WOODSON C. MERRELL, M.D.

WOODSON C. MERRELL, M.D. 44 EAST 67th STREET NEW YORK, NEW YORK 10065 Telephone: (212) 535-1012 Fax: (212) 535-1172 Date: July 27, 2011 Patient: Jeffrey Epstein (Email: [email protected]) rim • Call me Monday afternoon, or sometime early next week to review today's lab results • Supplements to begin for now: o Niacin 500mg twice a day (taking with food may reduce flushing); if flushing is too much, call me or Rony for a prescription for a sustained release form o One Enteric-coated baby aspirin every 1 to 2 days o Because of partial folic acid enzyme converting deficiency (MTHFR), take FolaPro form of folic acid by Metagenics; 1 twice a week o Nordic Naturals Omega 3 Fatty Acid Fish Oil; 1 capsule twice a day or 2 capsules once a day (approx 800 mg OPA/DHA) o Magnesium Citrate (Solgar is a good brand); 200mg once a day (taken at bedtime may act as a mild muscle relaxant) o Sublingual (under the tongue) B12 (Solgar is a good brand); 1,000mcg daily o Culturelle is an excellent brand of probiotic (acidophilus) to help digestion and intestinal immunity; one capsule/day • Give a trial of a very low dose of Crestor. Start with /2 of a 5mg tablet twice a week. If no side effects occur (usually musculoskeletal or cognitive) after 2 weeks, increase to every other day. After 3-4 weeks on this dosage regimen recheck cholesterol blood test. Stop at any time if side effects occur • Follow up with Dr. Rony Shimony 110 East 59th Street 8th Floor NY NY 10021 - - 212- 752-2700 for cardiovascular cholesterol consultation after above blood test: I will send him a note with a copy of today's • Schedule a one hour visit for an annual check up in the fall • We discussed that the triglycerides are still high; cut back not only on starches, but also oils (this will help with weight loss as well) • Due to a tendency for slightly high blood sugar (elevated glycohemoglobin), eliminate all refined carbohydrates (sugar, white flour, white rice, rolls, potatoes, etc.). Use small amounts of complex carbohydrates (whole grains); use lots of vegetables and a couple fruits as your main source of starch • Eliminate all saturated fats from your diet. This is obviously important for your cardiovascular and cholesterol issues, but saturated fat also promotes inflammation (inflammatory prostaglandins, cytokines, etc) in the body in general • Begin a regular aerobic exercise program • Try to do a daily breath-based session/meditation (at least 2 minutes, preferably 15) with frequent breath breaks throughout the day. This will not only reduce stress in general and on your cardiovascular system, but reduce cortisol levels as well • If your PTH has gone up significantly from previous, you should see your Yale parathyroid specialist (depending on today's lab results) • Try as much as possible to go on a plant-based diet. Consider reading Arthur Agatston's "The South Beach Diet" and Dean Omish's "Reversing Heart Disease" EFTA01108062 09/23/2011 11:59 2123695048 ADV CARDIOVASC IMAG PAGE 01 Cd13011 imaging A550. W/44/ZUAL `$:15:4U AM SAUL 1/0V1 r LATver Advannufainikwasathirlwaghtg 62 East 88th St New York, NY 10128 Phone (212) 3894200 FAX (212)3894048 Steven D. Wolff, M.D., Phi) Director Rony Simony 110 e 59 St Ste 8A New York. NY 10022 Patient Name: EPSTEIN, JEFFREY DOB: 01/20/1953 Exam Completed: 00/22/2011 5:55PM Examination LUMBAR SPINE MRI Comparison None available Clinical Weary Pain in back and legs Technique Sagittal FSE, Axial FSE. SagIttal FLAIR Tt. Sagittal IR Findings ACC. 727659 MRN: 0406090 There is minimal degeneratiw grade 1 anterollsthesis 011.4 on L5. Conus ends normally at the loww, T12 lava' and appears intrinsically normal. There Is no acute fracture 711412-L2-L3 them Is no focal disc herniation or stenos's. 134.4. there is disc bulge end facet arthrosis. 144.5. Mere it anterolisthesis, there is broad disc bulge with facet arthrosis ant ligernenturn eawm hypertrophy. There is severe central canal. substitute, arid moderate to marked trammel stenceil. Then• It Impingement of the L5 and encroachment on the exiting L4 nerves. 1541 there is diet: bulge asymmetrIC to the tight yen right greeter than in t= it arises*. There is mild to moderate right suberticvlar stenos is with encroachment on the right S1 nano. Impression Stare 144.5 and to a lesser depose rIgMe Med 15,51 stenos's. Thank you for the courtesy of this retinal. Dictated by: Jaws, Mohammad MD Electronically Signed By: Awl. Mohammad, MD 09/23/2011 914 AM Transcribed by: Mars. Mohammad, MD on September 23, 2011 9:14 AM EFTA01108063 Sent 10/02/2009 09:24:15. Page - 2 !R!callLTHD;SLPP66;SLPI6.31IPPI10;EXIT; FINAL REPORT EPSTEIN,JEFFREY DOB:01/20/53 56Y Sex: M ACCT #: 060006996 TRANS: AMBULATORY F#: OCC OCC 8000434390 ADM: MOSKOWITZ,BRUCE W ORD: MOSKOWITZ,BRUCE W Exam: 7508 MR MRI LUMBAR SPINE W/O CNTRST Ord Diag.: 724.4-LUMBOSACRAL NEURITIS NO SEDATION : NO-SEDATION ADMINISTERED CONTRAST USED: *NONE* MRI of the lumbar spine without contrast: Exam Date: 10/02/09 0829 CI#: 3308778 ORD#: 0003 Sagittal Ti, T2 and STIR images demonstrate normal bone marrow signal. There is diminished signal within the L1 to and L4-L5 intervertebral discs. These findings are consistent with dehydration. There is a disc bulge which is diffuse at the L4-L5 level with protrusion centrally associated with moderate degenerative changes of the apophyseal joints bilaterally the combination causing a moderate central stenosis. There is also mild encroachment on the left lateral recess. There is a disc bulge at L5-S1 but no significant central or lateral re ss tehgais. IMPRESSION: , - There is a d ffuse disc bulge at 1 associated with central prof ' AUSihd m ate .tenosis as well as left lateral recess stenosis. Transcriptionist- HOWARD 0 BUTLER, M.D. Reading Radiologist- HOWARD 0 BUTLER, M.D. Released Date Time- 10/02/09 0923 MOSKOWITZ,BRUCE W 1411 N Flagler Dr, #9300 W Palm Beach, FL 33401 EFTA01108064 SODIUM POTASSIUM CHLORIDE CARBON DIOXIDE UREA NITROGEN CREATININE BUN/CREATININE RATIO O Quest Diagnostics QUEST DIAGNOSTICS INCORPORATED CLIENT SERVICE 800.631.1390 SPECIMEN INFORMATION SPECIMEN: K2534668 REQUISITION: MANUAL327631 COLLECTED: 07/27/2011 13:05 RECEIVED: 07/27/2011 20:43 REPORTED: 08/04/2011 08:15 PATIENT INFORMATION EPSTEIN, JEFFREY DOB: 01/20/1953 AGE: 58 GENDER: M FASTING: N PHONE: 212.750.9895 SEFCRT STATUS FINAL ORDERING PHYSICIAN CLIENT INFORMATION T11886 WOODSON MERRELL, M.D. 44 E 67TH STREET NEW YORK, NY 10065 10013575 Teat Name COMP METAB PANEL GLUCOSE In Range 102 The glucose reference range 142 4.1 107 21 24 0.94 NOTE Bun/Creatinine ratio is not reported when the Bun Creatinine values are within normal limits. CALCIUM 9.5 PROTEIN, TOTAL 6.9 ALBUMIN 4.4 GLOBULIN, CALCULATED 2.5 A/G RATIO 1.8 BILIRUBIN, TOTAL 0.5 ALKALINE PHOSPHATASE 57 AST 19 ALT 16 EGFR NON AFR AMERICAN 89 EGFR AFRICAN AMERICAN 103 URIC ACID 7.7 GGT 14 TSH,3RD GENERATION 1.67 FERRITIN 88 Out of Range Reference Range 65-139 mg/dL is based on a non-fasting state. 135-146 mmol/L 3.5-5.3 mmol/L 98-110 mmol/L 21-33 MMO1/L 7-25 mg/dL 0.76-1.46 mg/dL 6-22 and 8.6-10.2 mg/dL 6.2-8.3 g/dL 3.6-5.1 g/dL 2.1-3.7 g/dL 1.0-2.1 0.2-1.2 mg/dL 40-115 U/L 10-35 U/L 9-60 U/L >=60 mL/min/1.73m2 >=60 mL/min/1.73m2 4.0-8.0 mg/dL 3-85 U/L 0.40-4.50 mIU/L 20-380 ng/mL VITAMIN B12 + FOLATE VITAMIN 812,SERUM 316 200-1100 Please note: although the reference range for Vitamin B12 is 200-1100 pg/mL, it has been reported that between 5 and 10% of patients with values between 200 and 400 pg/mL may experience neuropsychiatric and hematologic abnormalities pg/mL Lab TBR TBR TBR TBR TBR TBR EPSTEIN,JEFFREY - K2534668 Page 1 - Continued on Page 2 Ian nwi ars.. Ike atrceliid kip Mae Ansiiiilfidaintlemeled4.nstka. sr* its esnr\.N Ned Deponiv. 0.4010Woadi MVMMM Y imphionew.1 % !XX 111,10 EFTA01108065 O Quest 4 Diagnostics GUEST DIAGNOSTICS INCORPORATED SPECIMEN INFORMATION SPECIMEN: X2534668 COLLECTED: 07/27/2011 13:05 REPORTED: 08/04/2011 08:15 PATIENT INFORMATION EPSTEIN, JEFFREY DOB: 01/20/1953 AGE: 58 GENDER: M FASTING: N T STATUS FINAL ORDERING PHYSICIAN CLIENT INFORMATION T11886 10013575 Test Name In Range Out of Range Reference Range due to occult 812 deficiency; less than 1% of patients with values above 400 pg/mt will have symptoms. FOLATE.SERUM 5.1 CORTISOL,E.N. CORTISOL (PM) DHEA SULFATE Normal: Borderline: Low: > 5.4 ng/mL >5.4 3.4-5.4 <3.4 10.6 3.0-17.0 mcg/dL 219 25-240 mcg/dL CARDIO CRP (R) 0.8 Lower relative cardiovascular guidelines. For ages >17 cCRP mg/L <1.0 1.0-3.0 3.1-10.0 >10.0 PSA, TOTAL See footnote 1 IDTKOOLOBINA1C Reference mg/L risk according to AHA/CDC Years: Risk according to AHA/CDC guidelines Lower relative cardiovascular risk. Average relative cardiovascular risk. Higher relative cardiovascular risk. Consider retesting in 1 to 2 weeks to exclude a benign transient elevation in the baseline CRP value secondary to infection or inflammation. Persistent elevation, upon retesting, may be associated with infection and inflammation. 0.5 <=4.0 ng/mL Range: < 5.7E 5.7-6.0% 6.1-6.4% > OR = 6.5E Percent Decreased risk of diabetes Increased risk of diabetes Higher risk of diabetes Consistent with diabetes Lab TER TBR TBR TBR TBR EPSTEIN,JEFFREY - K2534668 Page 2 - Continued on Page 3 Owo Opea0oplesIL. t..statillcd lye amoomeaOseilliouvoc..heibit•Orielrwhaultsci Ong ly• 4`0141i0•81PCSITICII moor:we Alcor{ 411•, 14 C1101.101. Rt. KC 10110. I ,S570 EFTA01108066 a% Quest e fi Diagnostics QUEST DIAGNOSTICS INCORPORATED SPECIMEN INFORMATION SPECIMEN: X2534668 COLLECTED: 07/27/2011 13:05 REPORTED: 08/04/2011 08:15 PATIENT I NPORMAT ION EPSTEIN,JEFFREY DOB: 01/20/1953 AGE: 58 GENDER: M FASTING: N REPORT STATUS FINAL ORDERING PHYSICIAN CLIENT INFORMATION T11886 10013575 Test Name In Range Out of Range Reference Range HOMOCYSTEINE,CARDIO HOMOCYSTICINS 16.1 H. 411.4:MICROM01/L VITAMIN D, VITAMIN VITAMIN VITAMIN 25-OH, LC/MS/MS D, 25-OH, TOTAL 30 30-100 ng/mL D, 25-OH, D3 30 ng/mL D, 25-0H, D2 <4 ng/mL 25-OHD3 indicates both endogenous production and supplementation. 25-0HD2 is an indicator of exogenous sources such as diet or supplementation. Therapy is based on measurement of Total 25-0HD, with levels <20 ng/mL indicative of Vitamin D deficiency, while levels between 20 ng/mL and 30 ng/mL suggest insufficiency. Optimal levels are or = 30 ng/mL. TESTOSTERONE, FREE, BIO/TOT TESTOSTBRONE,TOTAL,LCMSM$ 152 : 250-1100 ng/dt TESTOSTERONE FREE 38.0' L 46,C-224.0 pg/mL TESTOSTERONE BIOAVAILABLE 78.1 . L 110.0-575.0 ng/dL SEEM 11 : 22-77 nmol/L ALBUMIN, SERUM 4.5 3.6-5.1 g/dL Lab TBR TBR AMD EPSTEIN,JEFFREY - K2534668 Page 3 - Continued on Page 4 •)/n/ Ilan/ Dar-v<. ibeast//41/0/taanlentin/olea 0av Dornie.t molt me *a ,..k...., I orimlllaVaat. / 0/./1O/Dirsilics INC•paridoel •I *els telWyee COMISIM.116•4•0 SM Sal 'inn EFTA01108067 a% Quest e r4 Diagnostics QUEST DIAGNOSTICS INCORPORATED SPECIMEN INFORMATION SPECIMEN: K2534668 COLLECTED: 07/27/2011 13:05 REPORTED: 08/04/2011 08:15 PATIENT INFORMATION EPSTEIN, JEFFREY DOB: 01/20/1953 AGE: 58 GENDER: M FASTING: N REPORT STATUS FINAL ORDERING PHYSICIAN CL I ENT INFORMATION T11886 10013575 Test Name VAP (TM) CHOLESTEROL TEST DIRECTLY MEASURED LIPID TOTAL LDL-C DIRECT (Desirable range <100 mg/dL for TOTAL HDL-C DIRECT TOTAL VLDL-C DIRECT SUM TOTAL CHOLESTEROL 187 TRIGLICERIDES-DIRECT Note: Triglycerides may be elevated if p 26 62 71 Tent has L H H not TOTAL NON-1410L-C(LDL+VLDL) 161 H FOR SETTING LDL-C GOAL LP(a) CHOLESTEROL 8.0 IDL-C 25 H REAL-LDL-C 67 SUM TOTAL LDL-C 99 REAL-LDL SIZE PATTERN A ( 1 I 1 I Pattern B Pattern Small, Dense LDL A/B In Range Out of Range Reference Range 99 <130 mg/dL CHD, Diabetes, or its equivalent) >40 mg/dL <30 mg/dL <200 mg/d1. <150 mg/dL fasted. <160 mg/dL <10 mg/dL <20 mg/dL <100 mg/dL <130 mg/dL A Pattern A e Buoyant LDL REMNANT LIPO (IDL+VLDL3) 52 H <30 ms/dL Presence of additional risk factors, consider lowering LDL-C goal. CONSIDER INSULIN RESIST/ METABOLIC SYNDROME SUB-CLASS INFORMATION HDL-2(LARGE,BUOYANT) HDL-3(SMALL,DENSE) VLDL-3(REMNANT LIPO) NO 8 L >10 mg/dL 18 L >30 mg/dL 27 H `10 mg/dL. Lab ATT ATT ATT ATT EPSTEIN,JEFFREY - K2534668 Page 4 - Continued on Page 5 liver I Ow an writ ituovaW rd • *sear. OSIAIN D tiresICS Mai OW IISIM011t elan DUWW. roe l DYISIKSIM1110•0011• Weft •tielted ODIECONTL RenteMs) Y.TI IISS70 EFTA01108068 alk Quest a d Diagnostics QUEST DIAGNOSTICS INCORPORATED SPECIMEN INFORMATION SPECIMEN: K2534668 COLLECTED: 07/27/2011 13:05 REPORTED: 08/04/2011 08:15 PATIENT INFORMATION EPSTEIN, JEFFREY DOB: 01/20/1953 AGE: 58 GENDER: M FASTING: N REPCRT STATUS FINAL ORDERING PHYSICIAN CLIENT INFORMATION T11886 10013575 FOOTNOTE(S): 1 This test was performed using the Siemens (Bayer) chemiluminescent method. Values obtained from different assay methods cannot be used interchangeably. PSA levels, regardless of value, should not be interpreted as absolute evidence of the presence or absence of disease. PERFORMING LABORATORY INFORMATION: AMD ATT TBR Quest Diagnostics Nichols Chantilly 14225 Newbrook Drive Chantilly VA 20151 Laboratory Director: Kenneth Sisco, MD,PhD CLIA No: 49D0221801 Atherotech Inc. 201 London Parkway Birmingham AL 35211 CLIA No: 01D0641541 Quest Diagnostics One Malcolm Avenue Teterboro NJ 07608 Laboratory Director: William E. Tarr, M.D. CLIA No: 3100696246 EPSTEIN,JEFFREY - K2534668 Page 5 - End of Report na , lettl:0•••••5441..7* auxiprei lup se Won 14•41C.KppioNlisav ,•• neimathn , ta.".1%• Cat , Corp..0 anent AN 'tea ...tom. OD YAM MTh kW., SDI SC* 11H/0 EFTA01108069 A418k (21JICSI lailler ‘ -41 Nagnostics QUEST DIAGNOSTICS INCORPORATED CLIENT SERVICE 800.631.1390 SPECIMEN INFORMATION SPECIMEN: K2534657 REQUISITION: COLLECTED: 07/27/2011 13:05 RECEIVED: 07/27/2011 20:42 REPORTED: 08/01/2011 08:15 PATIENT INFORMATION EPSTEIN, JEFFREY DOB: 01/20/1953 AGE: 58 GENDER: M FASTING: N PHONE: 212.750.9895 Rl PQRT STA:US FINAL ORDERING PHYSICIAN CLIENT INFORMATION T11886 WOODSON MERRELL, M.D. 44 E 67TH STREET NEW YORK, NY 10065 10013575 Teat Name MERCURY, BLOOD ARSENIC, BLOOD In Range 5 <3 Out of Range Urine is usually the best specimen for the analysis of Arsenic in body fluids. Blood levels tend to be low even when urine concentrations are high. PERFORMING LABORATORY INFORMATION: AND Quest Diagnostics Nichols Chantilly 14225 NembrOOk Drive Chantilly VA 20151 Laboratory Director: XenneLh SISCO, MD. PhD CLIA NO: 49D0221801 Reference Rang. <=10 mcg/L <23 mcg/L Lab AND AND EPSTEIN,JEFFREY - K2534657 11.y..a •,•••,./...i.baMil. ••,....0). as 4.• naol)I ...... 11.“111. Page 1 - End of Report lk • • CLI, M4iPain•INg•••••...4 ia.• •••#n4106t4 02111•1111. &WAS NI 50 .111611 EFTA01108070 lrift (.211(!st • liar imi lAagnostics PATIENT INPORMATION EPSTEIN, JEFFREY REPORT STATUS FINAL GUEST DIAGNOSTICS INCORPORATED CLIENT SERVICE 800.631.1790 SPECIMEN INFORMATION DOB: 01/20/1953 AGE: 58 GENDER: M FASTING: N ORDERING PHYSICIAN CLIENT INFORMATION SPECIMEN: F0887635 T11886 10013575 REQUISITION: PHONE: 212.750.9895 WOODSON MERRELL, M.D. 44 E 67TH STREET NEW YORK, NY 10065 COLLECTED: 07/27/2011 13:05 RECEIVED: 07/27/2011 23:26 REPORTED: 07/29/2011 08:15 Test Name In Range Out of Range Reference Range CALCIUM 9.6 PTH,INTACT Interpretive Guide Normal Parathyroid Function Hypoparathyroidism Primary Hyperparathyroidism Secondary Hyperparathyroidism Tertiary Hyperparathyroidism Non-Parathyroid Hypercalcemia Intact Normal Low or Low Normal Normal or High High High Low or Low Normal 8.6-10.2 mg/dL 10-65 pg/mL Calcium Normal Low High Normal or Low High High PERFORMING LABORATORY INFORMATION: TBR Guest Diagnostics One Malco:r Avenue Teterboro NJ 07608 Laboratory Director: CLIA NO: 31D069&246 William E. Tarr. M.D. Lab TBR TBR EPSTEIN,JEFFREY - F0887635 Page 1 - End of Report EFTA01108071 Quest Diagnostic! Date of Report: 07/29/2011 Patient Name: EPSTEIN. JEFFREY Specimen: F0887635 Patient ID: (80443348 Age: 58 Sex: M Intact Parathyroid Hormone and Total Calcium Patient Results - Intact Mil 104.00 Inhnl I Calcium 9.60 Quest Diagnostics One Malcolm Avenue Teterboro. New Jersey 07608-1070 800.63 I . I 390 111886 10013575 WOODSON MERRELL, M.D. 44 E 67TH STREET NEW YORK, NY 10065 Quest Trail, 2.0 4.0 6.0 8.0 10.0 12.0 14.0 Total Calcium (mg/dL) Ordering Physician: Route: 10013575 Account Number: TI l886 61 Legend A Primary or Tertiary Hyperparathyroidism a Secondary Hyperparathyroidism O Hypercalcemia of Malignancy 0 Hypoparathyroidism 0 Patient Result 'This paphwal represeniation in not intended to nulnaiime fur the Clinical laboratory Report afiirh may contain more complete information. Refererne value. on the graph shove are horn a Nuptial:my data net from Quem Diagnostics Nichol% Manure. Intact PTH valuta phoned on thin graph were unelyaerl ttning an 'mat PTH IRMA rasa) 'chow perfamance chafer tetr, tict ae very 'imam to the DPC method currently colored at Quern DicIgnO•Ik's. Qucg.ljucsi Ihistivnth.h. llc u.sorisied Ingo out *It whociattd ljunt thurnomics saris .rc the fel:bitted tbdemurk%•f (Ith•I Disietunliv• IncorpoiScd. C Ifil I Quca hiagyhhtic. laccrphruhcil. All herd% rt.hr. yd. EFTA01108072 FROM TO 012125351172 01/10/2011 15 38 41 #4236 P 001/002 TO: ATTENTION: RYS/F 1 8 212-434.6971 free: S L fleas - Digiliedlx F9 2, 3 11/18/11 1.38 pe DEPARTMENT of trinitvEK110NAI. CARDIAC a VASCPLAR SEM1CZ Lemur Hill Heart sod Vascular Institute of New York PATIENT: Epstein, Jeffrey AGE: 57 SEX: M SALIENT ISSUES • Blood tests done with Dr. Woodson Merrell on 11/18/2010 revealed a total cholesterol of 199 end HDL of 26. LDL could not be calculated secondary to trig)ycerides of 679. The cholesterol to HDL ratio was 7.7. CRP was 0.9. Hemoglobin Mc was 5.8. REVIEW OF SYSTEMS • Review of systems in detail is otherwise negative. PHYSICAL EXAMINATION • GENERAL' On physical examination, he is in no distress. • VITAL SIGNS BP 120/70 mmHg. • THORAXANDLuta:is Chest is clear. • CARDIOVASCULAR. There is no S3 gallop. • ABDOMEN. Abdomen is soft. • EXTREMITIES. Extremities are benign. DIAGNOSTIC STUDIES • A CTA of the coronary arteries done today revealed a total coronary calcium score of 53 (0 in the left main artery and 53 in the left anterior descending artery). This represented a 13% increase from 2008. There was a zero calcium score seen in the circumflex artery and the right coronary artery. The resultant was less than 50% calcified plaque in the proximal to mid left anterior descending artery. There was 25% to 50% stenosis in the ostial part of first diagonal artery. The right coronary artery and the circumflex artery as well as the left main artery were normal. • An echocardiogram done today revealed normal left ventricular size and systolic function. The valvular structures were normal There was trivial mitral regurgitation secondary to valve leaflet closure. • On exercise treadmill test today. he exercised to 20.4 METs with a peak heart rate of 148 beats per minute, representing 90% of predicted maximum heart rate. The peak blood pressure was 145/70 inning. There was no chest pain, no ST segment depressions to suggest ischemia, and no arrhythmias. An echocardiogram done immediately post peak exercise demonstrated normal left ventricular size, systolic function, and augmentation, with no regional wall motion abnormality. IMPRESSION • Mr. Epstein had muscular reaction with cramps to Lipitor as well as Crestor. His blood tests reflect lack of exercise for 6 months as well as no medications. We will start him on Livalo (piUtvastatin) at 2 mg p.o. daily ae well es Niaspan 500 mg p.o. daily, to be titrated to 1000 mg. He tolerated Niaspan in the past well. He will also be placed on a baby aspirin 81 mg p.o. daily. He is to have blood tests done in 6 weeks. The patient has been Rony Y. Shimony, M.D., F.A.CC. Derider, neer fir Candiskuntir Duran Lemon Hai 1-14upkil Han sell Vega, butisor N 19th Sinn PROGRESS NOTES DATE: December 2, 2010 (continued) Lenox Hill buenintional Cardiac end Vascular Sancta PC • 110 Brat 59th Street, Sth Floor, Nen York, NY 100224304 Tell 212 752 2700 • Am: 212 7522949 EFTA01108073 FROM TO 012125351172 01/10/2011 15 38 52 #4236 P 002/002 To: ATIENT101: RYS/F i 1 0 212.431.6971 Froa: S 1. Ream - DigItiedix F9 3/ 3 81/111/11 pa DEPARTMENT t1F INTEIMiNT1ONAL CARDIAC & VA44:111All silanas RoityY. Shimony, M.D., F.A.C.C. Lenox Hill Heart and Vascular Institute of New York Epstein, Jeffrey Demur, C haft fe Cartsnavbr DIMON LIM% Hill Her en! Vanier hinds ar 5.Pth Srrnt PROGRESS NOTES Page 2 of 2 December 2, 2010 complaining of some leg cramps with exercise. We will proceed with peripheral vascular evaluation of his carotid arteries, abdominal aorta, and lower extremities with ABI/PVR and Doppler studies. PLAN • Start l.ivalo (pitavastatin) 2 mg p.o. daily and Niaspan 500 mg p.o. daily, titrating to 1000 mg. Baby aspirin 81 mg p.o. • Blood tate in 6 weeks. • Peripheral vascular evaluation of carotids, abdominal aorta, and lower extremities with ABI/PVR and Doppler studies. • Medications and plan reviewed with patient in detail. 0:12/2/201012.NET (002) /RYS T: 12/ 4/7010 10:2$ ET/ tan /air cci Dr. Woodson Merrell (Phone 212-535-1012, Fax: 212.535.1172) Dr. Eva Anderson-Dubin 1040 Sth Ave Fl 15 New York NY 10028 RONY Y. SHIMONY, MD, FACC ADDENDUM DIAGNOSTIC STUDIES • Carotid Dopplers done today were normal. A lower extremity vasculature study was entirely normal and triphasic. The study was done due to his complaint of claudication. • A BI/P VR of the lower extremities revealed a brachial-ankle index of 1.1 on the right and 1.13 on the left both are normal. The aorta below the renal arteries and above the iliac arteries was normal in size, measuring 2.0 x 1.9 cm in maximum diameter in the mid section. IMPRESSION • Mr. Epstein's leg symptoms may be coming from spinal issues. He will follow up with Dr. Woodson Merrell. PLAN • Followup with Dr. Woodson Merrell. D:12/2/701013:22 ET (005) IRIS T 12/0/2010 10:18 ET/um/sk cc: Dr. Woodson Merrell (Phone: 212-535-1012, Fax: 212.535.1172) Dr. Eva Andersson-Dubin 1040 5th Ave Fl 15 New York NY 10028 11-4S4t . /.. • s .....1. RONY Y. SHIMONY, MD, FACC Era ILE Intenenlionel Canfisc and Vaaculas Services, PC • 110 East 59th Street, alb Flow, New York, NY 100M-1504 Telt 212 7522700 • Nun 212 752 2949 EFTA01108074 FROM T0012126351172 01/10/2011 156427 #4238 P 002/003 Sent 12/02/2010 14 14 56. Page - 2 LENOX RILL HOSPITAL TRENT OF RADIOLOGY Fi .1/Addendum PATIENT: EPSTEIN,JEFFREY PT TYPE: OP MR NO: 1530026 ACCT 101888945 DOH: 01/20/1953 HOS? SVC: PCV CLI: PCV ATTENDING PRY ICILH: RONY . SHIMONY, MD ORDERING PHYSIC/AN: BONY Y. SHIMONY, MD EXAM: 12/02/2010 1000 CT ANGIO CORONARY ARTERIES CPT:75574 ADMIT DIAGNOSIS: REASON: SCREENING •c3.,./(O INTERPRETATION: 256 MDCT Coronary Angiogram: Age: 57 years Gender: Male Indication: SCREENING Phase: 15% HR: 13 Calcium Coron Total: 53 : 0 LAD: 53 LCx: 0 RCA: 0 Coron rtery Calcium Percentile: 58% Aortic calcium: Mild Aortic valve calcium: 0 Mitral annular calcium: 0 Dominance: Right Left Main Coronary Artery: Normal Left Anterior Descending Coronary Artery: There is lees than 50% stenoais in the calcified proximal to mid segment. There ie 25 to 50% oetial first diagonal atenosis Left Circumflex Coronary Artery: Normal DICTATED: 12/02/2010 RADIOLOGY ATTENDING STEPHEN MACHNICKI, MD 12/02/2010 ACCS: 26116CT10 LOCATION: PRIVATE CARDIO VASCULAR PAGE: 1 (Page 1 of 3. Continued on next page) EFTA01108075 FROM TO 012125351172 01/10/2011 15:54 34 #4238 P 003/003 Sent 12/02/2010 14 14 $6. Page - 4 LENOX HILL HOSPITAL DEPARTMENT OF RADIOLOGY Final/Addendum PATIENT: EPSTEIN,JEFFREY PT TYPE: OP MR NO: 1530026 ACCT *: 101888945 DOB: 01/20/1953 HOSP SVC: PCV CLI: PCV ATTENDING PHYSICIAN: RONY Y. SHIMONY, MD ORDERING PHYSICIAN: RONY Y. SHIMONY, MD EXAM: 12/02/2010 1000 CT ANGIO CORONARY ARTERIES CPT:75574 ADMIT DIAGNOSIS: REASON: SCREENING INTERPRETATION: administration of intravenous contrast material. This report refers to the non-coronary portion of the exam. PRIOR STUDIES: CT angiography of the coronary arteries dated 6/13/08. FINDINGS: The heart is normal in size. No pericardial effusion is seen. The visualized contrast enhanced images of the aorta and pulmonary artery are unremarkable. No mediastinal or hilar lymphadenopathy is seen. Limited evaluation of the pulmonary parenchyma demonstrates no abnormality. No pleural effusions are seen. Evaluation of the osseous structures demonstrates degenerative changes of the spine. IMPRESSION: Unremarkable exam. Reviewed by 8.3181 Michael Karachalios, MD Reviewed by 83181 Michael Karachalios, MDand Signed by 02007 Stephen Machnicki, MD; 12/2/2010 2:10 PM DICTATED: 12/02/2010 RADIOLOGY ATTENDING STEPHEN MACHNICKI. MD 12/02/2010 ACC#: 26116CT10 LOCATION: PRIVATE CARDIO VASCULAR PAGE; 3 EFTA01108076