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

/es/ Sharon Deo

Medical Support Assistant

Signed: 07/12/2022 15:02

Date/Time: 08 Jul 2022 @ 1527

Note Title: Letter to Patient

Location: No CA Healthcare Sys-Martinez

Signed By: JONES,SHEARON

Co-signed By: JONES,SHEARON

Date/Time Signed: 08 Jul 2022 @ 1532

Note

 LOCAL TITLE: Letter to Patient

STANDARD TITLE: LETTERS

DATE OF NOTE: JUL 08, 2022@15:27 ENTRY DATE: JUL 08, 2022@15:27:16

 AUTHOR: JONES,SHEARON EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 Department Of Veterans 

Affairs

 VA Northern California Health Care System 

(VANCHCS)

 CLINIC ADDRESS:

 5342 Dudley Blvd., McClellan, CA 95652

JULY 8, 2022

 ROBERT ALLEN ROSS

Dear Mr. ROSS:

Dr. Dulai, your primary care provider, wants you to know that the myocardial 

perfusion study completed on July 7, 2022 shows no perfusion defects 

suggestive of ischemia or a prior myocardial infarction. Your left ventricle 

ejection fraction is normal at 71%. There is a 9mm right upper lobe pulmonary 

groundglass opacity noted. Dr. Dulai recommends follow up with a CT scan in 

six months which has been ordered.

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APPENDIX 615

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 1 of 41 PageID 7294
Impression:

 1. No evidence for reversible or fixed perfusion defects

 suggestive of ischemia or prior myocardial infarction is

 identified. 

 2. Normal LV systolic function. LVEF = 71% (normal >= 50%). 

 3. Incidental noncontrast CT findings include aortic and

 coronary artery atherosclerosis, 9 mm right upper lobe pulmonary

 groundglass opacity. Recommend follow-up CT at 6 months. 

Should you have questions, please call 1-800-382-8387.

 Sincerely,

 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Patient Record Number 7366310

Date/Time: 07 Jul 2022 @ 1556

Note Title: Care Management Nursing Note

Location: No CA Healthcare Sys-Martinez

Signed By: JONES,SHEARON

Co-signed By: JONES,SHEARON

Date/Time Signed: 07 Jul 2022 @ 1605

Note

 LOCAL TITLE: Care Management Nursing Note

STANDARD TITLE: CARE MANAGEMENT NURSING NOTE

DATE OF NOTE: JUL 07, 2022@15:56 ENTRY DATE: JUL 07, 2022@15:56:51

 AUTHOR: JONES,SHEARON EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Care Management Nursing Note Has ADDENDA ***

COVID-19 Telephone Follow-Up

Patient notified of positive COVID-19 test result.

 Symptoms:

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APPENDIX 616

1. No evidence for reversible or fixed perfusion defects

suggestive of ischemia or prior myocardial infarction is

identified.

Care Management Nursing Note

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 2 of 41 PageID 7295
 The patient was asked if in the last 14 days they have had new onset of 

 any COVID-19 symptoms. They report the following:

 Cough

 Comment: Patient began coughing on today.

 Headache

 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).

 Care Disposition

 Positive COVID-19 must ISOLATE

 - Regardless of vaccination status

 - Day 0 is the first day of symptoms or a positive viral

 test. The count of days starts the next full day.

 - Asymptomatic patients may end isolation after 5 full days.

 - Symptomatic patients (mild/moderate illness) may end

 isolation after 5 full days if fever-free (without

 fever-reducing medication use) and symptoms have improved.

 Patient condition:

 Does not meet CDC guidelines to end isolation.

 - Discussed continued measures to avoid transmission and what to do

 if symptoms significantly worsen.

 Patient can care for self at home.

 Plan and Patient Education

 Patient was advised to notify contacts, including home health workers, of 

 COVID positive exposure/status.

 Information provided on preventing the spread of COVID-19.

 - Stay at home except to get medical care that cannot be provided

 by a telephone or video visit.

 - Get rest and stay hydrated.

 - Call ahead before visiting your doctor.

 - Wear a facemask around others if you are sick.

 - Cover your coughs and sneezes.

 - Clean your hands often.

 - Keep a six-foot distance from others in your home, ideally in a

 separate room. Isolate in a private room, if available.

 - Avoid sharing household items.

 - Disinfect high touch surfaces daily, ideally with a product

 that kills cold and flu viruses.

 Time spent: 10 minutes

/es/ Shearon Jones, RN

Nursing Service, Case Manager, Primary Care

Signed: 07/07/2022 16:05

Receipt Acknowledged By:

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APPENDIX 617

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 3 of 41 PageID 7296
07/07/2022 16:21 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

07/07/2022 ADDENDUM STATUS: COMPLETED

Veteran request a note stating his Covid 19 (+) condition, so he can submit to 

his employer tomorrow (7/8/22).

If possible please E-mail: 1RROSS@COMCAST.NET

PH# - Cell: (

Thank you,

/es/ MICHELLE L RAWLINGS

VISN 21 TLC/CCC, AMSA

Signed: 07/07/2022 18:30

Receipt Acknowledged By:

07/12/2022 10:45 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

07/07/2022 19:15 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

07/07/2022 ADDENDUM STATUS: COMPLETED

please write letter for employer. Also possibly someone else can pick up for 

him or we can do thru secure messaging?

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 07/07/2022 19:16

Receipt Acknowledged By:

07/08/2022 15:35 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 07 Jul 2022 @ 1412

Note Title: Holter Monitor Note

Location: No CA Healthcare Sys-Martinez

Signed By: SOUSA,MARIA FATIMA

Co-signed By: SOUSA,MARIA FATIMA

Date/Time Signed: 07 Jul 2022 @ 1416

Note

 LOCAL TITLE: Holter Monitor Note

STANDARD TITLE: CARDIOLOGY PROCEDURE NOTE

DATE OF NOTE: JUL 07, 2022@14:12 ENTRY DATE: JUL 07, 2022@14:12:52

 AUTHOR: SOUSA,MARIA FATIMA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

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APPENDIX 618

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 4 of 41 PageID 7297
ZIOPATCH INSTALL

ROSS,ROBERT ALLEN was given a Ziopatch monitor per

DULAI,KAMALPREET's request because of SYNCOPE.

Ziopatch Serial Number: N891049874

Device registered on the Ziopatch Company website? Yes

Patient will remove device on Jul 21,2022 and mail in to the Ziopatch

company using prepaid postage.

/es/ Sousa, Maria

Contractor, Medical Inst Tech/Cardiology, SAC

Signed: 07/07/2022 14:16

Date/Time: 07 Jul 2022 @ 1215

Note Title: Screening Covid

Location: No CA Healthcare Sys-Martinez

Signed By: LEMMONS,TAREZ

Co-signed By: LEMMONS,TAREZ

Date/Time Signed: 07 Jul 2022 @ 1217

Note

 LOCAL TITLE: Screening Covid

STANDARD TITLE: INFECTIOUS DISEASE RISK ASSESSMENT SCREENING NOT

DATE OF NOTE: JUL 07, 2022@12:15 ENTRY DATE: JUL 07, 2022@12:16

 AUTHOR: LEMMONS,TAREZ EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Coronavirus Disease 2019 (COVID-19) Screen

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

COVID-19 symptoms. They report the following:

 Cough

 Headache

 Muscle pain (Myalgias)

 Runny nose (Rhinorrhea)

The patient reports close exposure (within 6 feet for more than 15 minutes) to 

someone with a febrile/respiratory illness within the last 14 days.

Result:

 Patient has a positive symptom or exposure and requires further evaluation.

 Date of the earliest symptom:

 Date: July 4, 2022

COVID-19 Secondary Screening

The patient has the following previously known conditions which may mimic

COVID-19 symptoms:

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APPENDIX 619

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 5 of 41 PageID 7298
None

Plan:

Home Care Instructions Reviewed, Tele/VVC appt scheduled with physician or

advanced practice provider, Report to testing center for swabbing

Veteran/caregiver verbalized an understanding of/agreed with the plan of care.

Veteran/caregiver instructed to call VetsCONNECT or the PACT care manager for

any future routine issues/concerns. Veteran/caregiver advised to call 911 for

any potentially life threatening problems/conditions.

COVID-19 Swab Testing

Swab completed for Covid-19

 CDC Person Under Investigation (PUI) form completed and to lab w/specimen

 Symptoms: MA COUGH RN ST

Plan: Discharged Home for Self-Quarantine, Post Swab Instructions Reviewed,

Home Care Instructions Reviewed

Veteran/caregiver verbalized an understanding of/agreed with the plan of care.

Veteran/caregiver instructed to call VetsCONNECT or the PACT care manager for

any future routine issues/concerns. Veteran/caregiver advised to call 911 for

any potentially life threatening problems/conditions.

/es/ TAREZ LEMMONS,BSN-RN,PMHN-BC

NURSE,COVID-19,MATHER

Signed: 07/07/2022 12:17

Date/Time: 07 Jul 2022 @ 0950

Note Title: Treadmill 30032

Location: No CA Healthcare Sys-Martinez

Signed By: CHAN,IAN

Co-signed By: CHAN,IAN

Date/Time Signed: 08 Jul 2022 @ 0946

Note

 LOCAL TITLE: Treadmill 30032

STANDARD TITLE: CARDIOLOGY PROCEDURE NOTE

DATE OF NOTE: JUL 07, 2022@09:50 ENTRY DATE: JUL 07, 2022@09:51

 AUTHOR: CHAN,IAN EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

ROSS,ROBERT ALLEN

GENDER:MALE

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

WEIGHT:170 lb [77.11 kg] (06/09/2022 10:06)

REFERRING PROVIDER: Dulai, Kamalapreet

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APPENDIX 620

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 6 of 41 PageID 7299
PROVIDER PERFORMING TEST: Sanchez, Irene

TECHNICIAN: Andrey Melnik

DATE OF TEST: Jul 7,2022

REASON FOR TEST: CAD

STRESS TEST PROTOCOL: LEXISCAN (pharmacologic)

RESTING HEART RATE: 58 bpm

MAXIMUM HEART RATE: 92 bpm

RESTING BLOOD PRESSURE: 151/84mmHg

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

RESTING ECG:NSR, RAD

CHEST PAIN: None

ARRHYTHMIAS: None

ST CHANGES: None

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

CONCLUSIONS:

 resting HTN

normal response to LExiscan infusion.

*** SEE SEPARATE RADIOLOGY REPORT FOR NUCLEAR IMAGING RESULTS ***

Preliminary data entered by Andrey Melnik, Jul 7,2022@09:51; data verified and

edited for accuracy as necessary. Final interpretation and report by Ian Chan, 

MD.

/es/ Ian Chan, MD

Staff Physician, Cardiology

Signed: 07/08/2022 09:46

Date/Time: 07 Jul 2022 @ 0747

Note Title: CONSENT CLINICAL IMED

Location: No CA Healthcare Sys-Martinez

Signed By: CVIX,IMEDWEBUSER

Date/Time Signed: 07 Jul 2022 @ 0747

Note

LOCAL TITLE: CONSENT CLINICAL IMED

STANDARD TITLE: CONSENT

DATE OF NOTE: JUL 07, 2022@07:47:13 ENTRY DATE: JUL 07, 2022@09:47:23

 AUTHOR: CVIX,IMEDWEBUSER EXP COSIGNER:

URGENCY: STATUS: COMPLETED

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APPENDIX 621

Date/Time Signed: 07 Jul 2022 @ 0747

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 7 of 41 PageID 7300
 VistA Imaging - Scanned Document

 Signature Informed Consent for Heart - Stress Test Regadenoson MPI

1. Anatomical Location: See description 

2. Informed consent was obtained at 9:25 AM on

 7/7/22. 

The full consent document can be accessed through Vista Imaging.

3. Patient name: ROSS, ROBERT ALLEN

4. The patient HAS decision-making capacity.

5. Surrogate (if applicable):

6. Reason for the treatment (diagnosis, condition, or indication): 

 To evaluate the function of the heart muscle before and during stress. To

detect and assess the risk of significant coronary artery disease. This test

helps find blocked arteries to the heart muscle. This test provides a prognosis

for those with known coronary blockage(s). This test will help estimate the

risk to the heart of an upcoming surgery. 

7. Treatment/procedure: This procedure involves using myocardial perfusion

imaging (MPI) to compare pictures of the heart at rest and during stress. A

radioactive tracer is used. It is injected in the blood stream. It is taken up 

by

living heart muscle cells. If these cells are able to take up the tracer, then

that area of the heart will light up on the images. If there is a significant

blockage in the heart arteries, or the heart muscle cells are damaged, then no

tracer will be seen. This will produce a dark area on the images. By

comparing the rest and stress images, your doctor can determine areas damaged or

having decreased blood flow. Regadenoson is a medicine that stimulates the 

heart

muscle without need for exercise. It works by enlarging the heart's blood

vessels; allowing good flow through normal vessels and less blood flow through

blocked ones. It is generally used for people who cannot tolerate exercise.

Your provider will put an IV (small plastic tube) into a vein. This is

usually in your arm. Your provider will also place small stickers on your skin. 

These are called electrodes. Your provider attaches these electrodes to a

recording machine. This machine is called an electrocardiogram (ECG). This 

allows

the provider to monitor your heart during the procedure. Your provider will

inject a small amount of radioactive material through the IV. You will be asked 

to

either sit or lie still in a nuclear camera. This will take pictures of your

heart over 10-20 minutes.

Your provider will then inject the Regadenoson through the IV. The

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APPENDIX 622

 Signature Informed Consent for Heart - Stress Test Regadenoson MPI

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 8 of 41 PageID 7301
radioactive material will be injected again. You will be asked to either sit or 

lie

still in a nuclear camera. A second set of pictures will be taken over 10-20

minutes. When the test is done, your provider will remove the electrodes and IV. 

8. No, neither anesthesia nor moderate sedation will be used in this

treatment/procedure.

9. Consent to Blood Products (if applicable):

 It is not expected that blood products will be used in this

treatment/procedure.

10. Practitioner obtaining consent: Irene Rachel Sanchez, NP 

11. Supervising practitioner:

12. Practitioner(s) performing or supervising treatment/procedure (if

 not listed above):

13. Witness Name(s):

14. Comments:

 *** SCANNED DOCUMENT ***

 SIGNATURE NOT REQUIRED

 Electronically Filed: 07/07/2022

 by: IMEDWEBUSER CVIX

Date/Time: 02 Jul 2022 @ 0902

Note Title: Radiology Note

Location: No CA Healthcare Sys-Martinez

Signed By: SWAN,NEPHTERIA

Co-signed By: SWAN,NEPHTERIA

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APPENDIX 623

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 9 of 41 PageID 7302
Date/Time Signed: 02 Jul 2022 @ 0903

Note

 LOCAL TITLE: Radiology Note

STANDARD TITLE: RADIOLOGY NOTE

DATE OF NOTE: JUL 02, 2022@09:02 ENTRY DATE: JUL 02, 2022@09:03:01

 AUTHOR: SWAN,NEPHTERIA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Radiology Note Has ADDENDA ***

EXAM CANCELLATION

Date order was placed: Jun 9,2022

The patient was scheduled to have a Ultrasound examination of the

 cartoid. This examination has been discontinued for the following

reason: PAT NO SHOWED; REORDER IF STILL INDICATED.

Thank you,

Radiology/Nuclear Medicine Service

/es/ Nephteria Swan

Medical Support Assistant

Signed: 07/02/2022 09:03

Receipt Acknowledged By:

07/04/2022 16:10 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

07/08/2022 ADDENDUM STATUS: COMPLETED

please re order pt called wanting to schedule

/es/ Nephteria Swan

Medical Support Assistant

Signed: 07/08/2022 15:36

Receipt Acknowledged By:

07/08/2022 16:27 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

Date/Time: 19 Jun 2022 @ 1536

Note Title: Radiology Note

Location: No CA Healthcare Sys-Martinez

Signed By: SWAN,NEPHTERIA

Co-signed By: SWAN,NEPHTERIA

Date/Time Signed: 19 Jun 2022 @ 1538

Note

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APPENDIX 624

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 10 of 41 PageID 7303
 LOCAL TITLE: Radiology Note

STANDARD TITLE: RADIOLOGY NOTE

DATE OF NOTE: JUN 19, 2022@15:36 ENTRY DATE: JUN 19, 2022@15:36:39

 AUTHOR: SWAN,NEPHTERIA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Northern California Health Care Systems Imaging Department

 JUN 19, 2022

 ROBERT ALLEN ROSS

 DEAR ROBERT ALLEN ROSS

Our records indicate that you missed the below appointment(s):

 Date/Time: Jun 19,2022

 Clinic: Ultrasound

 Telephone: 916-364-3158 - Ultrasound, Mather/McClellan

To reschedule this appointment, please contact the Radiology at

the telephone number listed above - Monday through Friday, 8:00 AM to 4:30 PM,

excluding holidays. Please contact us within 14 days of date of this letter to

reschedule or your order will be cancelled due to being obsolete.

If you are unable to keep future appointments, please call Radiology to cancel

or reschedule your appointment. This will assist us in our efforts to assure

timely access to care for all of our veterans.

VA Northern California Health Care System

Sacramento Medical Center

10535 Hospital Way

Mather, CA 95655

/es/ Nephteria Swan

Medical Support Assistant

Signed: 06/19/2022 15:38

Date/Time: 16 Jun 2022 @ 1515

Note Title: Cardiology EKG Completion Note

Location: No CA Healthcare Sys-Martinez

Signed By: SIMON,CAMILLE

Co-signed By: SIMON,CAMILLE

Date/Time Signed: 16 Jun 2022 @ 1518

Note

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APPENDIX 625

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 11 of 41 PageID 7304
 LOCAL TITLE: Cardiology EKG Completion Note

STANDARD TITLE: CARDIOLOGY DIAGNOSTIC STUDY NOTE

DATE OF NOTE: JUN 16, 2022@15:15 ENTRY DATE: JUN 16, 2022@15:15:45

 AUTHOR: SIMON,CAMILLE EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

The patient ID self by full name and DOB. 

EKG COMPLETION - NURSE/TECH

 EKG completed and given to Dr. Doctor. for review: Result: "Normal sinus 

rhythm, normal ECG."

Provided patient with updated list of upcoming appointments. 

Patient declined shingrix vaccine at this time. 

/es/ CAMILLE SIMON

Primary Care, MCC

Signed: 06/16/2022 15:18

Date/Time: 14 Jun 2022 @ 0848

Note Title: Letter to Patient

Location: No CA Healthcare Sys-Martinez

Signed By: JONES,SHEARON

Co-signed By: JONES,SHEARON

Date/Time Signed: 14 Jun 2022 @ 0911

Note

 LOCAL TITLE: Letter to Patient

STANDARD TITLE: LETTERS

DATE OF NOTE: JUN 14, 2022@08:48 ENTRY DATE: JUN 14, 2022@08:48:18

 AUTHOR: JONES,SHEARON EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 Department Of Veterans 

Affairs

 VA Northern California Health Care System 

(VANCHCS)

 CLINIC ADDRESS:

 5342 Dudley Blvd., McClellan, CA 95652

JUNE 14, 2022

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APPENDIX 626

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 12 of 41 PageID 7305
 ROBERT ALLEN ROSS

 4701 HAYLOFT COURT

Dear Mr. ROSS:

Per our conversation, your LDL (low-density lipoprotein), which is sometimes 

called "bad" cholesterol, is not at goal. Per your agreement, 

medication

Atorvastatin 40mg is being mailed to you to take orally daily.

Your hemoglobin A1c, which tells us what your average blood sugar has been 

over the three months prior to the blood draw, is 6% and the normal range is 

4.1-5.7%. Please monitor your diet by eating healthy carbohydrates such as 

fruits, vegetables, whole grains, legumes and low-fat dairy products. Avoid 

less healthy carbohydrates such as foods or drinks with added fats, sugars and 

sodium. Choose healthy carbohydrates, fiber-rich foods, fish and 

"good" fats.

Your potassium is higher than normal. Please avoid foods with high potassium 

like avocados, bananas, oranges, grapefruit juice, green leafy vegetables and 

melons of all kinds.

Your B12 is still low. As we discussed, you just started taking the Vitamin 

B12 supplement daily. Fasting labs are ordered for you to complete in three 

months (September 2022).

Should you have questions, please call 1-800-382-8387.

 Sincerely,

 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Patient Record Number 7366310

Date/Time: 09 Jun 2022 @ 1420

Note Title: PCMHI Primary Care Mental Health Consult

Location: No CA Healthcare Sys-Martinez

Signed By: ARANETA,ANGELA M

Co-signed By: ARANETA,ANGELA M

Date/Time Signed: 09 Jun 2022 @ 1505

Note

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APPENDIX 627

Date/Time Signed: 09 Jun 2022 @ 1505

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 13 of 41 PageID 7306
 LOCAL TITLE: PCMHI Primary Care Mental Health Consult

STANDARD TITLE: MENTAL HEALTH CONSULT

DATE OF NOTE: JUN 09, 2022@14:20 ENTRY DATE: JUN 09, 2022@14:21:04

AUTHOR: ARANETA,ANGELA M 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 62 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

06/09/2022 11:39 PHQ9 20 PHQ9 GAD-7:

MHAS - MHA Score

Date Instrument Raw Trans Scale

06/09/2022 11:39 GAD-7 14 Anxiety

REFERRED BY: Dr. Dulai

REASON FOR REFERRAL: depression and passive SI

VISIT DURATION (minutes): 30 mins

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

events, etc.): Vet described "so much going on in my mind" along with 

chronic

conflict in his work place that have led him to symptoms of depression, anxiety, 

and passive suicidal ideation (without intent or plan). He described a 2 year 

lawsuit against the union which has been led to chronic stress. He also 

mentioned tension in his marriage surrounding finances and parenting styles.

 __________________________________________________________________________

FUNCTIONAL ASSESSMENT:

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APPENDIX 628

PCMHI Primary Care Mental Health Consult Has ADDENDA ***

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

events, etc.): Vet described "so much going on in my mind" along with

chronic

conflict in his work place that have led him to symptoms of depression, anxiety,

and passive suicidal ideation (without intent or plan). He described a 2 year 

lawsuit against the union which has been led to chronic stress. He also

mentioned tension in his marriage surrounding finances and parenting styles.

_________________________________________________________________

MENTAL HEALTH CONSULT

JUN 09, 2022@14:20 

depression and passive SI

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 14 of 41 PageID 7307
Sleep: Problems with sleep tossing and turning. His flight scheduled vary which 

also exacerbates sleep. He sleeps separately from his wife due to his 

restlessness- wakes multiple times per night- estimates no more than 5 hours of 

sleep on average

Work: Described stress related to his occupation as a flight attendant. He was a 

former union leader but now is involved in a lawsuit against the union. He feels 

others have been spreading false information about him on social media.

Close relationships: Today was his 22nd wedding anniversary. He described his 

marriage as "ŽŬĂLJ." He stated that their finances 

and create 

strain for his wife. He also noted divergent parenting styles for their two 

children who are currently in college. He expressed dissatisfaction that their 

son is not held accountable

__________________________________________________________________________

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

hospitalization, inpatient treatment, etc.):

He was seen for a comp assessment in 2015. He was prescribed 50mg Sertralinetook it for a couple months but he did not feel it made much of a difference.

__________________________________________________________________________

Substance use history:

One glass of wine on occasion at night. Denied tobacco or drug use.

__________________________________________________________________________

RISK ASSESSMENT:

Suicidal/Homicidal/Assaultive Ideation/Intent/Plan:

Yes- passive SI in the context of being overwhelmed by situational stress 

stressors- denied intent or plan

CSSRS was negative

Columbia Suicide Severity Rating Scale (C-SSRS) 

 Date Given: 06/09/2022

 Clinician: Colemon,Vivian Denise 

 Location: Nsac Pact Green

 Veteran: Ross,Robert Allen

 SSN: xxx-xx-5153

 DOB: (62)

 Gender: Male 

 Suicidal Ideation in Past Month: Yes - Suicidal thoughts

 Method/Plan/Intent in Past Month: No method, no specific plan, and no intent

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APPENDIX 629

Sleep: Problems with sleep tossing and turning. His flight scheduled vary which p pg gg

also exacerbates sleep pp y . He sleeps separately from his wife due to his

restlessness- wakes multiple times per night- estimates no more than 5 hours of

sleep on average

Work: Described stress related to his occupation as a flight attendant. He was a

former union leader but now is involved in a lawsuit against the union. He feels 

others have been spreading false information about him on social media.

Close relationships: Today was his 22nd wedding anniversary. He described his py g

marriage as " g ŽŬĂLJ." He stated that their finances

and create

strain for his wife. He also noted diverg p gy ent parenting styles for their two

children who are currently in college. He expressed dissatisfaction that their y

son is not held accountable

Yes- passive SI in the context of being overwhelmed by situational stress

stressors- denied intent or plan

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 15 of 41 PageID 7308
 Suicidal Behavior: No Past Suicidal Behavior Reported

 KEY INDICATORS:

 Questions and Answers: 

 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? 

 Yes

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

 No

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

acting on them? 

 No

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

details of how to kill yourself?

 No

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

plan?

 Not asked (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?

 Not asked (due to responses to other questions) 

__________________________________________________________________________

MENTAL STATUS EXAM:

 Appearance: older Caucasian male with short straight white male, average 

build, well groomed

 Demeanor: engaged, animated, talkative

 Mood: depressed and anxious

 Affect: full, congruent with content

 Psychotic symptoms/Thought content: no psychosis; thought content focused on 

stressors

 Cognitive deficits/Memory Impairment: recent problems with attention and 

focus; not formally assessed today

 Judgment/Insight: fair/limited

__________________________________________________________________________

DIAGNOSTIC IMPRESSIONS:

Depressive Disorder; Anxiety

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APPENDIX 630

Depressive Disorder; Anxiety

Questions and Answers: 

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?

Yes

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

No

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

acting on them? 

No

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

details of how to kill yourself?

No

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

plan?

Not asked (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?

Not asked (due to responses to other questions)

Mood: depressed and anxious

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 16 of 41 PageID 7309
 __________________________________________________________________________

INTERVENTION:

Psychotherapy: Symptom review, functional assessment, risk assessment, 

medication use, ideas for managing stress, overview of treatment options

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

accessing emergency services (Veterans Crisis Line, 1-800-273-8255, VA or 

local

hospital).

Veteran's questions and/or concerns were addressed.

FOLLOW-UP PLAN:

Referral to other Mental Health services: GMH Consult for therapy and 

medications placed today

Vet is open to medication trial. Will consult with Dr. Nuismer regarding 

medication options

Action Plan for Veteran: Encouraged him to limit time spent on social media. 

Gave him VCL magnet and encouraged him to reach out as needed

/es/ Angela M. Araneta, PsyD

Mental Health, Clinical Psychologist

Signed: 06/09/2022 15:05

Receipt Acknowledged By:

06/10/2022 08:49 /es/ Amy Nuismer, MD

 Psychiatry, Family Practice/Women's Health

06/10/2022 ADDENDUM STATUS: COMPLETED

Chart reviewed and case disussed with Dr. Araneta. Only previous medication 

trial of Zoloft but not adequate trial in terms of dose nor length of tx. 

Recommend re-trial and titrating up dose as needed to reach effect. 

/es/ Amy Nuismer, MD

Psychiatry, Family Practice/Women's Health

Signed: 06/10/2022 08:50

Date/Time: 09 Jun 2022 @ 1010

Note Title: Preventive Health Screen 11514

Location: No CA Healthcare Sys-Martinez

Signed By: COLEMON,VIVIAN DENISE

Co-signed By: COLEMON,VIVIAN DENISE

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APPENDIX 631

Psychotherapy: Symptom review, functional assessment, risk assessment, 

medication use, ideas for managing stress, overview of treatment options

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

accessing emergency services (Veterans Crisis Line, 1-800-273-8255, VA or 

local

hospital).

Veteran's questions and/or concerns were addressed.

FOLLOW-UP PLAN:

Referral to other Mental Health services: GMH Consult for therapy and

medications placed today

Vet is open to medication trial. Will consult with Dr. Nuismer regarding

medication options

Action Plan for Veteran: Encouraged him to limit time spent on social media.

Gave him VCL magnet and encouraged him to reach out as needed

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 17 of 41 PageID 7310
Date/Time Signed: 09 Jun 2022 @ 1022

Note

 LOCAL TITLE: Preventive Health Screen 11514

STANDARD TITLE: PREVENTIVE MEDICINE RISK ASSESSMENT SCREENING NO

DATE OF NOTE: JUN 09, 2022@10:10 ENTRY DATE: JUN 09, 2022@10:11:03

 AUTHOR: COLEMON,VIVIAN DENI EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Clinical Reminders:

 Medication Inventory:

 Does the VA medication list below reflect EXACTLY what the patient and/or 

 caregiver state the patient is taking (including non-VA prescriptions, over 

 the counter medications, vitamins and herbal supplements)?

 Unable to review with patient/caregiver due to the following reason:

 -Other: Review with pcp.

 Allergies:

 ERYTHROMYCIN, VICODIN, DARVOCET-N

 Active and Recently Expired Outpatient Medications (excluding Supplies):

 Active Outpatient Medications Status

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

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

 BY MOUTH ONCE DAILY FOR 4 WEEKS, THEN TAKE ONE

 TABLET ONCE DAILY FOR VITAMIN D SUPPLEMENT

 2) CYANOCOBALAMIN 500MCG TAB TAKE ONE TABLET BY MOUTH ACTIVE

 ONCE DAILY FOR VITAMIN B-12 SUPPLEMENT

 3) 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 No Active Remote 

 Medications for this patient

 Nutrition Screening:

 Most recent measurements:

 Measurement DT WEIGHT

 LB(KG)[BMI]

 06/09/2022 10:06 170(77.11)[26]

 09/15/2020 12:27 167(75.75)[25]

 07/26/2019 13:37 165(74.84)[25]

 08/17/2015 11:24 164(74.39)[25]

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

 BMI 25.9

 Depression Screening:

 Perform PHQ-2

 A PHQ-2 screen was performed. The score was 6 which is a positive 

 screen for depression.

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APPENDIX 632

 A PHQ-2 screen was performed. The score was 6 which is a positive

 screen for depression.

09 Jun 2022 @ 1022

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 18 of 41 PageID 7311
 Over the past two weeks, how often have you been bothered by the 

 following problems?

 1. Little interest or pleasure in doing things

 Nearly every day

 2. Feeling down, depressed, or hopeless

 Nearly every day

 Licensed Independent Provider notified of positive screen and need for 

 follow-up.

 Name of provider notified: Dr. Dulai,Kamalpreet

 Braden Skin Risk Assessment:

 No impairment or abnormality in sensory perception, moisture, activity, 

 mobility, nutrition, or friction.

 Emotional Health Screening (Nurse):

 The Veteran states they have worry or stress in their life.

 Source of concern: anxiety, anger issues, financial issues.

 Acknowledged Veterans concerns about their emotional health.

 Patient to discuss with provider in appointment today.

 MOVE! Screening- Overweight/Obesity:

 Calculated BMI: 25.9 Weight: 170 lb [77.11 kg] (06/09/2022 10:06)

 Educated on the health risks of overweight/obesity including:

 heart disease|hypertension

 The patient was educated on the available weight management programs and 

 declines treatment at this time.

 The patient has not participated in an organized weight management program 

 in the past year.

 Vitals:

 Most recent VS: Wt. 170 lb [77.11 kg] (06/09/2022 10:06)

 BP 137/83 (06/09/2022 10:06)

 HR 67 (06/09/2022 10:06)

 Temp 98.8 F [37.1 C] (06/09/2022 10:06)

 BMI 25.9

 Barriers to Education Not Recorded:

 The patient has a potential barrier to learning due to a visual 

 limitation.

 Suicide Screen:

 C-SSRS Screening

 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?

 Yes

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

 this?

 No

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APPENDIX 633

 Little interest or pleasure in doing things

 Nearly every day

 2. Feeling down, depressed, or hopeless

 Nearly every day

 The Veteran states they have worry or stress in their life.

 Source of concern: anxiety, anger issues, financial issues.

 Acknowledged Veterans concerns about their emotional health.

 Patient to discuss with provider in appointment today.

 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?

Yes

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 19 of 41 PageID 7312
 4. Over the past month, have you had these thoughts and had some 

 intention of acting on them?

 No

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

 the details of how to kill yourself?

 No

 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.

 Opioid Risk Tool:

 OPIOID RISK TOOL (ORT)

 Family history of substance abuse:

 0 - None

 Personal history of substance abuse:

 0 - None

 Age:

 0 - Age greater than 45 (This patient's age is 62)

 Psychological Disease:

 2 - Attention Deficit Disorder, Obsessive Compulsive Disorder,

 Bipolar, Schizophrenia

 Risk Category: Low Risk (0-3)

 Total score:

 2

/es/ Vivian Denise Colemon, LVN

Nursing Service, Specialty Clinic

Signed: 06/09/2022 10:22

Date/Time: 09 Jun 2022 @ 0953

Note Title: Primary Care Note

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 09 Jun 2022 @ 1148

Note

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APPENDIX 634

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 20 of 41 PageID 7313
 LOCAL TITLE: Primary Care Note

STANDARD TITLE: PRIMARY CARE NOTE

DATE OF NOTE: JUN 09, 2022@09:53 ENTRY DATE: JUN 09, 2022@09:53:33

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Primary Care Note Has ADDENDA ***

C/C: f/u

HPI: Pt is a 62yo here today for reg med follow up with followign issues:

1. Phlegmy cough since 1/2020, believes he might have had COVID. Has had 

vaccinations. Not hydrating and also has cramps in hands, LE as well. Using 

flonase PRN. NO fever with this, no SOB. Continues to have it, and clearing 

throat, does nto smoke, was not consistent with flonase. 

2. continues to have a lot of stress at work. Works as flight attendant, has 

law suit going on,stress on family, cannot concentrate at work, thinks about SI 

daily. Wants to sleep and not wake up, but no plan drawn out on how to do it. 

Has 2 kids in college. +depression. 

3. Passed out yesterday in the garden, does not hydrate. States woke up to wife 

calling his name, denies CP or SOb, no palpitations, however has been having 

worsenign memory for some time now. No fever. no loss of bowel or urination, 

no tongue biting or shaking noted by wife. 

4. +urgnecy and strainign to urinate, waking up multiple times to urinate. 

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 08/31/15 WEBER,DIANE ELL

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

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APPENDIX 635

2. 

DATE OF NOTE: JUN 09, 2022@09:53 ENTRY DATE: JUN 09, 2022@09:53:33

 continues to have a lot of stress at work. Works as flight attendant, has

law suit going on,stress on family, cannot concentrate at work, thinks about SI 

daily. Wants to sleep and not wake up, but no plan drawn out on how to do it.

Has 2 kids in college. +depression. 

3. Passed out yesterday in the garden, does not hydrate. States woke up to wife 

calling his name, denies CP or SOb, no palpitations, however has been having

worsenign memory for some time now. No fever. no loss of bowel or urination,

no tongue biting or shaking noted by wife. 

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 21 of 41 PageID 7314
current (ICD-9-CM 836.1)

Medications:

see med list

Immunizations:

PCE IMMUNIZATIONS

Immunization Series Date Facility Reaction Info

COVID-19 (MODERNA), MRNA, LNP-S,* 2 03/27/2021 El Dorado*

 1 02/27/2021 EL DORADO *

INFLUENZA, INJECTABLE, QUADRIVALE* 10/06/2020 MCCLELLAN *

TD(ADULT) UNSPECIFIED FORMULATION 06/00/2005 No Site

TDAP 07/26/2019 MCCLELLAN *

PCE HEALTH FACTORS SELECTED

 IMMUNIZATION [C]

08/17/2015 Refused Td / Tdap / Dtap

07/18/2014 Refused Td / Tdap / Dtap

04/24/2013 Refused Influenza Immunization

03/07/2012 Refused Influenza Immunization

 Refused Td / Tdap / Dtap

02/24/2011 Refused Influenza Immunization

05/24/2010 Refused Influenza H1n1

 Refused Influenza Immunization

12/18/2008 Refused Td / Tdap / Dtap

ROS:

CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae.

Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore

throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No

palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain

or blood.

NEUROLOGICAL: syncope

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

PSYCHIATRIC: depression or anxiety.

PE: A/A/O x3, NAD, WN, WD. VS reviewed

HEENT: Head is normocephalic. The sinuses are nontender. Pupils are equal and 

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APPENDIX 636

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 22 of 41 PageID 7315
reactive. The nares

are patent. Oropharynx reveals clear without lesions.

HEART: Regular rate and rhythm.

LUNGS: No crackles or wheezes are heard. CTAB

EXTREMITIES: Without cyanosis, clubbing or edema.

NEUROLOGICAL: Gross nonfocal.

Skin: Warm and dry without any rash.

Musculoskeletal: FROM, no deformities noted

Pertinent Labs:

Collection DT Spec CHOL TRIGLYC HDL LDL-CHO

12/08/2021 12:52 PLASM 260 H 171 H 50 176 H

08/20/2020 10:36 PLASM 234 H 285 H 38 L 139

SCL1 - Partial CBC

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

SCL1 - Lab Cum Selected 1

Collection DT Spec NA K CL CO2 CALCIUM

12/08/2021 12:52 PLASM 137 4.2 101 27 9.5

SCL2 - Lab Cum Selected 2

Collection DT Spec GLUCOSE BUN CREAT eGFR

12/08/2021 12:52 PLASM 100 15 0.90 >60

08/20/2020 10:35 PLASM 117 19 1.10 >60

SCL3 - Lab Cum Selected 3

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

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

HbA1c-last 3

Collection DT Spec HGBA1c

12/08/2021 12:53 BLOOD 6.0 H

07/26/2019 14:54 BLOOD 5.9 H

SCL1 - PSA

Collection DT Spec PSA

12/08/2021 12:53 SERUM 1.23

07/25/2019 10:35 SERUM 1.04

08/06/2015 13:38 SERUM 0.79

07/16/2014 11:17 SERUM 0.68

05/13/2010 11:26 SERUM 0.69

SCLU - TSH

Collection DT Spec Tsh

12/08/2021 12:53 SERUM 3.26

08/20/2020 10:35 SERUM 3.51

Patient

Patient Sex: M

Total Cholesterol: 260 mg/dL (12/8/2021)

HDL Cholesterol: 50 mg/dL (12/8/2021)

Blood Pressure: 123/70

Smoking status evaluates as: Non-Smoker

Blood pressure treatment evaluates as: Untreated SBP

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APPENDIX 637

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 23 of 41 PageID 7316
Diabetes evaluates as: Non-Diabetic

10-year CV risk: 11.7%

10-year CV risk for an African-American: 8.9%

A/p:

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

-saw ortho 4/2022, deciding to hold off on any surgeries at this time and if in 

future desired, will make appt for possible arthrscopy again

-NSAID PRN, use sparingly to avoid HTN

-diclofenac gel PRN

-FMLA paperwork done 12/2021

2. allerigc rhinitis/Cough: chronic, likely PND, encourage hydration and flonase 

and zyrtec daily for 4 weeks and if not helping, Update PC to refer to ent

-check cxr today

3. BPH w/luts: will try Flomox 0.4mg daily

4. L cataract: will f/u with eye clnic

5. Low B12: on supplement

6. Vitamin D: on supplement

7. A1c in PreDm: lifestyle changes, pending now

8. Hyperlipidemia: LDL not at goal 12/2021, watch diet and repeat now

9. Syncopal episode? stress rxn, dehydraton vs cards?

-worseing memory, likely due to increased stress, refer to PCHMI today

-ekg, carotid US, echocardiogram, MRI brain, NMPS, ziopatch ordered

-if happens again, will need to go to ER immediately. 

-cotninue hydration as well

10. +SI to provider, states thoughts of SI daily, no plan

-increased stress at work, warm hand off to PCHMI today

HCM:

Colon Ca screening: last Cscope done 2011 and wnl, FIT neg 2/2022

Labs pending

Immunizations: shingrix #1 hold off today

f/u in 3 months or sooner PRN

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APPENDIX 638

of SI daily, no plan

-increased stress at work, warm hand off to PCHMI today

8. Hyperlipidemia: LDL not at goal 12/2021, watch diet and repeat now

9. Syncopal episode? stress rxn, dehydraton vs cards?

-worseing memory, likely due to increased stress, refer to PCHMI today

-ekg, carotid US, echocardiogram, MRI brain, NMPS, ziopatch ordered

-if happens again, will need to go to ER immediately.

-cotninue hydration as well

10. +SI to provider, states thoughts 

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 24 of 41 PageID 7317
Clinical Reminders:

 Emotional Health Screening (Provider):

 Patient screened positive for emotional health concerns with nurse.

 REMINDER FACTORS [C]

 06/09/2022 Worry/Stress Life Yes

 anxiety, anger issues, financial issues.

 Acknowledged Veterans concerns about their emotional health. Resources 

 Offered to Veteran: Primary Care Mental Health Integration (PCMHI: Insomnia 

 Class, Depression, etc)

 Follow-Up Pos PTSD/Depression:

 I have reviewed the results of the Mental Health screens and have evaluated 

 the patient. Based on the evaluation, the following disposition plan will 

 be implemented:

 Patient to be evaluated by Mental Health

 Stat/Emergent Mental Health Evaluation needed.

 Comment: warm hand off to PCHMI

 Medication Reconciliation:

 Med Rec performed with patient/caregiver:

 -Home meds compared with CPRS meds

 -Medication allergies (local and remote) reviewed

 -Discrepancies, if any, discussed with patient/caregiver

 -Changes, if any, addressed in "Plan" section of visit note and

 reflected in CPRS medication list

 -Patient/caregiver provided with an updated medication list (or

 written instructions provided for minor med changes)

 -Education provided regarding managing personal medication

 information, including carrying an updated med list at all times

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 06/09/2022 11:48

06/13/2022 ADDENDUM STATUS: COMPLETED

please let pt know LDL not at goal, rec starting atorvastatin 40mg, if 

agreeable, please pend for me

HbA1c is at 6,needs to monitor with diet, low processed sugar/carb diet 

K is higher than normal, please avoid foods with high K like avocado and banana

b12 is still low, if taking it daily, must double it. and repeat in 3 months and 

if still low, may need injections monthly

/es/ Kamalpreet Dulai, MD

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APPENDIX 639

 06/09/2022 Worry/Stress Life Yes

 anxiety, anger issues, financial issues.

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 25 of 41 PageID 7318
Physician, Primary Care

Signed: 06/13/2022 09:18

Receipt Acknowledged By:

06/14/2022 09:37 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

06/13/2022 ADDENDUM STATUS: COMPLETED

Called patient and he was identified using 2/3 patient identifiers (full name, 

full soc sec number, birth date).

Mr. Ross was informed that his LDL is not at goal. He agrees to start taking 

medication Atorvastatin 40mg daily. 

He was informed that his hemoglobin A1c, which tells what your average blood 

sugar has been over the three months prior to the blood draw, was 6% when 

checked on June 9, 2022 and that the normal range is 4.1-5.7%. He was 

encouraged to monitor his diet and to have meals and snacks with vegetables, 

fruits, lean meats or other healthy proteins, whole grains, and low-fat or 

nonfat dairy products. 

Mr. Ross was told that his potassium is higher than normal and to avoid avocados 

and bananas.

He was also informed that his vitamin B12 is low and states that he just began 

taking the vitamin B12 supplement daily. He will repeat labs in three months.

Provider to be informed.

/es/ Shearon Jones, RN

Nursing Service, Case Manager, Primary Care

Signed: 06/13/2022 14:17

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Cosigned: 06/13/2022 14:22

07/07/2022 ADDENDUM STATUS: COMPLETED

Please let pt know NMPS shows no perfusion defects suggestive of ischemia or 

prior MI. Normal LVEF at 71%. 

There is 9mm R upper lobe pulm groundglass opacity noted, i rec followup with CT 

in 6 months, ordered. 

Impression:

 1. No evidence for reversible or fixed perfusion defects

 suggestive of ischemia or prior myocardial infarction is

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APPENDIX 640

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 26 of 41 PageID 7319
 identified. 

 2. Normal LV systolic function. LVEF = 71% (normal >= 50%). 

 3. Incidental noncontrast CT findings include aortic and

 coronary artery atherosclerosis, 9 mm right upper lobe pulmonary

 groundglass opacity. Recommend follow-up CT at 6 months. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 07/07/2022 15:14

Receipt Acknowledged By:

07/12/2022 11:30 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

07/22/2022 ADDENDUM STATUS: COMPLETED

please let pt know ziopatch is overall benign, no arrythmia cause noted for 

syncope, no afib noted, good news!

CONCLUSIONS:

1. Predominant rhythm is Sinus with an avg rate of 79 bpm, range: 51-155 bpm.

2. Triggered events and diary entries do not correlate with significant 

arrhythmia.

3. No Atrial Fibrillation seen for period observed.

4. No pauses or significant bradyarrhythmia observed.

5. Overall, benign Ziopatch. No arrhythmogenic cause for syncope observed.

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 07/22/2022 10:49

Receipt Acknowledged By:

07/22/2022 11:46 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

08/01/2022 ADDENDUM STATUS: COMPLETED

MRI brain is normal, please let pt know. 

 Impression:

 Unremarkable MRI of brain.

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 08/01/2022 10:12

Receipt Acknowledged By:

08/01/2022 11:37 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

08/01/2022 ADDENDUM STATUS: COMPLETED

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APPENDIX 641

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 27 of 41 PageID 7320
Called patient and he was identified using 2/3 patient identifiers (full name, 

full soc sec number, birth date).

Mr. Ross was informed that the MRI of his brain that was completed on July 31, 

2022 was normal.

Patient asks that the order for an ultrasound of his abdomen be re-entered. He 

states that he called to cancel it previously. He was provided with the 

telephone number for Radiology at Mather VA Medical Center. 

Provider to be informed.

/es/ Shearon Jones, RN

Nursing Service, Case Manager, Primary Care

Signed: 08/01/2022 11:45

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Cosigned: 08/01/2022 11:50

08/01/2022 ADDENDUM STATUS: COMPLETED

Carotid US reordered for full workup of syncope

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 08/01/2022 11:50

08/17/2022 ADDENDUM STATUS: COMPLETED

Carotid US and CXR nml, please let pt know 

 Impression:

 Minimal plaque. No stenosis. 

 Impression:

 No radiographic evidence of acute cardiopulmonary disease. No 

 pulmonary edema, soft tissue pulmonary nodules, or lobar alveolar 

 consolidation/pneumonia appreciated. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 08/17/2022 10:54

Receipt Acknowledged By:

08/17/2022 12:37 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

08/31/2022 ADDENDUM STATUS: COMPLETED

NMPS normal, please let pt know.

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APPENDIX 642

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 28 of 41 PageID 7321
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.

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 08/31/2022 17:28

Receipt Acknowledged By:

09/07/2022 12:55 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 26 Apr 2022 @ 1325

Note Title: Orthopedic 14333

Location: No CA Healthcare Sys-Martinez

Signed By: ANDERSON,BRETT CARL

Co-signed By: ANDERSON,BRETT CARL

Date/Time Signed: 26 Apr 2022 @ 1332

Note

 LOCAL TITLE: Orthopedic 14333

STANDARD TITLE: ORTHOPEDIC SURGERY NOTE

DATE OF NOTE: APR 26, 2022@13:25 ENTRY DATE: APR 26, 2022@13:25:05

 AUTHOR: ANDERSON,BRETT CARL EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

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

HISTORY OF PRESENT ILLNESS: the patient is a 62-year-old male here for another 

opinion regarding his left knee. He is having pain on the posterior medial 

aspect of his knee that worsens with long standing or attempts at squatting. 

Once he squats down he has a hard time standing back up again. He has been 

limping around on his long international flights which is causing some 

increased back pain as well. He has had 3 prior arthroscopies with variable 

results. He has had multiple corticosteroid injections over the years with 

very short term improvement recently. He has not been wearing any bracing. He 

would prefer not to have surgery.

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 

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APPENDIX 643

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 29 of 41 PageID 7322
GENERAL ORTHOPEDIC

Left knee: No effusion, range of motion 0 to 120? with pain at terminal 

flexion, positive medial joint line tenderness, positive McMurray, normal 

gait, neutral to 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 from 3 prior meniscectomies, moderate chondral thinning in the medial 

compartment with good preservation of the lateral compartment

ASSESSMENT: Left knee medial meniscal tear with moderate osteoarthritis

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

injections versus viscosupplementation versus arthroscopy versus total knee 

arthroplasty versus unicompartmental arthroplasty. He is having enough 

mechanical symptoms warrant arthroscopy may be helpful however he has had 3 

prior arthroscopic surgeries and has a very thin rim of meniscal tissue. I 

counseled him that arthroscopy in the presence of osteoarthritis has very 

variable outcomes. Long-term, a total knee arthroplasty is where he is 

heading. He would like to avoid surgery at this point. If his mechanical 

symptoms worsen, he will contact us to discuss an arthroscopy again. He will 

do anti-inflammatories versus Tylenol in the meantime.

//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: 04/26/2022 13:32

Date/Time: 05 Apr 2022 @ 1620

Note Title: Orthopedic Knee 60266

Location: No CA Healthcare Sys-Martinez

Signed By: MOITOZA,JAMES RAYMOND

Co-signed By: MOITOZA,JAMES RAYMOND

Date/Time Signed: 05 Apr 2022 @ 1633

Note

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APPENDIX 644

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 30 of 41 PageID 7323
 LOCAL TITLE: Orthopedic Knee 60266

STANDARD TITLE: ORTHOPEDIC SURGERY E & M NOTE

DATE OF NOTE: APR 05, 2022@16:20 ENTRY DATE: APR 05, 2022@16:20:22

 AUTHOR: MOITOZA,JAMES RAYMO EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Chief complaint: Medial LEFT knee pain, aggravated by squatting

History of present illness: 62-year-old flight attendant and service-connected 

US Air Force veteran returns for reevaluation of his left knee problem 

following MRI scan obtained on February 26, 2022. He was seen in consultation 

on December 21, 2021, presenting with a long history of chronic left knee 

problems.

He had been seen here in orthopedics in 2014 by Dr. Jeffrey Taylor and 

received

a steroid injection of his knee with some transient benefit. I also 

administered a steroid injection on December 21, 2021 but with only transient 

benefit.

 Mr. Ross is continue to work as a flight attendant but has had to 

change his work schedule because he is no longer able to squat down to help 

with the galley and to reach down to the bottom of the carts. He notes that 

anytime he has to bend down, he has to modify his position to keep his left 

knee extended and this has aggravated pain in his lower back radiating into 

the left SI joint area. He notes that he limps a lot and his wife has remarked 

on this. He has a medial clicking sensation when he pivots and notes that his 

knee will sometimes lock up but he unlocks it by forcibly flexing it and then 

feels a click.

PHYSICAL EXAM: Patient is a comfortable slender Caucasian male who is in no 

obvious distress or discomfort.

Left knee: His gait is not particularly antalgic. However he is not able to 

squat. He lacks approximately 10 degrees of flexion compared to the right 

side. He is stable to varus valgus stress. McMurray maneuvers did not cause 

any pain or mechanical clunks.

MRI scan: February 26, 2022 = there is significant medial compartment 

arthritis and loss of cartilage from medial femoral condyle. There is an 

oblique tear of the posterior horn of the medial meniscus and some flare 

stress reactions in the area of the medial tibial plateau that is centered 

from anterior to posterior.

Impression:

1. Posterior horn medial meniscus tear LEFT knee with mechanical symptoms on 

squatting.

2. Moderate medial compartment osteoarthritis with progression from 

approximately 20% medial joint space narrowing 2013 to 50% in 2021.

ASSESSMENT: The patient's history of clicking and discomfort with 

squatting are consistent with damage of the posterior horn of the medial 

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APPENDIX 645

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 31 of 41 PageID 7324
meniscus as the medial femoral condyle "rolls up" onto the meniscus. He 

does

have medial compartment arthritis and eventually will require an arthroplasty. 

However, I believe he may benefit from an aggressive debridement of the 

posterior horn of the medial meniscus to remove some of these mechanical 

symptoms that he has with squatting. It is definitely too soon to repeat a 

steroid injection at this time.

PLAN:

1. Refer the patient to Dr. Brett Anderson for consideration of aggressive 

arthroscopic debridement of posterior horn medial meniscus tear.

2. Eventual left total knee arthroplasty will be required but hopefully can be 

delayed/deferred for many years after successful arthroscopic debridement.

/es/ James Raymond Moitoza, M.D.

Orthopaedic Surgeon

Signed: 04/05/2022 16:33

Receipt Acknowledged By:

04/06/2022 08:23 /es/ Brett C Anderson, MD

 Orthopaedic Surgeon - Sports Medicine

04/05/2022 17:26 /es/ Brandae M. Johnston, RN, BSN, AA

 Nursing Service, Surg Spec Ortho/SAC

Date/Time: 08 Jan 2022 @ 1434

Note Title: Radiology Note

Location: No CA Healthcare Sys-Martinez

Signed By: SWAN,NEPHTERIA

Co-signed By: SWAN,NEPHTERIA

Date/Time Signed: 08 Jan 2022 @ 1434

Note

 LOCAL TITLE: Radiology Note

STANDARD TITLE: RADIOLOGY NOTE

DATE OF NOTE: JAN 08, 2022@14:34 ENTRY DATE: JAN 08, 2022@14:34:32

 AUTHOR: SWAN,NEPHTERIA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

RADIOLOGY COVID19 LETTER

 JAN 08, 2022

 ROBERT ALLEN ROSS

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APPENDIX 646

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 32 of 41 PageID 7325
 DEAR ROBERT ALLEN ROSS

We are sending a reminder to inform you that you have a pending xray order(s),

we are accepting walk-ins, please check into Building 700, Radiology department

between 8:00am and 4:30pm Monday-Friday. The order will be pending until up to

80 days of the date of this letter.

We appreciate your understanding during this time. Please contact your primary

care doctor with any immediate health concerns or go to the closest emergency

room.

Thank you,

/es/ Nephteria Swan

Medical Support Assistant

Signed: 01/08/2022 14:34

Date/Time: 21 Dec 2021 @ 0926

Note Title: Orthopedics Consult

Location: No CA Healthcare Sys-Martinez

Signed By: MOITOZA,JAMES RAYMOND

Co-signed By: MOITOZA,JAMES RAYMOND

Date/Time Signed: 21 Dec 2021 @ 1633

Note

 LOCAL TITLE: Orthopedics Consult

STANDARD TITLE: ORTHOPEDIC SURGERY CONSULT

DATE OF NOTE: DEC 21, 2021@09:26 ENTRY DATE: DEC 21, 2021@09:26:41

 AUTHOR: MOITOZA,JAMES RAYMO EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Orthopedics Consult Has ADDENDA ***

Chief complaint: 62-year-old flight attendant and service-connected US 

Air Force veteran presents with a long history of chronic left knee problems. 

He was last seen here in orthopedics in 2014 by Dr. Jeffrey Taylor and received 

a steroid injection of his knee with some transient benefit. However recently 

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APPENDIX 647

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 33 of 41 PageID 7326
he has been having more problems with limping his knee and particularly problems 

bending his knee. He is not able to ambulate over uneven terrain and 

particularly has difficulty at work while pushing heavy carts on carpet. He is 

not able to squat on his left knee and is difficult for him to don his socks and 

shoes. He has been using a local Voltaren gel which is been somewhat helpful. 

He takes ibuprofen sparingly because it bothers his stomach. He notes that his 

lower back is aggravated when he is limping and long flights are very difficult 

for him. He has a medial clicking sensation when he pivots and notes that his 

knee will sometimes lock up but he unlocks it by forcibly flexing it and then 

feels a click.

 He also feels localized popliteal fossa pain that radiates into the 

proximal mid calf posteriorly, especially painful at night. He wondered if it 

was varicose veins but there are no veins there. He does have low back pain but 

no radiating sciatic pain.

Past medical history: Patient underwent a partial arthroscopic medial 

meniscectomy of the left knee by Dr. Andrew Ho here in May 2012. Delaminated 

horizontal tear of the medial meniscus was described with the superior flap 

being debrided. He did well for a while after that but is then had steroid 

injections by Dr. Taylor.

KNEES: Gait: antalgia = minimal antalgia on the left

Heel walk = normal/moderate antalgia, difficulty extending

Toe walk = normal bilaterally

One Leg Squats (R/L) = normal bilaterally

Varus Thrust (R/L) = normal/mild

One leg hop/pivot (R/L) = normal/mild pain

Effusion: None bilaterally

PROM: (R/L) Extension = 0/0; Flexion = 140/130

Ligament stress/stability (R/L)

Varus = stable/stable 

Valgus = stable/stable

Lachmann = good end stops bilaterally ant. Drawer =

Pivot Shift = negative bilaterally

McMurray stress (R/L) = negative/mild pain no clicks

Patello-femoral(R/L)

inhibition/grind = negative bilaterally

apprehension = negative bilaterally

Quad strength (R/L) = good/good

Medial Joint line (R/L)= none/moderate anterior

Lateral Joint line (R/L)= none/none

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APPENDIX 648

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 34 of 41 PageID 7327
Patellar tendon (R/L)= none/none

Quad tendon (R/L)= none/none

Pes anserinus (R/L)= none/none

PROCEDURE: After verbal discussion and written consent, patient underwent 

an arthrocentesis of the LEFT knee utilizing the superior lateral subpatellar 

approach. Skin was prepped with Betadine, then alcohol. 5 cc of 0.5% 

bupivacaine and 50 mg of Kenalog was injected atraumatically using a 21-gauge 1-

1/2 inch needle. After approximately 5 minutes patient was reexamined: Patient 

felt comfortable and had no significant pain. Hopping activity was not as 

painful but still had difficulty flexing knee enough to don shoes and socks.

RADIOGRAPHS: September 15, 2020 = STANDING views bilateral knees in extension of 

flexion, lateral and sunrise view of left knee revealed mild medial joint space 

narrowing with a very small medial spur from the proximal left tibial plateau.

MRI scan: February 11, 2012 = complex horizontal and superior medial 

meniscus tear of left knee without significant osteoarthritis.

IMPRESSION:

1. Possible recurrent left knee medial meniscus tear

2. Probable osteoarthritis, medial compartment, left knee

ASSESSMENT: The patient seems to have been improved for the past 9 years 

following the partial meniscectomy in May 2012. Progressive osteoarthritis is 

expected but is not evident on the radiographs 15 months ago in September 2020. 

Therefore repeat standing x-rays are indicated and a repeat MRI scan to see if 

another arthroscopic procedure might buy him more time before a total knee 

arthroplasty is required.

PLAN:

1. Anesthetic and steroid injection left knee = done

2. STANDING radiographs bilateral knees

3. MRI scan LEFT knee

4. Follow-up evaluation after MRI scan available. 

/es/ James Raymond Moitoza, M.D.

Orthopaedic Surgeon

Signed: 12/21/2021 16:33

03/01/2022 ADDENDUM STATUS: COMPLETED

I have personally reviewed the patient's MRI scan of February 26, 2022.

There

is evidence of a oblique tear of the posterior horn of the medial meniscus that 

is more obvious on the sagittal views than the coronal. There is also evidence 

of tricompartmental arthritis and stress reactions in the medial tibial plateau 

both the mid aspect as well as in the posterior medial aspect of the medial 

compartment.

 I have also reviewed the patient's STANDING radiographs and compared 

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APPENDIX 649

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 35 of 41 PageID 7328
January 27, 2022 to the radiographs 15 months earlier in September 15 of 2020. 

There has been ominous progression of the narrowing of at least 50% more 

narrowing now.

It is unlikely that a partial meniscectomy, taking out the rest of the posterior 

horn, is going to significantly improve this patient. He is demonstrating the 

expected progression to osteoarthritis. I did inject his knee with 

corticosteroid on December 21, 2021 and hopefully he got some benefit from this. 

I believe that the patient is most likely going to need a total knee 

arthroplasty in the future and I do not believe that arthroscopic intervention 

will prevent this or delay it. She should be seen for follow-up evaluation now 

that his MRI scan has been obtained and the above discussion presented to the 

patient.

/es/ James Raymond Moitoza, M.D.

Orthopaedic Surgeon

Signed: 03/01/2022 10:48

Date/Time: 21 Dec 2021 @ 0919

Note Title: CONSENT CLINICAL IMED

Location: No CA Healthcare Sys-Martinez

Signed By: CVIX,IMEDWEBUSER

Date/Time Signed: 21 Dec 2021 @ 0919

Note

 LOCAL TITLE: CONSENT CLINICAL IMED

STANDARD TITLE: CONSENT

DATE OF NOTE: DEC 21, 2021@09:19:23 ENTRY DATE: DEC 21, 2021@09:19:30

 AUTHOR: CVIX,IMEDWEBUSER EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 VistA Imaging - Scanned Document

 Signature Informed Consent for Joint - Injection of Joint (Injection of Joint)

1. Anatomical Location: LEFT knee arthrocentesis and injection with local

anesthetic and steroid 

2. Informed consent was obtained at 9:16 AM on

 12/21/21. 

The full consent document can be accessed through Vista Imaging.

3. Patient name: ROSS, ROBERT ALLEN

4. The patient HAS decision-making capacity.

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APPENDIX 650

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 36 of 41 PageID 7329
5. Surrogate (if applicable):

6. Reason for the treatment (diagnosis, condition, or indication): 

 Painful, worn, injured, or infected joint. 

7. Treatment/procedure: This procedure involves the injection of a joint for

diagnostic or therapeutic intervention, most commonly using medications for the

treatment of pain and inflammation. 

 Sacramento Mather VAMC

8. No, neither anesthesia nor moderate sedation will be used in this

treatment/procedure.

9. Consent to Blood Products (if applicable):

 It is not expected that blood products will be used in this

treatment/procedure.

10. Practitioner obtaining consent: James Raymond Moitoza, MD 

11. Supervising practitioner:

12. Practitioner(s) performing or supervising treatment/procedure (if

 not listed above):

13. Witness Name(s):

14. Comments:

 *** SCANNED DOCUMENT ***

 SIGNATURE NOT REQUIRED

 Electronically Filed: 12/21/2021

 by: IMEDWEBUSER CVIX

Date/Time: 09 Dec 2021 @ 1148

Note Title: Care Management Nursing Note

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APPENDIX 651

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 37 of 41 PageID 7330
Location: No CA Healthcare Sys-Martinez

Signed By: JONES,SHEARON

Co-signed By: JONES,SHEARON

Date/Time Signed: 09 Dec 2021 @ 1312

Note

 LOCAL TITLE: Care Management Nursing Note

STANDARD TITLE: CARE MANAGEMENT NURSING NOTE

DATE OF NOTE: DEC 09, 2021@11:48 ENTRY DATE: DEC 09, 2021@11:48:40

 AUTHOR: JONES,SHEARON EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Patient identified using 2/3 patient identifiers (full name, full soc sec 

number, birth date).

Mr. Ross presents to the clinic to have his blood pressure checked. It is 

123/70 and his pulse is 74. Patient denies having a severe headache, blurred 

vision, nausea, vomiting, drowsiness, confusion and persistent numbness and 

tingling in his hands and feet.

He was informed that his vitamin B12 is very low and that Vitamin B12 500mcg has 

been mailed to him to take daily. His vitamin D is also very low and Vitamin D 

4000iu was mailed to him to take daily for one month and then 2000iu daily 

thereafter.

Patient was informed that his hemoglobin A1c, which tells us what your average 

blood sugar has been over the three months prior to the blood draw, is in the 

pre-diabetic range and is 6.0%. He was encouraged to monitor his diet and to 

eat low glycemic foods.

In addition, he was informed that his LDL is not at goal and was 176 when 

checked. He will complete fasting labs in six months.

FMLA paperwork was completed by primary care provider and given to patient.

Provider in to discuss lab results with patient. He was informed that a consult 

to the Orthopedic Department was entered for assessment of left knee pain. 

Patient encouraged to eat a well-balanced, low-fat, low-salt diet. 

Patient verbalized understanding and voiced no other needs.

/es/ Shearon Jones, RN

Nursing Service, Case Manager, Primary Care

Signed: 12/09/2021 13:12

Receipt Acknowledged By:

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APPENDIX 652

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 38 of 41 PageID 7331
12/09/2021 13:37 /es/ Kamalpreet Dulai, MD

Physician, Primary Care

Date/Time: 02 Dec 2021 @ 1055

Note Title: Primary Care Telephone Note

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 02 Dec 2021 @ 1105

Note

 LOCAL TITLE: Primary Care Telephone Note

STANDARD TITLE: PRIMARY CARE TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: DEC 02, 2021@10:55 ENTRY DATE: DEC 02, 2021@10:55:27

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

URGENCY: STATUS: COMPLETED

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

C/C: est care, FMLA paperwork

HPI: Pt is a 62yo M TAP today to discuss soem concerns:

1. Needs FMLA paperwork filled out for his L knee. SC for this. s/p 3

surgeries. Continues to bother him, he is a pilot for AA, and when exacerbated,

he does need to rest it for 5-7 days. This occurs 2-3 x a year. He would like 

to see ortho and get reimaging as symptoms are worsening. Pain is in back of 

knee as well. 

Ϯ͘ Phlegmy cough since 1/2020, believes he might have had COVID. Has had

vaccinations. Not hydrating and also has cramps in hands, LE as well. Using

flonase PRN. NO fever with this, no SOB.

ϯ͘ L cataract, will f/u with eye clinic

κ͘ Increased stress at workǁŝƚŚŚŝƐƵŶŝŽŶ. Checking BP at home during 

stressful times and always >140/90 per pt.

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 08/31/15 WEBER,DIANE ELL

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

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

72866009)

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APPENDIX 653

Increased stress at workǁŝƚŚ ŚŝƐ ƵŶŝŽŶ. Checking BP at home during 

stressful times and always >140/90 per pt.

Date/Time Signed: 02 Dec 2021 @ 1105

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 39 of 41 PageID 7332
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:

see med list

Immunizations:

PCE IMMUNIZATIONS

Immunization Series Date Facility Reaction Info

COVID-19 (MODERNA), MRNA, LNP-S,* 2 03/27/2021 El Dorado*

 1 02/27/2021 EL DORADO *

INFLUENZA, INJECTABLE, QUADRIVALE* 10/06/2020 MCCLELLAN *

TD(ADULT) UNSPECIFIED FORMULATION 06/00/2005 No Site

TDAP 07/26/2019 MCCLELLAN *

PCE HEALTH FACTORS SELECTED

 IMMUNIZATION [C]

08/17/2015 Refused Td / Tdap / Dtap

07/18/2014 Refused Td / Tdap / Dtap

04/24/2013 Refused Influenza Immunization

03/07/2012 Refused Influenza Immunization

 Refused Td / Tdap / Dtap

02/24/2011 Refused Influenza Immunization

05/24/2010 Refused Influenza H1n1

 Refused Influenza Immunization

12/18/2008 Refused Td / Tdap / Dtap

ROS:

CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae.

Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore

throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No

palpitations or edema.

RESPIRATORY: cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain

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APPENDIX 654

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 40 of 41 PageID 7333
or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or

tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: L knee pain

Pertinent Labs:

Collection DT Spec Lab CHOL TRIGLYC HDL LDL-CHO

08/20/2020 10:36 PLASM [634] 234 H 285 H 38 L 139

07/25/2019 10:35 PLASM [634] 259 H 277 H 38 L 166 H

Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

SCL1 - Partial CBC

Collection DT Spec Lab WBC HGB HCT MCV MCHC PLT

08/20/2020 10:35 BLOOD [634] 5.1 15.7 46.7 89.0 33.6 307

Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

SCL1 - Lab Cum Selected 1

Collection DT Spec Lab NA K CL CO2 CALCIUM

08/20/2020 10:35 PLASM [634] 134 L 4.1 99 24 9.3

Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

SCL2 - Lab Cum Selected 2

Collection DT Spec Lab GLUCOSE BUN CREAT eGFR

08/20/2020 10:35 PLASM [634] 117 19 1.10 >60

07/26/2019 14:54 PLASM [634] 100 21 1.03 >60

Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

SCL3 - Lab Cum Selected 3

Collection DT Spec Lab PROTEIN ALBUMIN T. BIL D BILI ALK PHO AST 

ALT

08/20/2020 10:35 PLASM [634] 7.3 4.5 0.6 <0.1 L 62 22 

21

Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

HbA1c-last 3

Collection DT Spec Lab HGBA1c

07/26/2019 14:54 BLOOD [634] 5.9 H

526652%(57$//(1

'DWHRI%LUWK Page 196 of 337

APPENDIX 655

Case 4:22-cv-00343-Y Document 239-15 Filed 04/26/24 Page 41 of 41 PageID 7334