Rodney Garutti v. KIM CO REFRIGERATION CORP. et al, 711901/2020, 93 (N.Y. Sup. Ct., Queens County Mar. 25, 2024) (2024)

`

`FILED: QUEENS COUNTY CLERK 03/25/2024 03:31 PM
`NYSCEF DOC. NO. 93
`Page 2
`11/28/23
`RODNEY GARUTTI
`
`INDEX NO. 711901/2020
`
`RECEIVED NYSCEF: 03/25/2024
`
`pain. Imaging studies revealed a femur fracture. The patient underwent ORIF of his left distal
`femur on 05/13/22 with Dr. Touliopoulos. The procedure was well-tolerated and uncomplicated.
`Mr. Garutti was followed postoperatively by Dr. Touliopoulos and his associates. He received a
`further course of physical therapy. On 03/21/23, Dr. Touliopoulos noted that the patient had
`unilateral swelling of the left leg and recommended vascular evaluation. The patient is still
`treating with Dr. Touliopoulos and is considering a total knee replacement. His pain has been
`poorly controlled and he is referred today for pain management.
`
`According to Elmhurst Hospital Emergency Room Records on 05/17/22, the patient presented
`with complaints of pain and swelling in his left ankle following his surgery. He was ambulating
`with crutches. X-rays of the left ankle were negative for any fractures. Doppler study of the left
`leg was negative for DVT. He was treated and released.
`
`According to a report by Dr. Guy on 02/14/23, there was atrophy of the left thigh. There was
`tenderness in the right knee. There was weakness of the left leg. There was diminished
`sensation in the left lateral thigh. His gait was antalgic. Dr. Guy was impressed that the patient
`had a permanent total disability as a consequence of the 12/27/19. He recommended a further
`course of treatment and evaluation.
`
`According to a report by Dr. Harrington on 03/23/23, the patient complained of left knee pain
`and swelling with left leg swelling and "bruising" of his left distal leg. His ability to walk was
`limited by pain. On examination, there was left knee and leg swelling with dermal vein clusters
`at the left ankle. Lower extremity venous Doppler exam revealed a partially occluded
`gastrocnemius vein on the right, a totally occluded popliteal vein on the left, and a partially
`occluded femoral and soleal vein on the left. Dr. Harrington was impressed that the patient had
`bilateral DVTs. The patient was prescribed Xarelto and a left leg compression stocking. The
`patient was reevaluated by Dr. Harrington on 03/31/23 and 04/11/23. Repeat Doppler studies
`revealed persistent occlusion.
`
`According to a report by Dr. Chideckel on 05/10/23, the patient complained of worsening
`swelling in his left leg. On examination, there was a vein pattern noted in the left distal calf with
`stasis and swelling of the left calf. Venous Doppler studies revealed left saphenous reflux with
`thrombus in the left femoral and popliteal vein. Dr. Chideckel was impressed that the patient had
`DVT of the left leg with reflux and incompetency of the left great saphenous vein. He
`recommended anticoagulation, compression stockings, and elevation of the left leg. Dr.
`Chideckel opined that the patient developed these vascular issues due to his surgical procedures
`and the associated convalescence due to the motor vehicle accident of 12/27/19. On 11/13/23,
`Dr. Chideckel noted that the patient had chronic residual DVT. He advised him to treat with his
`hematologist, Dr. Diamond.
`
`According to a report by Dr. Diamond on 10/20/23, the patient presented for evaluation of
`bilateral DVTs. Dr. Diamond recommended hematological workup and prescribed Xarelto.
`On 11/14/23, Dr. Diamond opined that the patient had an underlying hypercoagulable condition
`with superimposed risk factors including major surgical procedures, trauma, and history of
`immobility after the surgery. Further treatment evaluation was advised.
`
`

`

`FILED: QUEENS COUNTY CLERK 03/25/2024 03:31 PM
`NYSCEF DOC. NO. 93
`Page 3
`11/28/23
`RODNEY GARUTTI
`
`INDEX NO. 711901/2020
`
`RECEIVED NYSCEF: 03/25/2024
`
`The patient was recently seen by a pain management physician, Dr. Sharma. The medical reports
`are unavailable for review. Dr. Sharma is requesting electrodiagnostic testing of the left leg.
`
`On questioning today, the patient reports he is having persistent pain and swelling in his left leg.
`This is associated with a tingling sensation. He grades the pain as 10/10. Initially, he was
`having some bluish discoloration in the left leg as well as dysesthesias. This seems to have
`resolved after he started the Xarelto. He denies any temperature changes.
`
`The patient is also experiencing pain and stiffness in his right knee that he grades 3/10. He denies
`low back pain.
`
`The pain in both of his legs is aggravated by movement. He has difficulty standing and walking.
`He uses a compression stocking on his left leg and uses a cane. He has been exercising at home
`and has a stationary bike. He tries to keep his leg elevated and applies cold compresses.
`
`PAST MEDICAL HISTORY: He denies any significant prior history of left leg problems.
`
`PAST SURGICAL HISTORY: Hernia repair. Left knee surgery x 2 (as above).
`
`REVIEW OF SYSTEMS: The patient denies any signs or symptoms of acute infection or fever.
`Review of systems including general, skin, eyes, ENT, breast, cardiac, pulmonary, GI, GU and
`hematological is non-contributory.
`
`MEDICATIONS: Tylenol, methocarbamol, Xarelto. He was recently prescribed gabapentin but
`could not tolerate it due to gastrointestinal side effects.
`
`ALLERGIES: No known drug allergies.
`
`FAMILY HISTORY: Non-contributory.
`
`OCCUPATIONAL/SOCIAL HISTORY: The patient previously worked as an electrician. He
`has been unable to return to his job. According to a report by Dr. Acer on 02/17/23, the patient
`was unable to return to the workforce in any capacity.
`
`PHYSICAL EXAMINATION: Vital signs are within normal limits. Examination of the
`pulmonary, cardiac, vascular, and gastrointestinal systems are unremarkable.
`
`NEUROLOGICAL EXAMINATION
`
`MENTAL STATUS: Patient is alert and oriented. Affect, mood and behavior is appropriate.
`Short-term memory is intact. Long-term memory is intact. There is no evidence of expressive
`aphasia. Repetition is intact. There is no evidence of receptive aphasia. Ability to process
`information and executive function is intact.
`
`CRANIAL NERVES: CNII-The pupils are equally reactive to light. CNIII, IV, &
`VI-Extraocular movements are full. There is no diplopia. CNV-Facial sensation is intact.
`CNVII- Muscular expression and movement of the face is within normal limits. CNVIII-
`
`

`

`FILED: QUEENS COUNTY CLERK 03/25/2024 03:31 PM
`NYSCEF DOC. NO. 93
`Page 4
`11/28/23
`RODNEY GARUTTI
`
`INDEX NO. 711901/2020
`
`RECEIVED NYSCEF: 03/25/2024
`
`Hearing is grossly intact on both sides. CNIX & X- Ability to swallow and movement of the
`palate is intact. There is no dysarthria or dysphonia. CNXI- Shoulder shrug is symmetric and
`intact. CNXII- Strength and movement of the tongue is within normal limits.
`
`MOTOR SYSTEM: Motor strength testing reveals 3+/5 weakness in left knee extensor. Motor
`strength testing reveals 4-/5 weakness in left knee flexor. Motor strength testing reveals 5-/5
`weakness in left ankle extensor. Motor strength testing reveals 5-/5 weakness in left EHL. The
`remainder of motor strength is intact in the upper and lower extremities and is graded as 5/5 in
`all myotomal groups tested. Volume is within normal limits and there is no measurable atrophy.
`Muscle tone is within normal limits in the extremities and there is no palpable spasticity. There
`is no dysmetria or tremors present.
`
`REFLEXES: Deep tendon reflexes are tested by percussion utilizing a Queen Square
`neurological reflex hammer and graded on a scale of 0-4 in accordance with standardized
`procedures. The results are as follows:
`
`Right Comment
`Left
`Reflex tested
`2
`2
`Biceps
`2
`2
`Brachioradialis
`2
`2
`Triceps
`2
`1
`Patellar
`2
`1
`Achilles
`Plantar response Flexor Flexor
`
`SENSORY: Light touch perception is within normal limits in the trunk and extremities.
`
`MECHANICAL: There is diffuse tenderness and swelling in the left knee joint with guarding
`against movement. There is diffuse edema in the left lower extremity. His left leg is slightly
`sweaty and dark in comparison to the contralateral side. I do not appreciate any significant
`temperature change. Straight leg raise testing is negative. The lumbar spine is nontender.
`
`FUNCTIONAL EXAMINATION: His gait is antalgic. He has difficulty bearing weight on his
`left leg.
`
`NEUROPSYCHOLOGICAL TEST RESULTS:
`Pain Disability Questionnaire (PDQ) 11/28/23 =140/150 indicative of severe functional and
`psychosocial impairment.
`
`DIAGNOSTIC TEST RESULTS:
`X-rays of the left knee 05/10/22 reveals a comminuted distal femur fracture with fragment
`displacement.
`CT scan of the left leg 05/11/22 reveals acute posttraumatic intra-articular comminuted distal
`femur fracture with subluxation and displacement of the patella and a posterior tibial
`intercondylar fracture deformity with associated bone fragments.
`X-rays of the left tibia and fibula 12/27/19 reveals intra-articular medial tibial plateau fracture.
`CT scan of left knee 12/27/19 reveals comminuted intra-articular and medial tibial plateau
`fracture with joint effusion.
`
`

`

`FILED: QUEENS COUNTY CLERK 03/25/2024 03:31 PM
`NYSCEF DOC. NO. 93
`Page 5
`11/28/23
`RODNEY GARUTTI
`
`INDEX NO. 711901/2020
`
`RECEIVED NYSCEF: 03/25/2024
`
`X-rays of the left ankle 05/17/22 are negative.
`CT scan of the left knee 01/09/20 reveals displaced comminuted PCL avulsion fracture, medial
`tibial plateau fracture, joint effusion, and MCL tear.
`MRI of the left knee 01/09/20 reveals comminuted displaced intra-articular medial tibial plateau
`fracture, medial meniscus tear, MCL tear, ACL tear, and joint effusion.
`Venous dopplers: Elmhurst 5/17/2022 normal; Dr. Harrington 3/23/2023, 3/31/2023 & 4/11/2023
`abnormal; Dr. Chideckel 5/10/2023 abnormal.
`
`IMPRESSION:
`Left knee trauma with tibial plateau fracture, medial meniscus tear, MCL tear, and ACL tear,
`status post arthroscopic surgery 07/30/20.
`Left femur fracture, status post ORIF 05/13/22.
`Bilateral lower extremity DVTs.
`Chronic neuropathic pain syndrome.
`
`PLAN: Mr. Garutti is a reliable historian. His injuries have been well documented. There is no
`prior history of left leg or knee problems. With a reasonable degree of medical certainty, his
`condition is causally related to the motor vehicle accident that occurred on 12/27/19, the
`consequential fall that occurred on 05/07/22, and the consequential DVT.
`
`The patient has been symptomatic for almost four years. He has received an extensive course of
`treatment including medications, rehabilitation, and injections. Prognosis is guarded for any
`further recovery. With a reasonable degree of medical certainty, his condition is permanent in
`nature.
`
`The patient has subjective complaints that are verified by the findings on physical exam. The
`x-rays, CAT scans, MRIs, and Doppler studies reveal objective evidence of pathology. He has
`difficulty standing and walking and these are expected medical consequences of a leg injury of
`this nature. With a reasonable degree of medical certainty, Mr. Garutti has sustained permanent
`consequential limitation of use of his left knee and leg.
`
`The patient has evidence of a chronic neuropathic pain syndrome with sympathetically
`maintained pain. He is in need of further pain management. He was unable to tolerate the
`gabapentin and I will start him on a trial of amitriptyline. I have prescribed oral and topical
`anti-inflammatories and I will renew his methocarbamol. I have recommended that he continue
`taking the Xarelto and follow up with his hematologist. I will arrange for NCV/EMG study of
`the lower extremities to assess for neuropathy. Three-phase bone scan should be considered.
`
`He is totally disabled and I have advised him to restrict his activities. He will be followed here
`for continued care.
`
`I, Aric Hausknecht, MD, being duly licensed to practice medicine in the State of New York,
`pursuant to the applicable provisions of the CPLR, hereby affirm under the penalty of perjury,
`that the statements contained herein are true and accurate.
`
`

`

`INDEX NO. 711901/2020
`
`RECEIVED NYSCEF: 03/25/2024
`
`FILED: QUEENS COUNTY CLERK 03/25/2024 03:31 PM
`NYSCEF DOC. NO. 93
`Page 6
`11/28/23
`RODNEY GARUTTI
`
`Sincerely,
`
`Aric Hausknecht, MD
`Diplomate, American Board of Psychiatry and Neurology
`Diplomate, American Academy of Pain Management
`
`