Q. Do most of your patients that come to your practice, do they mostly have appointments in advance or do they come in as walk-ins?
A. There are some of them appointments, some of them walk-in.
Q. What percentage of your patients do you believe are walk-ins?
A. I cannot really - I didn't make any study about that.
Q. Do you have any notation on how Mr. Dimitrov first came to you see, whether it was a scheduled appointment or a walk-in?
A. There is a referral, I can check the front page. I will tell you if somebody referred to me or is walk-in or just sent from his friend. I don't know. He looks like walk-in. Nobody referred him to me.
Q. The modalities that we have been discussing today that you've gone over previously, those are performed by physical therapists that you have - that you have on your staff here at your practice?
Q. Okay. And you yourself do not administer any of those modalities?
A. I don't do any physical therapy, no.
Q. And who trains your office staff, your physical therapist?
A. She's trained on herself. She has the experiences.
Q. The report that you have enclosed in your documents, that report was prepared by you or was it dictated by you and prepared by someone else?
A. I dictated - I dictate the report and they type it.
Q. And do you review prior to signing it?!
Q. Do you compare your reports after they are dictated to the records that you have with - for the patient that the report is written on?!
A. Yeah, sometimes. Sometimes I - I add some things. I subscribe some things. I forget something.
Q. And I think you've stated - you stated earlier, but before looking at the records that you have in front of you, you had no independent recollection of Mr. Dimitrov or his treatment prior to looking at your records, correct?
Q. Okay. And you had no independent recollection of his complaints, his diagnosis or what his treatment was prior to looking at the records, correct?
Q. And you turned over all of your records pursuant to subpoena that was issued on you?
A. I think the office returned everything.! Q. Okay. And that includes all of your records of the diagnosis, the treatments and narrative reports and the progress reports, correct?
Q. And that is including what your physical therapists have done also, correct?
Q. Okay. If we can refer to the intake report that was done with Mr. for a second. A. My report?
Q. Yeah, the initial intake.
A. Oh, the initial admission.
Q. Admission. Do you call it an admission report?
Q. I apologize. You stated earlier that normally this whole - the front, the top part would have been filled out by the patient?
A. By the patient.
Q. And you're not sure why this was not filled out by Mr. Dimitrov, correct?
A. Most probably, as I said in my - previously, that you see we use for admission sheet a green sheet. And most probably they didn't have the green sheet, so they cut the green sheet and they put it there.
Q. And is it normal that there would be no indication of any family history, problems, or notations in the general health section?
A. Usually, if there is nothing there, I don't write it.
Q. Wouldn't you say that it's very important for an accurate assessment of the patient to have all the history possible of the patient?
A. Correct. Correct.
Q. And wouldn't you say that having all of the patient's history, prior history of any medical - all medical treatment would be important for your diagnosis of that patient?
Q. And the history of the patient would be very important for you to set out a treatment plan for that patient, correct?
Q. Okay. The history that you have of Mr. Dimitrov is solely from what he told you on January 27th, 1995, correct?
Q Normally with the patient, you would review all prior records if they brought them in such as emergency room records, any other records from any: other doctors that they saw prior to you for the injuries that they're trying to get treatment from 3 you, correct?
Q. However, in this case, Mr. Dimitrov brought no prior records, no emergency room records or anything for you to review prior to him seeing you initially, correct?
Q. You previously went over the difference between subjective and objective - objective findings when you were eliciting information from a patient. Isn't it correct that it's desired to have objective information over subjective information when making a diagnosis or a treatment plan for a patient?
Q. Isn't it correct that the tolerance of pain for each individual or patient that comes in greatly varies so that's another reason why objective findings are probably more desirable than subjective findings when diagnosing and treating and setting out a treatment plan for a patient, correct?
Q. Ordinarily you take notes each time you see a patient, correct?
Q. Okay. And it's important that each time that you see the patient, that those notes be very detailed, because as we've noted here today, it's very hard to have an independent recollection every time someone comes in to see you, correct?
Q. And you would - is it accurate to say you would note all important things after talking to a patient each time that they come in in your notes for that day?
Q. Okay. Is it accurate to say if your notes are not detailed and pretty specific with what the patient says, that your diagnosis and treatment of the patient could suffer?
A. It has nothing to do with that. It has to do with what I described is important, as you said, before. 5
Q. You first - Mr. Dimitrov first came to your practice for treatment on January 27th, 1995, correct?
Q. And you never saw Mr. Dimitrov prior to January 2 7th, 1995, correct?
Q. Okay. So as we previously just stated, you had no prior medical history from the plaintiff, whether it be records or any other, even oral history from him, to compare your findings after you - while you were treating the plaintiff, correct?
Q. So is it accurate to say that you had to rely solely on the subjective information given by the plaintiff - by Mr. Dimitrov to set your treatment plan and diagnose the patient, correct?
A. This is not correct because what you said is subjective only. It's subjective and objective, plus the history of the trauma.
Q. Do you know how Mr. Dimitrov got to his physical therapy sessions?
A. Kow many times?
Q. Do you know how he got there? Do you know if he drove himself or did you take any notations regarding that?
A. I have no recollection of it.
Q. During your initial examination of
Mr. Dimitrov, he did not make any mention of any loss of consciousness as a result of the accident, correct?
Q. And he - Mr. Dimitrov did not make any mention of any cuts or bleeding as a result of the accident, correct?
Q. And if Dimitrov would have had any of those things happen as a result of the accident, you would have made notation of that in your notes, correct?
Q. In your initial examination of Mr. Dimitrov, you took his vital signs, correct?
Q. In your opinion, if a - well, strike that. Mr. Dimitrov's vital signs, would you have made note if any - if he was in distress or if there was anything that would indicate that he was in stress or in pain due to his vital signs., you would have made\ a note of that?
Q. And your summary report is from March 15th, 1996, correct?
Q. Okay. You stated that Mr. Dimitrov made complaints of headaches, pain in his neck and shoulders?
Q. And sickness to his stomach in your report?
Q. Now, you prescribed a course of physical therapy to treat these complaints, correct?
Q. Okay. Now, did the physical therapy that you - that you prescribed for Mr. Dimitrov, is it accurate to say that those weren't - that that physical therapy would not treat headaches and dizziness and sickness to the stomach?
A. This is wrong because headache can come from a trauma to the cervical spine. Dizziness also can be caused by the trauma to the neck or cervical spine. The stomach, sure, has the - if the pain in the stomach of queasy stomach comes after the trauma, it's mostly psychological.
Q. Now you state, sir, that the physical therapy could treat headaches and the dizziness?
Q. However, is it accurate - well, is it accurate to say you didn't do any further testing to find out if there was anything else that could be causing the headaches and the dizziness?
A. No, I didn't do that. But I know by experience that any neck trauma, any injury to the neck makes headache and dizziness.
Q. Did you ever refer Mr. Dimitrov to see a neurologist for his headache or dizziness?
Q. Did you refer Mr. Dimitrov to any other specialist or any other doctor for any reason as a - for any of the complaints that he was making?
Q. Besides - you said earlier that when you would see Mr. Dimitrov, you did kind of a hands-on examination. Were there any other testing that you did yourself to treat Mr. Dimitrov?
A. I don't remember. But usually when I check the patient. I check him from head to toes and ask him all questions about the different organs and different parts of the body.
Q. If you had done any - well, is it accurate to say that if you had done any other examination besides physically putting your hands on Mr. Dimitrov to see what was - what his complaints were or to treat him, you would have made notation of those examinations or treatments in your notes, correct?
A. If there are exceptional examinations.
Q. So specifically what medical testing was done in total, in all of Mr. Dimitrov's treatment with you, what medical tests did you conduct on him?
A. Do you want to - from the beginning to the end?
Q. Solely by you.
A. Yeah. For the pupils, for example, we use light. For the ear, we use also otoscope. For the mouth, we use light. For the neck, we use our hand and then we turn the head right and left in order to see if there is any, any - any injury to the neck which was - which will follow symptoms to the shoulders and the arms.
The heart, we'll use the stethoscope. The lungs we'll use the stethoscope. We use also the pulses on both sides of the wrists to see if there is any injury of the neck has influenced the - influenced the pulses of the wrists.
For the abdomen, we use manually, we check manually. We check also with a stethoscope, the bowel sounds.
For the neck - for the back, we use manually if there's any pain or any tenderness or spasm of the muscles. We use also the reflexes at the level of the elbow, the wrist, the knees, both knees and both ankles.
Q. Did you ever conduct a neurological examination or have a neurological examination done on Mr. Dimitrov?
A. This is what I told you by checking the neck, checking the wrist, the reflexes of the elbows, the reflexes of the knees, the usual reflexes of the feet.
Q. And you did have x-rays of parts of Mr. Dimitrov's body taken, correct?
Q. And there were x-rays done on his cervical area, region?
A. Cervical and chest.
Q. Okay. And the cervical x-rays came back negative and within normal limits, correct?
Q. And pursuant to the subpoena that was issued on you, you were to bring in all the records regarding all the treatment and all tests that were given to Mr. Dimitrov, correct?
Q. Okay. Now, you read the x-rays yourself of his cervical and chest area?.
Q. Wouldn't - wouldn't it be - would it be accurate that you would have put the results or the - some notation in your notes regarding the reading of those x-rays?
A. We put that in the report that I sent it to you.
Q. Okay. Were any - any other x-rays besides the chest and the cervical area taken?
Q. You stated earlier that 90 some percent of x-rays don't show injury to the soft tissue area?
Q. Correct? Am I saying that correct?
A. Correct, only some swelling sometimes.
Q. What percentage of x-rays would show soft tissue injury in your opinion? i
A. It depends really on the x-ray and the technology. And sometimes you - I cannot tell you percentage-wise.
Q. Would you characterize - is it accurate to say you would characterize Mr. Dimitrov's injuries as soft tissue injuries?
A. As a sprain of the neck, yeah.
Q. Well, the sprain of the neck, would you characterize that as a soft tissue injury?
A. Soft tissue injury. No bone injury.
Q. Is there any test that could have been done that would have shown soft tissue injury as an objective finding?
A. Yeah, if you want to pay more money, you can do MRIs and CAT scans and every kind of things which would show the swelling of the muscles and ail this.
Q. And were any MRIs or CAT scans -
Q. (continuing) - scans taken of Mr. Dimitrov?
Q. The diagnosis in your report is that Mr. Dimitrov had a sprain of his neck and a contusion of the chest, correct?
Q. Okay. And you stated earlier that a contusion is not always seen by discoloration or something - discoloration or something that you could see on the actual body, correct?
Q. Okay. So how did you diagnose that Mr. Dimitrov had a contusion of the chest?
A. The history of the accident and plus the clinical finding, which is tenderness over the chest.
Q. And earlier you stated that in your opinion, tenderness was an objective finding?
Q. Okay. Now you stated that just for clarification, when you say it's your opinion, do other doctors not believe that tenderness is an objective finding?
A. No, I believe that other doctors believe that tenderness is objective.
Q. The bill that was issued has as one of the diagnoses, back sprain, unspecified, correct?
A. I don't know what the bookkeeping did
Q. Okay. And the back sprain is not mentioned - and you did not put the back sprain in your report, correct?
A. As 1 said, they put - they put as a CPT code, but I don't check the CPT code myself.
Q. So you're saying that the bill that was issued has an incorrect diagnosis on it?
A. If they said it's backache, if it involved the neck, it's correct. If you want to consider the back, the neck is not the back, then it is incorrect.
Q. Okay. Well, just for clarification, maybe you want to look at what I'm talking about. I'm asking you specifically if on the bill where it says diagnosis, back sprain, unspecified, if that is an inaccurate statement on the bill?
A. No, it's not inaccurate because it's the back - if you involve the neck as the back, yes, it's correct. That's what I'm saying.
Q. Weil, normally do you consider the neck part of the back?
A. If -
Q. Or is that separate?
A. If the pain is at the base of the neck, it's part of the back.
Q. Well, does that follow what Mr. Dimitrov made complaints of to you?
Q. Is it accurate to say that the modalities that Mr. Dimitrov received each time he went in for physical therapy was the same each time? He received the same treatment or modalities each time he went in for physical therapy, correct?
A. Correct. Excuse me, the first few - the first few, they were normal McManus, McManus things. And then after that, she used the McManus procedure.
Q. Is - in the bill each time, it shows up as an office visit before each physical therapy session?
Q. Who was that office visit with? That was not with you, that was with the physical therapist?
A. With the physical therapist.
Q. And you actually only saw Mr. Dimitrov three times total?
Q. And you never actually discharged
Mr. Dimitrov, or did you?
A. I didn't write he's discharged. It looks like I discharged him.
Q. Did you tell Mr. Dimitrov that he was able to come back if he had any - if he experienced any pain in the future?
Q. Isn't it true, Doctor, that the human body can basically heal soft tissue injuries by itself? A. It depends on the injury. You cannot generalise that.
Q. If left unattended, isn't it true that these types of injuries, the soft tissue injuries, neck sprain, they will more often than not heal on their own?
A. They can heal on their own. But they might stay for three or six months the same.
Q. You stated earlier that when Mr. Dimitrov stopped treatment with your - at your practice, he was not completely healed, correct?
A. Correct. Yeah.
Q. The physical therapy is a separate bill than the bill that you rendered, correct?
Q. Who exactly administered the physical therapy, who specifically?
A, I don't remember. 1 remember that she was a Russian - Russian physical therapist.
Q. So the physical therapist that administered the physical therapy to Mr. Dimitrov is no longer working at your practice?
Q. Going through the physical - just looking briefly at the physical therapy notes, are you able to read any of the physical notes?
A. Unfortunately, no.
Q. You cannot. Do you have any indication in your notes when Mr. Dimitrov started feeling any better or what his progress was, when the first time
Q. Q. (continuing) that he made an improvement?
A. I think the last visit I said no spastic muscle or no spasm in the muscle. My last visit.
Q. And you know of no time before that last visit if Mr. Dimitrov was doing any better if he was progressing at all?
A. As you said, I saw him just twice. And these both, there were - one day after and about one week to 10 days after the first visit.
Q. Going back to the physical therapy bill. What exactly does an office visit entail with the physical therapist? i
A. It entails asking him how is he doing, checking him, the same thing, most of the time checking him, what's going on with his neck, with his shoulder. And how is the physical therapy working with him.
Q. And despite the fact that you gave - at the end of Mr. Dimitrov's treatment you stated that he had a guarded prognosis, isn't it true that Mr. Dimitrov never returned to seek any further treatment from you or anyone at your facility?
Q. Okay. And Mr. Dimitrov - you stated earlier that Mr. Dimitrov drives in some capacity for a living, that's his job, correct?
Q. Did you take any description of what his work active - what he does at work or what his work activities are when you initially met with him or any other time that you saw him?
A. He's a driver. That's all that I can tell you.
Q. Okay. You stated earlier that you prescribed Naprosyn for Mr. Dimitrov, correct, for pain relief?
A. For pain relief and muscle relaxant, the same thing.
Q. And you stated that you told Mr. Dimitrov that he should not drive, was that your testimony?
Q. Isn't that something important that you would have noted in your records, that he should not perform his job on a daily basis?
A. It is better, yes.
Q. And you never - you - normally you would have written in your records that he should not perform his job while he's taking that medication? A. Sometimes yes, sometimes no. But it is better to write it.
Q. Did Mr. Dimitrov at any time ask you for something in writing stating that he should not
Q. (continuing) - as a result of the injuries from this accident?
A. I don't remember that. He might, but I don't remember that.
Q. And if he would have - if Mr. Dimitrov would have asked you to write something stating that he shouldn't work for a certain time period, would you have made - you would have made a notation somewhere in your progress notes?
A. I would have a copy.
Q. If you would have restricted Mr. Dimitrov from participating in any activities or hobby, anything of that nature, would you have made a notation of that in your progress notes? A. Sometimes yes, sometimes no.
Q. Regarding making notations of restrictions and not performing their job why sometimes yes and why - why sometimes would you make nations of that and why sometimes would you make notations of that? Would't you characterize those things as -
MR. SPINAK: Well, are we going to have a compound? I'm going to object. You already - you asked a question and now -
MS. COHEN: I'm just trying to clarify.
BY MS. COHEN:
Wouldn't you recommending not working and restricting a patient from participating in activities and hobbies, wouldn't those be the type of things that you would put in your notes?
A. As I said before, it is better to put them in my notes. But sometimes, as any human being, I'm sloppy in writing that. I recognize that.
Q. Wouldn't you characterize telling a patient not to work or telling a patient not to participate in activities and hobbies something important that you would use in - in further assessing their prognosis with their treatment?
A. As I repeat, it's - I mean you are repeating the same question, about the same question. It is important and better to write everything. But I'm sometimes, as a human being, sloppy and tired or - and I don't write it.
If Mr. Dimitrov himself would have told you he was having any problems participating in any activities or hobbies, would you have put that - is that something that you would have felt important enough to put in your notes?
Q. So because there's nothing mentioned in the notes that you have regarding Mr. Dimitrov telling you that there were activities or hobbies he could not do, is it accurate to say that he did not make - he did not mention anything of that type to you?
A. According to the records, he didn't mention anything.
Q. Okay. If Mr. Dimitrov would have told you that he was unable to perform his job due to the pain he was in, due to the injuries he is alleging from this accident, is that something important enough that you would have put in your records, in your notes?
A. Don't you remember I already said that because of the Naprosyn and the pain, I recommend him not to work. So I didn't put it on the - on the - on my chart, but I recommended it. normally, generally when you're not being - making human error or you're not being sloppy, you would put in your notes -
MR. SPINAK: I'm going to object. That
question has been asked repeatedly. He can answer it, ... but I'm just making the objection. BY MS. COHEN:
Q. You would put in your -
Q. Who prepares the bills that come out of your practice, whether it be the physical therapy bill or your bill?
A. The bookkeeping of Diversey Medical Center. Q. And both bills are prepared through your bookkeeping?
Q. Do you review all of the bills that come out of Diversey?
Q. Do you review all of the bills that are with your name on them from your examination?
Q. Does anybody review the bills besides bookkeeping?
A. As I said, the bookkeeping. I don't review.
Q. After you send out - after - generally after you send out an initial bill, do you send out follow-up bills if those bills are not paid?
A. I leave it to the bookkeeping people to cover all this.
Q. Okay. Just generally, you really don't have anything to do with the actual billing of the clients - of your patients? Excuse me.
A. Not whatsoever.
Q. Earlier you stated you weren't sure how many times you had testified I think you said at trial. Am I correct on that? Or did you mean deposition testimony?
A. Deposition testimony.
Q. Okay. Do you know how many times that you've testified at trial or in the form of an evidence deposition?
A. Very occasionally.
Q. And all the times that you've testified at trial or via an evidence deposition, those are for - on behalf of a patient that you've treated, correct?
Q. And you stated that you don't do evaluations or any expert work, correct?
Q. Do you know how many times that you've testified in a case that Mr. Spinak has been counsel in or anyone at his office?
A. I met Mr. Spinak the first time.
MR. SPINAK: Today.
THE WITNESS: Today\
BY MS. COHEN:
Q. Is it accurate to say that all of the! findings that you have regarding Mr. Dimitrov's injuries have all been subjective findings?
A. It's not fair at all, because a spasm and tenderness are objective.
Q. Earlier you stated - I'm sorry. Earlier you stated that it was your opinion that Mr. Dimitrov's injuries were painful, correct?
Q. Okay. And is it accurate - correct to say that that's just - you're basing that solely on your own opinion, correct?
A. Please repeat what you said. I didn't understand you.
Q. Is it safe to say that I mean besides the fact that Mr. Dimitrov told you that he was in pain, there would be no way for you to be able to say whether or not - how painful - how much pain Mr. Dimitrov was in, correct?
A. I think 40 years of expertise in medical profession will give me the privilege to tell that this trauma is painful or not.
Q. Isn't it true, though, that -
A. Even if the patient - I'm sorry. Even if the patient tell me it's painful, it's not painful.
Q. Isn't it true that pain is a subjective - is a subjective complaint and that pain varies from patient to patient?
?? answered. You may answer
THE WITNESS: Yes, pain is subjective. I told you before.
MS. COHEN: That's it. No further questions.
MR. SPINAK: I have a few things, Doctor. I'll try to be very quick.
BY MR. SPINAK:
Q. When counsel started her cross examination, she immediately went to your record and asked you about the history. Did I understand you correctly that in the absence of notations in your record, that's an indication to you that there was nothing significant in the history given to you that was applicable to the injury complained of?
Q. Ail right. And counsel further asked you about a series of things that are not listed in your records. Is it again fair to interpret your record keeping as being one that includes those things that you consider important to your understanding of the care - the patient's complaints and your care and treatment of them?
Q. And so the fact that your notes, for example, don't describe point by point each of the things you use to test each of the part of the patient's body is because it's not relevant except when noted to what you did as a medical professional?
Q. All right. Now, you - counsel asked you about weren't there other tests you could have performed. And you responded by saying, yes, if we wanted to spend a lot of money, we could have done MRIs and CAT scans. If, in fact, you felt it was necessary, notwithstanding the cost for a patient to undergo an MRI or a CAT scan, which I believe it's fair to characterize as sort of advanced forms of visuslizing the human body, that you would have done so?
A. Correct. If we find that this is necessary, we'll do that. But we cannot - in this case, we cannot do it the first week or the second week. We have to watch what's going on.
Q. So as you watched, did you determine by your second visit with the patient on February 6th that it wasn't necessary to take further measures in that regard?
Q. Doctor, would it be fair to say that had you taken those measures, it would have at least doubled the charges to the patient?
A. Oh, for sure.
Q. All right. Is it your habit to perform unnecessary tests on patients?
A. I believe so too.
Q. You believe you do?
A. No, I believe that if we did a CAT scan or MRI in this case is unnecessary.
Q. It would be unnecessary. So it's not your practice to perform tests unless you find -
A. Unless I find that it is necessary.
Q. All right. And is it further true then that based upon the progress that was being made by the patient, that in your estimation he was making sufficient progress as he was going through the physical therapy which you had recommended?
Q. And that physical therapy is done under your supervision in terms of being the head of the medical facility?
Q. All right. And you delegate the responsibility to, in this case, it was a physical therapist, a Russian lady?
Q. Was she a licensed physical therapist?
A. She's licensed.
Q. And she's licensed by the State of Illinois?
A. I don't know. I don't remember, but she's licensed, I remember that.
Q. They have to have licenses?
Q. And you're licensed by the State of Illinois?
MR. SPINAK: Okay. Doctor, I thank you I have nothing further.