Declaration of Steven Shelton, M.D. 

Attachment 1; Page 1 of 100 

( 

OREGON DEPARTMENT OF CORRECTIONS 

Prob em Ust 

co 493 I-I (11/93) 

SStkjUilq • 381 

Health Insurance_Wk Veteran "V', 

Open 

SAIFFWC Closed 

1 Dale 

Prob. 

Na.o 

• 

Problems JP- ell to 

Date 

Flesolv - • 

/7 7-60,0 • 6.0.,• rt.—ILI-- WitS4 1, Cdi • 1/4- a I — AV," ilk

6 

GI(.• frvAV4 

't I 10 -9 Fe. ru- a oat 

6G 

 ,) 

..A 

,7/42.0 c--Lii,-,7).d6 - Lep ' 1 . 

• ,1 

. 

. . 

. 

. 

. 

. 

. 

• 

. . . 

. 

IMMUNIZATIONS: • 

. 

Tetanus/1-1 ' 

• ' 

IOW enza Vaccine 4i.— '-i':407 ' f,1,.i: • ...::,•,:, ,,,, 

-lap A ' .-' 

Pneurnovax 

• 

i is --r 

. `•••',:i- r, -4. .! I 

r• 

.t.' /. 

- At Twin Rix 41 - 7-6 tl a ry 

. ,......- 

Hep 8 ., yi :(i. ,,.. 4 l•ft-A. ... L-7.:- 

' - 1-- . Twin Rix #2 1q11. 0 ,-,,i34,m. : 1 th 

gL , ARIOS-KARTINEZ, MISES ,,•:••

,

$dlTwin Rix #3 9-41(1 ii: fi .' 31D414201155 ,?i ,: A , 

llergle4/Sensiiivities "- , MVA,.,,,o. ir, . . .'4',;, . -' . I 

LAR-MAR-PLT- 011 

Dale Received Date Paroled Dale Received Date Paroled 

'-/./Lo /O 
1 

OREGON DEPARTMENT OF CORRECTIONS 

PHYSICAL EXAMINATION 

DISTANT VISION Cl With yiwithout Glasses R ° 

HEARING y Adequate 1 CI Not Adequate (Spoken voice at 20 feet) 

5_u3JECTIVE 

CURRENT COMPLAINT: IA_ 114_ 

OBJECTIVE 

Make pertinent comments regarding positive findings, correlate with positive history when indicated. 

WNL indicates that the examiner found no clinical evidence of disease or other health condition. 

SYSTEM +HISTORY • EXAMINATION 

I. Integument 

sears 

scalp 

hair 

skin 

nails 

kl5) 

(4/11/1-- 

-.IL HEENT 

head 

eyes 

ears 

nose 

throat/mouth 

1 

III. Lymph Nodes ViPIA--- 

11/, Breasts 

t(//ti— 

V. Lungs/Chest 

_______ZOIAL, 

VI. Cardiae/Circ. 

'E./ 

VII. Abdomen 101—• 

?C•Male CI Female 

Height e (9v*. Weight 

Pulse S B/P _L_/—/A 

Temp 

LAURIOSAvIARTINEZ,MOIsES 

141201.155 

co 12991i pi (/1/R4) 

LAR-MAR-PLI- 202 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 2 of 1130 
Declaration of Steven Shelton, M.D. 

Attachment 1; Page 3 of 100 

Cl Diet/Exercise 

Back Care 

klitelf-Tes eieular Exam 

I:1 Self Breast Exam 

CI Smoking Cessation 

CI Medications 

O Weight Reduction 

p

reammunicable Disease Control 

SYSTEM +HISTORY EXAMINATION 

VIII, Hernia 

ri--k 

IX. GU (Male) 

Penis 

testeskonstum 2/bOt.- 

X. Rectum )70" 

XL GU (Female) 

ESU/ex.ternal 

cervix 

uterus 

actnexa 

X11. Nervous System W1/1--, 

VIII, Othopedic Mit 

XIV. Mental Status /1174— 

AUESSIVISENT 

Wrltc raajo.t diagnocs/probleros on Problem List, 

MAN 

1, Write necessary follow-up on Order Sheet. 

2. Write brief SOAP note in Progress Notes. 

_PATIENT TEACHING COMTLETTD DURING EXAMINATION 

Instructions/Comments 

LAR-MAR-PLT- 182 

t 

Date 

Signature of haaitiortor 

LAURI° S-IVIARTINEZ,MOISES 

14201155 
TRAUMA/ORTHOPEDIC/HOSPITALIZATION 

(Significant Only) 

vg-Pgd l_)1( 

(41 

A ILY _G. /1( )Cf4/5 

/ 2 ) MEDICAL HISTORY 

Check appropriate response. Explain all "yes' answers briefly .g, dale of occurrence or diagnosis, type and length al 

treatment ar prescriptions. 

YES 

1. ArthrItIs n 

2. Eczema/Skin Condition D 

3. Eye disease/Blindness D 

4. Thyroid Trouble • Li 

5, Heart Trouble n 

6. High Blood Pressure 0 

7. Emphysema/Asthma a 

8. Slomech Trouble 0 

9. Hepatitls/Llver Disease 0 

19. Gall Bladder Problem a 

11. Diabetes 0 

12. Kidney/Bladder Problem C 

13. Prostate Trouble n 

14. Rectal Bleeding/Hemorrhoids ID 

15. Epilepsy U 

16. Cancer 0 

17. Blood Disorder ID 

16. HIV 0 

19. STD's 0 

injuries: 

Surgeries: 

Hospitalization: 

COMMENT 

pPelds0 tel-c& 

uriy4___ ty 

/,.. 

114Y 

Ler 14-- 

Enter date received or N! 

MMR Tetanus? 

IMMUNIZATION HISTORY 

Pneurnovax ? • Hep Hep B? TwIfirlx? 

FAMILY HISTORY 

Are any or your relative known to have; 

YES 

1. Arthritis 0 

2. Allergies 0 

3, Anemia 0 

4. Bleeding Tendencies Li L] 

5. Cancer CI 

6. Diabetes 0 

7. Epilepsy CI 

8. Heart Trouble El 

B. Hypertension 0 LI 

10. Mental Illness 0 LI 

11. Other Inherited Disease. 0 LI 

COMMENTS 

ADDITIO 

Is there anythIng else about your health illstolyistains th 

If yes, explain 

AL INFORMATION 

we should be aware of? YesEl NoD 

Idkums_m 

14201155 AR TINEzNoisEs 

LAR-MAR-PLT- 203 

Declaration of Steven Shelton. M.D. 

Attachment 1; Page 4 of 100 
2, Dantal Screening completed Yes® NoD 

3. Are you currently on medications? 

Medications: 

1 „ 

0- 4, 

V OR 

JulENTAL 

STATUS 

SKIN 

P EARANCE CONDITION 

LEVEL OF 

CONSCIOUSNESS 

4ee) 

4. Do you have or have you had any communicabte seases? 

Explain: 

Amount: Last Use: 

5. Alcohol arid drug use; YesD NoD 

Alcohol: Type;_ 

Routine RI Urget 0 0.............. Emergent©

Yeab NoD 

Yes0 Nc0 

.0. up: 

len 

Confused 

DAgitated 

AIT 

mai 

DLInaps 

LIStaggering 

DOth er 

dented A0x3 

EINorrnal Affect 

ElFlat Affect 

DElated 

❑ Fea rful 

❑ Hyper vigilant 

DHallucinating 

0 Deluslonai 

['Incoherent 

Coupe relive 

['Pas-sive 

['Evasive 

DDeirranding 

DAngry 

['Threatening 

1=IComballve 

DAppeers in Pain 

e laxed 

Dela@ NW! at 

❑ Dleheveled 

EIDIrty 

['Body Odor 

['Tremulous 

['Body Deformity 

°Prosthetics 

171Poor Dentition 

Unremarkable 

ElBruises 

['Breaks In Skin 

EIRash 

0 Diaphoretic 

❑ Infestation 

ONeedle Marks 

0Lasions 

IllOther 

1, Do you have any current Illness, Injury, or special health requirements? 

Explain: 

Yes1=1 

Tobacco Type: How much?. 

Drugs; TZ Use 

ow Many Years? 

Last Used. Duration Mode 

f58 OREGON DEPARTMENT OF DEPARTMENT 

MED: RECEIVING SCREENING/MEDICAL HISTO' 

6. Have you had serious withdrawal symptoms (seizures DT's) after slopping drugs UTalco iol? Yes]] 

Expiain: 

Reactions: 62.Nr c)" 

7. ALLERGIES: 

Are you pregnant now? 

Yes No Comments 

0 ❑ 

❑ • I=1 

Data 

Yes© 1400 

a, P 

b, s in Erma 

c. Meno use! 

d, Gyn S 

I.Tubal 

II.Flyst/W 

ili.Pan s hy? 

Iv.0 S 

Pregnancy Hist° 

a G Rendes 

b. 

0, At3lmlacar ages 

d, 

a. t. 

Birth Control Method 

LAURIOS-MARTINEZ,/v1OISUS 

14201.155 

LAR-MAR-PLT- 204 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 5 of 100 
If yes, explain; 

******Okkh*****A**** ickAiriFAA*IFIrkkik**A*********14*******74 

DIS 051 40N 

Mental Health Referral: YesEl N 

Who did you contact? 

111*******.**Ori*****A*********Aft**15*********A***A**Ok 

What tim 

Medical Referral 

Who did you contact? 

Population: 

General popuretio 

/ 6 

Yes0 No 

hal time? 

General pa ulation w/reforral D 

Instructed in accessing health care? Ye Non 

if no, why? 

Date /Time Screened' 

Infirmary 0 

Signature 

Signal 

Signature: 

Irre211, 

41/Pv 

P rade-mar signature 

LAI3RIOS-NIARTINEZ,MOISES 

142411155 

Da to 

Dale: 

MENTAL HEALTH 

1, Have you ever been treated for menial health or emotional problems? Yesp 

if yes. when. why, & where? 

Medication? 

2. Have you been a mental health or suicide risk during Incarceration at DOG facility? YesO N❑ 

If yes, explain? 

3, Have you ever been hospitalized For mental Illness Yes1=1 N 

If yes, where and how long? 

4. Have you ever attempled/consIder suicide? Yes[ No 

If yes, when, why, & how? 

5. Ara you thinking of hurling and/or killing yourself? Yes( j ly 

If yes, explain 

6. Do you feel there Is nothing to look forward to In the Immediate future? (Inmate expressing hopelessness cl/or 

heipissartess7) Yeen N 

]f yea, explain 

7. Was the inmate a medical,-mental health or suicide risk during the Incarceration in the sending institution, andfor 

does the transporting office believed that the Inmate is a medical, mental health or suicide risk now? 

• Yesp Non 

LAR-MAR-PLT- 183 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 6 of 100 
1.-P.-•-•*"“Aprst•-•v•-i9••,•-= -; - • ...•rm - •,•••••• ' • •.=•••*.- --•••• 

•1-A-4a,S.-414r.V.AWV. 

4111 44,5ar'' 

-,N40.5-UrLa•V••°,80; -,•••••••04 g 

k 

-Arowor•• 

fO. 

••"14 

• • •••••••••• • • 

• 

Neg 

12 W ks 

Neg 

Nag 

• 

e 

71! 

hJ I 

28 Wks 

4$ wks36-W 

.48--Wks • 

;48 wks 

24 wks 

32 wks 

Neg 44 wks 

Bocepre 

2 

6 

Treatment-paIve 4 wits-

. .4Wks 

Cirrhstics. 

Null:t4§pOjr*ti 

Peg = Peginterferon 

Rib = Rib2vIrIn 

wks 

6 

- LAOS-MARTINEZ, MOISES 

14201155 

STOPPING RULES/TREATMENT FUTILITY: ]f HCV RNA 1.00 1U/mL at 

inreek 12, or detectable. at any level at week 24, discontinue all 

treatment. It isn't working. 

LAR-MAR-P LT- 013 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 7 of 100 
. Hepatitis C Viral Eradication Treatment Monitoring 

0 Z

?h 

Genotype I or 4 

Genotype 2 or 3 Wk 0 Date 9 C 

Begin Viral Eradication Treatment 

Order CMP, CBC, assessments wkly 

.---,--,—T--c-----

for four weeks 

WWg11 7r ~011ocls___ 

Hepatitis C Genotype: 

Order Medication Therapy, • 

1. Genotypes 1 or 4: If weight >t65.pounds: Ribavin 600 mg p.o. bid x 12 weeks. 

If weight <155 pounds: Ribavin 400 nig p.o. q am. and B00 rrig p.o. q p.m. x 12 weeks 

Genotypes 2 or 3: Ribavirin 400 mg bid x 12 weeks 

2. Pepylated interferon alpha-2a 1130 meg sc evert week x 12 weeks 

Baseline Hepatitis C Quantitative Viral Load for Genotypes 1 and 4: 

Wk 1 I Date 1 Assessment, CBC, CMP J 0 See Chart Notes 

Subjective 

Objective 

Assessment . 

Plan 

Wk 2 Date y Assessment, CBC CMP 1 S- - Cart Notes 

Subjective 40 1 fo_ Pit 

-It Objective 

3kj46 Alt— L__ 

Assessment 

14;(/ I , A 2 

Plan ___ t 'vv. Nsr . z__ reAmiii mi./ 

I rii1 /414 cel 

4. ci 

( zi 

Wk 37 Date 1112 Assessment, Ci3C, CMP • I LI See Chart- to-gates 

Subjective it. b 

" v tfirfr140- .4 ltr-A (it. it41/64 4fier , 114 ,/1 fii7(% 

Objective 

114(1 (A4 - -'oo''' Itk(fl fit _ 

Assessment '\ 

016 of/( rtiori, t4it 0111( r /cult. rem/ 

Plan 

61/ 44. / i\rh(iL ie 4 - 

Date • Assessment CBC CMP 0 ea Chart Notes 

.. 

Subjeclive ii 

WW1_ Pal (11 

Objective (A( f 

Ni aft.._ g) 66Amt c,,rit ct4 

LiV1 -- q 

$E-11'4 i C Ni-, 

evefy 2 weolfor 4 weeks. 

oti ( bi4 

Assessment 

kV t la Nam 

• LAR 

811.41420 

Plan 

Ffin MAun"...] Ilv 

*Order GEC, CMP, assessments 

48 weeks 

24 weeks 

Mani taring: (see reverse) 

LAB; C13G and CMP weekly kir 

.4 weeks then monthly. irstable. -

Best to get lab 24 hot rs before 

dosing Tnterferon. 

TS11: baseline, and at 12 wks 

Viral load: baseline and at 

12 works for Genotype 1 or 4 

HCV RNA WANT (Viral Load); 

Do at baseline and at 12 weeks fox 

Genotypes 1 or 4. Repeat 6 mos. 

atter treatment is complete for all. 

ALT; If over 2 times baseline, 

consider Interferon induced 

anted:mune Hepatitis, consider 

stopping Intraferon therapy. 

Hgb: 

>10• No intervention unless 

symptoms 

8.5-9.9 Decrease Ribavirin by 

200 mg per day or add EPO 

-43.5 Ho td Ribavirin and/or 

add.EPO 

>500 No intervention unless 

symptoms 

250-500 Consider Interferon 

Reduction or add Neupogeu 

<250 Should. bold Interferon 

and/or add Neupagen (sea "Viral 

Eradication. Therapy Guidelines") 

Platelets: • 

>501c No intervention 

25-5010 %Warm reduction. 

<251C. Hold interferon until 

>50IC, then resume at 50% dose 

Directed Physical Exam: 

Do a directed physical exam at 

each visit Respiratory problems 

somewhat cernMon with 

Interferon. Consider Chest X-ray. 

Mental Health: Evaluate fur 

depression, aggression, ding abuse 

at each visit and consult CTS prn. 

OS-MARTINEZ, MOISES 

155 

LAR-MAR-PLT- 019 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 8 of 100 
Wk 6 Date Assessment, C, CMP 

Subjective 

Objective 

Assessment 

Plan - 

Wk 8 Date /0/111( Assessment, CE1C_, CMP 

Subject 01%.,4t,to Lop4i r? u.-141 L 

Objective Ilem,fr kit 

Assessment p LAg 6t Y 111 

See Chart Notes 

P(14 V tz 

Am —0,7 t44, 

Name 

SID# 

... 

Hepatitis C Viral Eradication Treatment Monitoring 

Genotype 1 or 4 48 weeks 

Genotype 2 or 3 24 weeks 

Monitoring: '(see reverse) 

LAB; CBC mad GNP weekl) 

4 weeks then monthly if stab I. 

Best to get lab 24 hours befor 

dosing Interferon_ 

TSEI: baseline, and at 12 wits 

Viral load: baseline and at 

12 weeks for Genotype 1 or 4 

1-1CV RNA QUANT (Viral Lc 

Do at baseline and at 12 weals 

Cpenotypes 1 or 4. Repeat 6 re 

after treatment is complete foi 

ALT: Waver 2 times baseline 

consider late,rferou induced • 

autoimmutte Hepatitis, consid. 

stopping Interferon therapy. 

(„9.4elin 

Plan Li5,. /40_ t.]1), Fliv‘ r(//?, 

(fzv, etrtotitt i ,„f4(4 14ft/16, 

'Order HepC Quarit Viral Load if Genotype -I or 4 in 4 weeks_ 

'Order TSH, CBC, CMP, evaluation in 4 weeks, 

El See Notes 

Zr tX3--tt*"7-- -kuivtro 

eel 

Asessinent7k41 elOrn rarb e (MI\ .k.6,1/( 

Plan If Genotype 1 or 4 Elcontin ontinue Ribavirin and interferon. 

/ 7 NAM: h 00.47 p , 

ickb-1 ('br 44- 

FplWorr dA p) rzrL, - "7- 1,7_-, /HA-- rr 

1/ • 

13(gb: 

>10 No intorvenbion un I 

symptoms 

}decrease Ribavirin I 

200 mg per day or add EP 0 

<8.5 Hold Ribavirin and. I 

add BP0 

ANC: 

>500 No intervention mile: 

symptoms 

250-500 Consider Interfenoo 

Re.ductIon or add Neupogsn 

<250 Should hold Inter Far: 

and/or add Noupogen (see "Vii 

Eradicatioa Therapy Guideline 

Platelets; • 

>50k No intervention 

25-50K Interferon reduction 

25K Hold interferon until 

>50Ic then resume at 50% d 

Date 1) Assessment, CBC, CMP, TSH 

Viral Load (ON) if Genotype .I or 4 

SM44K/7 AA via '70 14 4(/ 

It continuing meds for Genotype 1 or 4, reorder meds for 36 additional we 

* If continuing meds. for Genotype 2 or 3, reorder meds for 12 additional weeks. 

Order CNC, CitillP, evaluation Every 4 weeks for 12 weeks if continuing treatment. 

Wk I Date Assessment, CDC, CMP ❑ See Chart Notes 

Subjective 

14-1/ 

Plan 

PIA/ 

Objective 

e\41 (At_ 

Assessment 

• 1•,-1c_ 

Directed Physical Exam: 

Do a directed physical exam at 

each visit Respiratory Frei:den 

somewhat eornmon with 

Interferon. Ceosiderchest X-r 

Meetat Real4A:, Evaluato for 

depression, aggression, drug ab 

at each visit and consult CTS p; 

LAR-MAR-PLT- 016 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 9 of 100 
Hepatitis. C Viral Eradication Treatment Monitoring 

Wk 20 Date A Assessment CBC, CMP • 

Subjective I) 

0---/. . 4 0 Allr 

(abjectly cy.,.,,millimum'amu,1 i t'fri..3 

Assessment it T 

ill V fri-Pc rt 

Plan 

j./ Pc 01-- c 1 - ,A2 6r Al 71 . ' _ Wk 24 ate 2/441+___Assessment CBC CMP rtiaehart Notes 

Subjective 

Czfrifti. d1 I t1/2 do italri._ 

ObJecilvey 1 

Of- 41 V-qt 6) (14*.e) f 0 kof 

-- 

Assessment 

kt47 Ir4. — ,bt rt 01011(r 

Plan v, Q IA z-- a 

`lf Genotype 2 or 3, stop Pegasys therapy. Recheck HCV Quaint Viral strii; 0 mos. 

''Order CBC, CMP, evaluation Every 4 weeks for 24 weeks if Genotyp 1 or4. 

Wk 28 Date I Assessment, clic, CMP 'I D See Chart Notes 

Subjective 

Objective 

• Assessment 

•----, 

Plan 

Wk 32 Date Assessinent, CRC, CMP MI See Chart Notes 

Subjective 

Objective 

• Assessment 

.._ .: '' - • . . • .... _ 

Plan 

. _LARIOs-ivrA 

14201155 

Genotype 1 or 4 48 weeks 

Genotype 2 or 3 24 weeks 

Monitoring: (see reverse) 

T.A13: CBC and CMP weekly' for 

4 weeks then monthly if stable. 

Best to get lab 24 hews before 

dosing Interferon„ 

'f$H: baseline, and at 12 Ars 

Viral load: baseline and at 

12 weeks for Genotype I or 4 

HMI TANA WANT (Viral Load): 

Do at baseline and at 12 weeks for 

Genotypes I or 4. Repeat 6 mos_ 

after treatment is complete for all, 

ALT: If overt times baseline, 

consider Interferon induced 

autoixnmuae IlepatitLs, consider 

stopping Interferon therapy. 

Hgb: 

>10 No intervention unless 

symptoms 

83-9.9 Decrease kibavirin 6y 

200 mg per day or add EPO 

<8.5 Hold Ribavirin tradior 

add EPO 

ANC: 

>500 No intervention unless 

symptoms 

250-500 Consider Interferon 

Reduction or add Neupogen 

<250 Should hold interferon 

and/or add Neupogen (see "Viral 

Eradication. Therapy Guidelines") 

Platelets: 

>50k No intervention 

25-50K Interferon reduction 

<25IC Hold interferon until 

>50K, tbenresume at 50% dose 

Directed Physical Exam: 

Do a directed physical exam at 

each. visit Respiratory problems 

somewhat common with

Interferon. considei Chest X-rai 

Mental Health: Evaluate for 

depression, aggression, drag abuse 

4-4 each visit and consult CTS pro. 

TIMM, MOISES 

LAR-MAR-PLT- 015 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 10 of 100 
:50 

Oregon Department of Corrections 

Hepatitis C Treatment Progtess Notes 

DATE WEEK # 

AP ,/,.. A, A aJI J -----•—. 

1.-16i/ vr,,,, R 0f _ . c (/ , 

rtr,e\r/t\ AI 

F., . ;:: 60(61 am' 

0:c i.6, IV_ t4,-- e=i,it 

444 iCi fay' 

kiP),, lWv 7,0 1') 7 (5--- . di 

ollta .1 'C't kiwi- ivaym , 41-rt. 

ik--A1-1_. ?q E, oi. 

c _ ) .,„ .... 

1 

L 

. . • 

' ' 0„. rt.. 7.... 014. .; 0.1. ,,:l:' 

gli 1 i . 

•Li . • P6-911*. . 

. 

. . 

.. A 

r 

aid tiiiirAW __ - • . 

A 

 _ .. ...Ammimfbrir* 

LARIOS-MARTINEZ, MOISES 

14201155 

LAR.-MAR-PLT- 136 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 11 of 100 
Hepatitis C Monitoring 

DATE 1 /0-/3-1/ 9- -.)?-- /2-- 

Subjective,) Lette"... pv/r) Xeer, 

Exam /.4..,-Ii4-. figgzo- IQ/ s7r-'2.--.. 

ALT/AST A4 2.7 LAYS C 

Other pertinent lab Vi. -/ 4.0i )-.5./ 2 di.oc.r0 i 6,c.Y.-9 

Possible Medical 

Contraindications or 

Barriers to Treatment with 

Ribavirin and Interferon 

(Check if Pertinent) 

Comments 

0 Major Medical 

0 Major Mental Health 

0 Risk Behavior for 

Hepatitis 

0 No Liver Enzyme 

• Elevation 

0 Time to Serve 

0 Decompensated 

Cirrhosis 

0 Aggressive Behavior 

0 Non-compliance 

0 Liver Biopsy Results 

0 Other 

ac. ee,y) 2-6/ 6 

1:1

rZ 

5- 9-

I b 

0 Major Medical 

0 Major Mental Health 

0 Risk Behavior for 

Hepatitis 

0 No Liver Enzyme 

Elevation 

0 Time to Serve 

0 Decompensated 

Cirrhosis 

0 Aggressive Behavior 

0 Non-compliance 

0 Liv'er Biopsy Results 

0 Other 

b Major Medical 

0 Major Mental-Health 

0 Risk Behavior for 

Hepatitis 

0 No Liver Enzyme 

Elevation 

.0 Time to Serve 

0 Decompensated 

Cirrhosis 

0 Aggressive Behavior 

0 Non-compliance 

0 Liver Biopsy Results 

0 Other 

Interval Change vit pleeeW 

Zi 91' — 96- 00644 , 

Assessment (Are e rt 01. 

160//4--d rr-2z) 

-Plan • . 

7713,142.- 

.... 

e 

See reverse for "Medical Contraindications"' LARIOS-IVIARTINEZ, MOISES Refer to 000C - Health Services "Medical Guidelines for Hepatitis C 1 01155 details ow ongoing monitoring of-patients, who. are Hepatitis C positive. 42, 

LAR-MAR-PLT- 135 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 12 of 1130 
Fle,t_edcitis C Evaluation Worksheet 

Date 

SACZIONScreenika:trkrmigaLt CmvIejeji.*. IL in 30 fin yL s Date 

HCV antibody positive? 324Tes 0 No yati/d 

Time left to serve greater than 12 months? 01 ›& ,g_Yes 

El Yes 

11No 

$No 

1-12.6p 

Hepaiis B surface antigen positive? (If yes, consider pecialty consult/1.11.C.) OVAIA 

HIV positive? (If yes; consider specialty consult/TLC.) D Yes Flo 

Date 

Date 

09 ,Pdo/C) 

ALT Values Baseline Result ArFat,OT; Cr..Vo 

Repeat six months Result Date Repeat 12 months Result 

Repeat 18 months Result 

If baseline ALT is abnormal and patient has 12-18 months 

Genotype fio Date 

to serve, obtain Hepatitis C Genotype. 

If type I or 4, pt needs 18 trona: to if type 2 or 3, 12 months is sufficient to complete treatment and foll ow-up. 

Is patient an appropriate candidate for futher evaluation for possible treatment 

with Interferon and Ribavirin? 

Ifyes, proceed to Sections 2, 3, and 4. If no, give reason. 

12::Yes 0 No 

.. 

__LAILiii. - V 

Signature Date 

.Pules 

1, Refer to ODOC - Health Services "Medical Guidelines for Hepatitis C Evaluation and Treatment" for details 

on the evaluation of patients who are Hepatitis C antibody positive. The instructions that follow are intended as 

2 F611 a 1% II 1%. I • 

2, If a patient's status regarding Hepatitis C has otherwise changed, initiate a new form, 

3. Section 1—Based on patient's medical status and current ODOC Health Services policy/protocol, decide if patient 

De,tds further evaluation for possible liver biopsy and treatment, If the patient has normal ALT or less than 12 months 

sentence to serve, patient generally would not proceed to liver biopsy. Patients who are Hepatitis C antibody positive and 

have normal liver enzymes can generally safely have ALT monitoring only, butt they still should have an initial medical . 

evaluation for the possible presence of liver cirrhosis. 

5. Section 2, 3, and 4 should be completed concurrently, and usually within three months of the date, at the toi‘i of the 

form. Avoid unnecessary delay in determining lithe patient is an appropriate treatment candidate based onmore . 

complete medical information. There are absolute and relative contraindications to treatment with Interferon and ' 

Ribavirin. (See "Medical Guidelines for Hepatitis C Evaluation and Treatment".) History, examination, and 

laboratory evaluation should help to determine if these exist or not. 

6, Section 5—Make a decision about the appropriateness of proceeding to liver biopsy and treatment for this patient 

based on current medical information. Generally you should be able to make this decision-within foufncionths oftlie date 

at the top of the form. If you are undecided because you need mare information, you may defer biopsy, but always 

document your clinical decision making process if you are not proceeding to Section 6, 

7. If, after completing sections 2, 3, 4, and 5, you consider your patient appropriate medically to proceed to liver biopsy, 

proceed to section 6. Bring all clinical information to TLC meetings for consideration by the committee. 

8. If, after completing sections 2, 3,4, and 5, there are medical or other contrainc LARIOS-MARTINEZ, MOISES 

already occurred, the patient should be followed clinically. Monitor patient at le SID#14201155 

(See form "Hepatitis C Monitoring",) D013 

LAR-IVIAR-PLT- 062 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 13 of 100 
SECTION 2 Further Medical Evaluation ' Date 

Directed History and Exam shows evidence of serious hepatic illness. 0 Yes - 

0 Yes 

i 

VI:-No 

ANo 

0 V/6 

/ 

2" A 

E vidence of decompeasated liver disease or clinical evidence of cirr osis, e.g., asi ( lf41144 es, 

history of hepatic ericephap6atlay, history of espitageal var.p4, etc. 

HIV/AIDS (IIW Ab positive)? 0 Yes A No 99- o 

Hepatitis B surface antigen positive? ,...-• No ," 0 Yes r. o i • 

Major Medical Illness poorly controlled, e.g. Diabetes, ASC ri, gins, CCP , 

Thyroid, Mental Health issues, Cancer, Anton:nu:lune Disorder, etc. Explain. 

C) '1)0 )10 130 

0 Yes 0 No 

Lab Evaluation (Do CBC, Metabolic Profile, 1NR, TSH, A, HIV testing). Any 

significant Abn6aliti. r • am. Pl4PA,6 2-9 

gYcs 0 No 

. 

. 6 (b 

t'irr 

a-CLIA),- 7 gil-s OveV,A.„fc__I.D 

SE'CTION 3 ilfental Health Considerntio s Date 

IMajor mental illness • • orly controlled? Cl Yes 13 No ,00 /13 

Evidence or history of suicide ideation and/or suicide attempt? 0-Yes 5;'No 

History of severe psychiatric disorder? 0 Yes g No 

CTS referral for evaluation indicated/ordered? 0 Yes IlL"No 

Recent aggressive behavior problems? 0 Yes lil No 

SECTION 4 Other Concerns D to 

Evidence of concerns with risk behaviors? 0 Yes 2F-No 06 

Evidence of non-compliance with treatment or evaluations? El Yes ya No 

Patient refused to sign contract? • 0 Yes 0 No 

Specialty Consult Needed_? Explain If &tined_ note results _ n Yes 1-1 No 

0 C 10.0,2' f - , (e.4.4 

Other Co ;corns? Explain. If --rdQ c4.,,,,,,_ .41 11- 

r Ty:. rt\A 0 i ,144 k\ 

6%.0 

0 Yes 0 No 

SECTION S Clinical Decision makin Cam lete within 120 dud Date 

Is patient an appropriate candidate for possible liver biopsy and treatment with Interferon 0 Yes ❑ No 

and Ribavirin? 

I YES roceed to Section 6--Bio and Treatment 

If patient is not an appropriate candidate at this time for liver biopsy and treatment, give reason: 

,_12:rsseatoliitisConitorii _t1-1 

fi.tICY,BioatLIireateni Date 

Liver biopsy approved? A Yes IJ No 

Liver biopsy results f0b(airr results within 180 dors) 

r _Yes El No 

/0/ i', 

0 JO 

Grade /3 iStage 1_, 

Genotype Results .. i 6 .. . (If not already done) 

Liver biopsy results to TLC 

Treatment with Ribavirin and Interferon approved by TLC? If yes, proceed to treatment. 

See "Treatment Monitoring" Form 

If no, proceed to "Hepatitis C Monitoring" 

0 Yes KNO 

' /C/1 ) 37/6 

HCV RNA results (Viral Load—Quantitative) 

LARIOS-MMITINEZ, MOISES 

• 14201155 

LAR-MAR-PLT- 053 

Declaration of Steven Shelton. M.D. 

Attachment 1; Page 14 of 100 
init71.1 1-3 v 1 . 

k r -• 1 • -r. •L ia fP 4V13 P31, .1., V.V%I 7 ..t.,:11);-Aq..1.,,15.il'ip4..1 

Fiep A V1S_Z:ADD L.) 4 A= •vr•rw5 pr . _ 2:?',. ,_ 

1 1.,, .I. .4 - - . 'Ar. Vt - -4.• IV "..- ' i ' - :.V.;"...t:VgS*1-6-ig)W.N:.;:'-_e. l

-Ffrf , ,J 0.%: 'if 5.1.'11•11, . 

Person getting I 

3hots The questions below will help us deeicle,which vaccines may be given today. If you need help 

with these questions, please ask the clinic staff to help you. 

• - D ate . 2. --:2 -16 yps 

NO 

1. Is the client Kiri' today? . 

. . 

2. Has the client had a bad reaction to a vaccine in the past?' . 

3. Has the client had a seizure or a brain problem? 

4. Does the client have cancer, leolermia, AIDS or other jzninnoe system problems? •- 

5. Has the client taken cornserne,predulsone or other steroids, anticancer or had x-ray 

treatinellt in the past 3 monthei 

b. Has the client received any blood or brood products, or been given a medicine 

called numorie (gamma) 0.obidin in the pas-t year? 

7. Is the client pregnant or is there a chance she,could become pregnant within the next month? 

8. Has the client received any vaccines in the past 4 weeks? 

9. Does the client have allergies to medicines, foods, latex ox vaccines? 4e . - k-: 

tr ri r - , ...". 

%Ltd 

. 4,-. A, . . ...., “Li .„ • . 

10. Has. the client bad a fainting episode with injections in the past? 

L' .,•.S. .4..7 rt ./.....,11-10A,-,744,004 UV W.V1..nOz.t.ithetcr,tkt .0.61.,,,r1--iNrg14.M.L.141.-`,,N1, .1'. .... :r,,•_.., f., XM •........}. ,I 

Dose - - -, - - - • - ., , ,.. .... , --1 Flui4 ,-, '0 1.-J I ell..31..} I 

The questions below will help us decide which vaccines may be given ronay. If you need 

with these questions, please ask the clinic staff to help you. Elate 

help Person getting 

Shots 

YES NO 

1. Is the client sick today? lit d 0 4.----- 

2. Has the client had a bad reaction to a vaccine in thepa.st? 

—.-•-". 

...---". 

3. Has the client bad a seizure or a brain problem? 

4. Does the client have cancer, leukemia, AIDS or other immune system problems? 

S. Has the client taken 

I:m

cortisone.,,prednisone or other steroids, anticancer,drogs, or had x-ray 

ufti:mut m the .ast 3 months! 

1 1 I C C cut Emery I any t Ong or I_ OD Pali uqs, or i - n given a ril cum 

called immune (gamma) go inlin in the past- year? ,"-- 

,../ 7 7. Is the client pregnant or is there a chance she could become pregnant within the next month? 

S. Has the client received any vaccines in the past 4 wee.lcs? / 

P41‘-i 

---- 

9. DoeS the client have allergies to medicines, foods, latex, or vaccines? k 

to, Has the client bad a fainting episode with injections iia the past?- r ./. 

•••-• 1 I, • • r .• • • ••• • •11 A rArl •,--i-••••••I•11", 

The tinesUons below will help us decide which vaccines may be given today. If you nee help 

with these questions, please ask the clinic staff to help you. Dateil i 

I -7(11 

Pcrsop getting 

Shots 

YES 

. 

NCY I 

i•-'-'-- 

1. Is the client sick today? 

2. Has the client had a bad reaction to a vaccine in the past? 1...-- 

3. Has the client had a seizure at a brain problem? ' 

4. Does the client have cancer, leukemia, AIDS or other immune system problems? 

5: Ras- the_cliPpt falotn r CIALSOLIZ 0 or other steroids, anticancer dpiga, or had x-ray 

a 

.

treatment in the past 3 m onths , 

6. -Has 0 CHentreceived any blond pr blood products, or been given a medicine - 

$xoniune (gam:* globuhn in the, pasl year? ...---- 

7. Is the client pregnant or is there a chance she could become pregnant within the next month? 

B. Has the client received any vaccines in the past 4 weeks? 

9. Does the client have allergies to medicines, foods, latex or vaccines? ..." 

LAR-MAR-PLT- 180 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 15 of 100 

EZ, MOISES 

Ouse 
Attachment.' 

P&P P-D-01.1 

Oregon Department of Corrections 

• Health Services Section 

Non Formulary Medication Eiception Request 

Please fill out ail entries, incomplete forms will not be processed. This order form nmyt be 

filled out and signed by.the practitioner and Designated Reviewer at each Institution. The 

request Is valid for the duration of the order. 

Medication: 

ILLAA fal i41 z2., 4 ' Aii:di.i' ' ii..ark 

0x for which tined is required: 1 t 

Reasons Formulary Medication not used: 

Date: Of ..2(? Provider Signature: 01, Ip• mt. 

URGENT NEED: CI < 24 hrs tk(.< 7.days 

Comments: 

Reviewer Signature; Date; 

To Med Review Committee: yes Li no • 

Medication Review Committee ornments• 

Ji 

Approved: Vis. yes For, (-)1' i on hs 1:1 no 

_ 

Signatunks:--2 Date: o' 

. 

.--------- 

LetlilOSIYIARTINEZ, 

14201155 

LAR-MAR-PLT- 020 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 16 of 100 
11) Oregon Depurtmeat Of Comedians 

licath- Seivices Division 

Non You:Wary Medication Exception Request 

Please fill out all entries. Ilictthapkte ferms wild not Be processed. 

• rltls orderforns must, befitted out Ond sighed by ftre Practitioner & .Designoted 

Revkiffer at Each Iitstlturlarr, . The qqiiest is wailer the dziratiotIsDhe order. 

INSTITUTION: S 

Medication: '0 k 'AN 

ed is r nested: 

._ __ for . 

c.. . a 71 y,04: 

Reasons Formulary Medication not used: ,./0- • - 

-,--, 

. 

. . 

Provider Signature: ,--7 4:_____) . 

.Date; 3-30.-,11 

URGENT NEED: . 0 < 2.e1lart: CI <7 days • 

Comments: . 

.. 

• 

. 

. . 

. - 

. • 

- 

Reviewer Signature: Date: 

to Med.Review Committee: ,0 yes U no . 

, 

• Would you like to see this added to the formulary? 0 yes no 

Medication Review Committee CoMments: . 

7?-11'')' ''''. bi---00- 111— Ce.../tvi 054. 

• _ 

Approved:, ' yes '• For _months T 0 no . . '.. 

Signatures: i-- Date I 

t..71 . 

Inmate Name 

rip S --- x, 

Sid 

LAR-MAR-PLT- 046 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 17 of 100 

.62Y 
ALLERGIES- 1 -L/1; 

SEND DUPLICATE TO PHARMACY 

INST. DNS 1:1 NAME: (kir t 65,fri DATE & TIME 

~ya 0 f/SS- ni1C0 042.5- 

ALLERGIES: 0.ti 

SEND DUPLICATE TO PHARMACY 

DNS El 

1-112-0 1/55 

LAR109.NiAR TINEZ, M0rSEt Slcq 14281166 

GAM'S PFS- 180itiC0/0.51§1L INJ 0 

JECT gONICo su actJ TANEOUsLY 

\ EVERY WEEK - CONTROL BY STAFF 

START: MVO STOP: 07/3 e 

[Antos-MARTINEZ, MOIset SID: 14201166 

PEGASYS PFS- 180151CM.5ML IA) 0 0 

DC1ED MED - 529614-0 

START: waits DC Oat 6: evisnots 

613 Z. Obi\ 

13L AlLet r 

t. • 

: 

• 

OREGON DEPARTMENT OF CORP,E.CTIONS 

PHYSICIAN'S ORDERS 

NAM Ecty-i DATE & TIME INST. 

/ 2 i "11.1,2. 

DNS n 

ALLERGIES: .76 

SEND DU PLICATE TO PHARMACY 

DNS El NAME:L DATE & TIME INST. 

ALLERGIES: 1.41 

SEND DUPLICATE TO PHARMAC 

Alf orders for schedule II and III meclication.will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 120 

Declaration of Steven Shelton. M.D. 

Attachment 1; Page 18 of 100 
DNS 1:1 i\iME: A2-103:- tiPiArvNo.,Ieu-vivE wi3 INST. 

--- 

SEND DUPLICATE TO PHARMACY 

OREGON DEPARTMENT OF CORREC1Ns 

PHYSICIAN'S ORDERS 

rc)' 

ALLERGIL

4

S: 

SEND DUPLICATE TO PHARMACY 

LAnlas-MARTS.Mz, 

310: 1 it 6 4 vvkj Y'o 

PEGASYS PFS- 1SONICGIE661,,IL a 

DC'ED MED - 519142-1 

DC Ono: 0103/2013 

ALLERGIES: 

// 

INST. DNS NAME: LARIOS-MARTINEZ, mcISEE &so; 142)I15G 

PKAsYS PFS- 1130MCG/0.5ML /NJ 0 (Fe 

135MCG EVERY WEEK- CONTROL 

STAFF 

sTANT: 01/23113 

START:. 12155.113 

stop: 07/31/1-6 

Drv-t---coeLeiCM2NLA-NE 1 

)1_)-7, 

DNS 1:1 

br6L44_ .r i ODE_ 

a, 

ALLERGIES:- 

SEND DUPLICATE TO PHARMACY 

IMEci „Sil_f_./ DNS 11 

LARI0S-MARTINEZ, MOISE£ 14201166 

OMEPRAZOLEA- 20M0 CAP IPRILOsSe) 

TAKE 1 CAPSULE ORALLY ONCE DAILY 

- OK IN CELL 

START: Mil 1113 STOP: 01tt1114 

0 PHARMACY \\ 

LA:flys-MARTINEZ, MOISEf SID: 14201166 

BISMUTH TAES-(PEPTO SOMALI 262M0 TAE 

TAKE 2 TABLETS ORALLY (524MG) 8Y 

'MOUTH 4 TIMES DAILY - OK IN CELL 

STA911' 01ntri aToP: 01/11/14 

- LARt0S-MARNNEz, 3I1a: 1120110 

WHITE PETROLATUM- Va,VAsELINR) 490M (% 

APPLY TO AFFECTED AREAS) ONCE 

DAILY - OK IN CELL 

START: 01111 STOP: 071.104113 

LERGIES: 

SEND DUPLICA 

All orders for schedule ll and Ill medication will be automatically st‘ippi=u 111 11 

LAR-MAR-PLT- 122 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 19 of 100 
START:OWM PC Oat*: 12.01312012 

INST. DN El 

LARIOSMARVIEZ. MOISEt SID: mom& 

SALINE^ NASAL SPRAY- OA% 451AL SPR (1 

USE i SPRAY INTO EACH NOSTRIL 4 

arders for schedule II and TIMES DAILY- OK IN CELL 

START: 12422112 STOP: 12/06:112 

I-AMOS-MARTINEZ, MOISEt 210: 14201166 

PEGASYS PPS- iSOMCG(0.5ML NJ 0 12 

135MCG SUBCUTANEOUSLY EVERY 

WEEK- CONTROL BY STAFF 

ART: 12/26f12 rroP: 034210112 

ALL 

• c..e.N.) 

OREGON DEPARTMENT OF CORRECTIONS 

PHYSICIAN'S ORDERS 

NAM E:i...ctei '0-5"tr.ir i ATE &TIME i)--7A0/ 

ft A-4261151C /'146 (3` 

ALLERGIEVCA) 

SEND DUPLICATE TO PHARMACY" 

LARIOS-MARTINEZ, Moisu SO714201164 

BISMUTH TABS-(Perto eismAL) 202MG TAE 

TAKE 2 TABLETS ORALLY (524MG) BY 

MOUTH 4 TIMES DAILY - °KIN CELL 

STARTt 1240012 MA: T2/30112 

LARIos-mARTINEZ, Mops so; 14201106 COXYCYCLINBA- Nye lama TAG (vuliRATAI 

TAKE 1 TABLET ORALLY TWICE DAILY 01( IN CELL 

armyt T212011* 

STOP :12/S0/12 

ALLERGIES: (-(0 

SEND DUPLICfAI h 10 PHARMACY 

LARIGEWARTINEZ, MOISEE 210: 24201166 

METRCIIIBAZ0LEA- (GEN FLAGYL) sos MG 

TAKE 1 TABLET ORALLY TWICE DAILY 

01( IN CELL 

START: 12120112 'SOP: 11030112 

-LARIOSMARTINE2, moisEi 210: 1001166 

_ CLARITHROSIVCINA- (GEN SlAxiN) 501040 

i TAKE 1 TABLET ORALLY BY MOUTH 

- TWICE DAILY- OK IN CEL L 

START: 12120112 ATOP: 1230/12 

NAME: DATE & TIME 

Mti /5-4'5 

NAME: /-6.,x'1 U5•' Ma. e /rive? DATE & TIME 

/We)11 e 

INST, dew DNS El 

uvuos-mmhNEz, MOISEE SID: 14201166 

OMEPRA2OLEA". (GEN PRLOSEC) 40MG CAP 

TAKE 1 CAPSULE ORALLY ONCE DAILY 

- OK IN CELL. 

START: 12/15112 STOP:12/13112 

t. AA] osNASTtNEL ',AMU 8101 i4141166 

NAP RoXENNGEN NAPR °SYR) 500M4 TAB 0 

DOSED MED - 481957-3 

START' OSO2It2 IIC 0414:12/13/2012 

ALLERGIES: 

LArlios•21ARTIV2', wises 0101 14101166 

OrdE AZOLE"- 20 MG CAP (PR1LCSEC)@ 

DC'ED MED - 504897-1 

 LARIOS4BARTINEZ, MO1SES 8H:2: 14202166 

NASUNIETONENGEN REI.AF N) 760MG TAS 

TAKE 1 TABLET ORALLY BY MOUTH 

TWICE DAILY- 01( IN CELL 

!TART: 12/11/12 sToP112113113 

t-242; 

SEND DUPLICATE [ 0 PHARMACY 

NAME: LA,/ tir/t,'ra DATE & TIME nitfli 

0J/0— MO (1; c-=:• 

F/4\40,, 

INST. DNS 01 

AALAR las-MARTINEZ, MGISES 818; 14001161 

oNDANSETRONIGEN ZGFRAN) 4MG rAB 

TAKE i TABLET ORALLY BY MOti H 

TWICE DAILY- OK IN CELL 

START: /2/06/12 STOP; 03/27/13 

LARRA.RIARTiNEz, mompt 012: 14261166 

f.EGAsys PPS- 180141CO/OAL INJ 0 

-DC'ED MED"- 515836-0 

— op IWO: t2106/2012 

0( 

"k v,64(_ tzot - 

atically Mopped in 72 hours, 

LAR-MAR-PLT- 125 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 20 of 100 
7P9-1 4).vi 

4/I, /ixf _..„,e,•1 DATE &TIME 

I 

D

Ts

v 

LARIOIARTINEZ, MolsEE 810: 14201166 

/c-rSTART: 11/16/12 STOP: 07/31//3 

SEND DUPLICATE TO PHARMACY 

„,7_,.•.7 DATE & TIME 

 jk INST. 1 

ttliu 

DNS 171 

o2O 

F EGON DEPARTMENT OF CORRECTIONS 

PHYSICIAN'S ORDER 

PEGASY0 PFS-100MC0101.5ML INJ 0 

INJECT 1130MC0 BUBCuTANEOUSLY EVERY WEER 

STARTING 916h2 - CONTRaL BY STAFF 

LAMAS-MARINER, 1v1010E$ SO: 1001166 

VVHITR PETROLATUM- ('VASELINE) 49GM 

APPLY TO AFFECTED ARENS) ONCE DAILY- OK IN CELL STARTS 10731112 STOP: 1973093 

ALLERGIES: FED 

SEND DUPLICATE TO PHARMACY 

INST. SLR DNS 171 

ALLERGIES: fr/e.,/ I 

SEND DUPLICATE TO PHARMACY 

NAME: z`4,9,-,- /416/2X/Aet2 

DATE & TIME I6 

64,) 

NAME:Z4y.61,5,_ DATE & TIME I6 

/ c // Cki6 C/f o'/Icf" Q 

1 

LARIOS•MARTINEZ, morsm 6.10: 14201146 

bEGASYS FPS- 7a0MCGM.SMI, NJ 0 g 

NJECT 16014C0 SUBCUTANEOUSLY EVERY WEER 

STARTING 5/5/12 • CONTROL BY STAFF 

NST, DNS LI 

LARlos.MARTINEz, mos g NI 2161164 

ICTRELIS (00CEREVIR) (20X12) 200MG CA 

rAKE 4 TABLETS 800MG BY MOUTH QS 

----OURS- CONTROL BY STAFF 

START: 10110112 STOP: 00t27i13 

LAMS-MARTINEZ, MOJSEi 89); 14293166 

klBAVIRINA-(GEN COPROUS)200M0 TAB {CC 

f AXE 3 TABLETS ORALLY (Boomoi SY 1.40LiTH 

ALLERGIES: A? START: 101(38/32 STOP:69,20m 

SEND DUPLICATE TO PHARMACY 

(VOCE BAIL,/ STARTING 0/6/12 CONTROL RV 

STOP; 02/27113 

STAFF sTAn :10,00102 

••••••261. 

All orders for schedule II and Ill medication will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 126 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 21 of 100 

INST, ow; 11 

reff 

011-MABTIN621 MOISES SKI: 94241166 

RIRAVIRIN^-(GEN COPEOus)200m0 TAB (a 

TARE 3 TABLETS ORALLY Immo) BY MOUTti 

TWICE DAILY STARTING 015/I - CoNTROL BY 

STAFF 

sun 11/16112 STOP: 01007113 

LAR -MAETINNZ, M013E5 SID: 1420116E 

VicTrdus (BOcEpREVIR) (28X12) 200M0 CA 

TAKE 4 CAPSULES ORALLY (NOW) BY 

HIOUTI-1Q13 1-101.1RS CONTROL BY STAFF 

START: 11336112 STOP; 06/22/19 

CLERGIES

:r46./ 
SEND DUPLICATE TO HARMACY 

SEND DUPLICATE TO PHARMACY 

NAME:lAwba, O

R

ATE &TIIVIE/74-1 2ytio INST9 DNS 17I 

// c) //..5 6

V

fika /0/A/ 

769/2`-1 i 4/kh‘ (-1) 

3fit it 

V r(4 

All orders for schedule II and Ill medication will ho automatically stopped in 72 hours. 

LAR-MAR-PLT- 127 

Declaration of Steven Shelton, M.D. 

Attachment 1: Page 22 of 100 

41> 

ALLERGIES: 

C)IT{ DEPARTMENT OF CORRECTIONS 

PHYSICIAN'S ORDERS 

NAME:Z # e? _ ,me i. t, DATE & TIME 

r iif INST. DNS 

ALLERGIES: Ile 

SEND DUPLICATE TO PHARMACY 

NAME: I 

NAME; as .14/a.4444s xel.../ DATE & TIME 

1A /L/ 2-0/t G. Or h 

Oniu

56 

s461011102, triOksti 

%v. 140ii 

owlEPRA101- 

206AG GAF ;,r1116.-0SEC4 

-T 0 A1( cp,psuix.

o0oE oNtY 

-0. cat. 

Aim 

• 

(howl 

0

,03S-MARTIATEX,POsm 

SW' 

INsT, DNS 

BACITRAcIN OPVITH. 1761-1.- 3.6 GNI 0 M 

APPLY 10 AFFV_CTEO ARMS) NAKEs 

VINIcE 

- COOT ROL 4V sTAv5 

strait Val3fiR 

STOP: 1011011t 

4 

ALL RGIES: 

V() 

SEND DUPLICATE TO PHARMACY 

ft... /DATE& TIIVIE —1 

2 r... 

INST. LS DNS El 

ALLERGIES: (Et/ 
NAME: mar4_1_ 4_,c DATE & TIME NS :. DN36 

NAME: Jr_ing 1-y-) DATE & TIME 

4 

DNS rii 

5ce-P60t.l< 

f4 V (i ( 

SEND DUPLICATE TO PHARMACY 

All orders for schedule II and III medication will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 128 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 23 of 100 

)ax 

OREGON DEPARTMENT OF CORRECTIONS 

PHYSICIAN'S ORDERS 

qa I 1 6-6 — trees 

LARK3S-MARTINET, MOISEF alo: IOM'S& 

- CALCIUM 600MGMT D AOOIUA^ TAB 103CA) 

TAKE I TABLET ORALLY 3 TIME-5 

- DAILY - OK IN CELL 

- aTARI OMariA %TOP: intirsMa 

ALLERGIES: pc,,_.?\4_ 

SEND DUPLICATE TO PHARMACY 

74:14ftlpsto NAME INST. DNS 1:1 

: .0S '--- DATE & TiiVE ni vEAmoose 

k--r-z--/AFtEA6$ 

LAR1OS-MARTINEZ, MOISge SIO: 14201165 

CUTIRIZINEA -IGEN ZyRin) EWMO TAB (Mil 

TAKE 1 TABLET ORALLY ONCE DAILY -

OK IN CELL 

START; Cleig.fi2 STOP: 6910.113 

ALLERGIES: pc, 1,_(_ 

TS ORALLY F9Y rvO 

714.10E SfARMIG 4/5/12- CM:42.ft 

ar

UTP-1 

prARr nykti.Y 

:osvactriZ 

Sri IXY/2413 

icts•INFITINEz, 410/8E$ RiSAVAito 20042 rite oa 

FAKE 9 raatE min.; 1420,1" 

ia0hiceSORcUTANE0LISLY EVERY WEEK 

STARTING 9:161 12 - CONTROL RY STAFF 

ATARI: OfiniV12 gi0Pr 0119119 • .• 

LARIO 944At Ti FIEZ. M018 ES V PD: N ICE DAR, y FECTE0 1165 - 454

SIAM RFS- CELL 

, Meamotli. INJ @ 

arop:03,4wo 

AP°1-Y TOPICALLY l'O 1"")11)" 

$0. $4241/66 

MCNVOL 

SEND DUPLICATE TO PHARMACY 

-XII Lz Afro( 1 IN IQ, %,(1/411 oj k9c--r ---I\4\: f.M izi_ief- "(0 ,l(2)-7 

4(4c Tr ils ' 4-. vi IT 4- 2I-1 I 

)i\, (0/I 0 Z 1,6< 4)4 i_i . , i i`f ( V i 1 LOA 1 NTAL ERGIES: C-P4- 

r. L,D. kr, 1,1 11,1 Id"-• A-Y1-. -C.^ ra_i A OIL An..--.`61 • 6 /1? 

CR Orb' ik/ 

DNS El 

ALLERGIES: 1_1(1

1V 
17171/41VIEIANgs,.._Max rAtjacDATE & TIME ,Y- INST. 

OREGON DEPARTMENT OF CORRECTIONS 

PHYSICIAN'S ORDERS 

NAME: s fvu,y,0pATE& TIM 

55 7- 

ALLERGIES: 

SEND DUPLiCATE 10 PHARMACY . 

MA-OWE & TIME gr 2. ad INST.S0---/ 

,evrtite,-)I D >cr77-)604-. 

NAME: 

141(9011fxe 

DNS CI 

ALLERGIES: pcx\ 

SEND DUPLICATE TO PHARMACY 

NAME 

# 144P-01 26 

ALLERGIES: r).. 

I" l-1] 

SEND DUPLICATE TO PHARMACY 

(4---02,04 vt-2y-triA 

ALLERGIES: "),. V\ 

SEND DUPLICATE TO PHARMACY 

'AA 

All orders for schedule H and III medication will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 129 

Declaration of Steven Shelton, M.D. 

Attachment 1: Page 24 of 100 

TyktiotoDATE & TIME f -1 p7/3 INST.. DNS El 

7_ Lu--114 if /.-4 S ÷ 6 odA4 

(12., 2- s I 31, a g 61--P-)i) ,K; 7C 71165 (-U 

DNS El 
4 

ALLERGIES: 

NAME.: DATE & - )--L-&-.5c, INS DNS in 0 

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ic) 

ALLERGIES:f 

SEND DUPLICATE TO P ARMACY 

a DA, • 

NAME: NST. DNS n 

tn. AI DATE & TIME 

# 

ALLERGIES: 

OREGON DEPARTMENT OF CORRECTIONS 

PHYSICIAN'S ORDERS 

NAMEz i 6Saur,¢2 DATE & TIME J. )2__ /.(' DNS 11 

# 1. 5 d VNS 

SEND DUPLICATE TO PHARMACY 

NAME: ei iLs (,2, DATE & TIME , z_ INSTS6z.e.--/ DNS CI 

# I 

-n-e_ 

ALLERGIES: 's• ,k/ 

SEND DUPLICATF TO Ph lAHMACY 

SEND DUPLICATE TO PHARMACY 

All corciel for schedule II and III medication will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 130 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 25 of 100 
OREGON DEPARTMENT OF CORRECTIONS 

NAME: • DNS n toY 08 neil DATE & r-) ,7--- 2 ,7,- 711\IST. 

SEND DUPLICATE PHARMACY 

NAME: taro & . nricv,h .42_ 1( INST, DNS 1, DATE & TIM 

N2,;1,S rnbiso,,S 

PHYSIUAN'S ORDERS 

) 

SEND DUPLICATE TO PHARMACY 

NAry 'DATE & TIME4. Vs 1 DNS ri 

0107- fiC 

ALLERGIES:---pr..".) 

NAME: I NISTS?) C DNS r 

SEND DUPLICATE TO PHARMACY 

DATE & TIME y 4k3c, 

rifri61 

vitip /re_t_ „vs 7.$o •taimi 

SO-7 IY-5 y 3 rk-ns; 

ALLERGIESrr-pzi 

SEND DUPLICATE TO PHARMACY 

All orders for schedule II and III medication will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 028 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 26 of 100 
" t• CA -• • L. ALLERGIES: 

NAME DNS ti. - 6 iii.-km2Th UUuici DATE & TIME 2. INST. 

NAMEWAYinS •tqcuckVei, 

DATE & TIME g 3 4,.1 NS1:80:5" DNS im 

ALLERGIES: - 

SEND DUPLICATE TO PHARMACY 

f_ er ,yik 7---k cyrq-4. r

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All orders for schedule II and 111 medication will be automatically stopped in 72 hours. 

r, I-1 .4 071-1 1.7 JO ": 

LAR-MAR-131,1-- 132 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 27 of 100 

C. 

OREGON DEPARTMENT ()F CORHECTIONS 

PHYSICIAN'S ORDERS 

NAMES (Liroi y,titu) Hof LiS 

.# HZ° (155. 

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ALLERGIES' . ' 0, NI 

SEND DUPLICATE TO PHARMACY 

DATE & TIME g —1.), INSTsoci DNS D 

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1. 

ALLERGIES: k: 

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NAME: 1-.6 

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io 

ALLERGIES 

OREGON DEPARTMENT OF cc RREcTIoNs 

PHYSICIAN'S ORDERS 

NAME: 1115_almitirti.z._ DATE & TIME Is--/j /6 INST.sp.c / DNS CI 

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SEND DuptIcATE TO ACY 

NAME: DATE & TIME k) /10 sz INST. aq DNS I:1 

00.- AA f 

SEND DU PL IcAI 0 PHARMACY 

All orders for schedule it and III medication will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 170 

Declaration of Steven Shelton. M.D. 

Attachment 1; Page 28 of 100 
0.7Y., 1" 

NAME: DATE & TIME 

/ 1-1 III 

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SEND DUPLICAI CTIMELARMACY 

cil-rA-u\x-itiL Ecis 

ALLE IES: 

SEND DUPLICATE TO PHARMACY 

— C-IAZUL/ 

0 s 

OREGON DEPARTMENT OF CORRECTIONS 

PHYSICIAN'S OR ERS 

NAME: DATE & TIME /0_f 7–id )67.vd INST. ,s-Aq DNS 

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All orders for schedule II and III m dication will be automatically stopped in 72 hours. 

LARMAR-PLT- 052 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 29 of 100 
Declaration of Steven Shelton. M.D. 

Attachment 1; Page 30 of 100 

OREGON DEPARTMENT OF CORRECTIONS 

PHYSiCIAWS ORDERS 

NAME: jAirki0S- irw-ci.,_1(6/,, DATE & TIME Oft 

ti 4'110 r-6 tYi iS4-'6 

ukv—ik 

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All orders for schedule n and 1II medication Will ha automatically stopped in 72 hours. 

LAR-MAR-PLT- 061 

ALLERGIES:pc to 

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SEND DUPLICATE TO PHARMAC 

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PHYSICIAN'S ORDERS 

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SEND DUPLICATE TO PHARMACY 

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SEND ritipl tCATE TO PHARMACY 

All orders for schedule If and III medication will be automatically stopped in 72 hours. 

LAR-MAR-PLT- 200 • 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 31 of 100 
A PP--' ( Via +.,1,41NS-7- 

ALLERGIES: fir 

SEND DUPLICATE TO' HARMACY 

J '2 3 

0ItLC•,ONI D7PARTMNT OF CORRLCTIONS 

PHYSIMAN'S ORDERS 

NAME: r 1 DATE & TIME L_Ln DNsT5 

SEND DUPLICATE TO PHARMACY 

Mr 

SEND DUPLICATE TO PHARMACY 

NAME: Larri6S-gaihrileil DATE & TIME h s I Mi,) I)) 0 INST., je_ci DNS El 

NAME: Lac, i y z DATE & TIME c ,33 coINST DNS CI 

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All orders for schedule It and III medication will be automatically stopped in 72 hours. 

CD 497H (2/9.- 

LAR-MAR-PLT- 199 

Declaration of Steven Shelton, M.D. 

Attachment 1: Page 32 of 100 

V 11.3ie 

jp I 6-111 1 

SEND DUPLICATE TO PHARMACY 
/15 

Oregon Department of Corrections 

Progress Notes 

DATE TIME PROBN 

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---- 

LARIOS-MARTINEZ, MOISES 

14201155 

95H (124i 

LAR-MAR-PLT- 121 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 33 of 100 
Oregon Department of Corrections 

Progress Notes 

DATE TIME PROB.# 

SRC-13378 • 

ba ci:Alj 

NAME 

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1424l LATHOS-MARTINEZ, MOSES ss' 

(1:1-1:-/) 

LAR-MAR-PLT- 224 

Declaration of Steven Shelton. M.D. 

Attachment 1;Page 34 of 100 
I 

DATE TIME PROM 

Oregon Department of Corrections 

Progress Notes 

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MOISES ____,. 

-At P 4 th— R, / 7 LARIOS-IVIARTINEZ, 

Allergy_____ 14201155 

CO 495E1(124 

LAR-MAR-PLT- 133 

Declaration of Steven Shelton, M.D. 

Attachment 1: Page 35 of 100 
LARIOS-MARTINEZ, MOISES 

14201155 

(oo 

DATE TIME PROB.# 

Oregon Department of Corrections 

Progress Notes 

6,/5/ j 2. 09-00 T. Bristol MD , -C Sturp_41,2_6,--4 pg„-e.....,— 

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Allergy 

• CD 995H (17.07 

LAR-MAR-PLT- 086 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 36 of 100 
Oregon Department of Corrections 

INFIRMARY PROGRESS NOTES 

DATE TIME CATEGORY 

Attachment 3 

P&P P--G703 

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Allergy ABIOS-IVIAIITINEZ, MOISES 

14201155 

Categories: !NEN], INF 1, INFO, INFO, INFL 

Page I Of I 

LAR-MAR-PLT- 027 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 37 of 100 
Attachment 6 

P&P P-G-D3' 

OREGON DEPARTMENT OF CORRECTIONS HEALTH SERVICES 

Nurse Infirmary Admission Note 

Diagnosis/Chief ComplaintlReason for. Admit: A j ,No 

Provider: ALLERGIES: 

Assessment: Daily BID CI Shift Other 

AdmitVital Signs: 7%eT P .__/R 1 BP X772 o2 Sat 

Weight Neuro checks o 

Initial Admission Note - To Include Reason for Aclnj4sion and ir4sessmept (To b 

completed within 2 hours of admission): Fy fre.) (27`15.9 ,;-'="/ .1' _ 

• 

0 Continued on Back 

Date Initials 

Noted Physician Orders 

Flow sheet filed in chart 

Completed Patient Assessment (SOAP) 

Procured Medications/MAR 

Updated Care Plan / Board 

infirmary Admit Computer Procedure 

PREP ADMIT (if applicable) ❑ Yes ❑ No 

Procedure: 

Patient given Prep Instructions: 

Date/Time Initials 

Food Services Notified: 

Date/Time Initials 

Nurse Signature: 

LAMS-MARTINEZ, MOISES 

14201155 

Page 1 of 2 

LAR-MAR-PLT- 087 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 38 of 100 
• e• 

DATE TIME PROB.# 

Oregon Department of Corrections 

Progress Notes 

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[ LARIOS-MARTINEZ, 11(41;ISES k

Allergy PO 14201155 

1.1.1MOCI 

CD 495H 03,1117 

LAR-MAR-PLT- 102 

Declaration of Steven Shelton, M.D. 

Attachment 1: Page 39 of 100 
Oregon Department of Corrections 

Progress Notes 

DATE TIME PROB,11 

Mig-dilia 

teg-to-' 

if(41 

focx> V4-11," etlabili i/o ‘,/66,1 .---------11 1,- 

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LARrOS-114A LIT] MOISES D. 

14201155 

CDOM.10.2.07) 

LAR-MAR-PLT- 104 

Declaration of Steven Shelton, M.D. 

Attachment 1: Page 40 of 100 
Oregon Department of Corrections 

Progress Notes 

DATE TIME PRO13.1# 

IA 3-5 ),41) SRC-4037 ,.._ &flaw Li - ( Y-Liyus>.ca. 2 Ai ilk 

LoNzr\O - 

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TAR 10S-MARTINIEZ, MOISES Allergy 14201155 D.: 

{12-07 

LAR-MAR-PLT- 105 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 41 of 100 
Oregon Department of Corrections 

Progress Notes 

DATE TIME PRO13.# 

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-- 

14201155 

H (1z-oly 

LAR-MAR-PLT- 039 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 42 of 100 
Attachment 6 

P&P P-G-133 

OREGON DEPARTMENT OF CORRECTIONS HEALTH SERVICES 

Nurse Infirmary Admission Note 

Diagnosis/Chief Complaint/Reason for Admit: -4//f;' .)/7 

Provider: aie2,1;:f-elialAsg, ALLERGIES: 

Assessment: ' Daily BID CI Shift Other 

Admit Vital Signs: 17.'ST cLP . 2 R 1 YA,, Bp rPZP2 Sat e)q 

Weight Neuro checks q 

Initial Admission Note - To /nciude Reason for Admission and Assessment cr.° be 

completed v./Rhin 2 hours of admission): 

_ezrez_./ 

C1 Continued on Back 

Date 

Noted Physician Orders 

Flow sheet filed in chart io-q- to 

Completed Patient Assessment (SOAP) it Lk- \ 

Procured Medications/MAR 

Updated Care Plan / Board 

Infirmary Admit Computer Procedure 

PREP ADMIT (if applicable) Kfes El No 

Procedure:6".4) 

Patient given Prep Instructions: /0-4- I 

Date/Time Initials 

Food Services Notified: 

DaterTime Initials 

Nurse Signature:, /X') 

rt 

 Date/Time: -- 15" / /1/6) 

LAMS-MARTINEZ, MOISES 

SID#14201155 

DOD 

Page 1 of 2 

LAR-MAR-PLT- 197 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 43 of 1O 
Oregon Department of Corrections 

Progress Notes 

ATE TIME. PROB.# 

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[ LARIOS-MARTINEZ, MOISES 

SID#14201155 

DOI3 

Allergy PC.1\A 

CO 49514 (12.1 

LAR-MAR-PLT- 065 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 44 of 100 
Oregon Department of Correc 

Progress Notes 

ATE TIME PROB.# 

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DO Allergy PC 

LAR-MAR-PLT- 060 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 45 of 100 
I 0 Oregon Department of Corrections 

Progress Notes 

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CO4V31.115-96) 

LAR-MAR-PLT- 196 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 46 of 100 
DATE TIME PROB.# 

Oregon. Department of Corrections 

Progress Notes 

eilo 1 V -4 C Y ri . Ue,-4.....----- C,,Q.Q-ci-L-r--, -)4 4_,-..,.,...-,-0 -J., :1_, ...__T--4 --{ .; 1.____-, 

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LARIOS-MARTINEZ MOISES 

SIDN14201.155 

DOB: 1 

Allergy 

CD 495H (5-96) 

LAR-MAR-PLT- 065 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 47 of 100 
Jregon Department of Corrections 

Progress Notes 

DATE TIME PROB.# 

. 

,)d i aozd , 

MOW Arid, 

rAININI 

infrignirit ,,,, 

Alrr 

lffNRFBMIWAejr 

4,0 " 

Coffee Creek Intake Transfer Out Chart Review 

Transfer Date ,,CA ip 0 Transferring to .5, r._..m._ I. State of general health - c2(-,,a,-- 

2. Date of last PPD ///ilio Results_Alt". 0-'"' r dreen sheet in health care record -1.0.t . 

b. Date chest x-ray completed if positive /ix!, // o,c. Chest x-ray results &,t/c.- t.t.,,,, A e_ •n 

3. Date intake physical completed , Vi/-42,6 0_ 4. Date dental intake completed _ _04-o, 

5. List any Special Needs/ Chronic ,Disease Jeas{-:,,F..... . PPP 

a. DOC 400 shows inmate special needs of ye...> . 

b. Twin Rix Vaccine series started; date of last vaccine A1,...,..x- Number in series Refusal__ 

10. Health status updated 

I I . Real chart being sent Overflow, number sent da--- a. X-rays sent 

RN Signature Date/Time s7iryl;%. 

ot. - 

6. List any disability or special equipment needs. iticrfr."`--- 

Equipment being sent with the inmate 

7. List any medications the inmate is receiving 

a. MAR pulled b. Medications and overflow medications pulled 

c. List any KOP mecls 

8: List pending medical appointments 9. Is the inmate on the BIB caseload -fro, 

Date Time Received from _C- ' CcE' 

Received at: F g-. Acct s to Delta] d Medical explained. PPl7 Trent 

Cleared Cor Food Service Y . , •-.1•04 

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eritaj,klealth Refeyral Y 

VVIA 

LAURIOS-MAIITINEZ,MOISES 

14201155 

CO 49514 (5-96) - 

LAR-MAR-PLT- 043 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 48 of 100 
12 / 11 / 20.1.2 0 1 28 M4 1J Alit. 

IN I IEIRPATH 

LAOORATONY 

//1J:31 ram bervor 

LARIOS-NARTIWZ. PAIS- Accl 12-20599 

DOB: 49y M Regs SRC-468 

De; GULICK. GARTH Ib ; 14201155 

Mallstop; FAX SSIlt 

Mountain Time 

Call: 12/10/2042 

Recd; 12/10/2012 

Rept; 12,11/2012 

Hrs Fast; 01/G 

Client: SHAKE RIVER CORRECTIONS 

07110 LARICS-HARTUEZ. HOIS Ate: 12.20599 

14:05 DOB; 49y H Req: SRC-468 

05:00 Dr: GULICK, GARTH 10 1 14201155 

Mailstop; FAX SSN: 

Mountain Time 

Coll: 12/10/2012 

Recd: 12110/2012 

Dept; 12/11/2012 

Mrs Fast: II/G 

07:10 

14:05 

06:00 

Test Value Reference Range Units LC Test Value Reference Range Units LC 

CBC 

WBC 4.5-11,0 

RBC IZ L 4.3-5,7 

HEMOGLOBIN 0,1 L 13.5-18.0 

HEMATOCBIT 41-50 

HCV 99.9 H 81.D9 

ROW 18,2H 10.5-15.0 

MCH aa 27-33 

MCMC 32 30-36 

PLATELET COUNT C

s5 140-440 

NEUTROPIIILS 40.4 39-00 

LYMPHOCYTES 51.1 H 24-44 

MONOCYTES 7,1 0-12 

tOSIHOPHILS 0.5 0-6 

BASOPHILS 0.9 C-2 

VERIFIED BY REPEAT ANALYSIS, LEH 

Sraear review has confirmed the above stated values. LEM 

PLATELET SLIDE ESTIMATE AGREES WITH CCUHT, LEM 

Abnormal RBC population suspected, Slide review to follow. 

TECHNICAL SLIDE SEE CCHMEMT AA 

RBC FORPHoLCM: Moderate Ardsocytasis( Macrocytes), Slight 

Hypochromnsia, Slight Poikilncytosis(Ovalocytes. Teardrop 

Cells. Schistacytes, 'Target Cells, Echinocytes).R0 

Smear review shows few large pIatelets,R0 

Mkt -ilAb 

trlas 18 A COMPLETED REPORT 

tARIOS14ARTINELtmon Coll: 12/10/2012 Rept: 12/11/2012 

LAR-MAR-PLT- 077 

Kitt] 

114/ 

W4 

BW 

BW 

BW 

BO 

BW 

OW 

OW 

OW 

OW 

BW 

BW 

BW 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 49 of 100 
11/30/2(012 12:02:15 PM PAGE 2/003 Fax Server 

client: 5NAkE RIVER CORRECTIONS 

11-53727 

SRC-8591 

14201165 

LARIOS-mARTIVEZ. MIDIS Acct 11-55727 

DOB! 49y M Reg; sRC-8591 

Dr: GULICK. GARTH JD 14201155 

Mailstop: FAX 5511: 

Mountain Time 

Coll: 11126/2012 

Recd: 11/26/2012 

Rept; 11/36/2012 

Hrs Fast; li/G 

06:30 LARICS-MAATINE2. Atc; 

12:41 0011:M.t 49y M Beg: 

13:01 Cr: GUL1 TR 10 : 

htilstop; FAX 56N: 

Mountain Time 

Coll: 11/26/2012 

Reed: 11126/2012 

Rept: 11/30/2012 

Mrs Fast; HUG 

06:30 

12:41 

13:01 

Test Value Reference Range Units 

CBC 

htIC 4.6-11.0 K/UI 

mac ?.5Z L 4,3-5,7 Mlul 

HEMOGLOBIN 11,7 L 13,5-18.0 g/di 

HEMATOCRIT 35,2 L 41-50 

98,8 81-99, fl 

ROW 18.9 H 10.5-15.0 

MCH 33 27-33 P9 

33 30-36 

PLATELET COUNT 140-440 K/ul 

Pr/ 

NEUTROPHILS 22_5 L 39-80 N 

LYMPHOCYTES 60.4 H 24-44 N 

MONOCYTES 9.1 0-12 % 

EOSINOPHILS 0.7 0-6' N 

BASOPIIILS 0,4 0-2 N 

Test Value Reference Range Units LC 

CHEW PLUS 1- CBC 

CHEM PLUS 

GLUCOSE 95 70-100 mg/(11, OW 

PHOSPHORUS. /NORA 2.7 2.5-6.0 mg/dL BW 

URIC ACID 4.1 L 4.4-7.6 mg/dL W4 

BILIROBIN. TOTAL 0.6 D.0-1.2 mg/dt 1141 

CALCIUM 8.4 9.4-16.2 mg/dL BW 

MAGNESIUm 2.2 1.7-2,5 mg/dL BW 

SODIUM 140 132-143 meq/L 11W 

POTASSIUM 4.1 3.6-S.1 meq/L BW 

CHLORIDE 111 95-112 meq/L 6W 

CARRON DIOXIDE 24 19-31 meq/L 11W 

UREA NITROGEN 14 6-23 mg/dL 11W 

CREATININE. SERUM 0.41 0.50-1.50 mg/dL OW 

GFR ESTIMATION MO ml/min BW 

Rl1I/CREAT.RAT10 15,4 5.0-26,6 OW 

PROTEIN 6,6 6,0-8.0 g/di 11W 

ALBUMIN 4,1 3.5-5.0 9/41 8W 

GLOBULIN 2,5 1.0-3.5 g/d1 OW 

AN RA716 1,6 1,1-2.4 BM 

68T 35 5-60 U/L DR 

ALKALINE PHOS 80 30-128 U/L OW 

AST(SGOT) 27 0-40 U/L OW 

ALT($GPT) 23 0-46 U/L BW 

LD 209 100-215 U/L RN 

CHoLE5TEROL 154 OpT; <200 mg/dL OW 

TRIGLIcERIDES 150 30-150 mg/d1. RR 

ROL 51.9 OPT: )40 mg/dL 61 

101 72 OPT; <100 mg/dL 04 

VLDL 30 4-40 mut& IlW 

IRON 211 H 37-160 wAIL OW 

T1BC 329 245-400 49/AL AA 

%SATURATION 70.811 20-55 11 M 

'ESTIMATED GER Reference Range: 

OFR Less than 60; Chronic Kidney Disease, if found over a 3 

month period. 

OFR — Less than 151 Kidney Failure, 

For African Americans. multiply the calculated GFR by 1,21, 

GFR calculation is not valid for patients under ago 18 years, 

For patients over age 70 please interpret results with caution 

as results have not been validated for this calculation method 

LC 

111.1 

Bil 

Ili 

BW 

BW 

1114 

VERIFIED BY REPEAT ANALYSIS. Swear review has confirmed the 

above stated Values. JMNEI 

MANUAL PLATELET ESTIMATE I 70.000. NO CLUMPING SEEN. FEW-GIANT 

PLATELETS. ..114NE1 

151. 3rd GEN. 3.72 -4.20 ullI/mI AA 

HCV WANT by PC 

HCV NOT DETECTLO DO tected IU/mL AA 

HCV NOT DETECTED detected Log 3U/mL M 

NOT DETECTED - The ess than the limit of detection. 

This does not rule out the presence of PCR inhibitors in the 

patient sample or hepatitis C virus concentrations below the 

level of detection of the assay. Care should be taken when 

interpreting any single viral load determination. 

NOT QUANTIFIED - The assay detected the presence of the virus 

but was unable to accurately quantify the number of copies, 

This would indicate a result between 1.3 log IU/mL (18 1U/mL) 

and 1,6 log IUMIL 143 IU/mL). 

The HCV PCR Ouantitation test is not intended for use as a 

screening test For the presence of MCV in blood or blood 

products, 

Assay methodology is an FDA approved nucleic acid amplification 

test for the quantitation of Hepatitis C RNA using the CODAS 

TaqMan analyzer, 

Clinical Utility: HRH 2002 recommendations state, Early viral 

response (EVR), defined as a minimum 2 log decrease in viral 

load during the first 12 weeks of treatment, is predictive of 

Sustained Virological Response (SVR) and should be a routine 

taffTINUEEEr'' A 

A--.1310 

LAR-MAR-PLT- 078 EE EZ Z 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 50 of 100 
T`5 11/8/Z012 7:01:57 AM PACE 4/004 Fax Server 

tss 

INTERPATH 

LABOHATONY 

Client; SNAKE RIVER ERRRcCIWNS 

Mountain Time Mountain Time 

tAl110S-ItARTINEL WAS Acc: 11-14952 Coll; 11/07/201Z N/G LARIOS-NAATINEZ. NOIS Ace; 11-14952 Coll' 11/07/2012 

408: 49y M Rev SRC-9066 Medi 11/07/2042 13'11 004' 49y 4 Req: SftC.9066 Reed' 11/07/2012 nal 

Dr: GULICK, GARTH ID 14201155 Rept: 11/09/2012 08;00 Dr; GULICK. GARTH ID ; 14201155 Rept; 11/09/2012 MOD 

Mailstop! FAX S510 Hrs Fast: NIG Mailstop: FAY SS/it Mrs Fast: ff/G 

Test Value Reference Range Units LC Test Value Reference Range Units IC 

HCV RNA QUART by PCR 

liCV NOT DUANTIFIED 

HCV ROT QUANTIFIED 

not detected 10/mL AA 

not detected Log 1U/rat M 

NOT CETECTED - The result is less than the limit of detection. 

This does not rule out the presence of PCR inhibitors in the 

patient sample or hepatitis C virus concentrations below the 

level of detection of the assay. Care should be taken when 

interpreting any single viral load determination. 

NOT QUANTIFIED - The assay detected the presence of the Virus 

but was unable to accurately -quantify the nester or copies. 

This would -Indicate a result between 1,3 log IU/m1 (1B 10/mL) 

and 1.6 log IU/nl_ (43 ID/aL). 

The HCV PCR Duantitation test is not intended for use as a 

screening test for the presence of HCV in blood or blood 

products. 

Assay methodology is an FDA appreVed rucleie acid amplification 

test for the quantitation of Hepatitis C RNA using the CO0AS 

Taglian analyzer. 

Clinical Utility: Hilt 2002 recommendations state. Early viral 

response (OM), defined as a minimum 2 log decrease In viral 

load during the first 12 weeks of treatment, is predictive of 

Sustained Virological Response (SVR) and should be a routine 

part of monitoring patients with genotype 1. Patients who rail 

to achieve an EVR at week 12 of treatment have a small chance 

of achieving and SYR even if therapy is continued far a full 

year. Treatment need not be extended beyond 12 weeks in these 

patients. 

Result 1117 to Oregon Health Dept by A.15U at 2012-11-09 

07:00:37 Comment; Sent by background process (111:7 Delivery) 

Result HL7 to Oregon Health Dept by AJS)E at 20/2-11-09 

07:00:37 Comment: Sent by background process (NU Delivery) 

11115 IS A PRELIMINARY REPORT 

LAR105-MARTINEZ, MOI5 Coll' 11/07(2012 Rept: 11/09/2012 

LA R-MAR-P LT- 079 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 51 of 100 
S 10/ 5 / 20125:02:00 A4 PAGE 2/n30 Fax Server 

magmagowia 

I NTER PATH 

kilDHAT C RY 

LARIOS-MARTINEZ, BOIS Ace: 10-1382 

008: H Reg: SRC-859S 

Dr: GULICK. GARTH ID : 14201155 

Mailstop: FAY SS11: 

Mountain Time 

Coll: 10/01/2012 00;00 

Recd; 10/01)2012 11144 

Rept; 10/05/2012 06:00 

Hrs Fast: 12 

Client: SNAKE RIVER CORRECTIONS 

LARIOS-MARTINEZ, 19715 Acc: 10-1382 

008: M Req: SRC-8595 

or; GULICK. GARTH ID r 14201155 

Mailstop: FAX SSN: 

HOGOt490 Time 

Call : luieirbalz 

Recd: 10/01/2012 

Rept: 10/05/2012 

Hro Fast; 12 

05:00 

13:44 

06:00 

Test 

CHEM PLUS 4 COO 

MEM PLUS 

Value Reference Range Units LO 

GLUCOSE 141H 70-100 mg/dt 1114 

PHOSPHORUS, MORO all L 2,5-5,0 mg/d4 SW 

URIC ACID • 4.0 2.3-7.6 mg/dt, BM 

BILIRUBIN. TOTAL 0,8 0.0-1.2 mg/dt BM 

CALCIUM 0,1 L 8.4-10.2 rag/dL BM 

MAGNESI04 2,01-1 1.7-2.5 mg/dL BW 

SODIUM 139 132-143 meg/L BW 

POTASSIUM 3.8 3,6-5.1 meg/L OW 

CHtORDIE 110 95-112 meg/L OW 

CARBON DIOXIDE 20 19-31 meg/L OW 

UREA NITROGEN 21 6-23 mghiL BW 

CREATININE. SERUM 0.84 4,51.5 mg/dL NW 

GDR ESTIMATION NOT PERFORMED ml/min 01•1 

OUNFCREAT.RATIO 25.0 6,0-20.6 OW 

PROTEIN 6.6 6.0-8.0 9/41 OW 

ALBUMIN 3,7 3,5-5,0 9/41 OW 

GLOBULIN 2.9 1.8-3.5 gml BP 

A(G RATIO 1.3 1.1-2.4 B11 

GGP 26 5-60 U/L BW 

ALKALINE PHO5 19 30-128 U/i. OW 

AST(SOOT) 27 0-40 U/L OW 

ALT(SGPT) 22 0-46 U/L OW 

LC' 212 11 100.215 U/L BW 

CHOLESTEROL 110 OPT: (200 mgfdi 

TIUGLYCERICES 108 30-150 BW 

Mot. 33,Q L OPT: >40 mg/dL BM 

LOL 55 OPT: LIDO 119/dL BM 

VLDL 22 4-40 mg/dL BW 

IRON zu H 37-160 ug/dL BM 

TIBC 298 245-400 ug/dL AA 

K SATURATION gLizli 20-55 3 AA 

ESTIMATED OFR Reference Ringer 

GER - Less than 60: Chronic Kidney Disease. if found over a 3 

month lArled. 

CFR - Less than 15: Kidney Failure. 

For African Americans, multiply the calculated GFR by 1.21. 

GFR calculation is not valid for patients under age 18 years. 

For patients over age 70 please interpret results with caution 

AS results have not been validated for this calculation method 

Test Value Reference Range Units LC 

COO 

lac RRC (1

1!_ ...--'4,5-11.0 Kful OW 

.3.8-5,7 F1/31 BW 

12.8 12.0-18,0 g/d1 Efii I(EMVELOBI# 

IEMATOCRIT 37.9 35.50 % DR 

1EV 95.1 01-99. fl OW 

ROW 15.7 h 10.5-15.0 % 9w 

FEN 32 27-33 PO BW 

WIC 34 30-36 % 8W 

PLATELET MUT 70 140-440 BW 

NEIMROPHILS 36,R L 39-80 N OW 

LYMPHOCYTES 93.4 H 24.44 % 811 

MONCOYTES 4.5 0-12 % BW 

EOSINOPHILS 0,7 0-6. % Wd 

BASOPHILS 0.2 0-2 % BW 

VERIFIED BY REPEAT ANALYSIS, Smear revivo has confirmed the 

above stated values. )HNEI 

MANUAL PLATELET ESTIMATE IS 100.000. NO CLUMPING SEEN, dMIIEI 

HCV RNA GUANT by PCR 

HCV 5506 II no detected ill/eL AA 

11CV 3,z •t detected Log IU/mt AA 

NOT DETECTED - The result is less than the limit of detection, 

This does not rule out the presence of PCR inhibitors in the 

patient sample or hepatitis C virus concentrations below the 

level of detection of the assay, Care should be taken when 

interpreting any single viral load determination, 

NOT DUANTJFILO - The assay detected the presence of the virus 

but was unable to accurately quantify the number of copies. 

This would indicate a result between 1.3 lug IUhmL (18 lUfmL) 

and 1.6 log )DIAL (43 Mi/mL), 

The HCV PCR Cmantitation test is not Intended for use as a 

screening test for the presence of IICV in blood or blood 

products, 

Assay methodology is an FDA approved nucleic acid amplification 

test for the quantitation of Hepatitis C NIA using the CMS 

Tactlan analyzer. 

Clinical Utility; NMI 2002 recomnendations state, Early viral 

response (EVR), defined as a minimum 2 log decrease in viral 

load during the first 12 weeks of treatment, is predictive of 

Sustained Virologital Response (SYR) and should be a routine 

part of monitoring patients with genotype 1. Patients who fail 

to achieve an EVR at week 12 of treatment have a small chance 

of achieVing and SYR even if therapy is continued for a full 

(CONTINUED) 

14 

LAR-MAR-PLT- 081 

Declaration of Steven Shelton, M.D. 

Attachment 1; Page 52 of 100