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Case 110-cr-00286-TSE Document 30-3 Filed 12/13/10 Page 1 of 4

Exhibit 3
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000490

Case 110-cr-OO286-TSE Document 30-3 Filed 12/13/10 Page 2 of 4

Vinson&Elkins
William E. Lawler, III wlawler@velaw.com Tel 202.639.6676 Fax 202.879.8876

July 9, 2010

Justin Shur Trial Attorney Public Integrity Section Department of Justice 1400 New York Avenue, NW Washington, DC 20005 I am writing to follow up on our telephone conversation of earlier this week. We are disappointed that the government has rejected our offer to resolve this investigation through the combination of the corporate plea by PMA and simultaneous individual plea by Paul Magliocchetti. We believe that our offer addresses the governments stated goals in resolving this matter while at the same time addressing the serious medical issues with which Mr. Magliocchetti is dealing. When we spoke, I requested the opportunity to meet with Public Integrity Section supervisors, Jack Smith and Ray Hulser, so that I could describe to them directly the reasons for our plea offer, as well as the impact Mr. Magliocchettis medical condition has on this matter, but was told that my request would not be granted. With the governments rejection of our plea offer, I understand that the government now intends to withdraw its own plea offer by the end of the day today and seek an indictment by the end of the month. In light of Mr. Magliocchettis medical condition, including some recent developments described below, I am requesting that the government maintain the status quo of this matter and not withdraw the plea offer or seek an indictment by the end of the month. As we previously described to you, Mr. Magliocchettis medical condition, which includes ongoing psychiatric treatment, medication and monitoring for suicide risk, is such that, at times, it renders him effectively unavailable for us to work with him. This past week has been one of those periods of unavailability. On the advice of his treating psychiatrist, Mr. Magliocchetti is being admitted to a psychiatric hospital in Baltimore, Maryland. While I do not know all the details of Mr. Magliocchettis evaluation and treatment, and indeed no one can predict all the aspects of that treatment, it will not be possible, or medically advisable, for us to work with Mr. Magliocchetti regarding the current investigation during the period in which he is

Vinson & Elkins LLP Attorneys at Law Austin Beijing Dallas Dubai Houston London Moscow New York Shanghai Tokyo Washington

The Willard Office Building, 1455 Pennsylvania Avenue NW, Suite 600 Washington, DC 20004-1008 Tel 202.639.6500 Fax 202.639.6604 www.velaw.com

EAOUSAFOIA0000491

Case 1:10-cr-00286-TSE Document 30-3 Filed 12/13/10 Page 3 of 4

V&

July 9, 2010 Page 2

receiving evaluation and treatment. This in patient treatment is expected to last approximately 30 days. I know the government has an interest in moving this case along and I recognize the general desirability of dealing with cases in a timely fashion. The requested maintenance of the status quo will not, however, in any way prejudice the government or its investigation. The payment and contribution issues the government believes violated the law have long since ceased. PMA is no longer an operational business. There are no PMA lobbyists or employees. Mr. Magliocchetti himself does not engage in any lobbying activity. In fact, due in large part to his medical condition, Mr. Magliocchetti has moved out of the Washington D.C. area. While I appreciate the fact that the government has listened to our descriptions of Mr. Magliocchettis medical condition, I continue to be concerned the government does not fully appreciate how that medical condition impacts, and could impact in the future, the present investigation. I am also concerned that the government does not seem particularly interested in fully understanding and appreciating Mr. Magliocchettis condition. As I told you when we spoke by phone this week, I am shocked that my request to meet with Mr. Smith and Mr. Hulser to explain to them directly these medical issues, as well as the basis for the plea offers that we made, will not be granted. We have offered to provide additional informa{ion regarding Mr. Magliocchettis medical condition, and have even offered to explore with you an independent medical examination. Rather than making any inquiries, however, the government has chosen to make decisions and set deadlines that seemingly do not consider the medical issues presented. I suspect that there are some government personnel involved in this investigation that might view Mr. Magliocchettis medical condition as not serious or as some sort of mechanism through which he is attempting to manipulate this investigation. Any such view would be ill-founded and contrary to the facts of this case, but it would be naive to think that such suspicions could not exist. Let me be clear, Mr. Magliocchettis medical condition is serious, ongoing and life threatening. We are asking the government to exercise its judgment and discretion. I fully appreciate that this is an adversarial proceeding and that the government has goals and interests far different than we do as Mr. Magliocchettis counsel. Nonetheless, there can and should be common ground. A pre-indictment resolution may well be in the best interest of both parties. If the case were to be resolved through a guilty plea, all counsel in the case,

EAOUSAFOIA0000492

Case 110-cr-00286-TSE Document 30-3 Filed 12/13/10 Page 4 of 4

V&E

July 9, 2010 Page 3

including government counsel, would have a collective ethical responsibility to ensure that any plea agreement presented to the court reflects Mr. Magliocchettis full understanding and consent. The appropriate level of understanding simply does not exist fight now, but it may be available after Mr. Magliocchettis inpatient treatment. Maintaining the status quo so that the results of that treatment can be learned will not harm the government and it may benefit all of us.

We are available at your convenience to discuss any of the matters referenced in this letter and hope for a favorable reply to our requests.

III

CC:

M. Kendall Day Kevin Driscoll Mark Lytle

US 464695v. 1

EAOUSAFOIA0000493

Case 110-cr-00286-TSE Document 30-4 Filed 12/13/10 Page 1 of 5

Exhibit 4
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000494

Case 1:10-cr-OO286-TSE Document30-4 Filed 12/13/10 Page2 of 5

Ron Kirsner, M.D.


Psychiatrist
482 Jacksonville Drive Jacksonville Beach, FL 32250 Phone: (904) 247-3600 Fax: (904) 2474926

October 25, 2010 The Honorable T.S. Ellis, III United States District Court for the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, Virginia 22314 Re: Paul Magliocchetti, Case No. 10-cr-286 Dear Judge Ellis, I am a Board Certified Psychiatrist and have been treating Mr. Magliocchetti since 08/31/10. The purpose of this note is to review his psychiatric history in the context of his subsequent treatment course. I will also highlight some of the issues relevant to his possible incarceration, since Mr. Magliocchetti is awaiting sentencing on charges related to illegal campaign contributions. I agree with Dr. David Blackmons neuropsychological evaluation, performed in September and October of 2010. He notes that Mr. Magliocchetti underwent a psychiatric/forensic evaluation by Dr. John Lyon on 08/13/10. At that time he had marked suicidal ideation with a plan to overdose on pills. He was deterred from suicide by the risk of forfeiture of his home, which was used as collateral for the bond that he posted. He presented with a plethora of symptoms with marked anxiety, depression, and cognitive impairment, but no thought disorder. Of note, Dr Lyon states that he considered electroconvulsive therapy (ECT) but that other medications and medication regimens should be tried first. He was also concerned that ECT might further aggravate the patients cognitive impairment. Usually, ECT is reserved for the most severe cases of Major Depressive Disorder. In Dr. Blackmons neuropsychological evaluation, he noted elevated alcohol use, and continued suicidal ideation with a question of cognitive impairment. An MRI suggested possible vascular white matter disease, in the context of type II diabetes, and also alcohol misuse which may independently lead to cognitive impairment. The patient presented to both Dr. Blackmon and me as hopeless, anhedonic, and ruminative with obsessive worry. The hopelessness, depressive symptoms, and anxiety, along with the other symptoms that he presented with were the target of Mr. Magliocchettis and my collaborative medication management and psychotherapy. Dr. Blackmon also noted a

EAOUSAFOIA0000495

Case 1:10-cr-OO286-TSE Document 30-4 Filed 12/13/10 Page 3 of 5

RE: PAUL MAGLIOCCHETTI

October 25, 2010

slow pace, attentional problems, forgetfulness, and a marked deterioration of cognitive function from baseline. Dr. Blackmon noted that there was severe depression and anxiety despite aggressive psychotherapy and medication management. An MMPI (personality test) revealed poor judgment and ruminative thinking, which may have implications during incarceration. One of my fears is that the patients poor judgment and anxious thinking style may lead to further suicidal ideation or even an attempt. He also met the criteria for Minimal Cognitive Impairment. Importantly, I agree with Dr. Blackmon who stated that Mr. Magliocchettis cognitive and psychiatric difficulties will worsen if incarcerated, especially in light of his age, depression, anxiety, cognitive deficits, psychiatric symptoms, diabetes, and other physical ailments. I agree that the patient will need aggressive psychiatric support while incarcerated since he will be at rather high suicide risk. To appreciate some of the challenges that might evolve were the patient incarcerated, it may be helpful to review his therapeutic progress at the Retreat at Sheppard Pratt from 7/16/10 to 8/18/10. The patient was referred by Dr. Ed Curcio, whom he had seen since 12/08. While there, the patient was treated with Remeron and Lithium. The latter agent was administered to reduce suicide risk. Hence, Lithium Carbonate is an important part of Mr. Magliocchettis current medication regimen, as suicidality has been a recurring theme during our work together. Unfortunately, circumstances at The Retreat were suboptimal for healing. For example, he had blood in his urine, or hematuria, and required a transurethral resection of the prostate. It was also discovered that he had type II diabetes. There was a fear that his cognitive dysfunction was so marked that it would be impair his ability to assist in his own legal defense. He also felt family issues caused a marked sense of betrayal. Indeed, during our worktogether he also had a belief that his wife (Rebecca or "Becky") and grandchildren would be better off without him. Interestingly, during a couples session, the patient maintained that he felt that Becky would leave him while he was incarcerated. He seemed to remain unconvinced, despite the fact that Becky was near tears when she was asking the patient how many times she would have to reassure him for him to believe that she would be faithful. The direct quote from the session: "Can I live without him for two years? Yes - I say it a million times - I can only say it so many times - you have to believe me." Because of the patients obsessive thinking style, he again remained unconvinced. Again backing up to his hospitalization at The Retreat at Sheppard Pratt, there was evidence of medical problems complicated by the adverse effects of psychiatric medication. For example, Remeron had to be temporarily stopped because of aggravation of urinary retention. This occurred despite the fact that Remeron does not have marked, "anticholinergic" side-effects, the usual cause of urinary retention. The Lithium Carbonate, which was also used as an augmentation or "booster" strategy to enhance antidepressant effectiveness, caused a markedly disruptive tremor and resolved only when the Lithium dose was decreased. The problem was that it was decreased to a subtherapeutic dose. During our course of treatment, I have advanced the Lithium, but cannot advance this agent to its potentially optimal dose because of this
2

EAOUSAFOIA0000496

Case 1:10-cr-00286-TSE Document 30-4 Filed 12/13/10 Page 4 of 5

RE: PAUL MAGLIOCCHETTI

October 25, 2010

side-effect. Similarly, I could not advance Remeron to a fully therapeutic dose because of daytime sedation, with the patient sleeping over 12 hours per 24. Mr. Magliocchettis extreme anxiety, a significant predictor of suicidal behavior, has been partially controlled with benzodiazepine use. A benzodiazepine would likely have to be continued in prison. The clinician could make him or herself aware that the addition of any psychotropic medications has required a delicate balance between therapeutic effects and worsening cognitive impairments. Other medical problems, including hypertension, may be aggravated by incarceration. Coronary stent placement, along with brain white matter vasculopathy (which some people call "mini strokes") will make aggressive management of vascular occlusive risk factors a high priority. With respect to psychiatric medication management, this has several important implications. For example, although there is a convincing and robust body of recent evidence supporting the use of novel antipsychotics such as Abilify or Seroquel to augment the effectiveness of antidepressants, this may be impractical in Mr. Magliocchettis case, since the addition of such powerful new medications may impair adequate glucose control and worsen Mr. Magliocchettis blood lipid profile. Of course, his complex medication regimen for nonpsychiatric illness, including Metformin, Metoprolol, Lovaza, Hydrochlorothiazide, Cozaar, Cardizem, Aspirin, Prilosec, and Glyburide may have clinically significant interactions with liver enzymes (the so-called "cytochrome P450" interaction). These may also change blood levels of medications in a subtle manner that will have to be carefully monitored by the clinician. Of course, serial serum Lithium levels will certainly be required, as well as regular assessment of thyroid and kidney function. Mr. Magliocchetti is at risk for kidney disease, given his hypertension and diabetes, and Lithium may also be toxic to the kidneys. Moreover, we are considering the addition of Synthroid, a thyroid medication, to the patients regimen, as Lithium frequently causes hypothyroidism. During our course of treatment, Lexapro was somewhat helpful, although it had to be discontinued because of sexual side-effects. The extended release formulation of Xanax was not tolerated because of excess sedation, but the immediate release formulation lasted much longer than typical and at low dose, was partially effective, perhaps because of lengthening of the half-life, or time it takes for the body to eliminate the Xanax, was extended. This lengthening of half-life may also apply to other medications and may stem from age, genetic factors, etc. I would like to comment on the patients cooperation with psychotherapy. Mr. Magliocchetti forms good, solid bonds with me and other therapists. In my clinical judgment, he is motivated to get better and is willing to try new medications or psychotherapeutic maneuvers to help him cope and improve. Indeed, he evidenced unusually robust signs of involvement and responsibility in his care, including knowing his psychotropic medicines and their dosages by heart. This is rather unusual in patients in his age group. When given an assignment (for homework or self-help), the patient would either comply or report that doing it would be too onerous. In my
3

EAOUSAFOIA0000497

Case 1:10-cr-00286-TSE Document 30-4 Filed 12/13/10 Page 5 of 5

RE: PAUL MAGLIOCCHETTI

October 25, 2010

experience, less than a quarter of patients will be so forthcoming, and most will initially say that they will adhere to the assignment and subsequently not comply ("the dog ate it"). The patient also engaged in cognitive and dialectical behavioral therapy while at Sheppard Pratt. This proved somewhat helpful and indeed during our work together; he noted how some of the lessons that he learned at The Retreat at Sheppard Pratt "stuck" and were helpful. Recently, we added Aplenzin, a formulation of Bupropion Extended Release. This helped decrease anxious ruminations and obsessions, although it caused a dissociated or "spaced out" feeling with marked flattening of mood and mood range. We are at a decision point of whether or not to discontinue this agent, change formulations to another form of Bupropion, etc. I intend to get Beckys input to help make this choice. In sum, Mr. Magliocchetti is an elderly gentleman presenting with severe depressive anxiety and cognitive symptomatology who has only partially responded to aggressive medication management and psychotherapy in a supportive environment. His medication management has been markedly complicated by medical comorbidities. His treatment team at a correctional facility may want to be mindful of these issues. Given his history of suicidality, I also recommend that efforts be made to ensure that the patient is not "cheeking" or hoarding medicines for an overdose attempt while incarcerated. He also may do well with a support group, or even Alcoholics Anonymous, if that is available. Cognitive behavioral therapy will also be helpful, perhaps in a group therapy setting. I hope this information has been helpful. Thank you. Sincerely,

Ron Kirsner, M.D. RK:amm #94812

EAOUSAFOIA0000498

Case 110-cr-00286-TSE Document 30-5 Filed 12/13/10 Page 1 of 7

Exhibit 5
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000499

Page 2 of 7 m~ilc~s~xlil0n-t~r~TSE D~qzcumen~:~0~/2oC~il~d 12/13/10


MAGLIOCCHETTI,PAUL 480447-2 652295 RETW 07/16/10

Shepp_ard Pratt

M o71221
136~3NOSTI~EVALI~TIOC~DTIV~qTMEl~rPt-,~ Patient Name: Paul Magliocchetti 8/2110
MR#480447-2

1. 841)IMARY OF RESIDENT INFOR~A ~deal~ng Infom~a~ion: Paul is a ~ ~u oH M~, c~atly u~lo~& ~ a c~lica~d legal si~o~ ~f~l~ of ~io~ ~W, ~ ~i~! ideation m ~exl ofte~a] di~culfi~. odor Ro~ of H~ of Pr~ent ~1~ a~d ~t Psy~ H~ Pad idenfif~s ~ ~ of~s ~ ~ ~ 20 ~ ago wh~ ~ ~v~ti~tion ~gan ~ ~l ~ai~ con~bufions his bbb~ng fi~ ~ r~y ~. In Nov~r of 2~8, ~ f~eral invmti@tom ~ ~m his ho~ and ~m ~t ~t on he ~s lost h~ co~y ~ ~s loss =esnl~g ~m ~gal f~s a~ loss of~. Si~ ~ legal s~fion ~ ~ ongoing, ~ ~n~ili~ ofin~c~t ~ai~ Pad ~s fdt "~ si~e" ~ ~s renea~ ~om p~ipafing m his life due m co~t m~=a~ ~ough~ ~g~g outc~ of~ ~e, He ~ifies t~ ~ion of s~dde ~ =PI~ A", ~ ~a~ ~y m solve ~ problem of ~tentitl ~ct ~ of ~ncial ~, ~d ~ ~ I~ w~ a~ g~chil~ On ad~n~ his sclf~md would ~ ~ ove~ose on ~dicafi~, and "~v~ ~ke up. He ~sefi~s ~e ~e of ~ l~t 20 ~ ~ ~s a ~d fi~ k~g up wi~- ~re h no defined e~ no ~y to pr~ict ~ ~tcome and he ~ ~nfiatly l~t co~! over ~ ~e, ~d ~ ~ ~ fina~l fie~om ~t h.~o~q ~& ~ a r~t of~ low ~o~ 1~ of sle~, ~ e~~n it w~ ~c~d ~t Paul s~ ~i~ k ~yehia~st ~o ~at ~s s~m~. He ~g~ C~io ~ ~c~ of2~8, wi~ ~tion ~gc~at ~e~mn for ~d s~0~ ~ sl~, Li~im for e~c ~cidali~) ~d ~mpy. Paul ~s asolid ~latio~p ~th ~S ~yc~a~st and ~g a ~t ~a! of~st ~ ~ Paul was referred to tbe Retreat.by Dr. Cutcio, as a result of most recent changes in u~ legal situation 3.4 weeks ago which IeR Paul i feting more hopc]css, more depressed, continuing to nan/hate over the potential outcomes of the situation, and with more pressing :need for rcsoltttion, which for Paul includes suicid~ Dr. Cun:io expressed great concern about Pauls safety and felt ~hat he needed to take morn aggressive ~ps in Pauls treatment. There are no repo.ed psychiatric problems prior to 20 months ago. Paul reports having a Io! of anxiety as a child and a lot of conflict with his father, none of which unrelated to seeking treatment/therapy in the past. Paul rcpo.s history of increased alcohol intake since the legal difficulties began. On admission, he reported having several alcoholic drinks a day and several glasses of wine with dinner, as well as a drink prior to bed time. The lack ofsuucturc he describes throughout the day, spending time by the pool and only having a few things to do in the morning in the bar hc owns, have contributed 1o a li~=style that worsens his mental state and allows him to continue to focus solely on his legal situation.
Aclivo Medieat Problems: Shortly aRcr admission to the Retreat, Paul was hospitalized at GBMC for gross hematmia and underwent TURP iax~cdure on 7/17/10 with negative prostate biopsy. He was also diagnosed with new onset Non-Insulin Dependent Diabetes Mellitus while in the hospital. Other medical problems include hypertension, poorly controlled at time of admission, dyslipidemia, history of 2 cardiac stems placed in 2000. He also has a hx of BPH with negative prostate biopsy in the past.

iCormnt Medicatior~: Psych/attic: Lithium ElL 900 mg PO qHS, Xanax 0.25 mg PO qAM, Kloaopin 0.25 rng PO qHS Metformin 500 rag PO BID, Glyburide 2.5 mg PO BID, Metopmtol Succinatc ER 50 mg PO BID, Lovaza 2000 rag PO BID, HCffZ 12.5 mg PO daily, Cardizem CD 180 rag PO daily, ASA 81 mg PO daily, Cozaar I00 mg PO daily, Pfiloscc 20 mg PO daily, Afrin nose spray, Patients and Fames Goals for Admission: Paul came m ~ Re~t at ~e ~fion of~ ~idc ~a~% ~ m ~ ~ of~ Dr. Cmcio ~d P~L ~t ~s c~o~c s~~l Mea~ ~H ~fi~tely ~s~t ~ self ~. In ii~t of~ levi u~uon a~ lack of~l~on ~ ~, Pa~ c~y Me~fi~ ~ele~n~ ~g~, ~ ngc ~ key ~cm~ m ~ S Pa~ s g~I f~ ~ b~n e~g~ by ~s psyc~t ~ by~ ~fc ~ ~ ~rc of~ f~i~ (im~e ~ a~ ~mc) ~d ~ ~ c~omble ~ys m e~ ~m

756-MR-0124 (10/04) (F3F)

EAOUSAFOIA0000500

pRI hnCue~%# ii (~-~r-~-TS E ]3~um entl~/~).-@ 2 ~d 12/1 ~~~~, 64 M 07/22/46


c~tic, al~u~ ~r~ ~ o~en fl~h~ o~Z~r ~z ~ ~ qu~e sc~ to ~os~ ~o~d ~ He ~ co~a~ eye ~ou~ ~en ~dness or h~ s~a~s ~ he ~o~s ~1 ~ o~en 1~ do~ and z~ ~ng ~e con~c~ ~is s~ch no~ in nze, rh~ and vo]u~. Hc s~a~ ~lc~]y, ~ a/bonSai a~ ~a~l w~y, wci~ h~ wo~ ve~ c~~l]y at t~, He ~n a~ar g~ ~ al ~wzs ~~ w ~Id ba~ on s~g ~ ~e ~ugh~ ~d f~lings. His affect is ~ ~d appr~te, his ~ is "ok s~e ~ys, ~ o~er days." His ~ughz process is li~ ~ ~al ~ect~, he s~ ~ ~gh~l, nc evidence of ~ug~ disor~r, al~ugh ~ ~is~n~ ~ou~ a~ut ~ legal si~o~ ou~o~s ~ "P~ m~ a ~ag q~li~ ~ th~ His ~]icf~t ~ ~ of no v~ to ~s fa~ly ~ess he is ~d ~d ~y is saved ~ c~inly ~v~alued. He r~o~ ~z al~u~ h a]~ys ~s s~cide on ~s ~& ~ ~ ~ co~ up ~th a pl~ or ~nl ~ in ~e hospi~L He ~ nge~[ th~ ~ fc]~gs low~ ~e indivi~ ~ h~ life who ~ve h~ ~ b~ ~e ~ no i~iaz ~g~ or ~n~z q~li~ ~ ~. H~ ~i~ht ~ ~, al~gh he ~es ~e a~e~ of his upb~ging ~d ~tio~h~p ~his ~cr o~ ~ ~cnt si~tion. His jud~cm d~ not ~pe~ ~i~d. .

II. EVALUA TIONS ~ndivid~l Therapy:.

Paul ]za~ b~n rather opezz about his sWaggles over the last 20 ~n~ ~ ~ e~dencc ~ ~y ~ide of~ Re~t. ~e prosing pmble~ 0fd~r~io~ ~ie~ a~ suici~i ideation ~e so ti@~y ~ociated wi~ his unce~ legal si~tion at~is poin~ ~t he has ~ a ~d ~me ~i~in~ f~ ~ng o~r ~n his p~istent ~bb~g"~ough~ ef ~at ~11 happ~ to h~. P~ has an ~t of~dyin8 anger a~ age, w~ch he wor~ ve~ ~ to k~ onuol ova- ~e s~e be~l he ~e~s ~ only ~ified by ~early e~e~es ~th his fa~er, for whom he ~ev~ g~ ~oo~" a~ ~ "could neger ~." He ~bes the~ ~la~p as f~l of re~nt and ~g~, and he left ~ ~ ~n ~ h~ ~ able ~ ~ on ~s o~. ~ese sa~ ~u~ ~ongly now ~ ~ legal predic~nt whc~ ~ ~s ~d to giw~ con~ol ~d ~z o~r ~t ~gs in his life, ~l~ng his wor~ the ~iness ~ ~ built up from s~t:h and ~ f~n~l co,on w~h ~ allow~ ~ to ~ p~l~pic, u ~U pm~ for ~s ~]y a~ ~s ~a~c~[~ ~ a ~sulL he ap~an to ~ld on to ~e id~ of suicide ~ ~e uhi~te po~ ned ~l he ~ m ex~ ~ ~t "he ~ and ~ey ~se." ~e~ ~ powe~l ~ges in Pauls ~ a~ it ~ been ~ c~itenging to sH~ his foc~ away ~om ~t ~d ~lp ~ ~lor his ~n~ of wo~ m his f~ily a~ m ~elf tf he d~snt ~ve ~ney ~d ~w~. In ~y, Paul ~$ bv~ to op~ ~ a~ut ~ upb~ng and ~e d~ s~ded conflic~ from e~y dcvclop~m ~t 6 Mm ~e feelings of age ~d s~me ~ ~fiences. He ~ ~so fo~ co~oa on ~ R~at ~ ~8 able to ~ o~sio~te ~ o~ resident, help ~m in ~owfi~~l ~, ~s fo~d so~ ~i~ wa~ to c~ ~s i~] c~ of ~u~t ~d ~l~sness ~ gm~ ~d ~eB~ufic exe~es. Some of ore wink ~ f~ed on not ~ces~ly ~ing away wi~ ~e "Plm A" but exp~g how he ~ enjoy ~ life for w~t it is ~w, ~fil so~ decision ~ ~ached a~ut ~s legal fate. ~s ~ m ~e indi~d~l ~py desk, s ~ fi~ ~ Pauls mood d~stttrbance and anxiety symptoms are undoobted]y co.elated with his ]ega| situation, which makes his syraptoms challenging to treat since we have no way to alleviate the external slzess of the situation. Neverthelegs, he has reported decreased anxiety in the mornings with Xanax, improved sleep with K|onopin at bedtin~, and we are continuing his outpatient regimen of Lithium ER foz chronic suicidality and mood stabilization, and will oal/hue to dlmte the dose to achieve an appropriate therapeutic level (last level checked was on 7/26 and was 0.33 with d~se of L.ithium ER 450 mg daily). Although Paul was on M~azapine when he was first admitted, wv have chosen not to continue this medication, as this may complicate has medical condition duc to r~sk of urinary relent/on. Thus far, Paul has not reported a signi/~cax~! change in his mood without ..vfirlazapinc on beard. Paul has a multiple n~Aiea] problent% a number of which are directly related to the stress he has been trader in the laxt 20 months. At time of admission, Pauls blood pressuz~ was very poorly controlled, (ranged lS0s-lS0s/90-100s) on three blood pressme agent~. Currently this has improved with minimal med~catioo adjustment and he maintains a blood pr~ssuse range of 120s/g0s. Paul has a I~ of elevated cholesterol and takes Fish oil supp]emen~s currently. His iabwork showed lipid panel to ~ largely w~z~n normal limits with LDL heing mildly elev-a~;! al 103. Paul was also diagnosed with new onset diabetes mellitus, with initial g]ncose reading of over 400. Whi]~ i~ the hospil~] for emergency surgery, he was started on 2 diabetic raedications, Metformin and Glyburide and has been able to maintain adeqztaze fingerstick glucose levels (undex 100) with medication compliance and diet control. Finally, Pauls iuida! presentation with gross hemat~wia lead him to have an emergency TURP sangory and proslatc biopsy. Tlze symptoms of hemataria, urinary urgoncy and frequency, a~ well levatr.d WBC (initial result of 22) have resolved. His tnitial labwork showed an elevat~] GGT wl~ch was consistent with chronic alcohol use prier to admission. A ,ecl~ck of GGT show,.d it Ue~lin$ down.

Psycldatric:

~edical:

EAOUSAFOIA0000501

Case 1:10-cr-002~]6-TS ED PRINTED BY: hp-aweeks


~:ial Wock:

Dcument-30"-5"ATE :ZO/:L; 2 o_to-FJ led 12/13/10 Page 4 of 7

Nursing:

This writer has been meeting with Paul fo b~h individ~l and group DBT sessions. Paul regularly attends the DBT skills training g~oup, but does not often contribute with his own experiences within the group. Paul stated that he does not want to in.act the other residents with his iatenu: thoagh~ visual images, and emotions. This need to protect those around [tim from his own anger and rage extends to family and loved ones, resulting in Pauls "plan A." Cont~ihoting to this dynamic, are Pauls intense thoughts. He finds these thoughts to be consun~g, and !~ d~fficulty obtaining any relief fi, om them. These thoughts sunound Pauls feelings ofloss ofcontre] over his life. They lie in extremes in which Paul feels that 1~ is "playing a gang of chicken" that wil| end in "sowxone loosing and someone winning." Creating a psycbological space outside of this outcome has been difficult. Paul has been aifle to find distraction since his arrival to the Retreat. He has found physical exe~-ise, experiential activities,. supporting.his peers, and other menial challe.nges that allow him to step outside ofl~is own situation. Paul has been encouraged to build on these newly k .amed skills to ereat.e that space outside of ~ Retreat. Hopefully be will Ix able to do this as his physical conditions continue to improve. In discassiog his discharge plan, Paul noted that he is n0t"nmning" hi.s .life at the moment. Although the expense of t~,e Retreat does phy into Pauls rage and gesentm~t, he is olgu to staying longer on the Retxeat ifit is indicated by the treatment team ;rod Dr. Curcio. On Pauls day of admission to the Reueat, he began to experience significant frank liemat~ria necessitating admission to GBMC. After his medical.hospitalization (including TURP surgery and prostate biopsy),. Paul returned to the Retreat for psychiatric treatment. While at GBMC, he was newly diagnosed with Type 2 Diabetes. A necessary gnat is that Paul needs to learn to manage th~s chronic illne~. Twice daily fingersti~s have ranged from 58.142: Paul has been educating hin~elf about diabetes and has become independent with fing~r~ieks for blood levels. He has been effective in managing his diet and has been fully compliant with all ntedications. Paul was evaluated at abe Departmem of Medicine for hypertension. BP reading~ are more stable at the present time. Initially, pts BP-was quite elevaled, but more recent r~. ings are approximately 115/73. Afollow-up urology consultation with Dr. Marc Siegelbaum was completed on 7/30/10 p~ recommendation. As a result, Paul has been told that his biopsy for-cancer is negative, is healing well from his ~urge~3, and has been encouraged to force fluids. Paul was admitted to the P,~treat becat~e his physician felt his stress level has caused his controls to he fragile and he may be at risk for self harm. Since admission, Paul is not actively suicidal, however h~ has thought era plan for stlicide that he l~ty coraplete a~eg discharge. He feels h~s continuotts high level of stress is destroying him Pauls goal for this admission is to be able to cope with the outcome of his legal situation and have his wife be happy with the end result, Paul stated he feels 1~ is never gelieved of thinking about his legal problems. Paul appears intense and frequently distracted. The only time Paul has som~ relief is when be is fully involved with an activiW. On the unik .Paul has been cooperative and has interacted with peers. He has bonded with a particular peer but is interactive with all peers. He has verbalized anger about h~s legal issues when talking to 1:] with staff but is able to be refocused when t~eded. Paul has not acted oft his feelings of anger and rage ycl at times he has verbalized the imensity ofthese feelings. He fee]s tapped. Paul stated that if he has any unoccupied t~me he will focu~ on h~s legal issues. He attends most but with minimal participation, Paul is a man of action and ira problem is idntified 1hen it rm_~gt be solved. He is not as aware of feelings and the negd to mamge the emotional aspect ofprobleat solving. C(msequently, he has no emotional outlet. He has joined the group for only occasional outings, but has spent much time with his family. Nursing would like to see Paul utilize DBT skills such a; mindfulness, and radical ac~. It may be helpful to continue to impleracnt mine physical activity into his schedule and to utilize nursing staff to assist in working thgoug~t press~g issues. In addition, exp|oring some auger management techniques may help him deal with his emotions and maintain safety. It is iraperative that

Paul maintains sobriety.


Recreational Therapy:. Paul comes to the Retxe, at to learn lgalthier ways to cope with the current stressors in his life. His tl~t there 1~ b~n a decxea~ intent ia his leisure lifestyk. He ha~ not been able to enjoy acti~ties in over a year and a half due to dept~ive symptorm. His past leisu~ interem have inluded his wife. They both enjoy very active activities including snowshoeing, Inking, swimming, biking. Lalely Paul has had trouble stayiug present m~aded during acavities. He relat~ th~ to the troubling thoughts that surrotmd kin~ He ha~ r~ofice that ffhe participated in activ~tiet that are mine e.halkaging&en he can engage and been present mined, While Paul has beeu oa the R~:at he b~n ~aterested in starting aa exe~dse program that would allow him works towards meetiag hi~ exe~ise goals. He would like to work towards maintaining n physical lifestyle tha~ wotdd allow him to r~om~ with his past ~ intere~s. This wril~r has d~ign~d exercise p~ that would mee1 Pauls goals. Deborah Quhk will be assisting Paul with his exercise

help motivate and support ~ile ~s ~i~r is


._Art _T~apy ,A. successful lobb.~ist and bu.~-~ owne% Paul comes to the Retreat ax age 64 for support in a 7.~>-1~-4)124 (10~04) (F3F)

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deslabil~ng d~ression lasting over 20 months. Paul is a normally social person devoted to his wife and gnndchildren and fmd~ d~e g~onps especially helped here, as they force ELm to "get o~ide my head," and foste~ conncclion to the h~e and now. Paurs first drawing, "Dark Kmght," is a selfportrait. A storm cloud looms overhead, ejec~ng thee lightening rods which Imncmre an already bleeding head crowned wi~h thorn~. "l was the White Knight ~fo~," explains the artist of his past commim~n! to charily, "But now Im the Dark Knight." Events leading to his occupational fall have lee a deep and unrelenting wound on Pauls sense of identity, expressed here in a facial.expression doneebed as "under constam presstL~e..,depressed, tired, and some sadness." This constant psychological pain is again capmrtd in a second untitled ohawing. A cross section profile presents a brain punctured by two extenml snows, not unlike the experien~, assault of legal accusations and pending rid. "Suffering, black tl~obbing pain.., it doesnt go away," Paul explains.. Pauls tree pictm ~titled ~Yes!! Sweet Revenge," clenchben exueme thoughts ar~ feelings turned outward, towards entities believed responsible for his current legal (and subsequent psycholngi~al) predicament Like exn~ne anger towards self, rage and aggression are prominent feelings heldtowards outside forees. Because t]mse emotions can be so strong and ahsolu~, having safe and constructive ways to express and con.lain them .v~.l. be vital as Paul moves fonvard. Continued work in at~ therapy will support thh safe onlinued explonttion and contmlof thoughts and feelings. _.
MovemenffMedi~don: Paul slated thal his hopes for his stay at the Rental were to "~I a sense ofbalance, get hack m doing

exercise and become more focused." Specifically hc wants 1o deal with "my constant exhaustion. I want to ,get rid of the cobwebs in~o, brain and regain my. shoe mrm memory. My worries and thoughts a~eso . constant that when I-am by myself I feel as if my-head explodes." He stated that he was a self mademan, hut.his youth was marked by ~physical and mental abuse from my father. Thee is a picture of me wheel. was five and when you look into the eyes ofdmt child you can see how disturbed hr was," Panl-has elected to use l~e acupuncture aspect of the Movement and Meditation program but has declined further m~tiugs with this writer.
Consullan~: Janet Leibowitz, LCSW.C, Family Therapitl Admission interviews were held with Pauls wife, Becky, and alone with Paul. He has become increasingly depr~tsed afl~ learning 20 monlhs ago d~at hc is being investigated fo~ making illegal political contributions. Pauls son is involved as a witness and hi~ plea bargain cotdd depend on Pauls conviction. Pan! continues to see his young and valued grandchildren (5 and 6 years old). But communication with his son is guarded. He closed his successful company downand he is concerned abou! signiticant legal expenses. Paul was born in Pi~burgh. PA, His father worked for the railroad and he, report~lly, was abusive, ha~h, and punitive. Paul and h~ father had a conflicted relationship and Paul blamed his father for his mothers neglected health care and eventual death. Paul is estranged from his sister because she was supportive of her father. Paul was mar~ed to his ftrst wife of 35 years. They have two children, a married ~on (35) with two childish ages six and four. Paul and Becky were both unhappily married when they met 13 years ago. Pauls daughter has refused to accept Becky and effuses to speak to her but mainlains contact with her father. Paul and Becky married in December, 2009 sad Becky was aware of the legal issues. Becky has a 28 year old daughter. The couple enjoyed uaveling and had an active social life. Becky, a controller, lost her job of 2] years as a result of Pauls legal issues. She all,ted her own business in Arlington, VA and their lives have been "turaed aroun&" The couple has homes in Virginia and Maryland. Paul is an articulate man who has been driven and successful. He "refuses" to loose, enjoys caring for others, and has be~n outgoing, loves people and never for~As ~ames. His personality can be labile and he can becor~ very angry bu calr~ down. He has hewn "biased and succ~sfa]" and always able to problem solve, cope, and confront a challenga. He can be unforgiving if he feels unfairly treated. Hh ix unable to endure this huge narcissist injury and has become more depressed, guarded, and anxious with increased drinking. He is concerned ahont has m~mery and has been sleeping more. He spends early mornings alone in his sports bar, tidies up and leaves before others arrive. The stuns has taken a to!! on his relationships and on his marriage. However, Paul and his wife s~em dedicated to each other; Becky is sul)portiv~ and gradually his assumed more respons~ility as Paul has become le4s engaged. They have some loyal friend~ but have lost contact with others. He is concerned aboul the huge legal fees but will refuse 1o plead guilty. He would mlher commit suicide I~n to lose. He is suffering from feelings of anger, shame, and embarrassment but pre-motbi(I]y, he is a swong a~d willfi~l man who always to put up a good fisht. Couples m~tinss and o~ conference calls are available as iadicated. Anxiety and Stress Disorders Censultati,m (Dr. Steve Shearer) The consultation reviewed Pauls mhtive lack of psychia~ic histmy pri~ to the start of legal problems. Dr. Shearer did no! iden6fy an}, immediate indica6ons of an anxiety disorder apart from the situational

7.56.MR,-.Q124 (10/04) (F3F)

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response he has experienced. No recommendation was made for cognitive trcatmem was made. Psychopharmacology Coasultation (Dr. Scott Aaromon) I)~. Aaronson concurred with the leams sense that Pauls ongoing stress from the legal situation pu~ him ax high chronic risk for s~v~de. Pauls tendency m ratio~ze his plan for suicide as alleviating t~manciat expense and stress on his fami]y continues to be worrisome and not easily addressed by m~iications. Department of Medleine Pauls hypertension was poorly con~i~ed p~or to adm~ssio& and recmungndafion to increase Cozaar f~om 50 rag.to 100 tag was implengnted with good results. Th~ advised to co~tL~u M~formin and Gl~ou~de for ~lucos control, Asp~,~ for c~diac risk.
~IL IJIAGNOSTIC ASSESSMENT .- ". DSM Diagnoses Axis .1:. Major Depressive Disorder, single episode, severe Anxiety Disorder NOS .Alcohol Abuse A~is I1: Deleted at this time, due Io chronic intense s~ess it is di~cult to assess Pauls permnt|ity ~&it~ at this point A~is Ill: Hx ofhernaturia, s/p TUR~ 7!17/10 with negative biopsy, Hypertemion, Dyslipidemia, s/p 2 stent placements in 2000, hx of BPH, new onset NIDDM Axia IV: Legal difficulties, financial strain . ~ds V: 55-60 - ....... . .... : O~emr~l Diag~~is: A~ symptom onset ha~ clearly correlated with an acute legal situation 20 months ago,~tdj~tment disorder is a reasonable considoration ,although ~: del~eSSive symptoms patient experiences are at this point Irate " consistent with MDD. BiaOn~s~ Fom~ula~ion: Paul is a 64 year old married white manwith no significam psychiatric historywho presents with anxiety, d~ression, and suicidal ideadon in conlext ofv~y serious legal difficulties in ~ last 20 months. The loss of power and conlrol Paul ha~ experienced have been extremely destructive, howev~ the uncertaintly.ofhis &ture and inability to effectively mak~ choices about his fate have led him to fh-mly believe that suicide is the only choice he has in ending his suffering on his own ~rms. Pauls upbringing was coloeed by shame and constant dissatisfactiou wi~h h~s achievements, and he has I&ely come to believe tl~t his exl~rnal worth to those mound him is m~ch more important tlum what he can offer his fan~ly as a husband, father, and Prognosis: At t~s point, it is difficult to say what Pauls prognosis is, as it depends in large part on the resolution of his legal stalus. The prognosis will also largely depend on Pauls ability U3 u~e the insight hc has gained from the work hes done to express rage and anger in healthier ways, identify ways to help with slres~ relief and find more meaaingful ways to en~oy ~ he has with his family.

IV. TREATMENT PLAN Palient 10enffmd Problems & Goals Goin~ Forward. Pa.l would like to idendfy ways to cope with the sl~ess and uncertainty of his situation He appreciales a sense of safety h=re on t~ unit, a~d would like to fred access to some aspects of Ibis omside of the Reueat - Paul would like to condnuc strengtheninghis relationship with his wife, Becky - Focus on physical health m assme proper diet habits in light of the new diabetes diagnosis Spe~: Treatment Recommendatk:ms: - Continue to participate in group activities focused on affect expression - Continue to learn skills and techniques forrelaxation and stresdanxiety managemem - Focus on improving daily stmca~ at home and identifying healthy leisure activities - C~inue family therapy work w~h focus ~n more effective commnaicatioa between Pa~l and his wife Continue to l~am about healthy food choices to address diabetes - Individusl psychodynamic psychotherapy with Dr. Nikhinson, 3~/week - Explore further any ~uropsychiatric~og~fitive isst~, including brain imaging and n~mopsycholo~ical te.q~ng Recommended Le~h of ,,q~,a~ 2 weel~ beyond the i~itia120 day-~

V. St(NATURES OF THE TREATMENT TEAM

l:~,~ ooctorrrhempist:
Psychiatrist:
o

Date: Marina Nikhinson. MD


Marina Ni~inson, MD

August 2~ 2010

756-MR-0124 !10/04} (F3F)

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,PAUl.

480447-~

The Retreat at Sheppard Prat~OB~.O~ Psychiatric Progress Note


Patient Name: Paul Magli~c~i "

Date~Friday, J~y 23, 2010 ~me s~: 2 PM

~~

_Summary of the Session: Met with Paul for a full session today. W~: discussed his experiences on the Retreat so far. He identifies that he is able to focus on his feelings and be more at ease when he is engaged in activities with therapists or other clients. He has gotten a lot out of art therapy and yoga and is enjoying being able to focus and clear his mind while he is engaged with someone else. We discussed the importance of this observation in helping him find way~ to relax his mindand also refocus on priorkies in his life. We discussed the noe.d he identifies to deal with his anger in ways that are much less deslructive than what hes experienced in the last 20 months. "" " ... Pout would iik~e to spend some time with his wife this:weekend and is looking at potentially having an ovcrnighi signout on Sunday evening. W~ discussed.the importance of abstaining, from alcohol. He was . agreeable to calling in Sunday everiing t0 check in with Smffanddocs not feel at this point that he would act upon his thoughts of hurting himself. If thoughts intensified he would be able to talk with his wife and. return to the Retreat. I have reviewed labwork with Paul and he is aware of the elevated GGT as well as low hematocrit. He continues to have discomfort around the tcsticular area that improves after a nights sl~cp and worsens throughout the day. This likely reflects inflammation, and I suggested that h take some Tylenol to help alleviate the discomfort. We also discussed taking a longer course of antibioti~ to assure that an infection does not occur as he is s/p TURP. He is ok with continuing to take Keflex for another 4 days. A follow up appt was scheduled for him with the urologist, Dr. $iegelhaum for Friday, July 30. Mental Statns Exam: Paul was neatly dressed and groomed today, ambulating without any problems, good consistent eye contact. His speech was fluent and clear, normal in volume/rate/rhythm. He described his mood as "less fired today" and his affect was appropriate. He became quiVz angry when discussing the legal issues at hand. His thought process is linear and goal directed. Thought content focused on worrying about potential ways that his case could be .sabotaged even while he is in the hospital. No frank delusions, no active suicidal ideation or plan. No ARNH, Insight and judgment grossly intact. Plau~ I. Continue work on exploring feelings without necessary action. 2. Next session planned for Monday, 3. Lithium level was 0.04, with only one dose so far, so will repeat the level on Monday along with a CBC, GGT, and BMP. Wilt plan for overnight signout on Sunday, with a check in phonecall Sunday night.

Nikhinson, MD Attending Psychiatrist

EAOUSAFOIA0000505

Case 110-cr-OO286-TSE Document 30-6 Filed 12/13/10 Page 1 of 3

Exhibit 6
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000506

Case 1:10-cr-OO286-TSE Document 30-6 Filed 12/13/10 Page 2 of 3


"---~9/28/2010 18:24 418-938-4296 DATE M~DICAL RECQPd)S 9/20/2010 PAGE 02/18

PRINTED B~: hp-aweeks

Fax: 410.93g.40~

652295

o7/22/46
PSYCHIATRIC / FORENSIC EVALUATION
PAUL MAGUOCHETri

1.3 August :2010

64 year old twice-married father of two, and a defense industry IobtWlst, is adm~ed for depression in connection with indictment for illegal campaign contdbutlon. The federal probe of his activities has taken place over the past 23 months, causi~ the patient to feel hopeless and suicidal; additionally, he feels massively betrayed by his son. (who worgs with him) and who by-passed any legal representation and openly disclosed to FBI agents information that led to his fathers charges, Now, acmrdln8 to Mr. Magliochetti, ~! no longer have a son." However, Mr. Magllochet~i sr~ll has a relationship with the sons chiidten wi~h whom he is very close, and the stress of not tal~ing with the son is great. Superimposed on this situation am other L~si~Ss la,~suits, the recent firing of the pazmnzs wife because of publicity about her husband, and recent diagnoses of prostate infection and diat~tes. Mr. Magltoche~ti st~es w~h great inten~p/that "1 cannot take anymore* and thus considers possibly overdosing with a medV.ation stockpile he has at home. He has never been suicidal before or suffered from a depression before, though the patients social use of alcohol is slgnZficant, and he talks about his having purchased a sports bar in FL where he has a retirement home. This home, incidentally, is the principle alleged deterrent to suicide imofar as the home Is the bond he posted in his case, and R would be forfeimd if he killed himself and thus did not show up at real There is suicide in the famih/tree, but the uncle who hung himself in the midst of depressran is not a blood retatlve. Mn Magl~ct~etlt verbalizes many conflicting emotions about suicide: that he would be rid of the harassment, that if his son and he had waged a defeflse battle to~e1:her, he would have be behaving according tO a badge of familial honor which he strongly believes in. While Mr. Magl{ochetti prides himself as a fighter, he now sees himself as quite depleted. The sons strange passivity in dealing with the FBI ("1 have always told him you never speak to anyone wi~hou~ a la~/er present) is deeply disturbing m Mr. Magliochetti and almost as infuriating to him as the Governments crimipal pursuit. Asked as to whether Mr. Magi!ochettl could endure a short prison sentence, the pa~ent replied that it was a possibility but he feels that anything longer would lead to his wifes leaving him, The wife knows about her husbands sul<:idaliw as an abstraction, but not any details about a potential overdose. There exists a single daughter, in her 30% who is desc~bed as "tough" and someone who would readjust to her fathers suicide, Mr. Magliochetti also complains of memory impairments which have led staff to wonder ~bout cognitive impairments which I imagine could be the result of urladdressed alcoholism or perhaps even vascular igness (he has had stents placed for coro~nf insuffidency) or diabetes; this is In the process of evaluation. In any event, it seems to me that ~he patient is quite overwhelmed by the s~vlrl of events around him, and anxieP/appea~s a large issue partly stemmed by anxiolytics (Xanax, YJonopin). He also receives lithium and Remeron which he claims have helped him,

Mr.Magliochetti was also questioned about homicidal ideation in connection with buslne_~ assodates who have so far testified against him. He rep/ied that what these people said pales in comparison with the magnitude aftthe disclosures made by his son; in any event, he does not hold any violent grudges at the present. Salient findings on examination are a high level of alertness and coherence, responsiveness to questions, and a reasonable degree of insight and introspectiveness. Dysthymia Is event, but not active suicidal ideation at the moment. Hostility was properly expressed; paranoia was absent. A range of affect was expressed, with sparse smilin8 but no tearfulness. I ~aw no evidence of a thought dlsorder.
!

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18:24 IMPRES..~ONS~I~ 418-938-4296

MEDICAL RECORDS

P~BE

83110

hp-aweeks PRINTF~BY:

DATE
6/2/2010

Mr. Ma~llochetti is not imminenrJy dangerous to himself or others. The matter of his possible suicide is obviously worrisome, but so mu~h depends on p(ea aFjeement~ and the ~otemial outcome of nei;otfations w~th the prosecutors in this case; a complication here is that the patient views his attorney as both intimidated by menta| illness and not intrinsically comforting, and I am not sum how td address this at present. Of higher ~erapeutlc concern is the so~s infidelity to him. I view this as the largest of the nar~sistic blows Mr. Mai~liochetti has enmuntered; there is, of course, the depression which fuels suicidal despair, but i broached with him the concept of ~orF~ivene~s and wondered whether there was anything at all that could repair the damace hem. He lkmr~_=d w~h ~eat interest, but th~ is not a man who allows much latitude ia relationships. Two other facto~ exist: they are anxiety, and cognitive impairmenu I think a driving force to suMidal thinkin is the patients anxiety, but recoRnize that too much medical(on could worsen his thinking. Still, the implications of an,/early brain impairment [dementia) needs confrontation. As to the depression, I h~d a morr~ms thought about ECr, but memon/is an i~ue and thee are still other drugs to try.

In summary, Mr. MaSliochetti is not an acute risk in society. My recommendation is to probe the matter of w~ether he and his so~ could ever effect a truce, to pur~ue the matter of o~anidty and mentation, and to monitor the patients ambient level of anxiety as a chief factor for suicide, Thank you for the

John R. Lion, M.D.~

MAG~IOCCN~TTX, PAUL
64 M 07/22/46

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Case 110-cr-00286-TSE Document 30-7 Filed 12/13/10 Page 1 of 11

Exhibit 7
DEFENDANTS MEMORANDUM IN AID OF SENTENCING United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000509

Case 1:10-cr-00286-TSE Document30-7 Filed 12/13/10 Page2 ofll

DAXn.D C. BLACKMON, PH.D. UC NS D SYCHOLOO ST, UC. PY0004360


482. ~ACKSONVILLE DRIv~

JACKSO ,NVILLF~ BEACH, Florida 32250

(904) 247-3600

NEUROPSYCHOLOGICAL EVALUATIO ~" Name: Date of Birth: Education: Marital Status: Occupation: Dates of Evaluation: Paul Maglioechetti 07/22/46 17 years Married Former Owner of Lobbying Firm/Unemp eyed 09114/I0, 09/15/10, 09/16/10, 09117/10, aml i0[ll/10 REASON FOR REFERRAL: Paul Magliocchetti was referred for evaluation through his psychiatrist D~. Ron Kirsncf. Mr. Maglioccherti is awaiting scnteacing on charges related to illegal camp fign contributions. As the bavestigation into his firras lobbying activities progressed over t[ e last 24 mouths, Magliocchetti reports iacteased alcohol use, severe depression with suicidal thinking, and pronounved anxiety. When he began to speak of suicide as ~Plan A: he was admired to an inpatient treatment program at Sheppafd. PrardThe Kerrat. Whi:; there, staff became progressively more concerned about Pauls ability to process al~d retain information effecfiwly. Th~se same concerns had previously been expressed by i ds outside psychiatrist and wife. An MKI of the brain suggested some microvascula~ changes,ffthe whit~ matter and a full aeuropsychologicaI evaluation was recommended. ASSESSMENT PROCEDURES: Review of records from Dr. Kirsner and from Sheppard Pratt, interview wifl3 patient, interview with patieats wife,, Wechsler Test of Adult Reading (WTAR), Wech ~l~r Adult Intelligence Scale-Third Edi~on (WAIS-III), selected portions of the Wrchs]~r Merao~ Scale-rr[, California Verbal Learning Test (CVLT), Rry Os~errieth Complex Fi~ are (ROCY), Sentence Repetition Test, motor function examination, Yinge~ Tapping, Seashore 1 rhythm Test, and Trail Making Test Par~ A and B from the Halstad-Reitan Neuropsycholoiical Battery (HRNB), Stroop Color-Word Test, Comers Continuous Performance Test-If (CI~ [-If), Beck Depression Inventory-II (BDI-II)~ Beck Anxiety Inv.entory, Minnesota Multiphasic i: ersonality Inventory-2 (MMI~I-2), Everyday Cognition Questionnaire (InformantiCaregiver ar.d Patient forms), and file Roy FiReen-Item Test (FIT).

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Case 1:10-cr-00286-TSE Document 30-7 Filed 12/13/10 Page 3 of 11

RELEVANT HISTORY:

Mr. Maglioccherti reported that he was born in Pittsburgh, Pennsylv~t" in. He reported that he had a reasonably happy childhood, although he was often in trouble a: out his mediocre marks at school. There are some indications that he may have had anxiety pr~.blems as a child, due to a high amount of conflict with his father. However, Mr. Ma!~ iocchetti never sought psychological or psychiatric treatment until approximately two years ago. He did acknowledge, however, having taken an SSRI medication prescrib~ d by his primary care physician ", "for stress...in the late 90s". IVlr. Magliocchetti graduated from West Liberty University with a Bachelor of Science in Management. He then pursued graduate work in Business Mauagemea~ r at George Washington University and the University of Michigan. Mr. Magliocchetti indicated that he had consistantly worked, even while in school. Following his education, I .~ worked at the General Accounting Office for 10 years and then with the Defense Appror.dations Committee for another I0 years. He then started his own lobbying firm, the PMA Ca, ~up, which he described es "the best firm in the city [Washington, D.C,]. Mr. Magliocchetti [.as two children from a previous marriage, Jennifer age 33 and Mark age 35. Mark Maglid~echetti worked for his father in the lobbying firm. Mr. Magliocchetti has been married to Rebecca, a 51-year-old government accountant, for the last two years. In November ot"2008, federal investigations were launched into Mr, {aglioechettis business affairs and he subsequently lost his compauy and estimates that bew een legal fees and lost income, he is down over $2 million. While he had been a moderate eial drinker prior to the federaI investigation, Mr. Magliocchetti acknowledged that he was ~ rather heavily prior to his admission at The Retrea~ His mood progressively orsened, he had s1.eep problems, hopelessness, auhedonia, shame, and prominent mminatiw~ worry. He was under treatment with Dr. Ed Cureio and was being treated with both Rein ~ron and Lithium. Fie began to talk of suicide as "Plan A" with a self-reported plan to overd )se on medications m~d "never wake up" according to records reviewed. Mr, Magliocchetri was admitted to The Retreat at Sheppard Pratt in J1~ ly of this year. Review of his discharge summary indicates that Mr. Magl~occhctti developed s~ rious medical problems ~ediately upon entering Sheppard Prat~. This led to a hospitalization for treatment of a pros~ate infection which required surgical resection. He also was bund to have Type II Diabetes. Following his medical clearance, he was returned to She.: pard Pratt. There, his situation continued to deteriorate. He was formerly indicted and atter .ded his arraignment in shackles and handcuffs, which was shameful and stressful for him His difficulties were compounded when he found out that his son, who had worked for hil a at the lobbying firm, had provided a ?~ajority of the information" used in the case against .1 ira. Mr. Maglio~heRi had very strong feelings of betrayal which deepened his depression at, 1 raised concerto about his suicidal risk. While in Sheppard Pratt, a psychiatric/forensic ev~uation was con& cted by John R. Lion, MD, He noted that Mr. Maglioceherti waz showing a high level of ale~ mess mad was coherent during the evaluation and that while mood and anxiety problems were. evident, there was no

EAOUSAFOIA0000511

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apparent paranoia or evidence of thought disorder.. Dr. Lion ide~,:, fled two factors which require further evaluation or intervention in his opinion. These iuch~ ied Mr. Magliocchettis overwhelming anxiety and the possibility of cognitive impairment. HI. cited excessive alcohol use and vascular illness (Mr. Magliocchettt had been treated for cot. ,nary insufficiency, with stent implantation in 2000), as well as his diabetes as possible e~[ology for "early brain impairment". WhLI at Sheppard Pratt Mr. Magliocchetti underwent an MPd c.the brain to evaluate cognitive and menibry changes. Results showed "very mild probable J~ LiCrovascular changes in the white matter, no ischemic event". He was discharged from Sh~ ~pard Pratt with an eye towards living in the familys retirement home and being involved i~ the familys sports bar business. He was discharged on medications for his diabetes and card: ovascular conditions, in addition to a regimen of psychiatric medications (Lithium 4:50 mg d~t .ly, Mirtazapine 7.5 mg daily, Alprazolam .25 mg daily, and Klonopin 0.25 mg daily). It w~ s agreed that he would participate in weddy psychotherapeutic sessions with Dr. Ron Kirsner vhe would also monitor his medication. Prognosis.from discharge was listed as "guarded". D~ Nikhinson, his primary clinician at The Retreat, wrote an addendum to his discharge ~ununary in which he acknowledged the diagnosis of "Cognitive Disorder, Not Otherwise Specialized was accidentally omitted in.the DSM IV Axis I, even though concern abe, tt cogaitive.impairment was discussed in the body of the discharge sumxnary. He also re~on, nnended "oatpatient

neuropsychological testing."
BEHAVIORAL OBSERVATIONS/INTERVII~ ~

Paul Magliocchetti is an average height/weight, 64-year-old, right-hand :d, white male. He was neatly dressed and groomed at all assessment sessions. He arrived c~ time, if not early, for each appointment. Mr. Magliocchetti, clearly very anxious, was friend.y aud cooperative with all assessment procedures. I-Ie clearly put forth a high level of error throughout tla6 testing. He would oftea cover his eyes, as if to shield out distractions, and to focus on gemeratiag responses to verbal questions or memory tasks. He often persevere~, beyond time limit on more challenging visual-perceptual ~tsks, which revealed a cc npetifive rtatttre, and determination to do well. There was no behavioral evidence o[ insut:gieient effort or malingering across the assessment process.
Most evident in Mr. Magliocchettis information processing style, wa~ his ~10w pace. There was ot~en a long latency between when a question was posed, an(I when he was able to organize an effective response. He oi~en had difficulty "zeroing in: on the most. essential elements when defining a relationship, or a word,, as required by the iatlligencc scale tasks. Some word finding problems were evident. Mr. Magliocchetti a l ~o showed a "spotty" performance on a number of the more concentration-intensive subtest~, suggesting attcntional problems. During the clinical interview, Mr. Maglioeehetti indicated that he ,, :es his .funefiorLing as having declined over the space of the last two years. He described thi:~ as, "a, B, maybe a B...not my A gaa~e by a long shot". He reported problems with slowed i afo.rmation processing. He also noted distortion, and inabtlity to retain information, partieuiarl:" when it was complex

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or highly emotional, such as d~ai!s of bJs legal case. He repots that he has to write "everyfl~ittg down" ~d s~ves to be excessively org~vd, to comb~ .t ~s forgc~ss. ~splaces ~gs, ge~ sidetracked when he a~p~ to complete ~ cs, ~d oR~ is told h~ repea~ &~gs. He noted &at I~ ~fe ~d good ~aRomey have t~ k~ to m~age his affa#s for h~ ~ he ~s~te~B, misc~st~es, or forgets ~o~4~ flea present~. He h~ placed ~ #~t ~ &era ia m~g decisio~ about his I#I easy. as he no long~ ~mp~ent ~ do so. He ~g~es ~& ~en s~ple tasks. He stated, "] h~ $300 billion appropfiafio~l Now I c~t ev~ b~ce my checkbook...My ~fe h~ ~ ov~

ev~g."
In addition to the medical history noted previously, which includes di~ ~etes, TURP procedure, Type II Diabetes, and stent inxplantafion, Mr. Magliocchetfi noted -zoo previous significant head igjuries. In the first one, he was struck by a oar and thrown ix~ :o a retaining wall. He spent five days in the hospital. He denied a loss of consciousness but :~ affered significant body trauma. In 2006, he was thrown from a horse and hit his head on dyer rock". Again, he reported no loss of consciousness, but was dazed and had headaches for three to four weeks (i.e. post-concussion symptoms). TEST RESULTS: On the Wechsler Test of Adult Reading, a measure of premorbid intellectual functioning, sugg,sted a full, likely premorbid Full Scale IQ Score ia neighborhool, of 1 !4 (+/- 15), which would have placed him in the High Average_ range. Current Full Seal ~ IQ Score, as assessed by the WAIS-II places him at a Standard Score of 104, which is at tl~ ~= 61a percentile, which places him in the middle of the Average range. Analysis ofkis WA.I~I-III Index Score profile reveals that a primary reason for his poorer than expected performanc, : on current intellectual testing is slowed processing speed. Indeed, on the Processing tipeed Index (PSi) Mr. Maglioechetti earned a score of 86, which places him at 18th petter.tile for his age group, which is within the Low Average range, and clearly discrepant from h: t likely premorbid level of ftmctioning. He showed a particularly poor performance on th-: Digit-Symbol Coding subtest, a measure of mental-manual speed. His poor score on the P: I, is likely traceable to both his prominent depression, and the white matter changes noted t,n the MRI. All other WAIS-II subtests/index scores were at or above the mean for his age gt, ~up.

On an abbreviated form of Weehsler Memory Scale-Third Edition, MMagLiocehetti showed a performance on the verbal memory tasks (Logical Memor~ I and which placed him at a level consistent with his estimated premorbid IQ. Likewise, kis peeler-mnce on the CVLT, an alternative measure of overall txew learning/memory placed him well ~,ithin normal limits in terms of verbal acquisitio~t and retention. In contrast, his perfonnanc~on the visual memory testing showed clear impairment. Mr. Magliocchettis recall of the , isual memory material (Family Pictures I), showed evidence of significant confusion ~1 distortion. This is
reminiscent of the memory dL~oulties noted by sta~ at The Retre. t, Mr. Magliocchettis

psychiatrist, and his wife. His recall of the complex pictorial info nation on this subtest
placed him al the 5* percentile for his age group. While his delay recit I was adequate, results from this portion of the testhg reflect diffieulry in managing more cmplex/novel incoming information.

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Similarly, Mr. Magliocchetti showed poorer than expected performanc ~ on the Delay Recall of the Osterrieth Complex Figure, another visual memory measure. WL le his copy accuracy on the ROCF placed him at the 84~ percentile for his age group, Mr. !v. ~gliocchettis 30 minute recall of the figure was highly distorted and lacking in detail. His scot; on this measure ~laced him at the 19th percentile for his age group, which is considered within the Low Ave.r.age range.

On the motor ftmctioaing examination, Mr. Maglioeehetti was found t~, be slightly awkward in performing skilled movement. He also showed raild resting tremlor, likely related to his treatment with Lithium. Finger tapping speed, using Halstead-R~ tan scoring guidelines, plaeed him within the Mildly Imoair_. ed range in terms of both dominat~ : and nondominant hand speed. He also showed a less than expected difference between rig~t and left hands, which placed him within the Mildly Impaired range as we!!.
On measures of executive functioning a number of scores were also markedly low. I~ this regard, Mr, Magliocehettis I-IRNB Trail Making performance- on h~th the straight forvv.ard part A, arid more complex part B- placed him within the Mild]it hnpair.ed range. Mr. Magliocchettis perform,anee on the Con,~o.Iled Oral Word Assoeiatk~ ~ subtest placed him at the 22"d percentile for h~s age group, which is considered to be Lo~ Average, and certainly below expectation based on his educational and professional baekgrou~ d. He b.lso scored more poorly than expected on the Figural Fluency Test (Five Dot Test), wh~ .~e he scored at the 27th percentile fox his age group. These suggest difficulties with mental ~xibility and processing speed. The clearest evidence of executive difficulty, however, was obs,.~ved on ~he Conners Continuous Performance Test-H (CPT-II). This is a compmer-base~[ measure of sustained attention, concentration and response speed. Mr. Magliocchetti was sl(~ ~rer to respond to target xgures than fulIy 99 out of 100 individuals in the standardization sam ~le. He was also much more variable in his response speed than the average individual, both c. ~er the course of the 14 minute CPT-II procedure, and as the length of time between stimul, s figures changed (i.e. from one, to two, to four seconds). The CPT Diserirainate Function At~ dysis suggests that Mr. Magliocchettis profile is more similar to a Clinical sample (that is, t~dividuals with known neurological impairment) versus Non-Clinical controls. Indeed, based apon the CPT-II alone, the chances are about 70 out of I00 that a clinically significant problem ~xists in this case. In any case where there is significant potential of primary or seeo~flary gain for feigning neuropsychological impairment, measures of malizgering/insuffidet. effort are necessary. This is referred to as Symptom Validity Testing (SVT). In this ease. symptom validity was assessed in a number of ways. First, on a free-standing screening m~ asur~ for malingering, ~1~,. Maglioeehetti showed vimmlly perfect performance, suggesting h-:was not attempting to feign impairment (i.e. FIT, all figures recalled, in appropriate rows). bedded SVT measures were also used, These measures utilized scores available through tests administered for another purpose, to evaluate the Likelihood of malingering. On men: ures derived from the CPT-II, CvLT, and Semenee Repetition subtest, Mr. Maglioeehetti performed far above clinical cut off_s. This suggests that he is not attempting to put forth i: tsufficielat effort, or to malinger impairment.

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BEHAVIORAL RATING/PERSONALITY ASSESSM3 ,NT DATA:

Mr. Maglioechetti arid his wife, Rebecca, separately completed the Ev,; ryd~y Cog~dfion Scale, an instrument designed to evaluate the.possibility ofneuroeognitive ~ )airment. In general, symptoms independently noted by Mr. Magliocchetti and his wife wer~ quite similar. Both indicated that he is "Consistently much worse", now, as compared to ! i years ago, on measures related to everyday memory, language functioning and executive ftmeli oning. Ms. Magliocchettis ratings of his functioningsuggested greater severity of ~lifficulties relative to Mr. Magliocehettis self-ratings. This is often seen in cases of dement xg illness, where family members are more aware of deficits than the patient, himself.
Mr. Magliocchetti was asked to complete a number of self-report insttat aaents designed to evaluate his level of depression and anxiety. On the BDI-II Mr. Magli~: eehetti earned a score (38) which placed him within the Severe depression range. Prominem, liffieulties were noted with suicidality, agitation, apathy, energy loss, and concentration diffic dty, His score on this measure (37) suggests ~ anxiety. It should be noted that these, pr~l aouneed scores on anxiety and depression were obtained despite the fact that Mr. Maglio, :hetti is living in relatively comfortable circumstances artd is undergoing weekly psychel herapy and is bittg provided with a comprehensive psychotropie regimen.

Mr. Magliocchetti was also admirdstered the Minnesota Multiphasic ersonality Inventory-II (MMPI-II). This is an objective measure of psychological/psyehiatr.. symptomology which also provides information regarding an individuals test taking attitude Mr. Maglioechetti was asked to complete the Minnesota Multiphasie Personality Inventory-Z (MMPI-II), This is an objective personality assessment instrument. It provides nformation regarding psychological/psychiatric difficulties, as well as test taldug attitude, the validity scales of
the MMI~I-II, Mr. Magliocchettis configuration suggests a "cry for h~ p" profile. Individuals with this pattern are acknowledging a wide range of problems, ofhigll severity. They exhibit inadequate defenses and are clearly overwhelmed. Mr. Maglioechetfis elinieal scale profde on the MMPI-H suggests he is experiencing a great deal of turmoil, and is not hezitmat to admit psychological problems. These individuals report feeling depressL d, worried, tense and nervous, They are oRen confused, and frequently in a state of near : anie. They show poor judgment and are nam.inative. They have difficulty makitig decisiov s, and tend to adopt a passive-dependent role.

CONCLUSIONS kND RECOMMENDATIONS ~


Paul Magliocchetti is a 64-year-old, right-handed, white male who was. efvrred for evaluation by his psychiatrist. Mr. Magliocchetti is awaiting sentencing on charge: related to violafiom of campaign law. Since the investigation into Mr. Maglioeeh~ds affa~ s began in November of 2008, he re, ports increased anxiety, depression, and alcohol use. Wh,: rt he became frankly suicidal, he was admitted into inpatient treatment at Sheppard Pratt/The Retreat. Skaff there observed evidence of cognitive impairment, which had previously been )bserved by his outside psyehiatrlzt and wife. An M1ZI suggested the presence ofproba~ ,le microvascular

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Case 1:10-cr-00286-TSE Document 30-7 Filed 12/13/10 Page 8 of 11

lesions in the white matter. Follow up ne~rocognifi,~e evaluation was ,~ aggested by h~s primary physician at The Retreat who diagnosed him as suffering from "Cogni ve Disorder, N.O.S."

Results from the current evaluation reflect the onset of what has been !, ,treed Mild Cognitive Impairment (-MCI). This recognized medical condition is an intermedi~ .re stage between normal age-related cognitive changes, and the onset ofdementla. It oft :n involves problems with memory, language, thinking and judgment. An individual is perc~ ived by others, who know him well, as having "slipped" but is basically still able to manag: most activities of daily living. Clearly Mr. Magliocchetti meets criteria for this condition, ~bows a number of risk factors associated with the onset oflV[CI. These include a history ofctdiovaseular difficulty, depression, excessive alcohol use, and previous head trauma. Psychonl ~tdcally, MCI is documented by M~. Magliocchettis depressed Full Scale IQ Score, as ompared to his estimated premorbid intellectual ability, based upon WTAR performar, ~e aud demogral~hie/edueational factors. Mr. Maglioechetti showed markedl) poor perfomaaaee on measures of processing speed, across a wide number ofmeasttres whiet, is likely related to both his residual depression symptoms and white mater lesions noted.: n the MRI. While verbal memory ftmctioning was within ~e expected range across seve~, d measures, visual memory functioning, whioh is more complex and novel, was substanti~t ly poorer. Self-rating of cognitive function, as corroborated by wifes independent report on ~he same instrument, suggests that Mr. Magliocchetti is "Consistently much worse" on meas. res of everyday m~mory functioning, language functioning, and executive functioning.
Results from the MMPI arid from the Symptom Self-Report Measures ;~ ~tggest that M~. Maglioeehe~ is eontiuuing to show significant anxiety mad depression tespite his relatively positive surroundings (living in his retirement home in Florida), weekly, psychotherapeutic support, and complex psychotropie regimen. It is this neuropsyehologi2 ts opinion that Mr, Magliocehetti would undoubtedly show worsening cognitive and emol onal difficulties were he to be incarcerated. Mr. Magliocchetfi is not a "career criminal", har t.ened to the rigors of prison life. Indeed, due to his age, neuroeognitive difficulties, psyehials ic symptomology, and physical ailments, the stress of prolonged incarceration is virtually cert.,, in to result in significant deterioration.

In prison, or even facing the hkelihood of a long prison sentence, Mr, ~, aglioeehetti is at high risk for suicide. Were he to be incarcerated, Mr. Magliocchetfi would ~: ~.rtainly require ongoing psychotherapeutic support, as well as taaintaince of his compl,. ~ psychiatric medication regimen. Mr. Magliocchetti should have a comprehensive 11 eurocognitive reevaluation in 9 to 12 months to determine .flre~ajeetory of his neurocof, aitive impairment and to determine whether additional medicat~o~ ~s (~.g. Cholinesterase inhibil ors, such as Arieept) might be warranted at ~at time.

DCB/am,~92995/92992

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TEST SCOPES

General AbiliW

MEASURE F~[I Scat IQ *Estimated Pmmorbid IQ

**SCORE LEVEL O1~ PERFORMANCE 61st percentile 104 83re percentile 114 +/-15.

RANGE Average

High
Average

Verbal Skills
MEASURE **SCORE LEVEL OF PERFORMANCE Verbal Comprehensioa Index 107 68m p~rcentile RANGE Average High Average Average High Average Average

CvcI)

Estimated Premorbid Yerbal VCI Information 0?AIS-I~ Vocabulary 0VAIS-m) Similarities (WAIS-m) Visual-Perceptual Skills FUNCTIONS P~rceptual Organization Index

115 +/- 15 105 110 105

84m percentile
63rd percentile

75m percentile 63rd percentile

SCORE LEVEL OF PERFORMANCE 77tn percentile 1 II0 +/- lg 5 0 75TH percentile


84t~ pefc~:Itile

RANGE High Average l--ligh Aversgg


l-lJ gh

(POI)

Estimated Premorbid POI

Matrix Reasoning (WAIS-III)


Block Design (WAIS-III)

Average High Average Picture Completion 63rd percentile Average 105 84~ percentile Key Osterdeth Complex Figure !15 High (ROCF)/Copy Avezage *Derived from results of WTAR and demographic factors-indicates per ~ntile rank at midpoint of 90% confidence interval **A11 Scores in this section converted to Standard Scores with Mean = t00, SD = 15 75t~ percentile

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Memory Functioning Verbal LEVEL OF PERFORMANCI; California Verbal Learning (CVLT) 53r~ percentile Total New Learning 50~ percentile Interference List 84tla percentile Short Delay-Free 84e percentile Short Delay-Cued Long Delay-Fre~ 846 percentile 50e pereen~e Long Dday-Cued 50e pereenfi!e Recognition Visual

MEASURE

RANGE
Average Average High Average

High Averag,
High Average Average Average

MEASURE ROCF-30 rain Delay

LEVEL OF PERFORMANCE 19m percentile

RANGE Low Aw: .age

M,oto, y, F..,~.. _t~igning/Mental-Manual Processing Speed Fin~er Oscillation Test MEASURE

Dominant Hand

LEVEL OF PERFORMANCE NDS=2 Iv ildly Impaired

Non-Dominant
Hand (Left Difference

41.4
R>L -- <1%

NDS -- 2
NDS = 2

h. ildly Impaked
h! ildly hnpa~r~l

Survey of Motor Functions Intact range of motion/coordination. Slight tremor. Proee~sin~ S~eed IVIEASURE

SCORE LEVEL OF 86
PERFORMANCE 15t~ percentile 6e percentile

SCORE Low Average Low Average

Frocessin~ Spe~d Index

(w ds-nr

Digit Symbol Coding (WAIS- 80

EAOUSAFOIA0000518

Case 1:10-cr-00286-TSE Document 30-7 Filed 12/13/10 Page 11 of 11

rid
Symbol Seszch (WAIS-III) Trials A (HRNB) Executive Functioning MEASURE

37t~ percentile 95 41 sec. NDS -- 2

Average Mildly I.mpaired

sCOl~ 88 sec. 30 (Adj)

Trials B
COWA (Ve~baI

RANGE LEVEL OF PERFORMANCE Mildly Impaired 22na percentile Low Normal 27~ percentile 70~h percentile

Fluency)

5 Dot (Figural Flu,ncy) 27 Working Memory Index 108 Digit Span (WAIS-III) Letter-Numbez Seq. ii0 115

Low Average High Average High Average High Average

(WAIS-m)

Comtors Continuous Performance Test-II (CPT-ED See Chart.

EAOUSAFOIA0000519

Case 110-cr-OO286-TSE Document 30-8 Filed 12/13/10 Page 1 of 2

Exhibit 8
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000520

Case 1:10-cr-00286-TSE Document 30-8 Filed 12/13/10 Page 2 of 2

The. treat at Sheppard Pratt


A flrst class setting for world class care
6501 N. Charles Sl~eet

P,O, Box 6815 F~x: 41

~raail. rctreat~ sh~t~ardpratt ag

Ootober 1, 2010 . William E. Lawle~, M Vinson & Elkins.Ll_~. " The Willard Office Btiildm.g . .. 1455 Petmsyl~tin ,Ave., NW. Suite 600

Was~gton, D.C..2oo0~i608

Dear Mr. Lawler,


I am writing to you oh.hehal.~?6f. Mr. Paul Magliocchetti who has given me permission to share the following information. Mr; Magli0c.ofiOtti..was a patient under my care at the Retie, at at Sheppard Pratt starting July 16, 20 I0 until August 18,. 20I 0)t~aving receafly reoeived a request for his raedioal records and upon reviewing his discharge stttrtmary, I noted.tha~ the diagnosis of Cognitive Disorder, Not Othea-wise Speoified was aeoidenmlly omitted in the DSM-4 Axis I list of diagnoses, even though concern for cognitive impairment was disoussed in the body of the diseherge ~mrnary as well as noted as the reason for reeommendatlon for outpatient neuropsychologioal testing.. In this letter, I Would therefo,r~ like to explicitly state that in my treatment of Mr. Magliooehetti I noted evidence of early memory impairmen~ arid information processing difficulties both in my individual sessions with him, and his a~cotmts o1 the legal, difficulties leading up to admission. Other members of the treatment team noted difficulty reraembcring task~ during groups and recounting information ac~atly. There are multiple possible etiologies to these sympton~., including cognitive impairment at times se~n with major depressive illness Mr. Maglioeehetti certainly presented with, as well as a consequence of chronic heavy alcohol use he had reported at time of admission. The possibility of early dementm process was also a concern, due to Mr. Magliooehettis long existing vascular disease (evidimced by cardiac disease requiring stenting) and diabetes meMtus. As a result ofthe abo.ve ob~a~atiorts in my treatment, Cognitive Disorder NOS should oertainly be part of his working diagnosis for future. l~eatment considerations and deserves continued evaluation and close monitoring.
Please contact m at 410~938:5323 with any further questions,

Marina Nikhinsoh, M.D. Attending Psyct~iatiist, The Retreat at Sheppard.l~att

EAOUSAFOIA0000521

Case 110-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 1 of 59

Exhibit 9
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000522

Case 1:10-cr-00286-TSE Document30-9 Filed 12/13/10 Page2of59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003 PHONE (703) 573-2045 FAX (703) 573-0760

CARDIOVASCULAR MEDICINE

November 12, 2009

To Whom This May Concem:


RE: Paul Magliocchetti DOB: 07/22/46

Mr. Magliocchetti is a sixty-three year old patient under my care for the last ten years for atherosclerotic cardiovascular disease, familial combined hyperlipidemia, and severe hypertension. When I first met him just a little over ten years ago he presented with a six-month history of exertional dyspnea associated with chest tightness, clearly consistent with angina. A treadmill test was abnormal on modest effort, and cardiac catheterization revealed multivessel disease with a highgrade obstruction in the mid fight coronary of approximately 95/o, but with 30% disease in the proximal to mid left anterior descending, 50% in the second marginal branch of the circumflex, and normal ventrieular function. He had moderate calcification of his vessels. He subsequently underwent a bare-metal stem angioplasty on January 3, 2000 to the fight coronary artery. Over the years he has been doing reasonably well with aggressive multidrug treatment. I have, however, had an increasingly difficult task of trying to control his blood pressure over the last year. His latest visit to me on October 30, 2009 is illustrative of what I often confront when he comes to my office. On that occasion his blood pressure was 174/106. At times the diastolic has been in the 120 range. The drug regimen that he was on in May of 2008 for hypertension was Cardizem CD 180 mg one day, alternating with 240 mg the next day and Hyzaar 100/25 each day. His current drug therapy has been Cardizem CD 360 mg q.d., Hyzaar 100/25 mg q.d., Toprol-XL 200 mg q.d., hydralazine 50 mg b.i.d, to t.i.d., Zetia 10 mg q.d., Crestor 20 mg q.d., Lovaza 1000 mg four capsules daily, Remeron liquid droplets at night, lithium, and Klonopin. His blood pressure on April 16, 2009 on that regimen was 136/96, which was the best I have had for the past year. Today he is again high despite having added the hydralazine to him last spring. I increased the hydralazine again on October 30, 2009 to 100 mg b.i.d, and then if the pressure is still remaining high to 100 mg t.i.d.

Paul clearly is extremely reactive to the ongoing stress in his life and I have asked Paul not to attempt to go back to work.

EAOUSAFOIA0000523

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 3 of 59

To Whom This May Concern RE: Paul Magliocchetti

November 9, 2009 Page Two

I did discuss with him a rare syndrome called Takotsubo syndrome, which is myocardial injury typically in the distribution of all three vessels, which is felt to be in part related to a vasospastic process under extreme periods of stress and tension. He certainly is continuing to go through that process of extreme amounts of stress and tension, and anything that could be done to help alleviate this would certainly be beneficial towards lowering his risk for a major vascular event. He is known to have triple vessel disease of at least ten years duration with a stent that was placed almost ten years ago now. He does get chest discomfort at times and did have a Lexisean dual isotope study on December 2, 2008, which I felt was normal without clear evidence of ischemia or scarring. Nonetheless, because of his underlying triple vessel disease accompanied by wide swings in his blood pressure, he is at risk of having a major cardiovascular event. If you have any questions I would be happy to try to answer them for you. Sincerely yours,

R.~~M~atth~w:, ~. C .~C~/~"~ RGM:ec

EAOUSAFOIA0000524

Case l:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 4 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003 PHONE (703) 573-?.045 * FAX (703) 533"0760

CARDIOVASCULAR MEDICINE

October 30, 2009 Edward P. Curcio, M.D. 2251 Pimmit Drive Suite C-3 Falls Church, Virginia 22043
RE: Paul Magliocchetti DOB: 07/22/46

Dear Dr. Cureio: Paul came in for a follow-up visit. He is sixty-three now, and I first saw him in October ten years ago when he presented with a six-month history of exertional dyspnea, at times associated with a slight pressure or tightness in his chest. He had been very active in an exercise program consisting of playing tennis in a competitive way, racquetball, elliptical trainer, and various weight and resistance machines. He had not had any significant dyspnea until six months before that first visit with me ten years ago. A treadmill test proved to be abnormal, and we discussed the option of proceeding with a stress dual isotope versus a cardiac catheterization and elected on the latter. Became he had some subtle symptoms that were of concern I felt even a normal nuclear scan at that point would not want to dissuade us from going further and looking at the coronary anatomy. On January 30, 1999 he underwent a cardiac catheterization. This revealed a 30% block of the proximal to mid left anterior descending, 50% block of the second marginal branch of the circumflex, 85 to 90% block of the mid right coronary, and normal ventricular ftmetion. He had moderate calcification in the proximal LAD, which gave offa fairly decent diagonal, and then 3 mm to 4 mm beyond that there was a smooth tubular 30% block. The left anterior descending was a fairly large vessel which went to and wrapped around the apex. The circumflex gave offa large first marginal and then a second smaller marginal. The second smaller marginal was moderate in size with a 50% smooth tubular narrowing as it separated from the circumflex. The circumflex then ended as a third smaller branch, barely exiting the AV groove. The right coronary was fairly dominant, and in the proximal one-third there was a smooth tubular narrowing of 20%. However, at the mid portion of the fight coronary there was a discrete 85 to 90% block, and there was a fairly large posterior descending branch and a smaller posterolateral left ventfieular branch. When he returned to have the stem on January 3, 2000 it appeared that the right coronary was actually closer to a 95% blocked vessel. This was successfully stented with a non-drug-eluting ACS Tristar 3.0 mm x 13 mm long stent. There was a good step up into the stent and a step down at the terminal end of the stent, and no residual stenosis. He still had some proximal 30% smooth tubular narrowing.

EAOUSAFOIA0000525

Case 1:10-cr-OO286-TSE Document30-9 Filed 12/13/10 Page5of59

Edward P. Curcio, M.D. RE: Paul Magliocchetti

October 30, 2009 Page Two

Paul has had a history of familia! combined hyperlipidemia, and has had significant hypertension which has become increasingly difficult to get close to optimal ranges. Since November of 2008 he has been under extreme stress with his business, a company based in the District of Columbia involved with lobbying. He has been under investigation by the Justice Department. During this time frame he has been under intense stress not knowing whether the Justice Department is going to proceed with legal action against him and his company. He has had increasingly difficult to achieve adequate control with his blood pressure during the past year despite increasing drug therapy. He does have a cuff and does check it on his own, as well as sometimes in a store. The lowest systolic he has had was in the upper 140s, and the lowest diastolic 89. For the most part, it is not uncommon to have numbers in the 170s to 180s or higher systolic and diastolics in the upper 90s to low 100s. This is an especially stressful day for him and his blood pressure was again significantly elevated. It should be noted that he has on occasion developed chest tightness sometimes when confronted with problems that he feels are related to the case, and he will develop a sense of tightening in the chest. It usually will last a few minutes and then gradually abate. He has not felt chest tightness when he is playing termis, taking his long walks, or swimming in a pool. He does have intermittent palpitations but no sustained tachyarrhythmias. He on occasion has exertional dyspnea going up a hill. There is no ankle edema, orthopnea, or PND.

Review of systems reveals that he does get headaches, which can be occipital on occasion, which might reflect a spike in his blood pressure. His vision is helped with his glasses but distance is better in the right eye, but he reads better with his left eye. His hearing he feels is generally fairly good. He does have a long history of upset stomach and occasional GERD. He does get water brash on occasion. He denies melena but does have occasional hematochezia. He drinks a lot of water in the evening and he has nocturia sometimes four times a night. He is known to have benign prostatic hypertrophy. He does have some diffuse arthralgias, which can involve his back and his hands. He has not had a history of a TIA, localized weakness or numbness. Where his blood pressure on April 16, 2009 when I last saw him was 136/96, his blood pressure today seated aRer we had been talking for about one-half hour was 174/106. He is a well-developed, well-nourished man. His face is somewhat red today. He is able to hear my fingers rubbing softly together on both sides but more easily on the right than the left. There is a faint arcus senilis. There is no xanthelasma around the eyelids. There is some conjunctival injection. Carotids are 2+ without audible bruits or delay in upstroke. Neck veins are not distended. Thyroid tissue is not palpable. There are no palpable anterior cervical or supraclavicular lymph nodes. I did not see any actinic keratoses on his face or forehead. The chest is entirely clear. He has a sinus rhythm. I did not hear any ectopy today. There is an atrial gallop and a grade I/6 systolic ejectio.n murmur at the base. His abdomen is soft. With inspiration the liver edge comes down two finger breadths below the right costal margin. It is smooth and nontender. I could not feel the spleen edge. There is no tenderness. He has good pedal pulses. There is no pitting edema.

EAOUSAFOIA0000526

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page6 of 59

Edward P. Curcio, M.D. RE: Paul Magliocchetti

October 30, 2009 Page Three

There are no significant osteoarthritic changes in his hands or fingers. Neurologic examination is grossly unremarkable. His gait is normal. EKG shows nonspecific ST-T abnonualities.
I am concerned about Paul. He is under I think intense stress with what has happened to his company. I did discuss with him that emotional stress triggers a fight or flight response in us, which results in an adrenaline surge, which results in an increased heart rate, increased blood pressure, and increased work stress on the heart. There is a syndrome called Takotsubo syndrome, which is a coronary vasospastic syndrome usually in our older patients, more oi~en in women than men where they constrict the distal half of the coronary circulation in a uniform manner while maintaining blood flow to the proximal half of the ventricle. They can infarct the apex of the ventricle, and Takotsubo is Japanese for octopus jar. The lef~ ventricle has the appearance of this kind of vessel because of the infarction and ischemic insult in the distal half of all three major coronary vessels. Patients have gone into congestive heart failure and some have died from this syndrome. Others can be supportod sometimes with aggressive measures such as an intmaortic balloon pump and vasopressor therapy to get them through the event. When they undergo heart catheterization they typically have normal coronary arteries, and this has resulted in the theory that this is a vasospastic condition which is operable long enough to cause a myocardial infarction. We have known that vasospasm can cause heart attacks for decades when we have done cardiac catheterizations on patients after they have had a true myocardial infarction with EKG and enzyme changes but at catheterization had normal coronary vessels. Takotsubo, however, appears to be associated more with older people who have experienced severe stress in their life. This can take the form of a death of a spouse or a child, the loss of a job, orthe illness era child. In that sense, I have asked Paul to bear this in mind and to try to find ways to remove some of this stress and tension that he is living with on a daily basis. Exercise is certainly one of the very best things he can do..

Right now his blood pressure is not acceptable, and I did put him on hydralazine which he thinks he has been taking b.i.d, he thought at about 50 rag. I have given him a prescription for 100 mg to go to b.i.d, initially, and then if the pressure is still high to go to three per day taking one tablet t.i.d. I would like Paul to get more readings, both when he is relaxed and when he is under stress so we get a better sense of just whether we are achieving some more optimal control. I am going to see him in four months, and two to three weeks before that he will redo the NMR. profile so we can cheek that. I hope the enclosed is helpful. Sincerely yours,

Robert G. Matthews, M.D., F.A.C.C. cc: Mr. Paul Magliocchetti RGM:cc

EAOUSAFOIA0000527

Case 1 10-cr-OO286-TSE Document 30-9 Filed

EAOUSAFOIA0000528

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 8 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003 PHONE (703) 573-2045 FAX (703) 5"73-0760

CARDIOVASCULAR M EDICIN E

October 30, 2009

Edward P. Curcio, M.D. 2251 Pimmit Drive Suite C-3 Falls Church, Virginia 22043
RE: Paul Maglioechetti DOB: 07/22/46

Dear Dr. Curcio:


Paul came in for a follow-up visit. He is sixty-three now, and I fh-st saw him in October ten years ago when he presented with a six-month history of exertional dyspnea, at times associated with a slight pressure or tightness in his chest. He had been very active in an exercise program consisting of playing tennis in a competitive way, racquetball, elliptical trainer, and various weight and resistance machines. He had not had any significant dyspnea until six months before that first visit with me ten years ago. A treadmill test proved to be abnormal, and we discussed the option of proceeding with a stress dual isotope versus a cardiac catheterization and elected on the latter. Because he had some subtle symptoms that were of concern I felt even a normal nuclear scan at that point would not want to dissuade us from going further and looking at the coronary anatomy.

On January 30, 1999 he underwent a cardiac catheterization. This revealed a 30% block of the proximal to mid left anterior descending, 50% block of the second marginal branch of the circumflex, g5 to 90% block of the mid right coronary, and normal ventricular function. He had moderate calcification in the proximal LAD, which gave offa fairly decent diagonal, and then 3 mm to 4 mm beyond that there was a smooth tubular 30% block. The left anterior descending was a fairly large vessel which went to and wrapped around the apex. The circumflex gave off a large first marginal and then a second smaller marginal. The second sraaller marginal was moderate in size with a 50% smooth tubular mowing as it separated from the circumflex. The circumflex then ended as a third smaller branch, barely exiting the AV groove. The right coronary was fairly dominant, and in the proximal one-third there was a smooth tubular narrowing of 20%. However, at the mid portion of the right coronary there was a discrete 85 to 90% block, and there was a fairly large posterior descending branch and a smaller posterolateral left ventricular branch.
When he returned to have the stent on January 3, 2000 it appeared that the right coronary was actually closer to a 95% blocked vessel. This was successfully stented with anon-drug-eluting ACS Tristar 3.0 mm x 13 mm long stent. There was a good step up into the stent and a step down at the terminal end of the stent, and no residual stenosis. He still had some proximal 30% smooth tubular narrowing,

EAOUSAFOIA0000529

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 9 of 59

Edward P. Curcio, M,D. RE: Paul Magliocchetti

October 30, 2009 Page Two

Paul has had a history of familial combined hyperlipidemia, and has had significant hypertension which has become increasingly difficult to get close to optimal ranges. Since November of 2008 he has been under extreme stress with his business, a company based in the District of Columbia involved with lobbying. He has been under investigation by the Justice Department. During this time frame he has been under intense stress not knowing whether the Justice Department is going to proceed with legal action against him and his company. He has had increasingly difficult to achieve adequate control with his blood pressure during the past year despite increasing drug therapy. He does have a cuff and does check it on his own, as well as sometimes in a store. The lowest systolic he has had was in the upper 140s, and the lowest diastolic 89. For the most part, it is not uncommon to have numbers in the 170s to 180s or higher systolic and diastolics in the upper 90s to low 100s. This is an especially stressful day for him and his blood pressure was again significantly elevated. It should be noted that he has on occasion developed chest tightness sometimes when confronted with problems that he feels are related to the case, and he will develop a sense of tightening in the chest. It usually will last a few minutes and then gradually abate. He has not felt chest tightness when he is playing tennis, taking his long walks, or swimming in a pool. He does have intermittent palpitations but no sustained tachyarthythmias. He on occasion has exerdonal dyspnea going up a hill. There is no ankle edema, orthopnea, or PND. Review of systems reveals that he does get headaches, which can be occipital on occasion, which might reflect a spike in his blood pressure. His vision is helped with his glasses but distance is better in the right eye, but he reads better with his left eye. His hearing he feels is generally fairly good. He does have a long history of upset stomach and occasional GERD. He does get water brash on occasion. He denies melena but does have occasional hematochezia. He drinks a lot of water in the evening and he has nocturia sometimes four times a night. He is known to have benign prostatic hypertrophy. He does have some diffuse arthralgias, which can involve his back and his hands. He has not had a history of a TIA, localized weakness or numbness.

Where his blood pressure on April 16, 2009 when I last saw him was 136/96, his blood pressure today seated aRer we had been talking for about one-half hour was 174/106. He is a well-developed, well-nourished man. His face is somewhat red today. He is able to hear my fingers rubbing softly together on both sides but more easily on the fight than the leR. There is a faint arcus senilis. There is no xanthelasma around the eyelids. There is some conjunctival injection. Carotids are 2+ without audible bruits or delay in upstroke. Neck veins are not distended. Thyroid tissue is not palpable, There are no palpable anterior cervical or supraclavicular lymph nodes. I did not see any actinic keratoses on his face or forehead. The chest is entirely clear. He has a sinus rhythm. I did not hear any ectopy today. There is an atrial gallop and a grade 1/6 systolic ejection murmur at the base. His abdomen is soR. With inspiration the liver edge comes down two finger breadths below the right costal margin. It is smooth and nontender. I could not feel the spleen edge. There is no tenderness. He has good pedal pulses. There is no pitting edema.

EAOUSAFOIA0000530

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 10 of 59

Edward P. Curcio, M.D. RE: Paul Magliocehetti

October 30, 2009 Page Three

There are no significant osteoarthritic changes in his hands or fingers. Neurologie examination is grossly unremarkable. His gait is normal. EKG shows nonspecifie ST-T abnormalities. I am concerned about Paul. He is under I think intense stress with what has happened to his company. I did discuss with him that emotional stress triggers a fight or flight response in us, which results in an adrenaline surge, which results in an increased heart rate, increased blood pressure, and increased work stress on the heart. There is a syndrome called Takotsubo syndrome, which is a coronary vasospastie syndrome usually in our older patients, more o~ten in women than men where they constrict the distal half of the coronary circulation in a uniform manner while maintaining blood flow to the proximal half of the ventricle. They can infarct the apex of the ventricle, and Takotsubo is Japanese for octopus jar. The lef~ ventricle has the appearance of this kind of vessel because of the infarction and isehernie insult in the distal half of all three major coronary vessels. Patients have gone into congestive heart failure and some have died from this syndrome. Others can be supported sometimes with aggressive measures such as an intraaortic balloon pump and vasopressor therapy to get them through the event. When they undergo heart catheterization they typically have normal coronary arteries, and this has resulted in the theory that this is a vasospastie condition which is operable long enough to cause a myocardial infarction. We have known that vasospasm ea.,a cause heart attacks for decades when we have done cardiac catheterizations on patients after they have had a true myocardial infarction with EKG and enzyme changes but at catheterization had normal coronary vessels. Takotsubo, however, appears to be associated more with older people who have experienced severe stress in their life. This can take the form of a death of a spouse or a child, the loss of a job, or the illness of a child. In that sense, I have asked Paul to bear this in mind and to try to find ways to remove some of this stress and tension that he is living with on a daily basis. Exercise is certainly one of the very best things he can do. Right now his blood pressure is not acceptable, and I did put him on hydralazine which he thinks he has been taking b.i.d, he thought at about 50 rag. I have given him a prescription for 100 mg to go to b.i.d, initially, and then if the pressure is still high to go to three per day taking one tablet t.i.d. I would like Paul to get more readings, both ",,,hen he is relaxed and when he is under stress so we get a better sense of just whether we are achieving some more optimal control. I am going to see him in four months, and two to three weeks before that he will redo the NMR profile so we can cheek that. I hope the enclosed is helpful. Sincerely yours,

Robert G. Matthews, M.D., F.A.C.C. cc: Mr. Paul Magliocchetti RGM:cc

EAOUSAFOIA0000531

Case 110-cr-00286-TSE Document30-9 Filed 12/13/10 Page 11 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 2200.3 PHONE (703) 573-2045 FAX (703) 573-0760

CARDIOVASCULAR MEDICINE

April 16, 2009

To Whom This May Concern:


RE: Paul Magliocchetti DOB: 07/22/46

Paul returned for a follow-up visit. He continues to be under tremendous stress where he is closing down his business here. He is hoping to gradually move to Florida over the next few months pending what the Justice Department does. Pauls attorneys feel that at this point the government does not have a justifiable case. Nonetheless, the process has done considerable damage to Paul and his business, which may never be retrievable. Paul has stopped his routine exercise habits, but I get a sense he is feeling a little bit better than he has felt in some time since all of this began last November. He initially was having chest tightness but that has considerably lessened. We did repeat his nuclear scan because of that tightness and a Lexiscan dual isotope on December 2, 2008 was normal without evidence of ischemia or scarring. He did have diaphragmatic attenuation artifact, and his ejection fraction was minimally depressed at 47% with normal being 50% or above. Paul denies any recent tightness or heaviness in his chest. He does walk up the equivalent of four or five flights in a commercial building here in Washington on a fairly routine basis. He is able to do it without stopping but he is short of breath at the top, although he is not aware of tightening in the chest, arms, throat, or jaw. He denies ankle edema, orthopnea, or PND. He denies palpitations or tachyarrhythmias. His diet is still not what it used to be, and he has not been able to exercise. He did not bring a list of his medications. As best i can determine he is on Cardizem, which I increased on his February 11, 2009 visit from 240 mg to 360 mg q.d. He continues Hyzaar 100125 mg q.d., and Toprol-XL I had written for 200 mg q.d. He had been on 50 mg of metoprolol two tablets daily. He tells me he is taking three tablets b.i.d, of what he thinks is Toprol but will check and call us back. I had prescribed hydralazine 50 mg t.i.d, but he does not believe he is taking that one at all. That would have been at the February 11, 2009 visit. He continues Zetia 10 mg q.d., Crestor 20 mg q.d., and Lovaza 1000 mg four capsules daily. He has been totally intolerant of the niacin. He is also on TriCot 145 mg q.d. He does take Remeron liquid droplets at night, lithium, and Klonopin prescribed by Dr. Curcio for his severe depression. Review of systems reveals he has not been troubled by headaches. His vision is not entirely normal. He finds he reads better with his left eye but distance is better in his right eye, and he is able to alternate as needed. He tells me his hearing is generally fairly good.

EAOUSAFOIA0000532

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 12 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003


PHONE (703) 573-2045 * FAX (703) 573-O7t~0

CARDIOVASCULAR MEDICINE

February 11, 2009

To Whom This May Concern: RE: Paul Magliocchetti DOB: 07/22/46

Paul has been seeing Dr. Curcio in the District of Columbia on referral from Dr. Thomas Wise, the Chairman of Psychiatry at Inova Fairfax Hospital. I did receive a phone call from him two nights ago and Paul was with him, but his blood pressure was very high. Paul at times when he has been in a conversation with someone regarding his company has had blood pressure which he thought was as high as 225/195, which would be an unusually narrow pulse pressure. That occurred last week. In the psychiatrists office it was still up in the 195/120 range, and we doubled his Toprol from 50 mg q.d. to b.i.d., although I thought I had asked him to do that in December. He was taking one per day. He is now taking two per day and his blood pressure was 168/116 today. His Cardizem is 240 mg one day and 180 mg the next, Hyzaar 100/25 mg every a.m., and metoprolol 50 mg two tablets q.d. Other drug therapy includes Crestor 20 mg q.d., Zetia 10 mg q.d., and Lovaza 1000 mg four capsules q.d. He has been unable to tolerate Niaspan. He is back on TriCor 145 mg q.d. In addition, he is taking medication to help him sleep from Dr. Curcio, which consists of Remeron liquid droplets at night and Klonopin, which seems to be helping him. He remains under intense stress with an article in The New York Times this morning about the lobbying ftrrn that he started, the widening investigation, and an inquiry into his business. He and his girlfriend that he has been with for several years did marry recently. However, Paul has stopped his routine exercise habits. He does do some walking but tends to walk slowly. When he is in Florida the blood pressure tends to be a little better, but if he gets a phone call that is upsetting it can become extremely high. He has had some chest pressure, which is most apparent when he is under intense mental stress. He does not, however, relate the chest pressure to physical exertion but has gotten away from some of his routine exercise habits. He is short of breath climbing several flights of stairs but denies ankle edema, orthopnea, or PND. He denies palpitations or tachyarrhythmJas. We did repeat a Lexiscan dual isotope on December 2, 2008, which was normal without evidence of isehemia or scarring. He had mild diaphragmatic attenuation artifact. The ejection fraction was 47% with normal 50%.

EAOUSAFOIA0000533

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 13 of 59

To Whom This May Concern RE: Paul Magliocchetti

February 11, 2009 Page Two

Review of systems reveals that his hearing generally is good. His vision is correctable. He has not had many headaches but does get some. He has an occasional upset stomach and rare GERD, and is also on Protonix 40 mg daily. He denies melena or hematoehezia. He has some diffuse musculoskeletal aches at times but he is extremely tense. Neurologic examination reveals no intermittent localized weakness in any limb suggestive of a TIA. On exam, his blood pressure was 168/116 seated at the start of the exam. He is a well-developed, very tense, quite depressed man. He has no xanthelasma or arcus senilis. Carotids are 2+ without bruits. Neck veins are not distended. Thyroid tissue is not palpable. There are no palpable cervical lymph nodes. The chest is entirely clear. He has a sinus rhythm. There is an atrial gallop, and a very faint systolic murmur at the base. The abdomen is sot~. Liver and spleen are not palpable. There are no masses or tenderness. He has excellent pedal pulses, and no pitting edema. Neurologic examination is grossly unremarkable. His gait is normal. Resting EKG shows some mild nonspecifie T-wave lowering but is otherwise unremarkable. Paul has known coronary disease. He developed exertional dyspnea in the fall of 1999, and had an abnormal stress test in October of 1999 which I thought could be a false abnormality due to his hypertension. He was having slight pressure and he underwent cardiac catheterization on December 30, 1999 with a 30% block of the proximal to mid LAD, 50% of the second marginal branch of the circumflex, 85 to 90% of the mid right coronary, and normal ventricular function. There was moderate calcification of the proximal LAD, and a smooth tubular 30% narrowing in the proximal to mid LAD. The LAD was a fairly large vessel, wrapping around the apex. The smaller second marginal was moderate in size with a 50% smooth tubular nan-owing as it separated from the main circumflex. There was a larger first obtuse marginal that ended as a third smaller branch. The right coronary was clearly dominant with a discrete 85 to 90% stenosis. On January 3, 2000 we stented the block with a Tdstar ACS 3 mm x 13 mm stent with a good step up and a step down into and from the stent. There was some smooth 30,/o proximal right coronary narrowing before that. At this point I have doubled the Toprol and va-itten for Toprol-XL 200 mg q.d. I have increased the Cardizem to 360 mg q.d. He will continue the Hyzaar 100/25 mg. I have also given him a prescription for hydralazine 50 mg t.i.d. He is getting ready to go with his wife to Florida on Friday, and I have asked him to call me on Monday so I can see how his blood pressure is doing. If necessary we can further increase the hydralazine.

I have encouraged him to try to do some walking. I do, however, waxtt him to avoid work right now. He is continuing to spike and has substantial elevations of both systolic and diastolic blood pressure, and was significantly elevated today. I feel until some of the tension is removed from this situation that he should not be going into work. I will see him again in six weeks, and I would like him to redo an NMR profile a couple weeks before that visit.

EAOUSAFOIA0000534

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 14 of 59

To Whom This May Concern RE: Paul Magliocchetti

February 11, 2009 Page Three

I spent minutes with the patient today, ~9 minutes of which were spent reviewing his medications, counseling him on lowering his fat intake, explaining what we can expect from the medications he is taking, and teaching him the necessity of proper diet and exercise. Best regards,

Robert G. Mat-thews, M.D., F.A.C.C. cc: Mr. Paul Magliocchetti RGM:cc

EAOUSAFOIA0000535

Case :lO-cr-

)Q

ge 15 of 59

EAOUSAFOIA0000536

Case 1:~.O..-,r~,p286-TSE Document 30-9 Filed 12/13/10 Page 16 of 59

Robert GTMatthews, M.D., F.A.C.C., C.B.N.C., Ltd.


3299 Woodburn Road Suite 200 Annandale, VA 22003 Phone (703) 573-2045 Fax (703) 573-0760 DUAL ISOTOPE PROTOCOL USING LEXISCAN GATED SPECT MYOVIEW/REST SPECT THALLIUM RE: MAGLIOCCHETTI, PAUL STUDY#15136 REFERRING PHYSICIAN: DR. V. NGUYEN RENDERING PHYSICIAN: DR. R. MATTHEWS TEST DATE: 12/02/08 INTERPRETATION DATE:!2/02/08 SEX: M DOB: 07/22146
LEXISCAN MYOVIEW/THALLIUM PERFUSION STUDY:

Procedure: The patient was injected with 3.18 mCi of Thallium and SPECT imaging was begun 15 minutes post injection. The camera obtained images with a 180-degree orbit around the patients heart. Alter the rest images, the patient was then prepped for a Lexiscan pharmacologic stress test. The patient was given 5 ml (0.4 nag) of IV Lexisean (Regadenoson) over a ten second rapid infusion with a flve to ten ml normal saline flush given immediately after the infusion. The patient was then given an intravenous injection of 32.9 mCi of Myoview followed by another five to ten ral normal saline flush. The patient was monitored for another eight to ten minutes or until the patients EKG, BP and symptoms.came back to baseline. Gated SPECT imaging was started at 66 minutes post injection. The patient was placed in the supine position and the images were obtained with a 180-degree orbit around the patients heart while gating to the patients EKG. The study was then processed and displayed for evaluation.

-)

Exercise: Blood Pressure Rest 162/102 Maximum 140/100 Heart Rate Rest 72 Maximum 96 The patient came into the lab with chest burning but no ischemic ST depression. The burning subsided before the test and did not return. No ischemic ST depression. Normal ECG response. (See enclosed exercise sheet.)

Interpretation: The quality of the study is good. Review of the cine raw projection data reveals no significant motion artifact. Review of the tomographic slices reveals a small mild area of diminished perfusion on the inferior wall closer to the base on both rest and stress images. No other significant perfusion defects are noted. Review of the wall motion study reveals uniform thickening and contraction in the myocardium with an overall ejection fraction of 47% (normal is greater than 50%). The CedarsSinai AutoQuant quantitative study does not identify any significant perfusion defects.
Conclusion: 1. Normal pharmacologic stress dual isotope study without evidence ofischemia or scarring. Mild diaphragmatic attenuation artifact is noted. 2. Normal wall motion with tmiform thickening and contraction and an overall ejection fraction of 47% which is just minimally depressed from the normal o f 50%. 3. Compared to the previous study of06/13/06, there does not appear to be a significant change. There was no evidence of ischemia or scarring and that was considered a normal stress duel isotope study. No diaphragmatic attenuation was commented upon. It did appeax from looking at the polar plots that there might have been some subtle diminished perfusion on the inferior wall. There was normal wall motion with uniform thickening and an ejection fractiox~ of 50%.

Interpreted by: Robert G. Matthews,ffl.D,, C.B.N.C. RGM: mare

EAOUSAFOIA0000537

Case 1:10-cr-OO286-TSE Document30-9 Filed 12/13/10 Page 17 of 59

329g WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003


PHONE (703) 573-2.045 = FAX (703) 573-0760

CARDIOVASCULAR MEDICINE

December 1, 2008

To Whom This May Concern: RE: Paul Magliocchetti DOB: 07122146

Paul called me last week from Colorado. He had something happen in his business that has been extremely upsetting to him and very stressful. This apparently started on November 19, 2008 on a Wednesday and involves Paul and his company in the District of Columbia, and it has also involved his son. I am not clear as to the exact nature of what has happened but Paul has felt extremely stressed. He has actually dropped his weight from what was 198 to 200 pounds to 182 pounds this morning. During this twelve-day period he has felt some intermittent chest tightness. It is in the center of the chest but does not radiate to the arms, throat, or jaw. It seems to come and go during the day. He did do some snowshoeing one week ago Saturday and felt very fatigued. Normallyhe would lead his family and the friends that would go with him, but now he found that he was stopping to catch his breath. Sometimes it would be associated with a sense of burning in the chest as if he had over exercised a muscle. Again, it was not radiating but he found himself pausing more and not keeping up with the others where he was usually leading the group of friends and family. He has not had recent ankle edema. He has had no orthopnea or PND but he is not sleeping well. He is using a sleeping pill at night to help him to sleep and it is not entirely effective. He has felt his heart pounding at times. It does not seem to be skipping but just racing. At times he has felt sweaty, and when he got back from the snowshoeing experience he was drenched in sweat. He does, however, start to perspire at other times when he is not exercising. He is more short of breath with exertion than he used to be. He does have a blood pressure cuff but has not been checking it. He missed his Hyzaar 100/25 mg this morning, as well as the Cardizem 240 mg one day and 180 mg the next. He did take it yesterday. Review of systems reveals that he has had some lower abdominal discomfort, more in the flank area bilaterally. He has also had hematochezia. His appetite has all but disappeared. He has a history of occasional reflux. He has had no melena. He does have some mild arthralgias. There is no history of a TIA, localized weakness or numbness.

EAOUSAFOIA0000538

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 18 of 59

To Whom This May Concern RE: Paul Magliocchetti

December 1, 2008 Page Two

Paul is currently taking Crestor 20 mg q.d., Zetia 10 mg q.d., and Lovaza 1000 mg four capsules per day. He has been unable to tolerate Niaspan. I did put him back on some TriCor last month and that was 145 mg per day but it is not clear he is taking that routinely. On exam, his blood pressure seated in both arms was 194-196/126. Recumbent at the end of the exam it was the same. He is a well-developed, extremely tense man today. His conjunctivae are injected. Carotids are 2-3+ without audible bruits. Neck veins are not distended. Thyroid is not palpable. He seems quite agitated at present and obviously very upset. He has a sinus rhythm. There was rare ectopy. There is an atrial gallop and a grade 1/6 systolic murmur at the base. The abdomen is soft. Liver and spleen are not palpable. He does have some subtle tenderness towards the lower quadrants on both sides. I could not feel any masses. He has excellent pedal pulses, and no pitting edema. Neurologic examination is grossly unremarkable. His resting EKG shows some left atrial enlargement but no other abnormality. The minor nonspecific ST-T abnormalities seen last month are no longer apparent on todays EKG. Paul has known coronary disease. He had some exertional dyspnea back in October of 1999. On January 3, 2000 he had a dominant fight coronary with a 95% block in the mid portion of the vessel. He had an abnormal stress test in October of 1999 suggestive of ischemia but I thought it could be a false abnormality due to hypertension. I also thought he had some slight chest pressure at the time that had been present for about six months, and felt he might be having some possible angina. This led to a catheterization on December 30, 1999. He had the 30% block of the proximal to mid left anterior descending, 50% block of the second marginal branch of the circumflex, 85 to 90% block of the mid fight coronary, and normal ventrieular function. He had moderate calcification of the proximal LAD. It gave off a fairly decent diagonal, and about 3 to 4 mm beyond that there was a smooth tubular 30% block. The LAD was a fairly large vessel and wrapped around the apex. The circumflex gave off a large first marginal and then a second smaller marginal. The smaller second marginal was moderate in size with a 50% smooth tubular narrowing as it separated from the circumflex main vessel. The circumflex ended as a third smaller branch, barely exiting the AV groove. The right coronary was dominant. In the proximal one-third there was a smooth tubular narrowing of 20%. In the mid portion of the right there was this discrete 85 to 90/, block. He had normal ventricular function. There was anomalous origin of an acute marginal branch coming off above the origin of the true native fight. On January 3, 2000 we stented a 95% blocked right coronary with a 3.0 mm x 13 mm TKISTAR ACS stent. There was a good step up into the stent and no residual stenosis in the area. There was still a proximal 30% smooth tubular narrowing in the fight coronary. His last nuclear scan was on June 13, 2006 as a stress dual isotope. He got into stage V of a Bruce test at a rate of 163 without chest discomfort, and was only mildly short of breath. There was no ischemic ST depression. The EKG was considered normal. The nuclear scan was likewise norma! without evidence ofischemia or scarfing, and normal wall motion with an ejection fraction of 50%.

EAOUSAFOIA0000539

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 19 of 59

To Whom This May Concern RE: Paul Maglioechetti

December 1, 2008 Page Three

At this point I feel we need to repeat the nuclear scan. However, because of his hypertension I am going to start him on Toprol-XL tonight at 50 mg b.i.d. He will go back and add the Cardizem, and also his Hyzaar. Tomorrow morning before he comes for the nuclear scan he will take his medication with a sip of water. Since the Toprol is going to blunt his heart rate response I am going to do this as a Lexiscan stress dual isotope study. If the study is abnormal it will be very clear that he needs to repeat a cardiac catheterization. If by chance it is normal, then the question will be whether to simply go ahead with an invasive study at any rate because of what is going on right now. His symptoms of angina I think were subtle but definitely there in 1999. I have asked him to get blood pressure readings so we can start to monitor that. I did also suggest that perhaps he might want to speak with a psychiatrist that perhaps could offer some counseling and perhaps some drug therapy that might ease some of the extreme amount of tension he is currently experiencing. This is a company that he started just about twenty years ago, and has been slowly trying to move somewhat away from and move into more of a retirement mode, and comes as an extremely stressing turn of events in his life. I did also give him a prescription for nitroglycerin 0.4 mg to take one if needed for chest tightness. I would like him to sit down or lie down if he did decide to use any.
Best regards,

Robert G. Matthews, M.D., F.A.C.C. RGM:cc

EAOUSAFOIA0000540

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 20 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003 PHONE (703) 5?3-2045 " FAX (703) 573-O760

CARDIOVASCULAR MEDICINE

October 2, 2008 To Whom This May Concern:


RE: Paul Magliocchetti DOB: 07/22/46

Paul returned for a routine visit. He has run out of his Hyzaar. I first saw him in October of 1999. He did have some exertional dyspnea, and cardiac catheterization on January 3, 2000 revealed a dominant right coronary with a 95% block in the mid portion of the vessel. He had an abnormal stress test when I saw him in October of 1999 suggestive of ischemia, but I thought could even be a false abnormality due to hypertension. However, I felt he was having some possible angina manifested by slight chest pressure, which had been present for about six months. This led to a cardiac catheterization on December 30, 1999. He had a 30% block of the proximal to mid left anterior descending, 50% block of the second marginal branch of the circumflex, 85 to 90% block of the mid right coronary artery, and normal ventricular function. There was moderate calcification in the proximal LAD. It gave offa fairly decent diagonal and about 3 to 4 mm beyond that there was a smooth tubular 30% block. The left anterior descending was a fairly large vessel, and went to and wrapped around the apex. The circumflex gave offa large first marginal and then a second smaller marginal. The smaller second marginal was moderate in size with a 50% smooth tubular narrowing as it separated from the circumflex. The circumflex ended as a third smaller branch, barely exiting the AV groove. The right coronary was fairly dominant. In the proximal one-third there was smooth tubular narrowing of about 20%. However, at the mid portion of the right coronary there was a discrete 85 to 90% block of the right coronary. There was a fairly large posterior descending branch and a smaller posterolateral left ventricular branch. There was an anomalous origin of an acute marginal branch coming off above the origin of the true native right. He had normal ventricular function with uniform contraction, and an ejection fraction estimated at 70%. On January 3, 2000 he came in for a stent, and it appeared now that the vessel was approximately 95% blocked. He had successful stenting with a non-drug-eluting ACS Tristar 3.0 mmx 13 nun long stent. There was a good step up into the stent, and no residual stenosis in the area that the stent was placed. There was still a proximal 30% smooth tubular narrowing. His last nuclear scan was on June 13, 2006. This was a stress dual isotope study with him exercising, getting into stage V of a Bruce test at a heart rate of 163. He had no chest discomfort. He was mildly short of breath. He had rare PVCs but no ischemic depression, and it was considered a normal maximal stress test. The nuclear scan was likewise normal with no evidence of ischemia or scarring, and normal wall motion with an ejection fraction of 50%.

EAOUSAFOIA0000541

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 21 of 59

To Whom This May Concern KE: Paul Magliocchetti

October 2, 2008 Page Two

Paul continues to exercise regularly. When he is in Florida they play vigorous tennis in a competitive way for several hours at a time. He also walks sometimes for two to two and one-half hours at a time on a regular basis. He denies any effort-induced chest, arm, neck, or jaw discomfort of any kind. He does, however, notice a little bit ofexertional dyspnea running up stairs, especially if he had to go several flights in a commercial building. He denies ankle edema, orthopnea, or PND. He rarely feels any palpitations, and has had no sustained tachyarrhythmias. He and his wife eat out a fair amount. He still eats a fair amount of pasta. He and his wife do enjoy cooking, and he is trying to get more into the wheat-based pasta. He has been totally intolerant of Niaspan and also water soluble erystalline niacin tried before. Sometimes he will get very red, hot, and itchy hours after he has taken it, remote from when he actually took the medication. Review of systems reveals that he does get reflux symptoms and actual water brash. He gets an occasional upset stomach. He has had no melena or hematochezia. He does have some polyps, which have been resected from his colon in the past several years. He has some mild arthralgias and stiffness. He does do some yoga exercises at times, and just stretching exercises which help him. He has no localized weakness or numbness. His current medications are Crestor 20 mg q.d., Zetia 10 mg q.d,, and Lovaza 1000 mg four capsules daily. He is off of the Niaspan and TriCor at present. He takes Cardizem CD 240 mg one day alternating with 180 mg the next, Hyzaar 100/25 mg but recently ran out, and he is on aspirin 81 mg. He uses Claritin or Afrin as needed. On exam, his blood pressure is 152/88. He is a well-developed, well-nourished man. Carotids are 2+ without audible bruits. Neck veins are not distended. Thyroid is not palpable. His chest is clear. He has a sinus rhythm. There is a faint atrial gallop and a grade 1/6 systolic ejection murmur at the base. The abdomen is soft. Liver and spleen are not palpable. There are no masses or tenderness. He has good pedal pulses and no pitting edema. Neurologic examination is grossly unremarkable. EKG shows left atrial enlargement, normal sinus rhythm, no ectopy, and nonspecific ST-T abnormalities which he has had intermittently in the past. His NMR profile is still not where he needs to be. On the above medication on September 8, 2008 his total cholesterol was 148, triglycerides 216, HDL 35, and LDL 70. The small LDL put him in the 97th percentile of MESA. LDL particle density was high at 1873.

I told Paul that I am disappointed that he was not able to tolerate the niacin, and I wish we had been able to find some way to do this. Merck had hoped to have a product on the market this past summer that combined a long acting niacin with a drug to inhibit prostaglandin release in the skin. Unfortunately, last winter the FDA asked for some more studies, so I do not know when that drug might be available.

EAOUSAFOIA0000542

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 22 of 59

To Whom This May Concern RE: Paul Magliocehetti

October 2, 2008 Page Three

Pfizer had worked for about twelve or thirteen years on Torcetrapib, only to pull it months before expected FDA approval in December of 2006.
Paul is in that group of patients that clearly I think would benefit from an improvement in his HDL level. His total cholesterol and LDL are certainly quite favorable, but triglycerides are too high. He is going to add back TriCor 145 mg q.d. I rewrote his prescriptions and gave him samples for TriCor and Hyzaar, which he had run out of. In addition, I have asked him to get a hepatic ultrasound scan to look for any fatty infiltration in the liver. He has had off and on intermittent abnormal liver function. He does enjoy wine but he had been offofany hard liquor for some time but recently had gone back to some scotch, and it is possible that may contribute to some of the issues. He is working on stopping that now. He has felt under quite a lot of business stress lately. I am going to see him again in four months, and two weeks before that he will redo his NMR study. Pending that study and what the ultrasound of the liver shows we might consider using Goldline slow release niacin, which has about a 5% incidence of abnormal liver function. I have been reluctant to do that because he has these subtle changes, but I am concerned about the small LDL particle class with Paul. Also, we are a little over two years since his last stress nuclear scan. He does not have any typical symptoms and remains very physically active, but I feel if we are not able to achieve more improvement in that small LDL class that it would probably be worthwhile sometime early next year to consider redoing the stress dual isotope study. Best regards,

Robert G. Matthews, M.D., F.A.C.C.


cc: Mr. Paul Magliocchetti RGM:cc

EAOUSAFOIA0000543

Case 110-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 23 of 59

3299 WOOD,BURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003 PHONE (703) 573"2045 FAX (703) 573"0760 CARDIOVASCULAR MEDICINE

May 20, 2008 Kerri Kustm, M.D. 2942 Hunter Mill Road Suite 102 Oakton, Virginia 22124-1762
RE: Paul Magliocchetti DOB: 07/22/46

Dear Kerri, I have been following Mr. Maglioechetti since October of 1999. He had developed some exertional dyspnea, and on January 3, 2000 cardiac catheterization revealed a dominant right coronary with a 95% block in the mid portion of the vessel. It was subsequently stented with a Tristar non-drugeluting stent that was a 3.0 mmx 13 mm long stent, with a good result. He had some smooth tubular narrowing above that area, and above an acute marginal branch that compromised the right coronary by 20 to 30%. He has had a familial combined hyperlipidemia with a low HDL syndrome that has been aggressively approached but his numbers have never been ideal. He comes in now with a history of having developed an increasing PSA level, which subsequently led to Dr. Hayes performing a prostate biopsy in the middle of January. He subsequently developed a fever and was treated initially with Cipro, and was resistant to that, and then eventually a variety of different antibiotics. He developed epididymitis, and he also had gross hematuria at times. He had an intervening sinus infection, and subsequent cystoscopy during the first quarter of this year. Initially a CT scan had suggested a possible tumor in the bladder but then nothing was found there, and it was felt to be a shadow created by his very large prostate gland. He also had upper endoscopy as he has had some reflux symptoms from time to time, and lower endoscopy with several small benign polyps biopsied. Paul has finally gotten over this period, but during the first three months of this year he was very sketchy on taking his Lipitor 40 mg, Zetia 10 mg, TriCot 145 mg, and Lovaza 1000 mg x4. He tried the Niaspan but it caused so much flushing he could not stay on that one at all. He is back to playing tennis now vigorously, and denies any effort-induced chest, arm, neck, or jaw discomfort. At times there might be a little exertional dyspnea. He has had some subtle rare edema. He has had no orthopnea or PND. He denies palpitations.

EAOUSAFOIA0000544

Case l:10-cr-OO286-TSE Document30-9 Filed 12/13/10 Page24of59

Kerri Kustra, M.D. RE: Paul Maglioeehetti

May 20, 2008 Page Two

Review of systems reveals occasional GEKD. He denies melena or hematoehezia. He has had no recurrent hematuria. He has some mild arthralgias. There is no localized weakness. On exam, his blood pressure is 146/88. His pulse is 70. Carotids are 2+ without bruits. Neck veins are not distended. Thyroid tissue is not palpable. His chest is clear. He has a sinus rhythm. There is an atrial gallop and a faint systolic murmur at the base. The abdomen is soft. Liver and spleen are not palpable. There are no masses or tenderness. He has good pedal pulses and no edema. Neurologic examination is grossly unremarkable. His EKG shows some minor nonspecific T-wave abnormalities. On May 5, 2008 with intermittent use of all cholesterol drugs but completely offofthe Niaspan his total cholesterol was 182, up from 149 in November of 2007. Tfiglycerides are now 133, down a little from 141. HDL is 39, down from 41. LDL is 116 now, up from 80. The small LDL is still elevated, putting him in about the 70th percentile of MESA. LDL particle density increased from I520 in November of 2007 to 1672, which is high. AST was normal at 40 units, and ALT mildly elevated at 50 units, top normal 45 units. His current list of medications includes Lipitor 40 mg, Zetia 10 rag, Lovaza 1000 mg x4, and TriCor 145 rag. All of this has been very sketchy in the first quarter of this year and leading up to this latest NMR study. He is offofthe niacin entirely. He does take Cardizem CD 180 mg one day-ggL12,0 mg the next day, but that actually may be 240 mg one day and 180 mg the next, and we need to cheek that on his next visit. He takes Hyzaar 100/25 mg every a.m., aspirin 81 rag, and occasional Claritin or Afrin nasal spray. ~ ..~to,~ ~ / ra,~, At this point I have discontinued the Lipitor and in hs place put him on Crestor 20 rag. I have added back Zetia, and we had a long discussion about the ENHANCE trial. He will continue Lovaza taking four of the 1000 mg capsules, but he will stay offof TriCor and Niaspan for now. He is aware that he needs to cut back on simple carbohydrates, and he has made some improvements in lessening the pasta but still does eat a fair amount. I would like him to get some more blood pressure readings to make sure his pressures are a little lower. I am going to see him again in September rather than going six months, and two weeks before that visit he will redo his NMR study. Probably before the end of the year or else next spring I am going to repeat a nuclear study on Paul. If there is any change in his symptoms I will eertairdy see him sooner. Best regards,

Robert G. Mat-thews, M.D., F.A.C.C. RGM:cc

EAOUSAFOIA0000545

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 25 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003 PHONE (?03) 5?3"2045 FAX (703) 573"O760

CARDIOVASCULAR MED|CIN E

November 15, 2007 James W. Turner, Jr,, M.D. 2942 Hunter Mill Road Suite 102 Oakton, Virginia 22124-1762 RE: Paul Magliocchetti
Dear Jim,

Paul came in for a follow-up visit. He was unable to tolerate the water soluble niacin. He did get from one of the nutrition stores the flush-free niacin and is on 1000 mg q.d. Unfortunately, it is a metabolite of niacin and while it does not cause flushing, it also has no significant effect on our lipids. Paul was horseback riding a little over a month ago outside of Seottsdale and the synch came loose on his saddle. He subsequently was bucked off of the horse and landed on his backside. He still has some discomfort in that area and has not been playing tennis since. He denies any effortrelated chest, arm, neck, or jaw discomfort. There is some subtle exertional dyspnea but no ankle edema, orthopnea, or PND and no palpitations. Review of systems reveals no particular abdominal upset, rare GERD, and no melena. Other than the back discomfort he has not been troubled by a lot of arthralgias. He has had no localized weakness. I first started to see Paul in 1999 when he came in with a six to eight-month history of some angina. Cardiac catheterization on December 30, 1999 showed moderate calcification in the proximal left anterior descending and a smooth short left main without any significant narrowing. The left anterior descending gave offa first diagonal and 3-4 mm beyond that there was a smooth tubular 30% LAD block. The LAD itself was a fairly large vessel and wrapped around the apex. The circumflex gave off a large first marginal and then a second smaller marginal. The second smaller marginal was moderate in size with a 50% smooth tubular narrowing as it separated from the cireurnflex. The circumflex ended as a smaller third marginal which barely left the atrioventricular groove. The right coronary was fairly dominant. In the proximal third there was a smooth tubular narrowing blocking the vessel by 20%. The mid-right, however, had a discrete 85-90% obstruction. There was a fairly large posterior descending and a smaller posterior lateral left ventricular branch. There was an anomalous origin of an acute marginal coming offabove the origin of the true native right coronary. He had normal ventricular function with an ejection fraction of 70%. On January 3, 2007, Kevin and I placed a 3.0 x 13 mm long ACS Tristar stent in the mid-right coronary with no residual stenosis at eighteen atmospheres post stent placement.

EAOUSAFOIA0000546

Case 1:10-cr-OO286-TSE Document30-9 Filed 12/13/10 Page26 of 59

James W. Turner, Jr., M.D. RE: Paul Magliocchetti

November 15, 2007 Page Two

His current medications are Lovaza 1000 mg x4, non-flush niacin 1000 mg, Zetia 10 rag, Lipitor 40 mg q.d., TriCor 145 mg q.d., and Cardizem CD 180 mg q.d. He had some difficulty with some sexual dysfunction on the 240 mg size in the past. He is also on Hyzaar 100/25 mg q.a.m., aspirin 81 mg, and occasional Claritin and Afrin nasal spray. On examination, his blood pressure is 150/104. It is a very rainy morning in Washington and traffic was just miserable and Paul was upset. Carotids are 2+ without bruits and the neck veins are not distended. Thyroid is not palpable and the chest is dear. He has a sinus rhythin. There is no murmur. Abdomen is soft. Liver and spleen are not palpable, with no masses or tenderness. He had good pedal pulses and no edema. Neurologie exam is grossly unremarkable and his resting EKG is normal with minor nonspecific T-waves less evident now compared to last August. His NMR on November 5, 2007, revealed a total cholesterol of 149, triglyeerides of 141, HDL of 41 and LDL of S0. Small LDL put him in the 73rd percentile of the small LDL particle class in the MESA trial. LDL particle density was elevated at 1520 nmol/L. I have asked him to try the new configuration of Niaspan, which is supposed to cause less flushing, 500 mg q.d.. for the first month after dinner or at bedtime and with Benadryl two tablets. After the first month, add a second Niaspan. If he needs to, he can take one early in the day and one late in the day. Once he gets to two a day, I have written out for him to discontinue the TriCot. In four months he will return for a visit and two weeks before that, repeat his NMR. Best regards,

.)

Robert G. Matthews, M.D., F.A.C.C.

RGM:dl

EAOUSAFOIA0000547

Case 1:10-cr-00286-TSE Document30-9 Filed 12/13/10 Page27 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003 PHONE (703) 573"2045 FAX (703) 573"0760

CARDIOVASCULAR MEDICI NE

Augustl, 2007

James W. Turner, Jr., M.D. 2942 Hunter Mill Road Suite 102 Oakton, Virginia 22124-1762
RE: Paul Magliocchetti

Dear Jim,
Paul came in for a follow-up visit. He continues to have a very busy schedule. He does go down to Florida where he and his wife have a home there. They do have a tennis pro that instructs them, and usually by the end of the week they are doing very well. He also will easily walk four miles a day. He denies any effort-induced chest, arm, neck, or jaw discomfort. He is seven and one-half years post stenting of the right coronary artery.

I first started to see him in late 1999 when he presented with a six to eight month history of angina. At cardiac catheterization he had a short smooth left main on December 30, 1999 with moderate calcification in the proximal left anterior descending. There was no narrowing in the left main. The left anterior descending gave offa fairly decent first diagonal, and 3 mm to 4 mm beyond that he had a smooth tubular 30% block. The left anterior descending was quite a large vessel and went to and wrapped around the apex. The circumflex gave offa large first marginal, and then a second smaller marginal. The second smaller marginal was just moderate in size with a 50% smooth tubular narrowing as it separated from the circumflex. The circumflex then ended as a smaller third marginal which barely exited the atrial ventricular groove. The right coronary was fairly dominant. At the proximal one-third there was smooth tubular narrowing of a 20% nature. In the mid right coronary there was a discrete 85% to 90% block. There was a fairly large posterior descending and also a smaller posterolateral left ventricular branch. There was an anomalous origin of an acute marginal coming off above the origin of the true native right coronary. He had normal ventrieular function with an estimated ejection fraction of 70%. On January 3, 2000 Kevin and I placed a 3.0 mm x 13 mm long ACS Tristar stent in the mid right with no residual stenosis at 1 g atmospheres of post stent placement. Paul denies any effort-related chest, arm, neck, or jaw discomfort. He has not been unusually breathless but sometimes rushing up stairs when he has been relaxed for a while he has some subtle dyspnea. He has no ankle edema, orthopnea, or PND, and no palpitations or tachyarrhythmias.

EAOUSAFOIA0000548

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 28 of 59

James W. Turner, Jr., M.D. RE: Paul Magliocchetti

August 1, 2007 Page Two

Review of systems reveals that Paul has had a history of significant acid reflux, which is provoked at times by pasta with spaghetti sauce and red wine. As long as he takes Protonix 40 mg he is not bothered by it. He has had no melena or hematochezia. He has minor arthralgias. There is no localized weakness or numbness. His current medications are Omaeor 1000 mg x 3, Lipitor 40 mg q.d., Zetia 10 mg q.d., TriCor 145 mg q.d., Cardizem CD 180 mg q.d., Hyzaar 100/25 rng every a.m., aspirin 81 mg, an occasional Claritin, and Afrin nasal spray. It should be noted that he was on Niaspan several years ago but could not get beyond two tablets a day, and did have considerable flushing with prolonged flushing and itching sometimes, and that was discontinued. On exam, his blood pressure is 144/86. Paul was rushing before getting here today. He is a welldeveloped, well-nourished man. There is no xanthelasma. Carotids are 2+ with no bruits or delay in upstroke. Neck veins are not distended. Thyroid is not palpable. The chest is clear. He has a sinus rhythm. There is no murmur or gallop. The abdomen is a little bit obese without palpable liver or spleen edge. There are no masses or tenderness. He has excellent pedal pulses and no edema. Neurologic examination is grossly unremarkable. EKG shows some nonspecifie T-wave abnormalities.
His NMR study on July 11, 2007 revealed a total cholesterol of 169, triglycerides of 137, HDL of 38, and LDL of 104. The small LDL put him in about the 71st percentile, down a little bit from February of 2007 but still not where Paul should be. Paul is trying to improve his diet, but he does eat a lot of pasta and bread. He has tried to go to sorbets instead of regular desserts.

At this point I have suggested he increase the Omacor to four capsules per day. I am going to try him on water soluble crystalline quick release tablets. While it has a tendency to cause a little more flushing initially, it is relatively brief. I suggested that for the first three weeks he take omtablet with a plain aspirin and with dinner, and after three weeks to add a second tablet with breakfast and a plain aspirin. Once he has the second he will discontinue the TriCor. In early October he will redo his NMR study and see me the third week of October. I did discuss with Paul that diet really does make a big difference with this kind of a lipid problem. He has a genetic issue where he has combined hyperlipidemia with a low HDL syndrome. It is a very difficult one to treat, but I would like to at least try the niacin again to see if he can tolerate this. I did write out Rugby or Major brand to get for his attempt.

EAOUSAFOIA0000549

Case 110-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 29 of 59

James W. Turner, Jr., M.D. RE: Paul Magliocchetti

August 1, 2007 Page Three

We are a little over one year since his last nuclear scan, which was normal. He is very physically active and not having angina, so I think we can wait another year. Best regards,

Robert G. Matthews, M.D., F.A.C.C. RGM:c

EAOUSAFOIA0000550

Case 110-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 30 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, V{RGINIA 22003 PHONE (703} 5?3-2045 FAX (703) 573-0760

CARDIOVASCULAR MEDICINE

March 7, 2007

James W. Turner, Jr., M.D. 2942 Hunter Mill Road Suite 102 Oakton, Virginia 22124-1762 RE: Paul Magliocchetti

Dear Jim,
Paul returned for a follow-up visit. He continues to be very active, spending the weekends in Florida where he can typically play tennis for one to two hours on a daily basis. He and his wife also ride bikes, and it is not uncommon for them to ride up and down the path to Mount Vernon and back through Old Town and Arlington on a weekend. That is about thirty-two miles. Down in Florida they typically will walk two and one-half miles to a store and then walk back two and one-half miles after they have had a light lunch. Paul denies any effort-related chest, arm, or neck diseomfort but did have stenting of a right coronary artery in 2000 using a 3 mmx 13 mm long stent to the mid right coronary on January 3, 2007. He does have some subtle exertional dyspnea if he is rushing up six flights in a commercial building where his office is. He has no ankle edema, sleeps on one pillow behind his head, and has no PND. He denies palpitations or tachyarrhythraias.

Review of systems reveals that he does get some indigestion and occasional reflux symptoms which are generally well controlled with generic Prilosec 10 rng q.d. There has been no recent water brash. He denies melena or hematochezia. He has very minor joint aches. There is no localized weakness or numbness.
His current medications are Lipitor 20 mg q.d., Zetia 10 mg q.d., TriCot 145 mg q.d., Omaeor 1000 mg two q.d., Cardizem CD 180 rag, Hyzaar 100/25 mg every a.m., aspirin 81 rag, and an occasional Claritin-D. He did take some Afrin nose spray before this visit.

On exam, his blood pressure is 130/86. His pulse is 70 without ectopy. He is a well-developed, muscular man. There is no xanthelasma. Carotids are 2+ with no bruits or delay in upstroke. Neck veins are not distended. Thyroid tissue is not palpable. His chest is clear. He has a sinus rhythm without a murmur or gallop. Abdomen is soft without palpable liver or spleen edge. There are no masses or tenderness. He has excellent pedal pulses and no edema. Neurologic examination is grossly unremarkable. His resting EKG is normal.

EAOUSAFOIA0000551

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 31 of 59

James W. Turner, Jr., M.D. RE: Paul Magliocchetti

March 7, 2007 Page Two

His NMR profile on February 20, 2007 revealed a total cholesterol of 167, down from 172 on October 5, 2006 before the addition of Omacor and TriCor. His triglycerides are now 157, down from 288. His HDL was 43 and it dropped to 41. LDL rose from 71 in October of 2006 to 95. The small dense LDL subclass did drop a little bit but is still higher than it should be in the 77th percentile of the MESA study. LDL particle density dropped from 1752 nmol!L to 1549 nmol/L, which remains borderline high. His AST was normal at 39, but the ALT was mildly elevated at 52 with top normal of 45 units. I suspect he may have a fatty liver.
At this point I have increased the Lipitor to 40 mg and the Omacor to three capsules per day. In mid July he will redo his NMR profile and see me in early August. He did try Niaspan but he had an awful lot of flushing and itching, sometimes for many hours from the time he actually took the dose, which is not unusual for a sustained release tablet.

Best regards,

Robert G. Matthews, M.D., F.A.C.C.


RGM:cc

EAOUSAFOIA0000552

Case 1:10-cr-OO286-TSE Document30-9 Filed 12/13/10 Page 32 of 59

3299 WOODBURN ROAD, SUITE 200 ANNANDALE, VIRGINIA 22003


PHONE (703) 573-2045 * FAX (703) 573-0760

CARDIOVASCULAR MEDICINE

November 2, 2006 James W. Turner, Jr., M.D. 2942 Hunter Mill Road Suite 102 Oakton, Virginia 22124-1762 RE: Paul Magliochetti Dear Jim, Paul returned for his follow-up visit. You should already have a copy of the normal nuclear scan we did earlier in the summer. As you know, he does a great deal of walking. He will often walk for two and one-half to three hours on weekends. He has not played tennis in about two months but plans to get back to some of that. He denies any effort-related chest, arm, neck, or jaw discomfort. He does notice some exertional dyspnea when he is rushing up some steps to his condominium. However, he has had no ankle edema, orthopnea, or PND. He denies palpitations or tachyarrhythmias. Review of systems reveals he denies abdominal upset but does get GERD. He relates a lot of this to pasta and spicy food. He denies melena or hematochezia. His liver function was slightly abnormal in April of 2006, and again when repeated here on October 5, 2006. His ALT was 82 with top normal 45. AST was 45 with top normal 43. In April of 2006 his ALT was 77 and AST 56. Paul does enjoy wine and believes that could be an explanation for these subtle abnormalities. He has on occasion had slight elevation in the past. He denies any significant arthritis. He did bump his left elbow against the door in the past couple of weeks and has what looks like some inflammation in the bursa. He is going to see an orthopaedist today. Otherwise there is not any significant arthritis. He denies localized weakness or numbness. He has had some problems with erectile dysfunction since I increased his Cardizem from 180 mg to 240 rag. He continues on Lipitor 20 mg q.d., Zetia 10 mg q.d., Protonix 40 mg q.d., Hyzaar 100/25 mg q.d., aspirin 81 rag, and he has been taking Claritin-D recently. On exam, his blood pressure is 136/86. He is a well-developed, welt-nourished man. There is no xanthelasma. The carotids are 2+ with no bruits or neck vein distention. Thyroid is not palpable. Chest is clear. He has a sinus rhythm with no murmur or gallop. The abdomen is soft without palpable liver or spleen edge. There are no masses or tenderness. He has excellent pedal pulses and no edema. Neurologic examination is grossly unremarkable. His resting EKG is normal.

EAOUSAFOIA0000553

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 33 of 59

James W. Turner, Jr., M.D. RE: Paul Magliochetti

November 2, 2006 Page Two

As yo~u recall, he had a 3 mm x 13 mm long stent placed in the mid right coronary on January 3, 2000. He does have a significant dyslipoproteinemia and the metabolic syndrome. Onhis recent LipoProfile NMR pattern on October 5, 2006 his total cholesterol was 172, triglycerides 288, HDL 43, and LDL 71. The small dense LDL subclass was substantially elevated putting him in about the 88th percentile and at a higher independent risk for a vascular event. LDL particle densi~ was likewise elevated at 1752 nmol/L which puts him in a higher risk category. I have reviewed all of this with Paul today, He is eating a lot of pasta and simple carbohydrates, as well as consuming a fair amount of wine according to Paul. He also eats a lot of desserts. We have discussed how triglycerides are formed and the importance to get these numbers substantially lower. His insurance company would~ot honor the prescription I wrote for Omaeor on his last visit. I have rewritten that to take two capsules q.d. If necessary Paul stated he would just try to purchase it himself. In addition, I have started TriCor 145 mg q.d. In late January we will redo .the NMR. profile, AST, ALT, and Lp(a), and I will see him in mid February. I did, however, give him a request to do a hepatic panel in the next several weeks and to call me one week after that. I am concerned about this lipid pattern. We do have to make some very major changes with Pauls diet. His divorce was recently finalized, and I am sure that added stress has probably been some problem for him and hopefully that is in the past and he will be able to move forward in doing some more aggressive prevention at this point. Best regards,

Robert G. Matthews, M.D., F.A.C.C.


RGM:cc

EAOUSAFOIA0000554

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 34 of 59

ROBERT G. MATTHEWS, M.D., F.A.C.C. CARDIAC CONSULTATION PATIENT: Paul Magliocchetti AGE: 59 REFERRING PHYSICIAN: James W. Turner, Jr., M.D. DATE: June 9, 2006 CHIEF COMPLAINT: The patient is here for reevaluation of vascular disease, high cholesterol, and history of hypertension. He had a prior stent placed to the right coronary artery on January 3, 2000. HISTORY OF PRESENT ILLNESS: Mr. Magliocchetti is an excellent historian. His risk factors for vascular disease besides age include a history of a dyslipoproteinemia. He has had a combined hyperlipidemia associated with a low HDL syndrome. He does enjoy pasta but has been trying to cut down on the portion of pasta that he eats. He has avoided white bread now, but he does enjoy red wine. His last LipoScience test done in April of 2003 revealed normal liver enzymes, total cholesterol of 174, LDL of 113, HDL of 33, and triglycerides of 200. He was on Lipitor 30 mg q.d. I subsequently in September of 2003 decreased the Lipitor from 30 mg to 20 mg and added 10 mg of Zetia. We also had him on Niaspan. He was taking just one q.d., but he would awaken at times even with that feeling itchy and uncomfortable, and would be red during the day. When he got to 1000 mg he was fairly uncomfortable. I have not seen him since September 22, 2003. His most recent LipoScience test now on the above change made three years ago revealed on April 13, 2006 a total cholesterol of 164, triglyeerides of 186, HDL of 37, and LDL of 90. The small dense LDL subclass did improve with this change, dropping from about the 92rid percentile to about the 72nd percentile. His ALT was a little high at 77 with top normal of 45, and AST high at 56 with top normal of 43. His LDL particle concentration was 1488 nmol/L. He has had a history of hypertension, and he does monitor it on occasion with the systolics typically in the mid 120s and diastolies 80 to 85, but usually" not checked under an immediate stressful situation but sometimes twenty or thirty minutes after playing termis. He had smoked a rare cigar, but never a cigarette and actually has stopped the cigars in the past couple of years. He has not been diabetic but his maternal grandmother in her eighties was diabetic. His father died in his late seventies of lung cancer related to asbestos exposure. His mother died after twenty years in a nursing home with some dementia. She was in her late seventies. He has one sister who is fiftyfive who has had breast cancer but has otherwise been healthy. Generally therc has been fairly good longevity with aunts and uncles on the maternal side, living well into their seventies and one uncle to eighty-nine. The uncle actually when he was eight-y-seven walked to a hospital with chest pain and then a heart attack, and had angioplasty.

EAOUSAFOIA0000555

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 35 of 59

Cardiac Consultation RE: Paul Magliocchetti

June 9, 2006 Page Two

HISTORY OF PRESENT ILLNESS (continued): The patients current weight is 180 to 185 pounds. He has a very routine habit of exercise, playing tennis sometimes for several hours at a time, racquetball for one hour, and he and his significant other will often walk fifteen-minute miles for one to two hours at a time. They can easily cover seven miles on a comfortable walk. During the past two winters he has been involved in doing some snowshoe exercise often for three or four hours at a time. One winter in the recent past he got a snowraobile stuck at 15,000 feet and he had to help pull it out. He was quite short of breath at the time. The patient was seen by me in October of 1999 with a six-month history of some exertional dyspnea. On occasion he felt a slight pressure or tightness in his chest but it was not as characteristic as the exertional dyspnea. He had a treadmill test which was abnormal, and we pursued cardiac catheterization. That study revealed a dominant right coronary artery with a 90 to 95% block in the mid portion of the vessel. He had a smooth left main without narrowing, and moderate calcification in the proximal left anterior descending. The LAD gave off a decent diagonal, and 3 mm to 4 mm beyond that had a smooth tubular 30% block best appreciated in the craniocaudal left anterior oblique view. The left anterior descending was quite a large vessel which wrapped around the apex. The circumflex gave off a large first marginal, and then a second smaller marginal. The second smaller marginal was moderate in size with a 50% smooth tubular narrowing as it separated from the circumflex. The circumflex then ended as a smaller third marginal which barely exited the atfioventricular groove. The right coronary was. fairly dominant with a proximal smooth tubular narrowing of about 20%, and the mid portion was the 90 to 95% obstruction. There was a fairly large posterior descending and a smaller posterolateral left ventricular branch. He also had an anomalous origin of an acute marginal branch coming off above the origin of the true native right coronary artery. He had normal ventricular function with an ejection fraction of 70%. On January 3, 2000 he had a 3 mm x 13 mm long stent positioned in the mid fight coronary artery. He had a normal stress dual .isotope study done on January 6, 2003 with normal wall motion and an ejection fraction of 53%. That was his last study. He has noted some shortness of breath on occasion rushing up stairs. If he climbs three flights, then climbing a fourth flight he might be a little bit dyspneic at the top. In a commercial building rushing up six flights causes a little shortness of breath. He is not sure if this symptom has actually worsened in the past several years. He denies ankle edema, orthopnea, or PND. He denies effort-induced chest, arm, neck, or jaw discomfort. He denies palpitations, tachyarrhythmias, or lightheadedness. He has a home in Florida where he is trying to spend more time, and he is very physically active there often playing tennis for several hours at a rime. PAST MEDICAL I-IISTORY: The usual childhood diseases. MAJOR ILLNESSES: Combined hypeflipidemia with a low HDL syndrome, hypertension, atherosclerotic cardiovascular disease, plantar faseiitis, GERD, and some mild arthralgias. He had some tendinitis in an Achilles tendon.

EAOUSAFOIA0000556

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 36 of 59

Cardiac Consultation RE: Paul Maglioechetti

June 9, 2006 Page Three

MEDICATIONS: Currently Lipitor 20 mg q.d., Zetia 10 mg q.d., he is off ofNiaspan, Protonix 40 mg q.d., Cartia XT 180 mg q.d., Hyzaar 100/25 mg q.d., aspirin 81 rag, and he takes something for anxiety. DRUG ALLERGIES: He was sensitive to tetanus on skin testing.

OPERATIONS: He had a stent placed to the dominant right coronary on January 3, 2000, tonsillectomy and adenoidectomy, and he has had three lipomas removed.
ACCIDENTS: He was helping an individual change her fire at the side of a road in 1982 when he was struck from behind by a drunk driver. He broke five transverse processes on five vertebrae. He does get intermittent discomfort. REVIEW OF SYSTEMS: HEENT: He is not troubled with headaches. His vision has been correctable with LASIK eye surgery. His hearing is good. GI: He has no dear history of a peptic ulcer but does get reflux, although with the Protonix it is really relatively rare. He denies recent abdominal pain, diverticular disease, melena, or hematochezia. GU: He has no history of kidney stones, kidney or bladder infections. His PSA was a little above 4.0 during the past year, and he saw a urologist and was felt to be okay. The plan was to do a free PSA level on the next occasion. Bone and Joint: He has some back discomfort on occasion. Neuromuscular: There is no localized weakness or numbness. He does use a roller on his right foot for the plantar fasciitis, and stretches it out which helps him a lot.

SOCIAL HISTORY: He is divorced. He has a son, thirty, who works in his business, and a daughter, twenty-eight, who works with the Yankees at their training camp in Tampa and has been with them for seven years. The patient has his own company which helps private industry interact with the federal government. He employs around fifty people now. It is very stressful at times. He is trying to slowly get away from the company and is trying to work just three days fight now. He enjoys travel. He usually has one or at the most two cups of coffee a day. He enjoys wine. He and his significant other, Becky DeRosa, who is also a patient of mine, will share a bottle of wine in the evening. He is getting ready to spend one month in Italy this August. He enjoys the snowshoe exercise but also is routine in his habits with racquetball, tennis, and walking. PHYSICAL EXAMINATION: His blood pressure initially right after he had received a phone call was 146/90. Within two minutes as he just relaxed it dropped to 130/86. He is a well-developed, well-nourished man. There is no xanthelasma. Carotids are 2+ with no bruits or delay in upstroke. His neck veins are not distended. Thyroid tissue is not palpable. His chest is clear. He has a sinus rhythm with no murmur or gallop. The abdomen is soft. Liver and spleen are not palpable. There are no masses or tenderness. He has excellent pedal pulses and no ankle edema. Neurologic examination is grossly unremarkable. Resting EKG is within normal limits.

EAOUSAFOIA0000557

Case 1:10-cr-OO286-TSE Document30-9 Filed 12/13/10 Page 37 of 59

Cardiac Consultation R.E: Paul Magliocchetti


IMPRESSION: 1. 2.

June 9, 2006 Page Four


Combined hyperlipidemia with a low HDL syndrome. Atherosclerotie cardiovascular disease with prior history of angina in the last half of 1999. Exertional dyspnea. In part that was a symptom that he had when he had a 90 to 95% dominant right coronary stenosis in 1999. Still elevated in the small dense LDL particle subclass, although his numbers have improved in the last three years. Hypertension. I suspect it is still somewhat labile. History of a 3 mm x 13 mm long stem placed to the mid right coronary on January 3, 2000 with a normal nuclear scan after that, and a normal nuclear scan in 2003. Plantar fasciitis of the right foot. He has a history of some Achilles inflammation in the past. GERD, infrequent at the present time. Some mild arthralgias in his back from an old injury. Abnormal liver function, subtle, perhaps related to a mild fatty liver.

9. 10.
DISPOSITION:

2. 3. 4. 5. 6. 7.

Hepatic panel with a copy to the patient. He will call us one week later for the results. Continue Lipitor 20 me, Zetia 10 me, and add Omacor 1000 mg two capsules q.d. He will try to moderate simple carbohydrate intake, which is feeding the triglyeeride level. We will plan to repeat his LipoScience test, AST, and ALT in early September, followed by an office visit towards the end of September. We are going to pursue a stress dual isotope. Increase the Cartia XT to 240 mg q.d. because of his hypertension. I indicated that I would prefer he did not do the real heavy sudden strenuous exercise that he did at 15,000 feet last winter, although it would be very difficult for him to extricate himself from that problem without some exertion. He was reluctant to want to try Niaspan again. They may be out with a lower flush version sometime later this year, and we could try that with him.

Robert G. Mat-thews, M.D., F.A.C.C.


cc: James W. Turner, Jr., M.D. RGM:cc

EAOUSAFOIA0000558

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 38 of 59 Robert 6. Matthews, M.D., F.A.C.C. CARDIAC CONSULTATION PATIENT: MAGLIOCCHETTI, PAUL AGE: 56 BATE: January 3, 2003 REFERRING PHYSICIAN: J. TURNER, M.D.

CHIEF COMPLAINT: 3 years today post stent placement to the right coronary artery, here for reevaluation. Recent episode of hypertension while in Florida this past November of a reading of 160/102 after a very stressful day.
HISTORY OF PRESENT ILLNESS: Mr. Magliocchetti was seen in October 1999 with a 6 month history of some exertional dyspnea. At times, he felt a very slight pressure or tightness in the chest but it was not as characteristic as the shortness of breath. He had been a routine exerciser, playing tennis in an aggressive fashion for some years, racquetball as well as using an elliptical trainer and various weight machines. Six months leading to that evaluation, he had developed the shortness of breath which was somewhat unusual along with occasional episodes of mild tightness. A treadmill test was abnormal. We discussed the possibility of proceeding with a stress dual isotope vs a cardiac cath. On January 3, he did undergo a cardiac catheterization. This study showed a dominant right coronary with a 95% obstruction of the mid portion of the vessel. This was subsequently stented with a TriStar 3.0 x 13m m long stent with a very good result. It should be noted there was some smooth tubular narrowing above the area that was stented and above the acute marginal branch compromising the vessel by 20-30~. The lesion was 4-5 mm below the takeoff of that acute marginal branch which was used as a guide in placing the stent. The patient did experience some mild burning and slight discomfort several times during the procedure. The right coronary was dominant with relatively mild plaques in his left system. On May 9, he underwent a stress thallium test getting halfway through stage V of a Bruce protocol at a rate of 159. On this occasion, he had no chest discomfort, ectopy, and no ischemic ST depression and the treadmill portion was normal as was the nuclear scan which showed no evidence of ischemia. The patient has not been seen in the office actually since following the stent procedure. He has remained physically active. He continues to play racquetball when he is up here. About every 2 weeks he will go and spend a weekend in Florida, which he is planning to do, where he has a place there and he plays tennis for 2 hours twice a day. Here he does a great deal of walking and also goes to a gym, uses various weights as well as playing racquetball.

He has felt well until November when, after a very stressful business day, and drinking more coffee than what he usually drank, he felt very shaky, was somewhat flushed and his blood pressure was 160/102. Dr. Turner subsequently increased the Hyzaar from 50 to IO0 mg q.d. and with that his blood pressure has dropped into the 110s over the mid 70s. In addition, he has gained weight, currently up closer to 190 although with the flu over the Thanksgiving period, he is down now to about 185. He finds his blood pressure is a direct correlation with his weight. He denies any effort induced chest, arm, neck, or jaw discomfort. He denies any unusual dyspnea, can play vigorously. Sometimes if he runs too fast for a ball, he may be just momentarily out of breath but no symptoms similar to what he had prior to the angioplasty of the right coronary 3 years ago today. He denies ankle edema, orthopnea, or PND. He is not really aware of palpitations except rarely maybe once a month just a few extra beats. No sudden tachyarrhythmias. No syncope, near syncope, no diaphoresis. Risk factors: He never smoked cigarettes. He smokes an occasional cigar. Cholesterol has been high at times and is high recently.

EAOUSAFOIA0000559

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 39 of 59 Page Two MAGLIOCCHETTI, PAUL

i/3/o3

On November 25, his total cholesterol was 187, LDL 120, HDL 46, triglycerides 138. Of interest is that his large HDL is 15, which is below the average and the small, atherogenic HDL fraction puts him in the 95th percentile. Small dense LDL particles put him in the 55% percentile. His VLDL was relatively low at 8. His LDL particle size places him just barely into a pattern A category. He does eat out and enjoys having a glass of wine and enjoys eating out which he does fairly often. He has always been a very physically active man. No history of diabetes. He has had hypertension for some time. No substantial family history of vascular disease. PAST MEDICAL HISTORY: Reveals the usual childhood diseases plus scarlet fever. MAJOR ILLNESSES: Atherosclerotic cardiovascular disease. Hypertension. Hypercholesterolemia. Some inflammation of his Achilles tendon noted by a trainer there in Florida. GERD. Intermittent mild back discomfort. ACCIDENTS: In 1982 while helping an individual change her tire on the side of the road, he was struck from behind by a drunk driver and broke the transverse processes of 5 vertebrae. He does experience intermittent back discomfort. OPEPJ~TIONS: Stent 3 years ago today to the mid right coronary 3.0 x 13 mm stent. Tonsillectomy and adenoidectomy. 3 lipomas removed. ALLERGIES:
Tetanus by skin test.

MEDICATIONS: Lipitor 20 mg q.d., Hyzaar 100/25 q.am., Cardizem CD 180 mg q.d., an aspirin, niacin 500 mg b.i.d. He is unable to tolerate a higher dose. Variety of vitamins. Prilosec 20 mg q.d. REVIEW OF SYSTEMS: HEENT: He is not troubled by headaches. He wears one contact which corrects his vision. Hearing is good. GI: Years ago, he thought he may have had an ulcer. It has never been clearly diagnosed. He does have GERD and does get occasional reflux but with Prilosec 20 mg q.d. he has no problems with reflux. No melena or hematochezia. GU: No history of kidney stones, kidney or bladder infections. PSA level has slightly elevated. He saw Dr. Chung and was told everything was okay. Bone and joint: He does have on rainy days the reminder of his spinal injuries from 1982. Neuromuscular: No history of localized weakness or numbness. He has had doppler of his Achilles and they were concerned that there was some inflammation there. He felt that he needed to do more stretching. No real myalgias. SOCIAL HISTORY: His wife is 54 and healthy. She is receiving some treatment for anxiety. He has 2 children, a son 27, a daughter 25 who works for the Yankees. He has his own business which helps private industry interact with the federal government. He employs 40 people. He has been trying to develop a successor. This fell through during the past year and was the cause of some of his recent stress. He relaxes by playing tennis which is often with his son and very competitive. He enjoys racquetball and exercise and he loves to travel. This past July he spent 5 days in San Francisco and the Napa Valley. He used to drink a fair amount of caffeine but after the event in November where he had some very strong Ethiopian coffee that actually caused a slight tremor, he has switched to decaffeinated coffee, some tea, maybe a cup a day of regular coffee. He may have wine with dinner. Every other week nd he does go and spend time in his place in Florida which he finds very relaxing.

EAOUSAFOIA0000560

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 40 of 59 Page Three MAGLIOCCHETTI, PAUL I/3/03 PHYSICAL EXAMINATION: His blood pressure was 130-132/74-76 in both arms. He is a we11-developed, well-nourished muscular man just mildly obese. No distress. There is no arcus senilis. There are no xanthelasma around the eyelids. Carotids are 2+ without audible bruits. Neck veins are not distended. The thyroid tissue is not palpable. Chest is entirely clear. He has a normal sinus rhythm. There is no murmur or gallop. Abdomen is soft. Liver and spleen are not palpable. No masses felt and no tenderness elicited. He had excellent pedal pulses and no ankle edema. No tenderness of his Achilles. Resting EKG is normal. IMPRESSION: 1. Atherosclerotic cardiovascular.disease. No symptoms of recurrent angina. 2. 3 years ago today 3 mm x 13 mm stent to the mid right coronary for a 95% stenosis, some proximal 20-30% disease in the right coronary. 3. Cholesterol is not yet at target. 4. Recent hypertension resolved with increasing his Hyzaar. 5. I suspect he does have some Achilles inflammation as his trainer had suggested. I dont think he is having any side effects from the Lipitor. I. We did discuss his lipoproteinprofile. He accordingly will increase the Lipitor to 30 mg q.d. If he cant break them in half, he will try to get three 10 mg tablets q.d. from his pharmacist. 2. He has a stress dual isotope scheduled for Monday. If that looks satisfactory, I would certainly encourage his continued active exercise program. A 10 pound weight loss would probably bring his cholesterol also down close to 160 which I feel is where he should be below 160 and LDL below 90, preferably below 80. If necessary we could increase the Lipitor or perhaps add one of the newer medications. 3. I have given him a slip to repeat a NMR lipid profile, AST, ALT end of March with an office visit here at the end of April.

DISPOSITION:

Robert G. Mat/thews, M.D.,-F.A.C.~./" / RGM/acw cc: James Turner, M.D.

EAOUSAFOIA0000561

Case 110-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 41 of 59

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Case 110-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 42 of 59

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Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 48 of 59

EAOUSAFOIA0000569

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 49 of 59

Robert G. Matthews, M.D., F.A.CC., C.B.N.C., Ltc


3299 Woodburn Road Suite 200 Annandale, VA 22003 Phone (703) 573-2045 Fax (703) 573-0760

DUAL ISOTOPE PROTOCOL USING STRESS GATED SPECT MYOVIEW/REST SPECT THALLIUM

RE: MAGLIOCCHETTI, PAUL REFERRING PHYSICIAN: DR. J. TUP,.NER RENDERING PHYSICIAN: DR. R, MATTHEWS TEST DATE: 06/13/06
MYOVIEWfrHALLIUM PERFUSION STUDY:

Procedure: The patient was injected with 3 mCi of thallium and SPECT imaging was begun 15 minutes post injection. The camera obtained images with a 180-degree orbit around the patients heart. After the rest images, the patient was then prepped for an exercised stress test and then exercised on the treadmill according to protocol. One minute prior to termination of exercise the patient was injected intravenously with approximately 30 mCi of myoview. Gated SPECT imaging was started at 30 minutes post injection. The patient was placed in the supine position and the images were obtained with a 180-degree orbit around the patients heart while gating to the patients EKG. The study was then processed and displayed for evaluafiort. Exercise Test Results: See enclosed exercise sheet protocol Interpretation: Review of the cine raw projection data reveals no significant motion artifact. Stress and rest tomographic images show normal myocardial activity. There are no significant defects or areas of reversibility seen. Cedars-Sinai AutoQuant quantitative analysis confirms this visual impression. The gated wall motion study reveals normal thickening and contraction throughout the left ventficular myocardium. There are no segmental wall motion abnormalities. The calculated left ventricular ejection fraction is 50% (normal is greater than 50%). Conclusion:

1. Normal stress dual isotope study without evidence of ischemia or scarring. 2. Normal wall motion with uniform thickening and contraction and an ejection fraction of 50%. 3. There are no prior studies available for comparison.

Interpreted by: Robert G. Matth~ws, M.D., C.B.N.C.

RGM: hna

EAOUSAFOIA0000570

Case 1:10-cr-OO286-TSE Document 30-9 Filed 12/13/10 Page 50 of 59

CARDIAC DIAGNOSTIC SERVICES OF VIRGINIA

3289 Woodbum Road, Suite 50 Annandale, Virginia 22003 (703) 641-0500 Fax (703) 204-9056

DUAL ISOTOPE PROTOCOL USING STRESS GATED SPECT MYOVIEW/REST SPECT THALLIUM RE: MAGLIOCCHETTI, PAUL REFERRING PHYSICIAN: DR. J. TURNER RENDERING PHYSICIAN: DR. R. MATTHEWS TEST DATE: 01/06/03 MYOVIEW/THALLIUM PER.FUSION STUDY: Procedure: The patient was injected with 3 mCi of thalliu_rn and SPECT imaging was begun 15 minutes post injection. The camera obtained images wkh a 180-degree orbit around the patients heart. After the rest images, the patient was then prepped for an exercised stress test and then exercised on the treadmill according to protocol. One minute prior to termination of exercise the patient was injected intravenously with approximately 30 mCi ofmyoview. Gated SPECT imaging was started at 15 minutes post injection. The patient was placed in the supine position and the images were obtained with a 180-degree orbit around the patients heart while gating to the patients EKG. The study was then processed and displayed for evaluation. Exercise Test Results: See enclosed exercise sheet protocol Interpretation: Cine review of the raw projection images shows no movement. SPECT stress and rest images show normal myocardial activity. There are no significant defects or areas of reversibility seen. Cedars-Sinai AutoQuant quantitative analysis confirms the visual interpretation. The gated wall motion study shows normal contraction with normal thickening throughout the left ventricular myocardium. There are no segmental wall motion abnormalities. The calculated left ejection fraction is 53%. (Normal is greater than 50%). Conclusion: 1. Normal stress and rest dual isotope study without scarfing or ischemia. 2. Normal wall motion with an ejection fi:action of 53%. 3. Compared to the previous study dated 5/9/00, there has been no significant change.

Interpreted by:Christine D. Bussey, M~,~ CDB:mhs

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INOVA FAIRFAX HOSPITAL


Inova Health System CARDIAC CATHETERIZATION MAGLIOCCHETTI, PAUL DATE OF CATHETERIZATION: CATHETERIZATION NUMBER: CARDIOLOGIST: PRECATHETERIZATION DIAGNOSIS: ROBERT G. MATTHEWS, M.D.
#202-21-91

z/3/oo

95% OBSTRUCTION OF THE MID RIGHT CORONARY ARTERY.

POSTCATHETERIZATION DIAGNOSIS: POST STENT PLACEMENT NO RESIDUAL NARROWING AT THE SITE OF STENOSIS WITH A STEP-UP INTO THE STENT. TITLE OF PROCEDURE: STENT PLACEMENT TO THE MID RIGHT CORONARY ARTERY.

DESCRIPTION OF PROCEDURE: The patient was brought to the catheterization laboratory in the fasting state having been premedicated with I0 mg of Valium with a sip of water. He was prepped and draped in the usual manner. After infiltrating the right groin with Xylocaine and using the Seldinger technique, an #8 French sheath was placed in the right femoral artery. An #8 French #4 right Judkins coronary artery catheter was introduced, but there was damping when it intubated the right coronary artery. It was decided to exchanged this for an #8 French #4 right with side holes which was done. Multiple guiding shots were obtained using Optiray contrast. After reviewing the guiding shots, a Photon 3.0 x 16 mm balloon and a 0.014 BHW guide wire was inserted. The guide wire passed relatively easily into the posterior descending branch of the distal right, and the balloon passed relatively easily into the 95% area of stenosis. Multiple inflations were performed, initially at 4 atmospheres and then at 8 atmospheres, performing just two inflations. The balloon was exchanged out, leaving the guide wire in place for an ACS Tri-Star 3.0 x 13 mm long stent. This was positioned in the area of stenosis with still a very slight residual eccentric ridge seen. At 6 atmospheres there was still a little indentation in the proximal half of the stent. At 14 atmospheres the stent was fully expanded. It appeared that the stent covered the area of stenosis more towards the proximal half of the stent rather than the distal half of the stent. After the 18 atmosphere injection, the balloon was pulled back and the guide wire left in place, and multiple guiding shots were CONTINUED

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INOVA FAIRFAX HOSPITAL


Inova Health System CARDIAC CATHETERIZATION MAGLIOCCHETTI, PAUL DATE OF CATHETERIZATION: PAGE TWO obtained to be satisfied that the stent adequately covered the lesion. It should be noted that at 6 atmospheres there was still an indentation in the stent of about one-third of the way into the body of the stent. Following angioplasty and stent placement, the guide wire was removed and the final guiding shots were obtained, demonstrating no residual narrowing at the area of the lesion. There was some smooth proximal tubular narrowing actually above the acute marginal branch which compromised the vessel by about 20-30%. The lesion actually was about 4-5 mm below the takeoff of a small marginal branch which was used as a guide. The patient did have some mild burning and slight discomfort several times during the procedure, but tolerated it very well and left the laboratory pain free. It was decided to do primary VasoSeal which was completed. He had received i0,000 units of heparin at the start of the study. He was also placed on I.V. nitroglycerin and several times did have some slight coronary spasm and received 200 ~g of intracoronary nitroglycerin several times during the procedure. The I.V. drip was left at 20 ~g. The patient tolerated the procedure very well and left pain free for the holding area awaiting bed assignment. CORONARY ANGIOGRAPHY: The right coronary is a dominant vessel with some mild tubular narrowing of 30% in nature throughout much of the proximal onethird. The area of stenosis is eccentric, about 5 mm below an acute marginal branch. Following stent placement there is no residual narrowing at that site, and there is a step-up into the stent. IMPRESSION: mid right coronary artery. Successful stent placement to the
#202-21-91

1/3/00

ROBERT G. MATTHEWS, M.D.

T: 113100

RGM:mdi:pmb D: 1/3/00 J: 17164 cc: Kevin Rogan, M.D. "END OF REPORT"

EAOUSAFOIA0000573

Case llO-cr-q~2~%T~.A~]~oC~r~t_30~:~ coF?i{ed 12/13/10 Page 53 of 59


INOVA Health System CAPJ31AC CATEZTZRIZATION REPORT
MAGLIOCCEETTI, PAUL DATE Or CATEZTERIZATION:

CARDIOLOGIST: PRECATEETERIZATION DIAGNOSIS: ORHAL TREADMILL TEST.

ROBERT MATTHZWS, M.D.

2.

POSSIBLE EIGHT-MONTH HISTORY Or ANGINA, NO PAIN IN THE PAST TWO NONTES. 3. EYPERTENSION. ~. APPARENT RELATIVE LOW HDL LEVEL.

POSTCA~HETERI ZATION DIAG~OSI 5: 1RTY PERCENT OBSTRUCTION Of 2.


TEE PROXIMAL TO MID LZ[T ANTZR! OR DESCENDING. EIET~ PERCENT OBSTRUCTION Of TEE SECOND MARGINAL BRANCH Of THE C I RObHI LEX. EIGHTY-fIVE TO NINZT~ PERCENT OBST~UCTION O~ THE HID RIGHT CORO~RR~ RRTER~ . MOR~L ~TRICULAR ~BCII 0~.

TITLE Of PROCEDURE:

RETROGRLDZ LEfT HEART CATEZTERIZATION, LEfT VZNTRICULAR ANGIOGR&PE~, BILATERLL SELECTIVE CORONAR~ ANGIOGR&PH VIA 3UDKINS TECENIOUE.

ANESTHESIA:

Local with 10 mg Valium po

DESCMPTION Of PROCEDURE: The patient was brought to the cardiac catheterization laboratory in a fasting state, having been premedlcated with I0 mg of Valium with a sip of water. Ee was prepped and draped in the usual sterile fashon. After infiltrating the right groin with xylocaine and using the Seldlnger technigue, a #~ french sheath was placed in the right femoral artery. A #~ french 4 left ~udkins coronary artery catheter was introduced and multiple views obtained of the left coronary artery. This catheter was exchanged over a tefloncoated guide wi~e for a 4 cm right ~udkins coronary artery catheter. Multiple views were obtained of the right coronary

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artery. This catheter was exchanged for a pigtail and

appropriate pressures were recorded from the left side of the heart. In a 300 right anterior oblique projection using contrast at 10 cc/second for four seconds a left ventriculogram was pelfoImed. This catheter was pu!led back demonstrating no gradient across the aortic valve and removed over a tefloncoated guide wire. Hemostasis was obtained with external compression over the light femoral artery. The patient tolerated the procedure well, had no chest discomfort, and left the cardiac catheterization laboratory in good condition with good right posterior tibial pulse.

PRECAI~IERIZAIION DIAGN0$15: .%bnormal treadmi!l test, possible eight-month history of angina, no pain in the past two months, hypertension, and apparent relative low hdl level.

POSTCAT~ZTE~IZATIO~ DIAGNOSIS:T~rty Fezee~t e.~.~tr~cti~n ~f t~e proximal to mid ieft anterior descending, fifty percent obstruction of the second marginal branch of the circumflex, eighty-five to ninety percent obstruction of the mid right coronary artery, normal ventricular function.
ANGTOGEA~S: The left main is a short smooth vessel with no areas of

narrowing. There is moderate calcification in the proximal left anterior descending coronary artery.
The left anterior descending coronary artery gives a fairly decent diagonal and about 3-~ mm beyond that has a smooth tubular 30% obstruction. This is best appreciated in the craniocaudal left anterior oblique view. The left anterior descending coronary artery is quite a large vessel which goes to a wraps around apex.

The circumflex gives off a large first marginal and then a


second smaller marginal. The second smaller marginal is a moderate size marginal with about a 50% smooth tubular narrowing as it separates from the circumflex. The circumflex ends as a smaller third marginal which balely exits the atrioventricular groove.

The right coronary artery Is a fairly dominant vessel. In the proximal one-third there is some smooth tubular narrowing of about a 20% nature. I n the mid portion of the right coronary artery there is a discrete 85-90% obstruction of the right coronary artery. There is a fairly large posterior descending artery and a smaller posterolateral left ventrlcular branch. There is also
an anomalous origin of an acute marginal branch coming off above the origin of the true native right.

Left ventriculogram reveals a normal left ventricle with uniform contraction and ejection fraction estimated at approximately

EAOUSAFOIA0000575

~[;~:~I~-cr-00286-TSE Doc~e~t ]~i~ed~2#~/~4~c~ge 55 of 59 history of occasional effort-induced dyspnea and mild chest tightness. Trea~ill test Iast October 18 was abnormal in Stage 5 with the patient having just some mild chest discomfort. He had delayed until now to pursue further investigation and we bad discussed the possibility of doing a cardiac catheterization vs a thallium. He has diminished his activity and denies any chest discomfort in the past two months. His wife also feels that at least he hasnt complained of anything in the past two months. He has some non-critical stenosis in the left coronary system with a 30% proximal-to-mid left anterior descending coronary artery lesion after the first diagonal, and a S0% second smaller marginal lesion. The principal problem is his dominant right which ha5 an 85-S0% stenosis. It is felt that he should be considered for angioplasty to this vessel. The patient has plans for next week to travel to florida and is reluctant to want to schedule it until a week after. We will start him on Plavix at this time.

ROBERT MATTHEWS, M.D.


RH/eff D: 12/30/99 T: 12/30/99 J: 16175

cc:

JAMES TURNER, M.D.

*** THIS IS A ON[IDENTIAL ~G~T INTENDED [OR TB ILZIPIE~T ONLY. "** *** II RECEIVED IN ERROR, CALL (703)20S-2282/2280. ***

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Case 1:10-cr-00286-TSE Document30-9 Filed 12/13/10 Page 56 of 59

PHYSICIANS & SURGEONS MEDICAL ARTS BUILDING 33OI WOODBURN ROAD, SUITE 304 ANNANDAL.E, VIRGINIA 22003

PHONE (703) ~573-2045 FAX (703) 573-0760

CARDIOVASCULAR MEDICINE

October 18, 1999

James W. Turner, Jr., M.D. 2942 Hunter Mill Rd. #102 Oakton, VA 22124-1703 RE: PAUL MAGLIOCCHETTI

Dear Jim: As I discussed with you, you will find enclosed myconsultation note and stress test on your patient. It is hard to be 100% sure whether his symptom of chest pressure is actually just shortness of breath as the patient suspects, or whether it does represent angina experienced during the past 6 months with his exercise program. The abnormality certainly is definite and could be due to his hypertension in this setting, but could also be due to a partial block. I have discussed the confidence levels of a doing a stress test as opposed to catheterization with the patient as well as the procedure and risks of catheterization. I will wait to hear further from you or the patient. I do feel that when I see someone with one other risk factor ~or heart disease, in this case hypertension, that he should drop his total cholesterol below 160 and the LDL below 80, which I did explain to the patient. I hope the enclosed is helpful and I appreciate the privilege of participating in his care with you. Best regards,

Robert G. Matthews, M.D., F.A.C.C. RGM/acw Enclosure: Consult and Treadmill Test

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CARDIAC CONSULTATION

PATIENT: MAGLIOCCHETTI, PAUL AGE: 53 REFERRING PHYSICIAN: J. TURNER, M.D. DATE: October 18, 1999 CHIEF COMPLAINT: Hypertension, concerned about hypertension, chest pressure, shortness of breath for 6 months duration. HISTORY OF PRESENT ILLNESS: Mr. Magliocchetti has some risk factors for vascular disease. During the past year, he has been hypertensive with pressures of 160/105-110. He has been on several medications which have brought his pressure down. He is on another drug now but he did not remember the name. He was able to identify Hyzaar I q.d. He smoked cigarettes as a kid but never up to a pack a day. He has smoked an occasional cigar. He is unaware of cholesterol levels. He has not been diabetic. He denies any significant family history of vascular disease. His father is 77 and in good health. His mother is 77 and had a cyst removed from her brain and has had to reside in a nursing home. He has one sister who is healthy. He has exercised fairly routinely. He had a friend that he used to play racquetball and tennis with but his friend tore his medial meniscus, and in the past year, the patient has been going to a fitness facility. He uses an elliptical machine for about a half hour and then weights for another 15 minutes to a half hour 3-4 times a week.
The patient initially denied any chest discomfort or symptoms that he would attribute to his heart. He does, however, note that he gets out of breath during the first half hour of his exercise. In addition, a little later in the conversation he also related that besides feeling short of breath, there is a slight sensation of pressure in the center of his chest. He felt that the latter symptom, however, was really more shortness of breath and difficulty trying to get a deep breath. There is no radiation of this pressure to the neck, jaw, or into the arms. It has been only present in the past 6 months and was not present, that he can recall, playing racquetball or in the first 6 months of the year. It goes away usually as he continues to exercise. He has never had a stress test before. He denies ankle edema, sleeps on one pillow, and has had no PND. He denies chronic cough, asthma, hemoptysis, but did have pneumonia when he was 40. He has noted that when the weather is hot and humid, sometimes he will feel a little more of a sensation of shortness of breath and pressure in his chest. This past weekend Saturday, which was a very nice day, he felt comfortable but Sunday, which was rainy, he felt a slight pressure. He is aware of some racing of his heart especially if he is lying down or in bed. He doesnt feel a lot of erratic beats or palpitations but just a rapid beat. He has had no syncopal or near syncopal events. He has not counted his heart rate when it has been racing but has not been diaphoretic. There is no history of rheumatic fever but he did have a heart murmur when he was younger. He did not do an EKG with Dr. Turner as he preferred to just proceed with doing a stress test.

PAST MEDICAL HISTORY: Reveals the usual childhood diseases. HA~ ILLNESSES: Hypertension. ACCIDENTS: 1982, when he had stopped on the Beltway to help someone in an accident, he was struck by a drunk driver and suffered 5 fractures of the transverse process in his back and was cared for by Dr. Vitek. OPERATIONS: Dr. Seneca has removed multiple lipomas. Tonsillectomy and adenoidectomy as a child.

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Page Two MAGLIOCCHETTI, PAUL 10/18/99 ALLERGIES: MEDICATIONS: Tetanus. Hyzaar I tablet q.am., Prilosec 20 mg q.d.

REVIEW OF SYSTEMS: HEENT: He is not troubled by headaches. He wears contacts which correct his vision. Hearing is good. GI: He had a history of reflux. No history of peptic ulcer disease. The Prilosec has resolved the reflux. He denies any recent abdominal pain, melena, hematochezia. GU: No history of kidney stones, kidney or bladder infections. Bone and joint: He does have some discomfort in his back sometimes, which is uncomfortable just bending over. Neuromuscular: No history of localized weakness or numbness. SOCIAL HISTORY: His wife is 51 and healthy. They have a son who is 24 in grad school in Eastern Carolina University getting a MBA degree, a daughter 22 who lives in Florida and is working for the Yankees. The patient owns his own consulting company, which he started in his basement. He now employs 30 people. He helps private industry interface with the federal government. He used to be a heavy consumer of caffeine and Starbucks and has now switched to tea and honey, and has about 2 cups a day. He drinks usually at least a glass of wine a day.
PHYSICAL EXAMINATION: Reveals his blood pressure to be 182/90. His pulse is 63. He is a well-developed, muscular, well-nourished man in no distress. There may be a very early arcus senilis. There are no xanthelasma around the eyelids. Carotids are I+ without audible bruits. There is no delay in upstroke. Neck veins are not distended. The thyroid is not palpably enlarged. Chest is clear. He has a normal sinus rhythm. There is no murmur or gallop. PMI appeared to be within the midclavicular line. Abdomen is soft. Liver and spleen are not palpable. No masses felt and no tenderness elicited. He had good dorsalis pedal pulses bilaterally, weak posterior tibial pulses bilaterally, and no ankle edema. Multistage Treadmill Test Report

RESTING EKG: and VG. STAGE


TIME SPEED ELEVATION HEART RATE BP

Nonspecific T wave abnormalities with T wave inversion in V5

I
3 min. 1.7 10% 104 190/90

II
3 min. 2.5 12% 122 196/90

III
3 min. 3.4 14% 138 200/90

IV
3 min. 4.2 16% 158 210/90

V
1 min. 5.0 18% 166 max

VI
5.5 20%

BP POST EXERCISE

20 sec. 196/100

2 min. 168/100

5 min. 160/100

8 min. 150/100

SUI~4ARY: The patient went 13 minutes, achieving a heart rate of 166 in Stage V of a Bruce test. He was fatigued and did feel shortness of breath but also at peak effort had slight pressure in his chest that went away fairly quickly within a couple of minutes into recovery. He did have 1-I/2 mm of slightly upward sloping ST depression most noticeable in V5 and V6 and 1 mm in II, Ill, aVF. Three minutes into recovery he flattened his ST segments in leads I, If, Ill, aVF, V4-5-6, and then inverted his T waves in the inferolateral leads.

EAOUSAFOIA0000579

Case 1:10-cr-00286-TSE Document 30-9 Filed 12/13/10 Page 59 of 59 Page Three MAGLIOCCHETTI, PAUL 10/18/99 This gradually came back to baseline. With the flat ST depression, he did have a millimeter of clear flat ST depression at that point. INTERPRETATION: I. Abnormal treadmill test suggestive of myocardial ischemia but possible false abnormality due to his hypertension. 2. Possible angina pectoris manifested by slight chest pressure during the past 6 months with exertion. 3. Hypertension of at least a years duration. 4. Possible hypercholesterolemia. 5. History of GERD.
1. I discussed with the patient the alternative methods of trying to resolve this abnormality, as to whether it represents a false abnormality due to hypertension, or a true block. We discussed the possibilities of a stress thallium with an 80-85% confidence interval, as opposed to cardiac catheterization, which would definitely address whether there is significant obstruction of a coronary vessel. 2. He is going to see Dr. Turner tomorrow and I did speak with Dr. Turner about it. The patient will decide whether he wants to go ahead with catheterization or do a stress thallium. We did discuss the risks of heart catheterization including the risks of death, heart attack, stroke, infections, clot threatening loss of limb, perforation of blood vessels, bleeding, and dye reactions. Robert G. Hatthews, M.D., F.A.C.C. cc: James W. Turner, Jr., M.D.

DISPOSITION:

EAOUSAFOIA0000580

Case 1:10-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 1 of 31

Exhibit 10
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000581

Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 2 of 31


j

Patient: MAGLIOCCHETTI,PAUL J

Account #: V00303720062 TRANSFER SUMMARY NOTE

Accdunt #:

V00303720062

Location:

U48

Room: I

4823

FAXCCI: Referring, NON GBMC,Physician FAXCC2: None Selected FAXCC3: SIEGELBAUM, MARC H M.D. FAXCC4: None Selected FAXCC5: None Selected DATE/TIME NOTE CREATED: 07/20/2010; 09:15 INTERN NAME: Zia, Sareer RESIDENT NAME: Marur, Surendra PCP: Referring, NON GBMC,Physician; Forward this note?: Yes SPECIALIST: Urology : MARC SEIGELBAUM DISCHARGE DIAGNOSES 1. Hematuria (599.71 Gross hematuda) 2/2 BPH and clot retention 2. Bacteruda (Ucx negative) (599.0 URINARY TRACT INFECTION) 3.. New onset type 2 Diabetes (250.00 DIABETES MELLITUS) 4. Depression, mood disorder (311 DEPRESSION) 5. HTN (401.9 ESSENTIAL HYPERTENSION) 6. BPH 7 Electrolyte anomalies (276.9 FLUID AND ELECTROLY-I-E DISORDERS) 8. hypophosphatemia (275.3 HYPOPHOSPHATEMIA) - Repleted 9. hypokalemia (276.8 HYPOKALEMIA) - Repleted 10. hypomagnesemia (275.2 HYPOMAGNESEMIA)- Replete Procedures: TURP on 7/1612010

HISTORY OF PRESENT ILLNESS HPI: Pt is a 63 yo gentleman with past history of alcoholism, BPH with elevated PSA negative prostate biopsy and 2 coronary stents who is currently being treated for depression at Sheppard Pratt. Pt noticed macrocitic hematuda and dysuria 7/15/2010 evening and was transferd to the GBMC ED. Initally the patient produced a around 500cc of frank blood from a small Foley which was placed, but the catheter soon occluded. The patient then developed suprapubic pain and distention, and continued to urinate frank viscous blood. The pt grew diaphoretic and tachycardic with HR into the 140s. Eventually, nursing was able to palce a large gauge Foley per urology recs and the patient produced a prodigious amount of bloody urine. The bladder was flushed with normal saline, and bleeding appeared to slow. PAST MEDICAL I SURGICAL HISTORY Past Medical History: Alcoholism 2 coronary stents depression Elevated PSA with negative prostate biopsy two years ago BPH

GREATER BALTIMORE MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0720-0033 PAGE 1 OF 6

EAOUSAFOIA0000582

Case 1:10-cr-OO286-TSE Document 30-10 Filed 12/13/10Page 3 of 31

@
Patient: MAGLIOCCHEnI,PAUL J ~LERGIES: Tetanus SOCIAL HISTORY Tobacco: No EtOH: Yes Occupation: Travel History: From Florida CODE STATUS: Full Code Account #: V00303720062

INTERVAL HISTORY: Patient reported developing fever last night for which he was given tylenol and the fever resolved. He denied having any abdominal discomfort though he reported having some pain at the tip of urethra.
**OBJECTIVE - EXAM**

VITALS
Name Temp Pulse RR Sys BP Dias BP 02 (L/min) 02 Sat (%) Method

07/19/10 07/19/10 14:10 10:06 37.0 36.9 85 88 16 20 156 136 81 91 99 Room Air 97 Room Air

07/19110 09:32 93,90 16

Daily Wei,qhts and BMI (if recorded) 07/18/10 06:13 Name Weight (Ibs.) 189.00 Meas. Method Wheelchair Name BMI Calculation 07/t 9110 12:43 27.9

" 07/t7/t 0 07:33 184.00 Wheelchair 0711 7/t 0 07:33 27.2

07117/10 06:02 184.00

PHYSICAL EXAM General: No acute distress; Appears stated age; Patient is in no acute distress, lying comfortably in bed. Eyes: Extra ocular movement intact; Pupils equal, round, reactive to light; No conjunctival injection; Sclera anicteric HENT: Normocephalic, atraumatic CV: Regular rate and rhythm Lung: clear to auscultation bilaterally Abd: non tender;, No guardinglrebound Ext: Pulses 2+ Neuro: Alert and oriented to person, place, time GU: No foley

TEST RESULTS
GREATER BALTIMORE MEDICAL CENTER 670t NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0720-0033 PAGE 2 OF 6

EAOUSAFOIA0000583

Case 1:10-cr-00286-TSE Document30-10 Filed 12/13/10 Page4of31

Patient: MAGLIOCCHETTI,PAUL J (* =High or Low ** =Critical)


Metabolics / Lipids Units Name mEQ/L NA M EQ/L K MEQ/L CL MEQ/L CO2 MG/DL BUN MG/DL Creat BUN Cr Ratio RATIO GLU Serum MG/DL MG/DL CA mOSM/KG OSMOC Anion Gap Name Total PROT Total BILl AST ALT ALKP Ionized CA ALB GLOB ALBGIobratio Name MG Name Phosphorus Units G/DL MG/DL lUlL lUlL lUlL MG/DL G/DL G/DL RATIO Units MG/DL Units MG/DL Range 133-145 3.3-5.1 96-108 22-29 8-29 0.5-1.2 8-29 70-115 8.8-10.2 277-297 5-16 Range 5.9-8.4 0-1.0 4--37 4-40 39-117 4.30-5.20 3.2-5.2 2.04.0 0.87-2.00 Range 1.59-2.56 Range 2.64.5

Account #: V00303720062

07119/t0 05:52 136 3.4 105 24 9 0.7 12.8 177" 7.6* 284 7.0 071t8/10 03:45 6.1 0.6 30 39 112 4.18" 2.9* 3.2 1.08 07/19110 05:52 1.94 07/18110 03:45 2.0"

07/18/10 19:43 131" 3.2* 102 22 13 0.7 18.5 361" 7.3* 286 7.0 071t7/10 10:35 6.2

07118/10 03:45 135 3.5 105 24 15 0.8 18.7 174" 7.7* 284 6.0 071t6110 17:36 7.7

4.25* 3.2 3.0 07118110 03:45 1.95 07/17/10 10:35 2.4*

4.26* 4.0 3.7 07117110 10:35 2.13 07/17110 02:09 0.5* 07/17/10 18:09 17.18" 11.9* 34.4* 89 130"

CBC / Blood Gases / Cardiac Enzymes / Coags / Fingerstick Glu 07/19110 07/18/10 Name Units Range 05:52 03:45 WBC thou/cram 4.00-11.00 8.44 12.85" Hemoglobin GM/DL 13.5-18.0 10.6" 10.9* Hematocdt % 40.0-54.0 30.0* 31.9" Mean Corp Volcu micrn 77-103 87 89 Platelet Count thou/cram 150450 132" 130"

Name Units C-reactive pro MG/DL Name Units Sed rate, auto mm/hr

Range 0.0-0.5 Range 0-20

07/16/t0 17:36 4.4* 07/16/10 17:36 53*

GREATER BALTIMORE MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0720-0033 PAGE 3 OF 6

EAOUSAFOIA0000584

Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 5 of 31

Patient: MAGLIOCCHETI1,PAUL J Name aPTT PT INR Units SECONDS SECONDS Range 24.9-34.5 13.0-15.3

Account #: V00303720062

07119110 05:52 33.8 14.3 1.02

07117/10 02:09 28.3 15.1 1.09

07/16110 17:36 29.2 13.4 0.94 07119/10 08:15 192 07/t 8/10 21:10 305

Name Finger Stick BG


Radiology

07/19/10 12:15 Units mg/dl (Norm 70-120mg/dl) 216

**SUMMARY** Pt is a 63 yo gentleman with past history of alcoholism, BPH with elevated PSA negative prostate biopsy 2 years ago and 2 coronary stents who is currently being treated for depression at Sheppard Pratt tx to GBMC for macrocitic hematuda and dysuda 7/1512010 evening, SIP TURP on 7/16. **HOSPITAL COURSE** 1 )Hematuria (599.71 Gross hematuda) Intem/Res Plan: Patient got TURP done 711712010 and is stable for now. Hematuda tremendously improved. HCT stable. Foley removed, pt able to urinate. flu with urology out pt in 2-4 week Dibucaine locally Status: Improved Last Modified: 7/17/2010

2)uT=
(599.0 URINARY TRACT INFECTION) Intern/Res Plan: Ceftdaxone IV day Urine culture sensitivity negative, will continue keflex for Last Modified: 7/17/2010 3)Anemia likely secondary to macroscopic hematuria. Intern/Res Plan: His crit is stable Last Modified: 7tl 9/2010 4)Electrolyte anomalies (276.9 FLUID AND ELECTROLYTE DISORDERS) Intem/Res Plan: Hypophasphatemia: Replete with neutrophos or other potassium supplements. Hypocalcemia: Replete. Hypokalemia: Resolved. Hypomagnesemia: Repleted and resolved today. Last Modified: 7/17/2010 5)lntem/Res Problem: New onset Diabetes type 2 (250.00 DIABETES MELLITUS) Interr#Res Plan: Hbalc- 9.7 Metformin 500 mg twice daily. Glybudde 2.5 mg twice da~qy. Ref. to Geckles DM center for DM ed. Last Modified: 7117/2010

GREATER BALTIMORE MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report ~. 0720-0033 PAGE 4 OF 6

EAOUSAFOIA0000585

Case 1:10-cr-00286-TSE Document30-10 Filed 12/13/10 Page6of31

Patient: MAGLIOCCHETTI,PAUL J Account #: V00303720062 6)lnternfRes Problem: HTN Uncontrolled 2/2 BP meds on hold (401.9 ESSENTIAL HYPERTENSION) ~ntem/Res Plan: Will Resume medications - hctz, cardizem, metoprolol with holding parameters Last Modified: 7/16/2010 7)Depression, mood disorder (311 DEPRESSION) InterNRes Plan: Psych evaluated the patient. Restarted on lithium, xanax prn Last Modified: 7/17/2010

8)Prophylaxis Intern/Res Plan: PPI/SCIDS Last Modified: 7/17/2010


**MEDICATIONS** Transfer Medications Mirtazapine 30mg po daily Metoprolol ER 50mg PO BID hold for sbp < 90, HR <60 Lovaza 1000mg PO BID Cozar 50mg PO daily Hold for sbp < 100 Hcrz 12.5mg PO daily hold for sbp <90 Lithium ER 450mg PO qhs Ativan per ClWA protocal Cardizem 180mg CD PO daily hold for sbp < 100, hr < 55 ASA 8ling PO daily Keflex 500 mg po bid for 3 more days Mefformin 500 mg po bid Glybudde 2.5 mg po bid Klonopin 0.25 mg po prn anxiety Xanax 0.25 mg po prn anxie~ **DISCHARGE INSTRUCTIONS** DIET: No concentrated sweet (Diabetes) FLUID RESTRICTION: None ACE / ARB for EF less than 40% or moderate / severe systolic dysfunction: Yes FOLLOW-UP Primary Care Physidan: Referring, NON GBMC,Physician; Forward this note?: Yes Other Physician(I): SIEGELBAUM, MARC H M.D.; Phone Number: 410 296 0967; Forward this note?: Yes Other Physician(1 ) Date/Time of follow up: 1-2 weeks

OTHER DISCHARGE INSTRUCTIONS: flu with urology in 2- ~, weeks. Avoid medications that can cause significant urinary retention, if pt develops retention of urine, hematuria pls call urology. Finger sticks AC and QHS
CONDITION ON DISCHARGE ! DISPOSITION Stable

**INTERN ADDmONAL COMMENTS / SIGNATURE*-*


GREATER BALTIMORE MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0720-0033 PAGE 5 OF 6

EAOUSAFOIA0000586

Page 7 of 31 Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10

Patient: MAGLIOCCHEI-rI,PAUL J

Account ~. V00303720062

INTERN SIGNATURE IN SALAR: Zia, Sareer ; Electronically signed by Sareer Zia, MD at 15:36; 7/19/2010; 15:36 **RESIDENT COMMENTS / SIGNATURE** Reviewed and edited. Pt medically stable for transfer. RESIDENT SIGNATURE IN SALAR: Electronically signed by Swapna Kolukula, MD at 10:38; 712012010; 10:38 **ATTENDING COMMENTS / SIGNATURE** Patient Status In System: I

GREATER BALTIMORE MEDICAL CEN I =--R 6701 NOR,3-H CHARLES STREET BALTIMORE, MD 21204 Report #: 0720-0033 PAGE 6 OF 6

EAOUSAFOIA0000587

Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 8 of 31

o GBMC
6701 North ~mrles Street Baltimore, Maryland 21204
V00303720062 MR.M002504256 Atn Dr. Obah,Eug~ne A IvLD. Sv~MED

PATIENT DISCHARGE/TRANSFER INSTRUCTIONS


Medications to.be taken at home or disqo_nfig__u_e[ (Resume L~-ev~._us M~ed~catigns" is

[[l$11111111[ll

ACTIVITY: Resume normal.acti~ties as tolerate~l unless sp~i:fied: DIET:. Q R~egnlar ~ He~z-t Healthy ~ No conc~ntrate~ sweet (Diabetes) ~ Othe~. FLUID RESTRICTION: ~i Non~ [~2 Liters (8 ful] glasses) ~10~ex. WEIGHT:. If you have CHF: W~gh dairy, call your physician if weight gain of 2 [bs i~ 2 days or 4 lbs ~n a week. PHYSICIAn: Prescribed ACE/A_~B for El~ less than 40% or moderate/severe systolic dysfunction? [:! Yes Q No, EF above 40% Q NO because

Physician: OTHER INSTRUCTIONS:


Pneumovax: ~3 Under age 65 and no risk factor for pneumovax Given this adm~sion ~1 Receivedaftex age 65 Received before age 65butlessth~Syea~ ago Patient refused pneamovax/xeason ~ -Not gtven due to current ch~mo, radt~outhereapy, b~nemarmw~msplant ~less than 12 months -

in/on

Phone

] Flu vaccine durin~ season only (October to March): [ [3 Under age 50/no risk fa~tor for flu vaccine ] ~1 Gtve~this admission ~ Receivectth~fl~u season ~ _~ ] ~3 Patient refused flu vaccine/~aso~_~ _ ] I:l N~tgivenduetocuffenth/oG~llizn-Bart~,bon~ma~owu-ansplantlessthan ] 12 month~

~~..~i~lstructed
Date PatienffOthe~leParty "

in and u~der~an~ the above in:formation and have received a copy of this form. Smoking Cessation previd ~e~l.~v~rse fd_e of form. ,.~ Prescriptions given to Patient/Family. , "- N~}[~seS~

EAOUSAFOIA0000588

Case 110-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 9 of 31


M002504256 GW-~U48 4823 A MAGLIOCCHE1 ~AUL J Marur, Surendra V003037200~.2 7116F20~0 4682 CARLTON DUNES DRIVE UNIT 13 FERNANDINA BF-~CH, FL 32034 CAT M 703-201-1.075 7/22/1946 63Y UNr~ED HF__~.~H~ARE 804436046

09:15 Intern Pager I Spectralink #: 095/4246 PCP: Referring, NON~GBMC,Physician Referring MD: J
" Fax N~? ~Yes Fax No~? [] Yes

SPECIALIST: U_~=_~/,: MARC SEIGELBAUM

Discharae Diaan0~es: 1. Hematuda (599.71 Gross I~ematuda) 2/2 8PH and clot retention 2. Bacteruria (Ucx negative) (599.0 URINARY TRACT INFECTION) &. Hew onset type 2 D~abetes (250.00 DIABETES MELUTUS) 4. Depress=on, m~x~d d=serder (3t 1 DEPRESSION) 5 HTN (401.9 ESSENTIAL HYPERTENSION) 6. BPH 7 Electrolyte anomalies (276 g FLUID AND ELECTROLYTE DISORDERS) 8. hypophosphatemla (275.3 HYPOPHOSPHATEMIA) - l~epleted 9. hypokalernle (276.8 HYPOKALEMIA) - Repleted 10 hypomagnesemla (275 2 HYPOMAGNESEMIA)- Replete Procedures: TURF on 7116/2010 ~ ~ ~e~t~. -,~-=~ ~

Pt is a 63 yo gentleman with past history of alco~olis~vated PS~gat;-ve prostate biopsy and 2 corona~t stents ~ho-ls currently befng treated for depression at Sheppard PratL Pt noticed macro~ti~tun~~..~/.l:8/20~0 evening and was transferd to the GBMC I=O.~ndally the. patient produced a around 500cc of frank blood from a small Fole~.,=~~theter soon occJuded The patient ~en dev~lpp~l~suprapubic pain and distention, and continued to urinate frank v~scous blood The~ --~ ........ chycardic ~ HR into the 140s. Ev6ntually, nu~slrfg ~,v~able to palce a large gauge Foley per urology recs and the patient produced a ~ount o~Toody udne. The bladder was flushed with- normal saline, and bleeding appeared to ~ Past Medical History: _~ ................. z~ ~ Alcoholism .... ~ ~ 2 coronary ste[~ts depression ~ ~ ~ Elevated PSA with negative pro~ ~

Past Surgical History:

Vaccines: Pneumonia: [] Under 65, no risk factor [] Received after age 65 [] Recvd before 65 & < 5 yrs ago [] Patient refused [] Allergy to vaccine [] Radiation ~erapy [] Bone marrow transplant < 12 month [] Under age 50 / no risk F-I Received this flu season [~ Allergy to vaccine [] Wo Guillian-Barre ~ [] Patient refused [] Bone marrow transplant < 12 month Reason For Refusal / Other Comments: Allergies: Tetanus Comments:

Social History: Tobacco Yes/(~) EtOH (~/ No per day / week

ppd

[] Used within last year [] Counseling, Socialdrug: Yes/ No [] Nursing Home Other:. Occupation:

Lh4ng Environment: [] Home [] Asst. Uving

Travel History:. From Florida

Sexual History:

GYN History:

~ode Status ~ Full Code [] DNR/DNI Interval History: Patient relxxted developing fever last night for which he was given tylenol and the fever res~ved He denied having any abdominal discomfort though he reported having some pain at the tip of urethra

. G: 670 o "m eM I d21204 GBMC{ tl~m~e..r~.r~g!~, rl:TA~ j. MRN: M002504256 - Pnnted: ~ees(~y, )Ju~ ~l{~,CZ/~~-~.~re~- ~{ge ~"PJ ~n

EAOUSAFOIA0000589

Case 110-cr-OO286-TSE Document 30-10Filed 12/13/10 Page 10 of 31


M002504256 GP" ",U48 4823 A MAGLIOCCHEf~. ~AUL J Marur, Surendra"~-" V00303720062 7116/2010 4682 CARLTON DUNES DRIVE UNIT 13 FERNANDINA BEACH, FL 32034 CAT M 703-201-1075 7/22/1946 63Y UNITED HEALTHCARE 804436046

V~AL SIGNS 07119110 02:t0 PM Name 37 0 Temp Pulse 88 RR Sys BP Dfas 8P


02 (UraLs) 02 Sat (%) Melhod

07/19/1010.06 AM 36 9 85 20 130 81
97 Room

07/19110 09:32 AM 93 90 16

t6 156 91
99 Room A~"

Daily Weights:

Name 07118/10 06:13 AM Weight (~s) 189.00 Meas Method Wheelchair Comments:

07/17/10 07:33 AM 0W17110 06:02 AM 184 Q0 184 00 Wheelchair

~ 07119110 12:43 PM BM~. 27 9

07/171t0 07:33 AM 27.2

Constitutional: ~ NAD ~ Appears stated age Patient Eyes: Neck: CV: Lung: Abd: ~ EOMI ~ PERRL ~No conjunctival i _ clera a

[] No bruits [] No LAN [] No thyroq~ ~-------------------~,~Z ~RRR ~]IRR [] NoPJG/M [] ~ CTA B/L [] No wheezeslral~! ~ Non-tender [] nl BS ~~nd [] No organomegaly ~.~ . nsion

Musculoskeletah [] joints nl Ext: [] No C/C/E [] No ca[ftende~es 2+ Neuro: [] No lateralizing deficits ~ A&O ~+~ [] Cranial Nerves II - XII [] Motor [] Sensory [] Gait normal [] Cerebellar signs GU: Skin: ~ No foley [~J Normal external genitalia [] No rash [] No bruising [] Decubitus

Metabolics:

GLU Serum

MG~L

70-115

177

36t

GLOB AL.BGIob~a~o

G~DL RATIO

20-4.0 0 87-2.00

3~

30

3.7 1 08

,Blood ~lases:

Cardiac Enzymes:

. ~ ~, GaMq~&~~~e~ .I- MRN" MO025~256 - Pnnted: ~e~dv, ~ ~,~ ~- ~e ~ M~ 570 o

im ~ ~ l d21204

EAOUSAFOIA0000590

Case 1:10-cr-00286-TSE Document30-10 Filed 12/13/10 Page 11 of 31


~ LOCAT|ON PATIENT NAME 4823 A MAGLIOCCHErTI, PAUL J ~,DMIT DATE 07/16/2010 ACCT # V00303720062 DATEI TIMENOTECREATED0712012010 09 15

M002504256 GF U48 4823 A MAGLIOCCHEt .._~AUL J

INTERN: Zla, Sareer RESIDENT "---~uJu,, Surendra ~TTND

Marur, 8u~en~,a V00303720062 7116/2010 4682 CARLTON DUNES DRIVE UNIT 13 FERNANDINA BEACH, FL 32034 CAT M 703-201-1075 7/22/1946 63Y UNITED HEALTHCARE ,804436046

Finqerstick Glucoses:
Finger S~:k 8G al~/dl (Nomt 70-12(~ag/dQ 216 t92 305

Microbioloqv:

Pt is a 63 yo gentleman with past history of alcoholism, BPH with=~ negative prostate biopsy 2 years ago and 2 coronary slants who is currently being treated for depression at Shep a~_~.tx to GBMC for macmcit~c hematuria and dysuna 711512010 evemng, SIP TURP pn 7116. ~
Acbve Problems

1) Hematuna (599 71 Gross hematuna)

|Pabent got TURP dode 7/1712010 and ~s stable for now H~~ ,tremendously ,mprovad HCT stable |Fo~y removed pt able Io umlate Jf/u wffh urology out pt =n 2-4 ~3ek [D(bucame locally

2) u~

(599.0 URINARY TRACT INFECTION) ~.,..~

Ceffnaxone IV day Unite culkJre sensdl~.J~tlve ~ katie ~or Lnt Anemia I~kely PIan seconda~t em/PA/NP/FelIow of Care to macrosc~a
;~ ~;:"

Select Dx Status
I Atle~~j Not~l~ of Care

/H=s cnt =s Stable 4) Electmlyfe anomalies (276 9 FLUID AND ELECTR~f3rE DISORDERS)

|Res, qntem/PA/NPYFel~ewPlan of Care |Hypopl~asphatem=a Rpplete w, ll~ ~eutrop,~#s or other pol~ss=urn supplements |Hypocalcemm Replete |Hypokatem~a |Hypomagnesemm Repleted and res~lvad today

A~en~ng Not~Plan of Care

_~ New onset O=abetes type 2 (250 00 DIABETES MELUTUS)

Ct~ange Dx Status

I Hbalc - 9 7 I Metforrnm 5~3Q mg twice dad I Glyounde 2 5 mg twine dady ~ Ref to Geckles DM center for DM ed 6) HTN Uncontrolled 2J2 BP reeds on hold (401 9 ESSENTIAL HYPERTENSION)

Last Modl~ed 7/1612010 Change Dx Status

| Res/tntam/PA/NP/Fellow Plan of Care [Will Resume med{calions - I~ card=z~m metoprolol ~lh holding parameters "7) Depression, mood d~sorder (311 DEPRESSION)
Res/lntenYPA/NP/Fellow Plan of Cam

I Atlendlng No~Ptan of Care

I
Attendzng Note/Plan o# Care

Last Modified 7t17/2010 Change Dx Status

Psych evaluated the pabenL Resta,f.eQ on IRh~L~, XaT~X pm

~81 Pro~s
ResJ~nlem/PA/NP/F~tb~w Plan of Cam I Attand~ng Nora!Plan of Care

Last Modified 711712010 Select Dx Status

PPI/SC~S

EAOUSAFOIA0000591

Case 110-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 12 of 31


LOCATION MAGUOCCHEI..__/AUL J Marur, Surendra V00303720062 7116/2010 4682 CARLTON DUNES DRIVE UNIT 13 FERNANDINA BEACH, FL 32034 CAT M 703-201-1075 7/22/1946 63Y UNITED HEALTHCARE 804436046

09.15

Current Inoatient Medfcation Orders:


OMEPRAZOLE 20MG P_.APCR (PRILO6EC CAP) 40 PO OAILY 7/17/2010 9"00-00 AM LOR,~.~am INJ 2 MG/ML VIAL (ATWAN IN J} 0 IVPUSH Q4H 7/17/2010 2.00 ~--~ ACETAMINOPHEN 325 MG TASI (rYLENQL TAB) 650 PO Q6H 7/17/2010 2.00~O AM OkOAN,~"I~ON INJ 4 MG/2 ML ~ tN~) 4 |v~USH 1~6H 7/17r2010 Z0~0o AM HYDROmo~phone INJ 1MG~R, SYR (HYDROmoq~onetNJ) 1 IVPUSH O4H 7/17/2~10 2"00 O0 AM D~_kTRO~ 5~ INJ 100 ML BAG 100 ML, MAGNESIUM SULF INJ I GMi2 ME ~ 2 GM IV PRN DEXTROSE 5% INJ 10Q ML BAG t00 ML, CALCIUM GL~ INJ 1 GM/IO ML VIAL 1 GM IV PRN 7117/201/~5~O AM DEXTROSE 5% INJ 100 ML BAG 100 ML, CALCIUM GLUC INJ 1GM/IO ML VI~L 2 GM IV PRN POtAS~IUM CI-IL 10MB~/10OML 10 MEQ/100 ML PLCT 100 ML IV PRN 7/17/2010 8 15~0 AM P~TA~IUM CHL 20MEQ/10OML 20 MEQ/100 ML PLCT 100ML IV PRN 7/17/2010 8 15"00 AM DEKrROSE 5% INJ 250 ML BAG 250 ML SODIUM PHOSPHATE INJ 3 MMtML V~AL 15 MM N PRN CEFTRIAXONE t GM/DSW IVPB 1GM/50 ML BAG 50 ML IV Q12H W17/2010 ~00 00 pM 0 4 IVPU~H INFCE 7117t2010 2~ 00 PM NALOXONEINJ 0 4 MG/ML tAAL (NARCAN INJ) DIBUCAINE 1% OINT 30 GM 0 TOPICAL Q2H 7117/2010 4 00 00 PM POTA~ UM CHLORI~ 20 MEQ TABSR 40 PO POTASSIUM CHLORIDE 20 MEQ TABSR 60 PO PRN PRN ~11~/2010 61]0"00 AM , 711BI2040 8t~O 00 AM

~OIUM CHL 0 9~ + KCL 20MEQ 1000 ML BAG 1000 ML IV ONE 7/1BI2010 11 18 0~P2/l~____z~- 7119t2~.~J~0"AM POT~IUM CHL 10% IJQ 20MEQ/15ML UO(~ (POTASSIUM CHLORIOE_ 10% UQ) 40 PO ~~o ~2.~59 00 PM 7119/2010 1 00 00 PM 500 PQ BID 7/~,~/2010 ~00"00 PM MErFORMIN 500 MG TAB (GLUCOPHAGE TAB) METFORMIN 500 MG TAB (GLUCOPHAGE TAB) 500 PO ONE 7/19/2{~t1~1,01~0 PM ~.j~ 02 00 PM GLYBunde 2.5 MG TAB (DIABETA TAB) 2 5 PO DAILY 7/26/2010~ GLYBunde 2.5 MG TAB (D~BETA TAB) 2.5 PO ONE W19/2010 :~, t9/2010 1 IT~3~ POTASSIUM PHOS/~DIUM PHo~ (PHO,.~4~AK~ PKT (pHOS-NAK pKI~----u~--~~ PO ~-~J~.9/20~6 00 O0 PM

Transfer Medications
M~tazapme 30rag po daily Metoprolol ER 50rag PO BID hold for sbp < =9~J~ Lovaza 1000rag PO BID~ ........... " ............... -~ ~ Cozar 50rag PO dady Hold for sbp < 10~;~.,, NCTZ 1ZSmg PO da=ly hold for sbp ~=~=~=~ Ldl~um ER 450rag PO qhs ~ A~van per CIWA protocal ~~ Ca~zem 180rag CD PO dady hold for sS-p-~..~~~" Keflex 500 mg po b~d for 3 more days Mefform=n 500 mg po b=d Glybunde 2 5 mg po b~d Klonopm 0 25 mg po pm an~ety Xanax 0 25 mg po pm an~ety D=buac~rte 1% apply topk~ally to t~p of pems q 2hrs pm pa=n

Comments:

ACTIVITY: Resume normal act=vities as tolerated unless specified: DIET: [] Regular [] Heart Healthy~ No concentrated sweet (Diabetes) [] Other:. FLUID RESTRICTION: ~ None [] 2 Liters (8 full glasses) [] Other:. Prescribed A CE/ARB for EF less than 40% or moderate/severe systolic ]~ Yes [] No, EF above 40% dysfunction? [] No, because: FOLLOW-UP: [-] Attending level review needed to complete follow-up Comments: Primary Care MD: Referring, NON GBMC,Physician Other MD SIEGELBAUM, MARC H M.D Other MD: Other MD: Comments: OTHER INSTRUCTIONS: f/u with uroloov in 2- 4 weeks Avoid medications that can cause siomficant udnarv retenfJon, if
G. ~ 670 o m ~.~ I d21204 Fwd INs Not~?

in/on in/on 1-2 weeks in/on in/on

Phone Phone 410 296 0967 Phone Phone

I~Yes
I~Yes [] Yes [] Yes

EAOUSAFOIA0000592

Case 1:10-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 13 of 31


,~r~-~ M002504256 GF " U48 4823 A MAGLIOCCHE-~ ~,AUL J Marur, Surendra~
V00303720062 7/16/2010 4682 CARLTON DUNES DRIVE UNIT 13 FERNANDINA BEACH, FL 32034 CAT M

09:15

703-201-1075 7/22/1946 63Y UNITED HEALTHCARE 804436046

OTHER INSTRUCTIONS: f/u with urology in 2- 4 weeks. Avoid medications that can cause significant urinary retention, if pt develops retention of urine, hematuria pls call urologic__ gy.
Finger sticks AC and QHS ~

Stable

INTERN 1 RESIDEN~-~IGNA~.URE
Additional Intern Comments:.

INTERN SIGNATURE: Signature attests that all pages ha~~ie~ed and completed. Zia, Sareer Electron=~t~~ed by- ~Tp..~ Zi , MD at 11:23
Intern Signature

7/20/2010 Date/Time

11:23

Additional Residerlt Comments: [~S~~f.~t=ern Reviewed and edited. Pt medically stable ~-ffst~r.

[] No intern documentation

~ I " "~-:~"~":" pl eted. RESIDENT SIGNATURE: S gn~a~r=~-~ ~.~at all ~>=a~ges have been reviewed and corn
Resident Signature .... ~_~_ .

7/20/2010 Date/Time

10 38

Attending Additions ! Comm~: [] Signed ahead of intern [] Signed ahead of resident

VISIT
Date of Service: I"] (~238) D/CDayMgrr=30r~n~ < [-I (~23~) D~Oay~g~>~On~n Pt. Status at Time Note Was Created: [~ I = inpt., O = Obs/Outpatient; E = ED

I
[] (~923~) ~W~tD/CSameD~y(Lo~ [] ~2~7) O~C~O~ch~je l--INo~ [] ResJFellowlnvolvement [] ~23~ ~W~CSa~eOay(M~e~e) [] Fe23~) ~r~OCSameDay0~h)

ATTENDING S|GNATURE
Attending Physician Signature Tit~e Date/Time

G M 670

e~

EAOUSAFOIA0000593

Page 14 of 31 Case 110-cr-OO286-TSE Document 30-10 Filed 12/13/10

,J63 M GBMC 6701 N. Chades Street Baltimore, MD 21204 Date: Roon~ ~ Reas~r~ ~ |Psychiatric Consultation DOB

lllilll|lilli
_ _| .,,. ~.J ~.~

C ~hief Com[daJnt and Histot~f of~resentIJlnesS:

Pe~nent Pindln~,

Substance Abuse O~ate~: E~Ctt.,-rerd: E3Pa~t Cocaine: ~uz~e~t ~Past

Seda~.ves: {~Zm:ze~t [~Past Stimulants: --IC~e~t C]P~

Family Psychlatdc History: [~cee kzo~x

Po~tive for.

722-15 Reg~d ~og

ULT

EAOUSAFOIA0000594

Case 110-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 15 of 31


MAGLIOCCHETTI,P~UL j 63 M DOB 07/22/1946 DO~OT/Id/IO V003057 ,7..~62 Am Dr:. ~ M.D. Svc:MED

GBMC 6701 N. Charles Street Baltimore, MD 21204 oiM H~story. Admit[ed Marital Status: Occupation/Hobbies:

Psychiatric Consultation Page 2 of 3

Initial CAM: [-[Neg [] Po~

Wei~t:.

EAOUSAFOIA0000595

Case 110-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 16 of 31


DOB 070.M1946 DOS 07/1~f10

EAOUSAFOIA0000596

Case 1:10-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 17 of 31

Patient: MAGLIOCCHETTI, PAUL J

Account #: V00303720062 ADMISSION NOTE

Account #:

V00303720062

Location: U57

Room:

5724

FAXCCI: Referring, NON GBMC,Physician FAXCC2: None Selected FAXCC3: None Selected FAXCC4: None Selected FAXCC5: None Selected

DATE/TIME NOTE CREATED: 2010/07/16; 23:44 INTERN NAME: Sedaghat, Farzad RESIDENT NAME: Obah, Eugene ATrENDING NAME: Obah, Eugene PCP: Referring, NON GBMO,Physician; Forward this note?: Yes
Chief Complaint: age: 63; sex: M; presents with: Massive macroscopic hematuria; duration: one day

HISTORY OF PRESENT ILLNESS Pt is a 63 yo gentleman with past history of alcoholism, BPH with elevated PSA negative prostate biopsy and 2 c,oronary stents who is currently being treated for depression at Sheppard Pratt. Pt noticed macrocitic hematuria and dysuda 7/15/2010 evening and was transferd to the GBMC ED. Initally the patient produced_a around 500cc of frank blood from a small Foley which was placed, but the catheter soon occluded. The patient then developed suprapubic pain and distention, and continued to urinate frank viscous blood. The pt grew diaphoretic and tachycardio with HR into the 140s. Eventually, nursingwas able to palce a large gauge Foley per urology recs and the patient produced a prodigious amount of bloody urine. The bladder was flushed with normal saline, and bleeding appeared to slbw.
REVIEW OF SYSTEMS -: RESPIRATORY:Normal; CARDIOVASCULAR: Normal; GASTROINTESTINAL: Normal; GENITOURINARY: Hematuda; PSYCHIATRIC: Depression

PAST MEDICAL HISTORY Alcoholism 2 coronary stents depression Elevated PSA with negative prostate biopsy two years ago BPH PAST SURGICAL HISTORY ALLERGIES: Tetanus HOME I OUTPATIENT MEDICATIONS Mirtazapine 30mg po daily Metoprolol ER 50mg PO BID GREATER BALTIMORE MEDICAL CEN]ER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0717-0011 PAGE 1 OF 5

EAOUSAFOIA0000597

Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10Page 18 of 31

Patient: MAGUOCCHEFrI, PAUL J Lovaza 1000mg PO BID Cozar 50mg PO daily HCTZ 12.5mg PO daily Olprazotam 0.25 PO daily in AM Lithium ER 450rag PO qday Ativan per CIWA protocal Cardizem 180rag CD PO da~]y ASA 8ling PO daily SOCIAL HISTORY Tobacco: No EtOH: Yes Occupation: Travel History: From Flodda
FAMILY HISTORY **OBJECTIVE - EXAM** VITALS

Account #: V00303720062

Name Temp Pulse RR Sys BP Dias BP 02 Sat (%) Method


Intake / Output Information

07/16110 23:38 36.6 130 28 152 70 93 Room Air

07/16tl 0 23:28 134 24 194 101 98 Room Air

07/16/10 22:24 87 20 137 92 98 Room Air

Daily Weiqhts and BMI (if recorded) 07/17/10 Name 06:02 Weight (Ibs.) 184.00 Meas. Method Wheelchair

07117/10 01:15 182.90

Name BMI Calculation

07/17110 07:33 27.2

PHYSICAL EXAM Constitutional: No acute distress; Appears stated age Eyes: EOMI HENT: NCAT Neck: No bruits CV: RRR Lung: CTA B/L; No wheeze~/raleslrhonchi Abd: Suprapubic distention Musculoskeletal: joints nl GREATER BALTIMORE MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0717-0011 PAGE 2 OF 5

EAOUSAFOIA0000598

Case 110-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 19 of 31

Patient: MAGLIOCCHETll,PAUL J Account #: V00303720062 Neuro: Alert and oriented to person, place, time; Motor, Sensory ~etlex: Left Bicep: 2+; Left Knee: 2+; Right Bicep: 2+; Right Knee: 2+ Skin: No rash TEST RESULTS (* =High or Low ** =Critical)
Metabolics / Lipids Name Units mEQ/L NA MEQ/L K CL MEQ/L CO2 MEQ/L MGfDL BUN MG/DL Creat BUN Cr Ratio RATIO GLU Serum MG/DL CA MGtDL OSMOC mOSM/KG Anion Gap Name Total PROT Total BILl AST ALT ALKP Ionized CA ALB GLOB ALBGIobratio Name MG Units G/DL MG/DL lUlL lUlL lUlL MG/DL G/,DL GIDL RATIO Units MG/DL Range 133-145 3.3-5.1 96-108 22-29 8~29 0,5-1.2 8~29 70-115 8,8-10,2 277-297 5-16 Range 5.9-8,4 0-1.0 4-37 4-40 38-117 4.30-5.20 3,2-5.2 2.0-4.0 0.87-2.00 Range 1,59-2.56 07/16/10 17:36 134 3.8 98 26 15 0.7 21.4 430* 8.7* 296 10.0 07/16/10 17:36 7.7 0.6 30 39 112 4.26* 4.0 3.7 1.08 07116/10 17:36 2.04

Name Phosphorus

Units MG/DL

Range 2.6-4.5

07/16/10 17:36 2.9


07/16110 22:58 8.25 15.6 44.7 88 169

CBC / Blood Gases / Cardiac Enzymes / Coa.qs / Fingerstick Glu 07117/10 07/17/10 Range 06:01 02:09 Name Units 17.99" W BC thou/cmm 4.00-11.00 22.37* Hemoglobin GM/DL 13.5-18.0 12.9" 13.0" 36.5* 36.7* Hematocdt % 40.0-54.0 88 88 Mean Corp Vol cu micro 77-103 144" 136" Platelet Count thou/cmm I50-450

Name

Units

Range

07116110 17:36

GREATER BALTIMOREMEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report#: 07t7-0011 PAGE 3 OF 5

EAOUSAFOIA0000599

Case 1:10-cr-00286-TSE Document30-10 Filed 12/13/10 Page20of31

Patient; MAGILIOCGH~P~UL J C-reactive pro:MG1DL " Units .:. -!il~ange Name Sod rate, auto :mrft/hr " .. .:iO~0 Name INR Name Finger Stick BG Rad olo,qy Units._.. . ---Range

Account-#: V00303720062 4.4* 0711.6/I0 17:36 53* 17:36 0.94

071t 6/10 .22:25 " :ur~its .;.,~l:"(Norm 70-120mg/dl) -430 .:

Pt is a 636~e~mas:;~t~#~t;~l~isto~ of alcol~olism~ .BPH.with elevated PSA nega~ve prostate biopsy .2~.~e~~S~:a~#~"~. ~ten~~oi~cu#e~ti-~being treated fordepression at Sheppard. P~ff}~td.~f~"~ocitic-hem~tuda ;~ha~d#ari& 7/~ 5/201.0 .evening, con~rn for

l~ternlRe~:~::Bi~:~i~

~ to UTl,-howeeEque~i~;of blood suggests ~tential of

prepared~ ;;P~0~(d~4 ~ja~saeita~n~::~h~ged:~5i6Y;tO~iple lumen for.~ntinuous

InterNR~;Pi~~;,Oe~:~l~,;fO~.no~. Ordered udne Culture, sensitivi~ 3)Electrol~e:a4em~iieS :~4~E-UID .AND ELEGTRO~E DISORDERS) Inte~ReS~Pi~6~:.Cdt ~0:~affer m&~iv~hematuria,: pt had drama~c electrol~e

4 ),ypophosPhat~ia :~(2~5~~.~OPH OSPHAT~ M IA)

GR~ERf~,MO~C".~CENTER:-~Oi~NOR~-~ES ST~ B~MO~,. MD 21204

EAOUSAFOIA0000600

Case 110-cr-00286-TSE Document30-10 Filed 12/13/10 Page21 of 31

\J
Patient: MAGLIOCCHETrI,PAUL J Intern/Res Plan: Replete Last Modified: 7/17/2010

Account #: V00303720062

7)Diabetes (250.00 DIABETES MELLITUS) Intern/Res Plan: New onset, wit|treat with lantus and medium dose sliding scale Last Modified: 7/17/20t0

8)Depression, mood disorder (311 DEPRESSION) Intern/Res Plan: Will restart meds when patient stabalizes Last Modified: 7117/2010
9)HTN (401.9 ESSENTIAL HYPERTENSION) Intem/Res Plan: Hold meds given blood loss Last Modified: 7/16/2010

10)Prophylaxis Intem/Res Plaq: PPi/SClDS Last Modified: 7117/2010


~COMMUNICA~ON~ Primary Care MD: Referring, NON GBMC,Physician; Forward this note?: Yes

**INTE DmON . CO i.fENTS S G. TURE**


INTERN SIGNATURE |N SA~: Sedaghat, Farzad ; Electronically signed by Farzad Sedaghat, MD at 08:42; 7/17/;~010; 08:42

**RESIDENT C~OMMI-~NTS:/~SIG NATU RE** Reviewed and ~ited db~e~!0~te. Agree with cystoscopy. Cunently receiving bladder in-igation. Continues to have hema{ur~a.;Rypotensive and tachycardic this am. Will volume resuscitate. Goal Hct > 25. PRBC 2 units type~l and crossed. RESIDENT SIGNATURF: 1NSALAR: Electronically signed by Swapna Kolukula, MD at 09:33; 7/17/2010; 09:33
**ATTENDING~COMMENTS I SIGNATURE** Attestation: ! saw and evaluate<J the patient with the clinician above. I discussed the case with the clinician, re.viewed the clinicians note and agree with the findings and plan as documented in the above assessment with any exceptions / additions noted above. VISIT: Patient seen on: 07/17t2010 Patient Status In System: !

Ai-rENDING SIGNATURE INSALAR: Electronically signed by Eugene Obah, MD at 17:30; 7/17/2010

GREATER BALTIMORE MEBICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report#: 0717-0011 PAGE 5 OF 5

EAOUSAFOIA0000601

Case 1 10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 22 of 31

Name: Magliocchet: aul J


Room/Bed: 4823 / A ~ Medical Record #: M002504256 Visit Number: V00303720062 Physician: Marur, Surendra M.D. Date: 7/20/2010 9:47:21 AM

[etanus

Allergy

7/I 6110

Yes

IV Medication Magnesium Sulf Inj Dr "se5%Inj ~_ Aication Calcium Gluc Inj Dextrose 5% Inj IV Medication Calcium Giuc Dextrose 5% lnj IV Medication P" "am Chl lOmeq/lOOml cation p)ot,,~lum Chl 20meq/100ml IV Medication Potassium Phos Inj Dextrose 5% Inj IV Medication Sodium Phosphate Inj I De~qse 5% Inj ,r-l~ication ! Ceftriaxone 1 Gm/DSW Ivpb r Omeprazole Calcium Carbonate Glyburide Mefformin HC! [ Potassium Phos/Sodium Phos Docusate Sodium Lithium Carbonate Dibucaine Acetaminophen Potassium Chloride Potassium Chloride Potassium Chloride Alp .r&.zolam Cionazepam l H" " "morphone HCI 1-~ ~etron HC!

104mls @ 100 mls/hr 2grn t00 ml 110n~s @ 200 nds/hr lgm I00 ml 120mls @ 200 mls/hr 2gm lOO ml lOOmls @ 100 mls/hr lOOmls@ I00 mls/hr 100 ml 255mls @ 42 mls/hr 15ram 250 rnl 255mls @ 42 mls/hr 250 ml 50mls @ 100 mls/hr 50ml 1000 mg 25rag 500 mg

PRN PRN IV IV IV IV IV IV PRN PRN PRN PRN PRN PRN PRN PRN PRN PRN PRN PRN Q12H DAILY BID DAILY BID BIDWM BID QHS Q2H Q6H Pl~ PP,_N PRN PRN PRN PKN PKN DAILY PRN QHS PRH Q4H PRN Q6~ PR~ 7120/10 09"34 7/20/10 09:35 7/20/10 09:35 7/20/10 09:35 7/20/10 09:34 7/20/10 09.37 7/19/10 14:32 7/19/10 2I:57 7/19110 14:00 7/19110 22:10 7/18/10 11.03 7/20/10 01:t2 7119/10 21:57 7/18/10 17:51 7/17/10 10:45 7118110 13:16

IV PO PO PO PO PO PO PO TOPICAL PO PO PO PO PO PO IVPUSH rvPUSH

tp~t
100rag 450 mg TO TIP OF PENIS 650rag 20meq 0.25 mg 025rag lmg 4mg

EAOUSAFOIA0000602

Filed 12/13/10 Page 23 of 31

Name: Magliocchet aul J


Room/Bed: 4823 / A Medical Record #: M002504256 Visit Number: V00303720062 Physician: Marur,Surendra M.D. Date: 7/20/2010 9:47:21 AM

Hct MCV MCH

Pit Count
Neutrophils % Lymphocytes % Mouocytes % _B:~-~ Neutrophil~ E~timate

(4.00-11.00) H (4.00-I 1.00) H (4.00-11.00) H (4.00-11.00) H # (4100-11.00) H 3.60 mil/eumm 4.16 rod/cumin 3.85 mil/cumm 4.18 reaVcu~n~ 4.16 rral/cumm (4.2-5.90) L (4.2-5.90) L (4.2-5.90) L (4.2-5.90) L (4.2-5.90) L 11.9 GM/DL 10.9 GM/DL 12.9 GM/DL 13.0 GM/DL 12.9 GM/DL (13.5-18.0) L (13.5-18.0) L (13,5-18.0) L (13.5-18.0) L (13.5-18.0) L 37.4 % (40.0-54.0) L 34.4 % (40.0-54.0) L 31.9 % (40.0-54.0) L 36.7 % (40.0-54.0) L 36.5 % (40.0-54.0) L 90 cu micrn (77-103) 89 cu micrn (77-103) 89 cu micra (77-103) 88 eu miem (77-103) Pending 30.9 picogram 30.3 picogram 31,1 picogram Pending 31.0 picogram (27.0-32.0) (27.0-32.0) (27.0-32.0) (27.0-32.0) 35,4 % (32.0-36.7) Pending 34.5 % 02.0-36.7) 34.6 % (32.0-36.7) 34.2 % 02.0-36.7) Pending 13.2 (11.5-14.5) 13.2 (11.5-14.5) 12.9 (11.5-14.5) 12.7.(11.5-14.5) 154 thou/cram 130 thou/cmm 130 thou/cram 136 thou/cram Pending (150-450) (150-450) L (150-450) L (150-450) L 78 % (21-77) H 4 % (15-55) L 8 % (2-6) H 10 %(3-17) Mild decreased

RBC Morphology

Normat ~ORMAL)

(AD~.QUATE) H

8~44 thou/cram (4.00-11.00) RBC

Hot MCV MCH MCHC RDW Pit Count Neutrpphils Lymphocytes, % P ~eutrophils

(4.2-5.90) L 10.6 GM/DL (13.5-18.0) L 30,0 % (40.0-54.0) L 33.5 % (40.0-54.0) L ,87 cu micro (77-103) 87 cu micra (77-103) 30.8 pieogram 29.9 picogram (27.0-32.0) (27.0-32.0) 35.3 % (32.0-36.7) 34.3 % 02.0-36.7) 12.6 (11.5-14.5) 12.6 (11.5-14.5) 132 thou/cram 158 thou/cram (150-450) L (150-450)

9.13 thou/err~ (4.00-11.00) 3.85 mil/cunan (4.2-5.90) L 11.5 GMIDL (13.5-18.o) L

}~_ tVlorphology

EAOUSAFOIA0000603

Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 24 of 31

Name: Magliocchet Paul J


Room/Bed: 4823 / A Medical Record #: M002504256 Visit Number: V00303720062 Physician: Marur,Surendra M.D.

Date: 7/20/2010 9:47:21 AM

PT 12qR PTT

15.1 SECONDS (13.0-15.3) 1.09 28.3 SECONDS (24.9-34.5)

14.3 SECONDS (13.0-15.3) 1.02 33.8 SECONDS (24.9-34.5)

Sodium Potassium Chloride Carbon Dioxide A"" ,ap r,..,alne BUN/Creatinine Ratio "Glucose Calculated Osmolafity

136mEQ/L

136 mEQ/L

(133-145)

(133-t45)

C:" "~m
\.

Iomzed Calcmm Cal Phosphorus Magnesium

tTotal Protein
Albumin Globulin TSH 3rd Generation

2.7 MEQ/L (3.3-5.1) 2.9 MEQ/L (3.3-5.1) L L 104 MEQ/L (96-108) 103 MEQ/L (96-108) 102 MEQ/L (96-108) 106 MEQ/L (96-108) 102 MEQ/L (96-108) 23 MEQ/L (22-29) 22 MEQ/L (22-29) 22 MEQ/L (22-29) 23 MEQ/L (22-29) 21 MEQ/L (22-29) L 11.0 (5-16) 11.0 (5-16) 7.0 (5-16) 13.0 (5-16) 9.0(5-16) 20 MG/DL (8-29) 19 MG/DL (8-29) 20 MG/DL (8-29) 22 MG/DL (8-29) 21 MG/DL (8-29) 0.9 MG/DL (0.5-1.2) 0.9 MG/DL (0.5-1.2) 0.9 MG/DL (0.5-1~.) 1.0 MG/DL (0.5-1.2) 0.8 MG/DL (0.5-1.2) 22.2 RATIO (8-29) 24.4 RATIO (8-29) 23.3 RATIO (8-29) 23.7 RATIO (8-29) 20.0 RATIO (8-29) 324 MG/DL (70-115) 335 MG/DL (70-115) 281 MG/DL (70-I 15) 218 MG/DL (70-I 15) 281 MG/DL (70-115) H H H H 297 mOSM/KG 297 mOSM/KG 292 mOSM/KG Pending 293 mOSM/KG (277-297) (277-297) (277-297) (277-297) 8.2 MG/DL 8.1 MG/DL Pending 8.0 MG/DL 7.8 MG/DL (8.8-I0.2) L (8.8-I0.2) L (8.8-10.2) L (8.8-I0.2) L 4.25 MG/DL (4.30-5.20) L 0.5 MG/DL (2.6-4.5) 2.4 MGiDL (2.6-4.5) L L 1.52 MG/DL 2.13 MG/DL (1_59-2.56) L (1.59-2.56) 6.2 G/DL (5.9-8.4) 3.2 G/DL (3.2-5.2) 3.0 G/DL (2.0-.4.0) 1.770 ulU/ML (0.38-4.70)

136 mEQ/L 136 mEQ~ (133-145) (133-145) 4.2 MEQ/L (3.3-5.1) 4.3 MEQ/L (3.3-5.1) 4.4 MEQ/L 0-3-5.1)

135

(133-145)

F I ~otassium I Chloride Carbon Dioxide

135 mEQ/L (133-145) 3.5 MEQ/L (3.3-5.1)

~o5 vmQ/L (96-io8)


24 MEQ/L (22-29)

102 MEQ/~(96-108) 105 MEQ/L (96-108) 107 MEQ/L (96-108) 22 MEQ/L (22-29) 24 MEQ/L (22-29) 25 MEQ/L (22-29)

EAOUSAFOIA0000604

Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 25 of 31

Name: Magliocchet .aul J


Room/Bed: 4823 / A "-"" Medical Record #: M002504256 Visit Number: V00303720062 Physician: Marur, Surendra M.D. Date: 7/20/2010 9:47:21 AM

BUN Creatinine BUN/Creafinine Ratio Glucose

Calculated Osmolality
Calcium

Calcium Calc
Phosphorus Magnesium Total Protein Alb,,min d Generation

9 MG/DL (8-29) 15 MG/DL (8-29) 13 MG/DL (8-29) 9 MG/DL (8-29) 0.SMG/DL (0.5-1.2) 0.7 MG/DL (0.5-1.2) 0.7 MG/DL (0.5-1.2) 0.7 MG/DL (0.5-1.2) 18.7 RATIo (8-29) 18.5 RATIO (8-29) 12.8 RATIO (8-29) 12.8 RATIO (8-29) 174 MG/DL (70-115)361 MG/DL (70-t 15)177 MG/DL (70-115) 114 MG/DL (7O-I 15) H H H 285 mOSM/KG 284 mOSM/KG 286 mOSM/KG 284 mOSM/KG (277-297) (277-297) (277-297) (277-297) 7.7 MG/DL 7.3 MG/DL 7.6 MG/DL 8.7 MG/DL ~8.8-10.2) L (8.8-10.2) L (8.8-10.2) L (8.8-10.2) L 4.tSMG/DL 4.63 MG/DL

(4.3O-5.20) L
2.0 MG~L (2.6-4 5) L t.95 MG/DL 1.94 MG/DL (1.59-2.56)

(4.30-5.20) 3.2 MG/DL (2.6-4.5)


2.00 MG/DL (1.59-2.56) 6.6 G/DL (5.9-8.4) 3.1 G/DL (3.2-5.2) L 3.5 G/DL (2.0-4.0)

(1.59-2.56) 6.1 O/DL (5.9-8.4)


2.9 6fDL (3.2-5.2) L 3.2 e/DL (2.0-4.0)

PCP-~OBIOLOGY ~.._.:OBIOLOGY MICROBIOLOGY

Jul 17, 2010 00:43 Jut 17, 2010 05:05 lul 17, 2010 05:05

MRSA SCREEN BLOOD CULTURE BLOOD CULTURE

Complete In Process In Process

EAOUSAFOIA0000605

Case 1:10-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 26 of 31

Patient: MAGLI(~CCHEITI,PAUL J

Account#: V00303720062 PROGRESS NOTE

4823 Location: U48 Account #: f V00303720062 PatJentName:IMAGE!OCCHETTI,PAULJtUnit#: IM002504256Room: DOB: 07/22/1946 I

DATE/TIME NO1"ECRF~TEE): 07/19/2010; 09:29 INTERN NAME:,Zia, Sareer .~ RESIDENT NAME~ Marur, Surer~dra ATIENDING NAME. Marur, Surendra **SU BJ ECTIVE** HP__J: Pt is a 63 yo gentleman With past history of alcoholism, BPH with elevated PSA negative prostate bioEsy ~,,~2 ~oronary stents who is currently being treated for depression at SheppardoPratt. Pt notic~d macroscopic hematuda and dysuria 7/15/2010 evening and was transferd to the GBMC ED. Initallyth6;pat.ient produced a around 500cc of frank blood from a small Foley which was placed, bu~t tr~e b,~th~ter soon occluded. The patient then developed suprapubic pain and distention, and continuedt,o~Q~6~t~e frank viscous blood. The pt grew diaphoretic and tachycardic with HR into th~ 140s~ Even.tuat~-y, nursing was able to palce a large gauge Foley per urology recs and the patient,,p~odu~ed &.pr.6d~gious amount of bloody urine. The bladder was flushed with normal saline, and bleeding appeared tb"slow.
Interval History: Patient r~_ po~ed developing fever last night for which he was given tylenol and thefever resolved, He denied having any abdominal discomfort though he reported having some-p&in ~at the tip of uret~hra. No excessive thirst.

REVIEW OF S~STEMS -: GI: Normal; CV: Normal; NEURO: Normal


CODE STATUS: Full Code **OBJECTIVE ,.EXAM** VITALS Name Temp Pulse RR Sys BP Dias BP 02 (L/rain) 02 Sat (%) Method Intake / Output Informat[or~ O7119110 0el0 37.2 93 18 130 85 95 Room Air 07/t 9110 03:50 37.9 92 24 145 92 95 Room Air 07/18110 20:35 37.3 81 18 106 52 Room Air

Name 07/1912010 06!_09~ AM Udnary Catheter TypelLocation Output, Urine Amount from Oath

Value 5 2300

Units ml

GREATER BA~.~ TIMORE MEDICAL CEN iER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0719-0037 PAGE 1 OF 6

EAOUSAFOIA0000606

Page 27 of 31 Case 1:10-cr-OO286-TSE Document 30-10 Filed 12/13/10

Patient. MAGLIOCCHETrI,PAU~ J 07/19/2010 01:30 AM Urinary Catheter Type/Location Output, Urine Ar~ount from Cath 07/18/2010 04:00 PM Urinary Catheter~ Type/Location Output, Udne Amount fromCath Daily Weights and BMI- (if recorded) Name Weight (tbs.) Meas. Method
Name BMI Calculation

Account #: V00303720062 5 2500 5 220 07/17/10 07:33 184.00 Wheelchair ml ml 07117110 06:02 184.00

06~13 189.00 Wheelchair


07117110 07:33 27.2

07t!8/t0

PHYSICAL EX~ General: No adjte distress; Appears stated age; Patient is in no acute distress, lying comfortably in bed. Eyes: Extra ocular mov~ement Intact; Pupils equal, round, react=ve to light; No conjunctival injection; Sclera ~nicteric HENT: Normoc~eph~lic, atraSmatic CV: Regular ~ate and rhythm" Lung: clear to au~cultatior$ b=l-ate~a!ly Abd: non tender;, No guardi~flr~bound Ext: Pulses 2+ Neuro: Alert aqd oriented {o person, place, time GU: Foley in place TEST RESULT~ (* =High or Low
Metabolics / Upids

** =cri~cal)
Range "[33-145 3.3-5.1 96-108 22-29 8-29 0.5-1.2 8-29 70-115 8.8-10.2 277-297 5-16 Range 5.9-8.4 0-1.0 4-37 07119/10 05:52 136 3.4 105 24 9 0.7 12.8 177" 7.6* 284 7.0 07/18110 03:45 6.1 0.6 30 07118/10 19:43 131" 3.2* 102 22 13 07 18.5 361" 7.3* 286 7.0 07117110 10:35 6.2 07/18110 03:45 135 3.5 105 24 15 0.8 18.7 174" 7.7* 284 6.0 07116110 17:36 7.7

Name Units NA nl~EQ/L K MEQ/L CL MEO]L C02 MEQ/L BUN MG/DL Creat MGtDL BUN Cr Ratio RATIO GLU Serum MG/DL CA MG/DL OSMOC mOSM/KG Anion Gap Name Total PROT Total BILl AST Units GIDL MG/DL lUlL

GREAI L-R B ,ALTIMOREMED1CAL CENi ~:R 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report#: 0719-0037 PAGE 2OF 6

EAOUSAFOIA0000607

Case 110-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 28 of 31

Patient: MAGUOCCHETT!,PAU~L.J 4-40 lUlL ALT 39-~117 lUlL ALKP 4.30-5.20 MGIDL Ionized CA 3.2-5.2 G/DL ALB 2.0-4.0 GtDL GLOB 0.87-2.00 ALBGIobratio RATIO

Account #: V00303720062 39 112 4.26* 4.25* 4.18" 4.0 3.2 2.9* 3.7 3.0 3.2 1.08

Name MG Name Phosphorus

Units MG/DL y_nits MG/DL

Range 4.59-2.56 Range 2.6-4.5

07/191t 0 05:52 1.94 07118110 03:45 2.0"

07118/10 03:45 1.95 07/17/10 10:35 2.4*

07117110 10:35 2.13 07/17110 02:09 0.5*


07/17/10 18:09 17.18" 11.9" 34.4* 89 130*

CBC / Blood Gases / Card~ Enz~a~nes/Coa.qs ! Fingerstick 07/18/10 07119It0 Rppge 05:52 03:45 Name Units 8.44 12.85" thou/cmm 4.~0-11.00 WBC 10.9" Hemoglobin ~M/DL 13.5-18.0 10.6" 31.9* 40;0-54.0 30.0* Hematocdt % ~7-103 87 89 Mean Corp Volcumicrn 150450 132" 130* Platelet Count thou/cram Name Units C-reactive pro MG/DL Name Units Sed rate, auto mm/hr Name aPTT PT INR ,Units SECOND.S SECONDS Range 0~0-0.5 Range 0-20 Range 24.9-34.5 13.0-15.3 07116/10 17:36 4.4* 07116/10 17:36 53* 07/191t 0 05:52 33.8 14.3 1.02 07/17/10 02:09 28.3 15.1 1.09 07/19/10 08:15 192

07116/10 17:36 29.2 13.4 0.94 07/18/10 21:10 305 07/18/10 18:16 209

Name Finger Stick BG

Units rngldl (Norm 70-120mg/dl)

Radioloqy 07/17/2010 ! 0~38 AM CHEST 1VW PORTABLE Hypoventitatory changes a~e seen in the lung bases. Cardiac silhouette is accentuated by the hypoventilatery~hange thoughts not grossly enlarged. Pulmonary vasculadty is not engorged. A focal pneumonltisJs not identified. IMPRESS1ON:~ No sped~c evidence of acute cardiopulmonary disease. Hypoventilatory changes are present. Other Results:

GREATER BA~, TIMORE~MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0719-0037 PAGE 3 OF 6

EAOUSAFOIA0000608

Case 1 10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 29 of 31

Accouht #: V00303720062

AC

~:Q6H ~1 IVPUSH Q4H

GL
ULF-INJ 1 GM/2 ML VIAL.2 GM IV PRN 1GM/10 MLVIAL.1 GM IV PRN GM/10 ML VIAL 2 GM IV PRN IL IM PRN

J3 MM/MLVIAL 15 MM IV PRN VIAL i5 MM IV PRN


NFCE 0 SUBCUT AC 0-SUBCUT HS

BY PHARMACY) 1 N/A ONE ONE negative prostate .pression at I, concern for ~urgery on board.

bio mali

~table.for now.-Hematuda tremendously removal of ~ririaw cath:eter~ Last 2)Attertdi.~g.i~re~ien~:: Ane~ja-:~liki~l~:se~ida~t:omacrosc0pic;hematur a. (285.9 ANEMIA SECONDARY TO

Repo~.#~ 07~9~037

PAGE4-~6

EAOUSAFOIA0000609

Case 1:10-cr-00286-TSE Document 30-10 Filed 12/13/10 Page 30 of 31

Pat=ent: MAGLIOCCHErrI,~AUL J

Account #: V00303720062

,)UTI (599.0 URINARY TRACT iNFECTION) Attending Plan: Urine Cx no~trowth presently. Because of pyuda, complete 5 day course of ABx. InterrYRes Plan: OeftriaxonelV for now. Ordered urine culture, sensit=vity still waiting on the microbiology. Present on Admission Status: Yes Status: Improved Last Modified: 7/17/20t0 4)Electrolyte anomalies (27~ ELUID AND ELECTROLYTE DISORDERS) Intern/Res Ram Hypopha~sphatemia: Replete with neutrophos or other potass=um supplements. Hypocalcemia:- Replete. Hypokalemia: Reselved. Hypomagnesemia! Repl~ted and resolved today. Last Modified: 711712010
5)Diabetes (250.00 DIABETES MELLITUS) Attending Plart:.~New d~ragnosls. ~ontact Geckle center for teaching. Treat with oral medications like glyburide 2.~Smg BID,~,ith rr~tform~n 500mg BID. Intern/Res Plan: lns.uli[~ d~scontJnued. Mefformin 500 mg twfce daily. Glybudde 5 mg.~wice da~ly. Ref. to Geck[e~ DM tenor for.DM ed. Present on Admission-Status: Yes Status: New Last Modified: 7117/2010 6)Depression, mood disorde~311.DEPRESSION) Attending Plan:, Retur~-t~-,~E~F~l~elr DC from GBMC. InternJResPlan: Will ~rt~t~&~s~wben patient stabilizes Present on Admission Stat8sr Yes Status: Stable, Last Modified: 7/17/20t0 7)HTN (401.9 ESSENTIAL HYPERTENSION) Attending Plan: Tomorrow, if BP >~f30180, would start low dose ACE-~. Intem/Res Plan: Hold meals gtven5lood loss. Present on Admission StatLis: Yes Status: Stable Last Modified: ~7/16t2010

8)Prophylaxis Intern/Res Plan: PPI/SCIDS Last Modified: 7t1712010


9)Attending Prob!em: BPH (600.00 BPH W/O URINARY OBS4"RUCTION W/OTHER LOWER URINARY TRACT SX) Attending Ran: S/P TURP. Present on Admission Status: Yes Status: Improved Last Modified: 7f1912010

GREATER BALTIMOFe~. 1/Ii~gi6~/8_ CEN~ER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0719-0037 PAGE 5 OF 6

EAOUSAFOIA0000610

Case 110-cr-OO286-TSE Document 30-10 Filed 12/13/10 Page 31 of 31

Patient: MAGLIOCCH ETTt, PAB~.. J **COMMUNICAI"iON**

Account#: V00303720062

Pdmary Care MD: Referring, NQN GBMC,Physician "INTERN ADDIII(~NAI~ CO~TS ! SIGNATURE** INTERN 81GNATI~RE IN SAi:AR: Zia, Sareer ; Electronically signed by Sareer Zia, MD at 10:05; 7/19/201 O; 10:05 **RESIDENT COMMENTS/.SI6NATURE** Patient post TURP, mi~]rrfa[~t{erri&tuda now, Hct stable, patient much improved clinically. Awaitin urology input regarding remQ~al of urinary catheter. Adjusting DM meds., will get Psych. consult 7/19/20~0 as p~tient may bestable for discharge later 7/19/2010 or tomorrow. RESIDENT SIGNATUREIN 8ALAR: Electronically signed by Rajesh Tota-Maharaj, MD at 11:49; 711912010; 11:49

"AI-rENDING ~OMMENTS:/SrGNA~TLI RE** Patient I~lans td ~etum to his:hS~e in Florida after DC from SEPH.
Attestation: I saw and eva],uated the patient with the clinician above. I discussed the case with the clinician, revrg~d-the clinicians note and agree with the findings and plan as documented in the above asses~sment with any exceptions/additions noted above.

Patient Status In System: I AnENDING SIGNATURE]N~SALAR: Electronically signed by Surendra Marur, MD at 20:40; 7/19/2010

GREATER~BA~-~ "TIMOREML=~iCAL CENTER 6~,0f NORTH CHARLES STREET BALTIMORE, MD 21204 Report #: 0719-0037 PAGE 6 OF 6

EAOUSAFOIA0000611

Case 110-cr-00286-TSE Document 30-11 Filed 12/13/10 Page 1 of 3

Exhibit 11
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000612

Case 1:10-cr-00286-TSE Document 30-11 Filed 12/13/10 Page 2 of 3

24200 Grand Ellison Court Aldie, Virginia 20105 October 27, 2010
The Honorable T.S. Ellis, III United States District Court for the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, Virginia 22314 Re: Paul Magliocchetti, Case No. 10-cr-286 Dear Judge Ellis: It is my understanding that Paul Magliocchetti is to be sentenced after pleading to charges concerning political campaign contributions. I would like to provide some personal insight into his character that may be useful to you. Paul and I have been friends for over 30 years. During our friendship, we have watched the collective growth of our children, shared social occasions, argued sports and politics, and other activities that allow people to form and nurture friendships. It is from this base that I offer comment. Over many years, his service on the House Defense Appropriations Committee has been well documented. During the course of his congressional career, Paul conducted a vigorous oversight of Department of Defense programs that resulted in millions of dollars in savings for US taxpayers. He was recognized as one the top budget analysts on Capitol Hill. I have frequently witnessed the mans generosity whether it was family-oriented or support for programs such as the "Wounded Warrior "at Walter Reed Hospital, the fledgling womens athletic program at East Carolina University or various religious foundations. Wherever he found legitimate need or was asked in his community or religious life to help, he did so freely. This type of behavior began many years before the inception of Paul Magliocchetti and Associates. To date, he has lost his company, relationships within his family and some individuals within his peer group. All of which, in my opinion, has seriously eroded his mental and physical health. I have seen him infrequently as of late because of the course of events; but at a brief luncheon recently, I observed that the vibrant, energetic, engaging man I have known is no longer there. He speaks softly and hesitantly as if he had to measure each word. Paul looked to me as if he had aged ten years. During our conversation, he appeared to have great difficulty focusing. I literally had to prompt him back into our conversation.

EAOUSAFOIA0000613

Case 110-cr-00286-TSE Document 30-11 Filed 12/13/10 Page 3 of 3

In summary your Honor, despite his recorded transgressions, Paul has enormous talents and human capacity that can continue to be used to the benefit of society. It is my fervent hope that somehow that can happen.

James D. Waiters Retired Principal Fairfax County Public Schools

EAOUSAFOIA0000614

Case 110-cr-OO286-TSE Document 30-12 Filed 12/13/10 Page 1 of 3

Exhibit 12
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000615

Case 1:10-cr-00286-TSE Document 30-12 Filed 12/13/10 Page 2 of 3

The Honorable T.S. Ellis, III United States District Court For the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, VA 22314

NovemberlO, 2010

Re: Paul Magliocchetti, Case No. :[0-cr-286

_Dear Judge_Ellis: I offer this letter of support for Mr. Paul Magliocchetti whom I have known for over :[5 years, i first met Paul in a business capacity as his firm represented my employer as a business development consultant and eventually performed lobbying services on behalf of the Company. Paul was instrumental in assisting the business become successful in the Government contracting industry. Paul was one of the best in the business. The organization performs research and development work in support of the Department of Defense. Thanks, in part, to Pauls business acumen and knowledge, the Company now employs over 1400 professionals throughout the nation. Some of the innovative solutions developed by the organization that have saved the lives of many Military personnel were the result of Pauls leadership and perseverance. Paul worked with and assisted me in doing business with the Executive and Legislative Branches of Government. Although companies retained Pauls organization for services to be provided, he always viewed his role as ensuring that whatever ideas were brought forward by companies his firm represented, they needed to be of value and be of benefit to the Government. His relationship with Members of Congress and the Executive branch was more important to him than a client who was trying to benefit from his knowledge of the business process and his relationships. He demonstrated a high degree of integrity when it came to accepting this self imposed responsibility. As a result of Pauls leadership and service and the talented leadership within the Company, the organization has achieved sustained growth and continues to assist the nations war fighters and the Intelligence Community with innovative solutions.

I also had the opportunity to work with Paul on charitable giving programs that benefitted many young people in Western Pennsylvania. Paul grew up in Western Pennsylvania and I always believed that he was willing to help with fundraising as a way to pay back those who helped him and to also pay it forward for new generations in Western Pennsylvania. Together, we worked at raising money for the Girls Scouts of Western Pennsylvania, The Challenge Program and other educational initiatives. During the time we worked on fundraising for Girl Scouts, we helped to raise over $600,000 of net proceeds

EAOUSAFOIA0000616

Case 1:10-cr-00286-TSE Document 30-12 Filed 12/13/10 Page 3 of 3

that was used to directly support programming aimed at assisting young girls achieve self esteem and confidence. Prior to our involvement, the Girl Scouts raised approximately ~;75,000 over the same .... number of years. -In addition, Paul and-his-firm helped to ra~semoney-for-The C-hallenge-Program~- This program assists high school students to be more conscientious about achieving success in school and to also learn about career opportunities in the region, based upon the businesses located there. Both of these programs grew more rapidly and they were able to assist many more young people because of Pauls direct involvement. And Paul never asked for anything in return. Over the years, Paul and I also became friends. Since the November 2008 raid, Pauls outlook and health have changed dramatically. He was always upbeat and he liked to do things for people, especially his family. He was proud of his family and extended family. He employed his son and his sister in law. Family was always involved with his life. More recently, Paul has been diagnosed with diabetes, depression and several other ailments and has had at least one surgery as a result of a serious prostate infection. Throughout this ordeal, he has experienced many lows. I have, on more than one occasion, been very con-c~rr~-~l-~l~out-I~b~,-I~i~--Sealt-h and his mental outlook. Paul has acknowledged that he made some missteps and he has been hard on himself and held himself to be accountable. While Paul has accepted responsibility for several inappropriate actions, I would urge you to consider Pauls service and generosity throughout his professional and personal life, i.e., his life time "body of work", when considering the level of punishment that is appropriate. I am appreciative of your time and consideration.

Sincerely,

802 Luzerne Street Johnstown, PA 15905

EAOUSAFOIA0000617

Case 110-cr-00286-TSE Document 30-13 Filed 12/13/10 Page 1 of 3

Exhibit 13
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000618

Case 1:10-cr-OO286-TSE Document 30-13 Filed 12/13/10 Page 2 of 3


Lou BROWN
4801 MAURY LANE ALEXANDRIA, VIRGINIA 22304

The Honorable T.S. Ellis III United States District Court For the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, VA 22314 Re: Paul Magliocchetti, Case No. 10-cr-286 Dear Judge Ellis:

I am a personal friend of Paul Mal~liocchetti, and have been for about 13 years. My initial connection to Paul was through business, but this then developed into a personal friendship, particularly cemented by our mutual love of good wine. Prior to the November 2008 raid, as you know, Paul was the owner and manager of a successful business, The PMA Group. Paul is clearly a Type-A personality, and had built his business over about 20 years, providing employment and value for many people. That all changed in November, 2008. This, of course, was not only a shocking event in itself, but Paul immediately saw everyone connected with him paying a huge price for what he had done, as well as the despair of watching his company and the work of his hands for the past 20 years disappear overnight. The subsequent stunning effect on Paul and his health was incredible. I personally spent many hours "talking him back off the ledge". He profoundly felt the intense impact of this, not only on himself, but more deeply on its related effect on many others, starting with his family and his employees. He went through deep depression, often feeling that he should end his life to make everything easier on others. I am no doctor or psychiatrist, but his deep-rooted feeling of regret for what he had done, his remorse for the life-changing negative effect on everyone around him, and being a negative force for so many others weighed on Paul heavily. It was almost more guilt and pressure than he could handle. Fortunately through counseling and medication he has survived, but the scars are with him forever. Paul ran The PMA Group as many Type-A folks do ... with an iron hand, but with a velvet glove. The PMA Group was, indeed, a "benevolent dictatorship", but a "very benevolent dictatorship". Paul was very generous with his employees, with friends and family providing employment for many who asked, and arranging employment for many others. Starting with his family and friends, he provided employment for many. He approached the Steinbrenner family to help get his daughter a job with the Yankees organization. He provided housing for his aging in-laws, as well as other relatives. He rarely denied requests, or at least he tried to help as best he could. Finally, after the November 2008 raid, he

EAOUSAFOIA0000619

Case 1:10-cr-00286-TSE Document 30-13 Filed 12/13/10 Page 3 of 3

refused to "throw others under the bus" just to try to secure a better position for himself in the negotiations of any settlement. Paul was also generous in other ways. Since Paul had a life-long connection to our armed forces from his days on the defense appropriations committee staff, he was a strong supporter of national defense, and especially our troops. Each Christmas he hosted a large Christmas party for wounded warriors from Walter Reed and their families. One would have to be there to feel the emotional warmth of what that meant to all who participated. Paul also was a generous donor to many charities ... The Challenge Program, the Girl Scouts, and the Womens" Shelter to mention a few. Finally, in my 13 year association with Paul, my observation was that he tried to do things the right way. If he made a commitment, he kept it. Indeed, his word was his bond. He was a tough but fair negotiator, but he always kept his word. I believe that in his heart Paul Magliocchetti is a good person and he has been a good friend.

Sincerely,

Lou Brown

EAOUSAFOIA0000620

Case 110-cr-00286-TSE Document 30-14 Filed 12/13/10 Page 1 of 3

Exhibit 14
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000621

Case 1:10-cr-00286-TSE Document 30-14 Filed 12/13/10 Page 2 of 3

Karen Oleyar 106 Dewey Street Pittsburgh, PA 15218

November 1, 2010 The Honorable T. S. Ellis, III United States District Court for the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, Virginia 22314 RE: Paul Magliocchetti, Case No. 10-cr-286 Dear Judge Ellis: I am writing this letter in support of my friend Paul Magliocchetti. I have known Paul for many years and have remained in close contact with him since the time of the investigation that has led to the current charges against him. I welcome this opportunity to write to you on his behalf because I continue to hold Paul in high regard and consider him a true friend. It is my sincere hope you will take into consideration my comments when determining Pauls sentencing. I have always known Paul to be a genuine, caring and selfless person. It came as no surprise to me that he put the interests, privacy and security of his family and friends ahead of his own during the course of the investigation, despite the additional legal and financial impact on him personally. Paul has always been a dedicated and committed husband to his wife Becky, father to his children and loyal friend to many - and this has not changed over the past several months. I have been in close contact and in his company on several occasions and see that he continues to be invested in his family and friends, providing emotional support, advice and personal guidance despite his current situation and the uncertainty of his future.

I feel that it is important to share with you that Pauls kindness and generosity have been extended well beyond his family and close friends. Paul has a tremendous admiration and respect for our service men and women. He has worked tirelessly on their behalf during his years as a staffer on the defense appropriations committee, and later in his career Paul routinely organized, sponsored and championed events to support our wounded warriors at Walter Reed Hospital. Paul also has a passion for children and education. Over the past years Paul supported the Sisters of St. Joseph School in Baden, Pennsylvania by donating computers, support staff to set them up, as well as funds and on-going supplies. Paul has been invested and is passionate in promoting advancements in the education of children.

EAOUSAFOIA0000622

Case 1:10-cr-OO286-TSE Document 30-14 Filed 12/13/10 Page 3 of 3

Sadly, the impact of this investigation has taken a tremendous toll on Paul personally. This once passionate, driven and contributing professional and member of the community not only lost his business and his professional reputation, but also his ability for involvement with others that he once helped in his community. Over the past months he has been faced with serious physical and mental health conditions that now require his constant attention and medical care. Pauls professional lobbying career is over and he poses no threat to the community. But with on-going medical treatment, continued support of his family and friends and leniency in sentencing, it my fervent hope that he will be able to be a part of his family and friends lives on an daily basis and once again be an active, contributing member to his community in the kind, caring and compassionate manner that he so frequently demonstrated through out his life. I truly believe that Paul has already paid a heavy price for his actions. I know he is sincerely remorseful, extremely saddened to have negatively impacted so many others and will continue to spend the rest of his life dealing with the consequences of his actions. I thank you for your time in reading this letter. I hope you will consider this perspective from a person that truly knows Paul and most importantly, that you come to believe as I do, that incarceration will serve no further societal or personal good. Thank you for your consideration.
Sincerely,

EAOUSAFOIA0000623

Case 110-cr-00286-TSE Document 30-15 Filed 12/13/10 Page 1 of 3

Exhibit 15
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000624

Case 1:10-cr-00286-TSE Document 30-15 Filed 12/13/10 Page 2 of 3

Kim W. Kunkle
111 ROOSEVELT BOULEVARD JOHNSTOWN, PENNSYLVANIA 15907

October 15, 2010

The Honorable T.S. Ellis, III United States District Court for the Eastern District of Virsinia 401 Courthouse Square, 9th Floor Alexandria, Virsinia 22314

Re: Paul Masliocchetti, Case No. :10-cr-286

Dear Judse Ellis:

I am writin8 a letter of support for Paul Masliocchetti. I have known Paul since the late 80s when he assisted our company in 8ettin8 started manufacturing electrical harnesses for the defense industry. Pauls knowledge of defense contracting combined with his patience 8ave a fledgling company a chance to compete in a national market that we did not think was possible. Paul also gave unselfishly of his time to assist the economic development organizations in Johnstown, Pennsylvania to learn the business of defense contractin8 so that they could encourage other entrepreneurs to do defense work. Johnstown was a community that had been ravaged by the decline of the steel and coal industry and was full of proud people with a strong work ethic who wanted to return to work. With Pauls Pittsburgh roots he could easily associate with the plight of Johnstown. He made countless trips from Washington D. C., numerous factory tours and conducted hundreds of meetinss to spur the development of our defense industry. Much of this work was done without compensation. Today Johnstown has a thriving defense industry with national class capabilities, high quality work and competitive cost structures. Paul tausht those people that he worked with that it was always important to do the right thing for the war fighter. He would not be a party to a project or a program that did not have justification and did not benefit the men and women in uniform. Throughout my association with Paul, he always gave unselfishly of his

EAOUSAFOIA0000625

Case 1:10-cr-00286-TSE Document 30-15 Filed 12/13/10 Page 3 of 3

-2-

time and money to support veterans and returning soldiers. I fondly remember going to his annual Christmas party in Washington for his clientele. It was always a great evening with a lot of good food and interesting people. Shortly after the Iraq war, he cancelled this dinner for his clients and instead invited people who were serving or injured in Iraq. This was a great decision and demonstrates that Pauls heart has always been in the right place. I understand that Paul has come to grips with his misconduct. I am writing to ask that you would judge him on his lifetime of work and not just on these few misdeeds. Sincerely,

Kim Kunkle

EAOUSAFOIA0000626

Case 110-cr-OO286-TSE Document 30-16 Filed 12/13/10 Page 1 of 3

Exhibit 16
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000627

Case 1:10-cr-00286-TSE Document 30-16 Filed 12/13/10 Page 2 of 3

The Honorable T.S. Ellis. III United States District Court for the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, Virginia 22314
Re: Paul Magliocchetti, Case No. 10-cr-286 October 14, 2010

Dear Judge Ellis,


The purpose of this letter is to provide you with insight into Paul Magliocchetti. Mr. Magliocchetti and I first met when he was working with the House Appropriations Defense Subcommittee. I am a retired USMC aviator with over 35 years of service. Mr. Magliocchetti was responsible for accounts that funded the aviation programs for the Marine Corps and for the Navy. ! was responsible for liaison with the Congress regarding funding of the US Marine aviation programs.

During the time that we had the opportunity to work together Mr. Magliocchetti was the consummate professional staff member and I considered him to be of highest integrity and professionalism. I also found him to be very insightful and innovative and directly because of his budgeting expertise and economy of management, Naval Aviation was able to procure more Air capability for less money than in any other comparable era of which Im aware. It is my opinion that he was directly responsible for improving both the Air attack and defense capability of both the Navy and the Marine Corps.
I would like to share one particularly heart-warming story that typifies his dedication to our Armed Forces. Mr. Magliocchetti had been told a story about an enlisted Marine, he knew as "Uncle Bobby" (although they were not related) who served in Korea. The story was Uncle Bobby and his unit were trapped in a rice paddy under heavy fire from the enemy. Less than 5 Marines made it out alive and all were severely wounded. Uncle Bobby ended up in a hospital in Korea and was eventually sent home to recover from his injuries. At the time, I was serving as a Marine Corps Legislative Liaison and Paul asked me to verify the story. Using Uncle Bobbys serial number, I was able to research and confirm the story. It was also discovered that Uncle Bobby had never received any of the medals he had been awarded as a direct result of his actions while trapped in that rice paddy under enemy attack. Paul decided that these medals were long overdue so together he and I and devised a plan to get Uncle Bobby to come to the Pentagon and in a surprise ceremony he was awarded the medals

EAOUSAFOIA0000628

Case 1:10-cr-00286-TSE Document 30-16 Filed 12/13/10 Page 3 of 3

due him by the then-Commandant of the Marine Corps, General Gray. It was a very emotional and gratifying day for both of us.
I would classify our relationship as cordial, professional and to a certain extent, spiritual. In my other walk of life, I am a hi-vocational Baptist minister and have worked with Mr. Magliocchetti on putting together two wedding ceremonies--one for an employee, and one for a family member. During the planning phases of both these weddings, I found him to be a faithful Catholic and feel certain that its his faith that is the impetus for his dedication and loyalty to his family, friends and colleagues. It would also be my opinion that his faith has been both comforting and distressing as he comes to terms with the devastating impact of recent events to himself, his family, friends and colleagues.

When Mr. Magliocchetti left government employment and joined the private sector we ceased to have an opportunity to work together regularly. I did see him from time to time at Washington charity events and knew that he actively supported the community through charity activities and financial support of the same.
Since I have no specific personal knowledge of his guilt or innocence, I will not comment on such, however, I do find the allegations against Mr. Magliocchetti to be out of character for the man that I know. I was saddened and disappointed when I became aware of the charges filed against him. Regardless of the outcome, this does not change my opinion of the man that I have described in this letter and I will continue to be proud to have worked with him on Capitol Hill. I believe that he has made significant contributions of a positive nature to both country and community.

Very respectfully,

Randy West

EAOUSAFOIA0000629

Case 1:10-cr-OO286-TSE Document 30-17 Filed 12/13/10 Page 1 of 10

Exhibit 17
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000630

Case 1:10-cr-OO286-TSE Document 30-17 Filed 12/13/10 Page 2 of 10

Summary Chartible Contributions 2005 2006 2007 2008 $136,856.42 ~; 191,431.28 $193,062.24 $194,376.00 715,725.94

The PMA Group

EAOUSAFOIA0000631

Case 1:10-cr-OO286-TSE Document 30-17 Filed 12/13/10 Page 3 of 10

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Case 1:10-cr-OO286-TSE Document 30-17 Filed 12/13/10 Page 4 of 10

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Case 110-cr-00286-TSE Document 30-17 Filed 12/13/10 Page 7 of 10

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Case 110-cr-OO286-TSE Document 30-17 Filed 12/13/10 Page 8 of 10

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Case 1:10-cr-OO286-TSE Document 30-17 Filed 12/13/10 Page 9 of 10

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Case 1:10-cr-OO286-TSE Document 30-17 Filed 12/13/10 Page 10 of 10

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Case 110-cr-00286-TSE Document 30-18 Filed 12/13/10 Page 1 of 2

Exhibit 18
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000640

Case 1:10-cr-00286-TSE Document 30-18 Filed 12/13/10 Page 2 of 2

71 Skytop Road Cedar Grove, NJ 07009 October 18, 2010

The Honorable T.S. Ellis, III United States District Court For the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, VA 223:~4 Reference: Paul Magliocchetti, Case No. 10-cr-286 Dear Judge Ellis: I have known Paul Magliocchetti for over twenty years. He always appeared to me to be an upstandin8 citizen. Paul always let me know of his pride for me for my service in the Marine Corps. All the years I have known Paul I was always impressed with what a true family man he was. Holidays were always a family celebration. Birthdays were always remembered as special occasions. Paul had a warm heart for the military, and each Christmas he rented a restaurant and gave everyone from Waiter Reed a holiday dinner. He also made numerous donations in support for Walter Reed. His professional work on the hill was always made in an effort to provide the utmost for our men and women in service. Their safety was always most important to Paul. The case brought against Paul has taken a toll on his mental health. I have observed several instances when he seemed very depressed. After one particular phone conversation with Paul, I flew to DC to help him regain his respect for life. I hope this information will have bearing on Pauls sentencing. I wrote this letter to give you a glimpse of the Paul Matliocchetti I know and respect. Best regards,

Robert Ringer

EAOUSAFOIA0000641

Case 110-cr-00286-TSE Document 30-19 Filed 12/13/10 Page 1 of 3

Exhibit 19
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000642

Case 1:10-cr-OO286-TSE Document 30-19 Filed 12/13/10 Page 2 of 3

The Honorable T.S. Ellis, Ill United States District Court for the Eastern District of Virginia 401 Courthouse Square, 9tl~ Floor Alexandria, VA 22314 Re: Paul Magliocchetti, Case No. 10-cr-286

Dear Judge Ellis:

My name is Kathleen Murphy. I worked for former Congressman Charlie Wilson (TX) from 1993 through nearly all of 1996. During that time I handled Appropriations issues, including Defense and Foreign Operations. I met Paul Magliocchetti during my first week with Charlie. I am an adult and have never mistaken the "friendship" or "concern" offered by a lobbyist as having any relationship to the real thing. Paul may have become my friend when I was in a position to be helpful to him, but he has remained my friend all these years after. He didnt quit being my friend or caring about my life or my well being or my family when I was no longer working for a Congressman. Following my time working on the Hill and when I was not in a position to be of help to Paul or his clients, he continued to be my friend and was readily available to provide help when it was needed. When my sisters and I set out to start an organization to help the families of deployed military, Paul became our advisor helping us build an effective strategy to secure funding and build a strong support system within the Pentagon so the program could become self sustaining. It is. He provided support and helpful contacts when I reached out to him to assist me with efforts to make sure children of injured soldiers at Walter Reed got Christmas presents. He made donations to help. I have a step daughter who has Cystic Fibrosis. Paul didnt hesitate when I asked him to become a sponsor for our annual fund raising event. He continued to sponsor this event until 2008 when his company was closed. When my brother was murdered, Paul was one of the first to call and offer support. And when I was diagnosed with cancer, Paul was there to offer support and help. He has never asked me for anything in return. He was never paid a penny for his help.

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Case 1:10-cr-00286-TSE Document 30-19 Filed 12/13/10 Page 3 of 3

Paul is a good man. I dont claim that he is a perfect man; he has flaws like everyone has, and he has made some terrible mistakes. But his mistakes dont change the fact that he is, at his core, a good and decent man. He is acutely aware of his failings and the destruction he has caused to be heaped on his family, friends and colleagues. Paul is clearly devastated. Having worked all his life to do good for people, he knows by these actions, he has failed them and he has failed himself. His smile is gone, his good cheer buried under the burden of all that has happened. But his concern for others is solidly in place. Before I can ask one word about him, he starts always by asking about my health and my family. As you are making your decision on what sentence to impose, I urge you to consider the whole man. I know that Paul had a kind of blind loyalty and friendship for a man who himself was involved in a politically charged sting operation. The difference is that Paul has chosen to be honest and own up to his mistakes rather than be dishonest in order to exonerate himself. I know that this man made demands on everyone around him and I believe this could have played a critical role in pushing Paul to go beyond what we know to be acceptable bounds. The campaign finance system is broken and fraught with opportunity for corruption and if you walk near the edge it is easier to fall off.

I hope you will consider my words when you make your decision about Pauls future. His life has been destroyed, his reputation lost, his family stricken. Please give him the opportunity to rebuild and repay by doing something positive and productive for the community rather than waste years of his life being uselessly warehoused. He has so much to offer and nothing would be gained by that.

Sincerely, Kathleen Murphy 1123 Crest Lane McLean, VA 22101

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Case 110-cr-OO286-TSE Document 30-20 Filed 12/13/10 Page 1 of 3

Exhibit 20
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

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Case 1:10-cr-00286-TSE Document 30-20 Filed 12/13/10 Page 2 of 3

The Honorable T.S. Ellis, III U.S. District Court 4th Eastern Division of Virginia 401 Courthouse Square, 9th floor Alexandria, Virginia 22314

Re: Paul Magliocchetti, Case #10-cr-286 Dear Judge Ellis, I am writing this letter regarding Paul Magliocchetti in behalf of his maternal family - an aunt, two uncles and myself, a first cousin. I cant pretend to fully understand or know the details of the charges brought against him therefore, I would only like to address the person we know as a member of our family. Paul was the first of our family to attend college (working his way through on his own) and graduate. Through the years after he left Pittsburgh to attend school and pursue his career in Washington, D.C., he always came back to visit and keep in touch with our family on a regular basis, even after the death of his parents. Everyone was so proud of him when he accepted his first job after college in Washington, D.C. to work for the government. During those first years there when we visited he would always take us on a grand tour of the city where he was so proud to work and live. Working at the Pentagon was a very prestigious place to be in the eyes of his family here in Pittsburgh. In many of the articles I have read regarding his case, the one word that was used again and again to describe Paul was "powerful." Yet, even though he held a supposedly powerful position, he didnt seem any different than the Paul we always knew. Paul never forgot his roots during those "powerful" years as a lobbyist. When he would be in Pittsburgh on business he would often bring his business colleagues to visit our family at the modest home of our grandparents, where our aunt still lives. He was very comfortable introducing his associates to his Italian, Pittsburgh family that he was proud of. Whether it was providing an opportunity for his aunts and uncles to attend the wedding of his son in Florida or taking them to dinner at a place they otherwise could not afford on their own, he was always extremely generous and thoughtful. He truly enjoyed the company of our aunts and uncles. They usually provided him with a relaxing time filled with laughter and fond memories of his childhood.

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In closing I hope this letter describes a side of Paul that you might not otherwise know about. Through all of his accomplislmaents and the success of his lobbying ftrrn he remained a thoughtful, caring, generous person to our family. Thank you for taking the time to read this.

Sincerely,

J~t Pelot

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Case 110-cr-00286-TSE Document 30-21 Filed 12/13/10 Page 1 of 2

Exhibit 21
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

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Case 1:10-cr-OO286-TSE Document 30-21 Filed 12/13/10 Page 2 of 2

November 10, 2010

The Honorable T.S. Ellis, III United States District Court for the Eastern District of Virsinia 401 Courthouse Square, 9th Floor Alexandria, Virginia, 22314 RE: Paul MasIoicchetti, Case No. 10-cr-286 Dear Judge Ellis, I am writing this letter in support of Mr. Paul Magloicchetti. I have had the pleasure of working with Paul for approximately three years, prior to November 2008. I was employed with Girl Scouts of Talus Rock Council, Johnstown, PA. Paul had assisted in the fundraising efforts of our Annual Girl Scouts dinner held in April. Each year prior to the dinner we would make plans to solicit sponsorships for the dinner in support of Girl Scout programming in the region. All funds received and information on sponsorships were sent directly to my attention to be recorded. I worked with him to make the contacts and arrangements for advertising and seating for the sponsors. Paul assisted committee members with the solicitation of funds for the event. He was successful in working with committee members to solicit sponsorship from local businesses and those with corporate office in the Virginia area. Pauls attitude was always positive and outgoing, and he was eager to help in making the dinner a success. I personally enjoyed working with Paul and have the utmost respect for his caring community minded values. I would like to note, that I noticed his poised and professional interactions with his employees, corporate contacts and nonprofit staff as well. Through my work with Paul on the dinner, I learned a lot about his family and how much he valued spending time with them. He often spoke of family vacations and how proud he was of his children. I know Paul to be a professional businessman who is credible in the eyes of his peers. He has very creative ideas and he had a caring commitment in assisting with the fundraising efforts of the Annual Girl Scout dinner. Please feel free to contact me should you have any questions, my contact information is listed below. Warm

ina Pelesky 220 Pelesky Rd Boswell, PA 15531 (814) 629-1590 tinapeleskv@~mail.com

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Case 110-cr-OO286-TSE Document 30-22 Filed 12/13/10 Page 1 of 3

Exhibit 22
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

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Case 1:10-cr-OO286-TSE Document 30-22 Filed 12/13/10 Page 2 of 3

..... Original Message ...... From: Susan Shahade [mailto:sshahade@womenshelpcenter.org] Sent: Wednesday, November i0, 2010 9:17 AM To: Riella, Amy Subject: Re: Paul Maegliochetti letter Please see below. Thanks, Susan
November 9, 2010

Advise me upon receipt (or not).

The Honorable T. S. Ellis, III United States District Court for Eastern Virginia 401 Courthouse Square, 9th Floor Alexandria, VA 22314 Re: Paul Magliocchetti, Case No. i0-cr-286
Dear Judge Ellis:

The Womenls Help Center is a non-profit human service agency based in Johnstown, PA. The program provides a full compliment of direct services, including emergency shelter, to victims of domestic violence and their dependant children. Life-saving services are provided 24 hours per day, every day. All contacts are completely confidential and all services are provided free of charge. Domestic violence is unique in that it is not limited to any one race, religion, or socio-economic level. It crosses al! boundaries. The cause is as varied as its victims. Battering is an abuse of power and controls and it is potentially lethal. Statistics show that fifty-two percent of murdered American women are murdered by the same man that is their husbands. And in thousands and thousands of cases, the batterer has taken everything but her life. Last year was another lethal one for victims of domestic violence across the state and within Cambria and Somerset Counties. The death toll continues to rise. The loss of life is profound. And the trend is terrifying. Data from the 2009 Domestic Violence Fatality Report, complied by the PA Coalition Against Domestic Violence, puts the death toll in the state at 180 women, men and children; up 22% over the 2008 death toll and an alarming 49% spike over 2007. In each and every case, a history of violence preceded murder. As was the case in previous years, there was a predicable and predominant weapon of choice, a gun. If anyone doubts the deadly nature of domestic violence, the coldblooded murders that took place in Pennsylvania homes should dispel the

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misperception that domestic violence is less than a crime and simply a private matter involving couples that fight with one another. Domestic violence is petrifying, brutal, and far too often deadly, not only for the person involved with the abuser, but also for others in proximity. And, its a crime. As the Executive Director of the Womenls Help Center, I had the honor of becoming acquainted with Paul Magliocchetti five years ago. And each and every year since then, Mr. Magliocchetti has lent his support to the program in immeasurable ways. It is with pleasure that I inform you of the inherent qualities and unending advocacy provided to the Womenls Help Center by Mr. Magliocchetti. He gives freely and frequently of his personal time and resources and shares his leadership expertise and access to community assets most willingly. The Womenls Help Center is the only domestic violence center and emergency shelter in the Cambria-Somerset Counties-a huge geographic area (1,700 + square miles). The demand for program services is on the upswing and the costs associated with provision of this vigorous and life-saving work are out-of-reach for a small non-profit agency due to budget shortfalls. Federal and State funding cuts imposed annually for the past six years (- $84,000 in FY 2009/10) dramatically impacted the program. Securing the funds necessary to maintain the current level of service provision, continue to meet the ever-increasing needs of the population at risk, and offer all services free of charge, is imperative. Mr. Magliochetti eagerly and successfully spearheaded efforts to ensure the continuation of uninterrupted program services, access to emergency shelter, and overall program stability. He is an absolute asset to the Womenls Help Center and its program recipients; adults and children abused in the one place they should feel safe-their own homes. Mr. Magliocchetti is a deeply concerned, competent and result oriented advocate. His commitment to the mission of the program is evidenced by his visible call to action. I am delighted have his support. He took a stand. He got involved. He made a difference. Mr. Magliocchetti helped the Womenls Help Center to end domestic violence, one life at a time. For that I am forever grateful.

Sincerely,

Susan S. Shahade Executive Director

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Case 110-cr-00286-TSE Document 30-23 Filed 12/13/10 Page 1 of 4

Exhibit 23
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

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Case 1:10-cr-00286-TSE Document 30-23 Filed 12/13/10 Page 2 of 4

RAFAGINO RESTAURANT
9570 Old Keene Mill Rd. Burke, Va 22015 (703) 451-1570

October 5th, 2010 The Honorable T.S. Ellis, lIl United States District Court For the Eastern District of Virginia 401 Courthouse Square, 9th floor Alexandria, Virginia 22314 Re: Paul Magliocchetti, Case No. 10-cr-286 Dear Judge Ellis:

My name is Paul Carvalho and with my wife Rosa, we own and operate Rafagino restaurant, a
small upscale, Italian neighborhood restaurant in a non descript strip mall in Burke, Virginia. About 15 years ago, I had the pleasure of meeting Paul Magliocchetti as he entered my establishment for the very first time with his wife, his wifes sister and her husband. Small talk ensued and after having very much enjoyed his dinner and meeting my wife and I, he vowed to come back soon. And so he did, over and over again, weekly mostly, until recently when he moved to Florida. Through our many conversations, his character started to emerge and a friendship materialized out of common goals, shared views and mutual admiration. As his returns added up, so did my appreciation for the person he was and the friend he was becoming. He was after all of Italian descent, and as such, he had a deep appreciation for family, friends and religion. I noticed that he was always with family members, always insisted on paying the checks for members of the clergy and was genuinely liked by other neighbors that frequented the restaurant as well as by all the "regulars" that often interacted with him. Very often he ran into old neighbors from his old house that he vacated more than 10 years ago and upon him leaving they would fondly offer up stories of how Paul helped the kids from the neighborhood, how he coached them soccer and how he would gather them up in his house with after school activities so they could have a safe place to stay until their respective parents would get home from work. Out of all of his many qualities, the one that awed me the most and the one that surfaced most often was his infinite generosity and his loyalty. Not only was he financially generous to family and friends, but he was also generous with his time and his actions. He seemed to be most happy when giving some of him to the benefit of others. He thrived in altruism.

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He had instructed me to always charge to him any meals consumed by members of the clergy even in his absence. He was especially found of the nuns whom he credited with whipping into him the discipline, the will, the morals and the principles that contributed so greatly to his professional success. He credited them with having molded him into the man he was today through corporal punishment rather than positive reinforcement. When a neighbors husband died, Paul went to great lengths to mentor their 2 children through their teenage years becoming a hugely positive influence in their lives, going as far as arranging for intern positions for the oldest and even writing letters of recommendation and visiting colleges, all the while making sure that their mother and them came out with him and his family to dinner at the restaurant as well as all other family gatherings. They became in fact an extension of his family. He doted constantly on his own kids. He often drove long distances to watch his son and his daughter play soccer and was an ever presence in their academic endeavors. As they got older, Paul continued to be a very strong presence in their pursuits helping them get jobs and providing them with constant guidance and advice in all things from personal fmance to work place etiquette. He was always available to them. When Thanksgiving would come along, Paul would spare no effort in order to gather all of his relatives. He would gather even the distant ones, even the ones he didnt much like and at great financial cost to him. He would often pay for trips and lodging so relatives could all be together for the holidays. His unyielding devotion to family was ever present. My wife and I had the privilege of becoming regulars at many of these family gatherings as we became part of his extended family. Through it all, his generosity and his devotion to family and friends, never ceased to amaze me. Even his employees were the recipients of his devotion, generosity and loyalty. Although extremely demanding of them in their performance and professionalism, he was also very protective of them. He treated his employees better than most, he paid them better and gave them better benefits than most people in his field of business and when the work day was over he often brought them and their families to mine or other restaurants. He also invited many of his employees and their families to his family gatherings, his sons wedding and his holiday parties. Over the past 15 years I have had the pleasure of being a part of Pauls life and that has given me a greater appreciation for whom he really is. I have had the privilege of meeting his close family, his distant relatives, all of his employees, many of his friends, lots of his neighbors and some of his clients. I am yet to meet one person that has something negative to say about him; or one that doesnt have a great degree of admiration and respect for Paul. Through the nature of my job at the restaurant, I am in a unique position to hear what people talk about Paul when hes not present or upon his leaving, when not knowing we are friends they confide some story about him. Yet, even in this privileged position, one where by default one could potential hear about some character defamation, or some slanderous accusation or simply negative idle chatter, never have I been privy to any comment not complimentary of Paul Magliocchetti. I for one am proud of calling him a friend. He has over the years proven to be of impeccable

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character, with strong morals and principles, and an acute moral compass. His fierce loyalty, his great sense of compassion and his extreme generosity make him out to be a great human being and an enviable friend. All of his qualifies were put on display in his recent ordeal. Upon being investigated and charged, rather that trying to secure a more advantageous deal for himself by incfiminatng others he has instead, found the strength in adversity to protect those around him and accept sole responsibility for the outcome of the investigation. His loyalty prevented him from cooperating against friends and family even when it could have possibly guaranteed a more favorable arrangement. Even though this case has compromised Pauls mental health, debilitated his physical well being and shown some negative impact on his now ever somber mood and lack of mental focus, it has not detracted from his understanding of misconduct and his constant confessed regret for the harm that his actions have caused to his family and friends. Rather than indulging in self-pity, Paul is still more worded about how his misconduct has victimized so many people that trusted him and how he should have known better and could have done better. Through it all, his uncompromising commitment to our men in uniform has been ever-present through his constant support for Walter Reed Hospital and his constant visits to returning veterans, his support for the USO and his continued support for all Veteran Affairs Organizations. I have overheard in various occasions a certain ex Secretary of the Army who happens to be a regular at the restaurant, speaking candidly to an ex Chairman of the Joint Chiefs and commending Pauls work on the Hill and his support for the military in general. His past work on the defense appropriations committee staff has obviously molded and guided Pauls support of the military through securing budgeting for government programs that contribute to combat troops safety and the readiness of our nations military. For what I have been able to witness over the past 15 years, Paul Maglioeehetti is a man with excellent qualities, stellar principles and a solid moral foundation. He is extremely loyal, superlatively generous and very dependable. A man I am proud to call a friend. But a man nonetheless. One capable of error and human after all. One capable of great deeds but also misconduct. He has however proven that his recent lapses in judgment are an exception not a rule, a stain on what has otherwise been a stellar career as a father, husband, friend and professional.

Paulo Carvalho

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Case 110-cr-00286-TSE Document 30-24 Filed 12/13/10 Page 1 of 3

Exhibit 24
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

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Case 1:10-cr-00286-TSE Document 30-24 Filed 12/13/10 Page 2 of 3

October 15, 2010

The Honorable T.S. Ellis, III United States District Court for the Eastern District of Virginia 401 Courthouse Square, 9th Floor Alexandria, Virginia 22314 RE: Paul Magliocchetti, Case No. 10-cr-286 Dear ]udge Ellis: I have known Paul since the summer of 2006. We met at a Nationals baseball game through an acquaintance. After the game my wife and I had dinner with Paul. From the time I met Paul I liked him and knew he was special. Since that time we have created a true friendship. I retired from IBM after 30 years. IBM taught me a lot of life lessons like valuing the people around you, caring for your clients, loyalW, and a commitment to high standards. I think that is why I became a good friend of Pauls. I recognized from the time that I met him that he held those same values.
I have never had a business relationship with Paul so I thought I could give you my perception of Paul over the four years that I have known him as a friend. Two years before the November 2008 raid on his office, and two years after that event. Before the 2008 event Paul was a highly energetic, tireless person who was physically active and who would do anything for you. Although Paul was a very popular and successful lobbyist, he never talked to me about his business. He kept a very low profile and never put on any airs. Paul was very "grounded" and he never pursued any publicity. He loved his family and friends. In many conversations with him he talked about how proud he was of his son and daughter. His grandchildren were precious to him. Paul also has a very big extended family, and I have met many of them. They are so proud of Paul. Not necessarily for his business successes, but because he is so involved in their lives. Giving emotional support to them and dedicating his time to be involved with their family for any business or health issues. Paul also has a way of"adopting" additional family. He befriends acquaintances of his family and treats them like long lost family. I guess I am one of this special family. That is just the way he is. Unselfish, and will do anything for you but asks nothing in return.

After the 2008 event Pauls entire life changed. He quickly lost his business and a lot of his business acquaintances. As a lobbyist your reputation is your business, and it was gone instantly. Paul was unemployed and unemployable.

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It didnt take long for Pauls physical and mental health to deteriorate. He felt terrible guilt for his employees and family. He felt responsible for letting them down. Putting his family, friends and employees through the grand juror process absolutely tore him apart. At times in this seemingly never ending process of two years Paul intimated to me the possibility of suicide as a way out. He thought this would lessen the burden on his family. The strain on his family showed as his son started withdrawing from contact with his father. Paul had less contact with his grandchildren, which depressed him even more. Over the past two years I have seen Paul drained physically, mentally and financially during a very drawn out process. In a town he once loved he cannot live. His former clients now reject him. Former employees blame him. His close family has withdrawn from him. I am not a Lawyer or a Judge. I grew up with simple mid-west values. I understand that Paul violated the law and must be punished.. I believe that the punishment should fit the crime. The reason that I am writing you is to let you know that Paul has been punished. What he has lost he cannot regain. I believe his punishment has already been severe. His time has been served.

Respectfully,
/

Paul J. Stevens

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Case 110-cr-00286-TSE Document 30-25 Filed 12/13/10 Page 1 of 2

Exhibit 25
DEFENDANTS MEMORANDUM IN AID OF SENTENCING
United States of America v. Paul J. Magliocchetti Criminal Action No. l10-cr-00286-TSE

EAOUSAFOIA0000660

Case 1:10-cr-00286-TSE Document 30-25 Filed 12/13/10 Page 2 of 2

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