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FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
"3"
Exhibit
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
CARE
ME DICAL
07/18/2021
KENNETH GAROFOLO
57 Cannon St Unit 601
Poughkeepsie, NY 12601-
Dear Mr. GAROFOLO,
RE: LAS RESULi5
It was a pleasure seeing you in our office. I have reviewed your results.
Alf your labs came back normal, except for anemia.
We will discuss your results again in your follow up evaluation.
if you have any questions please call our office.
CBC - AUTO + AUTO DIFF. 07/07/2021 09:30
Flag Result Range Component Units
5.6 44-11.1 WBC K/ul
L 3.91 4A0-630 RBC M/ul
L 13.0 14.0-18.0 HEMOGLOBIN GM/DL
L 39.5 41.0-51.0 HEMATOCRIT %
H 101.0 80.0-96.0 MCV FL
H 33.2 26.0-32D MCH PG
32.9 B2.0-369 MCHC G/DL
13.5 11.5-14.5 RDW %
262 140-450 PLATELET COUNT K/ul
10.4 9.4-12.4 MPV FL
72.4 30.0-75.0 NEUTROPHKS %
15.2 10.0-50.0 LYMPHOCYTES %
9.7 4.0-13.0 MONOCYTES %
1.8 0.0-6.0 EOSINOPHILS %
0.5 0.0-2.0 BASOPHILS %
4.05 1.8-7.0 ABS. NEUTROPHILS K/ul
L 0.85 1.0-4.8 ABS. LYMPHOCYTES K/ul
0.54 0.0-0.8 ABS. MONOCYTES K/ul
0.10 0.0-0.5 ABS- EOSINOPHILS K/ul
0.03 0.0-0.2 ABS. BASOPHILS K/ul
0.02 D.00-035 ABS. IG K/ul
0.4 0.0-5.0 IG %
GAROFOLO, KENNETH W 000003138056 01/23/196007/18/2021 10:55 AM Page: 1/3
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
COMPREHENSlVE METABOLIC PANEL 07/07/2021 09:30
Flag Result Range Component Units
139 135-145 SODIUM MMOL/L
3.9 3.5-5.5 POTASSIUM MMOUL
107 95-108 CHLORIDE MMOL/L
22 22-32 CO2 MMOUL
H 101 60-99 GLUCOSE MG/DL
9.4 8.5-10.5 CALCluM MG/OL
17 8-22 UREA NITROGEN MG/DL
1-1 0.5-1,5 CREATININE, SERUM MG/DL
72.1 60-120 eGFR /1.73m2
mL/min
6.7 6.0-8,5 TOTAL PROTEIN G/DL
4.3 3,5-5.0 ALSUMIN G/DL
2.4 1.5-4.5 GLOSULIN G/DL
0.3 0.2-1.3 TOTAL BILIRUSIN MG/DL
24 5-50 SGOf (AST) U/L
21 <50 U/L SGPT (ALT) U/L
54 35-125 ALKALINE PHOSPHATASE U/L
FOLATE. 07/07/2021 09:30
Flag Result Range Component Units
18.3 2.8->20 FOLATE ng/mL
KEPPRA (LEVETIRACETAM) 07/07/2021 09:30
Flag Result Range Component Units
17,2 12.0-46.0 LEVETIRACETAM mcg/mL
LYME TITER W.REFLEX-WB 07/07/2021 09 30
Flag Result Range Component Units
0.05 0.00-0.89 LYME AB
Negative LYME INTERPRETATION
LYME, WESTERN BLOT, SERUM. 07/07/2021 09:30
Flag Result Range Component Units
NON-REAC 18 KO (IGG) BAND
TIVE
NON-REAC 23 KD (IGG) BAND
TIVE
NON-REAC 28 KD (IGG) BAND
TIVE
NON-REAC 30 KD (IGG) BAND
TIVE
NON-REAC 39 KD (IGG) BAND
TIVE
NON-REAC 41 KD (IGG) BAND
TIVE
NON-REAC 45 KD (IGG) BAND
TIVE
NON-REAC 58 KD (IGG) BAND
TIVE
NON-REAC 66 KO (IGG) BAND
TIVE
NON-REAC 93 KD (IGG) BAND
TIVE
NON-REAC 39 KD (IGM) BAND
TIVE
NON-REAC 23 KD (IGM) BAND
GAROFOLO, KENNETH W. 000003138056 01/23/196007/18/2021 10:55 AM Page: 2/3
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
TIVE
NON-REAC 41 KD (IGM) SAND
TIVE
NEGATIVE NEGATIVE LYME DISEASE
AB(IGG),BLOT
NEGATIVE NEGATIVE LYM E DISEASE
AB(IGM),BLOT
T4 TOTAL, 07/07/2021 09:30
Flag Result Range Component Units
7.9 5.53-11.0 TOTAL T4 uG/DL
TOPAMAX (TOPIRAMATE) 07/07/2021 09-30
Flag Result Range Component Units
6.4 see note TOPIRAMATE mcg/mL
TSH, ULTRASENSITIVE 07/07/202109:30
Flag Result Range Component Units
2.22 0.474,7 TSH ulU/ML
Sincere7
Shaheda N. Azher MD
Document generated by: Shaheda N. Azher 07/18/2021
CareMount Medical
90 South Bedford Road
Mount Kisco, NY 10549-3412
Phone: (845) 231-5600
Far (914) 816-2672
Electronically signed by Shaheda N. Azher MD on 07/18/2021 10:57 AM
GAROFOLO, KENNETH W 000003138056 01/23/1960 07/18/2021 10:55 AM Page: 3/3
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
ARE
M E D I C A L
Patient: KENNETH GAROFOLO
Date of Birth:
Date: 07/07/2021 9:15 AM
Historian: self
Visit Type: Office Visit
This 61 year old male presents for follow up of TBI, follow up of seizure and follow up of gait issues,
History of Present IIIness
1. Follow Up of TBI
2. Follow Up of seizure
3, Follow Up of gait issues
HPI Summary:
CC: Follow up on TBI. He was diagnosed with prostate cancer a year ago and
currently following urologist.
Last time he moved to Manhattan to live with bis daughter. But now he said his back and is
staying in an apartment here
dose to his brothers etc. He also got his license back and driving. He continues to have some gait imbalance but
otherwise reported doing very well
He also complaining numbness in his both hands but mostly in the dorsum aspect.
He said now she is divorced from his wife. He mported now more
walking and also getting physical exercises daily he
now works with a personal trainer, He said he is more alert and his gait is improving. Please see
my prior notes for details.
HPI: Follow up on postconcussive symptoms, headaches, Meningitis.
his MRI brain showed Multiple stable foci of white matter T2 hyperintensity, which are nonspecific but may represent a
mild to moderate chronic microvascular ischemic changes. He denied any new changes, His EEG from 12/1/17 normal
He received IV Rocephin last time
Hospital follow up. this is a follow up evaluation for Mr.Garofolo, for post concussive symptoms, headaches, behavioral
problems, seizure.
He was admitted to Vassar hospital on 11/9/ 17 with worst headaches of the life and lethargy., He was treated with IV
Recephin, He was noted to have some behavioral symptoms with agitation but
currently denies any symptoms , He
received cognitive therapy by Dr2elek,
He is a 61-year-old man referred by Dr. Diminica, for severe facial trauma, concussion seizure that occurred at Mahoney's
pub when he was assaulted on 11/22/2014.
Review of Systems
System Neg/Pos Details
Constitutional Negative Fatigue. Fever, Malaise, Night sweats, Weight gain and Weight loss.
GAROFOLO, KENNETH W. 0000031380S6 01/23/1960 07/07/2021 09:15 AM 1/5
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
Respiratory Negative Cough and Dyspnea.
Cardio Negative Chest pain Claudication,Edema and irregular heartbeat/palpitations.
GI Negative Blood in stool, Decreased appetite, Diarrhea, Heartburn Nausea and
Vomiting.
GU Negative Dysuria, Polyuria (Genitourinary) and Urinary incontinence.
Endocrine Negative Cold intolerance.
Neuro Positive Galt disturbance, Memory impairment.
Neuro Negative Dizziness, Headache, seizures and Trernors.
Psych Negative Insomnia.
Integumentary Negative Change in shape/sizeof mole(s), Hair loss, Pruritus and Skin lesion.
MS Negative Back pain and Musde weakness.
Hema/Lymph Negative Easy bleeding, Easy bruising and Lymphadenopathy.
Allergic/immuno Negative Contact allergy and Food allergies.
Problem List
Problem Description Onset Date Chronic
Concussion 12/23/2014 N
Hypertriglyceridemia 04/22/2013 N
Seizure disorder 12/02/2014 N
Chest pain 04/01/2013 N
Belts palsy 04/01/2013 N
Dyspnea 04/01/2013 N
Patent foramen ovale 04/22/2013 N
Hypertensive disorder N
TBI (traumatic brain injuty) 03/O3/2015
Cervical radiculopathy 03/03/2015
Past Medical/5urgical History (Detailed)
Disease/disorder Onset Date Management Date Comments
Osteopenia 02/2020
Prostate Gleason to begin hormonal tx 12/24/2019
(4+5=9) and then XRT
Tubular adenoma of re-colon 7-2024 07/25/2019
colon
C diff gastrointestinal SNA 03/03/2015 -
tract infection
Hypertension
Head trauma SNA 03/03/2015 -
TBI
Depression
Seizure disorder
CONTUSION OF
ORBITAL TISSUES
(ICD-921 2)
A&P #1: s/p trauma
11.22.14
pt on oral ab×
GAROFOLO, l(ENNETH W. 000003138056 01/23/1960 07/07/2021 09:15 AM 2/5
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
multiple fxs to sphenoid
as well as nondisplaced
fx of forbiral floor on left
no evidence of
enophthalmos, muscle
entrapement clinically
pt to see plastric sr for
Family History (Detailed)
Relationship Name Deceased Age/Death Condition Onset Age COD
Father Unknown N
Mother Hypertension N
Mother Alzheimer's disease N
Allergies
Ingredient Reaction (Severity) Medication Comment
Name
CODEINE (moderate)
HYDROMORPHONE Dilaudid
HCL
Reviewed. no changes.
Medicatiorts:
MEDICATON RECONCILIATION:
Medications reconciled today.
Medication Name Sig Start Date
abiraterone 250 mg tablet take 1 tablet by oral route every day with water 01/18/2021
on an empty stomach at least 1 hour before or
2 hours afterfood
LEVETlRACETAM 500 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 04/13/2021
Lipitor 10 mg tablet take 1 by oral route every bedtime 02/02/2021
Lupron Depot 22.5 mg (3 month) intramuscular inject (22.5MG) by Intramuscular route
every 3 01/24/2021
syringe kit months
Norvase 2.5 mg tablet take 1 tablet by oral route every day 02/17/2021
Prolia 60 mg/mL subcutaneous syringe inject 1 milliliter by subcutaneous route every 6 01/24/2021
months in the upper arm, upper thigh or
abdomen
PROPRANOLOL 20 MG TABLET TAKE 1 TABLET BY MOUTH EVERY DAY 04/13/2021
sildenafil 100 mg tablet take 1 tablet by oral route every day as needed 05/21/2021
approximately 1 hour before sexual activity
TOPIRAMATE 100 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 05/03/2021
valsartan 320 mg tablet take 1 tablet by oral route every day 02/17/2021
Social History: (Detailed)
Tobacco use reviewed.
Preferred language is English.
MARITAL STATUS/FAMILY/SOCIAL SUPPORT
GAROFOLO, KENNETH W. 00000313805601/23/1960 07/07/2021 09·15 AM 3/5
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
Marital status: Legally Separated
Tobacco use status: Ex-user of moist powdered tobacco.
Smoking status: Former smoker.
VAPING USE
Screened for vaping? Yes
Status: Not a current user
TOSACCONAPING EXPOSURE
No passive vaping exposure.
There is passive smoke exposure.
The patient has not had exposure to second hand smoke in the home environment.
Vital Signs
Time BP Pulse Resp Temp F @ttft Ht in Mt cm Wt Ib Wt kg BMI BSA m2 O2
mm/Hg /min /min kg/m2 Sat%
9:10 136/78 88 18 5.0 8.00 172.72 218.00 98.883 33.15
AM
Time Measured by
9:10 AM Kathleen Dragos
PE Summary:
General
Well developed, well nourished in no acute distress
HEENT: Normocephalic, eyes normal, no ptosis
Nede normal, no soft tissue swelling or lymphadenopathy
Heart : S152
Lungs : Clear to auscultation
Extremities: no cyanosis, clubbing or edema
Skin: normal, no rash
Psych: Mood normal, no depression
Neuro: MS: Alert awake, oriented to place and time. Attention normat speech - otherthan some pauses, his speech is
normal.
CN: It to XII intact. Pupils equal, reactive to light. Facial sensation normal Normal facial muscle strength. Bilateral
hearing
normal . Tongue in midline. palate elevated normally.
Motor exam: Normal tone , bulk and strength 5/5 proximal and distal in bilateral upper and lower
extremities. DTR Brisk
right sMe serebellar: absence of any dysmetria on finger to nose.
Sensonf Grossly intact to all modalities. Gait : Mild
unsteady gait
Assessment/Plan
# Detail Type Description
1, Assessment Postconcussional syndrome (F07.81}_
Plan Orders CBC - AUTO + AUTO DIFF. to be performed., COMPREHENSIVE METABOLIC PANEL, to be
performed., FOLATE. to be performect, KEPPRA (LEVETIRACETAM) to be performed., LYME
TITER W.REFLEX - WESTERN BLOT. to be perfortned., LYME, WESTERN BLOT, SERUM. to be
performed., T4 TOTAL. to be performed., TOPAMAX (TOPIRAMATE) to be performed. and
GAROFOLO, KENNETH W. 000003138086 01/23/1960 07/07/2021 09:15 AM 4/5
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
TSH, ULTRASENSITIVE. to be performed.
2. Assessment Seizure after head injury (R56.1).
Patient Plan He denied any further seizures. He will continue Keppra at the current dosage. We will
also continue his Topamax for headaches that also has a seizure medications. Since he is
undergoing therapy for his prostate cancer we deferred changing any of his medicatiors.
3. Assessment Traumatic brain injury with loss of consciousness, sequela (S06.9x95).
Patient Plan He reported that his cognition and cognitive skills also improved
I told him to continue doing mental exercises such as puzzles etc. and also physical
exercises. He was getting physical training before. He now started driving. He will come
back for a follow-up evaluation in 3 months we will order labs to include Keppra and
Topamax level CBC CMP,
Shaheda N. Azher MD
CareMount Medical
30 Columbia Street
Poughkeepsie, NY 12601-3906
Phone: (845) 231-5600
Fax: (914) 816-2672
Document generated by: Shaheda N. Azher 07/07/2021 08:31 PM
Electronically signed by Shaheda N. Azher MD on 07/07/2021 08:31 PM
GAROFOLO, KENNETH W. 000003138056 01/23/1960 07/07/2021 09·15 AM 5/5
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
CARE
MEDICAL
VISIT SUMMARY
Thank you for choosing us for your healthcare needs. The following Is a summary of the outcome of today's visit and
other instructions and information we hope you find helpful.
Future Appointment Date:
Appointment Date Event Location Provider/Location
07/23/2021 2:00PM OTTo Virtual Visit Telehealth Grimaldi MD, Thomas
01/07/2022 10:30AM office Visit MH Columbia Poughkeepsie Azher MD, Shaheda N
office
Primany Care PMvider: Geninger, Michael
Reason(s) for Visit:
Follow Up of TBL Follow Up of seizure, Follow Up of gait issues.
Assessment/Plam
# Detail Type Description
L Assessment Postconcussional syndrome (F07,81),
2. Assessment Seizure after head injury (R56,1).
Patient Plan He denied any further seizures. He will continue Keppra at the current dosage. We will
also continue his Topamax for headaches that also has a seizure medrations. Since he is
undergoing therapy for his prostate cancer we deferred changing any of his medications.
3. Assessment Traumatic brain injury with loss of consciousness, sequela (S06.9x95).
Patient Plan He reported that his cognition and cognitive skills also improved
I told him to continue doing mental exercises such as puzzles etc. and also physical
exercises. He was getting physical training before. He now started driving. He will come
back for a follow-up evaluation in 3 months we will order labs to include Keppra and
Topamax level CBC CMP.
Medications:
Medication Name Sig Start Date
abiraterone 250 mg tablet take 1 tablet by oral route every day with water 01/18/2021
on an empty stomach at least 1 hour before or
2 hours afterfood
GAROFOLO, KENNETH W. 000003138056 01/23/196007/07/2021 09:15 AM Page: 1/3
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
LEVET1RACETAM 500 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 04/13/2021
Lipitor 10 mg tablet take 1 by oral route every bedtime 02/02/2021
Lupron Depot 22,5 mg (3 month) intramuscular inject (22,SMG) by intramuscular route
every 3 01/24/2021
syringe kit months
Norvasc 2.5 mg tablet take 1 tablet by oral route every day 02/17/2021
Prolia 60 mg/mL subcutaneous syringe inject 1 milliliter by subcutaneous route every 6 01/24/2021
months in the upper arm, upper thigh or
abdomen
PROPRANOLOL 20 MG TABLET TAKE 1 TABLET BY MOUTH EVERY DAY 04/13/2021
slidenafil 100 mg tablet take 1 tablet by oral route evety day as needed 05/21/2021
approximately 1 hour before sexual
activity
TOPIRAMATE 100 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 05/03/2021
valsartan 320 mg tablet take 1 tablet by oral route 02/17/2021
every day
Vital Signs:
Date BP Pulse Resp Temp Height Weight Ounces BMI
07/07/2021 138/78 88 18 68.00 218.00 33.15
01/18/2021 136/88 68 68.00 218.00 33.15
11/30/2020 121/66 78 16 68.00 220.00 33.45
08/10/2020 108/60 64 16 96.8 68.00 221.00 33.60
FOLLOW UP
To Be Sciteduled/Oniered;
Order Assessment Timeframe Appointment interpretation
COMPREHENSlVE Postconcussional
METABOLIC PANEL syndrome
CBC - AUTO + AUTO Postconcussional
DIFF. syndrome
LYME TITER W.REFLEX - Postooncussional
WESTERN BLOT. syndrome
LYME, WESTERN BLOT, Postconcussional
SERUM. syndrome
KEPPRA Postconcussional
(LEVETERACETAM) syndrome
TOPAMAX Postconcussional
(TOPIRAMATE) syndrome
FOLATE. Postconcussional
syndrome
T4 TOTAL Postconcussional
syndrome
TSH, ULTRASENSITIVE. Postconcussional
syndrome
other Health information:
5moking status: Former smoker.
VAPING USE
Screened for vaping? Yes
Status: Not a current user
TOBACCO/VAPING EXPOSURE
GAROFOLO, KENNETH W. 000003138056 01/23/1960 07/07/2021 09:15 AM Page 2/3
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
No passive vaping exposure.
There 15passive smoke exposure.
The patient has not had exposure to second hand smoke in the home environment
Allergies:
Ingredient Reaction Medication Name Comment
(Severity)
CODEINE (moderate)
HYDROMORPHONE HCL Dilaudld
Problem Ust
Problem Description Onset Date Chronic
Concussion 12/23/2014 N
Hypertriglyceridemia 04/22/2013 N
Seizure disorder 12/02/2014 N
Chest pain 04/01/2013 N
Belis palsy 04/01/2013 N
Dyspnea 04/01/2013 N
Patent foremen ovale 04/22/2013 N
Hypertensive disorder N
TBI (traumatic brain injury) 03/03/2015
Cervical radiculopathy 03/03/2015
Demographics:
Ser Male
Race: White
Ethnicity-
Non-Hispanic
Preferred Language: English
sincerely,
Provider: Shaheda N. Asher MD07/07/2021 08:31 PM
CareMount Medical
30 Columbia Street
Poughkeepsie, NY 12601-3906
Phone: (845) 231-5600
Far (914) 816-2672
Document generated by Shaheda N. Azher on 07/07/2021
GAROFOLO, KENNETH W. 000003138056 01/23/1960 07/07/2021 09:15 AM Page: 3/3
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
ARE
M E D I C A L
Patient: KENNETH GAROFOLO
Date of Birth:
Date: 11/30/2020 2:00 PM
Historian: self
Visit Type: Office Visit
This 60 year old male presents for recent dx Prostrate CA and follow up of TBt.
History of Present Illness:
1. recent dx Prostrate CA
2, Follow Up of TBI
HPI Summary:
CCfollow up on TRI
Interval history: Since last visit he moved to Manhattan to live with his daughter. He said now she is divorced from his
wife. He also reported that his wife always tends to show as if he is more <»nfused or sedated. He reported
now more
walidng and also getting physical exer cises daily he now works with a personal trainer. He said he is more alert and his gait
is improving.
HPi: Follow up on postconcussive symptoms. headaches. Meningitis.
1also obtained history on a telephonic conversation with his daughter.
His daughter reported that he is not agitated and does not exhibit any behavioral symptoms
his MRI brain showed Multiple stable foci of white matter T2 hyperintensity, which are nonspecific but
may represent a
mild to moderate chronic microvascular ischemic changes. He denied any new changes, His EEG from 12/1/17 normal
He received IV Rocephin last time
Hospital follow up. this is a follow up evaluation for Mr.Garofolo, for post concussive symptoms, behavioral
headaches,
problems, seizure.
He was admitted to Vassar hospital on 11/9/ 17 with worst headaches of the life and lethargy.
, He was treated with IV Rocephin. Medication remnciliation they denied any seizures previously he would have a
behavioral symptoms with agitation etc.
es He is a 56-year-old man refered by Dr. Diminico, for severe facial trauma, concussion seizure that occurred at
Mahoney's pub when he was assaulted on 11/22/2014.
He received cognitive therapy by Dr.Zelek.
Review of Systems
System Neg/Pos Details
Constitutional Positive Fatigue.
Constitutional Negative Fever, Malaise, Night sweats, Weight gain and Weight loss.
GAROFOLO, KENNETH W. 000003138056 01/23/1960 11/30/2020 02-00 PM 1/5
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
Respiratory Negative Cough and Dyspnea.
Cardio Negative Chest pain, Claudication, Edema and Irregular heartbeat/palpitations,
GI Negative Blood in stool, Decreased appetite, Diarrhea, Heartbum, Nausea and
Vomiting.
GU Negative Dysuria, Polyuria (Genitourinary) and Urinary incontinence.
Endocrine Negative Cold intolerance.
Neuro Positive Gait disturbance.
Neuro Negative Dizziness, Headache, Memory impairment, Seizures and Tremort
Psych Negative insomnia.
Integumentary Negative Change in shape/size of mole(s), Hair loss, Pruritus and Skin lesion.
MS Negative Back pain and Musde weakness.
Hema/Lymph Negative Easy bleeding, Easy bruising and Lymphadenopathy.
Allergic/lmmuno Negative Contact allergy and Foodallergies.
Problem List
Problem Description Onset Date Chronic
Concussion 12/23/2014 N
Hypertriglyceridemia 04/22/2013 N
Seizure disorder 12/02/2014 N
Chest pain 04/01/2013 N
Bel's palsy 04/01/2013 N
Dyspnea 04/01/2013 N
Patent foramen ovale
04/22/2013 N
Hypertensive disorder N
TBI (traumatic brain injury) 03/03/2015
Cervical radiculopathy 03/03/2015
Past Medical/Sumical History (Detailed)
Disease/disorder Onset Date Management Date Comments
Osteopenia 02/2020
Prostate Gleason to begin hormonal tx 12/24/2019
(4+5=9) and then XRT
Tubular adenoma of re-colon 7-2024 07/25/2019
colon
C diff gastrointestinal SNA 03/03/2015 -
tract infection
Hypertension
Head trauma SNA 03/03/2015 -
TBf
Depression
Seizure disorder
CONTUSON OF
ORBITAL TISSUES
(ICD-921,2)
A&P #1: s/p trauma
11.22.14
pt on oral abx
GAROFOLO, KENNETH W. 000003138056 01/23/1960 11/30/202002:00 PM 2/5
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023
multiple fxs to sphenoid
as well as nondisplaced
fx of forbiral floor on left
no evidence of
enophthalmos, muscle
entrapement clinically
pt to see plasttic sr for
History'
Family (Detailed)
Relationship Name Deceased Age/Death Condition Onset Age COD
Father Unknown N
Mother Hypertension N
Mother Alzheimers disease N
Allergies
Ingredient Reaction (Severity) Medication Name Comment
CODEINE (moderate)
HYDROMORPHONE Dilaudid
HCL
Reviewed, no changes.
Medications:
MEDICATION RECONCILIATION:
Medications reconciled today.
Medication Name Sig Start Date
Keppra 500 mg tablet TAKE 1 TABLET BY MOUTH TWICE A DAY 05/28/2020
Lipitor 10 mg tablet take 1 by oral route every bedtime 11/06/2020
Nexium 40 mg capsule,delayed release take 1 capsule by oral route even) day 10/17/2019
Norvasc 2.5 mg tablet take 1 tablet by oral route every day
prednisone 5 mg tablet take 1 tablet by oral route every day
PROPRANOLOL 20 MG TABLET TAKE 1 TABLET BY MOUTH EVERY DAY 09/20/2020
SERTRALINE HCL 100 MG TABLET TAKE 1 ABLET BY MOUTH TWICE A DAY 10/07/2020
TOPIRAMATE 100 MG TABLET TAKE t TA
Preview
FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 "3" Exhibit FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 CARE ME DICAL 07/18/2021 KENNETH GAROFOLO 57 Cannon St Unit 601 Poughkeepsie, NY 12601- Dear Mr. GAROFOLO, RE: LAS RESULi5 It was a pleasure seeing you in our office. I have reviewed your results. Alf your labs came back normal, except for anemia. We will discuss your results again in your follow up evaluation. if you have any questions please call our office. CBC - AUTO + AUTO DIFF. 07/07/2021 09:30 Flag Result Range Component Units 5.6 44-11.1 WBC K/ul L 3.91 4A0-630 RBC M/ul L 13.0 14.0-18.0 HEMOGLOBIN GM/DL L 39.5 41.0-51.0 HEMATOCRIT % H 101.0 80.0-96.0 MCV FL H 33.2 26.0-32D MCH PG 32.9 B2.0-369 MCHC G/DL 13.5 11.5-14.5 RDW % 262 140-450 PLATELET COUNT K/ul 10.4 9.4-12.4 MPV FL 72.4 30.0-75.0 NEUTROPHKS % 15.2 10.0-50.0 LYMPHOCYTES % 9.7 4.0-13.0 MONOCYTES % 1.8 0.0-6.0 EOSINOPHILS % 0.5 0.0-2.0 BASOPHILS % 4.05 1.8-7.0 ABS. NEUTROPHILS K/ul L 0.85 1.0-4.8 ABS. LYMPHOCYTES K/ul 0.54 0.0-0.8 ABS. MONOCYTES K/ul 0.10 0.0-0.5 ABS- EOSINOPHILS K/ul 0.03 0.0-0.2 ABS. BASOPHILS K/ul 0.02 D.00-035 ABS. IG K/ul 0.4 0.0-5.0 IG % GAROFOLO, KENNETH W 000003138056 01/23/196007/18/2021 10:55 AM Page: 1/3 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 COMPREHENSlVE METABOLIC PANEL 07/07/2021 09:30 Flag Result Range Component Units 139 135-145 SODIUM MMOL/L 3.9 3.5-5.5 POTASSIUM MMOUL 107 95-108 CHLORIDE MMOL/L 22 22-32 CO2 MMOUL H 101 60-99 GLUCOSE MG/DL 9.4 8.5-10.5 CALCluM MG/OL 17 8-22 UREA NITROGEN MG/DL 1-1 0.5-1,5 CREATININE, SERUM MG/DL 72.1 60-120 eGFR /1.73m2 mL/min 6.7 6.0-8,5 TOTAL PROTEIN G/DL 4.3 3,5-5.0 ALSUMIN G/DL 2.4 1.5-4.5 GLOSULIN G/DL 0.3 0.2-1.3 TOTAL BILIRUSIN MG/DL 24 5-50 SGOf (AST) U/L 21 <50 U/L SGPT (ALT) U/L 54 35-125 ALKALINE PHOSPHATASE U/L FOLATE. 07/07/2021 09:30 Flag Result Range Component Units 18.3 2.8->20 FOLATE ng/mL KEPPRA (LEVETIRACETAM) 07/07/2021 09:30 Flag Result Range Component Units 17,2 12.0-46.0 LEVETIRACETAM mcg/mL LYME TITER W.REFLEX-WB 07/07/2021 09 30 Flag Result Range Component Units 0.05 0.00-0.89 LYME AB Negative LYME INTERPRETATION LYME, WESTERN BLOT, SERUM. 07/07/2021 09:30 Flag Result Range Component Units NON-REAC 18 KO (IGG) BAND TIVE NON-REAC 23 KD (IGG) BAND TIVE NON-REAC 28 KD (IGG) BAND TIVE NON-REAC 30 KD (IGG) BAND TIVE NON-REAC 39 KD (IGG) BAND TIVE NON-REAC 41 KD (IGG) BAND TIVE NON-REAC 45 KD (IGG) BAND TIVE NON-REAC 58 KD (IGG) BAND TIVE NON-REAC 66 KO (IGG) BAND TIVE NON-REAC 93 KD (IGG) BAND TIVE NON-REAC 39 KD (IGM) BAND TIVE NON-REAC 23 KD (IGM) BAND GAROFOLO, KENNETH W. 000003138056 01/23/196007/18/2021 10:55 AM Page: 2/3 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 TIVE NON-REAC 41 KD (IGM) SAND TIVE NEGATIVE NEGATIVE LYME DISEASE AB(IGG),BLOT NEGATIVE NEGATIVE LYM E DISEASE AB(IGM),BLOT T4 TOTAL, 07/07/2021 09:30 Flag Result Range Component Units 7.9 5.53-11.0 TOTAL T4 uG/DL TOPAMAX (TOPIRAMATE) 07/07/2021 09-30 Flag Result Range Component Units 6.4 see note TOPIRAMATE mcg/mL TSH, ULTRASENSITIVE 07/07/202109:30 Flag Result Range Component Units 2.22 0.474,7 TSH ulU/ML Sincere7 Shaheda N. Azher MD Document generated by: Shaheda N. Azher 07/18/2021 CareMount Medical 90 South Bedford Road Mount Kisco, NY 10549-3412 Phone: (845) 231-5600 Far (914) 816-2672 Electronically signed by Shaheda N. Azher MD on 07/18/2021 10:57 AM GAROFOLO, KENNETH W 000003138056 01/23/1960 07/18/2021 10:55 AM Page: 3/3 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 ARE M E D I C A L Patient: KENNETH GAROFOLO Date of Birth: Date: 07/07/2021 9:15 AM Historian: self Visit Type: Office Visit This 61 year old male presents for follow up of TBI, follow up of seizure and follow up of gait issues, History of Present IIIness 1. Follow Up of TBI 2. Follow Up of seizure 3, Follow Up of gait issues HPI Summary: CC: Follow up on TBI. He was diagnosed with prostate cancer a year ago and currently following urologist. Last time he moved to Manhattan to live with bis daughter. But now he said his back and is staying in an apartment here dose to his brothers etc. He also got his license back and driving. He continues to have some gait imbalance but otherwise reported doing very well He also complaining numbness in his both hands but mostly in the dorsum aspect. He said now she is divorced from his wife. He mported now more walking and also getting physical exercises daily he now works with a personal trainer, He said he is more alert and his gait is improving. Please see my prior notes for details. HPI: Follow up on postconcussive symptoms, headaches, Meningitis. his MRI brain showed Multiple stable foci of white matter T2 hyperintensity, which are nonspecific but may represent a mild to moderate chronic microvascular ischemic changes. He denied any new changes, His EEG from 12/1/17 normal He received IV Rocephin last time Hospital follow up. this is a follow up evaluation for Mr.Garofolo, for post concussive symptoms, headaches, behavioral problems, seizure. He was admitted to Vassar hospital on 11/9/ 17 with worst headaches of the life and lethargy., He was treated with IV Recephin, He was noted to have some behavioral symptoms with agitation but currently denies any symptoms , He received cognitive therapy by Dr2elek, He is a 61-year-old man referred by Dr. Diminica, for severe facial trauma, concussion seizure that occurred at Mahoney's pub when he was assaulted on 11/22/2014. Review of Systems System Neg/Pos Details Constitutional Negative Fatigue. Fever, Malaise, Night sweats, Weight gain and Weight loss. GAROFOLO, KENNETH W. 0000031380S6 01/23/1960 07/07/2021 09:15 AM 1/5 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 Respiratory Negative Cough and Dyspnea. Cardio Negative Chest pain Claudication,Edema and irregular heartbeat/palpitations. GI Negative Blood in stool, Decreased appetite, Diarrhea, Heartburn Nausea and Vomiting. GU Negative Dysuria, Polyuria (Genitourinary) and Urinary incontinence. Endocrine Negative Cold intolerance. Neuro Positive Galt disturbance, Memory impairment. Neuro Negative Dizziness, Headache, seizures and Trernors. Psych Negative Insomnia. Integumentary Negative Change in shape/sizeof mole(s), Hair loss, Pruritus and Skin lesion. MS Negative Back pain and Musde weakness. Hema/Lymph Negative Easy bleeding, Easy bruising and Lymphadenopathy. Allergic/immuno Negative Contact allergy and Food allergies. Problem List Problem Description Onset Date Chronic Concussion 12/23/2014 N Hypertriglyceridemia 04/22/2013 N Seizure disorder 12/02/2014 N Chest pain 04/01/2013 N Belts palsy 04/01/2013 N Dyspnea 04/01/2013 N Patent foramen ovale 04/22/2013 N Hypertensive disorder N TBI (traumatic brain injuty) 03/O3/2015 Cervical radiculopathy 03/03/2015 Past Medical/5urgical History (Detailed) Disease/disorder Onset Date Management Date Comments Osteopenia 02/2020 Prostate Gleason to begin hormonal tx 12/24/2019 (4+5=9) and then XRT Tubular adenoma of re-colon 7-2024 07/25/2019 colon C diff gastrointestinal SNA 03/03/2015 - tract infection Hypertension Head trauma SNA 03/03/2015 - TBI Depression Seizure disorder CONTUSION OF ORBITAL TISSUES (ICD-921 2) A&P #1: s/p trauma 11.22.14 pt on oral ab× GAROFOLO, l(ENNETH W. 000003138056 01/23/1960 07/07/2021 09:15 AM 2/5 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 multiple fxs to sphenoid as well as nondisplaced fx of forbiral floor on left no evidence of enophthalmos, muscle entrapement clinically pt to see plastric sr for Family History (Detailed) Relationship Name Deceased Age/Death Condition Onset Age COD Father Unknown N Mother Hypertension N Mother Alzheimer's disease N Allergies Ingredient Reaction (Severity) Medication Comment Name CODEINE (moderate) HYDROMORPHONE Dilaudid HCL Reviewed. no changes. Medicatiorts: MEDICATON RECONCILIATION: Medications reconciled today. Medication Name Sig Start Date abiraterone 250 mg tablet take 1 tablet by oral route every day with water 01/18/2021 on an empty stomach at least 1 hour before or 2 hours afterfood LEVETlRACETAM 500 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 04/13/2021 Lipitor 10 mg tablet take 1 by oral route every bedtime 02/02/2021 Lupron Depot 22.5 mg (3 month) intramuscular inject (22.5MG) by Intramuscular route every 3 01/24/2021 syringe kit months Norvase 2.5 mg tablet take 1 tablet by oral route every day 02/17/2021 Prolia 60 mg/mL subcutaneous syringe inject 1 milliliter by subcutaneous route every 6 01/24/2021 months in the upper arm, upper thigh or abdomen PROPRANOLOL 20 MG TABLET TAKE 1 TABLET BY MOUTH EVERY DAY 04/13/2021 sildenafil 100 mg tablet take 1 tablet by oral route every day as needed 05/21/2021 approximately 1 hour before sexual activity TOPIRAMATE 100 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 05/03/2021 valsartan 320 mg tablet take 1 tablet by oral route every day 02/17/2021 Social History: (Detailed) Tobacco use reviewed. Preferred language is English. MARITAL STATUS/FAMILY/SOCIAL SUPPORT GAROFOLO, KENNETH W. 00000313805601/23/1960 07/07/2021 09·15 AM 3/5 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 Marital status: Legally Separated Tobacco use status: Ex-user of moist powdered tobacco. Smoking status: Former smoker. VAPING USE Screened for vaping? Yes Status: Not a current user TOSACCONAPING EXPOSURE No passive vaping exposure. There is passive smoke exposure. The patient has not had exposure to second hand smoke in the home environment. Vital Signs Time BP Pulse Resp Temp F @ttft Ht in Mt cm Wt Ib Wt kg BMI BSA m2 O2 mm/Hg /min /min kg/m2 Sat% 9:10 136/78 88 18 5.0 8.00 172.72 218.00 98.883 33.15 AM Time Measured by 9:10 AM Kathleen Dragos PE Summary: General Well developed, well nourished in no acute distress HEENT: Normocephalic, eyes normal, no ptosis Nede normal, no soft tissue swelling or lymphadenopathy Heart : S152 Lungs : Clear to auscultation Extremities: no cyanosis, clubbing or edema Skin: normal, no rash Psych: Mood normal, no depression Neuro: MS: Alert awake, oriented to place and time. Attention normat speech - otherthan some pauses, his speech is normal. CN: It to XII intact. Pupils equal, reactive to light. Facial sensation normal Normal facial muscle strength. Bilateral hearing normal . Tongue in midline. palate elevated normally. Motor exam: Normal tone , bulk and strength 5/5 proximal and distal in bilateral upper and lower extremities. DTR Brisk right sMe serebellar: absence of any dysmetria on finger to nose. Sensonf Grossly intact to all modalities. Gait : Mild unsteady gait Assessment/Plan # Detail Type Description 1, Assessment Postconcussional syndrome (F07.81}_ Plan Orders CBC - AUTO + AUTO DIFF. to be performed., COMPREHENSIVE METABOLIC PANEL, to be performed., FOLATE. to be performect, KEPPRA (LEVETIRACETAM) to be performed., LYME TITER W.REFLEX - WESTERN BLOT. to be perfortned., LYME, WESTERN BLOT, SERUM. to be performed., T4 TOTAL. to be performed., TOPAMAX (TOPIRAMATE) to be performed. and GAROFOLO, KENNETH W. 000003138086 01/23/1960 07/07/2021 09:15 AM 4/5 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 TSH, ULTRASENSITIVE. to be performed. 2. Assessment Seizure after head injury (R56.1). Patient Plan He denied any further seizures. He will continue Keppra at the current dosage. We will also continue his Topamax for headaches that also has a seizure medications. Since he is undergoing therapy for his prostate cancer we deferred changing any of his medicatiors. 3. Assessment Traumatic brain injury with loss of consciousness, sequela (S06.9x95). Patient Plan He reported that his cognition and cognitive skills also improved I told him to continue doing mental exercises such as puzzles etc. and also physical exercises. He was getting physical training before. He now started driving. He will come back for a follow-up evaluation in 3 months we will order labs to include Keppra and Topamax level CBC CMP, Shaheda N. Azher MD CareMount Medical 30 Columbia Street Poughkeepsie, NY 12601-3906 Phone: (845) 231-5600 Fax: (914) 816-2672 Document generated by: Shaheda N. Azher 07/07/2021 08:31 PM Electronically signed by Shaheda N. Azher MD on 07/07/2021 08:31 PM GAROFOLO, KENNETH W. 000003138056 01/23/1960 07/07/2021 09·15 AM 5/5 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 CARE MEDICAL VISIT SUMMARY Thank you for choosing us for your healthcare needs. The following Is a summary of the outcome of today's visit and other instructions and information we hope you find helpful. Future Appointment Date: Appointment Date Event Location Provider/Location 07/23/2021 2:00PM OTTo Virtual Visit Telehealth Grimaldi MD, Thomas 01/07/2022 10:30AM office Visit MH Columbia Poughkeepsie Azher MD, Shaheda N office Primany Care PMvider: Geninger, Michael Reason(s) for Visit: Follow Up of TBL Follow Up of seizure, Follow Up of gait issues. Assessment/Plam # Detail Type Description L Assessment Postconcussional syndrome (F07,81), 2. Assessment Seizure after head injury (R56,1). Patient Plan He denied any further seizures. He will continue Keppra at the current dosage. We will also continue his Topamax for headaches that also has a seizure medrations. Since he is undergoing therapy for his prostate cancer we deferred changing any of his medications. 3. Assessment Traumatic brain injury with loss of consciousness, sequela (S06.9x95). Patient Plan He reported that his cognition and cognitive skills also improved I told him to continue doing mental exercises such as puzzles etc. and also physical exercises. He was getting physical training before. He now started driving. He will come back for a follow-up evaluation in 3 months we will order labs to include Keppra and Topamax level CBC CMP. Medications: Medication Name Sig Start Date abiraterone 250 mg tablet take 1 tablet by oral route every day with water 01/18/2021 on an empty stomach at least 1 hour before or 2 hours afterfood GAROFOLO, KENNETH W. 000003138056 01/23/196007/07/2021 09:15 AM Page: 1/3 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 LEVET1RACETAM 500 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 04/13/2021 Lipitor 10 mg tablet take 1 by oral route every bedtime 02/02/2021 Lupron Depot 22,5 mg (3 month) intramuscular inject (22,SMG) by intramuscular route every 3 01/24/2021 syringe kit months Norvasc 2.5 mg tablet take 1 tablet by oral route every day 02/17/2021 Prolia 60 mg/mL subcutaneous syringe inject 1 milliliter by subcutaneous route every 6 01/24/2021 months in the upper arm, upper thigh or abdomen PROPRANOLOL 20 MG TABLET TAKE 1 TABLET BY MOUTH EVERY DAY 04/13/2021 slidenafil 100 mg tablet take 1 tablet by oral route evety day as needed 05/21/2021 approximately 1 hour before sexual activity TOPIRAMATE 100 MG TABLET TAKE 1 TABLET BY MOUTH TWICE A DAY 05/03/2021 valsartan 320 mg tablet take 1 tablet by oral route 02/17/2021 every day Vital Signs: Date BP Pulse Resp Temp Height Weight Ounces BMI 07/07/2021 138/78 88 18 68.00 218.00 33.15 01/18/2021 136/88 68 68.00 218.00 33.15 11/30/2020 121/66 78 16 68.00 220.00 33.45 08/10/2020 108/60 64 16 96.8 68.00 221.00 33.60 FOLLOW UP To Be Sciteduled/Oniered; Order Assessment Timeframe Appointment interpretation COMPREHENSlVE Postconcussional METABOLIC PANEL syndrome CBC - AUTO + AUTO Postconcussional DIFF. syndrome LYME TITER W.REFLEX - Postooncussional WESTERN BLOT. syndrome LYME, WESTERN BLOT, Postconcussional SERUM. syndrome KEPPRA Postconcussional (LEVETERACETAM) syndrome TOPAMAX Postconcussional (TOPIRAMATE) syndrome FOLATE. Postconcussional syndrome T4 TOTAL Postconcussional syndrome TSH, ULTRASENSITIVE. Postconcussional syndrome other Health information: 5moking status: Former smoker. VAPING USE Screened for vaping? Yes Status: Not a current user TOBACCO/VAPING EXPOSURE GAROFOLO, KENNETH W. 000003138056 01/23/1960 07/07/2021 09:15 AM Page 2/3 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 No passive vaping exposure. There 15passive smoke exposure. The patient has not had exposure to second hand smoke in the home environment Allergies: Ingredient Reaction Medication Name Comment (Severity) CODEINE (moderate) HYDROMORPHONE HCL Dilaudld Problem Ust Problem Description Onset Date Chronic Concussion 12/23/2014 N Hypertriglyceridemia 04/22/2013 N Seizure disorder 12/02/2014 N Chest pain 04/01/2013 N Belis palsy 04/01/2013 N Dyspnea 04/01/2013 N Patent foremen ovale 04/22/2013 N Hypertensive disorder N TBI (traumatic brain injury) 03/03/2015 Cervical radiculopathy 03/03/2015 Demographics: Ser Male Race: White Ethnicity- Non-Hispanic Preferred Language: English sincerely, Provider: Shaheda N. Asher MD07/07/2021 08:31 PM CareMount Medical 30 Columbia Street Poughkeepsie, NY 12601-3906 Phone: (845) 231-5600 Far (914) 816-2672 Document generated by Shaheda N. Azher on 07/07/2021 GAROFOLO, KENNETH W. 000003138056 01/23/1960 07/07/2021 09:15 AM Page: 3/3 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 ARE M E D I C A L Patient: KENNETH GAROFOLO Date of Birth: Date: 11/30/2020 2:00 PM Historian: self Visit Type: Office Visit This 60 year old male presents for recent dx Prostrate CA and follow up of TBt. History of Present Illness: 1. recent dx Prostrate CA 2, Follow Up of TBI HPI Summary: CCfollow up on TRI Interval history: Since last visit he moved to Manhattan to live with his daughter. He said now she is divorced from his wife. He also reported that his wife always tends to show as if he is more <»nfused or sedated. He reported now more walidng and also getting physical exer cises daily he now works with a personal trainer. He said he is more alert and his gait is improving. HPi: Follow up on postconcussive symptoms. headaches. Meningitis. 1also obtained history on a telephonic conversation with his daughter. His daughter reported that he is not agitated and does not exhibit any behavioral symptoms his MRI brain showed Multiple stable foci of white matter T2 hyperintensity, which are nonspecific but may represent a mild to moderate chronic microvascular ischemic changes. He denied any new changes, His EEG from 12/1/17 normal He received IV Rocephin last time Hospital follow up. this is a follow up evaluation for Mr.Garofolo, for post concussive symptoms, behavioral headaches, problems, seizure. He was admitted to Vassar hospital on 11/9/ 17 with worst headaches of the life and lethargy. , He was treated with IV Rocephin. Medication remnciliation they denied any seizures previously he would have a behavioral symptoms with agitation etc. es He is a 56-year-old man refered by Dr. Diminico, for severe facial trauma, concussion seizure that occurred at Mahoney's pub when he was assaulted on 11/22/2014. He received cognitive therapy by Dr.Zelek. Review of Systems System Neg/Pos Details Constitutional Positive Fatigue. Constitutional Negative Fever, Malaise, Night sweats, Weight gain and Weight loss. GAROFOLO, KENNETH W. 000003138056 01/23/1960 11/30/2020 02-00 PM 1/5 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 Respiratory Negative Cough and Dyspnea. Cardio Negative Chest pain, Claudication, Edema and Irregular heartbeat/palpitations, GI Negative Blood in stool, Decreased appetite, Diarrhea, Heartbum, Nausea and Vomiting. GU Negative Dysuria, Polyuria (Genitourinary) and Urinary incontinence. Endocrine Negative Cold intolerance. Neuro Positive Gait disturbance. Neuro Negative Dizziness, Headache, Memory impairment, Seizures and Tremort Psych Negative insomnia. Integumentary Negative Change in shape/size of mole(s), Hair loss, Pruritus and Skin lesion. MS Negative Back pain and Musde weakness. Hema/Lymph Negative Easy bleeding, Easy bruising and Lymphadenopathy. Allergic/lmmuno Negative Contact allergy and Foodallergies. Problem List Problem Description Onset Date Chronic Concussion 12/23/2014 N Hypertriglyceridemia 04/22/2013 N Seizure disorder 12/02/2014 N Chest pain 04/01/2013 N Bel's palsy 04/01/2013 N Dyspnea 04/01/2013 N Patent foramen ovale 04/22/2013 N Hypertensive disorder N TBI (traumatic brain injury) 03/03/2015 Cervical radiculopathy 03/03/2015 Past Medical/Sumical History (Detailed) Disease/disorder Onset Date Management Date Comments Osteopenia 02/2020 Prostate Gleason to begin hormonal tx 12/24/2019 (4+5=9) and then XRT Tubular adenoma of re-colon 7-2024 07/25/2019 colon C diff gastrointestinal SNA 03/03/2015 - tract infection Hypertension Head trauma SNA 03/03/2015 - TBf Depression Seizure disorder CONTUSON OF ORBITAL TISSUES (ICD-921,2) A&P #1: s/p trauma 11.22.14 pt on oral abx GAROFOLO, KENNETH W. 000003138056 01/23/1960 11/30/202002:00 PM 2/5 FILED: DUTCHESS COUNTY CLERK 12/14/2023 10:47 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 128 RECEIVED NYSCEF: 12/14/2023 multiple fxs to sphenoid as well as nondisplaced fx of forbiral floor on left no evidence of enophthalmos, muscle entrapement clinically pt to see plasttic sr for History' Family (Detailed) Relationship Name Deceased Age/Death Condition Onset Age COD Father Unknown N Mother Hypertension N Mother Alzheimers disease N Allergies Ingredient Reaction (Severity) Medication Name Comment CODEINE (moderate) HYDROMORPHONE Dilaudid HCL Reviewed, no changes. Medications: MEDICATION RECONCILIATION: Medications reconciled today. Medication Name Sig Start Date Keppra 500 mg tablet TAKE 1 TABLET BY MOUTH TWICE A DAY 05/28/2020 Lipitor 10 mg tablet take 1 by oral route every bedtime 11/06/2020 Nexium 40 mg capsule,delayed release take 1 capsule by oral route even) day 10/17/2019 Norvasc 2.5 mg tablet take 1 tablet by oral route every day prednisone 5 mg tablet take 1 tablet by oral route every day PROPRANOLOL 20 MG TABLET TAKE 1 TABLET BY MOUTH EVERY DAY 09/20/2020 SERTRALINE HCL 100 MG TABLET TAKE 1 ABLET BY MOUTH TWICE A DAY 10/07/2020 TOPIRAMATE 100 MG TABLET TAKE t TA