African American >60 >=60 mL/min/1.73 Electronically signed by Lalos, Stavros, MD on 8/4/2023 6:34 PM Discharge Instructions by Lalos, Stavros, MD at 8/4/2023 6:15 PM Version 2 of 3 Author: Lalos, Stavros, MD Service: — Author Type: Resident Filed: 8/4/2023 6:15 PM Date of Service: 8/4/2023 6:15 PM Status: Edited Editor: Lalos, Stavros, MD (Resident) Related Notes: Addendum by Lalos, Stavros, MD (Resident) filed at 8/4/2023 6:34 PM Original Note by Lalos, Stavros, MD (Resident) filed at 8/4/2023 6:15 PM Follow-Up Instructions - Follow-up with your primary care doctor. Have your doctor review your test results. - If any medications were prescribed to you during this visit, please read the medication package insert. The package insert includes all the adverse effects and side effects as well as warnings for these medications. - Return to the ED for fever, vomiting, chest pain, difficulty breathing, passing out, persistent or worsening Generated on 9/15/23 8:47 AM Page 11 14 of 82 FILED: SUFFOLK COUNTY CLERK 10/04/2023 02:38 PM INDEX NO. 620036/2023 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 10/04/2023 GOOD SAMARITAN Ortiz, Joseph UNIVERSITY HOSPITAL MRN: E1432160, DOB: 9/17/1989, Sex: M 1000 Mon