1 NewYork-Presbyterian The University Hospital of Columbia and Cornell

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1 FILED: KINGS COUNTY CLERK 03/08/ :18 PM INDEX NO /2014 NYSCEF DOC. NO. 67 RECEIVED NYSCEF: 03/08/ NewYork-Presbyterian The University Hospital of Columbia and Cornell Dear. Sir/Madam: Please be advised that we only certify the medical records in response to a court ordered subpoena. Thank you. Medical Correspondence Unit NewYork-Presbyterian Hospital

2 'An MRN: NY-Presbyterian Weill Visit: il. Ge nder: Female Cornell Age: 2y6m -2012) 1 1 Location: Cardiology, i Pediatric *****************************-**************************************************************** Ped Neurology CEC Attending Note [Authored: 14-Sep :59]- for Visit: , Complete, Entered, Signed in Full, General Start Date: September 13, 2012 End Date: September 14, :30 Clinical Diagnosis: Convulsions. History: 2 month old ex-36.5 week girl induced at birth due to decreased fetal movements with possible hemorrhage on prior OSH MRI with, h/o apneic episodes, eye deviation, and staring with shaking episodes concerning for apneic seizures. Exam is normal except for subtle left 6th nerve palsy. Video EEG monitoring due to capture/characterize events and background. Medications: No AEDs. CONDITIONS OF RECORDING: The XLTEK 32 channel computerized EEG was performed using scalp surface recording electru des placed according to the 10/20 international system. Neonatal referential and bipolar montages, and cardiac rhythm monitoring, were employed. FINDINGS: The recording was well organized, continuous, with a normal admixture of frequencies and range of amplitude plus symmetry for age. There was anterior and central beta bilaterally. There was normal cycling between awake and sleep states. SLOWING: Abnormal slowing did not occur. PAROXYSMAL ACTIVITY: Paroxysmal activity did not occur. CLINICAL EVENTS: There were several events of arm jerking and one brief event of perioral cyanosis on 9/14, none of which had an electrographic correlate. SPECIAL FINDINGS: A single lead EKG tracing showed a normal sinus rhythm. Requested by: Ngang, Divine (Med Rcds), 09-Jan :15 Page 16 of 75 2

3 MRN: Visit: Age: 2y6m 2012) Gender: Fethale NY-Presbyterian Weill Cornell Location: Cardiology Pediatric IMPRESSION: This is a normal continuous video EEG, with the patient in the awake and sleep states. Events of arm jerking and perioral cyanosis did not have an electrographic correlate. Electronic Signatures: Paolicchi, Juliann Marie (MD)(Signed 15-Sep :02) Authored Last Updated: 15-Sep :02 *************Or****************************************************************Ir********************* Attending Note [Authored: 14-Sep :111- for Visit: , Complete, Entered, Signed in Full, General PICU Attending Progress Note History reviewed. Patient examined. Case discussed with PICU team. Please see residents note for full details. s a 2 month old female admitted for evaluation of cyanotic episodes. Condition guarded due `To potential for respiratory deterioration. Interval Hx: Clinically well-appearing, Feeding easily. Social smile. No documented events since admission. CXR WNL. Flex laryngoscopy WNL. Neuro exam WNL (except for possible mild CN6 palsy), No evidence of dyshythmia on telemetry. TFT's WNL. EEG and UGI today, On twice daily PPI. Plan for DL-bronch Monday am. Physical Exam: Vital signs as charted. General: WNWD infant, in no distress. HEENT: NCAT, AFOF, PERRL, sclera and conj clear, nose and pharynx clear, MMM. Neck: supple, no LA. CV: RRR, n1 s1 and s2, no murmurs, strong peripheral pulses, warm and well-perfused. Lungs: CTAB; no wheezing, crackles, tachypnea, or retractions. Abdomen: soft, nt, nd, NABS, no HSM. Genitalia: tanner 1 female, Ext: wwp, brisk cap refill. Skin: clear, warm, and dry. Neuro: alert, vigorous infant. PERRL. Face symmetrical. Normal tone. Moving all extremities equally. +Moro. +Grasp. Strong suck. Social smile. 1. Requested by: Ngang, Divine (Med Rods), 09-Jan :15 Page 17 of 75 3

4 1 i MRN: A 1 ',- N Y: -Presbytenan Weill.., Visit i Gender: Female i Cornell Age: 2y6m gergeff-2012) i Location: Cardiology t i. i Pediatric Pt taken to MRI with Simone, PNP. Given chloral hydrate by PNP prior to procedure. Mother at ledside, updated on plan and accompained pt to procedure. Pt care transferred of Simone PNP. Electronic Signatures: Peck, Colleen (Nurse) (Signed 21-Sep :04) Authored Last Updated: 21 -Sep :04 **********************************11-*****I1+*****************************v1-***11.************************ NYP Discharge Summary Note [Authored: 21-Sep :401- for Visit: , Complete, Not Revised, Signed in Full, General Hospital Information: Date of Admission: Admission Date/Time: 13-Sep :00:00 PM. Reason for Admission: Reason for Admission: Investigation of Cyanotic Episodes. Progress Towards Hospital Goals/Plan: The following goal(s) of this hospitalization were met. To perform a diagnostic or surgical procedure. Physical Condition Upon Discharge: Good. Psychosocial Status Upon Discharge: Good. Date of Discharge: Discharge Date: 24-Sep-2012 Time:. Provider: Attending of Record: Dr. Veler. Discharge Diagnosis: Include health problems pertinent to this admission Central Sleep apnea of the newborn. Procedures: Direct iaryngoscopy, Bronchoscopy Sleep study Video EEG Swallow evaluation MRI Chest. Admitting History and Physical: CC Noisy breathing and blue discoloration HPI his a 2 mo F who is an ex-36.5 week premie who has intermittent episodes of noisy breathing and stridor associated with perioral and facial cyanosis at least once daily. She was born by an induced vaginal delivery and she was in the NICU for 3 days at an OSH, was i Requested by: Ngang, Divine (Med Rcds), 09-Jan :16 Page 21 of 51 4

5 MRN: NY-Presbyterian Weill -- Visit: Gender: e Cornell Age: 2y6m (1012) Location: Cardiology! Pediatric discharged home for 1 night, and then was admitted for 2 weeks after turning blue at home. She has been at home on a monitor since that discharge. She has cyanosis at least daily when she gets agitated and has tachycardia. Today she was at her outpatient pulmonology visit with Dr. Stone who called us to admit her. She has also had seizure-like activity in the past, the most recent was yesterday when she had an episode of whole body shaking and staring, and she has had an MRI and a VEEG that reportedly were both abnormal. She has also had a ph probe. New Born screen ne ative. PMH has had many symptoms since birth but has not had any firm diagnoses yet. Shas had episodes of turning blue at least once daily since she has been born and discharged from the hospital. She has a monitor at home and she desaturates down to the 60s intermittently. Her mother reports that a cardiologist told her that'll/had a hole in her heart based on echo and that she would need to follow-up, and she had an echo here 9/6 with Dr. Steinberg that was normal, an EKG, and a hotter monitor at home. She has had seizure-like activity and has had an MRI and VEEG that both reportedly revealed abnormalities, Family History: Family History: Mother: Alive Age: Well. Father: Alive Age: Well. Sisters: # of sisters: Ages: Ava has one older sister who is well.medical Problems: None. Non contributory. Social History: Social History: Living Situation: With family/friends Home Services: Home pulse oximeter monitor Relationship: Single Review of Systems: Review of Systems: Constitutional remarkable Specify:Turns blue when agitated Eyes unremarkable ENT unremarkable CV remarkable Specify:Perioral and facial cyanosis when she gets agitated Resp remarkable Specify: Intermittent stridor and noisy breathing GI unremarkable GU unremarkable Integumentary remarkable Specify:Turns blue periorally and on her face at least once a day Neuro remarkable Specify:Seizure-like activity with episodes of whole body movements and staring Psych unremarkable Endocrine unremarkable Heme/lymph unremarkable Allergy/Immunology unremarkable Allergies: Allergen/Product No Known Allergies Requested by: Ngang, Divine (Med Rcds), 09-Jan :16 Page 22 of 51 I 5

6 1.111R: NY-Presbyterian Weill Visit: Gender: Femaie Cornell Age: 2y6m (iggii-2012) Location: Cardiology Pediatric i Outpatient Medication Profile: * No Current Medications as of 13-Sep :52 documented in Structured Notes Flowsheet Data: I & O Summary [retrieved fori at 13 Sep :13]: 24h Total ( IN I OUT I NET ): II 0 Since 7A Today ( IN I OUT I NET ): +240 I -35 II 205. Physical Exam: sical Exam General: Mr is in no acute distress and is alert and interactive. HEENT: Anterior fontanelle is open and flat. Eyes have positive red reflex bilaterally. No scleral icterus. Moist mucous membranes. Normal oral cavity. Nares patent. Tympanic membranes have positive light reflex. CV: RRR, S1 and S2 present, no murmurs, rubs, or gallops appreciated. Pulses present and equal bilaterally. Capillary refill < 2 seconds. Resp: Lungs clear to auscultation bilaterally. No wheezes, rhonchi, or rales. Abdomen: Soft, nontender, nondistended, no HSM. BS present bilaterally. GU: Normal female external genitalia. Anus patent, no sacral pit. Extremities: No edema, no cyanosis or clubbing. Well perfused. Neuro: Strong suck, good moro reflex, cranial nerves intact. Normal extraocular movement. Full range of motion of extremities, strength 5/5. Skin: No rashes or lesions. Radiology/Other Results: 09/13/2012 CXR Clinical statement: History of noisy breathing, intermittent stridor. Technique: PA and lateral views of the chest. Comparison: None ' Findings: The lungs are clear. There is no pneumothorax or pleural effusion. The cardiomediastinal silhouette is within normal limits. Impression: No evidence of acute cardiopulmonary disease. Allergies: No Known Allergies Wov.W.W. Allergen/Product Hospital Course: Summary of Cornell Admission Consultations: - Cardiology (Dr Steinberg), Neurology (Dr Merchant), ENT (Dr Modi), Pulmonology (Dr Merchant) V.S.O.Weee u Yeeneeetelennre..*VoYeee,Vb: lee,leenar*,,,,,,r.t.wer.v.w.m.yree..efee...y.wwleanwedvetennehybrie.v.imarior...1,61.w.i.vveee. Investigations: - Echo 9/6: Normal, closed PFO. Repeat on 9/18 shows normal left-sided arch, normal great vessels. Requested by: Ngang, Divine (Med Rcds), 09-Jan-2015 Page 23 of 51 6

7 i MRN: Visit: Age: 2y6m ( ) Gender: Female NY-Presbyterian Weill Cornell Location: Cardiology Pediatric - 24h Home hotter monitor 9/7 showed sinus tachycardia with an averageheart rate around 163 or 180 and a min hr of 109 and a max hr of 213, according to Dr. Steinberg - Barium: Esophagogram 9/14: Normal swallow. Small amount of reflux in distal esophagus, commenced on Lansoprazole q12h. Flex larygngoscopy 9/13: Normal - veeg 9/16 repeated here: normal study, no correlation with push-button events - DL Bronchoscopy 9/17: Bronchomalacia in LMB with up to 50% obstruction partially corrected with CPAP. Dr Modi recommended Chest MRI with contrast to assess for possible extrinsic compression from LPA / LA. - Chest MRI 9/22: Normal study, no evidence of airway compression, normal calibre airways. - Speech and swallow eval 9/18 - normal study. - Metabolic workup per neuro - Normal CK, Lactate. Urine AA shows mild branched-chain ketoaciduria suggesting catabolic state. Plasma AA, Pyruvate sent. - Sleep study 9/23: Central sleep apnea of infancy. Report: "This was a slightly abnormal study. There were 59 episodes of central apnea and 9 episodes of obstructive hypopnea. Overall Apnea Hypopnea Index (AHI) was 7.3 events/hr. Baseline oxygen saturation was 95.1% and the nadir 02 saturation was 83.3%, the more profound desaturations were associated with periodic breathing/central apneas and were all brief.and self-resolving., Snore was not present. Paradoxical breathing was present and is normal at this age." Clinical Progress: - Note ongoing intermittent perioral cyanotic episodes as described above, all self-limiting, not always associated with saturations on continuous monitor. Never bradycardic. Never commenced on 02 in PICU. - Tolerating Nutramigen feeds (started at home due to?rash with conventional formula) - Follow-up appointments arranged with Pulm, Cardiology, Neurology, PMD - Continue with Lansoprazole q12h (script given to mother) - Medically cleared for discharge however discharge on hold until Monday when SW can arrange for home sleep apnea monitor. Discharge Medications: * No Current Medications as of 14-Sep :36 documented in Prescription Writer apnea monitor: Apnea >20 sec Heart Rate - Max 220 BPM, Min 60 BPM Indication - Specify: Central sleep apnea *Dose Unknown or Not Applicable, *Frequency Unknown or Not Applicable, *Indication Unknown or Not Applicable, *Route Not Applicable, Active, 0, None lansoprazole 3 mglml oral suspension: 1 ml orally 2 times a day x 14 days Indication: GI Inflammation/Acid Reduction, Active, 1, None Health Maintenance: COPD: Does the patient have COPD? No. Stroke Quality Measures: Was this patient diagnosed with a stroke or TIA during this hospitalization? No. Wound Care/Ostomy Site/Device Care: Please call your doctor if you experience: Worsening Symptoms, Shortness of Breath,. Instructions: Diet/Nutrition: Regular Diet: Eat a wide variety of foods including fresh fruits and vegetables, whole grains, lean Requested by: Ngang, Divine (Med Rods), 09-Jan :16 Page 24 of 51 7

8 MRN: Visit: Age: 2y6m (2012) Gender: Female NY-Presbyterian Weill 1 Cornell 1 Location: Cardiology I Pediatric meats, poultry and fish and low-fat dairy products Infant Formula (Bottle Feed) Infant Formula (Bottle Feed): Nutramigen Lipil ml by mouth every hour(s). Activity: No restrictions. Additional Instructions: apnea monitor should arrive at your home tonight. Follow-up Appointments: FOLLOW-UP APPOINTMENT/REFERRAL 1 - Name: Dr Steinberg (Pediatric cardiology). When: 02-Oct-2012 Time: 01:00 PM. Where (location): 525 East 68th Street F677 New York, NY Phone #: (212) Comment/Purpose: Cardiology follow-up. FOLLOW-UP APPOINTMENT/REFERRAL 2 - Name: Dr Stone (Pediatric Pulmonology). When: 03-Oct-2012 Time: 01 :15 PM. Where (location): 505 East 70th Street Helmsley Tower, 3rd Floor New York, NY Phone #: (646) , FOLLOW-UP APPOINTMENT/REFERRAL 3 - Name: Dr Merchant (Pediatric Neurology). Call for appointment: Appointment already made. FOLLOW-UP APPOINTMENT/REFERRAL 4 - Name: HT3 Pediatric Clinic. When: 02-Oct-2012 Time: 09:50 AM. Where (location): HT3 Helmsley Tower. Phone #: Electronic Signatures: Chan, June (MBBS) (Signed 23-Sep :00) Entered: Admitting History and Physical, Follow-up Appointments, Discharge Medications, Hospital Course, Hospital Information, Health Maintenance Authored: Hospital Information, Admitting History and Physical, Hospital Course, Discharge Medications, Health Maintenance, Follow-up Appointments Gex, Saskia Elizabeth (MD) Entered: Follow-up Appointments, Instructions, Wound Care/Ostomy Site/Device Care, Health Maintenance, Discharge Medications, Allergies, Hospital Information Patel, Anita K (MD) (Signed 22-Sep :29) Authored: Hospital Course, Discharge Medications Veler, Haviva (MD) (Signed 02-Jan :08) Authored: HospitatInformation, Allergies, Discharge Medications, Health Maintenance, Fiequeted 25-0f 51 8

9 I PERSONAL TOUCH EARLY INTERVENTION*ROGRAM nd Avenue Fresh Meadows, NY BILIGNUAL PSYCHOLOGICAL EVALUATION Name: Date of IMSOM,2012 Bh Date. of Exam: February 25, 2014 Chronological Age: 1 year 7 months Language of Exam: English/Spanish Address: 290 Empire Blvd, apt. 3C Brooklyn, NY Telephone #: (631) Clinician: Dr. L. Ashmore Kearse CPT Code: CD-9 Code: Reason for Referrailawas referred for a psychological evaluation to rule out autism spectrum disorder. Her mother is very concerned and would like for her to receive the appropriate services. Parental Interview: was born premature 36 weeks and she spent four days in the NICU. She was home for one day and she started to turn blue. Theyreturned to the hospital and she remained there for 11 days. Her oxygen levels were low. She was prescribed oxygen when she was discharged.. She was also diagnosed with central apena and prescribed machine that she uses at night. She also was diagnosed with tachycardia, reverse epligadus and metabolic disease, She has a history of chronic fluid in her ears and she had surgery to put tubes in her ears..411 is reported to eye seizures and she requires constant supervision. Her left eye is said `,wk. Her mother reported that she keeps repeating her daughter's 11 her out of it. presenting with some atypical behaviors that her mother is

10 very concerned about. She is reported to exhibit blank stares and she loses control quickly. Her mother reported that she will "Beat the crap out of you." She will attack and she does not know when to stop. She is said to be "violent". She is reported to attack her older sister. She is unable to tolerate someone touching her things and this could trigger a rage reaction, Her mother reported that she is very possessive. is said to have tantrums, which consist of her screaming, crying and jumping up and down and there are times when she can become aggressive as well. She is easily stattied. his currently receiving occupational therapy, physical therapy and speech therapy. She was recommended to receive special instruction, but it has not started yet. She is reported to lose strength throughout the day. She does not sleep and she tends to go to bed around 4 am. Her mother feels that her sleeping pattern is like a new born; She is not eating solids as of yet. She is reported to be at a three month old level with feeding. ON is said to drink 12 to 14 bottles of formula per day. Her mother reported that ',has difficulty moving her jaw and her mouth, which negatively impacts on her feeding. She is reported to gag and to hold food in her mouth. Sometimes the food falls out or her mother just removes it. is reported to have difficulty bonding with her mother. Her mother does not feel as though she is connected with her, but she seems to be closer to.her sister and father. She is reported to be self-directed (wanting to do her own thing). She is said to have tantrums, which consist of her smashing her head and pulling her hair out.when she is angry and frustrated. She is reportedco have a high tolerance for pain. She is reported to laugh inappropriately at times and there are times when she will cry when something is funny. Her behavior is reported to be erractic. They are looking into getting her a helmet because of the head banging. She is reported to scream for long periods of time. She is said to break out in a sweat when she is upset or frustrated. is reported to have no opportunity to play with other children. Also her mother is too afraid to have her play with other children., because of her aggressive behaviors. She does not show interest in other children. They keep her home a lot because of her poor immunune system. Mis said to say approximately five words. She engages in babbling mostly. Her voice is reported to be hoarse. She has difficulty following basic commands without visual cues. She is reported to respond to her 10

11 name, but she does not consistently.acknowledge that someone is speaking to her. Her eye contact is said to be inconsistent. She is not pointing to body parts. Ot1` is unable to tolerate bath time, her diaper being changed and he clothing being changed. She has difficulty tolerating her nails being cut. Her mother reported that she does not like to be touched. She has difficulty tolerating her hair being washed. In the bathtub she will throw her face under the water and the throw her head backwards into the water when she is having a tantrum. Mpt. is reported to be afraid of things that most children are not afraid of, which was observed during the evaluation. She was afraid to the farmer's truck. She iš reported to eat paper and strings. She is reported to have difficult with crowds and. with new jtsople and places. She is said to have difficulty adapting to new places. W. is reported to mouth objects and to drool. She is said to spin until she falls. She is reported to spin the wheels and to rock, She likes to bang the doors shut. She is reported to line things up, mostly her favorite things. She becomes very angry when things are moved from the line. She is said to inspect things. Method of Assessment: ADOS 1.1 Toddler Module Vineland Social Emotional Early Childhood Scales Clinical Interview and Observation Behavioral Observation:1M was evaluated in her home with her mother present throughout the evaluation. She seemed to be aware of examiner. She was pointing to the examiner's bag and she did give eye contact during this exchange. She was heard to say, "mama". She was observed to walk in circles and her gate appeared to be wide. Her feet tended to turn inward. Her pointing was vague and she tended to roam around the apartment aimlessly. She tended to have something in her hand and she was observed to "w" sit. She engaged in gibberish Sometimes directed toward mom other times to herself She was observed to hit her mother. =was pacing back and forth and walking in circles. She was taking the head band on and off in a repetitive manner. She tended to be fussy and she was afraid of testing materials (bubbles, farm truck), She circled the truck. She demonstrated low frustration tolerance, She would take the examiner's hand to do the work for her. She exhibited limited joint attention and referencing. She jumbled the shapes and she engaged in inappropriate

12 - I t laughter. She did not point to share an interest and her mother reported that she does not do that. s sister returned home and she did'not acknowledge her, but she did acknowledge her father. She was observed to drool. She was jumping up and down and she may flap her hand when she engaged in this behavior. Social Emotional: Impressions from clinical interview, observation and behavioral scales were of a distractible, active and self-directed youngster who can has difficulty relating to others. Mit shows limited interest in other children and she does not know how to play with. them. She tends to play with the toys by herself and on occasion may bring a toy over to her mother for her mother to play with her. She is reported to spin and walk in circles. She is said to spin the wheels. She is does not imitate consistently. It was a struggle to get her attention and she demonstrated poor joint attention and referencing. appears to have sensory integration difficulties that are negatively impacting on her overall functioning. She is presenting with self-stimulatory behaviors (walking in circles, spinning, spinning objects, rocking and roaming around aimlessly, etc.). She is reported to tantrum frequently, consisting of her head banging, screaming, throwing things and crying. She does not consistently respond to her name and she does not consistently acknowledge that someone is speaking to her klemonstrated marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures and gestures to regulate social interaction. There is a lack of spontaneous -seeking to share enjoyment, interests or achievements with other people ' (e.g., by a lack of showing, bringing, or pointing out objects of interest). She demonstrated a lack of social and emotional reciprocity and a failure to develop peer relationships appropriate to developmental level. The Autism Diagnostic Observation Schedule 2, Toddler Module, is a semi structured observation instrument used to assess social and communicative behaviors in children with autism. This instrument includes a series ofseini-structured tasks of high interest to children with autism. = obtained a score of 15, which indicates moderate to severe concern that WM is on the autism spectrum. According to the Vineland, her socialization skills yielded a standard score of 70, which are two standard deviations below the mean, 12

13 According to the DSM-5, does meet the criteria for the disorder. Children with this disorder.display deficits in social-emotional reciprocity, ranging -fxom abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions or affect; to failure to initiate or respond to social interactions. There is also a deficit in nonverbal communicative behaviors used for social interaction, ranging from poorly integrated.verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.. Deficits are noted in developing, maintaining, and understanding relationships, ranging from difficulties adjusting behavior to suit various social contexts, to difficulties in sharing imaginary play or in making friends; to absence of interest in peers. iiiiippresented with all the above issues, which was reported in the body of the report. Also according to the DSM 5, children within the spectrum also demonstrate stereotyped or repetitive motor movements, use of objects or speech, spin objects, spins himself, jumble objects, pacing, jumping up and down, hand flapping etc. Within the disorder there are children who insistent on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior..lays with the materials the way she wants to.. Some children display a hyper or hypo reactivity to sensory input or unusual interest-in "sensory A-spepts of the environment. Suznmary and Recommendation: 1111Wwas referred for a psychological evaluation to rule out autism spectrum disorder. She demonstrated significant and pervasive impairment in the development of reciprocal social interaction, and verbal and nonverbal communication. She would greatly benefit from a well-structured environment with whatever behavioral approach her parents may choose. It should be implemented in an. intensive and consistent manner. It would be in. the parent's best interest to be trained in the behavioral technique they choose. Social work services are also recommended to help the parents gain the necessary resources/support system that is available for families of autistic children and to educate the parents on the disorder. Family training is also recommended to help the family and the individual therapist service better. She should continue with the recommended services

14 The testing environment was adequate (including lights, noise level and visual stimulation) and her mother was present to provide her with the emotional support during the evaluation. The conditions and environment were suitable for testing purposes and the results appear to be reflective of ability at that time. Hermother agreed with the testing results and is interested in, getting her the help that she needs. Her behavior was reported to be typical. DSICA IV: 299,00 Autism Spectrum Disorder "I certify that I personally evaluated employing age appropriate instruments and procedures as well as an informed clinical opinion. I further certify that the findings contained in this report are an accurate representation of the child's level of functioning at the time of my assessment" Leona Ashvn Bilingual NYS i = License 4: 014 sy.d. d Psychologist ' 6 Z 0-0N 4/ tin 11 "NI

15 [Chart] [Ava Rios][45616] ILJI Lalngone MEDICAL CENTER Patint Name: Procedure Date: 6/11/ :58 AM MRN: Account Number: Date of Birth: Admit Type: Outpatient Age: 1 Gender: Female Note Status: Addendum Attending MD: Mikhail Kazachkov, MD Procedure Date: 6/11/2014 Procedure: Bronchos o Indications: Child with complicated medical history has ferquent episodes of labored breathing, breathing cessation. She was diagnosed with bronchomalacia arid vocal cord dysfunction (?) in the past. She is being workd up for "tripple A syndrlme" (Alacrymia, acholasia, Adrenal insufficiency), however her AM cortlsol level was normal, Providers: Mikhail Kazachkov, MD (Doctor), Winifred Frimpong, RN Referring MD: Francis DeVlto, MD Requesting Physician: Scott Rickert, MD Complications: none Procedure: Findings: Pre-Anesthesia Assessment: - A History and Physical has been performed. Patient meds and allergies have been reviewed. The risks and benefits of the procedure and the a ion op ions an re is - - VT e re a swe an. s and proposed procedure were verified prior to the procedure. Mental Status Examination: alert and oriented. ASA Grade Assessment: ill - A patient with severe systemic disease. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. The anesthesia plan was to use general anesthesia. Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives. The. 3 f " "71114WASIMilia " Tracheobronchial Tree.01 sr- heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure. The physical status of the patient was re-assessed after the procedure. ' After obtaining informed consent, the was introduced through the left nostril and advanced to the tracheobronchial tree of both lungs. Nasal passages and pharynx look nomal except for modereately enlarged tonsils. Epiglottis is long and bulky, it folds in during inspiration. Short areo-epiglottic folds. Bulky arytenoids fold in glottis creating airway obstruction and noise. Normal subglottic space. Trachea and bronchi ara normal, mucosa is normal, secretions are scant, RIGID LARYNGOSCOPY was done by Dr. Rickert and it confirmed the above findings. EGD was done by Dr. Kaistha, it was unremarkable. Addi images: U Moderate tonsils fl Larynx, beginning of le Larynx, deep inspirations,,, enlargement Inspiration collapse of arytenoids, ' Impression: 1. Laryngomalacia. 2. Normal lower airway. Recommendation: Sleep study is required. We shall consider laryngoplasty and supraglottoplasty if it is abnormal, since laryngomalacia may be responsible for her upper airway symptoms. Powered by Provation MO Page 1 [Page 325 of 392] 15

16 [Chart][Ava Rios][45616] Q.N11117JI L n es n et MEDICAL CENTER Patient Name: Procedure Date: 6/11/201410:58 AM MRN: Date of Birth: Admit Type: Outpatient Age: 1 Gender: Female Note Status: Addendum Attending MD: Mikhail Kazachkov, MD Procedure Date: 6/11/2014 Mikhail Kazachkov, MD 6/11/ ,3.62 PM Number of Addenda: 1 Note Initiated On: :58:41 AM Powered by Provation MD Page 2 [Page 326 of 392] 16

17 North Staten Island Shore L. l juniversity Hospital DONNA PROSKE, MS, RN EXECUTIVE DIRECTOR CERTIFICATION I, Gregg Healy, Radiology Manager of the Radiology Department of Staten Island University Hospital, 375 Seguine Avenue, Staten Island, New York 10309, hereby certify that the record attached is an exact copy of the radiology record of the condition, act, transaction, occurrence or event of this institution, including all radiographs, Ct Scans, MRI, Ultrasound and Nuclear Medicine reports and readings. Patient Name: Patient address of Record: Number of cd's enclosed: \ c.)a- 1 aowt* I further certify that this record was made in the regular course of business at the above address to make such record, and such record was made at the time of the condition, act, transaction, occurrence or event, or within a reasonable time thereafter. Date: fis- Gregg Heal Radiology Manag Angela P retta Radiology Department 475 Seaview Avenue, Staten island, New York NPW York One Edgewater Plaza, Staten island. New York 10305

18 STATEN ISLAND ERSffY UNIV HOSPITAL 475 SEAVIEW AVENUE, STATEN ISLAND, NEW YORK ANTHONY C. FERRER! PRESIDENT & CHIEF EXECUTIVE OFFICER (718) STATEN ISLAND UNIVERSITY HOSPITAL, SOUTH 375 SEGUINE AVENUE, STATEN ISLAND, NEW YORK STATEN ISLAND UNIVERSITY HOSPITAL, BUSINESS CENTER 1 EDGEWATER PLAZA, STATEN ISLAND, NEW YORK Patient Name: RON IR DOB: iii.2012 Patient ID: Account: Patient Location: MRI/CT SCAN SEDATION - SC Accession: Procedure: MRI BRAIN WO CONTRAST Date of Exam: 01/02/ :22 PM Attending Physician: STEVEN SCHWARTZBERG Requesting Physician: STEVEN SCHWARTZBERG Clinical History / Reason for exam: Developmental delay and seizures. MRI OF THE BRAIN WITHOUT CONTRAST TECHNIQUE: Multiple transaxial and sagittal Ti-weighted images and transaxial T2, FLAIR, gradient echo and Diffusion weighted images of the brain were obtained. Corona]. T2, coronal flair, coronal proton density, coronal T1-3-D fast spin echo inversion recovery and transaxial T1-3-D fast spin echo inversion recovery images were obtained. FINDINGS: Patchy foci of hyperintense signal intensity in the periatrial white matter on the T2 and flair images can be within noimal limits through the second decade. The third, fourth and lateral ventricles are noimal in size and position. There is no shift of the midline structures. IMPRESSION: Essentially unremarkable noncontrast MRI of the brain. Original report dictated and signed by Dr. LYNNE VOUTSINAS on 01/03/ :47 AM 18

19 [Chart][Ava Rios][45616] Fax Server.1/3/2015 3,1;48:40 Alvi PAGE 1/00.1. Fax Server Us firefirp ATY HO P v1i1WAPEME4 &MYR 115L41t1),, 01BlrYORiC swam JamwouNIFERS1T SOU771..orilloNv a 0= =cum Aram s1:47zit 1$4414D, Nint,yoRle PRESIDENT. CILIRF vaicumg magi (716) szatiasutvz>tawnrsu s'ainra.48;1.20fas CENTER 1 EacuzirArRit PLAT.(, rizand. Nen,WILK mos PatieniaLl. a ne: _ 1700: Patient ID: Account: Patient Location: IVIRI/CT. SCAN SEDATION - SC..... 'AOCession: PreCedure: IVIRI BRAIN WO CONTRAST Date Of Exam: Of/02/ :2217'M Attending. Physician: STEVEN SCHWARTZBERG Requesting PhysiCian: STEVEN SCHWARTZE3ERG. Clinical History / Reason for exam: Developmental delay and seizures. MRI OF THE BRAIN WITHOUT CONTRAST TECHNIQUE: Multiple transaxial and sagittal Tl-weighted images and transaxial T2, FLAIR, gradient echo and Diffusion' weighted images of the brain were obtained. Corona' T2, Corona' flair, coronal. proton density, corona' TI-34) fast spin echo inversion recovery and transaxial TI-$-D fast spin echo inversion recovety images were obtained... FINDINGS: Patchy foci ofityperintense signal intensity in.the per&tdalwhite matter on the T2 and flair itnages can be ' within normal limits through the second decade... Thetlitr. c' fourth and lateral ventricles are normal in size and position. There is no shift of the rniclline structures. IMPRESSION: Essentially unremarkable-noncontrast MRI bf the brain. Original report dietatct anci signed hy.d.r. LYNNE VOUTSINA$ on 01/03/ :47 AM, 01/03/415 11:47AM Digitally signed by Steven Schwartzberg,. MD on. 01/0MIN 15;y1';? A% [Page 53 of 95] 19

20 WMATY HOSPITAL 475 Soaview Avenue Staten Wand, NY PROGRESS NOTES 002Y MR: DDB: 111,2012 F ADM: 1/02/2015 PED T A ACM: (347) DR: CHANG, JUAE CYNTHIA MD DATE TIME f6214 tei a41. cit eptoob r esdkt,v1- /v./it"( ito /, evran 4/2ci țt.±. ;pt- / (Lk Acs4 evel-=" C 4ati zsr-cie,a4, L re-rvi"k YKINIED BY: ARUbb

21 [Chart][Ava Rios][45616].; y Dear Dr. Mahale: ligal.thoarg...a$$qciate$14.medic100.,..pc.2535 Arthur. Kill Road,: Stateti Island, Aiv.Ydrk !1 Tel..--: Rik :....,, --, --,.: :,:-.:44:A, 1'..,1",--:,:t ' ':,, ot r4-...,:-...h%.. -,.-:'.,...1..,." -', :17',1?...;!..4.,.,. 49., i ;!,, ;:.....: -::!,,....., t ::',.,..4;41:::," -...,, :iretifiedbf:...,,-...,;...,...-,.-2 orpe t....!.-s ;. %,;...:..., 5....:. ' ::-... oofilia.leolek,o, FAAN,P;ido:. January 6,, ,,..,Fidringaiemod Stem UncD0....: ',. " i :..: 'i..''.'..!.... f...,?.. PEDATRIC Ni0Ficii0Or ' R. Manale, M.D.... :-"stevon a ScInvitzfilig, Md;... ' 8008 Third Avenue NEUROSURGERY:. Brooklyn, NY 11209: Edda lit Chat, MIA FAC,'. ' John S. Shlini, MD, ACS. '.:..AnthonyJ.0.Alestm;:M0 RE: : NEuNopsiNoioey. MaeliCat Record Numbsr: /Visit ID#: DbEi".:.:.:41iiii 'Age: 2 Y. ORTHapAibsiC& John P..RelIV,:MI:i,.,. 4osirph J.Glovino, g:t MD,.FACS Vincent RutiefO, 40. Jules D, thieflon4, Ay.,... moyvv,aoktmo..::. This is en update on who I saw in my office today for follow'up. The. Laton a. enisimboib.- :Jonathan m, Goss,' MD, FADS,; patient's prior history and examination were reviewed. RADIGLGO... Richard a Pinto, MD, FACR &Wee DeSensy Mb. The patient had undergone an MRI brain study at S.I.U.H. last week which wasanormal.exam; A copy.is enclosed for your perusal. Additionally, the PM NMANAGNENi patient.underwent video EEG monitoring, the resultsof which I discussed. oentiotoun,nowo,md,fow.m.. k. -. Glenn D. Eitilit..9,130 with Dt.:.Ohiasien on the telephone today. There were some areas. of,nmo Gupta, MD diffuse slowing noted but no specific epileptiform discharges. The patient Pravda il4diai5y: Alifene'ro'f. Mationc 111" teal-wt. did grace the hospital staff with a few of her unresponsive staring events otkoimickin,tt... while on video EEG monitoring and ho fetal discharge's were apparerit.,, OCCDPATIONALTNEfiAP.Y i.: ' 1 īir'egsaritially rules but any underlying epileptic disorder. Theṅiother Mona Semen, 61R4_, GIV, Bart Zylewiar, OTR/1.. infortneifrne that thecardiologiateare planning* to do:prolongesthehibulatory..., ADMINIW'RAPON. EKG 6)6*ot-frig in light of her history of tachycardia..i feel this would be a Pal I, Berkley, FAcMpE Mignon M. Tra'monlana.. good idea, especially in light of the EEG findings ?zoltan Weiss,' PhD, Mode atfody, PhD.... EAtuffiis.. Joseph A. Suate4 MCI FACj I advise the mother ta kelliiiiback to you for regular medical care and.. Alberta Accettdo, in, MD:. proceed with the planned cardiological work up Sin relji yours, T. Steven SBS/ED Schwartzberg, MD Ave (DOB: ) 01/06/2015 Page 1-of 1 Neurostience Associates.of NY Imaging Center &SI Orthopaedic Associates WW1' ' 1099i-0/gee Street h Avenue 65 ColtiMbus Avenue j.;i71 Wan Boulevard 3333 h1)4an Boulevard, Staten Island, NY BroOklyn, NY Staten Island, NY Staten Island, NY Staten Wand, NY Tel: Tel: Tel: ret : Tel: [Page 52 of 95] 21