Gary Kiser 34 rue du Président Wilson 63100 Clermont-Ferrand, France +33 (0) 953 998 073 +33 (0) 663 601 144 [email protected] Clermont-Ferrand, June 22, 2009 To: all medical professionals concerned with the medical issues of my father, Kenneth W. Kiser, During his recent visit to Clermont-Ferrand, my father had severe breathing problems. After consulting with my personal general practitioner, Dr. René Debra (who has been regularly informed and consulted concerning my father's various health issues), my father was admitted to the emergency unit at the CHU Gabriel Montpied Hospital in Clermont-Ferrand. At first, the emergency staff suspected a pulmonary embolism and performed an angio scan, which I believe is the same as a CT Scan (my father said they had the same machine as used in Las Vegas). The scan showed no signs of pulmonary embolism. A cardiologist, Dr. Frédéric Jean, confirmed my father's suspicions that the batteries were dangerously low in his pacemaker. On June 5, 2009, the pacemaker was replaced in the cardiology unit at the CHU Gabriel Montpied Hospital by Dr. Jean. Dr. Jean stated no complications during the operation. He inspected the pacemaker leads and found them to be fully functional. The pacemaker leads were not replaced. Dr. Jean furnished documentation as to how the pacemaker was programmed. My father is in possession of this documentation. As a side issue, the CT scan has alarmed the scanner supervisor, Dr. Alfidja (who verified the scanner technician's report). He was alarmed by what seems to be two swollen ganglia – one in my father's neck and the other under his right arm – and a metastasis near the third rib on the right side near vertebrae T2 and T3. Dr. Jean and Dr. Debra have both expressed concern by the scanner findings and hope these findings are immediately reviewed by appropriate Las Vegas medical staff. My father is in possession of a CD with the scanner images and data. The CD has an image viewer that will run on Windows or Mac operating systems. Below, you will find the scanner technicians report as well as Dr. Jean's post-op report. I have done my best to translate these texts. The doctors themselves explained their reports and I have tried my best to convey this information. I may lack proper medical terminology. Both Dr. Jean and Dr. Debra would like to see a scintigraphy performed on the entire body. They find it unimaginable that not even a bone scintigraphy has ever been prescribed. If you need further information, please don't hesitate to contact me. Dr. Jean and Dr. Debra have both declared their availability to answer any questions about any treatment administered to my father during his recent stay. They are both fluent in English. Cordially, Gary Kiser

[TRANSLATION OF THE SCANNER REPORT]

Scanner GM : date June 2, 2009

INDICATIONS : History of metastasis in the liver. 26 hours of travel three days ago. Shortness of breath since Saturday. Suspicion of a pulmonary embolism.

RESULTS : - No pulmonary embolism found. - Laterotracheal adenoids (ganglia) to the right of the throat measuring 21mm x 21mm. There is another tissue mass under the right armpit as well. - Multiple bilateral pulmonary nodules with the largest measuring 6mm x 7mm on the upper back of left node and 9,5mm x 10mm on the upper back of right node. - Tissue mass to the right of spine near vertebrae T2 and T3 measuring 37mm x 30mm near the back arch of third rib. - Flagrant enlarged goiter in the trachea.

CONCLUSION : - No pulmonary embolism found. - Laterotracheal adenoids (ganglia) to the right of the throat measuring 21mm x 21mm. There is another tissue mass under the right armpit as well. - Multiple bilateral pulmonary nodules with the largest measuring 6mm x 7mm on the upper back of left node and 9,5mm x 10mm on the upper back of right node. - Tissue mass to the right of spine near vertebrae T2 and T3 measuring 37mm x 30mm near the back arch of third rib. - Flagrant enlarged goiter in the trachea.

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[ORIGINAL SCANNER REPORT – page 2 / 2]

[DR. JEAN'S REPORT TRANSLATED]

Letter addressed to : Copy to : Dr. René DEBRA - 14 place de la Victoire - 63000 CLERMONT-FERRAND Dear Associate, Your patient MR KISER Kenneth, 81-year-old, stayed shortly in our service for complaints of shortness of breath. His history includes an operation for malignant melanoma in the liver in November, 2008. Moreover, he has a double probe pacemaker installed 8 years ago. He was therefore hospitalized considering his shortness of breath for several days. With early suspicions of pulmonary embolism, an angio scanner was done which eliminated these thoughts. Clinically, there is no sign of right or left cardiac insufficiency. The ECG shows a right ventricular stimulation with P wave P retrogression. This mode of stimulation shows pacemaker wear imposing its quick replacement. On biological plan, the pro BNP is augmented to 3817. There is not sign of infection. After discussion with the patient and his son, they decide to replace the pacemaker in France before his departure to the UNITED STATES. I therefore undertook the replacement of the unit, a pacemaker model MEDTRONIC ADAPTS. A verification of the leads showed the were functioning well. I undertook final configuration of the pacemaker per standard procedure. The stitches are disolvable. The procedure was done taking all consideration of the patients blood thinners. I explained to MR KISER and his son that in case of any complication, he could re-contact me and I would see him immediately. Supplemental examination of the angio scanner data clearly shows a tissue mass to the right of the spinal column looking at T2 and T3 measuring in 37 X 30 mm which seems attached to the back arch of the third rib. To supplement these findings, it would be necessary to perform a scintigraphy in search of secondary metastatic locations on the skeleton. This exam can be done in the UNITED STATES after his return. Attached, find the results of the tomodensitometric exam which was done in emergency. I am at your full disposal to see MR KISER again if needed. Cordially, DOCTOR F. JEAN

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