FILED: NEW YORK COUNTY CLERK 04/12/ :57 PM INDEX NO /2011 NYSCEF DOC. NO RECEIVED NYSCEF: 04/12/2018

Transcription

1

2 ' NYNeurological.- 't Associates, P.C. e 3He e a David Dc vld Snyder, M.D. Emilio Oribe, M.D., F.A.C.P Tonya FOtiml, M.D. Yvonne Zoharckis, M,b. July 3, 2017 Sabatini 4 Associates 237 West 356 Street, Suite New York, NY RE: Francesco Belluccia Vs- Schindler Elevator Date of Birtb 06/10/1967 Social Security No: Date of Accident: 05/18/2011 To Whom It May Concern: Belluccia is a height of 5 feet 10 inches and weight of 210 pounds, black eyes and black hair. He is married and is a former carpenter. Examination was performed in the presence of his attorney. History of Present Injury: Mr. Belluccia is a 50-year-old male that on 05/18/2011, he reports that he was riding in elevator on its way up and between the fourth and fifth floors it plunged into the basement where it crashed, He says that he remembers the elevator car coming down and being thrown back. He hit the back of the head on the steel elevator and injured his neck and low back as well as his knees. He was at that time working as a carpenter at a construction site and the construction crew was on the elevator. It was a freight elevator, He was taken to hospital by ambulance and he was released after a day, He had developed body neck and back pain. pains on the right side more than on the left and severe spasms of his MANHATTAN A5TORIA FRESHMEADOWS 162 East 78th St Crescent St. # th St. New York. NY Astorlo, NY Fresh Meadows. NY T: (212) T: (718) T: (718) F: (212) [212) F; P(718) F ~ (718) r718) '!sl' 'd 960K 9606 '))o)) e9> AC9):)) (, LLOYD ( I()< 'E) ~( :Fr

3 RE: Francesco Belluccia Page 2 Over the next few days, he developed headaches involving the back of the head, felt dizzy and vertiginous and over time he developed hearing loss in both ears. He also reports photophobia and difficulty with speech and trouble finding words. He noticed impairment of his higher cortical function and decreased ability tofocus and concentrate. He developed at a later time inappropriate laughter and crying for which he received medication that according to him in the records was helpful. He also reported tingling and burning of his legs and feet associated with numbness that also involve his fingers and arms. He falls asleep easily. He reports that his symptoms have gotten gradually worse. He underwent right knee arthroscopy for a meniscal tear in 2011 and left knee arthroscopy for a similar lesion in He reports slight improvement as far as knee pain following the surgeries. He reports also receiving epidural injections in 2011, 2012 and Also he had shots in his back and neck. Current medications include gabapentin, Flexeril, tramadol, meclizine, Celebrex and Nuedexta. He reports that he has been using a cane since the accident and has been out of work since the accident. He continues to see a neurologist on a regular basis as well as an orthopedic surgeon and receives cognitive therapy. Patient denies any significant prior medical or surgical history and took no medications prior to this accident. He does not smoke and drinks occasionally. e 'Oe os IN9>:I,. COOK 'EI 'I "i

4 RE: Francesco Belluccia Page 3 Neurological examination at this time reveals his mentation to be grossly normal. He remember the names of the last five presidents. He was oriented x3, He was able to recall names of five objects and was good with serial sevens. Cranial nerves examination was within normal limits. Extraocular movements were full. No nystagmus was present. Pupils were 5 mm in size, equal and reactive to light and accommodation, Faoial sensation was well preserved as well as facial motion. Patient reported r decreased hearing bilaterally. Examimtion of the IX and X cranial nerves was normal by history and testing. Hypoglossal nerve was intact. Deep tendon reflexes were 2 and symmetrical including his biceps jerks, brachioradialis, triceps jerks, knee jerks and ankle jerks. He had a bilateral plantar flexor response. No pathological reflexes were present. Motor exam was within normal limits. There was no evidence of atrophy or fasciculations. Cerebellar exam was within normal limits. Finger-to-nose and rapid alternating movements were normal. Heel-to-shin was also normal. Gait was slow and somewhat unsteady with no clear abnormality. He helps himself with a cane. He was able to tandem walk and expressed discomfort when trying to walk on his heels and tiptoes, Sensory examination revealed decreased sensation to pin in the left upper extremity and decreased position sense in the right lower extremity. Impression: During the accidental file the claimant reports, as a result of the fall of a freight elevator that he was riding, injuries to his neck, low back and knees. A review of the records from EMS and Bellevue Hospital where he was taken indicate that there was no loss of consciousness at the time of the accident. Over the next few weeks, the patient also reports the development of tinnitus, vertigo and hearing loss as well as at a later date emotional liability and inappropriate crying and snd iauglgd,g. laughing. 0 'd 9605 'N el>:!i L9! I <!07 gt07 6!!V E! In

5 RB: Francesco Belluccia Page 4 Neurological examination at this time is within normal limits and fails to reveal any objective evidence of neurological dysfunction. Based on my exam and nature of the injuries and review review' of the medical records including MRIs of cervical and lumbar spine as well as MRI of the brain I find no evidence of neurological dysfunction nor do I find a neurological disability. Sincerely yours, /. HERBSTEIN M.D. 960K on est l LlOE';.s;"