`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 A
`NYSCI EF DOC. NO. 37
`NYSCEF DOC. NO. 37
`
`IND
`EX NO.
`716814/2020
`INDEX NO. 716814/2020
`
`
` EIVE iD
` EF’:
`
`06/08/2022
`RECEIVED NYSCEF: 06/08/2022
`
` NYSCI
`
`C
`EXHIBIT
`EXHIBIT C
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`TM
`
`Name:
`
`Stephanie
`
`Bertrand
`
`Date:
`
`6/15/2020
`
`Chief
`
`Complaint-
`
`neck
`
`pain,
`
`low back
`
`pain
`
`History
`accident
`
`of present
`
`illness-
`
`patient
`
`is a 35-year-old
`
`female
`
`was
`
`injured
`
`in a motor
`
`vehicle
`
`on 1/21/2020.
`
`Patient
`
`complains
`
`of pain
`
`and
`
`stiffness
`
`in cervical
`
`spine
`
`and
`
`lumbar
`
`spine.
`
`Patient
`
`states
`
`that
`
`the
`
`issue
`
`exercise,
`
`states
`
`that
`
`sitting,
`she
`
`Patient
`
`rates
`
`the
`
`pain
`
`standing,
`
`walking,
`
`has never
`
`had
`
`any
`as a 8 out
`
`is worsening
`repetitive
`
`and
`
`the
`
`pain
`
`keeps
`
`motion
`
`causes
`
`the
`
`pain
`
`her
`
`up at night.
`to become
`worse.
`
`Any
`
`Patient
`
`problems
`
`with
`
`the
`
`neck
`
`or
`
`low back
`
`prior
`
`to this
`
`injury.
`
`of 10.
`
`Patient
`
`is currently
`anti-inflammatories
`
`not working.
`
`The
`
`patient
`
`has been
`
`in
`
`without
`
`relief.
`
`physical
`
`therapy
`
`since
`
`the
`
`accident,
`
`taking
`
`Past Medical
`
`History-denies
`
`Past Surgical
`
`History
`
`denies
`
`Medication-
`
`anti-inflammatories
`
`Allergies-
`
`no Known
`
`drug
`
`allergies
`
`Social/Family
`
`History-
`
`denies
`
`alcohol
`
`tobacco
`
`or drug
`
`abuse
`
`Review
`
`Of systems-
`
`the
`
`patient
`
`denies
`
`any
`
`fever,
`
`chills,
`
`fatigue,
`
`chest
`
`pain,
`
`palpitations,
`
`shortness
`
`of breath,
`
`nausea,
`
`vomiting,
`
`diarrhea,
`
`constipation,
`
`or ataxia.
`
`Physical
`
`Exam-
`
`Mental
`
`status-
`
`alert
`
`and
`
`oriented
`
`×3
`
`Eyes-
`Dr. Joseph W i
`
`ei
`
`clear
`
`reactive
`
`to light
`
`Musculoskeletal-
`
`cervical
`
`spine-skin
`
`is clean
`
`dry
`
`and
`
`intact.
`
`There
`
`is pain
`
`to
`
`palpation
`
`at
`
`the
`
`paraspinal
`
`musculature
`
`of
`
`the
`
`cervical
`
`spine.
`
`Power
`
`is 5 out
`
`of
`
`5. Sensation
`
`is decreased
`
`C4-5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`Hoffmann's.
`
`Positive
`
`sparlings
`
`exam.
`
`Address:
`Office
`68-15 Main Street
`New York
`Flushing,
`
`11367
`
`718.313.0766
`Phone:
`Fax: 347.507.5553
`www.coseny.com
`
`Orthopedic
`Attending
`at
`Surgeon
`Sinai Beth
`Mount
`New York Hospital
`
`Israel
`Queens
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Cervical
`
`Spine
`
`Degree
`
`on Exam
`
`Normal
`
`Range
`
`of
`
`Flexion
`
`Extension
`
`Right
`
`Lateral
`
`Bending
`
`Left
`
`Lateral
`
`Bending
`
`Rotation
`
`to the
`
`right
`
`Rotation
`
`to the
`
`left
`
`40°
`
`40°
`
`25°
`
`30°
`
`60°
`
`55°
`
`Motion
`
`50°
`
`60°
`
`45°
`
`45°
`
`80°
`
`80°
`
`. .
`
`.......
`
`Lumbar
`
`spine-
`
`skin
`
`is clean
`
`dry
`
`and
`
`intact.
`
`There
`
`is pain
`
`to palpation
`
`at
`
`the
`
`paraspinal
`
`musculature
`
`of
`
`the
`
`lumbar
`
`spine.
`
`Power
`
`is 5 out
`
`of 5. Sensation
`
`is decreased
`
`bilateral
`
`L4-L5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`is able
`
`to heel walk
`
`and
`
`toe walk.
`
`Positive
`
`straight
`
`Negative
`
`clonus,
`
`leg raise
`
`test
`
`downgoing
`left
`
`on the
`
`Babinski.
`
`Patient
`
`and
`
`right.
`
`Spine
`
`Lumbar
`
`Flexion
`
`Extension
`
`on Exam
`
`Degree
`50°
`
`10°
`
`5°
`
`Range
`
`of Motior
`
`Normal
`90°
`
`20°
`
`25°
`
`Right
`
`bending
`Left Bendin
`
`g
`
`10°
`
`25°
`
`Radiology
`
`dislocations.
`
`cervical
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures
`
`or
`
`There
`
`is reversal
`
`of
`
`the
`
`normal
`
`cervical
`
`lordosis
`
`Impression
`
`loss
`
`of normal
`
`cervical
`
`lordosis
`
`Lumbar
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures.
`
`Impression
`
`no gross
`
`fractures
`
`lumbar
`
`spine
`
`Diagnosis
`
`cervical
`
`radiculopathy,
`
`lumbar
`
`radiculopathy
`
`P_jan.1
`
`options
`
`for
`
`treatment
`
`and
`
`nontreatment,
`
`possible
`
`risks
`
`and
`
`complications,
`
`and
`
`alternative
`
`treatments
`
`were
`
`discussed.
`
`Current
`
`medications
`
`and
`
`allergies
`
`were
`
`reviewed.
`
`Patient
`
`understood
`
`the
`
`therapeutic
`
`options
`
`and
`
`the
`
`potential
`
`risk
`
`for
`
`having
`
`a treatment
`
`for
`
`the
`
`procedure
`
`performed.
`
`If
`
`the
`
`history
`
`given
`
`by the
`
`patient
`
`is accurate,
`
`then
`
`within
`
`a reasonable
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`degree
`
`of medical
`
`event/accident
`
`certainty
`this
`
`record.
`
`of
`
`the
`
`above
`
`noted
`
`injuries
`
`were
`
`directly
`
`the
`
`result
`
`of
`
`the
`
`2. After
`
`extensive
`
`conversation
`
`regarding
`
`her
`
`diagnosis
`
`and
`
`prognosis
`
`recommend
`
`anti-
`
`inflammatories
`
`as needed
`
`for
`
`pain.
`
`Recommend
`
`Flexeril.
`
`3. Recommend
`
`pain management
`
`consultation
`
`with
`
`epidural
`
`injection.
`
`4. Patient
`
`worse
`
`return
`
`to follow
`
`up after
`immediately.
`
`pain management.
`
`Patient
`
`told
`
`that
`
`if her
`
`pain
`
`or symptoms
`
`get
`
`I am a Physician
`
`licensed
`
`to practice
`
`medicine
`
`in the State
`
`of New York
`
`and
`
`affirm
`
`the
`
`truth
`
`duly
`under
`
`of
`the
`forgoing
`by me and
`is based
`are made
`which
`
`penalty
`on my observation
`within
`a reasonable
`
`the
`
`of perjury.
`
`Pursuant
`
`to CPLR 2106.
`
`This
`
`report
`
`was
`
`prepared
`
`and
`
`treatment
`
`of
`
`the
`
`patient
`
`and
`
`contains
`
`my opinions,
`
`degree
`
`of medical
`
`certainty.
`
`foseph Weinstein
`
`D.O.
`
`Dictated
`
`by Not Proofread
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`ru
`
`Name:
`
`Stephanie
`
`Bertrand
`
`Date:
`
`8/3/2020
`
`Chief
`
`Complaint-
`
`neck
`
`pain,
`
`low back
`
`pain
`
`History
`
`accident
`
`of present
`
`illness-
`
`patient
`
`is a 35-year-old
`
`female
`
`was
`
`injured
`
`in a motor
`
`vehicle
`
`on
`
`1/21/2020.
`
`Patient
`
`complains
`
`of pain
`
`and
`
`stiffness
`
`in cervical
`
`spine
`
`and
`
`lumbar
`
`spine.
`
`Patient
`
`states
`
`that
`
`the
`
`issue
`
`is better
`
`and
`
`the
`
`pain
`
`keeps
`
`repetitive
`
`motion
`
`causes
`
`the
`
`pain
`
`her
`
`up at night.
`to become
`worse.
`
`Any
`Patient
`
`exercise,
`
`states
`
`sitting,
`
`that
`
`she
`
`standing,
`has
`
`never
`
`walking,
`
`had
`
`rates
`
`the
`
`pain
`
`as a 6 out
`
`physical
`
`since
`
`the
`
`accident,
`
`taking
`
`problems
`
`with
`
`the
`
`neck
`
`or
`
`low back
`
`prior
`
`to this
`
`injury.
`
`Patient
`
`any
`of 10.
`
`Patient
`
`is currently
`anti-inflammatories
`
`not working.
`
`The
`
`patient
`
`has been
`
`in
`
`without
`
`relief.
`
`therapy
`
`Past Medical
`
`History-denies
`
`Past Surgical
`
`History
`
`denies
`
`Medication-
`
`anti-inflammatories
`
`Allergies-
`
`no Known
`
`drug
`
`allergies
`
`Social/Family
`
`History-
`
`denies
`
`alcohol
`
`tobacco
`
`or drug
`
`abuse
`
`Review
`
`Of systems-
`
`the
`
`patient
`
`denies
`
`any
`
`fever,
`
`chills,
`
`fatigue,
`
`chest
`
`pain,
`
`palpitations,
`
`shortness
`
`of breath,
`
`nausea,
`
`vomiting,
`
`diarrhea,
`
`constipation,
`
`or ataxia.
`
`Physical
`
`Exam-
`
`Mental
`
`status-
`
`alert
`
`and
`
`oriented
`
`×3
`
`Eyes-
`
`clear
`
`reactive
`
`to light
`
`Dr. Joseph W i
`
`ei
`
`Address:
`Office
`68-15 Main Street
`New York
`Flushing,
`
`11367
`
`718.313.0766
`Phone:
`347.507.5553
`Fax:
`www.coseny.com
`
`Orthopedic
`Attending
`at
`Surgeon
`Sinai Beth
`Mount
`New York Hospital
`
`Israel
`Queens
`
`Musculoskeletal-
`
`cervical
`
`spine-skin
`
`is clean
`
`dry
`
`and
`
`intact.
`
`There
`
`is pain
`
`to
`
`palpation
`
`at
`
`the
`
`paraspinal
`
`musculature
`
`of
`
`the
`
`cervical
`
`spine.
`
`Power
`
`is 5 out
`
`of
`
`5. Sensation
`
`is decreased
`
`C4-5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`Hoffmann's.
`
`Positive
`
`sparlings
`
`exam.
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Cervical
`
`Spine
`
`Degree
`
`on Exam
`
`Range
`
`of
`
`Normal
`
`Motion
`
`Flexion
`
`Extension
`
`Right
`
`Lateral
`
`Bending
`
`Left
`
`Lateral
`
`Bending
`
`Rotation
`
`to the
`
`right
`
`Rotation
`
`to the
`
`left
`
`40°
`
`50°
`
`35°
`
`30°
`
`60°
`
`65°
`
`....
`
`....
`
`50°
`
`60°
`
`45°
`
`45°
`
`80°
`
`80°
`
`Lumbar
`
`spine-
`
`skin
`
`is clean
`
`musculature
`
`of
`
`the
`
`lumbar
`
`and
`
`dry
`spine.
`
`intact.
`
`There
`
`is pain
`
`to palpation
`
`at
`
`the
`
`paraspinal
`
`Power
`
`is 5 out
`
`of 5. Sensation
`
`is decreased
`
`bilateral
`
`L4-L5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`is able
`
`to heel walk
`
`and
`
`toe walk.
`
`Positive
`
`straight
`
`Negative
`
`clonus,
`
`leg raise
`
`test
`
`downgoing
`on the
`
`left
`
`Babinski.
`
`Patient
`
`and
`
`right.
`
`Spine
`
`Lumbar
`
`Flexion
`
`Extension
`
`on Exam
`
`Degree
`55°
`
`10°
`
`Range
`
`of Motion
`
`Normal
`90°
`
`20°
`
`25°
`
`Right
`bending
`Left Bending
`
`10°
`
`10°
`
`25°
`
`Radiology
`
`dislocations.
`
`cervical
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures
`
`or
`
`There
`
`is reversal
`
`of
`
`the
`
`normal
`
`cervical
`
`lordosis
`
`Impression
`
`loss
`
`of
`
`normal
`
`cervical
`
`lordosis
`
`Lumbar
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures.
`
`Impression
`
`no gross
`
`fractures
`
`lumbar
`
`spine
`
`Diagnosis
`
`cervical
`
`radiculopathy,
`
`lumbar
`
`radiculopathy
`
`Plan
`
`1 options
`
`for
`
`treatment
`
`and
`
`nontreatment,
`
`possible
`
`risks
`
`and
`
`complications,
`
`and
`
`alternative
`
`treatments
`
`were
`
`discussed.
`
`Current
`
`medications
`
`and
`
`allergies
`
`were
`
`reviewed.
`
`Patient
`
`understood
`
`the
`
`therapeutic
`
`options
`
`and
`
`the
`
`potential
`
`risk
`
`for
`
`procedure
`
`performed.
`
`If
`
`the
`
`history
`
`given
`
`by the
`
`patient
`
`is accurate,
`
`having
`then
`within
`
`a treatment
`
`for
`
`the
`
`a reasonable
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Tu
`
`Name:
`
`Stephanie
`
`Bertrand
`
`Date:
`
`11/16/2020
`
`Chief
`
`Complaint-
`
`neck
`
`pain,
`
`low back
`
`pain
`
`History
`accident
`
`of present
`
`illness-
`
`patient
`
`is a 35-year-old
`
`female
`
`was
`
`injured
`
`in a motor
`
`vehicle
`
`on 1/21/2020.
`
`Patient
`
`complains
`
`of pain
`
`and
`
`stiffness
`
`in cervical
`
`spine
`
`and
`
`lumbar
`
`spine.
`
`Patient
`
`states
`
`that
`
`the
`
`issue
`
`exercise,
`
`sitting,
`
`states
`
`that
`
`she
`
`standing,
`has never
`
`Patient
`
`rates
`
`the
`
`pain
`
`physical
`
`walking,
`
`had
`
`any
`as a 8 out
`
`is getting
`repetitive
`
`worse
`
`and
`
`the
`
`pain
`
`keeps
`
`motion
`
`causes
`
`the
`
`pain
`
`her
`
`up at night.
`worse.
`to become
`
`Any
`Patient
`
`problems
`
`with
`
`the
`
`neck
`
`or
`
`low back
`
`prior
`
`to this
`
`injury.
`
`of 10.
`
`Patient
`
`not working.
`
`The
`
`patient
`
`has been
`
`in
`
`relief.
`
`Patient
`
`complains
`
`therapy
`increased
`pain
`
`of
`
`since
`
`the
`
`accident,
`
`after
`
`cervical
`
`is currently
`anti-inflammatories
`
`without
`
`taking
`discectomy.
`
`Past Medical
`
`History-denies
`
`Past Surgical
`
`History
`
`denies
`
`Medication-
`
`anti-inflammatories
`
`Allergies-
`
`no Known
`
`drug
`
`allergies
`
`Social/Family
`
`History-
`
`denies
`
`alcohol
`
`tobacco
`
`or drug
`
`abuse
`
`Review
`
`Of systems-
`
`the
`
`patient
`
`denies
`
`any
`
`fever,
`
`chills,
`
`fatigue,
`
`chest
`
`pain,
`
`palpitations,
`
`shortness
`
`of breath,
`
`nausea,
`
`vomiting,
`
`diarrhea,
`
`constipation,
`
`or ataxia.
`
`Physical
`
`Exam-
`
`Mental
`
`status-
`
`alert
`
`and
`
`oriented
`
`×3
`
`Dr. Joseph
`
`V4YSReislear
`
`reactive
`
`to light
`
`Musculoskeletal-
`
`cervical
`
`spine-skin
`
`is clean
`
`palpation
`
`at
`
`the
`
`paraspinal
`
`musculature
`
`of
`
`dry
`the
`
`and
`
`intact.
`
`There
`
`is pain
`
`to
`
`cervical
`
`spine.
`
`Power
`
`is 5 out
`
`of
`
`Addre4Veck-
`Office
`68-15 Main Street
`New York
`Flushing,
`
`supple
`
`11367
`
`718.313.0766
`Phone:
`Fax: 347.507.5553
`www.coscny.com
`
`Orthopedic
`Attending
`at
`Surgeon
`Sinai Beth
`Mount
`New York Hospital
`
`Israel
`Queens
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`5. Sensation
`
`is decreased
`
`C4-5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`Hoffmann's.
`
`Positive
`
`sparlings
`
`exam.
`
`Cervical
`
`Spine
`
`Degree
`
`on Exam
`
`Normal
`
`Range
`
`of
`
`Flexion
`
`Extension
`
`Right
`
`Lateral
`
`Bending
`
`Left
`
`Lateral
`
`Bending
`
`Rotation
`
`to the
`
`right
`
`Rotation
`
`to the
`
`left
`
`30°
`
`40°
`
`25°
`
`30°
`
`50°
`
`45°
`
`Motion
`
`..._
`
`50°
`
`60°
`
`45°
`
`45°
`
`80°
`
`80°
`
`. .
`
`Lumbar
`
`spine-
`
`skin
`
`is clean
`
`dry
`
`and
`
`intact.
`
`There
`
`is pain
`
`to palpation
`
`at
`
`the
`
`paraspinal
`
`musculature
`
`distribution.
`
`is able
`
`to
`
`of
`
`the
`
`lumbar
`
`spine.
`
`Power
`
`is 5 out
`
`of 5. Sensation
`
`is decreased
`
`bilateral
`
`L4-L5
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`clonus,
`
`downgoing
`
`Babinski.
`
`Patient
`
`and
`
`right.
`
`heel walk
`
`and
`
`toe walk.
`
`Positive
`
`straight
`
`leg raise
`
`test
`
`on the
`
`left
`
`Spine
`
`Lumbar
`
`Flexion
`
`Extension
`
`Right
`bending
`Left Bending
`
`Degree
`50°
`
`on Exam
`
`5°
`
`10°
`
`10°
`
`Range
`
`of Mo_tion
`
`Normal
`90°
`
`20°
`
`25°
`
`25°
`
`Radiology
`
`dislocations.
`
`cervical
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures
`
`or
`
`There
`
`is reversal
`
`of
`
`the
`
`normal
`
`cervical
`
`lordosis
`
`Impression
`
`loss
`
`of normal
`
`cervical
`
`lordosis
`
`Lumbar
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures.
`
`Impression
`
`no gross
`
`fractures
`
`lumbar
`
`spine
`
`Diagnosis
`
`cervical
`
`radiculopathy,
`
`lumbar
`
`radiculopathy
`
`Plan
`
`1 options
`
`for
`
`treatment
`
`and
`
`nontreatment,
`
`possible
`
`risks
`
`and
`
`complications,
`
`and
`
`alternative
`
`treatments
`
`were
`
`discussed.
`
`Current
`
`medications
`
`and
`
`allergies
`
`were
`
`reviewed.
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Patient
`
`understood
`
`the
`
`therapeutic
`
`options
`
`and
`
`the
`
`potential
`
`risk
`
`for
`
`a treatment
`
`for
`
`the
`
`having
`within
`
`then
`
`a reasonable
`
`procedure
`
`performed.
`
`If
`
`the
`
`history
`
`degree
`
`of medical
`
`certainty
`
`the
`
`above
`
`event/accident
`
`of
`
`this
`
`record.
`
`given
`
`by the
`injuries
`noted
`
`patient
`
`is accurate,
`
`were
`
`directly
`
`the
`
`result
`
`of
`
`the
`
`2. After
`
`extensive
`
`conversation
`
`regarding
`
`her
`
`diagnosis
`
`and
`
`prognosis
`
`recommend
`
`repeat
`
`MRI
`
`cervical
`
`of
`
`the
`
`spine.
`
`3. Recommend
`
`patient
`
`follow-up
`
`worse
`
`return
`
`immediately.
`
`with
`
`the MRI.
`
`Patient
`
`told
`
`that
`
`if her
`
`pain
`
`or symptoms
`
`get
`
`I am a Physician
`
`licensed
`
`to practice
`
`medicine
`
`in the State
`
`of New York
`
`and
`
`affirm
`
`the
`
`truth
`
`duly
`under
`
`of
`the
`forgoing
`by me and
`is based
`which
`are made
`
`penalty
`on my observation
`a reasonable
`within
`
`the
`
`of perjury.
`
`Pursuant
`
`to CPLR 2106.
`
`This
`
`report
`
`was
`
`prepared
`
`and
`
`treatment
`
`of
`
`the
`
`patient
`
`and
`
`contains
`
`my opinions,
`
`degree
`
`of medical
`
`certainty.
`
`Joseph Weinstein
`
`D.O.
`
`Dictated
`
`by Not Proofread
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Tu
`
`Name:
`
`Stephanie
`
`Bertrand
`
`Date:
`
`12/7/2020
`
`Chief
`
`Complaint-
`
`neck
`
`pain,
`
`low back
`
`pain
`
`History
`
`accident
`
`of present
`
`illness-
`
`patient
`
`is a 35-year-old
`
`female
`
`was
`
`injured
`
`in a motor
`
`vehicle
`
`on 1/21/2020.
`
`Patient
`
`complains
`
`of pain
`
`and
`
`stiffness
`
`in cervical
`
`spine
`
`and
`
`lumbar
`
`spine.
`
`Patient
`
`states
`
`that
`
`the
`
`issue
`
`exercise,
`
`states
`
`that
`
`sitting
`she
`
`, standing,
`has
`
`never
`
`Patient
`
`rates
`
`the
`
`pain
`
`walking,
`
`had
`
`any
`as a 8 out
`
`physical
`
`the
`
`is staying
`repetitive
`
`the
`
`same
`
`the
`
`pain
`
`keeps
`
`motion
`
`causes
`
`the
`
`pain
`
`her
`
`up at night.
`to become
`worse.
`
`Any
`Patient
`
`problems
`
`with
`
`the
`
`neck
`
`or
`
`low back
`
`prior
`
`to this
`
`injury.
`
`of 10.
`
`Patient
`
`is currently
`anti-inflammatories
`
`not working.
`
`The
`
`patient
`
`has been
`
`in
`
`without
`
`relief.
`
`Patient
`
`returns
`
`therapy
`MRI.
`Patient
`
`after
`
`since
`
`accident,
`
`taking
`
`denies
`
`any
`
`fever
`
`chills
`
`or
`
`recent
`
`sickness.
`
`Past Medical
`
`History-denies
`
`Past Surgical
`
`History
`
`denies
`
`Medication-
`
`anti-inflammatories
`
`Allergies-
`
`no Known
`
`drug
`
`allergies
`
`Social/Family
`
`History-
`
`denies
`
`alcohol
`
`tobacco
`
`or drug
`
`abuse
`
`Review
`
`Of systems-
`
`the
`
`patient
`
`denies
`
`any
`
`fever,
`
`chills,
`
`fatigue,
`
`chest
`
`pain,
`
`palpitations,
`
`shortness
`
`of breath,
`
`nausea,
`
`vomiting,
`
`diarrhea,
`
`constipation,
`
`or ataxia.
`
`Physical
`
`Exam-
`
`Mental
`
`status-
`
`alert
`
`and
`
`oriented
`
`×3
`
`Dr. Joseph
`
`V4193eif,iear
`
`reactive
`
`to light
`
`Musculoskeletal-
`
`cervical
`
`spine-skin
`
`.
`
`.
`is clean
`
`dry
`
`and
`
`intact.
`
`There
`
`is pain
`
`to
`
`palpation
`
`at
`
`the
`
`paraspinal
`
`musculature
`
`of
`
`the
`
`cervical
`
`spine.
`
`Power
`
`is 5 out
`
`of
`
`Addres Meck-
`Office
`68-15 Main Street
`New York
`Flushing,
`
`supple
`
`11367
`
`718.313.0766
`Phone:
`Fax: 347.507.5553
`www.coscny.com
`
`Orthopedic
`Attending
`at
`Surgeon
`Sinai Beth
`Mount
`New York Hospital
`
`Israel
`Queens
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`5. Sensation
`
`is decreased
`
`C4-5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`Hoffmann's.
`
`Positive
`
`sparlings
`
`exam.
`
`Cervical
`
`Spine
`
`Degree
`
`on Exam
`
`Normal
`
`Range
`
`of
`
`Flexion
`
`Extension
`
`Right
`
`Lateral
`
`Bending
`
`Left
`
`Lateral
`
`Bending
`
`Rotation
`
`to the
`
`right
`
`Rotation
`
`to the
`
`left
`
`30°
`
`35°
`
`25°
`
`30°
`
`50°
`
`45°
`
`.
`
`..
`
`Motion
`
`50°
`
`60°
`
`45°
`
`45°
`
`80°
`
`80°
`
`...
`
`. .
`
`..
`
`. .. .._
`
`Lumbar
`
`spine-
`
`skin
`
`is clean
`
`musculature
`
`of
`
`the
`
`lumbar
`
`and
`
`dry
`spine.
`
`intact.
`
`There
`
`is pain
`
`to palpation
`
`at
`
`the
`
`paraspinal
`
`Power
`
`is 5 out
`
`of 5. Sensation
`
`is decreased
`
`bilateral
`
`L4-L5
`
`distribution.
`
`is able
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`clonus,
`
`Babinski.
`
`Patient
`
`right.
`
`to heel walk
`
`and
`
`toe walk.
`
`Positive
`
`straight
`
`leg raise
`
`test
`
`downgoing
`on the
`left
`
`and
`
`Spine
`
`Lumbar
`
`Flexion
`
`Extension
`
`Right
`bending
`Left Bending
`
`Degree
`50°
`
`on Exam
`
`5°
`
`10°
`
`10°
`
`Range
`
`of Motion
`
`Normal
`90°
`
`20°
`
`25°
`
`25°
`
`Radiology
`
`dislocations.
`
`cervical
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures
`
`or
`
`There
`
`is reversal
`
`of
`
`the
`
`normal
`
`cervical
`
`lordosis
`
`Impression
`
`loss
`
`of normal
`
`cervical
`
`lordosis
`
`Lumbar
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures.
`
`Impression
`
`no gross
`
`fractures
`
`lumbar
`
`spine
`
`Diagnosis
`
`cervical
`
`radiculopathy,
`
`lumbar
`
`radiculopathy
`
`Plan_1
`
`options
`
`for
`
`treatment
`
`and
`
`nontreatment,
`
`possible
`
`risks
`
`and
`
`complications,
`
`and
`
`alternative
`
`treatments
`
`were
`
`discussed.
`
`Current
`
`medications
`
`and
`
`allergies
`
`were
`
`reviewed.
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Patient
`
`understood
`
`the
`
`therapeutic
`
`options
`
`and
`
`the
`
`potential
`
`risk
`
`for
`
`a treatment
`
`for
`
`the
`
`having
`then
`
`within
`
`a reasonable
`
`procedure
`
`performed.
`
`If
`
`the
`
`history
`
`degree
`
`of medical
`
`event/accident
`
`certainty
`this
`record.
`
`of
`
`the
`
`above
`
`given
`
`by the
`noted
`injuries
`
`patient
`
`is accurate,
`
`were
`
`directly
`
`the
`
`result
`
`of
`
`the
`
`2. After
`
`extensive
`
`conversation
`
`regarding
`
`her
`
`diagnosis
`
`and
`
`prognosis
`
`reviewed
`
`MRI
`
`study.
`
`Recommend
`
`Recommend
`
`patient
`
`go to the
`
`room for
`
`possible
`
`osteomyelitis
`
`of
`
`the
`
`neck.
`
`of
`
`the
`
`MRI with
`
`emergency
`and without
`
`contrast
`
`of
`
`the
`
`cervical
`
`spine.
`
`Recommend
`
`CAT scan
`
`cervical
`
`spine.
`
`Recommend
`
`ESR CRP and CBC.
`
`3. Recommend
`
`patient
`
`follow-up
`
`worse
`
`return
`
`immediately.
`
`after
`
`workup.
`
`Patient
`
`told
`
`that
`
`if her
`
`pain
`
`or symptoms
`
`get
`
`I am a Physician
`
`licensed
`
`to practice
`
`medicine
`
`in the State
`
`of New York
`
`and
`
`affirm
`
`the
`
`truth
`
`duly
`under
`
`of
`the
`forgoing
`by me and
`is based
`are made
`which
`
`penalty
`on my observation
`within
`a reasonable
`
`the
`
`of perjury.
`
`Pursuant
`
`to CPLR 2106.
`
`This
`
`report
`
`was
`
`prepared
`
`and
`
`treatment
`
`of
`
`the
`
`patient
`
`and
`
`contains
`
`my opinions,
`
`degree
`
`of medical
`
`certainty.
`
`Joseph Weinstein
`
`D.O.
`
`Dictated
`
`by Not Proofread
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Name:
`
`Stephanie
`
`Bertrand
`
`Date:
`
`12/11/2020
`
`Chief
`
`Complaint-
`
`neck
`
`pain,
`
`low back
`
`pain
`
`History
`accident
`
`of present
`
`illness-
`
`patient
`
`is a 35-year-old
`
`female
`
`was
`
`injured
`
`in a motor
`
`vehicle
`
`on 1/21/2020.
`
`Patient
`
`complains
`
`of pain
`
`and
`
`stiffness
`
`in cervical
`
`spine
`
`and
`
`lumbar
`
`spine.
`
`Patient
`
`states
`
`that
`
`the
`
`issue
`
`exercise,
`
`sitting,
`
`states
`
`that
`
`she
`
`standing,
`has
`
`never
`
`Patient
`
`rates
`
`the
`
`pain
`
`walking,
`
`had
`
`any
`as a 8 out
`
`physical
`
`since
`
`the
`
`is staying
`repetitive
`
`the
`
`same
`
`the
`
`pain
`
`keeps
`
`motion
`
`causes
`
`the
`
`pain
`
`her
`
`up at night.
`to become
`worse.
`
`Any
`
`Patient
`
`problems
`
`with
`
`the
`
`neck
`
`or
`
`low back
`
`prior
`
`to this
`
`injury.
`
`of 10.
`
`Patient
`
`is currently
`anti-inflammatories
`
`not working.
`
`The
`
`patient
`
`has been
`
`in
`
`Patient
`
`returns
`
`after
`
`MRI
`
`therapy
`and CAT scan.
`
`Past Medical
`
`History-denies
`
`accident,
`
`Patient
`
`taking
`denies
`
`any
`
`without
`
`relief.
`
`fever
`
`chills
`
`or
`
`recent
`
`sickness.
`
`Past Surgical
`
`History
`
`denies
`
`Medication-
`
`anti-inflammatories
`
`Allergies-
`
`no Known
`
`drug
`
`allergies
`
`Social/Family
`
`History-
`
`denies
`
`alcohol
`
`tobacco
`
`or drug
`
`abuse
`
`Review
`
`Of systems-
`
`the
`
`patient
`
`denies
`
`any
`
`fever,
`
`chills,
`
`fatigue,
`
`chest
`
`pain,
`
`palpitations,
`
`shortness
`
`of breath,
`
`nausea,
`
`vomiting,
`
`diarrhea,
`
`constipation,
`
`or ataxia.
`
`Physical
`
`Exam-
`
`Mental
`
`status-
`
`alert
`
`and
`
`oriented
`
`×3
`
`Dr. Joseph
`
`V4Weislear
`
`reactive
`
`to light
`
`Musculoskeletal-
`
`cervical
`
`spine-skin
`
`is clean
`
`palpation
`
`at
`
`the
`
`paraspinal
`
`musculature
`
`of
`
`dry
`the
`
`and
`
`intact.
`
`There
`
`is pain
`
`to
`
`cervical
`
`spine.
`
`Power
`
`is 5 out
`
`of
`
`Addrespreck-
`Office
`68-15 Main Street
`New York
`Flushing,
`
`supple
`
`11367
`
`718.313.0766
`Phone:
`347.507.5553
`Fax:
`www.coseny.com
`
`Orthopedic
`Attending
`at
`Surgeon
`Sinai Beth
`Mount
`New York Hospital
`
`Israel
`Queens
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`5. Sensation
`
`is decreased
`
`C4-5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`Hoffmann's.
`
`Positive
`
`sparlings
`
`exam.
`
`Cervical
`
`Spine
`
`Degree
`
`on Exam
`
`Normal
`
`Range
`
`of
`
`Flexion
`
`Extension
`
`Right
`
`Lateral
`
`Bending
`
`Left
`
`Lateral
`
`Bending
`
`Rotation
`
`to the
`
`right
`
`Rotation
`
`to the
`
`left
`
`25°
`
`35°
`
`25°
`
`30°
`
`45°
`
`45°
`
`Motion
`
`50°
`
`60°
`
`45°
`
`45°
`
`80°
`
`80°
`
`Lumbar
`
`spine-
`
`skin
`
`is clean
`
`musculature
`
`of
`
`the
`
`lumbar
`
`and
`
`dry
`spine.
`
`intact.
`
`There
`
`is pain
`
`to palpation
`
`at
`
`the
`
`paraspinal
`
`Power
`
`is 5 out
`
`of 5. Sensation
`
`is decreased
`
`bilateral
`
`L4-L5
`
`distribution.
`
`Reflexes
`
`are
`
`brisk
`
`and
`
`symmetrical.
`
`Negative
`
`is able
`
`to heel walk
`
`and
`
`clonus,
`
`test
`
`Babinski.
`
`Patient
`
`and
`
`right.
`
`toe walk.
`
`Positive
`
`straight
`
`leg raise
`
`downgoing
`on the
`left
`
`Degree
`50°
`
`on Exam
`
`5°
`
`10°
`
`10°
`
`Range
`
`of Motion
`
`Normal
`90°
`
`20°
`
`25°
`
`25°
`
`Spine
`
`Lumbar
`
`Flexion
`
`Extension
`
`Right
`bending
`Left Bending
`
`Radiology
`
`cervical
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures
`
`or
`
`dislocations.
`
`There
`
`is reversal
`
`of
`
`the
`
`normal
`
`cervical
`
`lordosis
`
`Impression
`
`loss
`
`of normal
`
`cervical
`
`lordosis
`
`Lumbar
`
`spine
`
`AP and
`
`lateral
`
`flexion
`
`and
`
`extension
`
`shows
`
`no gross
`
`fractures.
`
`Impression
`
`no gross
`
`fractures
`
`lumbar
`
`spine
`
`Diagnosis
`
`cervical
`
`radiculopathy/rule
`
`out
`
`osteomyelitis/discitis,
`
`lumbar
`
`radiculopathy
`
`Plan
`
`1 options
`
`for
`
`treatment
`
`and
`
`nontreatment,
`
`possible
`
`risks
`
`and
`
`complications,
`
`and
`
`alternative
`
`treatments
`
`were
`
`discussed.
`
`Current
`
`medications
`
`and
`
`allergies
`
`were
`
`reviewed.
`
`
`
`FILED: QUEENS COUNTY CLERK 06/08/2022 09:42 AM
`NYSCEF DOC. NO. 37
`
`INDEX NO. 716814/2020
`
`RECEIVED NYSCEF: 06/08/2022
`
`Patient
`
`understood
`
`the
`
`therapeutic
`
`options
`
`and
`
`the
`
`potential
`
`risk
`
`for
`
`having
`
`a treatment
`
`for
`
`the
`
`procedure
`
`performed.
`
`If
`
`the
`
`history
`
`degree
`
`of medical
`
`event/accident
`
`certainty
`this
`record.
`
`of
`
`the
`
`above
`
`given
`
`by the
`noted
`injuries
`
`patient
`
`is accurate,
`
`then
`
`within
`
`a reasonable
`
`were
`
`directly
`
`the
`
`result
`
`of
`
`the
`
`2. After
`
`extensive
`
`conversation
`
`regarding
`
`her
`
`diagnosis
`
`and
`
`prognosis
`
`reviewed
`
`all
`
`imaging
`
`studies.
`
`Discussed
`
`MRI
`
`and CAT scan
`
`radiologists.
`
`Recommend
`
`patient
`
`proceed
`
`to the
`
`emergency
`
`room
`
`for
`
`rule
`
`out
`
`discitis
`
`with
`
`infectious
`
`disease
`
`workup.
`
`3. Recommend
`
`patient
`
`follow-up
`
`worse
`
`return
`
`immediately.
`
`after
`
`workup.
`
`Patient
`
`told
`
`that
`
`if her
`
`pain
`
`or symptoms
`
`get
`
`I am a Physician
`
`duly
`
`licensed
`
`to practice
`
`medicine
`
`in the State
`
`of New York
`
`and
`
`affirm
`
`the
`
`truth
`
`under
`
`of
`the
`forgoing
`by me and
`is based
`are made
`which
`
`penalty
`on my observation
`within
`a reasonable
`
`the
`
`of perjury.
`
`Pursuant
`
`to CPLR 2106.
`
`This
`
`report
`
`was
`
`prepared
`
`and
`
`treatment
`
`of
`
`the
`
`patient
`
`and
`
`contains
`
`my opinions,
`
`degree
`
`of medical
`
`certainty.
`
`Joseph Weinstein
`
`D.O.
`
`Dictated
`
`by Not Proofread
`
`