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

 of acting on them?

 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.

 Have you experienced thoughts about harming others in the last 12 months?

 No

 Do you have access to firearms or other weapons?

 No

SUBSTANCE USE within the last 12 months?

 Yes

 Alcohol:

 Reported has 1 glass of wine or beer, maybe nightly, social basis only; 

states takes drug test randomly for work, and therefore is cautious of alcohol 

intake.

MEASUREMENT BASED TOOLS

PHQ-9

 A PHQ-9 screen was performed. The score was 19 which is suggestive of 

 moderately severe depression.

 1. Little interest or pleasure in doing things

 Not at all

 2. Feeling down, depressed, or hopeless

 Nearly every day

 3. Trouble falling or staying asleep, or sleeping too much

 Nearly every day

 4. Feeling tired or having little energy

 More than half the days

 5. Poor appetite or overeating

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APPENDIX 528

3. Trouble falling or staying asleep, or sleeping too much 3. Trouble falling or staying 

 Nearly every day

 4. Feeling tired or having little energy

 More than half the days

 A PHQ-9 screen was performed. The score was 19 which is suggestive of 

 moderately severe depression.

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 1 of 41 PageID 7207
 Not at all

 6. Feeling bad about yourself or that you are a failure or have let yourself 

 or your family down

 Nearly every day

 7. Trouble concentrating on things, such as reading the newspaper or watching 

 television

 Nearly every day

 8. Moving or speaking so slowly that other people could have noticed. Or the 

 opposite being so fidgety or restless that you have been moving around a lot 

 more than usual

 Nearly every day

 9. Thoughts that you would be better off dead or of hurting yourself in some 

 way

 More than half the days

 10. If you checked off any problems, how DIFFICULT have these problems made 

 it for you to do your work, take care of things at home or get along with 

 other people?

 Extremely difficult

GAD-7

 1. Feeling nervous, anxious or on edge

 Nearly every day

 2. Not being able to stop or control worrying

 Nearly every day

 3. Worrying too much about different things

 Nearly every day

 4. Trouble relaxing

 Nearly every day

 5. Being so restless that it is hard to sit still

 Nearly every day

 6. Becoming easily annoyed or irritable

 Nearly every day

 7. Feeling afraid as if something awful might happen

 Not at all

NOTABLE MEDICAL UPDATES since last assessment was completed?

 Yes

 States has high blood pressure, has been prescribed medications to manage 

mood.

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APPENDIX 529

 Feeling bad about yourself or that you are a failure or have let yourself

or your family down

Nearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching

television

Nearly every day

8. Moving or speaking so slowly that other people could have noticed. Or the

opposite being so fidgety or restless that you have been moving around a lot

more than usual

Nearly every day

9. Thoughts that you would be better off dead or of hurting yourself in some 

way

More than half the days

10. If you checked off any problems, how DIFFICULT have these problems made 

it for you to do your work, take care of things at home or get along with

other people?

Extremely difficult

GAD-7

1. Feeling nervous, anxious or on edge

Nearly every day

2. Not being able to stop or control worrying

Nearly every day

3. Worrying too much about different things

Nearly every day

4. Trouble relaxing

Nearly every day

5. Being so restless that it is hard to sit still

Nearly every day

6. Becoming easily annoyed or irritable

Nearly every day

7. Feeling afraid as if something awful might happen

Not at all

NOTABLE MEDICAL UPDATES since last assessment was completed?

Yes

States has high blood pressure, has been prescribed medications to manage 

mood.

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 2 of 41 PageID 7208
PSYCHOSOCIAL UPDATE

 Relationship Status:Married

 Current Housing: Stable

 Finances: Stable

 Employment: Stable

Describes relationship with spouse as "horrible," "made me 

intolerant of what 

I've tolerated." States has "good relationshp with the kids...if 

spouse would 

stay out of it." Identifies close network of friends, lot of supporters, and 

stated is well liked. However, noted that due to false accusations, social media 

has been detrimental. States that he enjoys golfing and enjoys going to Lake 

Tahoe, but lacks time to engage in leisure activities. Reported is heavily 

involved in swim community and family does not have day off.

 Additional Info: Since you were last seen in Mental Health, have there

 been any other changes to your functioning or social circumstances that

 we should be aware of?

See above.

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, down, guarded

Speech: Normal in prosody, rate, and volume

Mood: anxious, some frustration

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:

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APPENDIX 530

Relationship Status:Married

Current Housing: Stable

Finances: Stable

Employment: Stable

Describes relationship with spouse as "horrible," "made me 

intolerant of what 

I've tolerated." States has "good relationshp with the kids...if

spouse would 

stay out of it." Identifies close network of friends, lot of supporters, and

stated is well liked. However, noted that due to false accusations, social media

has been detrimental. States that he enjoys golfing and enjoys going to Lake

Tahoe, but lacks time to engage in leisure activities. Reported is heavily

involved in swim community and family does not have day off.

Additional Info: Since you were last seen in Mental Health, have there

been any other changes to your functioning or social circumstances that

we should be aware of?

See above.

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, down, guarded

Speech: Normal in prosody, rate, and volume

Mood: anxious, some frustration

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

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 3 of 41 PageID 7209
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. 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 

SUMMARY AND TREATMENT RECOMMENDATIONS:

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

requesting to return to 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 today endorsing sxs of anxiety and depression 

and significant workplace and related legal stressors. Veteran also endorsing 

passive SI, but adamantly denying any bxs, plan or intent. Denies access to 

weapons. Veteran requesting EBP therapy with VA and informed of wait times. 

Veteran declined med eval, groups, and Peer Support services. Stated that he 

does not wish to take any medications and is not open to attending groups or 

receiving other support services. Veteran and clinician reviewed all mental 

health treatment options: medication management for mood, EBP individual and 

group therapy, Peer Support, ARTS and/or other Specialty treatment. Consult 

placed for EBP ind therapy. Veteran offered bridge appt for additional support 

and accepted. RTC to be placed.

1. Provided empathy, active listening, unconditional positive regard and

supportive counseling to Veteran.

2. Educated Veteran about available services in the General Mental Health

Clinic including Access, individual therapy, group therapy, medication

management and ARTS Programming. 

3. Provided Access/Triage LCSW direct contact and contact information for the

Veterans Crisis Line 988, #1

4. 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 declined. Veteran prefers 

to wait for a VA therapist. EBP consult to be placed.

5. Veteran offered med eval and declined.

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APPENDIX 531

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

SUMMARY AND TREATMENT RECOMMENDATIONS:

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

requesting to return to 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 today endorsing sxs of anxiety and depression

and significant workplace and related legal stressors. Veteran also endorsing

passive SI, but adamantly denying any bxs, plan or intent. Denies access to

weapons. Veteran requesting EBP therapy with VA and informed of wait times.

Veteran declined med eval, groups, and Peer Support services. Stated that he

does not wish to take any medications and is not open to attending groups or 

receiving other support services. Veteran and clinician reviewed all mental

health treatment options: medication management for mood, EBP individual and 

group therapy, Peer Support, ARTS and/or other Specialty treatment. Consult 

placed for EBP ind therapy. Veteran offered bridge appt for additional support 

and accepted. RTC to be placed.

1. Provided empathy, active listening, unconditional positive regard and

supportive counseling to Veteran.

2. Educated Veteran about available services in the General Mental Health

Clinic including Access, individual therapy, group therapy, medication

management and ARTS Programming.

3. Provided Access/Triage LCSW direct contact and contact information for the

Veterans Crisis Line 988, #1

4. 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 declined. Veteran prefers

to wait for a VA therapist. EBP consult to be placed.

5. Veteran offered med eval and declined.

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 4 of 41 PageID 7210
6. Veteran offered group therapy and Peer Support services and declined.

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

interim and/or resources.

Clinical Reminders:

 Depression Screening:

 Perform PHQ-2

 A PHQ-2 screen was performed. The score was 3 which is a positive 

 screen for depression.

 Over the past two weeks, how often have you been bothered by the 

 following problems?

 1. Little interest or pleasure in doing things

 Not at all

 2. Feeling down, depressed, or hopeless

 Nearly every day

/es/ Eliza Yumiko Maile Rosburg, LCSW

Signed: 07/07/2023 10:29

Date/Time: 13 Jun 2023 @ 1540

Note Title: PCMHI Care Management Note

Location: No CA Healthcare Sys-Martinez

Signed By: BRAKEL,MICHAEL JASON

Co-signed By: BRAKEL,MICHAEL JASON

Date/Time Signed: 13 Jun 2023 @ 1542

Note

 LOCAL TITLE: PCMHI Care Management Note

STANDARD TITLE: CARE MANAGEMENT NURSING NOTE

DATE OF NOTE: JUN 13, 2023@15:40:05 ENTRY DATE: JUN 13, 2023@15:40:05

 AUTHOR: BRAKEL,MICHAEL JASO EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Reviewed by PCMHI RNCM:

Suicidal/Homicidal/Assaultive Ideation/Intent/Plan:

Yes, Veteran states only passive SI related to workplace stress but reports he

does not have a plan or intent to hurt himself or others.

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APPENDIX 532

Yes, Veteran states only passive SI related to workplace stress but reports he

does not have a plan or intent to hurt himself or others.

Depression Screening:

Perform PHQ-2

A PHQ-2 screen was performed. The score was 3 which is a positive

screen for depression.

Over the past two weeks, how often have you been bothered by the

following problems?

1. Little interest or pleasure in doing things

Not at all

2. Feeling down, depressed, or hopeless wn, depressed, 

Nearly every day

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

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

interim and/or resources.

Suicidal/Homicidal/Assaultive Ideation/Intent/Plan: Assaultive

Date/Time Signed: 13 Jun 2023 @ 1542

LOCAL TITLE: PCMHI Care Management Note

STANDARD TITLE: CARE MANAGEMENT NURSING NOTE

DATE OF NOTE: JUN 13, 2023@15:40:05 ENTRY DATE: JUN13, 2023@15:40:05

AUTHOR: BRAKEL,MICHAEL JASO EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 5 of 41 PageID 7211
Name: ROSS, ROBERT ALLEN

Date of visit: 6/13/2023 3:37:00 PM

These assessments were sent to the Veteran via text/email and were completed by 

the Veteran on their own device.

************************************************************

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

The patient reported symptoms consistent with a major depressive episode.

Patient reported being bothered by the following over the last 2 weeks:

1. Little interest or pleasure: More than half the days

2. Feeling down, depressed or hopeless: Nearly every day

3. Trouble sleeping: Nearly every day

4. Tired, low energy: More than half the days

5. Poor appetite, over-eating: Nearly every day

6. Feelings of failure, guilt: Nearly every day

7. Trouble concentrating: Nearly every day

8. Motor retardation, agitation: Not at all

9. Thoughts better off dead/hurting self: Several Days

PHQ-9 total score = 20

1-4 = minimal symptoms 5-9= mild symptoms

10-14= moderate symptoms 15-19= moderately severe symptoms

20-27= severe depressive symptoms

The patient stated that the depressive symptoms made it extremely difficult to 

work, take care of things at home, or get along with others.

PHQ-9 Total Score (past 180 days):

 06/13/2023 20

************************************************************

GENERAL ANXIETY DISORDER-7 (GAD-7)

Patient reported being bothered by the following over the last two weeks:

1. Feeling nervous, anxious or on edge: Nearly every day

2. Not being able to stop or control worrying: Nearly every day

3. Worrying too much about different things: Nearly every day

4. Trouble relaxing: Nearly every day

5. Feeling restless (hard to sit still): Not at all

6. Becoming easily annoyed or irritable: Nearly every day

7. Afraid as if something awful might happen: More than half the days

GAD-7 total score = 17

0-4=minimal symptoms 5-9=mild symptoms

10-14=moderate symptoms 15-21=severe symptoms

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APPENDIX 533

GENERAL ANXIETY DISORDER-7 (GAD-7)

Patient reported being bothered by the following over the last two weeks:

1. Feeling nervous, anxious or on edge: Nearly every day

2. Not being able to stop or control worrying: Nearly every day

3. Worrying too much about different things: Nearly every day

4. Trouble relaxing: Nearly every day

5. Feeling restless (hard to sit still): Not at all

6. Becoming easily annoyed or irritable: Nearly every day

7. Afraid as if something awful might happen: More than half the days

GAD-7 total score = 17

0-4=minimal symptoms 5-9=mild symptoms

10-14=moderate symptoms 15-21=severe symptoms

The patient reported symptoms consistent with a major depressive episode.

Patient reported being bothered by the following over the last 2 weeks:

1. Little interest or pleasure: More than half the days

2. Feeling down, depressed or hopeless: Nearly every day

3. Trouble sleeping: Nearly every day

4. Tired, low energy: More than half the days

5. Poor appetite, over-eating: Nearly every day

6. Feelings of failure, guilt: Nearly every day

7. Trouble concentrating: Nearly every day

8. Motor retardation, agitation: Not at all

9. Thoughts better off dead/hurting self: Several Days

PHQ-9 total score = 20

1-4 = minimal symptoms 5-9= mild symptoms

10-14= moderate symptoms 15-19= moderately severe symptoms

20-27= severe depressive symptoms

The patient stated that the depressive symptoms made it extremely difficult to 

work, take care of things at home, or get along with others.

PHQ-9 Total Score (past 180 days):

 06/13/2023 20

6/13/2023 3:37:00 PM

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 6 of 41 PageID 7212
The patient stated that the anxiety symptoms made it very difficult to work, 

take care of things at home, or get along with others.

GAD-7 Total Score (past 180 days):

 06/13/2023 17

/es/ Michael Jason Brakel, RN BSN

PCMHI RN Case Manager

Signed: 06/13/2023 15:42

Date/Time: 12 Jun 2023 @ 1319

Note Title: PCMHI Primary Care Mental Health Consult

Location: No CA Healthcare Sys-Martinez

Signed By: BRAKEL,MICHAEL JASON

Co-signed By: BRAKEL,MICHAEL JASON

Date/Time Signed: 12 Jun 2023 @ 1342

Note

 LOCAL TITLE: PCMHI Primary Care Mental Health Consult

STANDARD TITLE: MENTAL HEALTH CONSULT

DATE OF NOTE: JUN 12, 2023@13:19 ENTRY DATE: JUN 12, 2023@13:19:47

 AUTHOR: BRAKEL,MICHAEL JASO EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** PCMHI Primary Care Mental Health Consult Has ADDENDA ***

Primary Care Mental Health Integration (PC-MHI) Assessment

Patient Identification: Patient is a 63 year old, DECLINED TO ANSWER MALE.

Veteran is seen by PC-MHI as part of the Patient-Aligned Care Team (PACT).

DS - Disabilities

Eligibility: SC LESS THAN 50% VERIFIED

Total S/C %: 30

LIMITED FLEXION OF KNEE 10% S/C

KNEE CONDITION 10% S/C

LIMITED FLEXION OF KNEE 10% S/C

SCREENINGS/MEASURES:

PHQ-9:

MHAS - PHQ9 SCORE

Date Instrument Raw Trans Scale

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APPENDIX 534

Date/Time Signed: 12 Jun 2023 @ 1342

The patient stated that the anxiety symptoms made it very difficult to work, 

take care of things at home, or get along with others.

MENTAL HEALTH CONSULT

DATE OF NOTE: JUN 12, 2023@13:19 ENTRY DATE: JUN 12, 2023@13:19:47

AUTHOR: BRAKEL,MICHAEL JASO EXP 

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 7 of 41 PageID 7213
06/09/2022 11:39 PHQ9 20 PHQ9 GAD-7:

MHAS - MHA Score

No data available for: GAD-7

REFERRED BY: Dr. Dulai.

REASON FOR REFERRAL: Mood and Stress related to workplace stress.

VISIT DURATION (minutes): 16 minutes

Veteran's primary concern(s) (duration, frequency, intensity, triggering

events, etc.): 

Per brief interview with Veteran and review of chart back to

2015.

-Veteran currently in a lawsuit with his Airline's labor union (long-haul

flight attendant). He was a former union steward who reported alleged

wrongdoing.

-Veteran reports this is primary stress and records shows workplace

stress in the past has affected personal relationships.

-Veteran reports his community care provider was not a good fit and is looking

for a provider at either McClellan or Mather for therapy to continue.

__________________________________________________________________________

FUNCTIONAL ASSESSMENT:

Sleep: Reports sleep is frequently off as he works 5 days on and has routes to

Alaska, Europe, and Asia. Veteran reports he flies across multiple time zones

and frequently works 12 hour days.

Work: See above. Also has pilot's license.

Close relationships: Wife and children (age 19 and 21).

Recreation: Hiking and golfing; however, Veteran reports he has been so busy

with work that he has not done either for a while.

Physical Activity: See above.

__________________________________________________________________________

Brief summary of past mental health treatment (e.g. therapy, medication,

hospitalization, inpatient treatment, etc.): 

Sertraline in the past but Veteran reports he has not taken and is not 

interested in medication at this time.

 __________________________________________________________________________

Substance use history: 

ETOH: Occasional wine with meal, occasional one beer at single setting.

Marijuana/Illicit Drugs/Tobacco: Denies.

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APPENDIX 535

REASON FOR REFERRAL: Mood and Stress related to workplace stress.

-Veteran currently in a lawsuit with his Airline's labor union (long-haul

flight attendant). He was a former union steward who reported alleged

wrongdoing.

-Veteran reports this is primary stress and recordsshows workplace

stress in the past has affected personal relationships.

Sleep: Reports sleep is frequently off as he works 5 days on and has routes to

Alaska, Europe, and Asia. Veteran reports he flies across multiple time zones

and frequently works 12 hour days.

06/09/2022 

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 8 of 41 PageID 7214
Caffeine: 2 cups of coffee before workday begins.

 __________________________________________________________________________

RISK ASSESSMENT:

Suicidal/Homicidal/Assaultive Ideation/Intent/Plan:

Yes, Veteran states only passive SI related to workplace stress but reports he

does not have a plan or intent to hurt himself or others.

__________________________________________________________________________

MENTAL STATUS EXAM:

 Appearance: Unable to assess, telephone appointment.

 Demeanor: Friendly, engaged, and goal-focused.

 Mood: OK.

 Affect: Euthymic.

 Psychotic symptoms/Thought content: Denies/goal directed towards treatment.

ŶdžŝĞƚLJͲƌĞůĂƚĞĚďĞŚĂǀŝŽƌ͘

 Cognitive deficits/Memory Impairment: None reported/recent and remote 

intact per interview content.

 Judgment/Insight: Good/Good.

__________________________________________________________________________

DIAGNOSTIC IMPRESSIONS:

63-year-old male USAF Veteran with past history of MH treatment and recent

community care provider. Veteran wishing to re-establish care with VA provider

at either McClellan or Mather.

__________________________________________________________________________

INTERVENTION:

Psychotherapy: See above.

Care Management: BHL screeners sent, safety screening complete, brief

functional assessment done by records review and brief interview.

Handouts provided: Deferred. Provided with this writer's contact number.

Limits of confidentiality, risks, benefits, and side effects of psychiatric

medications and/or therapy were discussed with the patient. The patient

expressed understanding and the willingness to take medications and/or engage

in treatment.

Veteran provided with Mental Health contact information and information for

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APPENDIX 536

RISK ASSESSMENT:

Suicidal/Homicidal/Assaultive Ideation/Intent/Plan:

Yes, Veteran states only passive SI related to workplace stress but reports he

does not have a plan or intent to hurt himself or others.

 Psychotic symptoms/Tho

ŶdžŝĞƚLJͲƌĞůĂƚĞĚďĞŚĂǀŝŽƌ͘

Psychotherapy: See above.

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 9 of 41 PageID 7215
accessing emergency services (Veterans Crisis Line, 988, VA or local

hospital).

Veteran's questions and/or concerns were addressed.

FOLLOW-UP PLAN:

Return for PC-MHI follow-up: 2-4 weeks for consult follow-up.

Referral to other Mental Health services: GMH per request.

Referral to additional VA/Community services (e.g. Social Work, Vet Center):

Deferred.

Action Plan for Veteran: Veteran is working this week with Wednesday (Jun 14th

being a good day for calls). Veteran to complete PHQ-9 and GAD-7 in next 24

hours.

/es/ Michael Jason Brakel, RN BSN

PCMHI RN Case Manager

Signed: 06/12/2023 13:42

06/22/2023 ADDENDUM STATUS: COMPLETED

Follow-up call on initial intake. Veteran states he has no current safety risk 

or concerns and is looking forward to 7/5 GMH intake appointment. This writer 

clarifies appointment date, time, provider, and structure. Veteran is thankful 

for this information.

Veteran will discuss with GMH team his work schedule and possibility of VVC vs 

Community Care options.

Veteran is welcomed to call this writer in the interim if any questions or care 

coordination arises. Veteran state no care coordination or follow-up is 

requested at this time.

/es/ Michael Jason Brakel, RN BSN

PCMHI RN Case Manager

Signed: 06/22/2023 13:00

Date/Time: 09 Jun 2023 @ 1155

Note Title: PCMHI Primary Care Mental Health Telephone Note

Location: No CA Healthcare Sys-Martinez

Signed By: BRAKEL,MICHAEL JASON

Co-signed By: BRAKEL,MICHAEL JASON

Date/Time Signed: 09 Jun 2023 @ 1159

Note

 LOCAL TITLE: PCMHI Primary Care Mental Health Telephone Note

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APPENDIX 537

Date/Time Signed: 09 Jun 2023 @ 1159

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 10 of 41 PageID 7216
STANDARD TITLE: MENTAL HEALTH TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: JUN 09, 2023@11:55 ENTRY DATE: JUN 09, 2023@11:56:01

AUTHOR: BRAKEL,MICHAEL JASO EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

PRIMARY CARE MENTAL HEALTH INTEGRATION (PCMHI) TELEPHONE NOTE

ROSS, ROBERT ALLEN is a 63-year-old MALE referred by DULAI, KAMALPREET regarding

symptoms of workplace stress and request for accommodations letter.

Call initiated by: Other: PCMHI RNCM.

Length of call: 1 minute.

Reason for call: Scheduling.

Summary of Call: Left HIPAA-compliant voice message requesting return call for

scheduling.

RISK ASSESSMENT:

Suicidal/Homicidal/Assaultive Ideation/Intent/Plan: Unable to assess.

Clinical Impression: Unable to assess.

Plan: Attempt follow-up call in 1-3 business days.

Veteran provided with Mental Health contact information and information for

accessing emergency services (Veterans Crisis Line, 988, VA or local

hospital).

Veteran's questions and/or concerns were addressed.

/es/ Michael Jason Brakel, RN BSN

PCMHI RN Case Manager

Signed: 06/09/2023 11:59

Date/Time: 08 Jun 2023 @ 1421

Note Title: Primary Care Telephone Note

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 08 Jun 2023 @ 1425

Note

LOCAL TITLE: Primary Care Telephone Note

STANDARD TITLE: PRIMARY CARE TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: JUN 08, 2023@14:21 ENTRY DATE: JUN 08, 2023@14:21:09

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

URGENCY: STATUS: COMPLETED

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APPENDIX 538

Suicidal/Homicidal/Assaultive Ideation/Intent/Plan: Unable to assess.

ROSS, ROBERT ALLEN is a 63-year-old MALE referred by DULAI, KAMALPREET regarding

symptoms of workplace stress and request for accommodations letter.

08 Jun 2023 @ 1425

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 11 of 41 PageID 7217
Called patient for telephone appointment today. Patient states he is in need of 

a letter discussing the negative impact work has had on his psychological 

status, physical status such as blood pressure, and marital status. He has a 

lawsuit against his union at work. He used to be the union president and false 

accusations were made about him at that time. Since then he has had a very 

hostile environment at work, which has really affected his personal life. He 

was seeing a psychologist through community care, however did not really connect 

with her. He would like to continue to see mental health. 

I have discussed with patient that it is best that mental health evaluate the 

patient, and he go through therapy with them. It would also be best to have the 

letter written by a therapist who is evaluating and treating the patient for 

this issue. Patient agrees, I will place another PCHMI referral.

Telephone appointment 8 minutes

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 06/08/2023 14:25

Date/Time: 03 May 2023 @ 1041

Note Title: Patient Scheduling Attempt Letter

Location: No CA Healthcare Sys-Martinez

Signed By: GARCIA,CORRIE C

Co-signed By: GARCIA,CORRIE C

Date/Time Signed: 03 May 2023 @ 1043

Note

 LOCAL TITLE: Patient Scheduling Attempt Letter

STANDARD TITLE: LETTERS

DATE OF NOTE: MAY 03, 2023@10:41 ENTRY DATE: MAY 03, 2023@10:42:05

 AUTHOR: GARCIA,CORRIE C EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 Department of Veterans 

Affairs

 VA Northern California Health Care System 

(VANCHCS)

MAY 03, 2023

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APPENDIX 539

Date/Time Signed: 03 May 2023 @ 1043

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 12 of 41 PageID 7218
 ROBERT ALLEN ROSS

Dear Mr. ROSS:

Your provider referred you to the Cognitive Behavioral Therapy for Insomnia

Group (CBT-I Group). This is a non-medication, evidence-based treatment for

chronic insomnia, currently offered on Webex video conferencing. Due to the 

high volume of referrals and long wait-time to start the CBT-I Group, we are 

now offering a onetime sleep education class ("Pillow Talk"), to help 

schedule

veterans sooner.

At the virtual Pillow Talk class, you will learn about behavioral strategies 

you can use to improve your sleep, including methods for treating insomnia 

(including CBT-I). If you would like to continue on and attend the CBT-I 

Group, the Pillow Talk facilitator can have you scheduled in the next 

available CBT-I Group start date.

If you are interested in scheduling an appointment to attend the Pillow Talk

sleep education class, please call 916-843-2972 to schedule an appointment to

attend the next available Pillow Talk class.

If you have not contacted us within 14 days of the letter, the appointment

request will be cancelled and returned to the requesting provider, requiring

you to contact the provider to re-submit the consult/appointment request.

We look forward to working with you to improve your health.

Primary Care - Mental Health Integration Clinic

Northern California Health Care System

Department of Veterans Affairs

10535 Hospital Way

Mather, CA 95655-4200

 **TIME SENSITIVE PLEASE RESPOND**

 **THIS IS NOT AN APPOINTMENT**

Date/Time: 20 Apr 2023 @ 1114

Note Title: Reusable Medical Equipment Note

Location: No CA Healthcare Sys-Martinez

Signed By: ROSENFELD,ADRIENNE DENISE

Co-signed By: ROSENFELD,ADRIENNE DENISE

Date/Time Signed: 20 Apr 2023 @ 1115

Note

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APPENDIX 540

Dear Mr. ROSS:

Your provider referred you to the Cognitive Behavioral Therapy for Insomnia

Group (CBT-I Group). This is a non-medication, evidence-based treatment for

chronic insomnia, currently offered on Webex video conferencing. Due to the 

high volume of referrals and long wait-time to start the CBT-I Group, we are

now offering a onetime sleep education class ("Pillow Talk"), to help 

schedule

veterans sooner.

At the virtual Pillow Talk class, you will learn about behavioral strategies

you can use to improve your sleep, including methods for treating insomnia

(including CBT-I). If you would like to continue on and attend the CBT-I

Group, the Pillow Talk facilitator can have you scheduled in the next 

available CBT-I Group start date.

If you are interested in scheduling an appointment to attend the Pillow Talk

sleep education class, please call 916-843-2972 to schedule an appointment to

attend the next available Pillow Talk class.

If you have not contacted us within 14 days of the letter, the appointment

request will be cancelled and returned to the requesting provider, requiring

you to contact the provider to re-submit the consult/appointment request.

We look forward to working with you to improve your health.

Primary Care - Mental Health Integration Clinic

Northern California Health Care System

Department of Veterans Affairs

10535 Hospital Way

Mather, CA 95655-4200

 **TIME SENSITIVE PLEASE RESPOND**

 **THIS IS NOT AN APPOINTMENT**

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 13 of 41 PageID 7219
 LOCAL TITLE: Reusable Medical Equipment Note

STANDARD TITLE: ADMINISTRATIVE NOTE

DATE OF NOTE: APR 20, 2023@11:14 ENTRY DATE: APR 20, 2023@11:14:37

 AUTHOR: ROSENFELD,ADRIENNE EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

REUSEABLE MEDICAL EQUIPEMT TRACKING:

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

 [SCOPE 1]:

 Serial#: 800957

/es/ Adrienne Denise Rosenfeld

LVN, Surgery Spec Clinic/ENT, SAC

Signed: 04/20/2023 11:15

Date/Time: 20 Apr 2023 @ 1044

Note Title: ENT Consult 15018

Location: No CA Healthcare Sys-Martinez

Signed By: FULLER,SCOTT

Co-signed By: FULLER,SCOTT

Date/Time Signed: 20 Apr 2023 @ 1454

Note

 LOCAL TITLE: ENT Consult 15018

STANDARD TITLE: OTOLARYNGOLOGY CONSULT

DATE OF NOTE: APR 20, 2023@10:44 ENTRY DATE: APR 20, 2023@10:44:10

 AUTHOR: FULLER,SCOTT EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

ROSS,ROBERT ALLEN

I.D.: 63MALE

Referral: "mild osa, nasal obstruction - declines cpap; pls eval and 

tx"

Chief Complaint: "My nose is plugged"

PAST MEDICAL HISTORY/ PROBLEM LIST:

Computerized Problem List is the source for the following:

1. Cough 09/30/20 

BUCAYCAY,ELEANO

2. Knee pain 08/26/20 

BUCAYCAY,ELEANO

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APPENDIX 541

Date/Time Signed: 20 Apr 2023 @ 1454

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 14 of 41 PageID 7220
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)

MEDICATIONS:

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

3) FLUTICASONE PROP 50MCG 120D NASAL INHL INSTILL 2 ACTIVE

 SPRAYS IN EACH NOSTRIL ONCE DAILY FOR ALLERGIC

 RHINITIS

4) LORATADINE 10MG TAB TAKE ONE TABLET BY MOUTH ONCE ACTIVE

 DAILY FOR ALLERGIC RHINITIS

5) SERTRALINE HCL 50MG TAB TAKE ONE-HALF TABLET BY MOUTH ACTIVE

 ONCE DAILY FOR 7 DAYS, THEN TAKE ONE TABLET ONCE

 DAILY FOR ANXIETY

6) TAMSULOSIN HCL 0.4MG CAP TAKE ONE CAPSULE BY MOUTH ACTIVE

 ONCE DAILY FOR PROSTATE - 30 MINUTES AFTER THE SAME

 MEAL EACH DAY

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APPENDIX 542

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 15 of 41 PageID 7221
 Active Non-VA Medications Status

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

1) Non-VA CYANOCOBALAMIN TAB MOUTH ACTIVE

7 Total Medications

ALLERGIES:

ERYTHROMYCIN, VICODIN, DARVOCET-N

HABITS:

 Smoking: Denies

 Alcohol: Occasional

 Other: Denies

FAMILY HISTORY:

- Noncontributory

PAST HEAD & NECK SURGICAL HISTORY:

- Septoplasty and turbinate reduction

- FESS

HISTORY OF PRESENT ILLNESS:

This veteran outlines a moderate OSA with an AHI of 17 at 3% criteria. Mild 

at 4% criteria. Not using CPAP secondary to frequent air travel as part of 

his occupation. Notes that he is rarely home more than 5 days per month. He 

endorses non-supine sleep to avoid exacerbating snoring and obstruction. His 

main concern is bilateral nasal obstruction despite steroidal and nonsteroidal nasal spray. He does endorse improvement in nasal airflow today 

with administration of oxymetazoline. He specifically denies any history of 

polyps, epistaxis, or recent nasal trauma. He previously had nasal surgery 

(15 years ago) but symptoms of obstruction have worsened over time. He 

indicates that this is worse when supine and affects his ability to wear an 

oral appliance for bruxism. He has been referred to discuss the prospect of 

surgical management of his nasal airway and potentially surgical management 

of his OSA.

SLEEP STUDY DATA:

AHI: 17 RDI: SaO2 Nadir: Arrhythmia: none

Other: nil

RESTLESS LEGS SYMPTOMS: none

Additional head and neck review of systems is as follows:

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APPENDIX 543

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 16 of 41 PageID 7222
Eyes: No diplopia, vision changes, pain, or epiphora.

Ears: No otalgia, otorrhea, hearing loss, tinnitus, or vertigo.

Nose: No epistaxis, nasal obstruction, change in nasal appearance, change in

sense of taste or smell.

Oral cavity: No loose teeth, ill fitting dental appliances, non healing 

masses ulcers or lesions, sensitivity to acidic or spicy foods, pain, 

bleeding, numbness, or difficulty with articulation. No trismus

Oropharynx/ Hypopharynx: No odynophagia, dysphagia, foreign body 

sensation,or hemoptysis.

Larynx: No dysphonia, odynophonia, dyspnea, cough, or stridor

Neck: No neck masses or point tenderness

Integument: No suspicious masses or lesions, erythema, draining wounds on 

skin of face, scalp, or neck.

Neurological: Denies facial numbness or weakness. No shoulder or tongue

weakness.

Salivary: No purulent/gritty/ foul tasting drainage from salivary ducts.

Endocrine: No heat or cold intolerance.

Constitutional: No fevers, chills, or unintentional weight loss

O/E:

25.7

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

General:

 Alert, awake, and appropriate. No apparent distress or discomfort.

 Decent historian

Skin:

 No suspicious masses, ulceration, or lesions on skin of face, scalp, 

or

 neck.

Eyes:

 PERLA, no epiphora, EOM intact, no scleral injection, or diplopia on

 testing

Ears:

 Rt TM : N

 Lt TM : N

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APPENDIX 544

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 17 of 41 PageID 7223
 External Auditory Canals : N

Nose:

 Septum : Post surgical. Midline. No perforation.

 Turbinates : 2+

 Nasal valve collapse: Present

 No polyps, masses, lesions, or telengectasia seen

Oral Cavity :

 Teeth : Class I; narrow arch

 Floor of Mouth : No lesions or tenderness to palpation, normal papillae

 Tongue : No lesions seen or palpated, range of motion normal

 Palate : No lesions seen

 Buccal Mucosa : No lesions seen

 Lips : No lesions seen

 Interincisural distance: WNL

Oropharynx :

 Tonsils : 1+

 Mallampati position: 2

 Soft palate: Moderate posterior pillar webbing

 Uvula: No elongation

 Posterior pharyngeal wall : N

 Bimanual palpation of tongue base: N

Neck :

 No palpable masses or adenopathy

 Thyroid not palpable

Neurological:

 Cranial nerves II- XII intact; nonfocal

FLEXIBLE FIBEROPTIC VIDEO LARYNGOSCOPY:

- Performed following verbal consent & adequate nasal topical anesthesia 

and

decongestion with 2% lidocaine and phenylephrine.

 Nose and Nasopharynx : Post surgical septum, 2+ turbinates. No 

polyps or masses

IMAGING:

- none

IMPRESSION:

- Moderate OSA

- Nasal obstruction with history of nasal surgery

MEDICAL DECISION MAKING:

Following discussion, the patient understands that evaluation by rhinology 

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APPENDIX 545

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 18 of 41 PageID 7224
would be most appropriate given his primary complaint. IF our rhinololgist 

is able to address complaints of obstruction (surgically or nonsurgically), 

then patient may be able to engage in oral appliance therapy. Can also

consider surgical management of OSA via phase I approach or HGNS if amenable 

to this, however not primary objective of patient at this point.

Thank you for referring this very interesting and pleasant veteran to our

clinic. I will keep you abreast of any additional diagnoses/ treatments that

are rendered on their behalf.

Approximately 40 minutes was spent discussing the patients diagnosis, 

treatment plan, and coordination of care.

/es/ Scott C. Fuller, M.D., M.S., FACS

Chief of Surgery- Northern California HCS

Signed: 04/20/2023 14:54

Receipt Acknowledged By:

04/28/2023 09:53 /es/ Toby O. Steele, MD

 Staff Otolaryngologist

Date/Time: 30 Jan 2023 @ 1050

Note Title: Orthopedic 14333

Location: No CA Healthcare Sys-Martinez

Signed By: ANDERSON,BRETT CARL

Co-signed By: ANDERSON,BRETT CARL

Date/Time Signed: 30 Jan 2023 @ 1056

Note

 LOCAL TITLE: Orthopedic 14333

STANDARD TITLE: ORTHOPEDIC SURGERY NOTE

DATE OF NOTE: JAN 30, 2023@10:50 ENTRY DATE: JAN 30, 2023@10:50:42

 AUTHOR: ANDERSON,BRETT CARL EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

CHIEF COMPLAINT: "I have pain in my left knee."

HISTORY OF PRESENT ILLNESS: the patient is a 63-year-old male here for followup of his left knee. He continues to have pain on the medial joint line that 

has significantly worsened since his last visit. He had to take a week and a 

half off of work because of pain and swelling in the knee. He has having a 

hard time pushing the heavy carts and equipment on the airlines. He has just 

been changed to an international flight rotation out of Dallas and is afraid 

this is going to give him more difficulty. He has an unloader brace from 

several years ago but he cannot use it at work. He has not been wearing the 

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APPENDIX 546

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 19 of 41 PageID 7225
brace otherwise.

OBJECTIVE: PHYSICAL EXAMINATION 

GENERAL PRESENTATION: normal development, no acute distress NEUROLOGIC: 

grossly intact bilateral sensation and muscle motor exam VASCULAR: warm 

extremities LYMPHATIC: no edema 

GENERAL ORTHOPEDIC

Left knee: Positive medial joint line tenderness, range of motion 0 to 110 

degrees, retropatellar crepitus, positive McMurray, antalgic gait with slight 

varus alignment, no lateral joint line tenderness

Left knee x-rays from 1/27/2022 are reviewed which show moderate medial joint 

space narrowing.

Left knee MRI from 2/26/2022 was also reviewed which shows a complex tear of 

the posterior horn of the medial meniscus with a very thin rim of meniscal 

tissue, moderate chondral thinning in the medial compartment with good 

preservation of the lateral compartment

ASSESSMENT: Left knee medial meniscal tear with mild to moderate 

osteoarthritis of the medial compartment

PLAN: We had a long discussion again regarding his options to include 

injections versus unloader bracing versus arthroscopy versus unicompartmental 

arthroplasty versus total knee arthroplasty. I think he has enough mechanical 

symptoms that an arthroscopy is still an option despite his arthritic changes. 

He wants to see how he does over the next month with this new workload and see 

if his symptoms can be tolerable. He would like to avoid surgery if possible. 

He will continue with Tylenol in the meantime. He will let us know how the 

knee is doing with his increased workload. He understands my concerns about 

an arthroscopy with his osteoarthritis and that we could tip him over the edge 

to the arthroplasty options if his arthritic symptoms are the dominant 

finding.

//signed//

Brett C. Anderson, MD

Orthopaedic Surgery - Sports Medicine

Fellow - AAOS

BCA/dns voice recognition technology and software, please excuse minor 

grammatical/typographical errors.

/es/ Brett C Anderson, MD

Orthopaedic Surgeon - Sports Medicine

Signed: 01/30/2023 10:56

Date/Time: 26 Jan 2023 @ 0724

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APPENDIX 547

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 20 of 41 PageID 7226
Note Title: Letter to Patient

Location: No CA Healthcare Sys-Martinez

Signed By: CIFFONE,GRANT MICHAEL

Co-signed By: CIFFONE,GRANT MICHAEL

Date/Time Signed: 26 Jan 2023 @ 0729

Note

 LOCAL TITLE: Letter to Patient

STANDARD TITLE: LETTERS

DATE OF NOTE: JAN 26, 2023@07:24 ENTRY DATE: JAN 26, 2023@07:24:39

 AUTHOR: CIFFONE,GRANT MICHA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 Department Of Veterans 

Affairs

 VA Northern California Health Care System 

(VANCHCS)

 CLINIC ADDRESS:

 5342 Dudley Blvd., McClellan, CA 95652

JAN 26, 2023

 ROBERT ALLEN ROSS

To whom it may concern,

Robert Ross had a scheduled had a scheduled radiology visit on 1/19/23. 

Robert also has a future appointment with an orthopedic surgeon on 1/30/23.

If there are any questions about the necessity of these appointments feel free 

to contact our office at 916-561-7400.

Respectfully,

Kamalpreet Dulai, MD

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APPENDIX 548

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 21 of 41 PageID 7227
(RNCM will give types letter to MD for signature)

 Sincerely,

 /es/ Grant Michael Ciffone, RN BSN

 PACT RN Care Manager

Patient Record Number 7366310

Date/Time: 24 Jan 2023 @ 2041

Note Title: Primary Care Secure Messaging

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 24 Jan 2023 @ 1741

Note

 LOCAL TITLE: Primary Care Secure Messaging

STANDARD TITLE: PRIMARY CARE SECURE MESSAGING

DATE OF NOTE: JAN 24, 2023@20:41 ENTRY DATE: JAN 24, 2023@17:41:50

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Primary Care Secure Messaging Has ADDENDA ***

------Original Message------------------------ 

Sent: 01/24/2023 05:43 PM ET 

From: ROSS, ROBERT ALLEN 

To: **Dulai, K (Primary Care) - McClellan 

Subject: General:General Inquiry 

Attachments: Block FMLA Jan 13-31 Request Office Visit Date.pdf (193.21 KB), 

RossR_VA Absence Jan 13-31 2023.pdf (90.79 KB) 

Thank you for the medication refills. I cannot thank you enough for your time 

spend with my case. UGH, however American Airlines is complicating this FMLA 

process and only feeding me minimal instruction at a time. 

Now they are requesting a medical visit date within (7) days of the start of my 

absence from work Jan 13-31. (See Attached Letter from AA Absence and Return 

department). Since they are requesting dates only and not diagnosis, and I have 

been unable to schedule my Ortho appointment before Jan. 30th at 10:30am, can I 

get a letter simply stating I had a Radiology visit on 01/19/23 and a 

Orthopedic Surgeon appointment following on 01/30/23. That would be sufficient 

to comply with their (7) day rule for Block FMLA and clear me through the 31st. 

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APPENDIX 549

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 22 of 41 PageID 7228
I wish I could say being off my flying schedule so far is making my knee less 

painful, but so far that is not the case.

Again Thank you for your help and understanding. 

Robert Ross/5153 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 01/24/2023 17:41

01/24/2023 ADDENDUM STATUS: COMPLETED

RNCM, can you please complete letter stating pt had a Radiology visit on 

01/19/23 and has an Orthopedic Surgeon appointment following on 01/30/23. 

I will sign after completed, thanks. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 01/24/2023 17:44

Receipt Acknowledged By:

01/26/2023 11:45 /es/ Grant Michael Ciffone, RN BSN

 PACT RN Care Manager

01/26/2023 ADDENDUM STATUS: COMPLETED

RNCM sent a secure message with the requested letter to the pt. Pt confirmed 

recipt.

/es/ Grant Michael Ciffone, RN BSN

PACT RN Care Manager

Signed: 01/26/2023 11:46

Date/Time: 23 Jan 2023 @ 1140

Note Title: Primary Care Secure Messaging

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 23 Jan 2023 @ 0840

Note

 LOCAL TITLE: Primary Care Secure Messaging

STANDARD TITLE: PRIMARY CARE SECURE MESSAGING

DATE OF NOTE: JAN 23, 2023@11:40 ENTRY DATE: JAN 23, 2023@08:40:26

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

------Original Message------------------------ 

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APPENDIX 550

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 23 of 41 PageID 7229
Sent: 01/23/2023 11:39 AM ET 

From: DULAI, KAMALPREET

To: ROSS, ROBERT ALLEN 

Subject: General:General Inquiry 

Hi Mr. Ross,

Are you taking your Atorvastatin (cholesterol med)? Your cholesterol is still 

high, if you are taking it, then I need to increase the dose, please let me 

know.

Your B12 is also low, I will mail out increased dose of B12 supplement.

Your blood sugars are a little better, still in the preDiabetes range.

Dr. Dulai 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 01/23/2023 08:40

Date/Time: 19 Jan 2023 @ 1545

Note Title: MH Cancellation Note

Location: No CA Healthcare Sys-Martinez

Signed By: SHARMA,RITA

Co-signed By: SHARMA,RITA

Date/Time Signed: 19 Jan 2023 @ 1612

Note

 LOCAL TITLE: MH Cancellation Note

STANDARD TITLE: ADMINISTRATIVE NOTE

DATE OF NOTE: JAN 19, 2023@15:45 ENTRY DATE: JAN 19, 2023@15:56:05

 AUTHOR: SHARMA,RITA EXP COSIGNER: DAHMEN,BRIAN

 URGENCY: STATUS: COMPLETED

Veteran called MSA during the class. He was unable to find the email with the 

WebEx link for the class. Writer called him back. He was able to find the email 

and writer walked him through how to join the class next month. Offered to email 

him a few more resources for him to use until next month's class (path to 

better

sleep, CBTi phone app and diaphragmatic breathing). 

All elements of this psychological evaluation including the clinical interview 

and plan for service, were planned and reviewed during a one-to-one meeting, in 

person/VVC/telephone, with supervising clinician, Brian Dahmen, PhD. We meet 

weekly for at least one hour of supervision.

/es/ Rita Sharma PsyD, MSW

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APPENDIX 551

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 24 of 41 PageID 7230
Psychologist

Signed: 01/19/2023 16:12

/es/ Brian Dahmen, PhD

Clinical Psychologist

Cosigned: 01/20/2023 09:21

Date/Time: 13 Jan 2023 @ 1230

Note Title: TCP Telephone Care Staff Short Note Only

Location: No CA Healthcare Sys-Martinez

Signed By: REYNA,ROSA GUADALUPE

Co-signed By: REYNA,ROSA GUADALUPE

Date/Time Signed: 13 Jan 2023 @ 1231

Note

 LOCAL TITLE: TCP Telephone Care Staff Short Note Only

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: JAN 13, 2023@12:30 ENTRY DATE: JAN 13, 2023@12:30:28

 AUTHOR: REYNA,ROSA GUADALUP EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** TCP Telephone Care Staff Short Note Only Has ADDENDA ***

PT WANTS TO KNOW IF PACT WAS ABLE TO COMPLETE HIS EMPLOYMENT WORK RELEASE, 

PLEASE ADVISE THANKS. 

/es/ ROSA GUADALUPE REYNA

MSA

Signed: 01/13/2023 12:31

Receipt Acknowledged By:

01/13/2023 12:50 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

01/13/2023 12:39 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

01/13/2023 ADDENDUM STATUS: COMPLETED

RNCM, this was completed yesterday, did you send to him?

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 01/13/2023 12:40

Receipt Acknowledged By:

01/13/2023 14:07 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

01/13/2023 ADDENDUM STATUS: COMPLETED

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APPENDIX 552

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 25 of 41 PageID 7231
pt returned your call 

/es/ Carolyn Inez Christanio

MSA, Call Center McClellan

Signed: 01/13/2023 12:58

Receipt Acknowledged By:

01/13/2023 15:52 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 12 Jan 2023 @ 1228

Note Title: TCP Telephone Care Staff Short Note Only

Location: No CA Healthcare Sys-Martinez

Signed By: KELLOUGH,NATALEE NICCOLE

Co-signed By: KELLOUGH,NATALEE NICCOLE

Date/Time Signed: 12 Jan 2023 @ 1229

Note

 LOCAL TITLE: TCP Telephone Care Staff Short Note Only

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: JAN 12, 2023@12:28 ENTRY DATE: JAN 12, 2023@12:28:33

 AUTHOR: KELLOUGH,NATALEE NI EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Patient called requesting for a call back from CM in regards to his work letter. 

He can be reached at 

/es/ NATALEE NICCOLE KELLOUGH

Martinez Call Center MSA

Signed: 01/12/2023 12:29

Receipt Acknowledged By:

01/12/2023 13:06 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 10 Jan 2023 @ 1236

Note Title: Primary Care Telephone Note

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 10 Jan 2023 @ 1238

Note

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APPENDIX 553

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 26 of 41 PageID 7232
 LOCAL TITLE: Primary Care Telephone Note

STANDARD TITLE: PRIMARY CARE TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: JAN 10, 2023@12:36 ENTRY DATE: JAN 10, 2023@12:36:09

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Primary Care Telephone Note Has ADDENDA ***

L knee worsening, needs to see ortho again to schedule surgery now. Needs work 

note to stay off L knee from 1/6-1/30 due to mod/severe osteoarthritis causing 

pain, and swelling. He will call ortho to schedule appt now. Does not need 

referral as seen <1 year ago for same issue, he agrees. 

A/p:

1. L knee pain s/p 3 surgeries, pain is now worsening, pt is SC for this. 

-saw ortho 4/2022, will make appt now for possible arthrscopy again

-NSAID PRN, use sparingly to avoid HTN

-diclofenac gel PRN

-FMLA paperwork done 9/2022, will also do work note to stay off knee from 1/16-

1/30.

telephone time 5 min

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 01/10/2023 12:38

01/10/2023 ADDENDUM STATUS: COMPLETED

RNCM, can you please write letter for pt to stay off L knee from 1/16-1/30 due 

to worsening OA. He can pickup when done, thanks. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 01/10/2023 12:39

Receipt Acknowledged By:

01/11/2023 12:57 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 05 Jan 2023 @ 1021

Note Title: Radiology Administrative Note

Location: No CA Healthcare Sys-Martinez

Signed By: CALDWELL,ALLISON CHERISE

Co-signed By: CALDWELL,ALLISON CHERISE

Date/Time Signed: 05 Jan 2023 @ 1021

Note

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APPENDIX 554

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 27 of 41 PageID 7233
 LOCAL TITLE: Radiology Administrative Note

STANDARD TITLE: RADIOLOGY ADMINISTRATIVE NOTE

DATE OF NOTE: JAN 05, 2023@10:21 ENTRY DATE: JAN 05, 2023@10:21:40

 AUTHOR: CALDWELL,ALLISON CH EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 Department Of Veterans 

Affairs

 VA Northern California Health Care System 

(VANCHCS)

RADIOLOGY SCHEDULING NO CONTACT LETTER

 JAN 05, 2023

 ROBERT ALLEN ROSS

 DEAR MR. ROBERT ALLEN ROSS

 We are attempting to schedule you for an imaging test ordered by your

 provider. We have attempted to contact you at the phone number listed

 in our database and have been unsuccessful. Please contact us within 14 days

 of date this letter to schedule your appointment for: CT SCAN

 You can reach us at:

 916-364-3170 - CT, Mather

 We look forward to assisting you in scheduling your imaging test.

 Sincerely,

 /es/ ALLISON CHERISE CALDWELL

Patient Record Number 7366310

Date/Time: 05 Jan 2023 @ 1020

Note Title: Radiology Note

Location: No CA Healthcare Sys-Martinez

Signed By: CALDWELL,ALLISON CHERISE

Co-signed By: CALDWELL,ALLISON CHERISE

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APPENDIX 555

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 28 of 41 PageID 7234
Date/Time Signed: 05 Jan 2023 @ 1021

Note

 LOCAL TITLE: Radiology Note

STANDARD TITLE: RADIOLOGY NOTE

DATE OF NOTE: JAN 05, 2023@10:20 ENTRY DATE: JAN 05, 2023@10:20:56

 AUTHOR: CALDWELL,ALLISON CH EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

RADIOLOGY APPOINTMENT TRACKING NOTE

Attempted to schedule the patient:

1st call

CT Scan

Date Desired: Jan 7,2023

Enter type of CT exam: Chest

IV Contrast:

Without contrast

"No Contact" letter sent stating patient needs to call to schedule an 

imaging

test.

Comments:

/es/ ALLISON CHERISE CALDWELL

Signed: 01/05/2023 10:21

Date/Time: 03 Jan 2023 @ 0751

Note Title: Sleep Clinic Telephone Note

Location: No CA Healthcare Sys-Martinez

Signed By: BUCKLEY,THERESA M

Co-signed By: BUCKLEY,THERESA M

Date/Time Signed: 03 Jan 2023 @ 1602

Note

 LOCAL TITLE: Sleep Clinic Telephone Note

STANDARD TITLE: NEUROLOGY TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: JAN 03, 2023@07:51 ENTRY DATE: JAN 03, 2023@07:51:46

 AUTHOR: BUCKLEY,THERESA M EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

VISIT CONDUCTED VIA PHONE DUE TO COVID-19

SLEEP MEDICINE CONSULT

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APPENDIX 556

Date/Time Signed: 03 Jan 2023 @ 1602

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 29 of 41 PageID 7235
Reason for consult: OSA, not interested in cpap per crh note

Clinical History and sleep study specifics, if applicable:

snoring, insomnia, fatigue

History of Presenting Illness: This is a 63 year old MALE with BMI: 25.1

referred with the following chief complaint:

Snoring, frequent awakenings. Wife sleeps separate room. Works for airline and 

hotel. Flight crew member. Late hours.

Lots of stress. Thinks this is contributing to trouble. Waiting to establish 

with new mental health.

History of achy legs during day and support socks helped. Not at night. Not 

aware of kicking legs at night.

Nightmares. 

Patient otherwise does not report additional symptoms of parasomnia, restless

legs, narcolepsy.

General sleep behaviors:

Works 15 days away (time zone changes to Midwest and East Coast). 2 days on and 

variable time off. Flight attendant.

Sleep Hygiene: 

On days off:

Goes to bed at MN and wakes up at 7 AM.

Wife to bed at 9 pm. 

It usually takes 15 minutes to fall asleep

The patient usually wakes up 10 times at night. Spont and try to turn his mind 

off. Says increased stressed. 

In bed the patient does not watches tv, read, use cellphone/laptop. May look at 

phone.

Does East coast and Midwest currently. Says upcoming mandatory commute to 

Dallas then internationalĂŶĚƐƚƌĞƐƐǁŝƚŚƵŶŝŽŶ. Now, increased stress over work.

Caffeine consumption: 3 c. in am

The patient has used or uses sleep medications: occ melatonin

The patient does not take Daytime naps - no naps

ROS:

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APPENDIX 557

Snoring, frequent awakenings. Wife sleeps separate room. Works for airline and

hotel. Flight crew member. Late hours.

with new mental health.

Lots of stress. Thinks this is contributing to trouble. Waiting to establish

Nightmares.

Patient otherwise does not report additional symptoms of parasomnia, restless

legs, narcolepsy.

y p

The patient usually wakes up 10 times at night. Spont and try to turn his mind p yp

off. Says increased stressed.

In bed the patient does not watches tv, read, use cellphone/laptop. May look at 

phone.

Does East coast and Midwest currently. Says upcoming mandatory commute to 

Dallas then international ĂŶĚ ƐƚƌĞƐƐǁŝƚŚ ƵŶŝŽŶ. Now, increased stress over work.

y yp g y

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 30 of 41 PageID 7236
Chronic or frequent nasal congestion? yes, takes astepro but still difficult

PMH:

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)

PSH:

Date of Surgery: 05/02/12

Surgeon: HO,ANDREW M

Operative Proc(s):

 LEFT KNEE ARTHROSCOPY,PARTIAL MENISECTOMY -

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) FLUTICASONE PROP 50MCG 120D NASAL INHL INSTILL 2 ACTIVE

SPRAYS IN EACH NOSTRIL ONCE DAILY FOR ALLERGIC

RHINITIS

3) LORATADINE 10MG TAB TAKE ONE TABLET BY MOUTH ONCE ACTIVE

DAILY FOR ALLERGIC RHINITIS

4) SERTRALINE HCL 50MG TAB TAKE ONE-HALF TABLET BY MOUTH ACTIVE

ONCE DAILY FOR 7 DAYS, THEN TAKE ONE TABLET ONCE

DAILY FOR ANXIETY

5) TAMSULOSIN HCL 0.4MG CAP TAKE ONE CAPSULE BY MOUTH ACTIVE

ONCE DAILY FOR PROSTATE - 30 MINUTES AFTER THE SAME

MEAL EACH DAY

All:

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APPENDIX 558

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 31 of 41 PageID 7237
ERYTHROMYCIN, VICODIN, DARVOCET-N

Family History:

 Family History

06/27/2008 Fh Of None Of These Dz

Social History:

Marital status: MARRIED

Occupation: flight attendant

SMOKING: none

ETOH: 0-2 wine or beer/night

Drugs (including marijuana):

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

Physical Exam:

Vitals - most recent BMI: 25.1

 Height: 68 in [172.7 cm] (07/26/2019 13:37)

 Weight: 165 lb [74.84 kg] (09/12/2022 09:53)

 Temp: 98.3 F [36.8 C] (09/12/2022 09:53)

 Pulse: 60 (09/12/2022 09:53)

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

 BP: 128/76 (09/12/2022 09:53)

General: In no apparent distress.

Pleasant, cooperative.

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

PRIOR SLEEP STUDIES:

 LOCAL TITLE: V21 CRH Sleep Study Results 

STANDARD TITLE: SLEEP MEDICINE NOTE 

DATE OF NOTE: OCT 20, 2022@10:23 ENTRY DATE: OCT 20, 2022@10:24:04 

 AUTHOR: SHELDON,RACHEL M EXP COSIGNER: GOMEZ,ALEXANDER 

 URGENCY: STATUS: COMPLETED 

 *** V21 CRH Sleep Study Results Has ADDENDA ***

** Sleep Clinical Resource Hub (CRH) Home Sleep Test Scored Technical Data

Results***

Veteran name: ROBERT ALLEN ROSS

Gender: MALE

Height: 68 in [172.7 cm] (07/26/2019 13:37)

Weight: 165 lb [74.84 kg] (09/12/2022 09:53)

BMI: 25.1

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APPENDIX 559

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 32 of 41 PageID 7238
Scoring Tech: Rachel Sheldon, RPSGT

Date of Study: Oct 11,2022

Date Scored: Oct 19,2022

Referring Provider: DULAI,KAMALPREET

Description of Study:

 Home sleep recording was performed using the Nox T3 system. The following

 channels were recorded: nasal-oral airflow thermocouple airflow sensors,

 respiratory effort (RIP belts), finger pulse oximetry, heart rate (pulse

 oximeter), and position. This study did not assess sleep by EEG. Both 3% 

and

 4% desaturation criteria for hypopneas will be reported below.

Data quality: Good

Reason for sleep study: Evaluate presence and/or severity of sleep apnea

Relevant Medical History:

Active Medications:

Active Outpatient Medications (including Supplies):

ATORVASTATIN CALCIUM 40MG TAB TAKE ONE TABLET BY MOUTH ACTIVE

 ONCE DAILY FOR CHOLESTEROL (DO NOT TAKE WITH GRAPEFRUIT

 JUICE.)

CHOLECALCIF 50MCG (D3-2,000UNIT) TAB TAKE TWO TABLETS BY ACTIVE

 MOUTH ONCE DAILY FOR 4 WEEKS, THEN TAKE ONE TABLET ONCE

 DAILY FOR VITAMIN D SUPPLEMENT

CYANOCOBALAMIN 500MCG TAB TAKE ONE TABLET BY MOUTH ONCE ACTIVE

 DAILY FOR VITAMIN B-12 SUPPLEMENT

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

FLUTICASONE PROP 50MCG 120D NASAL INHL INSTILL 2 SPRAYS IN ACTIVE

 EACH NOSTRIL ONCE DAILY FOR ALLERGIC RHINITIS

LORATADINE 10MG TAB TAKE ONE TABLET BY MOUTH ONCE DAILY ACTIVE

 FOR ALLERGIC RHINITIS

SERTRALINE HCL 50MG TAB TAKE ONE-HALF TABLET BY MOUTH ONCE ACTIVE

 DAILY FOR 7 DAYS, THEN TAKE ONE TABLET ONCE DAILY FOR

 ANXIETY

TAMSULOSIN HCL 0.4MG CAP TAKE ONE CAPSULE BY MOUTH ONCE ACTIVE

 DAILY FOR PROSTATE - 30 MINUTES AFTER THE SAME MEAL EACH

 DAY

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APPENDIX 560

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 33 of 41 PageID 7239
DATE OF INTERPRETATION: 10/20/2022 8:56:42 AM

DATE OF STUDY 10/11/2022

SCORING SLEEP TECHNITIAN Rachel Sheldon, RPSGT 

Height (inch) 68

Weight (lb) 165

BMI 25.1

Age 62

Analysis Start Time: 11:06 PM

Analysis End Time 6:51 AM

Total Analysis Duration: 7h 45m

3% CRITERIA (NORMAL AHI is <5 e/hr)

AHI (#events/hr): 17.8

ODI (#events/hr): 15.2

Obstructive A + H + mixed : 16.1e/hr (90.6% of total AHI)

Central A : 1.7e/hr (9.4% of total AHI)

RESPIRATORY COUNTS

APNEAS (e/hr): 5.3 

OBSTRUCTIVE: 3.5 

CENTRAL: 1.7 

MIXED: 0.1

HYPOPNEAS (e/hr): 12.5

Time spent Supine: 0.3 min (0.1%)

Supine AHI (e/hr) 0 

Time spent non-supine 465 min (99.9%)

Non-Supine AHI (e/hr) 17.8

Non-Supine Position Breakdown

Right Side: 76.3min (16.4%) 

Left Side: 153.7min (33%) 

Prone 235min (50.5%)

AHI Right: 3.1/h 

AHI Left: 6.2/hr 

AHI Prone: 30.1/hr

4% CRITERIA (NORMAL AHI is <5 e/hr)

AHI 10.2 e/hr

ODI 5.9 e/hr

SNORE %: 77.7

 OXYGEN SATURATION DATA: 

SPO2 NADIR (%): 85

Average SpO2 (%): 92.7

SpO2 duration<90% 3.9 min 0.8 %

SpO2 duration<89% 1.4 min ( 0.3%)

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APPENDIX 561

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 34 of 41 PageID 7240
SpO2 duration<85% 0 min ( 0 %)

Average pulse (bpm): 58.9

Highest pulse (bpm) 98

Lowest pulse (bpm) 51

Brady index 0

Tachy index 0

SIGNAL QUALITY 

Oximeter Quality (%): 100

Flow Quality (%): 100

Abdomen RIP Quality (%) 100

Thorax RIP Quality (%): 100

*******************************************

 Summary: Sleep Apnea

 moderate elevation of the apnea-hypopnea index. 

 Heavy snoring was recorded

 Mild oxyhemoglobin desaturation was seen.

/es/ RACHEL M SHELDON

RPSGT/MIT

Signed: 10/20/2022 10:33

/es/ ALEXANDER GOMEZ, MD

V21 Sleep Clinical Resource Hub (CRH)

Cosigned: 10/27/2022 00:49

10/27/2022 ADDENDUM STATUS: COMPLETED

*** Sleep Clinical Resource Hub (CRH) Home Sleep Test Interpretation ***

 IMPRESSION

 Abnormal Study

 Elevated AHI 18 events/hr (normal <5/hr) based on 3% oxygen

 desaturation criteria for hypopneas . 

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APPENDIX 562

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 35 of 41 PageID 7241
 Events are primarily hypopneas; paradoxical breathing is noted with both 

 hypopneas and occasional obstructive apneas.

 AHI likely underestimates the severity of sleep disordered breathing 

 due to limitations in scoring with home testing. There are frequent 

 episodes of flattening of the nasal flow signal followed by increases

 in the heart rate suggesting nondesaturating hypopneas. 

 Flattening of the nasal flow signal is observed for most of the study.

 Snore trains are recorded for 77.7% of the study, during which time:

 - 91.0% snores > 70 decibels

 - 74.7% snores > 80 decibels

 Breathing events were more frequent in the prone position 

 (prone AHI 30 x 50% TST; nonprone AHI 5 x 50%). The patient confirmed he 

 was wearing the sleep testing equipment with proper orientation of the 

 device.

 Oxygen indices showed average O2 92.7 and

 0.3% of analysis time (1.4 minutes) at O2 sat < 89%. 

 DIAGNOSIS

 Moderate obstructive sleep apnea 

 RECOMMENDATIONS

 The Veteran has significant OSA and disturbed sleep. He 

 has indicated that he is not interested in CPAP; he would benefit from a 

 visit with provider to review available treatment options. The Veteran 

 will be scheduled into sleep clinic. Side sleeping is recommended in the 

 mean time. 

 - Avoid alcohol and sedatives before bedtime since these may

 greatly increase the severity of sleep apnea.

 - Summary sheet and sample epochs will be scanned to chart.

 - Patient notified by phone of testing results. 

 - Follow up will be scheduled in sleep clinic for full clinical

 evaluation

/es/ ALEXANDER GOMEZ, MD

V21 Sleep Clinical Resource Hub (CRH)

Signed: 10/27/2022 12:21

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

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APPENDIX 563

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 36 of 41 PageID 7242
Labs:

Collection DT Spec WBC HGB HCT PLT MCV MCHC

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

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

07/25/2019 10:35 BLOOD 4.7 L 16.1 47.0 332 88.7 34.3

B12 and Folate

Collection DT Spec B12

06/09/2022 12:05 SERUM 110 L

12/08/2021 12:53 SERUM 110 L

SLT - IRON

No data available for: IRON

SLT - Ferritin

No data available for: FERRITIN

ZZFERRITIN (OLD)

SCL1 - CHEMISTRIES

Collection DT Spec NA K CL CO2 BUN CREAT

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

12/08/2021 12:52 PLASM 137 4.2 101 27 15 0.90

08/20/2020 10:35 PLASM 134 L 4.1 99 24 19 1.10

07/26/2019 14:54 PLASM 132 L 4.6 99 26 21 1.03

07/25/2019 10:35 PLASM 137 4.1 102 24 23 1.08

LAB CUMULATIVE SELECTED 1

Collection DT Spec CALCIUM ALBUMIN ALK PHO

06/09/2022 12:07 PLASM 9.9

12/08/2021 12:52 PLASM 9.5 4.9 H 60

08/20/2020 10:35 PLASM 9.3 4.5 62

07/26/2019 14:54 PLASM 9.2 4.8 53

07/25/2019 10:35 PLASM 9.5 4.5 52

08/06/2015 13:38 PLASM 9.4 4.3 56

HbA1c, TSH, Uric Acid

LAB CUMULATIVE SELECTED 1

Collection DT Spec HGBA1c Tsh

06/09/2022 12:05 BLOOD 6.0 H

06/09/2022 12:05 SERUM 3.06

12/08/2021 12:53 SERUM 3.26

12/08/2021 12:53 BLOOD 6.0 H

08/20/2020 10:35 SERUM 3.51

07/26/2019 14:54 BLOOD 5.9 H

07/25/2019 10:35 SERUM 2.64

Cardiology:

Pg. 1 01/03/23 07:51

 CP ECHO SAC

ROSS,ROBERT ALLEN DOB: (63) NOT

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APPENDIX 564

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 37 of 41 PageID 7243
INPATIENT

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

 LOCAL TITLE: CP Cardiology Procedure Report

STANDARD TITLE: CARDIOLOGY DIAGNOSTIC STUDY REPORT

DATE OF NOTE: AUG 31, 2022@14:20:55 ENTRY DATE: AUG 31, 2022@14:20:55

 AUTHOR: CLINICAL,DEVICE PRO EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

** DOCUMENT IN VISTA IMAGING **

SEE FULL REPORT IN VISTA IMAGING

SIGNATURE NOT REQUIRED

SEE SIGNATURE IN VISTA IMAGING

** (XCELERA ISCV ECHO SAC) AUTO-INSTRUMENT DIAGNOSIS **

Procedure: ADULT Adult

Release Status: Released Off-Line Verified

Date Verified: Aug 31, 2022@14:20:33

CP Order Number: 3220831000029

VAMC Sacramento +------------------------------------+

10535 Hospital Way : :

Mather, CA 95655 +------------------------------------+

 Transthoracic Echocardiogram Report

------------------------------------------------------------------------------+

:Name: ROSS, ROBERT ALLENStudy Date: 08/31/2022 Height: 68

in :

:MRN: CP #: 3220831000029 Weight: 170

lb:

:DOB: 10/28/ Gender: Male BSA: 1.9 m2

:

: yrs Patient Location: SAC CARDIO ECHO TECH RAD

:

:Reason For Study: Syncope

:

---------------------------------------------------------++-------------------+

:

::Sonographer: Yi Qin:

----------------------------------------------------------+-------------------+

:Referring Physician: DULAI, KAMALPREET

:

------------------------------------------------------------------------------+

Procedure: A two-dimensional transthoracic echocardiogram with color flow

and Doppler was performed. There is no prior echocardiogram noted for this

patient. The patient was in normal sinus rhythm during the exam.

Left Ventricle: The left ventricle is normal in size. Left ventricular

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APPENDIX 565

 Syncope

CARDIOLOGY DIAGNOSTIC STUDY REPORT

AUG 31, 2022@14:20:55 

 CP Cardiology Procedure Report

The patient was in normal sinus rhythm during the exam.

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 38 of 41 PageID 7244
systolic function is normal. The ejection fraction estimate is 55-60%. The

left ventricular wall motion is normal. Assessment of diastolic parameters

indicates normal left ventricular diastolic function and normal filling

pressures.

Pg. 2 01/03/23 07:51

 CP ECHO SAC

ROSS,ROBERT ALLEN DOB: (63) NOT

INPATIENT

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

Right Ventricle: The right ventricle is normal in size and function.

Atria: The left atrial size is normal. Right atrial size is normal. The

atrial septum is aneurysmal.

Aortic Valve: The aortic valve is normal in structure and function. The

aortic valve is trileaflet. The aortic valve opens well. There is no aortic

valve stenosis. No aortic regurgitation is present.

Mitral Valve: There is mild mitral annular calcification. The mitral valve

leaflets are thickened, but show no functional abnormalities. There is no

mitral valve stenosis. There is trace mitral regurgitation.

Pulmonic Valve: The pulmonic valve is not well seen, but is grossly normal.

There is no pulmonic valvular regurgitation.

Tricuspid Valve: There is tricuspid annular calcification. The tricuspid

valve is not well visualized, but is grossly normal. There is trace tricuspid

regurgitation. TR doppler is inadequate to accurately estimate right

ventricular systolic pressure (RVSP).

Great Vessels: The aortic root is normal size. The inferior vena cava

appears normal.

Pericardium/ Pleural Space: There is no pericardial effusion. Pleural

effusion noted.

MMode/2D Measurements \T\ Calculations

IVSd: 1.1 cm LVIDd: 4.3 cm Ao root diam: 3.2 cm asc Aorta Diam:

LVPWd: 1.1 cm LVIDs: 3.0 cm LA dimension: 3.4 cm 3.0 cm

______________________________________________________________________________

TAPSE_phl: 2.0 cm IVC Diam_phl: RA Length_phl: 5.1 cm RV Mid_phl:

 1.4 cm RA Width_phl: 3.4 cm 2.1 cm

______________________________________________________________________________

LAV(MOD-sp2): LAV(MOD-sp4): LAV(MOD-sp4) index:

34.2 ml 40.4 ml

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APPENDIX 566

ht Ventricle: The right ventricle is normal in size and function.

Atria: The left atrial size is normal. Right atrial size is normal. The normal.

atrial septum is aneurysmal.

Aortic Valve: The aortic valve is normal in structure and function. The

aortic valve is trileaflet. The aortic valve opens well. There is no aortic

valve stenosis. No aortic regurgitation is present.

Mitral Valve: There is mild mitral annular calcification. The mitral valve

leaflets are thickened, but show no functional abnormalities. There is no

mitral valve stenosis. There is trace mitral regurgitation.

Pulmonic Valve: The pulmonic valve is not well seen, but is grossly normal.

There is no pulmonic valvular regurgitation.

Tricuspid Valve: There is tricuspid annular calcification. The tricuspid

valve is not well visualized, but is grossly normal. There is trace tricuspid

regurgitation. TR doppler is inadequate to accurately estimate right

ventricular systolic pressure (RVSP).

Great Vessels: The aortic root is normal size. The inferior vena cava

appears normal.

Pericardium/ Pleural Space: There is no pericardial effusion. Pleural

effusion noted.

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 39 of 41 PageID 7245
 21.2 ml/m2

Doppler Measurements \T\ Calculations

MV E max vel: Lat Peak E' Vel: MVP1/2T: 62.5 sec e': 11.2 

cm/sec

73.7 cm/sec 11.0 cm/sec MV dec slope: E/e': 6.6

MV A max vel: Med Peak E' Vel: 345.5 cm/sec2

70.3 cm/sec 6.3 cm/sec

MV E/A: 1.0

MV dec time:

0.22 sec

______________________________________________________________________________

Ao V2 max: LV V1 max: PA acc time: PA pr(Accel):

130.3 cm/sec 95.6 cm/sec 0.10 sec 33.1 mmHg

Ao max PG: 6.8 mmHg LV V1 max PG:

Pg. 3 01/03/23 07:51

 CP ECHO SAC

ROSS,ROBERT ALLEN DOB: (63) NOT

INPATIENT

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

Ao mean PG: 3.8 mmHg3.7 mmHg

Ao V2 VTI: 29.0 cm LV V1 mean PG:

 1.5 mmHg

 LV V1 VTI: 19.7 cm

______________________________________________________________________________

Pulm A Revs Vel: AV VR_phl: 0.73 MV P1/2t-pr_phl:

33.1 cm/sec 62.5 msec

Pulm A Revs Dur:

0.14 sec

Interpretation Summary

The left ventricle is normal in size.

The ejection fraction estimate is 55-60%.

The right ventricle is normal in size and function.

Normal sized atria.

No valvular heart disease.

The inferior vena cava appears normal.

No prior study for comparison.

______________________________________________________________________________

 Electronically signed by: Matthew Lam, MD on 08/31/2022

Reading Physician:02:20 PM

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APPENDIX 567

Pg. 3 01/03/23 07:51

Interpretation Summary

The left ventricle is normal in size.

The ejection fraction estimate is 55-60%.

The right ventricle is normal in size and function.

Normal sized atria.

No valvular heart disease.

The inferior vena cava appears normal.

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 40 of 41 PageID 7246
Administrative Closure: 08/31/2022

 by:

 CLINICAL,DEVICE PROXY SERVICE

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

NOTE: Images are associated with this procedure.

 Please use Imaging Display to view the images.

EKG Date: 7/7/22 @ 0949

Vent Rate: 65 PR Interval: 162

QRS Duration: 74 QT: 358

QTC: 372 P Axis: 118

R Axis: T Axis: 33

Confirmation Status: Interpreted By: YU,KATHERINE M

Auto Instrument Diagnosis:

 Normal sinus rhythm

 Low voltage QRS

 Borderline ECG

 Confirmed by YU, MD, KATHERINE (527) on 7/8/2022 4:14:44 PM

Auto Instrument Data?:

Primary Provider: YU,KATHERINE M

 No data available

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

Assessment/Recommendations:

# Mild sleep apnea

3% CRITERIA (NORMAL AHI is <5 e/hr)

AHI (#events/hr): 17.8

Nadir 85%

Time spent Supine: 0.3 min (0.1%)

Supine AHI (e/hr) 0 

Time spent non-supine 465 min (99.9%)

Non-Supine AHI (e/hr) 17.8

Non-Supine Position Breakdown

Right Side: 76.3min (16.4%) 

Left Side: 153.7min (33%) 

Prone 235min (50.5%)

AHI Right: 3.1/h 

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APPENDIX 568

EKG Date: 7/7/22 @ 0949

Case 4:22-cv-00343-Y Document 239-13 Filed 04/26/24 Page 41 of 41 PageID 7247