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RETURN DATE: JUNE 9, 2020 : SUPERIOR COURT
VITO MONTALBO : J.D. OF STAMFORD
ve : AT STAMFORD
GREENWICH HOSPITAL : MAY 13, 2020
COMPLAINT
COUNT ONE — Medical Malpractice
1.
The plaintiff Vito Montalbo is an individual residing in the Town of Purling, County
of Greene County, State of New York.
The defendant Greenwich Hospital is a corporate entity doing business as a
hospital health care facility, including an emergency room, at 5 Perryridge Road,
Greenwich CT.
July 13, 2018, Vito Montalbo presented to the Greenwich Hospital emergency
room with complaints of a lacerated right 2™ finger mechanism of injury ‘cut while
hammering tile.’
The mechanism of injury suggests a penetrating injury.
An on-call physician’s assistant (PA) attended to the patient.
The PA is a duly authorized agent and/or employee of Greenwich Hospital.
The PA did a physical examination.
The PA did not order any radiology studies.
The PA performed a 4 suture laceration repair at bedside.
Montalbo was discharged with instructions to follow up suture removal.
July 24, 2018, Montalbo returned to Greenwich Hospital with on-going complaints
right 2" finger.12.
13.
14.
15.
16.
17.
18.
19.
20.
He was noted to still suffer edema and swelling at the surgical site.
August 14, 2018, Montalbo presented to a hand surgeon who noted ‘numbness on
the back of the finger, difficulty moving the finger, painful on the dorsal aspect of
[the finger], a sensation that it locks or clicks ..., a prominent hypertrophic scar
tender to palpation, decreased sensation in the distribution of the ... radial nerve,
and difficulty touching fingertip to palm.’
X-rays revealed the presence of a small radiopaque body and MRI was
recommended.
August 29, 2018, MRI showed ‘a 2-3 mm foreign body within the dorsal soft tissues
of the 2" finger ...
September 7, 2018, surgical procedure to remove a ‘2 mm white foreign body
consistent with a ceramic tile sliver.’
After the surgical removal of the foreign body, follow up medical examination
determined that the patient suffered tendon adhesions and/or atypical trigger
finger causing constant throbbing pain and restricted range of motion.
On final discharge, Montalbo was determined to suffer permanent partial disability
to the finger 6%.
In connection with their health care provider-patient relationship, the defendant
had a duty to render proper and adequate medical services to the plaintiff in
accordance with the standard of care.
On July 13, 2018, the defendant hospital, by and through its authorized agents and
employees, was negligent by failing to meet the standard of care for treating the
plaintiff in one or more of the following ways:
a. Failure upon examination to detect the presence of the foreign body
b. Failure to order radiology studies to detect the presence of a foreign bodyc. Failure to remove the foreign body
d. Suturing the foreign body into the plaintiff's finger
e. Sealing the foreign body inside the finger for 7+ weeks until surgical removal
21. Asa result of said negligence of the defendant the plaintiff suffered the following
injuries, some or all of which are permanent in nature:
a. Delayed prolonged healing from injury
b. Adhesions
c. Trigger finger
d. Loss of range of motion
e. Loss of strength
f. Loss of dexterity and
g. Pain and suffering.
22. Asa further result of the defendant’s negligence, the plaintiff has incurred and will
continue to incur expenses for surgical procedures, medical care, and
prescriptions.
23. Asa further result of the defendant’s negligence, the plaintiff has been impaired in
his ability to perform his job responsibilities.
24. Asa further result of the defendant’s negligence, the plaintiff has been impaired in
his ability to carry on and enjoy life's activities.WHEREFORE, the plaintiff claims:
Damages.
Dated at Danbury, Connecticut, this 13" day of May, 2020.
THE PLAINTIFF,
» Cnn
Gregory P. Klein — Attorney
Alan Barry & Associates; LLC
5 Shelter Rock Road
Danbury, Connecticut 06810
(203) 797-9600
Juris No. 423851RETURN DATE: JUNE 9, 2020 : SUPERIOR COURT
VITO MONTALBO : J.D. OF STAMFORD
v. : AT STAMFORD
GREENWICH HOSPITAL : MAY 13, 2020
STATEMENT OF AMOUNT IN DEMAND
The plaintiff states that the amount in demand is in excess of $15,000, exclusive
of interest and costs.
THE PLAINTIFF,
vy Qua Ny
regory P. Klein - Attorney
Alan Barry & Associates, LLC
5 Shelter Rock Road
Danbury, Connecticut 06810
(203) 797-9600
Juris No. 423851RETURN DATE: JUNE 9, 2020 : SUPERIOR COURT
VITO MONTALBO. : J.D. OF STAMFORD
v. : AT STAMFORD
GREENWICH HOSPITAL : MAY 13, 2020
CERTIFICATE OF INQUIRY UNDER
Conn. Gen. Stat. Sec. 52-190a
| hereby certify that | have made a reasonable inquiry to determine if there is a basis for
a good-faith belief of negligence in the care or treatment of Vito Montalbo. This inquiry
has given rise to a good-faith belief on my part that grounds exist for an action against
the defendant Greenwich Hospital for negligence by and through its authorized agent
and/or employee a Physician’s Assistant. This good faith belief is supported by a report
by a similar health care provider, as required by CGS sec. 52-184c. EXHIBIT A.
THE PLAINTIFF,
By: (oad | Wy
Gregory P. Klein — — Attorney
Alan Barry & Associates, LLC
5 Shelter Rock Road
Danbury, Connecticut 06810
(203) 797-9600
Juris No. 423851Clinical Documentation Specialist
Physician Assistant -Emergency Medicine
Re: Vito Montalbo v Greenwich Hospital
DOB 7/01/1976
This is a report regarding the care rendered to Vito Montalbo who was treated in the Emergency Room
of Greenwich Hospital at 5 Perryridge Road Greenwich CT. 06830 on July 13, 2018. The following are a
list of medical records that were sent to me for review. | was asked to review this case and render my
clinical opinion in regards to the care given to Vito Montalbo. | can only comment on the documents
that were given to me. My opinions are based on a reasonable degree of medical certainty. |ama
Physician Assistant. | have 30 years in Emergency Medicine. | therefore will be rendering my opinion on
the scope of practice of a Physician Assistant in the specialty of Emergency Medicine.
The scope of the Physician Assistant is defined by his/her training and by their Supervising Physician.
Emergency Room Initial Visit Record dated July 13 2018---MR # 3797371
Emergency Room fellow up visit dated July 24** 2018-----MR # 3797371
Office Visit-Orthopedic& Neurosurgery Specialist visit dated August 14** 2018
MRI done August 29*" 2018 at South Shore Radiology Howard Beach
Ambulatory Services - Orthopedic& Neurosurgery Specialist visit dated September 07" 2018
Pathology Report -From Yale New Haven Health Greenwich Hospital
Office Visit Orthopedist & Neurosurgery Specialist visit September 18" 2018
Office Visit Orthopedist & Neurosurgery Specialist visit October 8" 2018
Office Visit Orthopedist & Neurosurgery Specialist visit November 5" 2018
Office Visit Orthopedist & Neurosurgery Specialist visit January 7" 2018
Office Visit Orthopedist & Neurosurgery Specialist visit April 29" 2018
Office Visit Orthopedist & Neurosurgery Specialist visit December 9"", 2019
Form C4.2 form
Chronological events-
On July 13** Mr. Montalbo presented to Greenwich Hospital Emergency Room.
Patient presents — Laceration
“States cut left 2"! finger on a tile approx. 1 hr. PTA. Approx. icm noted, no active bleeding
Mechanism of injury -while hammering tile. He was working with raw sewage”
Physical exam:
Right Index finger: dorsal aspect, 1-centimeter laceration over the PIP with mild active bleeding
No sensory or motor deficit
Laceration Repair done at bedside-
Digital block 25 G needle with Lidocaine w/o epi
Exploration of wound through full range of motion
4 simple interrupted sutures.
Extensive cleaning
Splint applied
Discharge instructions included having the patient take Keflex (since he was working with raw sewage)
and updated Tetanus. Follow up for suture removal.
Exhibit "A ”JULY 24™-FOLLOW UP VISIT FOR SUTURE REMOVAL
Follow-up visit on July 24" 2018 for suture removal.
Mr. Montalbo states: “at times pain and numbness” of the affected finger. There is edema.
Physical exam- “Edema and swelling to the PIP of his 2" finger with 4 sutures in place. NO surrounding
erythema. He has full strength against resistance with a range of motion in tact however he cannot fully
flex the finger secondary to swelling.”
Patient given instructions to follow up with the hand surgeon Dr. Vitale 6 at Greenwich Office Park Ct.
HAND SURGEON CONSULTATION AUGUST 14* 2018- Dr. Vitale
Dr. Vitale’s History of Present Illness describes the events on July 13". He states that an x-ray was not
obtained. As per Dr. Vitale’s report ... “he has had numbness on the back of the finger, difficulty moving
the finger and painful on the dorsal aspect of the index PIP joint. He has a sensation that the finger
sometimes locks up or clicks when he bends it.”
PHYSICIAL EXAM- “there is a prominent hypertrophic scar on the dorsal aspect of the right index finger
PIP joint. Tender to palpation.” There is decreased sensation in the distribution of the superficial sensory
radial nerve to.the index finger and also proximal to the laceration at the level of the dorsal.radial hand
and the dorsal of the thumb.” “...he has difficulty touching his index fingertip to the palm where he
does have about a 1 cm index fingertip pulp to palm distance.”
Xray’s revealed on the dorsal aspect of the index finger at the level of the PIP joint a small radiopaque
body which may represent a foreign body.
MRI was recommended and if there is evidence of foreign body then surgical treatment is
recommended.
MRI REPORT- AUGUST 29™ 2018 from South Shore Radiology Howard Beach
“A 2-3 mm foreign body within the dorsal soft tissues of the 2" finger at the level of the distal proximal
phalanx.”
PROCEDURE DATE SEPTEMBER 7™ 2018-
Removal of the 2 mm white foreign body consistent with a ceramic tile sliver. The hypertrophic distal
portion of the scar was excised and a rotational flap was used to close the dorsal wound.
Pathology confirmed 0.3x0.1x0.1 cm irregular hard fragment No adherent soft tissue.
SUTURE REMOVAL SEPTEMBER 18™ 2018
Sutures removed and wound care instructions with follow up in 3 weeks.
FOLLOW UP VISIT OCTOBER 7, 2018
PHYSICIAL EXAM- “The patient does have apparent tendon adhesions with active digital flexion less than
passive digital flexion specifically at the PIP joint right can bend him down to 90 degrees but passively he
can only get to about 60 degrees. The central slip is intact there is a negative Elson’s test. Sensation is
intact to light touch in the median, radial and ulnar nerve distribution.”
PLAN: formal therapy with a hand therapist. Dr. Vitale feels this is medically necessary.FOLLOW UP VISIT NOVEMBER 7™ 2018-
*(no hand physical therapy evaluation in record since patient did home therapy) — “He does have some
pain on the dorsal aspect of the finger when he makes a tight fist, but he thinks this is improving”.
“He is now able to bend the PIP joint to 100 degrees and his DIP joint to about 80 degrees. Some pain on
the dorsal aspect of the index finger with deep digital flexion.” “Sensation is intact to light touch in the
median radial and ulnar nerve distribution.”
Plan — Dr. Vitale recommended the continued home exercise program versus formal physical therapy to
work on tendon adhesions. Dr. Vitale states “that it is very likely that his symptoms will improve with
continued time and stretching.”
Follow up in 2 months.
FOLLOW UP VISIT JANUARY 10", 2019-
Exam reveals stiffness and likely tendon adhesions — He has full digital extension but has a mild deficit in
terms of digital flexion.
PLAN- recommendation of a certified hand therapist to address the adhesions which are likely the cause
of the symptoms. -
Apart of the record are prescriptions for a physical hand therapist as well as heat pack the right hand/
index finger.
FOLLOW UP VISIT APRIL 29™ 2019-
Examination of the right hand some tenderness of the A-1 pulley of the index finger but no frank
triggering.
*(no formal physical therapy report from a certified hand therapist) to comment on.
Patient may have atypical trigger finger which could have developed from the swelling he experienced
postoperatively as well as from the initial trauma. Recommendation was a corticosteroid injection.
FOLLOW UP VISIT- DECEMBER 10* 2019-
He returns for follow up with the complaint that the pain is throbbing and constant. Worse in the cold
eliciting pins and needles. Having difficulty holding a drill or a power tool.
PHYSICIAL EXAM- stiffness with only about 90 degrees of flexion at the PIP joint in the right index finger
compared to 120 in the left. He has 30 degrees of DIP joint flexion of the right index finger compared to
60 degrees in the left index finger.
Plan-There is mild permanent disability and a C4.2 form will be filled out quantifying the disability.
COMMENTS-Upon review of Mr. Montalbo’s ED visits and consultation visits with Dr. Vitale (including
MRI report and pathology report) there is a reasonable degree of medical probability to suggest there
was a deviation in the standard of care. Based on the mechanism of injury, namely the hammering of
tile causing the laceration, one would think a penetrating injury. An x-ray would rule out a piece
penetrating the skin causing the laceration.
Dr. Vitale removed the piece of tile on September 7, 2018 and performed a scar revision. During the
subsequent visit of October 7", 2018, he states that there are tendon adhesions. A certified hand
therapist was recommended. The patient did home therapy instead. The November assessment by Dr.
Vitale states that Mr. Montalbo is able to bend the PIP of the affected finger 100 degrees. This is normalflexion of the PIP. He was doing better. Sensation was intact for radial sensory nerve. Continued home
therapy was recommended. From the November visit till the January visit it is unclear if therapy was
continued.
It was at the January visit that Dr. Vitale again recommended that Mr. Montalbo see a certified hand
therapist to address his tendon adhesions. The April visit revealed an atypical trigger finger and a
cortisone injection into the right flexor tendon sheath was performed.
The last physical exam from Dr. Vitale was on December 2019. At that time the record states there is no
trigger finger. The patient continues to have some stiffness with only 90 degrees of flexion at the PIP
joint in the right index finger. It is here that Dr. Vitale states he has mild permanent disability. He further
states he will fill out a C4.2
To conclude, had an x-ray been taken in the ED, the recognition of the foreign body would have been
made sooner. It is difficult to determine if the tendon adhesions and the sensory deficits would have
occurred even if the foreign body was removed at the time of initial presentation to the ED. These
adhesions may have been a consequence of the injury and subsequent recovery regardless of when the
foreign body was removed. The home therapy did improve his ability to flex the affected finger as
documented at the November visit. | am unable to determine if the adjunctive therapies that a certified
hand therapist uses would have improved his overall symptoms and deficits.
Regardless, the absence of an x-ray prevented prompt diagnosis of the foreign body. This did prolong his
recovery. There is documentation from the Neuro-orthopedist stating he believes there is partial
permanent disability.
Having carefully and thoroughly reviewed the documents provided to me, | can say with a reasonable
degree of medical probability that there was a deviation in the standard of care in the prompt
recognition of the foreign body. The relationship between the recognition /removal of the foreign body
and the patient’s partial permanent disability cannot be commented on. This is not my role in this report
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RETURN DATE: JUNE 9, 2020 : SUPERIOR COURT VITO MONTALBO : J.D. OF STAMFORD ve : AT STAMFORD GREENWICH HOSPITAL : MAY 13, 2020 COMPLAINT COUNT ONE — Medical Malpractice 1. The plaintiff Vito Montalbo is an individual residing in the Town of Purling, County of Greene County, State of New York. The defendant Greenwich Hospital is a corporate entity doing business as a hospital health care facility, including an emergency room, at 5 Perryridge Road, Greenwich CT. July 13, 2018, Vito Montalbo presented to the Greenwich Hospital emergency room with complaints of a lacerated right 2™ finger mechanism of injury ‘cut while hammering tile.’ The mechanism of injury suggests a penetrating injury. An on-call physician’s assistant (PA) attended to the patient. The PA is a duly authorized agent and/or employee of Greenwich Hospital. The PA did a physical examination. The PA did not order any radiology studies. The PA performed a 4 suture laceration repair at bedside. Montalbo was discharged with instructions to follow up suture removal. July 24, 2018, Montalbo returned to Greenwich Hospital with on-going complaints right 2" finger.12. 13. 14. 15. 16. 17. 18. 19. 20. He was noted to still suffer edema and swelling at the surgical site. August 14, 2018, Montalbo presented to a hand surgeon who noted ‘numbness on the back of the finger, difficulty moving the finger, painful on the dorsal aspect of [the finger], a sensation that it locks or clicks ..., a prominent hypertrophic scar tender to palpation, decreased sensation in the distribution of the ... radial nerve, and difficulty touching fingertip to palm.’ X-rays revealed the presence of a small radiopaque body and MRI was recommended. August 29, 2018, MRI showed ‘a 2-3 mm foreign body within the dorsal soft tissues of the 2" finger ... September 7, 2018, surgical procedure to remove a ‘2 mm white foreign body consistent with a ceramic tile sliver.’ After the surgical removal of the foreign body, follow up medical examination determined that the patient suffered tendon adhesions and/or atypical trigger finger causing constant throbbing pain and restricted range of motion. On final discharge, Montalbo was determined to suffer permanent partial disability to the finger 6%. In connection with their health care provider-patient relationship, the defendant had a duty to render proper and adequate medical services to the plaintiff in accordance with the standard of care. On July 13, 2018, the defendant hospital, by and through its authorized agents and employees, was negligent by failing to meet the standard of care for treating the plaintiff in one or more of the following ways: a. Failure upon examination to detect the presence of the foreign body b. Failure to order radiology studies to detect the presence of a foreign bodyc. Failure to remove the foreign body d. Suturing the foreign body into the plaintiff's finger e. Sealing the foreign body inside the finger for 7+ weeks until surgical removal 21. Asa result of said negligence of the defendant the plaintiff suffered the following injuries, some or all of which are permanent in nature: a. Delayed prolonged healing from injury b. Adhesions c. Trigger finger d. Loss of range of motion e. Loss of strength f. Loss of dexterity and g. Pain and suffering. 22. Asa further result of the defendant’s negligence, the plaintiff has incurred and will continue to incur expenses for surgical procedures, medical care, and prescriptions. 23. Asa further result of the defendant’s negligence, the plaintiff has been impaired in his ability to perform his job responsibilities. 24. Asa further result of the defendant’s negligence, the plaintiff has been impaired in his ability to carry on and enjoy life's activities.WHEREFORE, the plaintiff claims: Damages. Dated at Danbury, Connecticut, this 13" day of May, 2020. THE PLAINTIFF, » Cnn Gregory P. Klein — Attorney Alan Barry & Associates; LLC 5 Shelter Rock Road Danbury, Connecticut 06810 (203) 797-9600 Juris No. 423851RETURN DATE: JUNE 9, 2020 : SUPERIOR COURT VITO MONTALBO : J.D. OF STAMFORD v. : AT STAMFORD GREENWICH HOSPITAL : MAY 13, 2020 STATEMENT OF AMOUNT IN DEMAND The plaintiff states that the amount in demand is in excess of $15,000, exclusive of interest and costs. THE PLAINTIFF, vy Qua Ny regory P. Klein - Attorney Alan Barry & Associates, LLC 5 Shelter Rock Road Danbury, Connecticut 06810 (203) 797-9600 Juris No. 423851RETURN DATE: JUNE 9, 2020 : SUPERIOR COURT VITO MONTALBO. : J.D. OF STAMFORD v. : AT STAMFORD GREENWICH HOSPITAL : MAY 13, 2020 CERTIFICATE OF INQUIRY UNDER Conn. Gen. Stat. Sec. 52-190a | hereby certify that | have made a reasonable inquiry to determine if there is a basis for a good-faith belief of negligence in the care or treatment of Vito Montalbo. This inquiry has given rise to a good-faith belief on my part that grounds exist for an action against the defendant Greenwich Hospital for negligence by and through its authorized agent and/or employee a Physician’s Assistant. This good faith belief is supported by a report by a similar health care provider, as required by CGS sec. 52-184c. EXHIBIT A. THE PLAINTIFF, By: (oad | Wy Gregory P. Klein — — Attorney Alan Barry & Associates, LLC 5 Shelter Rock Road Danbury, Connecticut 06810 (203) 797-9600 Juris No. 423851Clinical Documentation Specialist Physician Assistant -Emergency Medicine Re: Vito Montalbo v Greenwich Hospital DOB 7/01/1976 This is a report regarding the care rendered to Vito Montalbo who was treated in the Emergency Room of Greenwich Hospital at 5 Perryridge Road Greenwich CT. 06830 on July 13, 2018. The following are a list of medical records that were sent to me for review. | was asked to review this case and render my clinical opinion in regards to the care given to Vito Montalbo. | can only comment on the documents that were given to me. My opinions are based on a reasonable degree of medical certainty. |ama Physician Assistant. | have 30 years in Emergency Medicine. | therefore will be rendering my opinion on the scope of practice of a Physician Assistant in the specialty of Emergency Medicine. The scope of the Physician Assistant is defined by his/her training and by their Supervising Physician. Emergency Room Initial Visit Record dated July 13 2018---MR # 3797371 Emergency Room fellow up visit dated July 24** 2018-----MR # 3797371 Office Visit-Orthopedic& Neurosurgery Specialist visit dated August 14** 2018 MRI done August 29*" 2018 at South Shore Radiology Howard Beach Ambulatory Services - Orthopedic& Neurosurgery Specialist visit dated September 07" 2018 Pathology Report -From Yale New Haven Health Greenwich Hospital Office Visit Orthopedist & Neurosurgery Specialist visit September 18" 2018 Office Visit Orthopedist & Neurosurgery Specialist visit October 8" 2018 Office Visit Orthopedist & Neurosurgery Specialist visit November 5" 2018 Office Visit Orthopedist & Neurosurgery Specialist visit January 7" 2018 Office Visit Orthopedist & Neurosurgery Specialist visit April 29" 2018 Office Visit Orthopedist & Neurosurgery Specialist visit December 9"", 2019 Form C4.2 form Chronological events- On July 13** Mr. Montalbo presented to Greenwich Hospital Emergency Room. Patient presents — Laceration “States cut left 2"! finger on a tile approx. 1 hr. PTA. Approx. icm noted, no active bleeding Mechanism of injury -while hammering tile. He was working with raw sewage” Physical exam: Right Index finger: dorsal aspect, 1-centimeter laceration over the PIP with mild active bleeding No sensory or motor deficit Laceration Repair done at bedside- Digital block 25 G needle with Lidocaine w/o epi Exploration of wound through full range of motion 4 simple interrupted sutures. Extensive cleaning Splint applied Discharge instructions included having the patient take Keflex (since he was working with raw sewage) and updated Tetanus. Follow up for suture removal. Exhibit "A ”JULY 24™-FOLLOW UP VISIT FOR SUTURE REMOVAL Follow-up visit on July 24" 2018 for suture removal. Mr. Montalbo states: “at times pain and numbness” of the affected finger. There is edema. Physical exam- “Edema and swelling to the PIP of his 2" finger with 4 sutures in place. NO surrounding erythema. He has full strength against resistance with a range of motion in tact however he cannot fully flex the finger secondary to swelling.” Patient given instructions to follow up with the hand surgeon Dr. Vitale 6 at Greenwich Office Park Ct. HAND SURGEON CONSULTATION AUGUST 14* 2018- Dr. Vitale Dr. Vitale’s History of Present Illness describes the events on July 13". He states that an x-ray was not obtained. As per Dr. Vitale’s report ... “he has had numbness on the back of the finger, difficulty moving the finger and painful on the dorsal aspect of the index PIP joint. He has a sensation that the finger sometimes locks up or clicks when he bends it.” PHYSICIAL EXAM- “there is a prominent hypertrophic scar on the dorsal aspect of the right index finger PIP joint. Tender to palpation.” There is decreased sensation in the distribution of the superficial sensory radial nerve to.the index finger and also proximal to the laceration at the level of the dorsal.radial hand and the dorsal of the thumb.” “...he has difficulty touching his index fingertip to the palm where he does have about a 1 cm index fingertip pulp to palm distance.” Xray’s revealed on the dorsal aspect of the index finger at the level of the PIP joint a small radiopaque body which may represent a foreign body. MRI was recommended and if there is evidence of foreign body then surgical treatment is recommended. MRI REPORT- AUGUST 29™ 2018 from South Shore Radiology Howard Beach “A 2-3 mm foreign body within the dorsal soft tissues of the 2" finger at the level of the distal proximal phalanx.” PROCEDURE DATE SEPTEMBER 7™ 2018- Removal of the 2 mm white foreign body consistent with a ceramic tile sliver. The hypertrophic distal portion of the scar was excised and a rotational flap was used to close the dorsal wound. Pathology confirmed 0.3x0.1x0.1 cm irregular hard fragment No adherent soft tissue. SUTURE REMOVAL SEPTEMBER 18™ 2018 Sutures removed and wound care instructions with follow up in 3 weeks. FOLLOW UP VISIT OCTOBER 7, 2018 PHYSICIAL EXAM- “The patient does have apparent tendon adhesions with active digital flexion less than passive digital flexion specifically at the PIP joint right can bend him down to 90 degrees but passively he can only get to about 60 degrees. The central slip is intact there is a negative Elson’s test. Sensation is intact to light touch in the median, radial and ulnar nerve distribution.” PLAN: formal therapy with a hand therapist. Dr. Vitale feels this is medically necessary.FOLLOW UP VISIT NOVEMBER 7™ 2018- *(no hand physical therapy evaluation in record since patient did home therapy) — “He does have some pain on the dorsal aspect of the finger when he makes a tight fist, but he thinks this is improving”. “He is now able to bend the PIP joint to 100 degrees and his DIP joint to about 80 degrees. Some pain on the dorsal aspect of the index finger with deep digital flexion.” “Sensation is intact to light touch in the median radial and ulnar nerve distribution.” Plan — Dr. Vitale recommended the continued home exercise program versus formal physical therapy to work on tendon adhesions. Dr. Vitale states “that it is very likely that his symptoms will improve with continued time and stretching.” Follow up in 2 months. FOLLOW UP VISIT JANUARY 10", 2019- Exam reveals stiffness and likely tendon adhesions — He has full digital extension but has a mild deficit in terms of digital flexion. PLAN- recommendation of a certified hand therapist to address the adhesions which are likely the cause of the symptoms. - Apart of the record are prescriptions for a physical hand therapist as well as heat pack the right hand/ index finger. FOLLOW UP VISIT APRIL 29™ 2019- Examination of the right hand some tenderness of the A-1 pulley of the index finger but no frank triggering. *(no formal physical therapy report from a certified hand therapist) to comment on. Patient may have atypical trigger finger which could have developed from the swelling he experienced postoperatively as well as from the initial trauma. Recommendation was a corticosteroid injection. FOLLOW UP VISIT- DECEMBER 10* 2019- He returns for follow up with the complaint that the pain is throbbing and constant. Worse in the cold eliciting pins and needles. Having difficulty holding a drill or a power tool. PHYSICIAL EXAM- stiffness with only about 90 degrees of flexion at the PIP joint in the right index finger compared to 120 in the left. He has 30 degrees of DIP joint flexion of the right index finger compared to 60 degrees in the left index finger. Plan-There is mild permanent disability and a C4.2 form will be filled out quantifying the disability. COMMENTS-Upon review of Mr. Montalbo’s ED visits and consultation visits with Dr. Vitale (including MRI report and pathology report) there is a reasonable degree of medical probability to suggest there was a deviation in the standard of care. Based on the mechanism of injury, namely the hammering of tile causing the laceration, one would think a penetrating injury. An x-ray would rule out a piece penetrating the skin causing the laceration. Dr. Vitale removed the piece of tile on September 7, 2018 and performed a scar revision. During the subsequent visit of October 7", 2018, he states that there are tendon adhesions. A certified hand therapist was recommended. The patient did home therapy instead. The November assessment by Dr. Vitale states that Mr. Montalbo is able to bend the PIP of the affected finger 100 degrees. This is normalflexion of the PIP. He was doing better. Sensation was intact for radial sensory nerve. Continued home therapy was recommended. From the November visit till the January visit it is unclear if therapy was continued. It was at the January visit that Dr. Vitale again recommended that Mr. Montalbo see a certified hand therapist to address his tendon adhesions. The April visit revealed an atypical trigger finger and a cortisone injection into the right flexor tendon sheath was performed. The last physical exam from Dr. Vitale was on December 2019. At that time the record states there is no trigger finger. The patient continues to have some stiffness with only 90 degrees of flexion at the PIP joint in the right index finger. It is here that Dr. Vitale states he has mild permanent disability. He further states he will fill out a C4.2 To conclude, had an x-ray been taken in the ED, the recognition of the foreign body would have been made sooner. It is difficult to determine if the tendon adhesions and the sensory deficits would have occurred even if the foreign body was removed at the time of initial presentation to the ED. These adhesions may have been a consequence of the injury and subsequent recovery regardless of when the foreign body was removed. The home therapy did improve his ability to flex the affected finger as documented at the November visit. | am unable to determine if the adjunctive therapies that a certified hand therapist uses would have improved his overall symptoms and deficits. Regardless, the absence of an x-ray prevented prompt diagnosis of the foreign body. This did prolong his recovery. There is documentation from the Neuro-orthopedist stating he believes there is partial permanent disability. Having carefully and thoroughly reviewed the documents provided to me, | can say with a reasonable degree of medical probability that there was a deviation in the standard of care in the prompt recognition of the foreign body. The relationship between the recognition /removal of the foreign body and the patient’s partial permanent disability cannot be commented on. This is not my role in this report