MIL 9 SCT Dec July 03, 2024 (2024)

 
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 1 STEVEN C. TOSCHI (SBN 124551) MEREDITH C. DOYLE (SBN 298880) 2 TOSCHI ▪ COLLINS ▪ DOYLE ▪ HOUVENER 5145 Johnson Drive 3 Pleasanton, CA 94588 T: (510) 835-3400 4 F: (510) 835-7800 E: reception@TCDLegal.com 5 Attorneys for Defendant, 6 DALE CRABLE 7 8 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ 9 UNLIMITED JURISDICTION10 YVONNE LEANN GRAVIL, ) Case No.: 20CV01017 )11 Plaintiff, ) ) DECLARATION OF STEVEN C.12 v. ) TOSCHI IN SUPPORT OF ) DEFENDANT’S OPPOSITION TO13 DALE CRABLE and DOES 1 through 50, ) PLAINTIFF’S MOTION IN LIMINE NO. INCLUSIVE, ) 9 TO EXCLUDE REFERENCE TO14 ) PLAINTIFF’S MARITAL HISTORY Defendants. ) AND HISTORY OF ABSUE AND15 ) TREATMENT OF ABUSE )16 ) Complaint Filed: April 21, 2020 / Trial Date: April 24, 20231718 I, STEVEN C. TOSCHI, declare:19 I am an attorney at law duly licensed to practice before all the Courts of the State of20 California, and a partner with the firm of TOSCHI, COLLINS, DOYLE & HOUVENER, APC,21 attorneys of record for Defendant DALE CRABLE (“Defendant”). I have personal knowledge of22 the facts set forth below, and if called upon as a witness at trial, I would and could competently23 testify to the following:24 1. Plaintiff alleged that she had a neck injury from the subject incident. Defendant25 argues that any complaints Plaintiff suffered from were degenerative and not related to the subject26 incidents.27 2. Plaintiff further alleges that she required a total cervical disc replacement at C4-C528 as a result of the subject incident. However, Defendant claims that Plaintiff’s alleged surgery was -1- DEFENDANT’S OPPOSITION TO PLAINTIFF’S MIL 9 1 not related to the subject incident and also that Plaintiff was not a candidate for the surgery 2 performed by Dr. Sherwin Hua. 3 3. Dr. Kondrashov has opined in his medical record review report dated April 19, 4 2024 that patients with psychosocial comorbidities are at a greater risk for chronic pain syndrome. 5 Further, psychosocial comorbidities important aspect of a patient’s life to consider when 6 determining the efficacy of surgery and whether they are candidates for spine surgery. Attached 7 hereto as EXHIBIT A is a true and correct copy of relevant excerpts from Dr. Kondrashov’s 8 deposition transcript. 9 4. Plaintiff is alleging that she experienced worsening psychological conditions10 following the subject incident and is also making claims for pain and suffering from the subject11 incident. Specifically, we expect her to attribute a diminished quality of life and psychological12 complaints to the subject incident. She told Defendant’s retained neuropsychological expert, Dr.13 Friedman, that following the subject incident, she was “sad and angry about what happened to14 her.” She further stated she has nightmares and intrusive thoughts about the subject incident,15 continues to feel angry and scared, continues to experience hypervigilance to danger, has16 depressed mood, and loss of appetite. Dr. Friedman further opined that objective testing did not17 verify the present of Posttraumatic Stress Disorder. He also opined that she was exaggerating18 symptoms on objective testing. He said that she is susceptible to depression because she has had19 severe depression in the past. Further, he noted that she did not fully report her past history, which20 indicates she was not forthright with regarding to the extent of her prior depression. Attached21 hereto as EXHIBIT B is a true and correct copy of Dr. Friedman’s report dated March 23, 2022.22 5. Plaintiff’s own retained psychologist Dr. Anthony Reading has testified her sex life23 was affected by her physical and emotional condition, including issues with her self-worth. This24 includes fear of abandonment and trust. Dr. Reading believes that her problems with trust were25 attributed to her former partner Etienne (her ex-husband). Her ability to trust in interpersonal26 relationships reportedly became worse after the accident. Dr. Reading further discussed that27 Plaintiff was depressed before the accident due to an abusive relationship, the fact that her partner28 had been cheating on her, the stress of the separation, financial concerns, significant issues with -2- DEFENDANT’S OPPOSITION TO PLAINTIFF’S MIL 9 1 her oldest child, and the premature birth of her second child. She acknowledged to Dr. Reading 2 that she would rarely have sex with her husband, which eroded her self-worth. She stated that on 3 one occasion her ex-husband sexually assaulted her. She also described her childhood as traumatic 4 because her father was an alcoholic and a drug addict. The family moved around frequently 5 because of his lifestyle. Her father was verbally abusive and would lock her and her sister in the 6 closet during parties. She reported her husband was abusive to her, and that after their separation, 7 she lost her friends at church. Dr. Reading stated that she has a history of trauma and PTSD arising 8 from a combination of adverse childhood experiences and being raped, which have been activated 9 with the conduct of her husband. Attached hereto as Exhibit C is a true and correct copy of10 excerpts from Volume I of Dr. Anything Reading’s deposition.11 6. Dr. Anthony Reading, PhD concluded in his February 27, 2023 report that there12 was “clear evidence for a change in Ms. Gravil’s emotional state and function, contingent upon the13 occurrence of the subject accident.” He further concluded her ongoing pain and functional14 limitations from the subject incident, “led to the onset of a depressive disorder, in the form of a15 Major Depressive Disorder, with symptoms of depressed mood, anhedonia, loss of motivation, loss16 of self-worth, irritability, disruption in her sleep and appetite and cognitive changes.” He rated her17 symptoms as moderate to severe. Dr. Reading further opined that the subject incident also18 reactivated prior trauma symptoms from a prior history of trauma symptoms with exposure to19 childhood experiences, domestic abuse, neglect and anal rape as a minor. He stated that the subject20 incident was a significant stressor that set in motion a reactivation of prior trauma disorder in the21 form of PTSD. Attached hereto as Exhibit D is a true and correct copy of Dr. Reading’s February22 27, 2023 report.23 I declare under penalty of perjury under the laws of the State of California that the24 foregoing is true and correct. Executed this 3rd day of July 2024, at Pleasanton, California.2526 _________________________________________27 STEVEN C. TOSCHI, ESQ.28 -3- DEFENDANT’S OPPOSITION TO PLAINTIFF’S MIL 9EXHIBIT A Dimitriy Kondrashov, MD Board Certified Orthopaedic Spine SurgeonApril 19, 2024Steven Toschi, Esq.Toschi Collins Doyle & Houvener5145 Johnson DrivePleasanton, CA 94588 MEDICAL RECORD REVIEWRE: Case Name: Gravil v. Crable Claimant Name: Yvonne Gravil Date of Loss: 11/15/2018Dear Mr. Toschi:I completed a Medical Record Review on claimant Yvonne Gravil.MEDICAL RECORDS REVIEW:Pre-accident records03/22/2011 – Dominican Hospital Emergency Department. Marc Yellin, MD. 38-year-old femalebrought in by family complaining of right thumb, hand pain. Fell back onto it. Fracture of hand,thumb pain. Impression: No acute osseus injury of the right hand.03/23/2011 – Santa Cruz Womens Health Center. Bilateral thumb pain. Hand pain. Stress.04/02/2013 – East Cliff Family Health Center. Maria Fuchs, PA-C. Back pain, lower back pain forone week. States was at gym working out, doing squats with 16-pound balls. Pulled muscle in thelower back. Complaining of lower back pain for one week. Was at the gym doing squats, throwingmedicine ball at the wall. Did not catch it correctly. Unable to sit or bend. Was better when layingflat in bed. Pain has been lessening. Chronic pain is 7/10. Unable to do normal daily activities.Denies any new tingling or numbness of lower extremities. Past medical history: Alcohol recovery.Cone biopsy. Asthma. Mild hyperlipidemia. Hives. Suicide attempts as teen. Idiopathic urticaria.Social history: Tobacco use. Former smoker greater than 10 years. Sober for 13 years. Alcohol:Has sponsor. Former smoker. No drugs. Height 63”. Weight 140. Assessment: Lower back pain.Start Flexeril. Start ibuprofen. Continue arnica.RE: Yvonne GravilApril 19, 2024Page 2 of 3104/03/2013 Santa Cruz Womens Health Center. Tom Smith DC. LBP. Lumbar sprain/ strain.04/10/2013 Santa Cruz Womens Health Center. Tom Smith DC.04/24/2013 Santa Cruz Womens Health Center. Tom Smith DC.10/09/2013 Santa Cruz Womens Health Center. Flexeril, Ibuprofen. R foot contusion.10/09/2013 Santa Cruz Womens Health Center. Flexeril, Ibuprofen. Gabapentin.12/18/2013 – East Cliff Family Health Center. Maria Fuchs, PA-C. Follow-up on meds. Discussedways to recognize when she was feeling anxious, angry, and frustrated. Working on not reacting tosituations. Identifying what is actually making her upset, what exact emotion she is experiencing.Even though thinks this is good at time, it can get her into depressive thought process because thinksshe should be feeling this or become analytical about the situation. Patient is feeling less hopelessness.Assessment: Lumbar back pain. Depression. Patient with an acute exacerbation. Saw Tom Smith.Advised patient to revisit for maintenance. Use arnica. Epsom salt bath. Use Flexeril.02/03/2014 Santa Cruz Womens Health Center. Flexeril, Ibuprofen, Neurontin. Severe depression,02/05/2014 Santa Cruz Womens Health Center. DC. LBP. Back spasm. Lumbar sprain. Strain. Muscleache. Lumbar/ thoracic manipulation.04/28/2014 Santa Cruz Womens Health Center. Ibuprofen, Gabapentin.09/26/2014 Santa Cruz Womens Health Center. Flexeril, Ibuprofen, Gabapentin.09/29/2014 Santa Cruz Womens Health Center. Flexeril, Ibuprofen, Gabapentin.10/21/2014 Santa Cruz Womens Health Center. Recent car accident. Flexeril, Ibuprofen, Gabapentin.03/24/2015 – Watsonville Community Hospital Emergency Department. Presenting complaint: Haveback pain five hours. Was at my Jiujitsu class. Now cannot straighten out completely. Complains ofpain in lumbar area. Pain radiates to right leg, left leg. Pain currently 9/10 on the pain scale. Noted tobe resistant with movement. Reports pain in lumbar area, left lower back, right lower back.Assessment: Reports lower back pain. Radiates posteriorly down both legs to the popliteal area.States legs feel weak. Reports pain after lifting a man in Jiujitsu class.04/29/2015 – East Cliff Family Health Center. X-ray of the chest. Normal chest.07/03/2015 – Doctors on Duty. New sinusitis. Review of systems: Positive for back pain. Positivefor headaches. Positive for anxiety, depression, sleep disturbances. Past medical history: Depression,alcoholism. Family history: Father positive for alcoholism, depression, hyperlipidemia, rheumatoidarthritis, coronary artery disease, myocardial infarction. Has a past history of cigarette smoking. Quitdate: 2002. Current medications: Albuterol, bupropion, gabapentin. Assessment: Acute sinusitis.RE: Yvonne GravilApril 19, 2024Page 3 of 3102/10/2016 – Doctors on Duty. Lee, MD. Recurrent sinusitis. Two or three episodes a year. Duringepisodes, has facial pressure, headache. Reports photophobia, phonophobia, flashes of light. Has beenoffered immunotherapy. Assessment: Allergic rhinitis. Recurrent sinusitis.02/16/2016 Santa Cruz Womens Health Center. Ibuprofen, Gabapentin. ROS: Neck pain.02/23/2016 Santa Cruz Womens Health Center. Ibuprofen, Gabapentin.02/29/2016 Santa Cruz Womens Health Center. Ibuprofen, Gabapentin.02/21/2017 – Watsonville Community Hospital ER. Chest pain, located primarily in the left lowerchest wall one day ago. Pain does not radiate. X-ray: Normal chest.12/02/2017 – Dominican Santa Cruz Hospital Emergency Department. Gregory Whitley, MD. Historyof asthma, shortness of breath. Presents with dyspnea. Admits to headache, neck stiffness, and cough.X-ray of the chest: No acute cardiopulmonary disease. Appears to have acute bronchitis which hasexacerbated her asthma.09/09/2018 – Watsonville Community Hospital Emergency Department. Ear pain, sinus pain, generalweakness. Review of systems positive for dizziness. Impression: Unspecified asthma.Post-accident records11/15/2018 – Watsonville Community Hospital Emergency Department. Complains of auto versuspedestrian. Pedestrian struck by moving vehicle on right elbow. Traveling very low speed. Sustainedright elbow painful injury, swelling, left hip painful injury. Amelioration of pain after being hit by aflower delivery van coming out of a driveway. Tells me the driver apparently did not see her andseemed to be accelerating. She was hit by the front of the van on the right elbow and pushed out onthe street, although she did not fall to the ground. Her right elbow hurt immediately, and then aftersome time her left hip began hurting, although it was not struck, nor did she fall. Does not have anyother complaints at this time. Did not strike her head. No headache, neck pain, back pain, numbness,tingling, or neurological deficits. The elbow is her primary concern. It is tender, mildly swollen,radiating swelling, discomfort into the hand. Blunt trauma. X-ray right elbow: No acuteabnormalities.11/20/2018 – Brennan Medical Clinic (Bayaca, MD). Hospital follow-up. Friday morning patientwalking on the sidewalk. Was hit by a van exiting the driveway. Was hit on the right elbow. Went toER. Had x-rays. Nothing was broken. Patient noted numbness and tingling in her right hand, digits 3to 5. Taking Tylenol or Advil. Patient is not taking it as frequently as prescribed because it irritatesher stomach. Keeping her arm in a sling. Today is the first day she has not really had to use the sling.Needs refill on her inhalers. Patient walks, exercises regularly. Assessment and plan: Pedestrian hitby motor vehicle. Pain in right arm. Asthma.11/21/2018 – Fernando Luque, DC. Chiropractic notes. Complains of right elbow, neck pain, lowback pain.RE: Yvonne GravilApril 19, 2024Page 4 of 3111/21/2018 – 12/13/2018 – Fernando Luque, DC. Chiropractic notes.12/17/2018 – Justin Lo, MD. Pain management consultation report. Social history: Positive smoking.Social drinking. Denies drug use. Personal assistant. Presents with right elbow pain, neck pain withradiation down her right arm, thoracic back pain with radiation to her abdomen in the T7-9distribution. Complaining of numbness and tingling of her right greater than left arms. Complainingof weakness of her right greater than left arms. Pain is present constantly. Worse with all movements,prolonged position, and all activities, exercise. Subjective complaints: Positive tenderness topalpation. Full range of motion. Spurling test negative. Pain worse in extension, flexion, rotation, andlateral flexion. Positive tenderness to palpation right lateral epicondyle. 5/5 motor strength. Noswelling or atrophy. Back: Positive tenderness to palpation. Full range of motion. Reflexes 2+.Assessment: Cervical radiculopathy. Thoracic radiculopathy. Thoracic strain. Right elbow pain.Start baclofen.12/19/2018 – (Bayaca, MD) Brennan Medical Clinic. Follow-up labs and x-rays. Has been seeingchiropractor twice a week for three weeks. Also had additional x-rays done. Also had TENS andtraction. Will be going to a nerve doctor, Dr. Lo, in San Jose. Patient saw him on Monday. Wasreferred to have an MRI of the neck due to loss of natural curvature of the neck. Assessment and plan:Hyperlipidemia. Cervicalgia. Asthma. Seborrhea.01/02/2019 – MRI of the cervical spine. History of neck pain after being hit by a car while walking.Loss of normal lordotic curvature. Edema interspinous ligamentous C5-6. C3-4 2 mm left paracentraldisc herniation. C4-5 3 mm left foraminal disc herniation. There are osteophytes. Herniated discextends beyond the margins of the osteophytes. Flattening of the left anterior cervical spinal cord.Mild central stenosis. 0.9 cm severe left, mild right, foraminal stenosis. C5-6 2 mm posterior centraldisc herniation. Mild central stenosis. C6-7 2 mm posterior central disc herniation. Herniated discsfrom C3-4 through C6-7. Injury to interspinous ligament, consistent with acute injuries. JosephKavanagh MD.01/02/2019 – MRI of T-spine. Thoracic spine MRI with contrast. Neck pain after being hit by a car.T3-4 posterior central disc herniation demonstrating elevation of posterior longitudinal ligament,effacement of the anterior thecal sac. No osteophytes. Mild central canal stenosis.01/09/2019 – Justin Lo, MD. Consultation report. Social history: Smoking. Social drinking.Stopped chiropractic care as it was making her pain worse. Worst pain is in the neck with bilateralshoulder, right arm radiation. Has been complaining of lower back pain with left posterior legradiation. Happened a few times since stopping chiropractic care. Notes bitemporal headaches whichoccur a couple of times per week and last a few hours. Baclofen helped her sleep. Objective: Neck:Positive tenderness to palpation. Full range of motion. Spurling test negative. Positive tenderness topalpation right lateral epicondyle. 5/5 motor strength. Back: Full range of motion. Pain worsenedwith extension, flexion, rotation, lateral flexion. Reflexes 2+. Assessment: Cervical radiculopathy.Thoracic radiculopathy. Thoracic strain. Right elbow pain. Lumbar radiculopathy. Acceptchiropractic care. DC Motrin. Start diclofenac. Cervical epidural steroid injection next available.RE: Yvonne GravilApril 19, 2024Page 5 of 3102/06/2019 – Spine & Sports Surgery Center. Operative report. Justin Lo, MD. Preoperativediagnosis: Cervical discogenic pain. Procedure: C7-T1 interlaminar epidural steroid injection underfluoroscopic guidance. C7-T1 epidurogram.02/11/2019 – Brennan Medical Clinic. Francis Bayaca, MD. Growth eyelashes, itchiness, refill. Wasin MVA in November. Had MRI. Noted with multiple cervical disc bulges. Had cortisone injections.Assessed feeling better and still dropping objects at times. Not lifting more than 10 pounds. Takingbaclofen. Also taking NSAID. Does not remember the name. Will also be sent to neurologistregarding dropping of objects.02/20/2019 – Justin Lo, MD. Consultation report. Stopped chiropractic care as it was making her painworse. Status post cervical epidural steroid injection 02/06/2019 with great relief of her pain andnumbness. Assessment: Cervical radiculopathy. Thoracic radiculopathy. Thoracic strain. Rightelbow pain. Lumbar radiculopathy. Had chiropractic care. Continue home exercise program andstretching. Cervical epidural steroid injection in the future. Will send her for PT x12 sessions forreconditioning. Status post epidural steroid injection as her pain has improved dramatically, but shestill feels weakness.03/07/2019 – PT. Select PT. Spine cervicalgia. Patient recently had cortisone injection andchiropractor services increased her pain. Injections seemed to help. Cortisone reduced numbness andtingling. Pain currently 3, worst at 7.03/11/2019 – Select PT. Cervicalgia. Unable to perform workout, running, boxing. Taking musclerelaxer for night. Describes pain as hot, numbness, tingling, electric shock, pain down both arms, bothhands, 3rd and 5th digits. Reported fatigue in neck muscles. Pain has not changed. Patient reportedpain in neck, bilateral shoulders.03/14/2019 – Select PT. Tearful today. Having some depression, anxiety, fear with leaving home dueto she is in pain. Unable to protect herself. She misses working out. Getting depressed. Reported3/10 pain today.03/19/2019 – Central California Neurology. Dale Helman, MD. EMG nerve conduction velocitiesabnormal due to bilateral carpal tunnel syndrome.03/19/2019 – Select PT. Increased pain in the afternoon. Feels tired, having to hold her head up.Went to neurologist.03/21/2019 – Select PT. Very tearful, upset this a.m. Crying due to children stating she is no funanymore since the accident. Reports continued pain and discomfort. Given information on homecervical traction unit and home electrical stim unit.03/25/2019 – Select PT. Feeling better, 5/10. Feels like she is getting stronger.03/28/2019 – Select PT. Reported muscle pain today. Pain in her hands. Dropped coffee mug due todropping objects.RE: Yvonne GravilApril 19, 2024Page 6 of 3104/01/2019 – Justin Lo, MD. Status post epidural steroid injection with great relief of pain andnumbness. PT and home exercise program with improvement of her strength. Still has occasional painin the right scapula with certain movements of her right shoulder. Plan: Chiropractic care did not helpher pain. Continue home exercise program, stretching. Cervical epidural steroid injection in the futureas needed. Continue PT. Start home traction, TENS unit. Return to clinic after she completes PT.Went to see neurologist who did the EMG and nerve conduction studies. Results not available yet.04/01/2019 – PT. Reported no pain at rest. Discomfort with retro bike. Right shoulder blade pain.Mild pain 3-4/10.04/04/2019 – Select PT. Was sore, uncomfortable. She was unable to perform bike. Her pain startedyesterday, has continued. Took a muscle relaxant. Did not help. Reported pinching pain left shoulder,base at the neck region sharp pain.04/08/2019 – PT. Not as flared up as last PT sessions.04/11/2019 – PT. Reported no pain today. Went to Pilates, which went well.04/19/2019 – Central California Neurology, Dale Helman, MD. Personal injury. Physical therapyclearly helping her. Having much less pain, particularly in her cervical spine. Could benefit fromphysical therapy some more. Reviewed MRI. Suspect physical therapy will continue to help.05/30/2019 – Physical therapy. Neck has been feeling better with no pain. Will continue to getoccasional tingling in the right hand.06/05/2019 – Physical therapy. Neck was feeling good after last session. On Saturday daughterattacked her. Twisted her arm, causing slight increase in pain in her right shoulder and neck.06/07/2019 – PT. Pain continues to get better. Had some muscle soreness after the last session.06/10/2019 – Her neck continues to improve. Did her exercise over the weekend.06/12/2019 – Had new muscle soreness after last session. No increase in pain.06/19/2019 – Select PT. Feels that she has made full recovery since start of care. Her neck has nopain. She is able to start getting back into her normal hobbies. Shoulder feeling stronger. No increasein symptoms.06/28/2019 – Central California Neurology. Follow-up appointment. Neurological exam. Follow-upof personal injury. Physical therapy did help. Still very symptomatic on cervical spine. Myimpression is that physical therapy helped. I am more concerned right now about worsening nerveimpingement throughout her spine, as well as nerve entrapment in the extremities. Sort this outobjectively. Need it to be left for diagnostic testing of the upper extremities compared to the one shehad done several months ago. Further recommendations such as pain management. Procedure:Surgical decompression. Will depend on the results. EMG performed. This showed bilateral C6-7radiculopathy, bilateral carpal tunnel syndrome. Dale Helman, MD. Reflexes diminished throughout.RE: Yvonne GravilApril 19, 2024Page 7 of 31Symmetric sensory. Diminished touch, right C5, C6, C7 distribution, left C6-7 distribution, right L4-S1 distribution, left L5-S1 distribution, bilateral median nerve distribution, bilateral peronealdistribution. Cervical spine spasms diffusely. Lumbar spine spasms diffusely. She had limited rangeof motion to both.07/05/2019 Santa Cruz Womens Health Center. Going to PT and chiro. Has BUE tingling here andthere. Much improved. Ibuprofen, Neurontin. Current smoker. ROS: musculoskeletal – deniessymptoms.07/20/2019 – MedTrak Diagnostics.07/22/2019 – MedTrak Diagnostics. Proposed care plan.08/05/2019 – Justin Lo, MD. Completed PT with very good relief of pain. Assessment: Sametreatment. Chiropractic care did not help her pain. Continue home exercise program, stretching.Cervical epidural steroid injection in the future as needed. Had PT. Continue with counseling. Starthome traction and TENS unit. Being worked up for memory loss and confusion. Losing totalrecollection of events that have recently passed. Has seen Dr. Helman for neurology evaluation. Herpain is tolerable, status post cervical epidural steroid injection and PT. Will release her from my care.Return to clinic p.r.n.08/19/2019 – Health Diagnostics. MRI of the brain. Travis Snyder, DO, neuroradiologist. Focal areasof abnormal increased flair on T2 signal, involving frontal subcortical white matter. Focal areas ofabnormal signal identified at the right white matter. Interface consistent with sharing diffuse axonalinjury, clinical history of head trauma.08/26/2019, 08/27/2019, 08/28/2019, 08/29/2019, 08/30/2019, 09/03/2/2019, 09/04/2019, 09/05/2019,09/06/2019, 09/09/2019, 09/10/2019, 09/20/2019 – Harpreet Singh, MD. Mind and Body Pain Clinic.Patient presents for rTMS. Chief complaint: Memory loss, headaches, poor balance, dizziness. Beingfollowed at Mind and Body Pain Clinic for management of neurological problems. Assessment andDiagnoses: Major depressive disorder, recurrent, severe, with psychotic symptoms. Memory loss.Traumatic brain injury. Post-concussional syndrome. Posttraumatic stress disorder. Posttraumaticheadache. Procedure: Therapeutic rTMS. Treatment: MRI of the brain without contrast.09/10/2019 – Justin Lo, MD. Completed PT. Continues with home exercise program, stretching.Started to see psychologist who suggested that she is experiencing PTSD. Complaining of nightterrors, sleep paralysis, anxiety, panic attacks, sense of impending doom. Assessment: Cervicalradiculopathy. Thoracic radiculopathy. Thoracic strain. Right elbow pain. Lumbar radiculopathy.PTSD like symptoms. Rule out TBI. Plan: Being worked up for memory loss and confusion. Losingtotal recollection of events that have recently passed. Started to see a psychologist. Has seen Dr.Helman for neurology evaluation. Seen Dr. Singh, neurology, for magnet therapy. Pain is tolerablestatus post cervical epidural steroid injection and PT.09/11/2019 – 10/02/2019 – H. Singh, MD. Mind and Body Pain Clinic. Memory loss, headaches,poor balance, dizziness, presents for rTMS.RE: Yvonne GravilApril 19, 2024Page 8 of 3110/03/2019 – Justin Lo, MD. Consultation report. Seen Dr. Singh, neurology, for magnet therapy,although her pain is still significantly less than prior to cervical epidural steroid injection, she doeshave some return of her neck pain and tingling and numbness of her arms. Repeat cervical epiduralsteroid injection.10/03/2019, 10/04/2019, 10/07/2019 – Singh, MD. Mind and Body Pain Clinic. Memory loss,headaches, poor balance, dizziness.10/16/2019 – Spine & Sports Surgery Center. Justin Lo, MD. Operative report. Preoperativediagnosis: Cervical discogenic pain. Procedure: C7-T1 interlaminar epidural steroid injection underfluoroscopic guidance. C7-T1 epidurogram. Status post cervical epidural steroid injection 02/06/2019with near 80 to 90% relief of her pain in the neck and arms. Also had resolution of her numbness,tingling of her hands and arms. Pain relief lasted for greater than six months, and then the pain startedto return. Currently pain relief is still 50% improved, compared to before the injection. Numbness andtingling present, intermittently worse. They were present constantly before the injection.11/14/2019 – East Cliff Family Health Center. Referral to neurology. Reported TBI. Brain imagingrequested. Here for breathing treatment for asthma. G-tube being out of control. Does use inhaler.Feels she overuses it. Patient would also like second opinion referral to neuro for past brain injury.Reports she has bulging discs in neck, status post being hit by a car in 2018. Told recently she hasTBI. Went to Mind and Body in Los Gatos, magnetic brain therapy daily for three weeks for a TBI.Seeing LMFT Shawna at PP in Watsonville with new night terrors, now difficulty sleeping, eating.Not sure if stress or TBI. Paranoid thoughts. Does have asthma. Fully controlled allergies.Assessment: Chronic posttraumatic stress disorder. Seeing LMFT at PP. Mixed obsessional thoughtsand acts.12/13/2019 – Milan Patel, MD. Loss of consciousness, cyst of pineal gland, chronic posttraumaticstress disorder, migraine aura without headache.01/24/2020 – Justin Lo, MD. Status post cervical epidural steroid injection 02/06/2019, 10/16/2019.Still has numbness, tingling, clumsiness of left hand; however, it is happening less than before.Completed PT. Continues with home exercise program, stretching. Also, continues to see apsychologist who suggested that she is experiencing PTSD. Right-sided neck pain with right shoulderradiation. She complains of numbness and tingling of her right arm. Complains of persistentheadache. Assessment: Cervical radiculopathy, thoracic radiculopathy, thoracic strain, right elbowpain, lumbar radiculopathy, PTSD-like symptoms, rule out TBI. Plan: Has had PT. Continue withcounseling. Start home traction. TENS unit. Being worked up for memory loss and confusion.Losing total recollection of events that have recently passed. Also started to see psychologist. It wassuggested she is experiencing PTSD. Has seen Dr. Helman for neurology evaluation. Seeing Dr.Singh. Neurology completed six weeks of magnet therapy which helped depression, cognitivefunction, although derives great benefit, a great relief, status post steroid injection for upward of sixmonths. Her pain does return back to her pre-injection level. Will refer to Dr. Hua for surgicalconsult.01/27/2020 – DimeSpine Neurosurgery, Sherwin Hua, MD. Had right funny bone tingling right afterthe accident. Then after, developed neck pain, back pain, shoulder pain, and also had numbness,RE: Yvonne GravilApril 19, 2024Page 9 of 31tingling in the right more than the left. Initially it was on both sides. Also reports dropping things.Has had cortisone shots, which helped temporarily, and then the symptoms returned. Went to achiropractor. It seemed to hurt instead of help, so she stopped going. Instead, she went to PT for along time with success. Then it was not long lasting. Then had cortisone shots. The pain interfereswith her sleep, her ability to sit in church and pray. Used to have migraines before the accident. Nowthe migraines are more intense, more frequent. Has a hard time concentrating, focusing on her prayersand rosary. Also interferes with her sleep. Scrubbing the toilet, position of leaning forward withoutstretched arms very painful. Denies having neck or back pain prior to the accident. Used to run 8miles a day and has five kids. Now her life is much different in terms of activities she can do after theaccident. Diagnoses: Post-concussional syndrome, spondylosis with radiculopathy cervical region,cervical disc disorder with radiculopathy, cervical disc displacement C4-5. Plan of treatment: She hastraumatic brain injury. MRI shows C4-5 traumatic injury to the disc and HNP with cord compression.Has hyperintensity of the STIR MRI of the disc space. Also cord compression from the HNP. Thiscorresponds to the symptoms of neck and shoulder pain, numbness, and dropping things from herhand. She has had this for more than a year. Is a candidate for C4-5 TDR surgery. She also hassymptoms of traumatic brain injury. This will still need further time for recovery.02/20/2020 – Watsonville Community Hospital. Complains of severe sinus pressure with sinussymptoms for greater than 10 days. Now all of her teeth hurt. Maxillary sinuses, particularly the left,are the worst. She is having frontal facial and nasal pressure. Review of systems: Neck negative forinjury, pain, stiffness, or swelling. Neuro positive for dizziness, headache. Negative for numbness,tingling, weakness.02/20/2020 – CT of the head. No CT evidence of acute intracranial pathology. Bilateral maxillary andright ethmoid sinus disease. X-ray of the chest: No acute cardiopulmonary disease.06/30/2020 – DimeSpine Neurosurgery. Surgery estimate: C3-4, C5-6 total disc replacement.Facility: Spine & Sports Surgery Center. Billing rates: $43,296.60.07/28/2020 – DimeSpine Neurosurgery. Sherwin Hua, MD. Pain is worse. Now the pain is a littlebetter when she was doing PT. Now the pain is worse down the right arm to the right hand. Has tostretch out right arm and neck every morning for a long time. The only time she is comfortable iswhen she takes muscle relaxant. Does not want to hide her pain by taking medications. In terms ofbrain injury, she said that she is off work, forgetful, loss of confidence of kids and friends. Has lost herfriends. She does not notice things, but her family and friends tell her she just sits around the housemost of the time. Diagnoses: Post-concussional syndrome, spondylosis with radiculopathy cervicalregion, cervical disc disorder with radiculopathy, cervical disc displacement C4-5. Plan of treatment:She is having worse pain. Has C4-5 bilateral foraminal stenosis with disc herniation, disc height loss,interdiscal hyperintensity, consistent with damage of the disc. Failed conservative treatment, includingPT. Still has ability to do basic life activities. Will need to proceed with surgery C4-5 TDR. LastMRI was 18 months ago. She should have another MRI of C-spine to rule out any changes from thefirst MRI and prior to surgery. She should also get a follow up brain MRI as well.08/03/2020 – MRI of C-spine. Indication: Neck pain following motor vehicle collision. Impression:Loss of normal lordotic curvature at C3-4. Left central focal disc herniation C4-5. Left paracentralneural foraminal focal disc herniation superimposed on diffuse bulge, indenting ventral thecal sac,RE: Yvonne GravilApril 19, 2024Page 10 of 31elevating posterior longitudinal ligament. Anterior and posterior osteophytes seen. Disc herniationextends posterior to posterior osteophytes. Mild spinal stenosis. C5-6 diffuse disc bulge. Mild spinalstenosis. Mild spinal cord deformity. C6-7 central focal disc herniation elevating posteriorlongitudinal ligament. Avery Knapp, MD. Note compared to prior MRI of cervical spine. Nosignificant interval change is seen.08/05/2020 Santa Cruz Womens Health Center. Preop for surgery.08/14/2020 – DimeSpine Neurosurgery. C4-5 TDR procedure note. Spinal Cord Surgery Center.Patient developed significant pain and numbness in the hands and neck after she was hit by a car whilerunning. Failed conservative treatment, including PT and injections. Patient was found to havecervical stenosis from herniated discs C4-5. Patient wished to proceed with surgery. Proceduredetails: Cervical C4-5 total disc arthroplasty.09/08/2020 – East Cliff Family Health Center. Telehealth. Julia Stevens, NP. Has asthma. Wildfires.Moderate persistent asthma. Lungs clear today, improved. Allergic rhinitis. Had back surgery.Recovering well.09/16/2020 – DimeSpine Neurosurgery. Sherwin Hua, MD. Doing well postop after cervical TDR.Assess fingers. Much less numb. Can control fingers. She says she used to not be able to feel them.Would drop things before surgery. Now things are much better. Has been active. Not back to runningyet.10/20/2020 – DimeSpine Neurosurgery. Sherwin Huan, MD. Doing okay. Asking when to restoreprevious intensive activities such as pullups, stretching exercises.10/23/2020 – SimonMed. X-ray C-Spine. Indication: Neck pain. Grade 1 anterolisthesis C5 on C6.Reduced in extension. Mild exaggeration in flexion. Straightening of normal cervical lordosis.11/06/2020 – East Cliff Family Health Center. Julia Stevens, NP. Asthma follow-up. Moderatepersistent asthma. Migraine without status migrainosus. Not intractable. Worse and more frequentsince MVA. Will follow up with neuro.11/11/2020 – DimeSpine Neurosurgery. Sherwin Hua, MD. Doing okay. Started having neck painwhen she was doing more exercise. Also hears clicking at times. She is afraid she is doing too much.Other times afraid she is not doing enough.11/16/2020 – Milan Patel, MD. Loss of consciousness. Migraine aura without headache. Cyst onpineal gland. Chronic posttraumatic stress disorder.12/03/2020 – Select PT. Cervicalgia, spondylosis without myelopathy, cervical disc degeneration,cervical disc disorder with radiculopathy. Pedestrian struck by car pulling out of a driveway. Began toexperience neck pain, right upper extremity pain, bilateral hand numbness and tingling. Participated inchiropractic, physical therapy, and had cervical injections. Symptoms persisted. Now status postcervical disc replacement surgery, anterior approach. PT. The patient is left-hand dominant. Spinecurrent 5/10. Worst 10/10. Best 0/10. Numbness and tingling bilateral hands reduced after surgery.RE: Yvonne GravilApril 19, 2024Page 11 of 31Still some numbness and tingling in fingers 2 through 5. Still quite a bit on the thumbs. Numbnessand tingling cause the patient to drop items. Pain location: Bilateral cervical paraspinals, rightparascapular area, generally 4-5/10. Intermittent pain right forearm and hand with activity. Has nopain at times when lying supine, not moving. Morning stiffness. Asthma, allergies, depression, andheadaches. Presentation: Numbness and tingling in both hands. Cervical range of motion limited.Motion extension, left side bend painful. Right upper extremity strength decreased. ADLs limited andpainful. Left leg and recreational activities limited.12/16/2020 – Milan Patel, MD. Loss of consciousness. Cyst on pineal gland. Migraine aura withheadache.12/18/2020 – East Cliff Family Health Center. Julia Stevens, NP. Smoking cessation. Telehealthvisit. Wants nebulizer at home. Social history: Tobacco use. Former smoker. Mild intermittentasthma. Migraine. May want Toradol injection. Dysfunctional uterine bleeding.02/09/2021 – DimeSpine Neurosurgery. Sherwin Hua, MD. Starting to do some activities now. Usedto swing the bo staff. Now starting to do it again. Feels it helps straighten her shoulders. Notes shedrops the bo staff more than previous to her injury. Had to pause PT due to Covid. Now has learnedexercises. Ready to do it on her own. Still babies her right arm. She has not trusted her right arm tosteer the car steering wheel by itself. She is left-hand dominant. Still notes that the right arm isweaker than it has been versus prior to the accident. For instance, she was massaging her partner. Theright arm started to be numb for the whole night towards the morning. She was still worried how shewould know when some activity is too much as the nerves in her right arm still are not normal. Willbecome numb when she does anything with any force. Feels she can feel the right arm and handnormally. She actually had cut her right hand while grabbing a tool. Did not realize it until she sawblood on it. She is recovering. Still having some weakness, numbness right arm. Overall, better. Willtake more time for further improvement. Follow up in three or four months.04/20/2021 – DimeSpine Neurosurgery. Sherwin Hua, MD. Doing okay. Has limits because if shelifts too much, then she gets some numbness and tingling in her fingers. She is doing yard work withraking, clearing the yard, picking up sticks and leaves. Does not hurt while she is actually doing it.Plan: Recovering still with some weakness. Will need x-ray flexion, extension of C-spine for nexttime.08/24/2021 – Central California Neurology. Dale Helman, MD. Neurological exam. Saw this patienttoday for reevaluation up to two years for her personal injury. She did undergo what sounds to be asuccessful surgery on her cervical spine. Very recently she has been getting a lot more pain symptomsin her upper extremities. There have been no new events such as another injury to account for this.Full motor exam: Symmetric with no focal atrophy or involuntary movement. Reflexes diminished atthe biceps at both sides. Sensory diminished in bilateral C6-7 distribution and bilateral median nervedistribution. Gait was unremarkable. No ataxia or incoordination. Cervical spine spasm diffuselywith some limited range of motion. Assessment: Somewhat concerning. She seems to havedeteriorated somewhat. Plans to get an updated MRI of her cervical spine and electrodiagnostic testing.Further recommendations such as physical therapy or even more aggressive measures will depend onthe above. EMG electromyography showed bilateral C6-7 radiculopathy, bilateral carpal tunnelsyndrome.RE: Yvonne GravilApril 19, 2024Page 12 of 3109/28/2021 – DimeSpine Neurosurgery. Sherwin Hua, MD. Says she has gotten better. Still hasnumbness in her right more than left arms and hands. Index and middle finger affected most. Returnswith flexion and extension x-rays. She had full flexion and extension. X-ray of C-spine shows stablemovement in flexion and extension compared with October 2020. Having continued symptoms ofnumbness because she cannot have MRI of C-spine due to artifact generated right cervical lymph node.Plan: Will need CT myelogram to see if there is buildup of PLL and nerve impingement in the area ofsurgery.09/28/2021 – X-ray C-spine. Indication: Pain. Impression: Intact surgical hardware at C4-5.Moderate degenerative spondylosis. Jennifer Lin, MD.01/21/2022 – Central California Neurology. Dale Helman, MD. Getting more symptoms in the cervicalspine and extremities more numbness. She has also had the same cognitive deficits. Very frustratedabout this. Full motor exam symmetric. No focal atrophy. Reflexes diminished at biceps, triceps,both sides. Sensory diminished touch right C5, C6, C7 distribution, left C6, C7, C8 distribution,bilateral median nerve distribution. Gait unremarkable. Cervical spine spasm diffusely with verylimited range of motion. Assessment/Impression: She is certainly no better. May be deteriorating alot again. She does have evidence of worsening nerve impingement in her cervical spine. Also,worsening nerve entrapment. Electrodiagnostic testing shows bilateral C6-7 radiculopathy, moderate tosevere bilateral carpal tunnel syndrome.02/10/2022 – SimonMed Imaging. Brain MRI. Post-concussion syndrome. Impression: Negativecontrast-enhanced brain MRI. No acute infarction, intracranial hemorrhage or intracranial mass lesion.Mucosal thickening, right maxillary sinus.03/28/2022 – Central California Neurology. Follow-up appointment. Dale Helman, MD. Neurologicalexam. Reevaluation of personal injury. Fortunately, MRI of her head was normal. She was veryhappy to hear this. Unfortunately, she is still getting severe pain in the cervical spine and surroundingarea despite being diligent with her home therapy program. Denies any new focal motor deficits ordecrease in cognitive status. Assessment: Somewhat concerned that her nerve impingementsymptoms are certainly not improving and possibly getting worse as well as possible traumaticneuropathy in upper extremities. These are serious conditions. Electrodiagnostic testing performed onthis patient showed bilateral C6-7 radiculopathy.04/15/2022 – Advantage Neurology. Fred Samimi, MD, neurologist, acupuncturist. Presents withchief complaint of headache, neck pain, bilateral shoulder pain, thoracic back pain, elbow pain, headnumbness, insomnia, anxiety, muscle spasms, forgetfulness, ringing in the ears. Neck spasm and painintensity 8/10, taking ibuprofen 600 mg twice daily as needed. Headache four times a week, intensity10/10. Pain in both shoulders, right elbow 5/10. Nonsmoker. Nondrinker. Single with five children.Review of systems: Insomnia, depression, anxiety, memory lapse, word finding difficulty, nightmares.Examination: Spasm in trapezius, paracervical region, low back. Assessment: Status post MVA,cervicalgia, cervical strain, headache, concussion, post-concussive syndrome, mild traumatic braininjury, lumbar strain, low back pain, muscle spasm, lumbar radiculopathy, occipital neuralgia.Telemedicine. Was struck by vehicle, had a head impact leading to loss of consciousness. She willobtain brain MRI with DTI (diffusion tensor imaging). Cervical MRI without contrast is indicated dueRE: Yvonne GravilApril 19, 2024Page 13 of 31to neck pain involvement. Continue physiotherapy, chiropractic care. She will perform Folsteinmedical examination after imaging.06/07/2022 – Brain MRI with DTI. Impression: A few scattered white matter signal foci. Differentialdiagnosis includes post-traumatic gliosis, chronic small vessel ischemic hypertensive changes orvasospastic phenomenon associated with chronic migraine headaches. I do not see specific evidence tosuggest demyelination. Brain parenchyma is otherwise unremarkable. No cerebral volume loss.Abnormal susceptibility weighted imaging with a focus of hemosiderin in the subcortical left temporallobe. Abnormal significantly decreased fractional anisotropy can be seen in the setting of mildtraumatic axonal injury. Darren Buono, MD.06/18/2022 – Advantage Neurology. Fred Samimi, MD. Follow-up. Presenting with symptoms ofheadache, shoulder pain, low back pain. Pain in the neck 7/10. Taking ibuprofen as needed. Pain inright shoulder, right elbow 10/10. Telemedicine/telehealth. Appears depressed, anxious.Experiencing extreme daily headache, for which she is requiring prophylaxis. Completing brain MRIDTI. Like to obtain neuropsychological testing.08/22/2022 – Precision Occupational Medical Group. Sanjay Deshmukh, MD. Sustained multipleinjuries when struck by a car. Status post cervical spine surgery. Complains of persistent neck painthat radiates to right upper extremity with numbness and tingling in the hands. Here for EMG of upperextremities. Exam: C-spine decreased range of motion. Tenderness to palpation paraspinals,trapezius. Healed anterior incision. Motor grossly 5-/5 bilateral upper extremities. Sensation grosslyintact bilateral upper extremities. Diagnosis: Neuralgia. Nerve conduction study bilateral upperextremities. Abnormal EMG with findings of mild right C6 radiculopathy. Normal nerve conductionstudies of upper extremities.11/23/2022 – DimeSpine Neurosurgery. Sherwin Hua, MD. Has more numbness of fingers and toes.Still experiences shooting pain through her arms when reaching her hands out to the side. Unable todo manicures because of the position of bending her head down to do her nails. Recently startedexperiencing ice cold sensation across the top of her head. Continues to have confusion, memorylapse, verbal and mental disorientation since the accident. Assessment: Post-concussional syndrome,spondylosis with radiculopathy cervical region, cervical disc disorder with radiculopathy, cervical discdisplacement C4-C5 level. Continues to experience cervical radiculopathy. Has not gotten CTmyelogram of C-spine yet. Will need the study to properly evaluate for potential progressive stenosisat TDR level. On MRI, the presence of Prodisc implant generates too much artifact. Will also need toretrieve records of her EMG/nerve conduction studies of both arms. Will refer her to Dr. Ibrahimi,TBI specialist, for further evaluation. Will reorder CT myelogram of C-spine.01/02/2023 – Advantage Neurology. Fred Samimi, MD, neurologist. Photophobia and headache.Pain in the mid back between shoulder blades, right shoulder, both shoulders, right hand, left hand,both wrists. Toes feeling tingly. 6/10. No medicine taken. Telemedicine. Assessment: Lumbarstrain, low back pain, muscle spasm, status post MVA, cervicalgia, cervical sprain, lumbarradiculopathy, headache, concussion with loss of consciousness, post-concussive syndrome, anxiety,mild cognitive impairment, vertigo.RE: Yvonne GravilApril 19, 2024Page 14 of 3101/23/2023 – Alireza Bagherian, DC. Functional capacity evaluation summary. Job title: Personalassistant.02/06/2023 – Mobin Neurosurgery. Fardad Mobin, MD, neurosurgeon. Neurosurgical evaluation.Chief complaint: Constant neck pain with radiation to bilateral extremities, right greater than left,constant weakness, tingling, numbness in bilateral lower extremities, constant mid back pain,intermittent pain in bilateral feet and toes, headaches, PTSD, limited range of motion. 50-year-old,left-hand dominant woman, status 

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