Preview
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
AFTER VISIT SUMMARY ellenle
9/15/2023 - 9/21/2023 Bellevue IP 19S PRISON HEALTH
Kadeem Drummond MRN: 4927779 9
Instructions
After Your Oral & Maxillofacial Surgery:
LIQUID DIET
PAIN: Some degree of pain is normal for all patients after the procedure. Unless contraindicated, we generally
prescribe ibuprofen, tylenol (acetaminophen), or if necessary, a tylenol-narcotic combination drug to control pain.
Please attempt to control pain with ibuprofen or plain tylenol as your first line agent. If additional pain control is
necessary, you may use the narcotic containing drug as needed. Please be aware that narcotics cause drowsiness
and sometimes nausea. Do not attempt to take additional plain tylenol (acetaminophen) if you are currently
taking another medication that already contains tylenol (acetaminophen) so as to avoid overdose.
Applying Ice packs to your face and keeping your head elevated will also be helpful to control the pain and
swelling.
Please also keep in mind that a sore throat is extremely common after general anesthesia; this is from the
breathing tube that was placed down your throat, and this pain should resolve quickly.
Always consult a physician or your surgeon prior to using any additional pain control medications or methods that
were not discussed prior to your discharge.
If you are experiencing Pain that can not be controlled with these methods, please inform your surgeon.
BLEEDING: Slight oozing of blood from ybur surgical sites is normal for the first few hours or so after surgery. For
this you should place gauze directly over the oozing sites, and add pressure to help stop bleeding. In the event of
excessive bleeding that can not be controlled with pressure, Apply a teabag over the site with more gauze and
apply continuous pressure, then proceed to the nearest emergency room and inform your doctor. Remember,
slight bleeding is acceptable, and the saliva in your mouth mixed with a small amount of blood may appear more
drastic than is.
SWELLING: Some swelling is also normal after this surgery. This will peak by about day 3 after surgery and should
gradually resolve on its own. In order to lessen the amount of swelling, please sleep with your head elevated using
pillows and apply ice packs to your face for the first 2-3 days.
CARE OF THE NOSE AND SINUSES:
If you had surgery on your upper jaw (maxilla) it is important to know that the necessary surgical treatments
occurred in the area in close proximity to your nose and sinuses. As such, some degree of swelling and local
changes in the area have occurred. This is why many patients have a complaint of sinus congestion and difficulty
breathing through their nose. This is normal, but it is important to take certain measures to ensure a good
surgical outcome and optimize your own comfort.
For the next 4-6 weeks, you should avoid blowing your nose, sneezing through your nose, or bending over.
" Pr,inted '
Kadeem Drummond (MRN: 49277.79) by Mercedes C at 9/21/2023 3:45 PM Page 1 of 8 4gic
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
Instructions (continued)
Remember, Nasal congestion may create a feeling of not being able to breathe. If this occurs you should stay calm
counter"
and take an "over the decongestant to relive it (nasal sprays or oral medicines as directed by your MD);
taking care to following the instructions on the bottle.
A humidifier and propping yourself up with pillows at night will also facilitate easier breathing.
DIET: For the next 3-7 days you should only be eating food that is soft and cool. Nothing spicy, nothing hot,
nothing crunchy or tough to chew. Your jaws are fragile after surgery, so you do not want to chew tough foods.
Hot and spicy foods can irritate your tissues after surgery and cause unnecessary bleeding
HYGIENE: Beginning tomorrow, you may gently rinse your mouth out with warm water/salt solution. You may
shower normally but avoid excessive steam or hot temperatures, as this can cause lightheadedness in the setting
of medications.
DRESSINGS: If you have any dressings/tapes/bandages applied please make note of the following: The non-
adhesive external gauze or stocking wraps may be removed at your leisure; they were placed to aid in propping
the ice packing for you while you were recovering from anesthesia. The adhesive dressings (steri-strips/tensoplast
tapes) were placed to cover wounds and/or provide compression to prevent swelling. These adhesive tapes
should remain in place until your doctor removes them, but if they begin to wash off or fall off in the shower etc.,
this is ok; they do not need to be replaced, just make sure they stay clean with gentle cleansing with soap and
water.
ACTIVITY: You should avoid any strenuous activity or exercise for the next 10-14 days. Light out of bed activity
(walking, shopping, etc) starting the day of your surgery is mandatory to prevent blood clots and other pulmonary
issues. Most patients after this procedure are able to return to work/school after two days. A gradual return to
your normal daily activity is the most sensible approach.
FOLI.OW UP: Please Follow up with your surgeon with the specified date noted above. Please call to make your
appointment as soon as possible.
WARNING SIGNS OF COMPLICATIONS:
Please be aware of these possible complications and inform your doctor if you encounter them.
In the event of a life-threatening emergency please call 911 and report to the nearest emergency room.
- Fevers/Chills
- Pus or foul odor/taste from surgical sites
- Excessive
bleeding
- Progressive severe pain and/or swelling
- Nausea/diarrhea
- or swallowing liquids
Difficulty breathing
*
Kadeem Drummond (MRN: " Printed Page 2 of 8 2fD
4927779) by Mercedes C at 9/21/2023 3:45 PM
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
InStrUCtions (Continued)
If you have any questions please feel free to contact us at our office.
No changes were made to your medications.
a Reason(s) for
my hospital
stay
Noted
Bilateral closed fracture of mandible (HCC) 9/15/2023
Malocclusion of jaws 9/19/2023
Continuous hallucinations 9/19/2023
auditory
incarceration 9/19/2023
H/O psychiatric hospitalization 9/19/2023
Cannabis use disorder 9/19/2023
Alcohol use disorder 9/19/2023
Nicotine use disorder 9/19/2023
H/O suicide attempt 9/19/2023
Chronic schizoaffective disorder with acute exacerbation (HCC) 9/19/2023
Fracture of angle of right mandible, initial encounter for closed 9/19/2023
fracture (HCC)
Assault by bodily force by person unknown to victim 9/19/2023
Refusal of treatment
by patient 9/19/2023
Paranoid delusion (HCC) 9/20/2023
Somatic delusion (HCC) 9/20/2023
Patient's intentional underdosing of medication regimen for other 9/20/2023
reason
S/P ORIF (open reduction internal fixation) fracture 9/21/2023
My allergies:
No active allergies
Past Procedures (last 120 days)
Past Procedures (5/24/2023 to Today)
Date Procedure/Visit Type Providers
09/18/2023 OPEN REDUCTION INTERNAL FlXATION MANDIBLE Kojanis, Lee, DDS
- left
body and righ angle
CLOSED REDUCTION MANDIBLE
09/20/2023 OPEN REDUCTION INTERNAL FlXATION MANDIBLE Goldman, Kim, DMD (Primary)
Naraine, Sanjay, DDS
Wu, Brendan, DMD
'
Kadeem Drummond (MRN: " P(iIted Page 3 of 8
4927779) by Mercedes C at 9/21/2023 3: 5 PM
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
Unresulted Tests
Procedure Component Value Units Date/Time
Cepheld COVID-19 RSV Influenza A/B PCR [529406088] Collected: 09/21/23 1506
Lab Status: No result Specimen: Nasal Swab
My follow-ups and appointments
Go to Bellevue Oral 462 1st Ave
Surgery
Wednesday Sep 27, 2023 New York NY 10016
Follow up at Bellevue Oral Surgery Clinic (Hospital Building, 5-S) on 212-562-8780
9/27/23 at 9:00 AM with Dr. Kim Goldman
.
My medicines and schedules
You have not been prescribed any medications.
' '
" Printed 3:45 PM Page 4 of 8
Kadeem Drummond (MRN: 4927779) by Mercedes C at 9/21/2023
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
COVID-19 Message
NYC
"4% MYCHART
For the latest information from NYC Health + Hospitals about COVID-19, including testing sites, vaccines, care &
treatment, and more resources go to www.nychealthandhospitals.orp
If you have a fever, cough, sore throat, or shortness of breath that is unrelated to an existing condition, or have questions
about COVID-19 testing, please call 1-844-NYC-4NYC (1-844-692-4692).
The updated booster vaccine is now available! To make an appointment or for information about vaccines, please call
1-877-VAX-4NYC (1-877-829-4692)
.
MyChart
.... - .. - ... ..... ... . .._ ___... . .. ..
to ] MYCHART
Our records indicate that your MyChart account has been deactivated.
If you would like to reactivate your account, please ask your clinic staff or local Health Information Department to
reactivate your account. You can also go to https://epIcmychart.nychhc.org/help and request a new activation
code.
Kadeem Drummond (MRN: 4927779) " Printed by.Mercedes C at 9/21/2023 3:45 PM Page 6 of 8 Slip
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
Patient/Representative After Visit Summary
Acknowledgement
" this document I acknowledge receipt of all pages of the After Visit Summary. I also understand the
By signing
information provided in these discharge instructions, information, should be followed in order to
including follow-up
ensure proper ongoing treatment of my diagnosis(es).
" A member of my treatment team has reviewed the discharge instructions provided to me and has answered any
questions I may have had regarding these instructions.
Patient/Representative Signature
Relationship to Patient
Date Time
Witness
Date Time
Thank you for being a patient at BELLEVUE IP 19S PRISON HEALTH today. If your prescription was sent to the internal
hospital pharmacy, please keep this paper for your records and provide to the pharmacist when you arrive. Thank you
again!
Patient EMPI: 28145458 - For Internal Use
Pharmacy Only
Kadeem (MRN: " Printed " Page 7 of 8
Drummond 4927779) by Mercedes C at 9/21/2023 3'45 PM
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
u mond
28145458
CSN: 128348824
DOB: 10/19/1989
(33 yrs) male
1028145458 MRN: 4927779 .
Adm Date:
9/14/2023
Kadeem Drummond (MRN: 4927779) " Printed by.Mercedes C at 9/21/2023 3:45 PM Page 8 of 8 43fp
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF 9/21/23,
DOC. 3:10NO.PM3 RECEIVED NYSCEF:
Drummond, Kadeem (MRN 4927779) Printed by Heyman, Budd, MD [38274] at 9/21/2023 3:10 PM
03/15/2024
MRNM92m9
Drummond, Kadeem
Wu, Brendan, DMD Discharge Summary d 5 . Date of Service: 09/21/23 1316
Resident Cosign Needed Creation Time: 09/21/23 1316
Oral Surgery
DISCHARGE NARRATIVE
Admit date: 9/14/2023
Discharge date: 9/21/2023
Admitting Physician: Vasiliki Karlis, DMD
Attending Authorizing Discharge: Kim E Goldman, DMD
Admission Diagnoses:
" Bilateral closed fracture of mandible (HCC)
" Malocclusion of jaws
" Continuous hallucinations
auditory
" Incarceration
" H/O psychiatric hospitalization
" Cannabis use disorder
" Alcohol use disorder
" Nicotine use disorder
" H/O suicide attempt
" Chronic schizoaffective disorder with acute exacerbation (HCC)
" Fracture of angle of right initial encounter for closed fracture
mandible, (HCC)
" Assault force
by bodily by person unknown to victim
" Refusal of treatment by patient
" Paranold delusion (HCC)
" Somatic delusion (HCC)
" Patient's intentional of medication
underdosing regimen for other reason
" S/P ORIF (open reduction internal fracture
fixation)
Discharge Diagnoses: Same
Admission Condition: good
Indication for Admission: Kadeem Drummond is a 33 y.o. male w/ PMH s/f schizoaffective disorder,
polysubstance abuse with left parasymphysis fx and right angle fracture of mandible presenting to BHC
ED s/p assault. Patient with previous right body fx and left angle fracture repaired here at BHC In 2014. CT
imaging reveals nondisplaced comminuted fracture of the right mandibular minimally angle and displaced
fracture of the left parasymphyseal mandible extending to the alveolus of the left mandibular lateral incisor
and canine. Plan for admission to OMFS service for open reduction internal fixation of mandibular
fractures via intraoral vs. transcutaneous approaches, possible closed reduction, placement of arch bars,
maxillomandibular fixation, possible extraction of indicated teeth in OR under GA.
Procedure: open reduction intemal fixation left mandibular parasymphseal fracture (21470), closed
reduction of right mandibular angle fracture with arch bars and maxillomandibular fixation (21453)
Complications: none
Consults:
Psychiatry
- No psychiatric indication for 1:1 observation. No SI/HI.
- Continue to offer Haldol (oral solution) BID
5mg
- Please and then continue to offer Depakene BID
modify 500mg
- Pt is to surgery however unclear if he comprehends so surgical procedure should be done with
assenting
2PC for medical necessity
Hospital Course:
The pt..arrived from Riker's to BHC ED with bilateral mandible fractures s/p assault. The patient refused
Haldol/Depakene as inpatient. The patient was planned for surgery on 9/18 for ORIF mandible fractures
but refused surgery that morning because he had "machines placed in his stomach". Psychiatry was
consulted. Haldol dosage was increased, though patient corftinued.to refus,e. Patient could assent but not
Printed by Heyman, Budd, MD [38274] 9/21/2023 3:10 PM . 1/3
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
9/21/23, 3:10 PM Drummond, Kadeem (MRN 4927779) Printed by Heyman, Budd, MD [38274] at 9/21/2023 3:10 PM
consent to surgery, so 2PC was obtained. On 9/20, the pt. was brought to the OR in stable condition and
underwent open reduction intemal fixation left mandibular parasymphseal fracture, closed reduction of
right mandibular angle fracture with arch bars and maxillomandibular fixation. The procedure was
successful from anesthetic and surgical perspectives, without untoward events. The pt. was extubated in
the OR and brought to the recovery room spontaneously ventilating on room air with all vital signs stable.
Once PAC-U criteria for transfer were met, the pt. was moved to floor where the pt. had no significant
events for the remainder of their admission. Post-op imaging was obtained in OMFS clinic on POD-1. At
the of discharge,
time the patient was stable with normal vital signs, ambulating and voiding freely, able to
take a modified PO diet, and with pain/symptoms controlled with PO medications.
Discharge Exam:
Gen: Age appropriate male, lying in hospital bed. In NAD.
Neuro: AAOx3. R and L CN V3 hypoesthesia,
remaining CNIl-XII grossly Intact.
HEENT: Moderate b/I lower facial swelling that is soft to palpation, -ttp. EOMI, PERRLA. Neck Is soft and
supple. Lower lip w/ moderate edema. Tensoplast and silk tape secured to chin. intraorally, surgical sites
are closed primarily w/ sutures in intact, grossly hemostatic. No signs of dehiscence of surgical sites. Arch
bars Intact with patient in MMF in heavy elastics.
Radiology:
CT Maxillofacial w/o contrast (9/14/23)
IMPRESSION:
Acute nondisplaced comminuted fracture of the right mandibular angle traversing the inferior alveolar
canal and root socket of the right mandibular third molar, and minimally displaced fracture of the left
parasymphyseal mandible extending to the root
socket of the left mandibular lateral incisor and canine. Overlying soft tissue swelling.
Prior bilateral mandibular plate and screw fixation without hardware fractures or loosening.
Panorex/CBCT (9/21/23)
Adequate reduction and fixation of left parasymphyseal fracture with Inferior border plate and screws;
maxillary and mandibular arch bars secured with wire loops
EKG:
9/19/23
Normal sinus rhythm
Normal ECG
DIscharged Condition: good
Disposition: Riker's Infirmary
DIscharge Plan:
- LIQUID DIET
- Ensure supplements with breakfast/Iunch/dinner
- Scissors available to cut elastics to release maxillomandibular fixation in case of emergency
readily
- AmoxIcillin 500 mg liquid TID x 7 days
-Acetaminophen 650 mg liquid Q6H PRN
mild pain
- ibuprofen 600 mg IIquid Q6H PRN moderate pain
- Oxycodone 5 mg liquid Q6H PRN severe pain
- Chlorhexidine 0.12% swish and spit TID x 4 weeks
- Haloperidol 5 Ilquid Q12H
mg
- Valproate 500 liquid Q12H
mg
- at Bellevue Oral CIlnic (Hospital 5- on 9/27/23 at 9:00 AM
Follow-up Surgery Building, South)
Signed:
Brendan Wu
9/21/2023
1:17 PM
Revision
History
Date/Time User Provider Type Action
09/21/23 1454 Wu, Brendan, DMD Resident Sign
09/21/23 1341 Wu, Brendan, DMD Resident Sign
Printed by Heyman, Budd, MD [38274) 9/21/2023 3:10 PM 2/3
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024
9/21/23, 3:08 PM Drummond, Kadeem (MRN 4927779) Printed by Heyman, Budd, MD [38274] at 9/21/2023 3:08 PM
MRNM92m9
Drummond, Kadeem
Wu, Brendan, DMD Discharge Summary 1 W Date of Service: 09/21/23 1316
Resident Cosign Needed Creation Time: 09/21/23 1316
Oral Surgery
DISCHARGE NARRATIVE
Admit date: 9/14/2023
Discharge date: 9/21/2023
Admitting Physician: Vasiliki Karlis, DMD
Attending Authorizing Discharge: Kim E Goldman, DMD
Admission Diagnoses:
" Bilateral closed fracture of mandible (HCC)
" Malocciusion of jaws
" Continuous hallucinations
auditory
" Incarceration
" H/O psychiatric hospitalization
" Cannabis use disorder
" Alcohol use disorder
" Nicotine use disorder
" H/O suicide attempt
" Chronic schizoaffective disorder with acute exacerbation (HCC)
" Fracture of angle of right initial encounter for closed fracture
mandible, (HCC)
" Assault force
by bodily by person unknown to victim
" Refusal of treatment by patient
" Paranoid delusion (HCC)
" Somatic delusion (HCC)
" Patient's intentional of medication regimen for other reason
underdosing
" S/P ORIF (open reductioh internal fracture
fixation)
DIscharge Diagnoses: Same
Admission Condition: good
Indication for Admission: Kadeem Drummond is a 33 y.o. male w/ PMH s/f schizoaffective disorder,
polysubstance abuse with left parasymphysis fx and right angle fracture of mandible presenting to BHC
ED s/p assault. Patient with previous right body fx and left angle fracture repaired here at BHC in 2014. CT
imaging reveals nondisplaced comminuted fracture of the right mandibular minimally angle and displaced
fracture of the left parasymphyseal mandible to the alveolus of the left mandibular lateral incisor
extending
and canine. Plan for admission to OMFS service for open reduction internal fixation of mandibular
fractures via intraoral vs. transcutaneous approaches, possible closed reduction, placement of arch bars,
maxillomandibular fixation, possible extraction of indicated teeth in OR under GA.
Procedure: open reduction internal fixation left mandibular parasymphseal fracture (21470), closed
reduction of right mandibular angle fracture with arch bars and maxillomandibular fixation (21453)
Complications: none
Consults:
Psychiatry
- No psychiatric Indication for 1:1 observation. No SI/HI.
- Continue to offer Haldol BID
5mg (oral solution)
- Please and then continue to offer Depakene BID
modify 500mg
- Pt is to surgery however unclear If he comprehends so surgical procedure should be done with
assenting
2PC for medical necessity
Hospital Course:
The pt. arrived from Riker's to BHC ED with bilateral mandible fractures s/p assault. The patient refused
Haldol/Depakene as inpatient. The patient was planned for surgery on 9/18 for ORIF mandible fractures
but refused surgery that moming because he had "machines placed in his stomach". Psychiatry was
consulted. Haldol dosage was increase'd, though patient continued to refuse. Patient could assent but not
Printed by Heyman, Budd, MD [38274] 9/21/2023 3:08 PM 1/3
FILED: BRONX COUNTY CLERK 03
Preview
FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 AFTER VISIT SUMMARY ellenle 9/15/2023 - 9/21/2023 Bellevue IP 19S PRISON HEALTH Kadeem Drummond MRN: 4927779 9 Instructions After Your Oral & Maxillofacial Surgery: LIQUID DIET PAIN: Some degree of pain is normal for all patients after the procedure. Unless contraindicated, we generally prescribe ibuprofen, tylenol (acetaminophen), or if necessary, a tylenol-narcotic combination drug to control pain. Please attempt to control pain with ibuprofen or plain tylenol as your first line agent. If additional pain control is necessary, you may use the narcotic containing drug as needed. Please be aware that narcotics cause drowsiness and sometimes nausea. Do not attempt to take additional plain tylenol (acetaminophen) if you are currently taking another medication that already contains tylenol (acetaminophen) so as to avoid overdose. Applying Ice packs to your face and keeping your head elevated will also be helpful to control the pain and swelling. Please also keep in mind that a sore throat is extremely common after general anesthesia; this is from the breathing tube that was placed down your throat, and this pain should resolve quickly. Always consult a physician or your surgeon prior to using any additional pain control medications or methods that were not discussed prior to your discharge. If you are experiencing Pain that can not be controlled with these methods, please inform your surgeon. BLEEDING: Slight oozing of blood from ybur surgical sites is normal for the first few hours or so after surgery. For this you should place gauze directly over the oozing sites, and add pressure to help stop bleeding. In the event of excessive bleeding that can not be controlled with pressure, Apply a teabag over the site with more gauze and apply continuous pressure, then proceed to the nearest emergency room and inform your doctor. Remember, slight bleeding is acceptable, and the saliva in your mouth mixed with a small amount of blood may appear more drastic than is. SWELLING: Some swelling is also normal after this surgery. This will peak by about day 3 after surgery and should gradually resolve on its own. In order to lessen the amount of swelling, please sleep with your head elevated using pillows and apply ice packs to your face for the first 2-3 days. CARE OF THE NOSE AND SINUSES: If you had surgery on your upper jaw (maxilla) it is important to know that the necessary surgical treatments occurred in the area in close proximity to your nose and sinuses. As such, some degree of swelling and local changes in the area have occurred. This is why many patients have a complaint of sinus congestion and difficulty breathing through their nose. This is normal, but it is important to take certain measures to ensure a good surgical outcome and optimize your own comfort. For the next 4-6 weeks, you should avoid blowing your nose, sneezing through your nose, or bending over. " Pr,inted ' Kadeem Drummond (MRN: 49277.79) by Mercedes C at 9/21/2023 3:45 PM Page 1 of 8 4gic FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 Instructions (continued) Remember, Nasal congestion may create a feeling of not being able to breathe. If this occurs you should stay calm counter" and take an "over the decongestant to relive it (nasal sprays or oral medicines as directed by your MD); taking care to following the instructions on the bottle. A humidifier and propping yourself up with pillows at night will also facilitate easier breathing. DIET: For the next 3-7 days you should only be eating food that is soft and cool. Nothing spicy, nothing hot, nothing crunchy or tough to chew. Your jaws are fragile after surgery, so you do not want to chew tough foods. Hot and spicy foods can irritate your tissues after surgery and cause unnecessary bleeding HYGIENE: Beginning tomorrow, you may gently rinse your mouth out with warm water/salt solution. You may shower normally but avoid excessive steam or hot temperatures, as this can cause lightheadedness in the setting of medications. DRESSINGS: If you have any dressings/tapes/bandages applied please make note of the following: The non- adhesive external gauze or stocking wraps may be removed at your leisure; they were placed to aid in propping the ice packing for you while you were recovering from anesthesia. The adhesive dressings (steri-strips/tensoplast tapes) were placed to cover wounds and/or provide compression to prevent swelling. These adhesive tapes should remain in place until your doctor removes them, but if they begin to wash off or fall off in the shower etc., this is ok; they do not need to be replaced, just make sure they stay clean with gentle cleansing with soap and water. ACTIVITY: You should avoid any strenuous activity or exercise for the next 10-14 days. Light out of bed activity (walking, shopping, etc) starting the day of your surgery is mandatory to prevent blood clots and other pulmonary issues. Most patients after this procedure are able to return to work/school after two days. A gradual return to your normal daily activity is the most sensible approach. FOLI.OW UP: Please Follow up with your surgeon with the specified date noted above. Please call to make your appointment as soon as possible. WARNING SIGNS OF COMPLICATIONS: Please be aware of these possible complications and inform your doctor if you encounter them. In the event of a life-threatening emergency please call 911 and report to the nearest emergency room. - Fevers/Chills - Pus or foul odor/taste from surgical sites - Excessive bleeding - Progressive severe pain and/or swelling - Nausea/diarrhea - or swallowing liquids Difficulty breathing * Kadeem Drummond (MRN: " Printed Page 2 of 8 2fD 4927779) by Mercedes C at 9/21/2023 3:45 PM FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 InStrUCtions (Continued) If you have any questions please feel free to contact us at our office. No changes were made to your medications. a Reason(s) for my hospital stay Noted Bilateral closed fracture of mandible (HCC) 9/15/2023 Malocclusion of jaws 9/19/2023 Continuous hallucinations 9/19/2023 auditory incarceration 9/19/2023 H/O psychiatric hospitalization 9/19/2023 Cannabis use disorder 9/19/2023 Alcohol use disorder 9/19/2023 Nicotine use disorder 9/19/2023 H/O suicide attempt 9/19/2023 Chronic schizoaffective disorder with acute exacerbation (HCC) 9/19/2023 Fracture of angle of right mandible, initial encounter for closed 9/19/2023 fracture (HCC) Assault by bodily force by person unknown to victim 9/19/2023 Refusal of treatment by patient 9/19/2023 Paranoid delusion (HCC) 9/20/2023 Somatic delusion (HCC) 9/20/2023 Patient's intentional underdosing of medication regimen for other 9/20/2023 reason S/P ORIF (open reduction internal fixation) fracture 9/21/2023 My allergies: No active allergies Past Procedures (last 120 days) Past Procedures (5/24/2023 to Today) Date Procedure/Visit Type Providers 09/18/2023 OPEN REDUCTION INTERNAL FlXATION MANDIBLE Kojanis, Lee, DDS - left body and righ angle CLOSED REDUCTION MANDIBLE 09/20/2023 OPEN REDUCTION INTERNAL FlXATION MANDIBLE Goldman, Kim, DMD (Primary) Naraine, Sanjay, DDS Wu, Brendan, DMD ' Kadeem Drummond (MRN: " P(iIted Page 3 of 8 4927779) by Mercedes C at 9/21/2023 3: 5 PM FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 Unresulted Tests Procedure Component Value Units Date/Time Cepheld COVID-19 RSV Influenza A/B PCR [529406088] Collected: 09/21/23 1506 Lab Status: No result Specimen: Nasal Swab My follow-ups and appointments Go to Bellevue Oral 462 1st Ave Surgery Wednesday Sep 27, 2023 New York NY 10016 Follow up at Bellevue Oral Surgery Clinic (Hospital Building, 5-S) on 212-562-8780 9/27/23 at 9:00 AM with Dr. Kim Goldman . My medicines and schedules You have not been prescribed any medications. ' ' " Printed 3:45 PM Page 4 of 8 Kadeem Drummond (MRN: 4927779) by Mercedes C at 9/21/2023 FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 COVID-19 Message NYC "4% MYCHART For the latest information from NYC Health + Hospitals about COVID-19, including testing sites, vaccines, care & treatment, and more resources go to www.nychealthandhospitals.orp If you have a fever, cough, sore throat, or shortness of breath that is unrelated to an existing condition, or have questions about COVID-19 testing, please call 1-844-NYC-4NYC (1-844-692-4692). The updated booster vaccine is now available! To make an appointment or for information about vaccines, please call 1-877-VAX-4NYC (1-877-829-4692) . MyChart .... - .. - ... ..... ... . .._ ___... . .. .. to ] MYCHART Our records indicate that your MyChart account has been deactivated. If you would like to reactivate your account, please ask your clinic staff or local Health Information Department to reactivate your account. You can also go to https://epIcmychart.nychhc.org/help and request a new activation code. Kadeem Drummond (MRN: 4927779) " Printed by.Mercedes C at 9/21/2023 3:45 PM Page 6 of 8 Slip FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 Patient/Representative After Visit Summary Acknowledgement " this document I acknowledge receipt of all pages of the After Visit Summary. I also understand the By signing information provided in these discharge instructions, information, should be followed in order to including follow-up ensure proper ongoing treatment of my diagnosis(es). " A member of my treatment team has reviewed the discharge instructions provided to me and has answered any questions I may have had regarding these instructions. Patient/Representative Signature Relationship to Patient Date Time Witness Date Time Thank you for being a patient at BELLEVUE IP 19S PRISON HEALTH today. If your prescription was sent to the internal hospital pharmacy, please keep this paper for your records and provide to the pharmacist when you arrive. Thank you again! Patient EMPI: 28145458 - For Internal Use Pharmacy Only Kadeem (MRN: " Printed " Page 7 of 8 Drummond 4927779) by Mercedes C at 9/21/2023 3'45 PM FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 u mond 28145458 CSN: 128348824 DOB: 10/19/1989 (33 yrs) male 1028145458 MRN: 4927779 . Adm Date: 9/14/2023 Kadeem Drummond (MRN: 4927779) " Printed by.Mercedes C at 9/21/2023 3:45 PM Page 8 of 8 43fp FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF 9/21/23, DOC. 3:10NO.PM3 RECEIVED NYSCEF: Drummond, Kadeem (MRN 4927779) Printed by Heyman, Budd, MD [38274] at 9/21/2023 3:10 PM 03/15/2024 MRNM92m9 Drummond, Kadeem Wu, Brendan, DMD Discharge Summary d 5 . Date of Service: 09/21/23 1316 Resident Cosign Needed Creation Time: 09/21/23 1316 Oral Surgery DISCHARGE NARRATIVE Admit date: 9/14/2023 Discharge date: 9/21/2023 Admitting Physician: Vasiliki Karlis, DMD Attending Authorizing Discharge: Kim E Goldman, DMD Admission Diagnoses: " Bilateral closed fracture of mandible (HCC) " Malocclusion of jaws " Continuous hallucinations auditory " Incarceration " H/O psychiatric hospitalization " Cannabis use disorder " Alcohol use disorder " Nicotine use disorder " H/O suicide attempt " Chronic schizoaffective disorder with acute exacerbation (HCC) " Fracture of angle of right initial encounter for closed fracture mandible, (HCC) " Assault force by bodily by person unknown to victim " Refusal of treatment by patient " Paranold delusion (HCC) " Somatic delusion (HCC) " Patient's intentional of medication underdosing regimen for other reason " S/P ORIF (open reduction internal fracture fixation) Discharge Diagnoses: Same Admission Condition: good Indication for Admission: Kadeem Drummond is a 33 y.o. male w/ PMH s/f schizoaffective disorder, polysubstance abuse with left parasymphysis fx and right angle fracture of mandible presenting to BHC ED s/p assault. Patient with previous right body fx and left angle fracture repaired here at BHC In 2014. CT imaging reveals nondisplaced comminuted fracture of the right mandibular minimally angle and displaced fracture of the left parasymphyseal mandible extending to the alveolus of the left mandibular lateral incisor and canine. Plan for admission to OMFS service for open reduction internal fixation of mandibular fractures via intraoral vs. transcutaneous approaches, possible closed reduction, placement of arch bars, maxillomandibular fixation, possible extraction of indicated teeth in OR under GA. Procedure: open reduction intemal fixation left mandibular parasymphseal fracture (21470), closed reduction of right mandibular angle fracture with arch bars and maxillomandibular fixation (21453) Complications: none Consults: Psychiatry - No psychiatric indication for 1:1 observation. No SI/HI. - Continue to offer Haldol (oral solution) BID 5mg - Please and then continue to offer Depakene BID modify 500mg - Pt is to surgery however unclear if he comprehends so surgical procedure should be done with assenting 2PC for medical necessity Hospital Course: The pt..arrived from Riker's to BHC ED with bilateral mandible fractures s/p assault. The patient refused Haldol/Depakene as inpatient. The patient was planned for surgery on 9/18 for ORIF mandible fractures but refused surgery that morning because he had "machines placed in his stomach". Psychiatry was consulted. Haldol dosage was increased, though patient corftinued.to refus,e. Patient could assent but not Printed by Heyman, Budd, MD [38274] 9/21/2023 3:10 PM . 1/3 FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 9/21/23, 3:10 PM Drummond, Kadeem (MRN 4927779) Printed by Heyman, Budd, MD [38274] at 9/21/2023 3:10 PM consent to surgery, so 2PC was obtained. On 9/20, the pt. was brought to the OR in stable condition and underwent open reduction intemal fixation left mandibular parasymphseal fracture, closed reduction of right mandibular angle fracture with arch bars and maxillomandibular fixation. The procedure was successful from anesthetic and surgical perspectives, without untoward events. The pt. was extubated in the OR and brought to the recovery room spontaneously ventilating on room air with all vital signs stable. Once PAC-U criteria for transfer were met, the pt. was moved to floor where the pt. had no significant events for the remainder of their admission. Post-op imaging was obtained in OMFS clinic on POD-1. At the of discharge, time the patient was stable with normal vital signs, ambulating and voiding freely, able to take a modified PO diet, and with pain/symptoms controlled with PO medications. Discharge Exam: Gen: Age appropriate male, lying in hospital bed. In NAD. Neuro: AAOx3. R and L CN V3 hypoesthesia, remaining CNIl-XII grossly Intact. HEENT: Moderate b/I lower facial swelling that is soft to palpation, -ttp. EOMI, PERRLA. Neck Is soft and supple. Lower lip w/ moderate edema. Tensoplast and silk tape secured to chin. intraorally, surgical sites are closed primarily w/ sutures in intact, grossly hemostatic. No signs of dehiscence of surgical sites. Arch bars Intact with patient in MMF in heavy elastics. Radiology: CT Maxillofacial w/o contrast (9/14/23) IMPRESSION: Acute nondisplaced comminuted fracture of the right mandibular angle traversing the inferior alveolar canal and root socket of the right mandibular third molar, and minimally displaced fracture of the left parasymphyseal mandible extending to the root socket of the left mandibular lateral incisor and canine. Overlying soft tissue swelling. Prior bilateral mandibular plate and screw fixation without hardware fractures or loosening. Panorex/CBCT (9/21/23) Adequate reduction and fixation of left parasymphyseal fracture with Inferior border plate and screws; maxillary and mandibular arch bars secured with wire loops EKG: 9/19/23 Normal sinus rhythm Normal ECG DIscharged Condition: good Disposition: Riker's Infirmary DIscharge Plan: - LIQUID DIET - Ensure supplements with breakfast/Iunch/dinner - Scissors available to cut elastics to release maxillomandibular fixation in case of emergency readily - AmoxIcillin 500 mg liquid TID x 7 days -Acetaminophen 650 mg liquid Q6H PRN mild pain - ibuprofen 600 mg IIquid Q6H PRN moderate pain - Oxycodone 5 mg liquid Q6H PRN severe pain - Chlorhexidine 0.12% swish and spit TID x 4 weeks - Haloperidol 5 Ilquid Q12H mg - Valproate 500 liquid Q12H mg - at Bellevue Oral CIlnic (Hospital 5- on 9/27/23 at 9:00 AM Follow-up Surgery Building, South) Signed: Brendan Wu 9/21/2023 1:17 PM Revision History Date/Time User Provider Type Action 09/21/23 1454 Wu, Brendan, DMD Resident Sign 09/21/23 1341 Wu, Brendan, DMD Resident Sign Printed by Heyman, Budd, MD [38274) 9/21/2023 3:10 PM 2/3 FILED: BRONX COUNTY CLERK 03/15/2024 11:31 AM INDEX NO. 804425/2024E NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 03/15/2024 9/21/23, 3:08 PM Drummond, Kadeem (MRN 4927779) Printed by Heyman, Budd, MD [38274] at 9/21/2023 3:08 PM MRNM92m9 Drummond, Kadeem Wu, Brendan, DMD Discharge Summary 1 W Date of Service: 09/21/23 1316 Resident Cosign Needed Creation Time: 09/21/23 1316 Oral Surgery DISCHARGE NARRATIVE Admit date: 9/14/2023 Discharge date: 9/21/2023 Admitting Physician: Vasiliki Karlis, DMD Attending Authorizing Discharge: Kim E Goldman, DMD Admission Diagnoses: " Bilateral closed fracture of mandible (HCC) " Malocciusion of jaws " Continuous hallucinations auditory " Incarceration " H/O psychiatric hospitalization " Cannabis use disorder " Alcohol use disorder " Nicotine use disorder " H/O suicide attempt " Chronic schizoaffective disorder with acute exacerbation (HCC) " Fracture of angle of right initial encounter for closed fracture mandible, (HCC) " Assault force by bodily by person unknown to victim " Refusal of treatment by patient " Paranoid delusion (HCC) " Somatic delusion (HCC) " Patient's intentional of medication regimen for other reason underdosing " S/P ORIF (open reductioh internal fracture fixation) DIscharge Diagnoses: Same Admission Condition: good Indication for Admission: Kadeem Drummond is a 33 y.o. male w/ PMH s/f schizoaffective disorder, polysubstance abuse with left parasymphysis fx and right angle fracture of mandible presenting to BHC ED s/p assault. Patient with previous right body fx and left angle fracture repaired here at BHC in 2014. CT imaging reveals nondisplaced comminuted fracture of the right mandibular minimally angle and displaced fracture of the left parasymphyseal mandible to the alveolus of the left mandibular lateral incisor extending and canine. Plan for admission to OMFS service for open reduction internal fixation of mandibular fractures via intraoral vs. transcutaneous approaches, possible closed reduction, placement of arch bars, maxillomandibular fixation, possible extraction of indicated teeth in OR under GA. Procedure: open reduction internal fixation left mandibular parasymphseal fracture (21470), closed reduction of right mandibular angle fracture with arch bars and maxillomandibular fixation (21453) Complications: none Consults: Psychiatry - No psychiatric Indication for 1:1 observation. No SI/HI. - Continue to offer Haldol BID 5mg (oral solution) - Please and then continue to offer Depakene BID modify 500mg - Pt is to surgery however unclear If he comprehends so surgical procedure should be done with assenting 2PC for medical necessity Hospital Course: The pt. arrived from Riker's to BHC ED with bilateral mandible fractures s/p assault. The patient refused Haldol/Depakene as inpatient. The patient was planned for surgery on 9/18 for ORIF mandible fractures but refused surgery that moming because he had "machines placed in his stomach". Psychiatry was consulted. Haldol dosage was increase'd, though patient continued to refuse. Patient could assent but not Printed by Heyman, Budd, MD [38274] 9/21/2023 3:08 PM 1/3 FILED: BRONX COUNTY CLERK 03