Kamran Ghalili, M.D. Rosamund Irwin, M.D.

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Time: Trans Available Status: Procedure Orders: 1.

1 Giffen, Todd Michael (29 yrs [3/13/1985]) Sex.M Procedure Notes Procedures filed by Ghalili, Kamran, MD at 10/08/ Author: Ghalili, Kamran, MD Service: (none) Author Physician Type: Filed: 10/08/ Note 09/22/ Trans ID: D Time: Trans Available Status: Procedure Orders: 1. HOLTER MONITOR [ ] ordered by liavin, Rosamund, MD at 09/18/ DATE OF STUDY: PATIENT NAME: Giffen, Todd Michael PATIENT AGE: 23 PATIENT LOCATION: CARL REFERRING PHYSICIAN: REFERRING PHYSICIAN: Rosamund Irwin, M.D. TYPE OF STUDY: HOLTER MONITOR INDICATIONS: Palpitations. FINDINGS: 1. Underlying rhythm is normal sinus rhythm. Average rate was 106 beats per minute. Sinus tachycardia. Minimum rate was 76 beats per minute at 1044 hours. Maximal rate was 160 beats per minute at 1656 hours. 2. No ventricular premature beats noted. 3. No significant ectopic beat noted. No obvious supraventricular tachycardia noted. IMPRESSION: Essentially during this Holter monitor recording patient is mostly in sinus tachycardia. No evidence of supraventricular or ventricular tachycardia noted. S I G N E D B Y K a m r a n Ghalili, M. D. 1 0 / 0 8 / : 2 9 P K a i s e r # ( I f A p p l i c a b l e ) : cc: Kamran Ghalili, M.D. Rosamund Irwin, M.D. Consult Notes Page 1 of 8

HOLTER MONITOR [13554779] Ordering Provider: Transcription Cardiac Lab-Stress Tests Document Text Resulted: 09/26/08 1253, Result Status:

2 Consult Notes (continued) Initial Assessment Notes H&P Summary Notes Discharge Summary Notes ER RECORDS ED Arrival Information Patient not seen in ED Diagnosis None ED Disposition None ED Notes Clinical Lab Results Lab Results No matching s found No matching s found HOLTER MONITOR [ ] Ordering Provider: Transcription Cardiac Lab-Stress Tests Document Text Resulted: 09/26/ , Result Status: Final Irwin, Rosamund, MD 09/18/ Order Status: Completed ID C^te and Time Author D /22/ :46 PM Ghalili, Kamran, MD Page 2 of

HOLTER MONITOR [13554779] (continued) Resulted: 09/26/08 1253, Result Status: Final DATE OF STUDY: PATIENT NAME: PATIENT AGE: PATIENT LOCATION: REFERRING PHYSICIAN: Giffen, Todd Michael 23 CARL

Sinus tachycardia. Minimum rate was 76 beats per minute at 1044 hours. Maximal rate was 160 beats per minute at 1656 hours. 2. No ventricular premature beats noted. 3.

3 HOLTER MONITOR [ ] (continued) Resulted: 09/26/ , Result Status: Final DATE OF STUDY: PATIENT NAME: PATIENT AGE: PATIENT LOCATION: REFERRING PHYSICIAN: Giffen, Todd Michael 23 CARL REFERRING PHYSICIAN: Rosamund Irwin, M.D. TYPE OF STUDY: HOLTER MONITOR INDICATIONS: Palpitations. FINDINGS: 1. Underlying rhythm is normal sinus rhythm. Average rate was 106 beats per minute. Sinus tachycardia. Minimum rate was 76 beats per minute at 1044 hours. Maximal rate was 160 beats per minute at 1656 hours. 2. No ventricular premature beats noted. 3. No significant ectopic beat noted. No obvious supraventricular tachycardia noted. IMPRESSION: Essentially during this Holter monitor recording patient is mostly in sinus tachycardia. No evidence of supraventricular or ventricular tachycardia noted. S I G N E D B Y K a m r a n Ghalili, M. D. 1 0 / 0 8 / : 2 9 P K a i s e r # ( I f A p p l i c a b l e ) : cc: Kamran Ghalili, M.D. Rosamund Irwin, M.D. ECHOCARDIOGRAPH [ ] Resulted: 09/18/ , Result Status: Final Ordering Unlisted, Provider, PA 09/18/ Order Status: Completed Provider: Specimen Resulting Lab: SALEM ECHO LAB [XECHO- 09/18/ ] Narrative: Ordered by Rosamund Irwin MD Page 3 of 8

ECHOCARDIOGRAPH [13554737] (continued) Resulted: 09/18/08 1544, Result Status: Final Component Value Flag INTERPRETATION SUMMARY PATIENT HEIGHT PATIENT WEIGHT BSA LEFT VENTRICLE RIGHT VENTRICLE ATRIA

was p e r f o r m e d. T h i s was e s s e n t i a l l y a n o r m a l s t u d y. T h e r e i s r n i l d t r i c u s p i d r e g u r g i t a t i o n. 74 in 179 lbs 2.

4 ECHOCARDIOGRAPH [ ] (continued) Resulted: 09/18/ , Result Status: Final Component Value Flag INTERPRETATION SUMMARY PATIENT HEIGHT PATIENT WEIGHT BSA LEFT VENTRICLE RIGHT VENTRICLE ATRIA MITRAL VALVE TRICUSPID VALVE AORTIC VALVE I n t e r p r e t a t i o n Summary A t w o - d i m e n s i o n a l t r a n s t h o r a c i c e c h o c a r d i o g r a m w i t h M- mode a n d D o p p l e r was p e r f o r m e d. T h i s was e s s e n t i a l l y a n o r m a l s t u d y. T h e r e i s r n i l d t r i c u s p i d r e g u r g i t a t i o n. 74 in 179 lbs 2.1 m L e f t V e n t r i c l e The l e f t v e n t r i c l e i s n o r m a l i n s i z e. T h e r e i s n o r m a l l e f t v e n t r i c u l a r w a l l t h i c k n e s s. E j e c t i o n F r a c t i o n = %. P v i g h t V e n t r i c l e The r i g h t v e n t r i c l e i s n o r m a l s i z e. A t r i a The l e f t a t r i a l s i z e i s n o r m a l. R i g h t a t r i a l s i z e i s n o r m a l. The JVC i s n o r m a l i n s i z e a n d c o l l a p s e s w i t h i n s p i r a t i o n. M i t r a l V a l v e The m i t r a l v a l v e l e a f l e t s a p p e a r n o r m a l. T h e r e i s no e v i d e n c e o f s t e n o s i s, f l u t t e r i n g, o r p r o l a p s e. T h e r e i s no m i t r a l r e g u r g i t a t i o n n o t e d. T r i c u s p i d V a l v e The t r i c u s p i d v a l v e i s n o t w e l l v i s u a l i z e d, b u t i s g r o s s l y n o r m a l. T h e r e i s m r l d t r i c u s p i d r e g u r g i t a t i o n. PULMONIC VALVE PERICARDIUM/PLEURAL A o r t i c V a l v e The a o r t i c v a l v e i s t r i l e a f l e t. The a o r t i c v a l v e o p e n s w e l l. Mo a o r t i c r e g u r g i t a t i o n i s p r e s e n t. P u l m o n i c V a l v e The p u l m o n i c, v a l v e i s n o t w e l l s e e n, b u t i s g r o s s l y n o r m a l. T h e r e i s no p u l m o n i c v a l v u l a r r e g u r g i t a t i o n. P e r i c a r d i u m. / P1 e u r a 1 T h e r e i s no p e r i c a r d i a l e f f u s i o n. Page 4 of 8

ECHOCARDIOGRAPH [13554737] (continued) MMODE 2D MEASUREMENTS & CALCULATIONS RVDD IVSD IVSS LVIDD LVIDS LVPWD LVPWS EF (EST.

V2 VTI TV V2 MAX TV MAX PG TV V2 MEAN TV MEAN PG PA V2 MAX PA MAX PG PA V2 MEAN PA MEAN PG PA V2 VTI TR MAX VEL TR MAX PG RVSP RAP SYSTOLE INTERPRETING PHYSICIAN Resulted: 09/18/08 1544, Result

5 ECHOCARDIOGRAPH [ ] (continued) MMODE 2D MEASUREMENTS & CALCULATIONS RVDD IVSD IVSS LVIDD LVIDS LVPWD LVPWS EF (EST.) MV EXCURSION MV E-F SLOPE AO ROOT DIAM ACS LA DIMENSION LVLS AP4 DOPPLER MEASUREMENTS & CALCULATIONS MVV2 MAX MV MAXPG MV V2 MEAN MV MEAN PG MV V2 VTI AO V2 MAX AO MAX PG AO V2 MEAN AO MEAN PG AO V2 VTI TV V2 MAX TV MAX PG TV V2 MEAN TV MEAN PG PA V2 MAX PA MAX PG PA V2 MEAN PA MEAN PG PA V2 VTI TR MAX VEL TR MAX PG RVSP RAP SYSTOLE INTERPRETING PHYSICIAN Resulted: 09/18/ , Result Status: Final MMode 2D Measurements & Calculations 3.0 cm 0.89 cm 1.2 cm 4.9 cm 3.5 cm 0.93 cm 1.6 cm 56 % 2.5 cm 20 cm/sec 2.8 cm 1.8 cm 2.9 cm 6.2 cm Doppler Measurements & Calculations 67 cm/sec 1.8 mmhg 45 cm/sec 0.90 mmhg 12 cm 93 cm/sec 3.5 mmhg 63 cm/sec 1.8 mmhg 15 cm 89 cm/sec 3.2 mmhg 45 cm/sec 0.95 mmhg 69 cm/sec 1.9 mmhg 51 cm/sec 1.2 mmhg 18 cm 221 cm/sec 20 mmhg 25 mmhg 5.0 mmhg I n t e r p r e t i n g P h y s i c i a n : James W a s e n m i l l e r, e l e c t r o n i c a l l y s i g n e d on :44:37 Procedure Notes Page 5 of 8

Consult Notes MRN:2110284 CSN:6308673 Initial Assessment Notes H&P Summary Notes Discharge Summary Notes ER RECORDS ED Arrival Information Patient not seen in ED Diagnoses.

Farthing. David G., MD Performed: 05/19/11 1602-05/19/11 1602 Resulting Lab: EPIC RADIANT Specimen: 05/19/11 Narrative: ESOPHAGRAM (Fluoroscopy time: 0 min. 36 sec. Room: 1) HISTORY: Dysphagia.

6 Consult Notes MRN: CSN: Initial Assessment Notes H&P Summary Notes Discharge Summary Notes ER RECORDS ED Arrival Information Patient not seen in ED Diagnoses.DysjDhagia, ^sogha^eam^/sn^^ Obstruction esophagus ED Disposition None ED Notes Clinical Lab Results Lab Results No matching s found Resulted: 05/19/ , Result Status: Final Resultedby: Farthing. David G., MD Performed: 05/19/ /19/ Resulting Lab: EPIC RADIANT Specimen: 05/19/11 Narrative: ESOPHAGRAM (Fluoroscopy time: 0 min. 36 sec. Room: 1) HISTORY: Dysphagia. FINDINGS: With the oral ingestion of contrast, the esophagus was examined. There is normal antegrade peristalsis. There is suggestion of a minimal sliding-type hiatal hernia. No reflux was elicited. 13 mm Page 6 of 8

MRN:2110284 CSN:6308673 (continued) Resulted: 05/19/11 1619, Result Status: Final pressed barium tablet passes normally down the esophagus.

No other abnormalities are identified. Reading Dr.: Farthing, M.D., David G This report has been electronically signed by: Farthing, M.D., David G Resulted: 05/19/11 1618, Result Status: Resultedby: Farthing, David G.

7 MRN: CSN: (continued) Resulted: 05/19/ , Result Status: Final pressed barium tablet passes normally down the esophagus. The fluoroscopic procedure was performed by Kevin Hutchins, RPA under direct supervision. Impression: IMPRESSION: Suggestion of a potential minimal sliding-type hiatal hernia but no reflux was seen. No other abnormalities are identified. Reading Dr.: Farthing, M.D., David G This report has been electronically signed by: Farthing, M.D., David G Resulted: 05/19/ , Result Status: Resultedby: Farthing, David G., MD Performed: Resulting Lab: EPIC RADIANT Specimen: Narrative: ESOPHAGRAM (Fluoroscopy time: 0 min. 36 sec. Room: 1) HISTORY: Dysphagia. FINDINGS: With the oral ingestion of contrast, the esophagus was examined. There is normal antegrade peristalsis. There is suggestion of a minimal sliding-type hiatal hernia. No reflux was elicited. 13 mm pressed barium tablet passes normally down the esophagus. 05/19/ /19/ /19/11 Preliminary Impression: IMPRESSION: Suggestion of a potential minimal slidmg-type hiatal hernia but no reflux was seen. No other abnormalities are identified. Reading Dr.: Farthing, M.D., David G Resulted: 05/19/ , Result Status: In Resulted by: Farthing, David G., ID Resulting Lab: EPIC RADIANT Resulted by: Farthing, David G., MD Specimen: 05/19/11 Performed: Specimen: 05/19/ /19/ /19/11 process Result Status: In process Performed: 05/19/ /19/ Testing Performed By Lab - Abbreviation Name Director Address Valid Date Range 54 - Unknown EPIC RADIANT Unknown Unknown 03/11/ Present Order Status: Completed Performed: 05/19/ /19/ Specimen: 05/19/11 [ ] Narrative: ESOPHAGRAM (Fluoroscopy time: 0 min. 36 sec. Room: 1 HISTORY: Dysphagia. Resulted: 05/19/ , Result Status: Final Resulted by: Resulting Lab: Farthing, David G., MD EPIC RADIANT Page 7 of 8

503-561 -5200 MRN:2110284 CSN:6308673 (continued) Resulted: 05/19/11 1619, Result Status: Final FINDINGS: With the oral ingestion of contrast, the esophagus was examined.

8 MRN: CSN: (continued) Resulted: 05/19/ , Result Status: Final FINDINGS: With the oral ingestion of contrast, the esophagus was examined. There is normal antegrade peristalsis. There is suggestion of a minimal sliding-type hiatal hernia. No reflux was elicited. 13 mm pressed barium tablet passes normally down the esophagus. The fluoroscopic procedure was performed by Kevin Hutchins, RPA under direct supervision. Impression: IMPRESSION: Suggestion of a potential minimal sliding-type hiatal hernia but no reflux was seen. No other abnormalities are identified. Reading Dr.: Farthing, M.D., David G This report has been electronically signed by: Farthing, M.D., David G Page 8 of 8

Test Date Job Number Referring Site

Test Date Job Number Referring Site hr Holter Analysis ECG On-Demand Black Barn, Cornwells Farm Sheephurst Lane, Marden Kent T S Details Patient ame Patient umber Patient D.O.B. Jane Smith // ( Years) Test Date Job umber Referring Site //