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APPENDIX 485

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 1 of 43 PageID 7164
	


	
		


	





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APPENDIX 486

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 2 of 43 PageID 7165
APPENDIX 487

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 3 of 43 PageID 7166
APPENDIX 488

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 4 of 43 PageID 7167
A

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 5 of 43 PageID 7
A

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 6 of 43 PageID 7
A

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 7 of 43 PageID 7
A

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 8 of 43 PageID 7
A

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 9 of 43 PageID 7
My Health Vet e

Personal Information Report

Produced by the VA Blue Button (v18.4)

31 Dec 2023 @ 1453

This Personal Information Report is a copy of information that you have selected from one or more of

the following:

Your Personal Health Record - Health related information that you self-entered.

Key information from your official VA medical health record. Please contact your VA health care

team if you have any questions about this information or if changes are needed.

Information from your Department of Defense military service record.

This report is intended for your personal use. It is not shared with VA. Portions of this report may 

contain sensitive personal health information from your official VA medical record. Protection of the 

information contained in this report is your responsibility and of those with whom you choose to share

this information.

NOTE:Your Personal Health Record does NOT contain all the information from your official VA medical 

record. If your VA medical center has transitioned to the new electronic health record system My VA 

Health you can access your medical information at . If there is www.patientportal.myhealth.va.gov

medical information not available to you online, contact your local VA facility Release of Information 

office.

Key: Double dashes (--) mean there is no information to display.

Name: ROSS, ROBERT ALLEN

526652%(57$//(1

Page 1 of 337

APPENDIX 494

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 10 of 43 PageID 7173
Download Request Summary

System Request Date/Time: 31 Dec 2023 @ 1453

File Name: mhv_ROSS_20231231_1453.pdf

Date Range Selected: 01 Jan 2020 to 31 Dec 2023

Data Types Selected: My HealtheVet Account Summary 

Self Reported Demographics 

VA Demographics

Self Reported Health Care Providers

Self Reported Treatment Facilities

Self Reported Health Insurance

VA Wellness Reminders

VA Appointments (Future) 

VA Appointments (Limited to past 2 years)

VA Allergies

Self Reported Allergies

VA Medication History

Self Reported Medications and Supplements 

VA Problem List

VA Admissions and Discharges

VA Notes

Self Reported Medical Events 

VA Immunizations

Self Reported Immunizations

VA Laboratory Results: Chemistry/Hematology/Microbiology

VA Pathology Reports: Surgical Pathology/Cytology/Electron Microscopy

Self Reported Labs and Tests 

VA Vitals and Readings

Self Reported Vitals and Readings

VA Radiology Reports

VA Electrocardiogram (EKG) Reports

Self Reported Family Health History 

Self Reported Military Health History

Self Reported Activity Journal

Self Reported Food Journal

DoD Military Service Information

Self Reported My Goals Current

Self Reported My Goals Completed

526652%(57$//(1

Page 2 of 337

APPENDIX 495

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 11 of 43 PageID 7174
My HealtheVet Account Summary

Source: VA

Authentication Status: Authenticated

Authentication Date: 07 Jul 2022

Authentication Facility Name: AUSTIN MHV

Authentication Facility ID: 200MH

VA Treatment Facility Type

Dallas TX VAMC (549) VAMC

Great Lakes Healthcare System (578) VAMC

No CA Healthcare Sys-Martinez (612) VAMC

San Francisco CA VAMC (662) VAMC

William S. Middleton Mem VAMC (607) VAMC

Note: The X represents your self-selected VA Medical Center preference.

526652%(57$//(1

Page 3 of 337

APPENDIX 496

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 12 of 43 PageID 7175
Self Reported Demographics

Source: Self-Entered

Your self-entered information saved in My HealtheVet is not shared with other sources.

First Name: ROBERT

Middle Initial: A

Last Name: ROSS

Suffix:

Alias:

Relationship to 

VA:

Patient

Current

Occupation

Home Phone 

Number:

Work Phone 

Number:

Pager Number:

Cell Phone 

Number:

FAX Number:

Date of 

Birth:

Birth Sex: Male

Blood

Type:

Organ

Donor:

Marital

Status:

Mailing or Destination Address:

Email Address: 1rross

Preferred Method of Contact: Email

526652%(57$//(1

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APPENDIX 497

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 13 of 43 PageID 7176
VA Medication History

Source: VA

Last Updated: 09 Oct 2023 @ 1152

Sorted By: Alphabetical Order then by Status

Remember to share all information about your medications or updates with your VA health care team. 

Also, check information in your VA Allergies and your Self-Reported Allergies. This may let you know if 

you had a reaction to a medication you received.

Please note that My HealtheVet does show medications that are/were administrated in a clinic or NOT

emergency department (such as clinic medications).

If you cannot view prescription(s) that should be displayed, contact your local VA Pharmacy for 

information. The phone number for the VA Pharmacy can be found on the prescription label.

Glossary of MHV Pharmacy Terms: Active: Refill in Process=A refill request is being processed by the 

VA pharmacy. When a prescription is in the Refill in Process status, the Fill Date will show when the 

prescription will be ready for delivery via mail by a VA Mail Order Pharmacy. This term may be shown as 

a VA Prescription status of "Active: Susp" on other VA medication lists. The refill Active: Submitted=

request has been received by My HealtheVet but has not been processed by the VA Pharmacy yet. 

Unknown=The status cannot be determined. Contact your VA care team when you need more of this 

VA prescription. A prescription stopped by a VA provider. It is no longer available to be filled. 

Transferred=A prescription moved to VA's new electronic health record. Go to My VA Health to manage 

transferred medications. This prescription may also be described as "Discontinued" on medication lists 

from your healthcare team. Take your medications as prescribed by your healthcare team.

Glossary of VA Pharmacy Terms: Active=A prescription that can be filled at the local VA pharmacy. If 

this prescription is refillable, you may request a refill of this VA prescription. An active Active: On Hold=

prescription that will not be filled until pharmacy resolves the issue. Contact your VA pharmacy when 

you need more of this VA prescription. A VA Prescription that is on file at VA Pharmacy Active: Parked=

and available for you to submit a fill request. This prescription may or may not have been previously 

filled. This prescription has been ordered by your VA provider but will not be sent to you until you 

request that it is filled. You may request this medication using MyHealtheVet, Rx Refill mobile app, VA 

phone service or mail in refills. A medication that came from someplace other than a Active: Non-VA=

VA pharmacy. This may be a prescription from either the VA or other providers that was filled outside 

the VA. Or, it may be an over the counter (OTC), herbal, dietary supplement or sample medication. 

Discontinued=A prescription stopped by a VA provider. It is no longer available to be filled. Contact your 

VA healthcare team when you need more of this VA prescription. A prescription which is too Expired=

old to fill. This does not refer to the expiration date of the medication in the container. Contact your VA 

healthcare team when you need more of this VA prescription.

Medication: OMEPRAZOLE 40MG EC CAP

Instructions: TAKE ONE CAPSULE BY MOUTH ONCE DAILY BEFORE A MEAL FOR GERD

Indication (Reason for use): FOR GERD

Status: Active

Refills Remaining: 6

Last Filled On: 22 Sep 2023

526652%(57$//(1

Page 29 of 337

APPENDIX 498

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 14 of 43 PageID 7177
Initially Ordered On: 22 Sep 2023

Quantity Days Supply Pharmacy Prescription Number

30 30 SACTO VA CENTER-119 26831144

Medication: CITALOPRAM HYDROBROMIDE 40MG TAB

Instructions: TAKE ONE-HALF TABLET BY MOUTH ONCE DAILY FOR DEPRESSION

Indication (Reason for use): FOR DEPRESSION

Status: Active

Refills Remaining: 3

Last Filled On: 22 Sep 2023

Initially Ordered On: 22 Sep 2023

Quantity Days Supply Pharmacy Prescription Number

15 30 SACTO VA CENTER-119 26831143

Medication: BUDESONIDE 0.5MG/2ML INH SUSP 2ML

Instructions: USE 1 RESPULE (0.5MG/2ML) IN EACH NOSTRIL ONCE DAILY FOR NASAL 

RINSE MIX RESPULE CONTENTS WITH NEILMED SINUS RINSE AND SPRAY 

IN EACH NOSTRIL ONCE DAILY. *PADR APPROVED VIA QUICK ORDER*

Indication (Reason for use): FOR NASAL RINSE

Status: Active

Refills Remaining: 11

Last Filled On: 22 Sep 2023

Initially Ordered On: 22 Sep 2023

Quantity Days Supply Pharmacy Prescription Number

30 30 SACTO VA CENTER-119 26831141

Medication: AZELASTINE 137MCG/SPRAY 200D NASAL INHL

Instructions: SPRAY 2 WHIFFS IN EACH NOSTRIL TWICE A DAY FOR ALLERGIC RHINITIS

Indication (Reason for use): FOR ALLERGIC RHINITIS

Status: Active

Refills Remaining: 11

Last Filled On: 22 Sep 2023

Initially Ordered On: 22 Sep 2023

Quantity Days Supply Pharmacy Prescription Number

1 30 SACTO VA CENTER-119 26831140

Medication: AMLODIPINE BESYLATE 5MG TAB

Instructions: TAKE ONE TABLET BY MOUTH ONCE DAILY FOR BLOOD PRESSURE -DO 

NOT TAKE WITH GRAPEFRUIT JUICE.

Indication (Reason for use): FOR BLOOD PRESSURE

Status: Active

Refills Remaining: 1

Last Filled On: 22 Sep 2023

Initially Ordered On: 22 Sep 2023

Quantity Days Supply Pharmacy Prescription Number

526652%(57$//(1

Page 30 of 337

APPENDIX 499

Medication: CITALOPRAM HYDROBROMIDE 40MG TAB

Indication (Reason for use): FOR DEPRESSION

Medication: AMLODIPINE BESYLATE 5MG TAB

Indication (Reason for use): FOR BLOOD PRESSURE

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 15 of 43 PageID 7178
VA Notes

Source: VA

Last Updated: 31 Dec 2023 @ 1453

Sorted By: Date/Time (Descending)

VA Notes from January 1, 2013 forward are available thirty-six (36) hours after they have been 

completed (except C&P Notes) and signed by all required members of your VA health care team. If you 

have any questions about your information please contact your VA health care team.

Date/Time: 27 Oct 2023 @ 1503

Note Title: V21 CCC PATIENT CONTACT NOTE

Location: No CA Healthcare Sys-Martinez

Signed By: HEITMAN,THERESA K

Co-signed By: HEITMAN,THERESA K

Date/Time Signed: 27 Oct 2023 @ 1505

Note

 LOCAL TITLE: V21 CCC PATIENT CONTACT NOTE

STANDARD TITLE: ADMINISTRATIVE NOTE

DATE OF NOTE: OCT 27, 2023@15:03 ENTRY DATE: OCT 27, 2023@15:03:33

 AUTHOR: HEITMAN,THERESA K EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Spoke with: Patient

Contact info per CPRS:

ROSS,ROBERT ALLEN

(

Reason for calling: Pt wanted message sent to let team know he sent a seccure 

message for the FMLA paperwork his employer needed clairfication for page 3 

question #5. Pt states files are attached. Time sensitive. Please F/u when able 

526652%(57$//(1

'DWHRI%LUWK Page 41 of 337

APPENDIX 500

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 16 of 43 PageID 7179
/es/ THERESA K HEITMAN

Advance MEDICAL SUPPORT ASSITANT

Signed: 10/27/2023 15:05

Receipt Acknowledged By:

10/30/2023 16:04 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 22 Sep 2023 @ 1430

Note Title: Nursing Emergency Dept Education

Location: No CA Healthcare Sys-Martinez

Signed By: SISON,ROSALIE C

Co-signed By: SISON,ROSALIE C

Date/Time Signed: 22 Sep 2023 @ 1430

Note

 LOCAL TITLE: Nursing Emergency Dept Education

STANDARD TITLE: EMERGENCY DEPT EDUCATION NOTE

DATE OF NOTE: SEP 22, 2023@14:30 ENTRY DATE: SEP 22, 2023@14:30:18

 AUTHOR: SISON,ROSALIE C EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

EMERGENCY DEPARTMENT PATIENT EDUCATION AND DISPOSITION

The patient's learning needs including cultural and religious beliefs,

emotional barriers, desire and motivation to learn, physical and cognitive

limitations and barriers to communication were assessed.

Patient had NO Barriers to education identified.

Readiness to Learn:

Ready to learn.

Patient Preferences for Learning:

Patient expresses no preference

Patient handout provided for primary complaint.

NO

Patient education provided on medications.

YES

Physician instructions reviewed with patient.

YES

Other Patient Education if necessary:

Patient and/or significant other received & verbalizes understand of their

discharge instructions.

YES

526652%(57$//(1

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APPENDIX 501

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 17 of 43 PageID 7180
Patient and/or significant other is able to return demonstrate as listed 

above:

NA

MENTAL STATUS:

 Level Of Awareness: Alert

 Oriented To: Person,place,date,situation.

DISPOSITION:

HOME

***

 Patient left Walking without assistance

VITAL SIGNS:

Measurement DT TEMP RESP PULSE BP POx

 F(C) (L/MIN)(%)

09/22/2023 14:00 98.3(36.8) 18 72 146/81 98

09/22/2023 13:00 16 72 148/89 99

09/22/2023 12:16 20 65 169/92 100

Measurement DT PAIN WEIGHT

 LB(KG)[BMI]

09/22/2023 14:00 0

09/22/2023 13:00 0

09/22/2023 12:16 0

/es/ Rosalie C. Sison, RN BSN

Nurse, Emergency Dept/SAC

Signed: 09/22/2023 14:30

Date/Time: 22 Sep 2023 @ 1421

Note Title: Nursing Emergency Dept Note

Location: No CA Healthcare Sys-Martinez

Signed By: SISON,ROSALIE C

Co-signed By: SISON,ROSALIE C

Date/Time Signed: 22 Sep 2023 @ 1430

Note

 LOCAL TITLE: Nursing Emergency Dept Note

STANDARD TITLE: NURSING EMERGENCY DEPARTMENT NOTE

DATE OF NOTE: SEP 22, 2023@14:21 ENTRY DATE: SEP 22, 2023@14:21:17

 AUTHOR: SISON,ROSALIE C EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

1400 Acting as break RN for primary Nurse,Pt. resting,denied pain/discomfort

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APPENDIX 502

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 18 of 43 PageID 7181
1415 Md at bedside with results and DC instructions

1429 Cleared for discharge.Instructions given,verbalized understanding, IV 

discontinued, catheter tip intact. Pressure dsg applied. Left ED in NAD with 

belongings.

/es/ Rosalie C. Sison, RN BSN

Nurse, Emergency Dept/SAC

Signed: 09/22/2023 14:30

Date/Time: 22 Sep 2023 @ 1407

Note Title: Emergency Dept Discharge

Location: No CA Healthcare Sys-Martinez

Signed By: DOMA,ANAMIKA K

Co-signed By: DOMA,ANAMIKA K

Date/Time Signed: 22 Sep 2023 @ 1410

Note

 LOCAL TITLE: Emergency Dept Discharge

STANDARD TITLE: DISCHARGE NOTE

DATE OF NOTE: SEP 22, 2023@14:07 ENTRY DATE: SEP 22, 2023@14:07:04

 AUTHOR: DOMA,ANAMIKA K EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

You have been evaluated in the Sacramento VA Medical Center Emergency

Department.

You were treated today for: Depression, chest pain

If your symptoms worsen or new symptoms develop, contact your physician or

return to the Emergency Department immediately.

For your specific condition you should look for warning signs that include:

Overwhelming feelings of sadness, suicidal ideations, worsening chest pain

-------------------------------------------------------------------------------

To follow up with your primary care provider please call 1 800-382-8387.

To follow up with the Mental Health Provider please call 1-916-366-5420 M to F.

The Suicide Hot line 24 / 7 at 1-800-273-8255

--------------------------------------------------------------------------------

*** THE TELEPHONE ADVICE NURSE CAN BE REACHED AT:1-800-382-8387. ***

We recommend that you follow up with your primary care provider

within 1 week. Your primary care provider along with your care

manager will be notified of your visit to the Emergency Department.There is a

possibility that your follow up may be accomplished with a telephone

appointment.

526652%(57$//(1

'DWHRI%LUWK Page 44 of 337

APPENDIX 503

You have been evaluated in the Sacramento VA Medical Center Emergency

Department.

You were treated today for: Depression, chest pain

If your symptoms worsen or new symptoms develop, contact your physician or

return to the Emergency Department immediately.

 ENTRY DATE: SEP 22, 2023@14:07:04

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 19 of 43 PageID 7182
1. Celexa 20 mg daily for depression.

2. Follow-up with therapist as outpatient.

3. Follow-up with your primary care physician in 1 week.

4. Return to ER for worsening symptoms.

/es/ Anamika K. Doma, DO

Physician, Emergency Medicine

Signed: 09/22/2023 14:10

Date/Time: 22 Sep 2023 @ 1223

Note Title: ENT Note 11301

Location: No CA Healthcare Sys-Martinez

Signed By: STEELE,TOBY OLIVER

Co-signed By: STEELE,TOBY OLIVER

Date/Time Signed: 22 Sep 2023 @ 1227

Note

 LOCAL TITLE: ENT Note 11301

STANDARD TITLE: OTOLARYNGOLOGY NOTE

DATE OF NOTE: SEP 22, 2023@12:23 ENTRY DATE: SEP 22, 2023@12:23:05

 AUTHOR: STEELE,TOBY OLIVER EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** ENT Note 11301 Has ADDENDA ***

ROSS,ROBERT ALLEN

F/U : Nasal obstruction/congestion, throat clearing. 

Interval History: The patient returns today in follow up for the above. Has seen 

Dr. Fuller to evaluate for UASS. He reports a long history of nasal 

congestion/obstruction and mucous discharge. He has PND and throat clearing. 

He's a pilot and flies internationally half of the month. He's tried 

fluticasone. Both sides are obstructed, but right more than left. He has nasal 

congestion. He also has some symptoms of otic barotrauma where he'll have a 

difficult time clearing his ears. Prior septoplaty and turbinate reduction. 

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APPENDIX 504

22 Sep 2023 @ 1227

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 20 of 43 PageID 7183
Active issues :

Computerized Problem List is the source for the following:

1. Cough 09/30/20 BUCAYCAY,ELEANO

2. Knee pain 08/26/20 BUCAYCAY,ELEANO

3. Depressive episode 08/31/22 ESPINOSA,SONJA

4. General Anxiety 08/31/15 WEBER,DIANE ELL

5. Varicose veins of lower extremity (SNOMED CT 08/04/14 TAYLOR,JEFFERY

72866009)

6. Impaired Fasting Glucose (ICD-9-CM 790.21) 04/24/13 DOCTOR,FEDERICO

7. GERD * (ICD-9-CM 530.81) 04/24/13 DOCTOR,FEDERICO

8. DJD, Knee/Lower Leg 03/04/13 TAYLOR,JEFFERY

9. CMP INT ORT DEV/GFT NOS 03/04/13 TAYLOR,JEFFERY

10. Low Back Pain * (ICD-9-CM 724.2) 08/09/12 DOCTOR,FEDERICO

11. Hearing loss * (ICD-9-CM 389.9) 05/24/10 DOCTOR,FEDERICO

12. Hyperlipidemia 06/30/08 WOO,JOSEPH C

13. Pain in joint involving lower leg (ICD-9-CM 06/27/08 WOO,JOSEPH C

719.46)

14. Tear of lateral cartilage or meniscus of knee, 06/27/08 WOO,JOSEPH C

current (ICD-9-CM 836.1)

Meds :

Active Outpatient Medications (excluding Supplies):

 Active Outpatient Medications Status

=========================================================================

1) ATORVASTATIN CALCIUM 40MG TAB TAKE ONE TABLET BY ACTIVE

 MOUTH ONCE DAILY FOR CHOLESTEROL (DO NOT TAKE WITH

 GRAPEFRUIT JUICE.)

2) DICLOFENAC NA 1% TOP GEL APPLY 2 GRAMS TOPICALLY FOUR ACTIVE

 TIMES A DAY USE DOSING CARD PROVIDED TO MEASURE

 DOSE. DON'T EXCEED 16 GRAMS DAILY TO A JOINT OF THE

 LOWER BODY. DON'T EXCEED 8 GRAMS DAILY TO A JOINT

 OF THE UPPER BODY. DON'T EXCEED A TOTAL DOSE OF 32

 GRAMS PER DAY. FOR PAIN AND INFLAMMATION

 Pending Outpatient Medications Status

=========================================================================

1) AZELASTINE 137MCG/SPRAY 200D NASAL INHL SPRAY 2 PENDING

 WHIFFS IN EACH NOSTRIL TWICE A DAY

2) BUDESONIDE 0.5MG/2ML INH SUSP 2ML USE 1 RESPULE PENDING

 (0.5MG/2ML) IN EACH NOSTRIL ONCE DAILY

3) OMEPRAZOLE 40MG EC CAP TAKE ONE CAPSULE BY MOUTH ONCE PENDING

 DAILY BEFORE A MEAL

 Active Non-VA Medications Status

=========================================================================

1) Non-VA CYANOCOBALAMIN TAB MOUTH ACTIVE

6 Total Medications

Allergies : ERYTHROMYCIN, VICODIN, DARVOCET-N

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APPENDIX 505

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 21 of 43 PageID 7184
O/E:

Gen: alert, oriented, NAD

Head: NCAT

Eyes: PERRL

Nose: Anterior rhinoscopy reveals mucosal edema

Procedure: Nasal Endoscopy

Anesthesia: 4% lidocaine and phenylephrine.

Details: A rigid endoscope was used to evaluate the bilateral nasal passages and

sinus ostia. Overall, mucosal inflammation is noted. Also noted is: 2+ ITs 

bilaterally. Midline septum. Mucostasis and mucous discharge from ITs 

bilaterally.

Impression:

Chronic rhinitis

Possible Chronic rhinosinusitis

LPR

Plan:

Start budesonide irrigations

Start PPI prior to meals

Start topical nasal antihistamine sprays. 

Could consider procedural interventions such as IT reduction, possible ESS, PNN 

ablation, pending CT imaging (if no improvement CT next steP)

/es/ Toby O. Steele, MD

Staff Otolaryngologist

Signed: 09/22/2023 12:27

09/22/2023 ADDENDUM STATUS: COMPLETED

Also try Hale nasal dilators to see how much valve is contributing. 

/es/ Toby O. Steele, MD

Staff Otolaryngologist

Signed: 09/22/2023 12:28

Date/Time: 22 Sep 2023 @ 1130

Note Title: Mental Health Inpatient Consult

Location: No CA Healthcare Sys-Martinez

Signed By: SILVA,STACIE K

Co-signed By: SILVA,STACIE K

Date/Time Signed: 22 Sep 2023 @ 1236

Note

LOCAL TITLE: Mental Health Inpatient Consult

STANDARD TITLE: MENTAL HEALTH CONSULT

DATE OF NOTE: SEP 22, 2023@11:30 ENTRY DATE: SEP 22, 2023@11:30:09

526652%(57$//(1

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APPENDIX 506

22 Sep 2023 @ 1236

 Consult

22 Sep 2023 @ 1130

Note Title: Mental Health Inpatient

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 22 of 43 PageID 7185
AUTHOR: SILVA,STACIE K EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Mental Health Inpatient Consult Has ADDENDA ***

Inpatient Mental Health Consultation Evaluation

CONSULT ISSUE(S): thoughts of wanting to go to sleep and not wake up

BRIEF HPI & INTERVIEW:

Mr. Ross is a 63 y/o male AF veteran with history of generalized anxiety 

disorder and depression who self-presented to the ED with CC of intermittent 

pectoral pain and throbbing neck pain during periods of stress, associated with 

feeling tingling and pale. Psychiatry was consulted due to pt endorsing thoughts 

of wanting to go to sleep and not wake up. Denies current intent or plan for 

self-harm, but reports recent stress r/t job and family life.

Briefly, Mr. Ross states that he has been involved in an extremely stressful 

legal situation since 2018, when he resigned as the Airline's labor union 

steward due to issues with harrassment from an individual d/t his reporting of 

alleged wrongdoing. He has been involved in lawsuits since then and harrassed on 

social media. He spends time fighting these wrong accusations and defending his 

name on social media platforms. Standing up for himself makes him feel better 

but he also reports significant anxiety and feeling all-consumed by the stress 

of these lawsuits. He has been having to commute long-distance to Texas for work 

and is able to spend less time at home. 

Reports stress at home r/t wife who works long hours and doesn't prefer to 

engage in discussions about his stress. They have been sleeping separately for 

the past year. Pt lives at home with wife and 2 adult children (ages 19 and 21) 

who are currently in college; he is paying a portion of their tuition and 

therefore cannot retire for another couple of years. He gets upset by their lack 

of motivation and has felt alone in trying to discipline them. 

Pt reports that he has been trying to get connected with a therapist for many 

many months now and still hasn't heard back regarding his CC referral. 

Previously saw a CC provider last yr. Reports that she provided little feedback 

other than to tell him that it sounds like he should leave his marriage, and he 

did not find it a good fit. He wants to address his anxiety r/t the trauma that 

he has sustained over the past 5 years and learn how to better cope with his 

current stressors. He reports thoughts of wanting to go to sleep and not wake 

up. He recalls times over the past several years in which he has asked God to 

take him from this life. However, he denies that he has thought of any plans to 

end his own life. He ultimately feels that the other side will "win" if 

he were 

to kill himself because they would assume that they were right the whole time. 

He states that he has had thoughts/ fantasies of harming the people who have 

soiled his name, but he does not think of plans or have any intent to harm them. 

526652%(57$//(1

'DWHRI%LUWK Page 48 of 337

APPENDIX 507

Briefly, Mr. Ross states that he has been involved in an extremely stressful

legal situation since 2018, when he resigned as the Airline's labor union

steward due to issues with harrassment from an individual d/t his reporting of 

alleged wrongdoing. He has been involved in lawsuits since then and harrassed on

social media. He spends time fighting these wrong accusations and defending his 

name on social media platforms. Standing up for himself makes him feel better

but he also reports significant anxiety and feeling all-consumed by the stress

of these lawsuits. He has been having to commute long-distance to Texas for work

and is able to spend less time at home. 

Reports stress at home r/t wife who works long hours and doesn't prefer to

engage in discussions about his stress. They have been sleeping separately for

the past year. Pt lives at home with wife and 2 adult children (ages 19 and 21) 

who are currently in college; he is paying a portion of their tuition and

therefore cannot retire for another couple of years. He gets upset by their lack

of motivation and has felt alone in trying to discipline them.

He ultimately feels that the other side will "win" if 

he were

to kill himself because they would assume that they were right the whole time. 

He states that he has had thoughts/ fantasies of harming the people who have

soiled his name, but he does not think of plans or have any intent to harm them.

. He wants to address his anxiety r/t the trauma that 

he has sustained over the past 5 years and learn how to better cope with his 

current stressors. He reports thoughts of wanting to go to sleep and not wake

up. He recalls times over the past several years in which he has asked God to

take him from this life. However, he denies that he has thought of any plans to

end his own life. 

BRIEF HPI & INTERVIEW:

Mr. Ross is a 63 y/o male AF veteran with history of generalized anxiety 

disorder and depression who self-presented to the ED with CC of intermittent 

pectoral pain and throbbing neck pain during periods of stress, associated with 

feeling tingling and pale. Psychiatry was consulted due to pt endorsing thoughts

of wanting to go to sleep and not wake up. Denies current intent or plan for

self-harm, but reports recent stress r/t job and family life.

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 23 of 43 PageID 7186
Denies access to lethal means including firearms. 

MENTAL STATUS EXAMINATION:

Older Caucasian male with average height and build, dressed in casual attire 

with good grooming/hygiene. Behavior is calm and cooperative, actively engaged 

with polite style. Good EC. Cognition grossly intact. No PMR/PMA. Speech is 

normal volume/rate/rhythm, conversant prosody. Mood is neutral, anxious. Affect 

full range. Thought process is circumstantial, and logical, no delusional 

content elicited. Denies AVH. Denies active SI or HI. Denies 

Active Outpatient Medications (excluding Supplies):

 Active Outpatient Medications Status

=========================================================================

1) ATORVASTATIN CALCIUM 40MG TAB TAKE ONE TABLET BY ACTIVE

 MOUTH ONCE DAILY FOR CHOLESTEROL (DO NOT TAKE WITH

 GRAPEFRUIT JUICE.)

2) DICLOFENAC NA 1% TOP GEL APPLY 2 GRAMS TOPICALLY FOUR ACTIVE

 TIMES A DAY USE DOSING CARD PROVIDED TO MEASURE

 DOSE. DON'T EXCEED 16 GRAMS DAILY TO A JOINT OF THE

 LOWER BODY. DON'T EXCEED 8 GRAMS DAILY TO A JOINT

 OF THE UPPER BODY. DON'T EXCEED A TOTAL DOSE OF 32

 GRAMS PER DAY. FOR PAIN AND INFLAMMATION

 Active Non-VA Medications Status

=========================================================================

1) Non-VA CYANOCOBALAMIN TAB MOUTH ACTIVE

3 Total Medications

Most recent vitals:

 Temp: 98.9 F [37.2 C] (09/22/2023 09:19)

 Pulse: 69 (09/22/2023 09:24)

 Resp: 17 (09/22/2023 09:24)

 BP: 152/94 (09/22/2023 09:24)

 Wt: 168.7 lb [76.52 kg] (04/20/2023 10:22)

DSM DIAGNOSIS:

Anxiety disorder, unspecified

GAD by history

ASSESSMENT: Mr. Ross is a 63 y/o male AF veteran with history of generalized 

anxiety disorder and depression who self-presented to the ED with CC of 

intermittent pectoral pain and throbbing neck pain during periods of stress, 

associated with feeling tingling and pale. Psychiatry was consulted due to pt 

endorsing thoughts of wanting to go to sleep and not wake up.

Mr. Ross has a history of seeking MH services in the past, first reaching out to 

PCMHI in 2012 and then again in 2015 but without significant follow-up, for 

symptoms of anxiety and depression in the context of significant marital and 

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APPENDIX 508

ASSESSMENT: Mr. Ross is a 63 y/o male AF veteran with history of generalized 

anxiety disorder and depression who self-presented to the ED with CC of 

intermittent pectoral pain and throbbing neck pain during periods of stress, 

associated with feeling tingling and pale. Psychiatry was consulted due to pt

endorsing thoughts of wanting to go to sleep and not wake up.

MENTAL STATUS EXAMINATION:

Older Caucasian male with average height and build, dressed in casual attire 

with good grooming/hygiene. Behavior is calm and cooperative, actively engaged 

with polite style. Good EC. Cognition grossly intact. No PMR/PMA. Speech is 

normal volume/rate/rhythm, conversant prosody. Mood is neutral, anxious. Affect 

full range. Thought process is circumstantial, and logical, no delusional

content elicited. Denies AVH. Denies active SI or HI. Denies

Anxiety disorder, unspecified

PCMHI in 2012 and then again in 2015 but without significant follow-up, for

symptoms of anxiety and depression in the context of significant marital and 

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 24 of 43 PageID 7187
financial stressors. He has tried sertraline in the past but prefers to minimize 

medications and focus on psychotherapy. Pt re-connected with MH services here at 

the VA in 2022 (received CC referral but did not mesh well with therapist) and 

then again in June 2023 (saw provider in PCMHI before getting connected with GMH 

clinic). Pt was evaluated by Eliza Rosburg for psychotherapy, and it appears 

that a CC referral was placed in 7/7/23 for psychotherapy due to long wait time 

in GMH. Per chart review, an email was sent to CC provider in El Dorado Hills 

8/29/23, but there has been no further communication regarding a plan for 

scheduling.

Mr. Ross reports an exacerbation in his anxiety symptoms in the context of 

chronic and ongoing social stressors. He would likely benefit signifciant for 

psychotherapy for his anxiety, especially with regards to enhancing coping 

skills, improving distress tolerance, and engaging in some cognitive 

reprocessing thru CBT. He reached out for these services in June of this year, 

but is still waiting to obtain a CC therapist to help him manage his anxiety and 

emotions. Although he does endorse thoughts of not wanting to wake up, it 

appears that these thoughts are relatively chronic in nature, and he denies any 

planning or intent to act on his passive thoughts. He appears to be at or close 

to his baseline risk for suicide at the present time and doesn't require 

admission to a psychaitric unit for stabilization of acute symptoms.

Rather, I will alert his outpatient providers to this assessment with request to 

expedite his CC referral as much as possible. He is waiting for communication 

from the VA and is eager to schedule with a CC provider as soon as possible. 

Pt is at LOW acute risk for suicide due to denial of active SI, future 

orientation, help-seeking behaviors, and family connectedness.

Pt is at LOW chronic risk for suicide due no prior MH hospitalizations, major MH 

diagnoses, or prior SA. Several static risk factors include age, gender, and 

historical affective dysregulation. Protective factors include future 

orientation, help-seeking behaviors, access to resources, and family support.

TREATMENT RECOMMENDATIONS:

- No indication for 5150 hold or voluntary hospitalization

- Okay to discha

rge home once medically cleared

- F/u with CC referral re: psychotherapy

Treatment options including pertinent risks and benefits were reviewed with the

patient or current decision-maker as clinically appropriate. The above

recommendations were discussed with the medical team.

Thank you for this consult. You may contact 1-5501 if you have any questions to 

reach the MH inpatient consult team.

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APPENDIX 509

medications and focus on psychotherapy. Pt re-connected with MH services here at

Mr. Ross reports an exacerbation in his anxiety symptoms in the context of 

chronic and ongoing social stressors. He would likely benefit signifciant for

psychotherapy for his anxiety, especially with regards to enhancing coping

skills, improving distress tolerance, and engaging in some cognitive 

reprocessing thru CBT. He reached out for these services in June of this year,

but is still waiting to obtain a CC therapist to help him manage his anxiety and 

emotions. Although he does endorse thoughts of not wanting to wake up, it

appears that these thoughts are relatively chronic in nature, and he denies any 

planning or intent to act on his passive thoughts. He appears to be at or close 

to his baseline risk for suicide at the present time and doesn't require 

admission to a psychaitric unit for stabilization of acute symptoms.

Rather, I will alert his outpatient providers to this assessment with request to 

expedite his CC referral as much as possible. He is waiting for communication

from the VA and is eager to schedule with a CC provider as soon as possible.

financial stressors. He has tried sertraline in the past but prefers to minimize 

clinic). Pt was evaluated by Eliza Rosburg for psychotherapy, and it appears 

that a CC referral was placed in 7/7/23 for psychotherapy due to long wait time

in GMH. Per chart review, an email was sent to CC provider in El Dorado Hills

8/29/23, but there has been no further communication regarding a plan for 

scheduling.

Pt is at LOW acute risk for suicide due to denial of active SI, future

orientation, help-seeking behaviors, and family connectedness.

Pt is at LOW chronic risk for suicide due no prior MH hospitalizations, major MH 

diagnoses, or prior SA. Several static risk factors include age, gender, and

historical affective dysregulation. Protective factors include future

orientation, help-seeking behaviors, access to resources, and family support.

TREATMENT RECOMMENDATIONS:

- No indication for 5150 hold or voluntary hospitalization

- Okay to discha

rge home once medically cleared

- F/u with CC referral re: psychotherapy

Treatment options including pertinent risks and benefits were reviewed with the

patient or current decision-maker as clinically appropriate. The above

recommendations were discussed with the medical team.

Thank you for this consult. You may contact 1-5501 if you have any questions to 

reach the MH inpatient consult team.

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 25 of 43 PageID 7188
/es/ Stacie K. Silva, MD

STAFF PSYCHIATRIST

Signed: 09/22/2023 12:36

Receipt Acknowledged By:

* AWAITING SIGNATURE * BRAKEL,MICHAEL JASON

09/25/2023 08:06 /es/ LCSW #110035

 Social Worker (BHIP)

09/25/2023 08:43 /es/ Eliza Yumiko Maile Rosburg, LCSW

* AWAITING SIGNATURE * NGUYEN,HAN THI NGOC

09/24/2023 14:59 /es/ Lee D. Sasse, LCSW-PIP

 Suicide Prevention, MHS

09/25/2023 ADDENDUM STATUS: COMPLETED

9/25/2023-discussed with BHIP team; suggestion to reach out to CC consult 

managers.

9/25/2023-sent Teams message to CC consult managers; G. Rutherford reports will 

address. Refer to 9/25/2023 comment on 7/7/2023 CC BH consult for details.

**Alerting G. Rutherford as FYI

**Alerting E. Rosburg as FYI

**Alerting L. Sommers-Tarca as FYI

**Alerting S. Silva as FYI

**Alerting M. Brakel as FYI

**Alerting H. Nguyen as FYI

**Alerting L. Sasse as FYI

/es/ LCSW #110035

Social Worker (BHIP)

Signed: 09/25/2023 14:15

Receipt Acknowledged By:

* AWAITING SIGNATURE * BRAKEL,MICHAEL JASON

* AWAITING SIGNATURE * NGUYEN,HAN THI NGOC

09/25/2023 14:59 /es/ Eliza Yumiko Maile Rosburg, LCSW

09/27/2023 08:10 /es/ GLADY RUTHERFORD, MSN, RN

 COMMUNITY CARE, MCCLELLAN VA

10/01/2023 16:42 /es/ Lee D. Sasse, LCSW-PIP

 Suicide Prevention, MHS

09/25/2023 14:43 /es/ Stacie K. Silva, MD

 STAFF PSYCHIATRIST

09/27/2023 12:09 /es/ Lacey M. Sommers-Tarca, PhD

 Clinical Psychologist

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APPENDIX 510

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 26 of 43 PageID 7189
Date/Time: 22 Sep 2023 @ 0923

Note Title: Nursing Emergency Dept Note

Location: No CA Healthcare Sys-Martinez

Signed By: MILES,KAREN

Co-signed By: MILES,KAREN

Date/Time Signed: 22 Sep 2023 @ 1441

Note

 LOCAL TITLE: Nursing Emergency Dept Note

STANDARD TITLE: NURSING EMERGENCY DEPARTMENT NOTE

DATE OF NOTE: SEP 22, 2023@09:23 ENTRY DATE: SEP 22, 2023@09:23:10

 AUTHOR: MILES,KAREN EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Mode of Arrival: Ambulatory

FALL SCREEN

Mather VA Emergency Department Fall Risk Assessment Tool

History of Falling in Last 3 Months:

 No = 0 points

Altered Mental Status (Dementia/Alzheimer's /Hypoglycemia Blood Sugar < 

50 or

symptomatic):

 No = 0 points

Intoxicated/Overdose (Alcohol and/or drugs, prescribed medications):

 No = 0 points

Medications given in ED (Cardiac/blood pressure, opiates, benzodiazepines,

antipsychotics, anticholinergic, muscle relaxants, sedatives, diuretics):

 No = 0 points

Impaired Gait/ Weakness /Impaired vision and or hearing:

 No = 0 points

Mobility Assisted Devise Used:

 No = 0 points

Mobility Hazards:

 Cardiac Monitor/Pulse Oximeter /BP cuff

 Yes (see above selections) = 1 point max

Increased Elimination:

 No = 0 points

Was the patient's presentation/chief compliant due to ANY of the following:

positive orthostatic vitals, light headedness, dizziness or syncope?

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APPENDIX 511

positive orthostatic vitals, light headedness, dizziness or syncope?

 2023@

22 Sep 2023 @ 1441 2023 @

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 27 of 43 PageID 7190
 Yes = 5 points

Fall Risk Score: High Risk = 5 points or more (Implement High Fall Risk

Interventions) Fall risk interventions implemented based on ED Fall Prevention

Standard Operating Procedure.

SAO2

 PERCENT: 100% sat on room air

BLOOD PRESSURE

 152/94

PULSE

 69

RESPIRATIONS

 17

PAIN LEVEL

 0

NOTE SUMMARY/ASSESSMENT

0924-Assumed care of patient, Pt shares that he has been under stress recently.

This am patient was at ENT and decided to come to ED. Describes chest pain

which radiates to back, occurs with tension. Feels his skin turns 

"white"

Denies any shortness of breath, or sweating, can occurr at any time.

No chest pain or discomfort at this time.

1005-Dr Doma aware of I-stat troponin 0.01.

1008-Portable chest x-ray done.

1009-Blood pressure, 174/101-70HR

Pt states that he under lots of stress.

1031-IV fluid NS infusing at 125ml/hr

ETOH level drawn.

1035-BP 155/80-Paul, pharmacist aware, okay per him to hold medication.

Dr Doma will be consulted, States to hold medication.

1109-Mental Health at bedside.

1400-report to Rosaline RN for lunch relief.

/es/ Karen Miles, RN, CCRN, MN

Staff Nurse, Emergency Department

Signed: 09/22/2023 14:41

Date/Time: 22 Sep 2023 @ 0920

Note Title: Emergency Dept Clinician Note

Location: No CA Healthcare Sys-Martinez

Signed By: DOMA,ANAMIKA K

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APPENDIX 512

NOTE SUMMARY/ASSESSMENT

0924-Assumed care of patient, Pt shares that he has been under stress recently.

This am patient was at ENT and decided to come to ED. Describes chest pain

which radiates to back, occurs with tension. Feels his skin turns

"white"

Denies any shortness of breath, or sweating, can occurr at any time.

No chest pain or discomfort at this time.

1009-Blood pressure, 174/101-70HR

Pt states that he under lots of stress.

22 Sep 2023 @ 0920

Emergency Dept Clinician Note

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 28 of 43 PageID 7191
Co-signed By: DOMA,ANAMIKA K

Date/Time Signed: 22 Sep 2023 @ 1411

Note

 LOCAL TITLE: Emergency Dept Clinician Note

STANDARD TITLE: PHYSICIAN EMERGENCY DEPARTMENT NOTE

DATE OF NOTE: SEP 22, 2023@09:20 ENTRY DATE: SEP 22, 2023@09:20:24

 AUTHOR: DOMA,ANAMIKA K EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Emergency Dept Clinician Note Has ADDENDA ***

SACRAMENTO MATHER EMERGENCY DEPARTMENT VISIT NOTE

SEP 22, 2023

 Sex: MALE Race:DECLINED TO ANSWER

CHIEF COMPLAINT / HISTORY OF PRESENTING ILLNESS:

------------------------------------------------

63y/o MALE with hypertension c/o bilateral chest pain (squeezing, 5/10, 

radiating to his back and right arm, lasting minutes) which has occurred 3 times 

in the past 5 days. Patient denies falls or chest trauma. He also felt his 

whole body tingling. Patient has been under a tremendous amount of stress at 

work. He has been feeling depressed and wishes that he does not wake up. 

Denies fever/chills, dysuria, n/v/d,productive cough, or CP/SOB/abdominal pain.

ROS: All 13 systems are negative unless otherwise stated above in HPI.

PAST HISTORY:

Per CPRS & previous notes.

Computerized Problem List is the source for the following:

1. Cough 09/30/20 BUCAYCAY,ELEANO

2. Knee pain 08/26/20 BUCAYCAY,ELEANO

3. Depressive episode 08/31/22 ESPINOSA,SONJA

4. General Anxiety 08/31/15 WEBER,DIANE ELL

5. Varicose veins of lower extremity (SNOMED CT 08/04/14 TAYLOR,JEFFERY

72866009)

6. Impaired Fasting Glucose (ICD-9-CM 790.21) 04/24/13 DOCTOR,FEDERICO

7. GERD * (ICD-9-CM 530.81) 04/24/13 DOCTOR,FEDERICO

8. DJD, Knee/Lower Leg 03/04/13 TAYLOR,JEFFERY

9. CMP INT ORT DEV/GFT NOS 03/04/13 TAYLOR,JEFFERY

10. Low Back Pain * (ICD-9-CM 724.2) 08/09/12 DOCTOR,FEDERICO

11. Hearing loss * (ICD-9-CM 389.9) 05/24/10 DOCTOR,FEDERICO

12. Hyperlipidemia 06/30/08 WOO,JOSEPH C

13. Pain in joint involving lower leg (ICD-9-CM 06/27/08 WOO,JOSEPH C

719.46)

14. Tear of lateral cartilage or meniscus of knee, 06/27/08 WOO,JOSEPH C

current (ICD-9-CM 836.1)

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APPENDIX 513

63y/o MALE with hypertension c/o bilateral chest pain (squeezing, 5/10, 

radiating to his back and right arm, lasting minutes) which has occurred 3 times 

in the past 5 days. Patient denies falls or chest trauma. He also felt his

whole body tingling. Patient has been under a tremendous amount of stress at 

work. He has been feeling depressed and wishes that he does not wake up.

Denies fever/chills, dysuria, n/v/d,productive cough, or CP/SOB/abdominal pain.

DATE OF NOTE: SEP 22, 2023@09:20 ENTRY DATE: SEP 22, 2023@09:20:24

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 29 of 43 PageID 7192
ALLERGIES:ERYTHROMYCIN, VICODIN, DARVOCET-N

MEDS: Per CPRS: reconciliation not completed

Computer is the source for the following medication list:

DICLOFENAC NA 1% TOP GEL Sig: APPLY 2 GRAMS TOPICALLY FOUR TIMES A DAY USE

DOSING CARD PROVIDED TO MEASURE DOSE. DON'T EXCEED 16 GRAMS DAILY TO A 

JOINT

OF THE LOWER BODY. DON'T EXCEED 8 GRAMS DAILY TO A JOINT OF THE UPPER 

BODY.

DON'T EXCEED A TOTAL DOSE OF 32 GRAMS PER DAY. FOR PAIN AND INFLAMMATION

ATORVASTATIN CALCIUM 40MG TAB Sig: TAKE ONE TABLET BY MOUTH ONCE DAILY FOR

CHOLESTEROL (DO NOT TAKE WITH GRAPEFRUIT JUICE.)

SOCIAL HX: non-smoker, no significant etoh/drug hx

PHYSICAL EXAMINATION:

VITALS: 04/20/2023 10:22 BP:137/87 HR:67 Wt:168.7 lb [76.52 k

RR: 16 (09/12/2022 09:53)

Temp: 97.7 F [36.5 C] (04/20/2023 10:22)

Pox: %RA Measurement DT POx

(L/MIN)(%)

04/20/2023 10:22 99

09/12/2022 09:53 98

General: A/Ox3, NAD, pleasant, calm & cooperative. Patient is very tearful.

He

appears sad.

HEENT: NC/AT, MMM's, oropharynx clear, nares patent, no discharge.

Neck: Supple, nml ROM.

CV: RRR, no MRG.

Lungs: BS=bilat, no wheezes, rales, or rhonchi.

Abd: Soft, NT/ND, nml BS's, no guarding/rebound.

Ext: MAEx4, no LE edema.

Skin: Nml color, dry, and warm.

Neuro: No focal deficits, strength & sensation grossly intact.

EKG: NSR@75 bpm, normal axis, no acute ST-T wave changes. Similar to prior EKGs 

in CPRS on July 7, 2022.

LABORATORY VALUES:

Collection DT Spec WBC HGB HCT MCV MCHC PLT

12/08/2021 12:53 BLOOD 6.7 15.8 48.0 90.4 32.9 360

08/20/2020 10:35 BLOOD 5.1 15.7 46.7 89.0 33.6 307

Collection DT Spec GLUCOSE BUN CREAT NA K CL CO2

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APPENDIX 514

NAD, pleasant, calm & cooperative. Patient is very tearful.

He

appears sad.

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 30 of 43 PageID 7193
01/19/2023 13:26PLASMA 116 19 0.91 135 L 4.2 99 27

06/09/2022 12:07PLASMA 115 19 1.00 137 5.3 H 105 28

Collection DT Spec ALT AST ALK PHO ALBUMIN T. BIL PROTEIN

01/19/2023 13:26 PLASM 18 17 57 4.5 0.9 7.6

12/08/2021 12:52 PLASM 26 24 60 4.9 H 0.8 7.7

SCL1 - UA

Collection DT Spec COLOR SP.GRAV UROBILI BILIRUB KETONES GLU Ur Prot

08/20/2020 10:35 URINE Amber 1.025 <0.2 L Negative Negative Negative

Negative

MIC - Microbiology

 No data available

----------------------------------------------------------------

LAB RESULTS LAST 24 HRS - NONE FOUND

IMAGING:

 09/22/2023 09:20

 No data available

MEDS DISPENSED IN EMERGENCY DEPARTMENT: per orders

--------------------------------------

ED COURSE:

------------

PCP added as additional signer to this note to assist with continuity of care.

14: 00 mental health has seen the patient and is recommending that he follow-up 

with outpatient psychotherapy. I strongly believe the patient needs to be 

started on an antidepressant until he sees a therapist. I will start him on a 

daily antidepressant and have him follow-up with mental health as outpatient. I 

will also have him follow-up with his primary care physician as outpatient.

DIFFERENTIAL/Medical Decision Making:

-------------------------------------

r/o PNA, UTI, electrolyte abn, anemia, dehydration, MI, PE, depression

IMPRESSION/PROBLEM LIST:

-----------------------

1. Chest pain

2. Depression

ED PLAN/RECOMMENDATIONS:

-----------------------

1. Celexa 20 mg daily for depression.

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APPENDIX 515

 depression

IMPRESSION/PROBLEM LIST:

-----------------------

1. Chest pain

2. Depression

ED PLAN/RECOMMENDATIONS:

1. Celexa 20 mg daily for depression.

14: 00 mental health has seen the patient and is recommending that he follow-up

with outpatient psychotherapy. I strongly believe the patient needs to be

started on an antidepressant until he sees a therapist. I will start him on a 

daily antidepressant and have him follow-up with mental health as outpatient. I

will also have him follow-up with his primary care physician as outpatient.

DIFFERENTIAL/Medical Decision Making:

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 31 of 43 PageID 7194
2. Follow-up with therapist as outpatient.

3. Follow-up with your primary care physician in 1 week.

4. Return to ER for worsening symptoms.

NSAIDs

Discussed long term side effects of pain medications including

effects on stomach, liver, kidneys, blood, bleeding, etc.

Patient understands, advised to use pain meds very judiciously and sparingly.

Tylenol/Acetaminophen containing products

Discussed possible long term side effects of medication use including

effects on stomach, liver, kidneys, blood, bleeding, etc. Patient

understands, advised that if so chooses to use this medication, to do so

judiciously and sparingly, maximum 4g total dose per 24hrs.

Continue current medications.

Diabetic patients advised to monitor blood glucose at home as instructed.

Advised to monitor blood pressure at home.

Patient advised to call for any concerns, questions or symptoms.

Return to Emergency Department if symptoms worsen.

Follow up with Primary Care Provider (PCP) - pt to contact PCP in 1-2 days.

Return to ED if presenting signs/symptoms persist, worsen or otherwise

concerned.

Treatment and plan discussed and agreed upon with the patient.

Disposition: Discharged home.

Condition: Improved, stable.

Referral to: Primary MD, pt will call for follow up.

Written Discharge Instructions provided to patient.

/es/ Anamika K. Doma, DO

Physician, Emergency Medicine

Signed: 09/22/2023 14:11

Receipt Acknowledged By:

09/22/2023 15:36 /es/ Kamalpreet Dulai, MD

Physician, Primary Care

09/22/2023 ADDENDUM STATUS: COMPLETED

14: 15 I will send patient home with Amlodipine 5 mg daily for his hypertension. 

/es/ Anamika K. Doma, DO

Physician, Emergency Medicine

Signed: 09/22/2023 14:18

Date/Time: 22 Sep 2023 @ 0918

Note Title: Nursing Emergency Dept Triage

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APPENDIX 516

Follow-up with therapist as outpatient.

3. Follow-up with your primary care physician in 1 week.

4. Return to ER for worsening symptoms.

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 32 of 43 PageID 7195
Location: No CA Healthcare Sys-Martinez

Signed By: TORRES,CATHY CHI

Co-signed By: TORRES,CATHY CHI

Date/Time Signed: 22 Sep 2023 @ 0923

Note

LOCAL TITLE: Nursing Emergency Dept Triage

STANDARD TITLE: NURSING EMERGENCY DEPARTMENT TRIAGE NOTE

DATE OF NOTE: SEP 22, 2023@09:18 ENTRY DATE: SEP 22, 2023@09:19:01

 AUTHOR: TORRES,CATHY CHI EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Emergency Department/Urgent Care Center Triage

Patient Sex: MALE

On arrival patient was: AMBULATORY

Patient phone number: ( PHONE NUMBER [CELLULAR] - (

Allergies: ERYTHROMYCIN, VICODIN, DARVOCET-N

Subjective/Chief Complaint:

Drove self to ED endorsing pectoral pain and neck pain that is thobbing and

intermittent when he is stressed. Noted tingling and paleness when he get that

way. Denies acute SOB/N/V/d/f/c.

Objective:

AAox4, speaking in full sentences. NAD. Ambulatory with steady gait. Skin is

warm dry and normal in color. VSs stable for now. Roomed in ED 11. EKG done.

The patient is not a fall risk.

Vital Signs:

Vitals Taken:

Temperature

 98.9 F (37.2 C)

Pulse

 74

Respirations

 16

Blood Pressure

 164/91

Pain scale recorded:

 9

Pulse Oximetry 99 Room Air

Emergency Severity Index (ESI) level

Level 3

Current Medications:

Active Outpatient Medications (excluding Supplies):

Active Outpatient Medications Status

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APPENDIX 517

Drove self to ED endorsing pectoral pain and neck pain that is thobbing and

intermittent when he is stressed. Noted tingling and paleness when he get that

way. Denies acute SOB/N/V/d/f/c.

Objective:

AAox4, speaking in full sentences. NAD. Ambulatory with steady gait. Skin is

warm dry and normal in color. VSs stable for now. Roomed in ED 11. EKG done.

The patient is not a fall risk.

22 Sep 2023 @ 0923

NURSING EMERGENCY DEPARTMENT TRIAGE NOTE TRIAGE

SEP 22, 2023@09:18 

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 33 of 43 PageID 7196
=========================================================================

1) ATORVASTATIN CALCIUM 40MG TAB TAKE ONE TABLET BY ACTIVE

 MOUTH ONCE DAILY FOR CHOLESTEROL (DO NOT TAKE WITH

 GRAPEFRUIT JUICE.)

2) DICLOFENAC NA 1% TOP GEL APPLY 2 GRAMS TOPICALLY FOUR ACTIVE

 TIMES A DAY USE DOSING CARD PROVIDED TO MEASURE

 DOSE. DON'T EXCEED 16 GRAMS DAILY TO A JOINT OF THE

 LOWER BODY. DON'T EXCEED 8 GRAMS DAILY TO A JOINT

 OF THE UPPER BODY. DON'T EXCEED A TOTAL DOSE OF 32

 GRAMS PER DAY. FOR PAIN AND INFLAMMATION

 Active Non-VA Medications Status

=========================================================================

1) Non-VA CYANOCOBALAMIN TAB MOUTH ACTIVE

3 Total Medications

Current Problems:

Computerized Problem List is the source for the following:

1. Cough 09/30/20 BUCAYCAY,ELEANO

2. Knee pain 08/26/20 BUCAYCAY,ELEANO

3. Depressive episode 08/31/22 ESPINOSA,SONJA

4. General Anxiety 08/31/15 WEBER,DIANE ELL

5. Varicose veins of lower extremity (SNOMED CT 08/04/14 TAYLOR,JEFFERY

72866009)

6. Impaired Fasting Glucose (ICD-9-CM 790.21) 04/24/13 DOCTOR,FEDERICO

7. GERD * (ICD-9-CM 530.81) 04/24/13 DOCTOR,FEDERICO

8. DJD, Knee/Lower Leg 03/04/13 TAYLOR,JEFFERY

9. CMP INT ORT DEV/GFT NOS 03/04/13 TAYLOR,JEFFERY

10. Low Back Pain * (ICD-9-CM 724.2) 08/09/12 DOCTOR,FEDERICO

11. Hearing loss * (ICD-9-CM 389.9) 05/24/10 DOCTOR,FEDERICO

12. Hyperlipidemia 06/30/08 WOO,JOSEPH C

13. Pain in joint involving lower leg (ICD-9-CM 06/27/08 WOO,JOSEPH C

719.46)

14. Tear of lateral cartilage or meniscus of knee, 06/27/08 WOO,JOSEPH C

current (ICD-9-CM 836.1)

Suicide Screen:

Columbia Suicide Severity Rating Scale (C-SSRS) screener

 1. Over the past month, have you wished you were dead or wished you could go 

 to sleep and not wake up?

 No

 2. Over the past month, have you had any actual thoughts of killing yourself?

 No

 3. Over the past month, have you been thinking about how you might do this?

 Response not required due to responses to other questions.

 4. Over the past month, have you had these thoughts and had some intention of 

 acting on them?

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APPENDIX 518

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 34 of 43 PageID 7197
 Response not required due to responses to other questions.

5. Over the past month, have you started to work out or worked out the

details of how to kill yourself?

Response not required due to responses to other questions.

6. If yes, at any time in the past month did you intend to carry out this

plan?

Response not required due to responses to other questions.

7. In your lifetime, have you ever done anything, started to do anything, or

prepared to do anything to end your life (for example, collected pills,

obtained a gun, gave away valuables, went to the roof but didn't jump)?

No

8. If YES, was this within the past 3 months?

Response not required due to responses to other questions.

MENTAL STATUS:

 Level Of Awareness: Alert

 Oriented To: Person,place,date,situation.

Female of Child-bearing age (< 52 yo)?

NO

DOMESTIC VIOLENCE SCREEN

Are you living in a home where you have been hit, kicked, verbally or sexually

threatened by someone recently?

No

SEPSIS SCREEN

Does the patient meet Two or more of the following parameters?

Temperature >100.4 F (38C) F or <96.8 F (36C)

Acute altered mental status GCS <15

Heart Rate >90 bpm

Respirations >20 bpm

WBC >12k or <4K (if known)

OR

Any one of the following:

SBP < 90 mmHg

SBP drop of 40mmHg from baseline

 NO

The patient was asked if in the last 14 days they have had new onset of any 

COVID-19 symptoms. They report the following:

 No symptoms

Within the past 14 days, the patient reports no exposure to someone with a 

febrile/respiratory illness or someone with a known or suspected case of 

COVID-19 (within 6 feet for > 15 minutes).

Result:

 Screen is negative.

Weapons/Contraband Screening:

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APPENDIX 519

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 35 of 43 PageID 7198
 Do you have any of the following items with you?

 Guns

 Knifes

 Illegal drugs, including Marijuana

 None

/es/ Cathy C. Torres, RN, BSN, CCRN

Nurse ED/SAC

Signed: 09/22/2023 09:23

Date/Time: 22 Sep 2023 @ 0859

Note Title: Reusable Medical Equipment Note

Location: No CA Healthcare Sys-Martinez

Signed By: SALGADO,SHELDON B

Co-signed By: SALGADO,SHELDON B

Date/Time Signed: 22 Sep 2023 @ 0906

Note

 LOCAL TITLE: Reusable Medical Equipment Note

STANDARD TITLE: ADMINISTRATIVE NOTE

DATE OF NOTE: SEP 22, 2023@08:59 ENTRY DATE: SEP 22, 2023@09:00:07

 AUTHOR: SALGADO,SHELDON B EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

REUSABLE MEDICAL EQUIPMENT TRACKING:

 A procedure was done using an endoscope with the following serial number

 [SCOPE 1]:

 Serial#: 800999

/es/ Sheldon B. Salgado

Health Technician, Mather

Signed: 09/22/2023 09:06

Date/Time: 18 Aug 2023 @ 1148

Note Title: COMMUNITY CARE-CARE COORDINATION PLAN NOTE

Location: No CA Healthcare Sys-Martinez

Signed By: CARRAS,JENNIFER ANN

Co-signed By: CARRAS,JENNIFER ANN

Date/Time Signed: 18 Aug 2023 @ 1149

Note

 LOCAL TITLE: COMMUNITY CARE-CARE COORDINATION PLAN NOTE

STANDARD TITLE: NONVA NOTE

DATE OF NOTE: AUG 18, 2023@11:48 ENTRY DATE: AUG 18, 2023@11:48:42

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APPENDIX 520

Date/Time Signed: 18 Aug 2023 @ 1149

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 36 of 43 PageID 7199
AUTHOR: CARRAS,JENNIFER ANN EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Community Care Consult: Behavioral Health

Consult No: 612_5937974

HSRM Referral #: VA0031123341

Chief Complaint: Depression, unspecified(ICD-10-CM F32.A)

Patient Admitted? No

Level of Care Coordination

 Moderate

 Care Coordination was determined from:

 Chart Review

 Facility Community Care Office Contact

 Care Coordination Point of Contact: Office of Community Care

Phone Number: 707-562-8430, opt 2

Services:

Basic Care Coordination Services

Direct communication to referring provider

Care management, if appropriate

Plan:

Assist PRN with communication between Community Care providers and the 

interdisciplinary VA team. Coordinate appropriate patient care along the 

continuum of the Community Care Consult.

/es/ JENNIFER ANN CARRAS

BSN, RN, Community Care, MCC

Signed: 08/18/2023 11:49

Date/Time: 14 Aug 2023 @ 1104

Note Title: MH Evidence Based Psychotherapy (EBP) Individual Note

Location: No CA Healthcare Sys-Martinez

Signed By: ROSBURG,ELIZA YUMIKO MAILE

Co-signed By: ROSBURG,ELIZA YUMIKO MAILE

Date/Time Signed: 18 Aug 2023 @ 0928

Note

 LOCAL TITLE: MH Evidence Based Psychotherapy (EBP) Individual No

STANDARD TITLE: MENTAL HEALTH NOTE

DATE OF NOTE: AUG 14, 2023@11:04 ENTRY DATE: AUG 14, 2023@11:05:03

AUTHOR: ROSBURG,ELIZA YUMIK EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

ROSS, ROBERT ALLEN is a 63 year old MALE

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APPENDIX 521

18 Aug 2023 @ 0928

Chief Complaint: Depression, unspecified(ICD-10-CM F32.A)

 MH Evidence Based Psychotherapy (EBP) Individual No

Community Care Consult: Behavioral Health

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 37 of 43 PageID 7200
Other Mental Health Providers, including Vet Center Staff:

 LCSW, MHTC

PURPOSE FOR SESSION:

Supportive therapy

TIME SPENT WITH PATIENT:

38-52 minutes (CPT: 90834)

INFORMED CONSENT

Patient's identity verified via name and DOB. Patient has been informed of 

limits of confidentiality and clinic policies including mandated reporting of 

abuse situations and confidentiality related to self/other harm. Patient 

provided informed consent for treatment including risks, benefits, and 

potential complications. Patient expressed understanding and agreed to 

voluntarily proceed with evaluation and/or treatment.

SUBJECTIVE CONTENT OF SESSION:

Veteran endorsing ongoing anxiety, anger and depression given continued legal 

stressors. Reported that his "basket is full" and distracts himself 

with

working and "pleasing others." Stated that he was seen by his PCP last 

year, as 

he was experiencing physiological sxs (i.e. heart racing), completed "stress 

test," given heart monitor, etc., but stated no significant medical concerns 

were identified. Reported that he continues with traveling out of state to begin 

his shift, as a flight attendant and with marriage and parenting stress. Noted 

however, that this lawsuit remains his primary concern and believes is biggest 

contributor to his sxs. Veteran reporting that he belongs to a FB page, of which 

he responds to false accusations made against him and describes this to be 

"cathartic." Endorsed passive SI, "go to sleep and not wake 

up," but adamantly 

denies any behaviors, plan, or intent. Reported that he would never do anything 

to harm himself. 

OBJECTIVE/INTERVENTION:

Met with Veteran today for supportive session. Focused on building rapport, 

offered active listening with reflective feedback. Provided some psychoeducation 

about anxiety (i.e. normal vs problematic), identifying coping skills, use of 

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APPENDIX 522

Veteran endorsing ongoing anxiety, anger and depression given continued legal

stressors. Reported that his "basket is full" and distracts himself 

with

working and "pleasing others." Stated that he was seen by his PCP last

year, as

he was experiencing physiological sxs (i.e. heart racing), completed "stress

test," given heart monitor, etc., but stated no significant medical concerns 

were identified. Reported that he continues with traveling out of state to begin

his shift, as a flight attendant and with marriage and parenting stress. Noted 

however, that this lawsuit remains his primary concern and believes is biggest 

contributor to his sxs. Veteran reporting that he belongs to a FB page, of which

he responds to false accusations made against him and describes this to be

"cathartic." Endorsed passive SI, "go to sleep and not wake

up," but adamantly

denies any behaviors, plan, or intent. Reported that he would never do anything

to harm himself. 

PURPOSE FOR SESSION:

Supportive therapy

OBJECTIVE/INTERVENTION:

Met with Veteran today for supportive session. Focused on building rapport, 

offered active listening with reflective feedback. Provided some psychoeducation

about anxiety (i.e. normal vs problematic), identifying coping skills, use of

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 38 of 43 PageID 7201
stress management to manage mood, and discussed benefits. Veteran receptive and 

participatory. Assessed for safety. Veteran endorsing passive SI, but adamantly 

denying any behaviors, plan, or intent. Denies HI. Denies access to firearms.

Veteran is a 63y/o, AF, Male, who was initially referred by PCMHI as 

Veteran requested to return to the VA after receiving ind therapy by CC provider 

and felt not a good fit. Veteran with comp assessment completed in 2015 and 

documented diagnosis of MDD and GAD. Veteran endorsing sxs of anxiety and 

depression and significant workplace and related legal stressors. Veteran 

requested EBP therapy with VA and informed of wait times at comp update 

appt (see CPRS), but today requesting to try CC again with preference to not be 

assigned previous clinician. This writer to notate request in consult and cancel 

active consult for ind EBP with VA. Discussed with Veteran that due to his 

changing work schedule, a CC provider may be the most suitable option vs 

engagement with VA provider for ind EBP. Veteran agreeable. Declines all other 

VA MH tx services at this time.

MENTAL STATUS EXAM

Appearance and Behavior: Veteran presented to appointment on time. Good eye 

contact. Casually dressed. Behavior congruent to situation. Appeared stated 

age.

 Grooming and Hygiene: Good

 Psychomotor Activity: Within normal limits

 Demeanor: Cooperative, engaged

Speech: Normal in prosody, rate, and volume

Mood: anxious, some frustration, down

Affect: Full range, congruent with mood

Thought Process: Logical and linear

Thought content/Perceptual Disturbances: future focused, goal directed, No 

abnormal thought content; no evidence of obsessions, delusions, or paranoia/ 

Denied AVH; did not appear to be responding to internal stimuli

Cognition:

 Orientation: Fully oriented

 Memory: No issues reported or observed but not formally assessed

 Attention: Within normal limits

 Insight/Judgment: Good/good

VETERAN WAS PROVIDED WITH THE FOLLOWING CONTACT INFORMATION:

Advised of clinic contact: Name/Phone Number: Eliza Rosburg, LCSW 

 Provided contact and instructions Veterans Crisis Line: 1-800-273-8255, 

option #1 at the prompt, or dial 988, option #1 at the prompt, or text to 

838255. Veteran aware of clinic hours, Access services for same day appt by 

phone or walkin, or visiting the nearest ED for a MH emergency. Veteran endorsed 

passive SI, but adamantly denied any bxs, plan or intent. Denies hx of SA/SIB. 

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APPENDIX 523

 anxious, some frustration

Veteran is a 63y/o, AF, Male, who was initially referred by PCMHI as 

Veteran requested to return to the VA after receiving ind therapy by CC provider 

and felt not a good fit. Veteran with comp assessment completed in 2015 and

documented diagnosis of MDD and GAD. Veteran endorsing sxs of anxiety and 

depression and significant workplace and related legal stressors. Veteran 

requested EBP therapy with VA and informed of wait times at comp update 

appt (see CPRS), but today requesting to try CC again with preference to not be

assigned previous clinician. This writer to notate request in consult and cancel

active consult for ind EBP with VA. Discussed with Veteran that due to his

changing work schedule, a CC provider may be the most suitable option vs 

engagement with VA provider for ind EBP. Veteran agreeable. Declines all other

VA MH tx services at this time.

stress management to manage mood, and discussed benefits. Veteran receptive and 

participatory. Assessed for safety. Veteran endorsing passive SI, but adamantly 

denying any behaviors, plan, or intent. Denies HI. Denies access to firearms.

down

passive SI, but adamantly denied any bxs, plan or intent. Denies hx of SA/SIB. adamantly

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 39 of 43 PageID 7202
Denies HI. Does not appear to be an imminent risk to self or others. No acute 

distress. Is at LOW acute/ chronic risk. Risk factors: gender, mood sxs, legal 

problems, work and marital stress. Protective factors: responsibility as parent, 

help seeking, desire to improve, denied access to firearms. Collective high 

confidence in the ability of the Veteran to independently maintain safety. 

Remains appropriate for outpatient care. 

DIAGNOSIS:

Depression d/o, unspecified

Anxiety d/o, unspecified 

PLAN

1. Veteran was familiarized with the BHIP model and EBPs to address treatment

goals in 8-16 sessions. Veteran was offered individual therapy, which he

accepted. Veteran was informed of the wait time at MCCL VA for a therapist and

consult for community therapist was offered, which he accepted.

2. Veteran offered med eval and declined.

3. Veteran offered group therapy and Peer Support services and declined.

4. Veteran was encouraged to contact this provider if he needs support in the

interim and/or resources.

5. Veteran informed of when and how to access routine and emergent mental health

care, as noted above and expressed understanding.

/es/ Eliza Yumiko Maile Rosburg, LCSW

Signed: 08/18/2023 09:28

Date/Time: 05 Jul 2023 @ 0830

Note Title: MHTC Assignment/Reassignment Note

Location: No CA Healthcare Sys-Martinez

Signed By: ROSBURG,ELIZA YUMIKO MAILE

Co-signed By: ROSBURG,ELIZA YUMIKO MAILE

Date/Time Signed: 07 Jul 2023 @ 1030

Note

LOCAL TITLE: MHTC Assignment/Reassignment Note

STANDARD TITLE: MENTAL HEALTH ADMINISTRATIVE NOTE

DATE OF NOTE: JUL 05, 2023@08:30 ENTRY DATE: JUL 06, 2023@09:15:07

 AUTHOR: ROSBURG,ELIZA YUMIK EXP COSIGNER:

URGENCY: STATUS: COMPLETED

MHTC Initial Assignment

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APPENDIX 524

DIAGNOSIS:

Depression d/o, unspecified

Anxiety d/o, unspecified

Denies HI. Does not appear to be an imminent risk to self or others. No acute 

distress. Is at LOW acute/ chronic risk. Risk factors: gender, mood sxs, legal 

problems, work and marital stress. Protective factors: responsibility as parent,

help seeking, desire to improve, denied access to firearms. Collective high 

confidence in the ability of the Veteran to independently maintain safety.

Remains appropriate for outpatient care.

Signed: 08/18/2023 09:28

Veteran offered group therapy and Peer Support services and declined.

4. Veteran was encouraged to contact this provider if he needs support in the

interim and/or resources.

5. Veteran informed of when and how to access routine and emergent mental health

07 Jul 2023 @ 1030

Veteran was familiarized with the BHIP model and EBPs to address treatment

goals in 8-16 sessions. Veteran was offered individual therapy, which he

accepted. Veteran was informed of the wait time at MCCL VA for a therapist and

consult for community therapist was offered, which he accepted.

2. Veteran offered med eval and declined.

MENTAL HEALTH ADMINISTRATIVE NOTE

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 40 of 43 PageID 7203
This note documents the initial assignment of the Veteran's Mental

Health Treatment Coordinator (MHTC) on Jul 5,2023. The Veteran's

new Mental Health Treatment Coordinator is:

MHTC Name: LCSW

MHTC Contact information:

 Office Phone:916-

 Other contact:

The assignment of the MHTC and education on the role of the MHTC in the

Veteran's mental health care was discussed with the Veteran,

who verbally concurred with the new assignment. The MHTC's

contact information was provided to the Veteran.

The Veteran's CPRS chart (i.e., PCMM) and MH Treatment Plan have been 

updated to

reflect the new MHTC Assignment. The Veteran's new MHTC, along with the 

previous

MHTC if applicable, are included as additional signers on this note.

The undersigned of this note is not the Veteran's new MHTC.

The Veteran and/or Veteran's Family has had or is scheduled to

have contact with the newly assigned MHTC: LCSW .

/es/ Eliza Yumiko Maile Rosburg, LCSW

Signed: 07/07/2023 10:30

Receipt Acknowledged By:

07/10/2023 09:11 /es/ LCSW #110035

 Social Worker (BHIP)

07/12/2023 14:48 /es/ HELEN TERRY STALLWORTH

 Program Support Assistant

Date/Time: 05 Jul 2023 @ 0758

Note Title: MH COMPREHENSIVE ASSESSMENT UPDATE CONSULT

Location: No CA Healthcare Sys-Martinez

Signed By: ROSBURG,ELIZA YUMIKO MAILE

Co-signed By: ROSBURG,ELIZA YUMIKO MAILE

Date/Time Signed: 07 Jul 2023 @ 1029

Note

 LOCAL TITLE: MH COMPREHENSIVE ASSESSMENT UPDATE CONSULT

STANDARD TITLE: MENTAL HEALTH CONSULT

DATE OF NOTE: JUL 05, 2023@07:58 ENTRY DATE: JUL 05, 2023@07:58:18

 AUTHOR: ROSBURG,ELIZA YUMIK EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

MENTAL HEALTH COMPREHENSIVE ASSESSMENT UPDATE CONSULT

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APPENDIX 525

Date/Time Signed: 07 Jul 2023 @ 1029

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 41 of 43 PageID 7204
The following assessment is an update to the Mental Health Comprehensive

Assessment which was completed on the date shown below. Please refer to that

initial assessment for historical data not subject to changing since that time.

 The information in this assessment was obtained by the Veteran and their

medical record.

Most recent MH Comprehensive Assessment

Information:

 Computed Finding: VA-Progress Note

 08/31/2015@13:19 value - MH COMPREHENSIVE ASSESSMENT; Author: WEBER,DIANE ELLA

DEMOGRAPHIC UPDATES:

Residential Address:

Phone: PHONE NUMBER [CELLULAR] - (

- Permission to leave confidential message? Yes

Email: EMAIL ADDRESS - 1RROSS@COMCAST.NET

Emergency Contact Information

 Contact: ROSS,KIMBERLY

Relationship: EXTENDED FAMILY MEMBER

 Address: 4701 HAYLOFT COURT

 EL DORADO HLS, CALIFORNIA 95762

 Phone: (916)933-8088

 Work Phone:

MODALITY OF VISIT: Face to Face

INFORMED CONSENT

Patient's identity verified via name and DOB. Patient has been informed of 

limits of confidentiality and clinic policies including mandated reporting of 

abuse situations and confidentiality related to self/other harm. Patient 

provided informed consent for treatment including risks, benefits, and potential 

complications. Patient expressed understanding and agreed to voluntarily proceed 

with evaluation and/or treatment.

In your own words what led you to seeking mental health services?

Verified Veteran's identify via name and DOB. Confirmed Veteran's 

address and 

phone number in CPRS. Veteran reporting significant stressors with family and 

work. Stated "last couple of years have been incredibly stress 

induced."

Described that he is not the same person he was, sharing mood to be angry, 

intolerant, and impatient, affecting his relationships at home and at work. 

Reported feeling depressed as his career is not where he thought it would be 

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APPENDIX 526

Described that he is not the same person he was, sharing mood to be angry, 

intolerant, and impatient, affecting his relationships at home and at work.

Reported feeling depressed as his career is not where he thought it would be 

phone number in CPRS. Veteran reporting significant stressors with family and

work. Stated "last couple of years have been incredibly stress

induced."

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 42 of 43 PageID 7205
with regard to his age. Stated that he has two grown children (ages 19 and 21), 

in college whom he financially supports, and therefore, not in a position to 

make any changes career wise. Reported that he has been a flight attendant for 

the last 40 years, but has his pilot license. Noted that he has made sacrifices 

for his family, and beginning in Feb 2023, had to begin commuting to work to 

Dallas which has added "exponentially" to his stress level. Reported he 

is not 

proud of who he has become. Stated that he is going through a lawsuit that began 

in 2020, as he was "wrongfully accused" at work. Explained that he 

feels

disrespected as a result and shared how this has created in himself 

"insecurities" and described others to be "mean spirited." 

Shared that he has 

also served as president of the flight attendant union. Endorsed trouble 

with sleep onset and maintenance and mind racing. Reported having thoughts of 

going to sleep and not waking up, but adamantly denies any bxs, plan or intent. 

Denies hx of SA/SIB. Denies that he would ever do anything to harm himself, as 

it would hurt his family (wife and children) which he does not want to do. 

Stated that he has lashed out in the past when angry, but denies ever wanting to 

hurt anyone. Denied HI.

What is your goal for receiving mental health care?

Stated is seeking ind therapy with VA therapist, as prior CC provider was not a 

good fit for him.

EPISODES OF CARE

Psychiatric hospitalizations since the last assessment was completed?

 Yes

 Stated was hospitalized for 24hrs when he lived in Ft Worth, TX in 2019 due 

to anger. Stated that a situation happened in his family, but did not provide 

details. Endorsed SI at the time.

Any outpatient Mental Health care in the last 2 years?

 Yes

 2022 with CC therapist

RISK ASSESSMENT

 Columbia Suicide Severity Rating Scale (C-SSRS) screener

 1. Over the past month, have you wished you were dead or wished you could 

 go to sleep and not wake up?

 Yes

 2. Over the past month, have you had any actual thoughts of killing 

 yourself?

 No

 3. Over the past month, have you been thinking about how you might do this?

 Response not required due to responses to other questions.

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APPENDIX 527

with regard to his age. Stated that he has two grown children (ages 19 and 21), 

in college whom he financially supports, and therefore, not in a position to

make any changes career wise. Reported that he has been a flight attendant for 

the last 40 years, but has his pilot license. Noted that he has made sacrifices 

for his family, and beginning in Feb 2023, had to begin commuting to work to

Dallas which has added "exponentially" to his stress level. Reported he

is not

proud of who he has become. Stated that he is going through a lawsuit that began

in 2020, as he was "wrongfully accused" at work. Explained that he 

feels

disrespected as a result and shared how this has created in himself 

"insecurities" and described others to be "mean spirited."

Shared that he has

also served as president of the flight attendant union. Endorsed trouble

with sleep onset and maintenance and mind racing. Reported having thoughts of 

going to sleep and not waking up, but adamantly denies any bxs, plan or intent.

Denies hx of SA/SIB. Denies that he would ever do anything to harm himself, as 

it would hurt his family (wife and children) which he does not want to do.

Stated that he has lashed out in the past when angry, but denies ever wanting to 

hurt anyone. Denied HI.

Stated is seeking ind therapy with VA therapist, as prior CC provider was not a 

good fit for him.

Psychiatric hospitalizations since the last assessment was completed?

Yes

 Stated was hospitalized for 24hrs when he lived in Ft Worth, TX in 2019 due 

to anger. Stated that a situation happened in his family, but did not provide

details. Endorsed SI at the time.

Any outpatient Mental Health care in the last 2 years?

Yes

 2022 with CC therapist

Case 4:22-cv-00343-Y Document 239-12 Filed 04/26/24 Page 43 of 43 PageID 7206