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Anthony J. Fernandez, Esq. (Bar No. 018342)

Ellen B. Burno, Esq. (Bar No. 033130)

QUINTAIROS, PRIETO, WOOD & BOYER, P.A.

2390 E. Camelback Road, Suite 440

Phoenix, Arizona 85016

Telephone: (602) 954-5605

Facsimile: (602) 954-5606

afernandez@qpwblaw.com

ellen.burno@qpwblaw.com

Attorneys for Defendants

UNITED STATES DISTRICT COURT

IN AND FOR THE DISTRICT OF ARIZONA

Jay Lynn Pember,

Plaintiff,

v.

Corizon Health, et, al.

Defendant.

Case No: 2:17-cv-04069-JJT-JFM

DEFENDANTS’ RESPONSE TO 

PLAINTIFF’S MOTION FOR 

PRELIMINARY INJUNCTION

(Docs. 15, 19, 25 & 29)

(Assigned to the Honorable James F. 

Metcalf)

Defendants Maureen Gay, NP and Glen Babich, MD, (“Defendants” herein), by and 

through undersigned counsel, hereby respond in opposition to Plaintiff’s Motion for 

Preliminary Injunction (“Plaintiff’s Motion”). Plaintiff requests an injunction ordering 

Defendants to provide him with pain medication and to have him seen by an off-site 

specialist for consultation related to his diagnosed injury in a 2016 MRI. As detailed 

herein, Plaintiff received a neurological consult on August 3, 2018, which was scheduled 

on April 16, 2018, prior to Plaintiff filing this Motion. A treatment plan has been put into 

place and has been initiated to determine if surgical intervention is necessary. Further, 

Plaintiff is currently receiving pain medications. Moreover, a neurologist did not find the 

need to make any changes to his current prescriptions. Accordingly, Defendants request 

that this Court deny Plaintiff’s Motion. 

MEMORANDUM OF POINTS AND AUTHORITIES

I. INTRODUCTION

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Plaintiff Jay Pember is an inmate in the custody of the Arizona Department of 

Corrections. See Inmate Synopsis, attached hereto as Exhibit 1. He filed his three-count 

First Amended Complaint on May 1, 2018, alleging that he has been denied 

constitutionally adequate care related to pain management. (Doc. 10) Plaintiff has filed an 

Amended Motion for Temporary Restraining Order and Preliminary Injunction (Doc. 15); 

Motion for Temporary Restraining Order and Preliminary Injunction (Doc. 19); Motion for 

Order for Access to Legal Supplies (Doc. 25) and a third Motion for Temporary 

Restraining Order and Preliminary Injunction. (Doc. 29)1 (hereafter “Plaintiff’s Motions) 

Per the Court’s August 8, 2018, Order (Doc. 37) Defendants are to respond to Plaintiff’s 

Motions by August 22, 2018.

In his motion, Plaintiff requests “to receive adequate recommended pain 

management medication .... and to be seen by outside specialist for a consult evaluation 

and recommendation for treatment plan related to his diagnosed injury in the 2016 MRI.” 

(Doc. 15 at 1) Plaintiff claims Defendants have failed to administer adequate medical care 

by not sending him to a neurologist for evaluation. Id. Moreover, Plaintiff claims 

Defendants have consistently fabricated his medical record to deny him adequate pain

management and to deny Plaintiff to be seen by a specialist. Id. at 2. Plaintiff asserts his 

injury has progressed to the point where he can only perform daily tasks, such as sitting 

and sleeping, for short periods of time. He also asserts he suffers from severe pain and 

alleged outrageous neuropathy sensations as well. Id. at 3. He alleges that if he does not 

receive the requested treatment he does not know what the outcome will be because the 

effects from his injury are supposedly unbearable.

Plaintiff’s MRI taken on May 13, 2016, revealed: straightening of the cervical spinal 

loss of lordosis was noted and may be secondary to cervical myositis; at the level of C5-

C6, there is moderate degenerative spurring anteriorly with bridging as well as 3.0 mm 

 1 Plaintiff’s various motions are duplicative in nature. Documents 15 and 19 both request 

relief regarding pain medical and a neurological consult and Defendants will address both 

documents together. Documents 25 and 29 both request relief regarding access to a 

typewriter and supplies and Defendant will address both documents together.

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central posterior disc bulge with slight impression upon the thecal sac and marked left 

foraminal impingement; at the level of C3-C4, moderate left foraminal impingement was 

noted. See MRI report, attached hereto as Exhibit 2.

On June 20, 2016, Plaintiff was seen for follow-up of MRI of the cervical spine. 

Mr. Pember was informed of the results. The plan of care was to continue medication, 

request pain management consult for possible spinal injections, and then re-evaluate. It 

was noted that Mr. Pember may need physical therapy also. Mr. Pember agreed with this 

plan of care. See medical records, attached hereto as Exhibit 3.

On July 26, 2016, Mr. Pember was seen at the off-site pain clinic. He received an 

epidural injection of Demerol for pain management. See medical records, attached hereto 

as Exhibit 4.

On November 7, 2016, Mr. Pember was seen by Nick Salyer, PA. PA Salyer 

assessed Mr. Pember and noted very mild left lateral cervical neck muscle atrophy, left 

shoulder muscle atrophy, left upper and lower arm muscle atrophy, weak left shoulder 

shrug and moderately weak left arm hand strength. The assessment noted in addition to 

Mr. Pember’s other chronic issues, chronic neuropathic pain due to cervical spinal stenosis 

under pain management. PA Salyer requested a consult for follow-up spinal injections; 

requested NFDR to increase Gabapentin to 900 mg PO BID; ordered labs and patient was 

to follow-up in three months or file an HNR if needed. The patient was educated on what 

to avoid and instructed he was able to do gentle AROM and stretching exercises only for 

now. See medical records, attached hereto as Exhibit 5.

On December 29, 2016, Mr. Pember was seen by Julie Hutchinson for follow-up 

care. He inquired about a follow-up epidural injection for his neck and arm pain. Mr. 

Pember reported he did not think Nortriptyline was helping his pain – he asked for an 

increase in Gabapentin. Ms. Hutchinson assessed the patient and discontinued 

Nortriptyline. The treatment plan noted Mr. Pember was scheduled for a cervical injection 

next week and he was to follow-up in one month for a pain assessment. She stated she 

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would consider increasing Gabapentin if indicated and the patient was educated on

medication side effects. See medical records, attached hereto as Exhibit 6.

On January 3, 2017, Mr. Pember was seen at the off-site pain clinic. He received an 

epidural injection of Demerol for pain management. See medical records, attached hereto 

as Exhibit 7.

On February 2, 2017, Mr. Pember was seen at the off-site pain clinic. He received 

an epidural injection of Demerol for pain management. See medical records, attached 

hereto as Exhibit 8.

Plaintiff was assessed by NP Gay on February 23, 2017, for follow-up care. They 

discussed the alternative treatment options for Gabapentin use as well as alternative 

treatment regarding Mr. Pember’s orthotics request. Mr. Pember stated he could not be 

taken off of Gabapentin because he had grand-mal seizures and he has not had a seizure 

since he began taking Gabapentin. NP Gay informed Mr. Pember that Gabapentin is not 

currently used for grand-mal seizure activity but it is an adjunct therapy for petite mal 

seizure activity. She also informed him about alternative therapies with other 

anticonvulsants which also treat neuropathy discomfort. Mr. Pember also complained of 

right foot deformity secondary to old injury with multiple surgical repairs secondary to 

gunshot wounds. He admitted some numbness and stiffness of the right foot and requested

ankle support. He stated an MRI cervical taken in May 2016 revealed a disc bulge in the 

C5-C6 region. Mr. Pember also reported he was seen by a neurosurgeon who suggested 

epidural injections. Mr. Pember received his second injection in January of 2017. NP Gay 

assessed Mr. Pember’s cervical spine and he had positive full range of motion noted with 

relation, fluxion and hyperextension and he had no discomfort on palpation. The 

assessment of the lumbar spine revealed he was ambulatory in the exam room with steady 

gait and no deformity or limp noted and positive, full range of motion was noted. Mr. 

Pember was diagnosed with lower back pain and cervicalgia. The treatment plan was: to 

continue to wean Mr. Pember off Gabapentin therapy; continue Nortriptyline and 

Amitriptyline. Mr. Pember was educated on medication changes and the alternative 

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treatment plan for chronic pain. He was told to follow-up as needed. See medical records, 

attached hereto as Exhibit 9.

On March 7, 2017, Mr. Pember was seen at the off-site pain clinic. He stated he 

received an epidural injection for pain management. See medical records, attached hereto 

as Exhibit 10.

On May 12, 2017, NP Gay noted Mr. Pember was seen for a follow-up visit after 

outside consultation for pain management. Mr. Pember reported he had a negative reaction 

to Cymbalta; this medication was discontinued. Patient admitted continued pain and 

discomfort in posterior neck and left arm, requested medication changes – wanted 

Gabapentin therapy. NP Gay spoke with Mr. Pember and educated him that Gabapentin

would not be prescribed because of changes in alternative therapy and treatment options. 

Mr. Pember had been prescribed Amitriptyline and Nortriptyline, but he refused to take the 

medication because he claimed it did not work. NP Gay offered Trileptal as an alternative; 

she discussed with Mr. Pember they would start on a low dose and titrate upward as 

needed. NP Gay fully assessed Mr. Pember and no apparent distress was noted – his neck 

had positive rotation without pain or stiffness noted and he was ambulatory with a steady 

gait and all of his extremities had full range of motion. The treatment plan was to also 

continue his home exercise program and continue warm water/compress to his lower back 

or cervical area. See medical records, attached hereto as Exhibit 11.

On June 21, 2017, Mr. Pember was evaluated by Dr. Watson for pain in his neck,

knees and ankles. It was noted the patient had pain in multiple joints, not just his cervical 

spine. Dr. Watson prescribed ibuprofen 600 mg, four times daily as needed, and ordered 

an x-ray for his ankles and knees. See medical records, attached hereto as Exhibit 12.

Mr. Pember was evaluated by NP Gay for a chronic care appointment on July 29, 

2017. He was ambulatory with a steady gait. Plan was to continue medication therapy 

with no changes for now, labs every 3 months and chronic care follow-up in 90 days. See 

medical records, attached hereto as Exhibit 13.

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On December 27, 2017, Mr. Pember was evaluated by Dr. Johnson. Mr. Pember 

complained of ibuprofen and Excedrin causing gastric irritation. Dr. Johnson re-prescribed 

Meloxicam at patient’s request and agreed to try Zonisamide. See medical records, 

attached hereto as Exhibit 14.

On January 27, 2018, Mr. Pember was evaluated by Nurse Vegara for a pain 

medication change. Mr. Pember reported Zonizamide was not working but the meloxicam 

seemed to be helping with arthritis. Nurse Vegara assessed Mr. Pember. He was noted to 

be ambulating without deficit and no grimacing was observed. She ordered a follow-up 

appointment with the health care practitioner. See medical records attached hereto as 

Exhibit 15

On February 10, 2018, Mr. Pember was evaluated by NP Gay for follow-up care to 

discuss treatment plan augmentation. Mr. Pember reported his current regimen was 

ineffective for pain management. He also stated his medication caused gastric upset with 

worsening symptoms for numbness. He denied any inability to participate in activities of 

daily living (except exercises). Mr. Pember requested pain management of more injections 

to cervical regions or discectomy as suggested by a neurologist in 2014. NP Gay had a 

lengthy discussion with Mr. Pember regarding his past pain treatment, including short 

course narcotic use with Tramadol. Mr. Pember stated Tramadol caused seizures in the 

past. NP Gay went through Mr. Pember’s old record history and noted: repeat MRI and 

neurosurgical evaluation in September of 2011 recommended no surgical corrections. He 

had another follow-up visit on July 17, 2012, and surgical intervention was not advised at 

this time. She noted the impressions of the 2016 MRI and that in 2017 Mr. Pember 

received injections in January, February and March. Mr. Pember admitted discomfort postcervical spine regions with increased numbness located post left arm involving left hand 

digits. A physical examination was given and the plan was to add Tylenol 325 mg bid as 

needed and continue current therapy for now until long term treatment options have been 

developed. Id. See medical records, attached hereto as Exhibit 16. 

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On March 15, 2018, Mr. Pember was evaluated by Dr. Stewart. Mr. Pember was 

upset his Gabapentin had been reduced. Dr. Stewart educated the patient that Gabapentin

is only being used for two medical instances and Mr. Pember did not have either of those 

conditions, so Gabapentin was not the appropriate treatment for him. Mr. Pember stated he 

would refuse anything at this time and he was interested in surgery. Dr. Stewart assessed 

Mr. Pember and refilled his codeine prescription. He also put in a consult request for a 

neurological consult and discussed this plan with Mr. Pember. The external consult was 

scheduled in April of 2018, but the soonest available appointment was the second week of 

August. Mr. Pember was placed on the cancellation list. See medical records, attached 

hereto as Exhibit 17 & 18.

Plaintiff had an outside neurosurgical consult on August 3, 2018. The treatment 

plan was to refer to neurology for an EMG, obtain MRI of cervical and thoracic spine, start 

physical therapy for neck and back pain and left arm weakness. Mr. Pember was instructed 

to complete the MRI, EMG and physical therapy and follow-up in two months. No 

medications were prescribed by the neurologist. See medical records, attached hereto as 

Exhibit 19.

On August 9, 2018, Plaintiff was evaluated by Dr. Johnson. Dr. Johnson reviewed 

the recommendations made by the neurologist and discussed the plan of care with Mr. 

Pember and discussed continuance of current medications for pain. Dr. Johnson issued a 

Special Needs Order for side restraints due to pain and numbness. He also put in consult 

requests for physical therapy, diagnostic imaging and neurology, which have been initiated 

by the clinical coordinator. See medical records, attached hereto as Exhibit 20. 

Mr. Pember is currently taking Codeine and Meloxicam for pain management. 

II. LEGAL ARGUMENT

A. Standard of Review 

The Supreme Court has made clear that preliminary injunctions are “an 

extraordinary remedy never awarded as of right.” Winter v. Nat. Res. Def. Council, Inc.,

555 U.S. 7, 129 (2008). Plaintiff may only obtain a preliminary injunction by showing 

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“that he is likely to succeed on the merits, that he is likely to suffer irreparable harm in the 

absence of preliminary relief, that the balance of equities tips in his favor, and that an 

injunction is in the public interest.” Id. at 20. A preliminary injunction may be appropriate 

if a plaintiff raises “serious questions going to the merits” of his claim, and the “balance of 

hardships tips sharply in the plaintiff’s favor,” as long as the other Winter factors are 

satisfied. Alliance for the Wild Rockies v. Cottrell, 632 F.3d 1127, 1135 (9th Cir. 2011) 

(emphasis added).

Further, mandatory injunctions are “particularly disfavored.” Garcia v. Google, 

Inc., 786 F.3d 733, 740 (9th Cir. 2015) (internal citations omitted). A plaintiff seeking a 

mandatory injunction, rather than a prohibitory one, “must establish that the law and facts 

clearly favor [his] position, not simply that [he] is likely to succeed.” Id. “In plain terms, 

mandatory injunctions should not issue in doubtful cases.” Id. (citing Park Vill. Apartment 

Tenants Ass'n v. Mortimer Howard Trust, 636 F.3d 1150, 1160 (9th Cir.2011)). 

With respect to an incarcerated plaintiff, federal law mandates that prospective 

relief in a civil action “shall extend no further than necessary to correct the violation of the 

Federal right of a particular plaintiff.” 18 U.S.C. § 3626 (a)(1). Preliminary injunctions 

“must be narrowly drawn, extend no further than necessary to correct the harm... and be 

the least intrusive means necessary to correct that harm.” 18 U.S.C. § 3626(a)(2). In other 

words, federal law prohibits courts from granting relief that extends beyond the 

constitutional minimum. Gilmore v. People of the State of California, 220 F.3d 987, 999 

(9th Cir. 2000).

In order “to maintain a [constitutional] claim based on prison medical treatment, an 

inmate must show ‘deliberate indifference to serious medical needs.’” Jett v. Penner, 439 

F.3d 1091, 1096 (9th Cir. 2006) (quoting Estelle v. Gamble, 429 U.S. 97, 104 (1976)). “In 

the Ninth Circuit, the test for deliberate indifference consists of two parts. First, the 

plaintiff must show a “serious medical need” by demonstrating that failure to treat a 

prisoner's condition could result in further significant injury or the unnecessary and wanton 

infliction of pain. Second, the plaintiff must show the defendant's response to the need was 

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deliberately indifferent. This second prong ... is satisfied by showing (a) a purposeful act or 

failure to respond to a prisoner's pain or possible medical need and (b) harm caused by the 

indifference.” Jett v. Penner, 439 F.3d at 1096 (internal citations, punctuation and 

quotation marks omitted); accord, Wilhelm v. Rotman, 680 F.3d 1113, 1122 (9th Cir.2012); 

Lemire v. California Dep't of Corr. & Rehab, 726 F.3d 1062, 1081 (9th Cir.2013).

“The indifference to a prisoner's medical needs must be substantial. Mere 

indifference, negligence, or medical malpractice will not support this claim. Even gross 

negligence is insufficient to establish deliberate indifference to serious medical needs.” 

Lemire, 726 F.3d at 1081 (emphasis added) (internal citations and quotations omitted). “A 

difference of opinion between a physician and the prisoner... concerning what medical 

care is appropriate does not amount to deliberate indifference.” Snow v. McDaniel, 681 

F.3d 978, 987 (9th Cir.2012) (overruled on other grounds)(citing Sanchez v. Vild, 891 

F.2d 240, 242 (9th Cir.1989)). 

Similarly, a “mere delay in [medical care], without more, is insufficient to state a 

claim of deliberate medical indifference.” Shapley v. Nevada Bd. Of State Prison

Comm’rs, 766 F.2d 404, 407 (9th Cir. 1985). Moreover, Plaintiff does not have a 

constitutional right to choose his own health care provider. See Kinney v. Kalfus, 25 F.3d 

633, 634-635 (8th Cir.1994); see also Coppinger v. Townsend, 398 F.2d 392, 394 (10th 

Cir. 1968) (“The prisoner's right is to medical care— not to the type or scope of medical 

care which he personally desires. A difference of opinion between a physician and a 

patient does not give rise to a constitutional right or sustain a claim under §1983.”)

B. Plaintiff Has Not Met His Burden of Demonstrating a Likelihood of Success 

On the Merits

A likelihood of success on the merits is the most important Winter factor, and, if a 

movant fails to meet this “threshold inquiry,” the court need not consider the other factors 

in the absence of “serious questions going to the merits.” Alliance for the Wild Rockies, 

632 F.3d at 1134-35. Plaintiff alleges that Defendants have violated his Eighth 

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Amendment constitutional rights by failing to provide appropriate pain management care, 

specifically pain medication (Gabapentin) and a neurological consult.

In his Motion, Plaintiff argues he has a great likelihood of success on the merits 

because “in his related case the Ninth Circuit has already decided his constitutional rights 

were violated.” This is a misstatement of the status of his related case. The current status 

of his related case is that the Ninth Circuit remanded the summary judgment dismissal of 

Defendant Baird to District Court for further proceedings. See Memorandum, attached 

hereto as Exhibit 21. Plaintiff also cites to Heard v. Tilden, 809 F.3d 974 (7th Cir. 2016) 

to support his likelihood of success. While Heard might be similar in that the Plaintiff in 

that case also had two separate and distinct cases for deliberate indifference, it does 

nothing to support Plaintiff’s likelihood of success on the merits in this case.

More importantly, the medical records do not support Plaintiff’s assertion that 

Defendants have failed to provide appropriate pain management related care and have 

failed to provide him with a consult with an off-site neurologist. In fact, Plaintiff was 

evaluated by an off-site neurologist on August 3, 2018, and a treatment plan 

recommended by the neurologist has been put into place. See Exhibits 18 & 19 supra.

In addition, Plaintiff has failed to produce any evidence that Defendants were

deliberately indifferent to Plaintiff’s serious medical needs. To the contrary, Plaintiff has 

received regular and continuing pain management care. 

Notably, Plaintiff has already received the care which is the part of his Motion, thus 

extinguishing any need for an injunction related to a neurological consult. Additionally, 

Plaintiff has continuously received pain medication. Moreover, when he has complained 

one medication was not working, a different medication was prescribed. Plaintiff also 

received epidural injections for his pain management. As noted, Plaintiff was evaluated by 

an offsite neurologist on August 3, 2018. This appointment was scheduled in April of 

2018, but the first opening in the neurologist’s office was in August. Moreover, Plaintiff 

has been seen regularly by his nurses and providers to assess his condition. Defendants 

have been consistently responsive to Plaintiff’s medical needs. 

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In sum, Plaintiff has not shown that Defendants have been indifferent – much less 

substantially indifferent – to his serious medical needs. Plaintiff has been provided the 

care which is the subject of his Motion, thus obviating the need for an injunction. Plaintiff 

has received consistent, timely and ongoing care for his pain management. Accordingly, 

Plaintiff has suffered no harm such that court intervention is needed to enforce future care.

C. Plaintiff Has Not Shown That He is at Risk of Immediate, Irreparable Harm 

As the movant, Plaintiff must demonstrate that, absent an injunction, he will be 

exposed to irreparable harm. Caribbean Marine Servs. Co. Baldridge, 844 F.2d 668, 674 

(9th Cir. 1988) (speculative injury is not irreparable injury sufficient for a preliminary 

injunction); see Winter, 555 U.S. at 22 (“A plaintiff must do more than merely allege 

imminent harm sufficient to establish standing; a plaintiff must demonstrate immediate 

threatened injury as a prerequisite to preliminary injunctive relief”). Additionally, a 

motion for preliminary injunction, including the likelihood of irreparable injury, must be 

supported by “[e]vidence that goes beyond the unverified allegations in the pleadings.” 

Fidelity Nat’l Title Ins. Co. v. Castle, 2011 WL 5882878 at *3 (N.D. Cal. 2011) (internal 

citations omitted). 

Here, Plaintiff attempts to leverage his alleged pain to show an imminent threat of 

harm. However, the record does not support Plaintiff’s claim or that he is otherwise at risk 

of imminent harm or death. In addition, Plaintiff has already received the requested relief 

and he has not shown that he suffers an ongoing, imminent threat to his health. While 

Plaintiff did not receive the specific pain medication he was requesting, Plaintiff does not 

have the right to dictate his own medical care. See Coppinger supra. Plaintiff has been 

receiving pain medication and has received epidural injections for pain management. 

Additionally, Plaintiff has received the neurological consult which he requests in his 

Motions. There is no evidence that he is being exposed to any risk of significant injury or 

the unnecessary and wanton infliction of pain such that Court intervention is warranted. 

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Plaintiff has done nothing more than allege imminent harm – he has done nothing to 

demonstrate an immediate threatened injury. Accordingly, Plaintiff has not met his burden 

in demonstrating a likelihood of imminent harm. 

D. Plaintiff’s Motion for Legal Supplies (Docs. 25 & 29)

Plaintiff filed additional motions for a Temporary Restraining Order and 

Preliminary injunction asking for a Court Order for access to a typewriter and related 

supplies. (Docs. 25 & 29) Throughout his motion Plaintiff refers to a prior case, in which 

he requested the same access.2

 Corizon Health, Inc. is a medical provider in certain 

Arizona Department of Corrections (“ADC”) facilities. The Arizona Department of 

Corrections is not a Defendant in this case. Per the Court’s May 31, 2018, Screening Order

(Doc. 17), all ADC Defendants were dismissed. Plaintiff requesting access to a typewriter 

from Defendants, current employees of Corizon Health, Inc., is improper. Further, 

Plaintiff’s request for access to a typewriter has no relation to the allegations remaining in 

his Complaint - whether or not Defendants Gay or Babich were deliberately indifferent to 

Plaintiff’s medical needs. Furthermore, Plaintiff has presented no evidence that he is 

unable to write in support of his claims. 

Plaintiff has failed to prove that he will likely be successful on the merits of this 

claim because his request is not related to any underlying claim in his Complaint. Plaintiff 

has also failed to produce any evidence that he is at risk for immediate, irreparable harm –

his allegations alone are insufficient. Plaintiff is clearly able to represent himself and 

further his case as is evident from the multiple filings he has made in this case. The fact 

that his ability to type his documents might be hindered on in the future, without Plaintiff 

producing any evidence that he is unable to write, is not enough to meet the high burden 

for a preliminary injunction and/or temporary restraining order. 

 2 The issue was never resolved in that case as Plaintiff was appointed counsel.

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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A. 13

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

For these reasons, Plaintiff’s Motion for an Order for access to legal supplies should 

be denied. 

III. CONCLUSION

In conclusion, no court order is necessary with respect to Plaintiff’s requests for a 

neurologist consult, as this relief has already been provided and the neurologist’s plan of 

care is also being implemented. Further, Plaintiff has consistently received pain 

management. In addition, Plaintiff has not shown a likelihood of success on the merits or 

that he is at risk of immediate, irreparable harm with respect to any of Plaintiff’s Motions. 

For these reasons, Defendants respectfully request that the Court deny Plaintiff’s Motions. 

RESPECTFULLY SUBMITTED this 22nd day of August, 2018. 

QUINTAIROS, PRIETO, WOOD & BOYER, P.A.

By: /s/Ellen Burno _________ Anthony J. Fernandez

Ellen B. Burno

Attorneys for Defendants

CERTIFICATE OF SERVICE

I hereby certify that on this 22nd day of August, 2018, I electronically transmitted the 

foregoing with the Clerk of the Court using the CM/ECF system for filing, with copies 

submitted by U.S. mail to the following recipients: 

ASPC-Eyman

Browning Unit

Inmate Jay Lynn Pember, ADC #067165

P.O Box 3400

Florence, AZ 85132

Plaintiff

By: /s/Kenya Owens

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 13 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 1

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 14 of 139
Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 15 of 139
Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 16 of 139
Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 17 of 139
Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 18 of 139
Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 19 of 139
Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 20 of 139
Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 21 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 2

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 22 of 139
7.05.2016 19:31 :58 retarus faxolution fro~ cgfax@aztechradiology.com for Aztech Radiology

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Radiology Report

Casa Grande Facility

NAME: 67165Jay Pember

O.O.B.: 07/21/1966

PATIENT #: AZ477372

D.O.S.: 05/13/16

PHYSICIAN: Ibrahim, Fuad, MD

Phone: (520) 868-4011 Ext 5731

Fax: (602) 258-7886

MRI Cervical Spine with & without Contrast

HISTORY: Chronic neck pain.

EXAMINATION, TECHNIQUE: Unenhanced and enhanced CT of the neck is provided

utilizing multiple plane imaging with multi sequential studies within a 1.5

Tesla magnet, and utilizing 10 cc of Omniscan IV. T1, T2, STI R, fat suppression

sequences are provided.

FINDINGS: There is no evidence of bone contusion, fracture, dislocation, or

true subluxation. There is straightening of cervical spine 1055 of lordosis

which may be secondary to cervical myositis. Also noted is moderate degenerative

spondylosis anteriorly with bridging involving C5, C6 vertebral bodies.

No neoplastic changes are suggested. No destructive alterations are

demonstrated.

The cervical portion of the spinal cord demonstrates satisfactory signal and

appearance. There is no evidence of herniation of the cerebellum or midbrain

through the foramen magnum. There is no evidence of demyelinating disease,

inflammatory change, or mass. No syrinx formation is demonstrated.

At the level of C2-C3, satisfactory anatomic findings are noted. At the level of

C3-C4, there is moderate left foraminal narrowing.

FDA Certified

Accredited by the American College of Radiology

Apache Casa Phoenix Women's

Ahwatukee Junction Grande Chandler Gilbert Maricopa Osborn Tempe Center

Phone: Phone: Phone: Phone: Phone: Phone: Phone: Phone: Phone:

480.893.1004 480.288.6400 520.876.0297 480.963.4183 480.354.9200 520.568.6411 602.277.4111 480.820.2021 480.455.1860

Fax: Fax: Fax: Fax: Fox: Fax: Fax: Fax: Fox:

480.893.0306 480.288.4079 520.876.0167 480.963.4184 480.354.9201 520.568.6312 602.277.1333 480.345.7080 480.455.1862

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 23 of 139
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Radiology Report

Casa Grande Facility

NAME: 67165Jay Pember

O.O.B.: 07/21/1966

PATIENT #: AZ477372

O.O.S.: 05/13/16

PHYSICIAN: Ibrahim, Fuad, MD

At the level of C4-C5, the anatomic findings are within normal limits.

At the level C5-C6 there is marked left foraminal narrowing with a 3.0 mm

central posterior disc bulge which slightly impresses upon the thecal sac.

At the levels of C6-C7, and C7-T1, satisfactory anatomic findings are noted.

Muscular and soft tissue signal and appearance is within normal limits.

IMPRESSIONS:

1. Straightening of the cervical spinal loss of lordosis is noted and may be

secondary to cervical myositis.

2. At the level of C5-C6, there is moderate degenerative spurring anteriorly

with bridging as well as a 3.0 mm central posterior disc bulge with slight

impression upon the thecal sac and marked left foraminal impingement.

3. At the level of C3-C4, moderate left foraminal impingement is noted.

Report dictated and electronically signed by: Davidson, Maurice A, DO

05116/2016 1:30 PM

FDA Certified

Accredited by the American College of Radiology

Apache Case Phoenix Women's

Ahwctukee Junenen Grande Chandler Gilbert Marlc:opa Osborn Tempe Center

Phone: Phone: Phone: Phone: Phone: Phone: Phone: Phone: Phone:

480.893.1004 480.288.6400 520.876.0297 480.963.4183 480.354.9200 520.568.641 1 602.277.4111 480.820.2021 480.455.1860

Fax: Fox: Fax: Fox: Fax: Fox: Fax: Fax: Fox:

480.893.0306 480.288.4079 520.876.0167 480.963.4184 480.354.9201 520.568.6312 602.277.1333 480.345.7080 480.455.1862

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 24 of 139
7.05.2016 19:31 :58 retarus faxolution fro. cgfax@aztechradiology.com for Aztech Radiology

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 25 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 3

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 26 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 08, 2018 

15:20:37

Encounter Header

Date*: 06/20/2016 Start Time*: 12:55:54

End Date*: 06/20/2016 End Time*: 13:01:40

Category: Medical Provider

Type*: Provider - Follow Up Care Encounter Close Date: 07/15/2016

Location*: ASPC-F CENTRAL I # [A01] Encounter Close Time: 08:43:08

Setting*: Clinic

Staff Member*: Lyons, Nicole

Title:

Form Type:

Subjective

Related Health Service Requests

Request Date Area of Interest Request Type Status

No Rows Found

Subjective Notes

Pt seen for f/u on MRI of CSP. Pt informed of results. plan of care is to continue medications, 

request pain management consult for possible spinal injections and then re-eval after. may need 

some physical therapy in addition d/t muscle weakness and atrophy to left arm. pt agrees. he c/o 

persistent numbness to entire left arm and pain to left side of neck and posterior shoulder area. 

Objective

Vital Signs (1 - 1 of 1)

Taken By Time Temp Pulse Resp HeightWeight BP

Systolic

BP

Diastolic

Blood

SugarComments

Sneckenburg, 

Karen 12:52 96.7 81 20 5 9 220 138 88 NA

Objective Notes

a/o x4, NAD, resps easy and unlabored

lungs CTA

RRR, s1s2, no murmurs, no lower ext edema, distal pulses palpable

m/s- obvious visible muscle atrophy to left upper arm and shoulder, L hand grasp weaker than R, cap 

refill <3 sec distally, diminished sensation to fingers of L hand, muscle tightness to left trapezius. 

mild tenderness to palpation of left CSP musculature.

MRI results 5/13/16:

1. straightening of the cervical spinal loss of lordosis is noted and may be secondary to cervical 

myositis.

2. at the level of C5-6 there is moderate degenerative spurring anteriorly with bridging as well as a 

3mm central posterior disc bulge with slight impression upon the thecal sac and marked left 

foraminal impingement.

CHSS027C - Health Services Encounter Page 1 of 6

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 27 of 139
3. at the level of C3-4, moderate left foraminal impingement is noted.

Assessment

Medical Diagnosis/Complaint

ICD Code Diagnosis/Complaint

No Rows Found

Active Allergies/Health Problems/Conditions (1 - 20 of 20)

ID 

Number Category Type National HIE Code(s) Diagnosis Code Status Status Date

001 Chronic 

Conditions Asthma Assessed 10/02/2013

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/2013

003 Communicable 

Diseases Hepatitis C Assessed 10/02/2013

004 Allergies -

Medication Carbamazepine Assessed 08/04/2014

005 Mental Health Mental Health Assessed 08/04/2014

006 Mental Health Mental Health Bipolar disorder 

NOS [296.80] Assessed 08/04/2014

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/2014

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/2014

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/2014

010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/2015

011 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism 

NOS [244.9] Assessed 09/30/2015

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/2015

013 Chronic 

Conditions Asthma Asthma NOS [493.90] Assessed 09/30/2015

014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions 

[R56.9]

Assessed 10/01/2015

015 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 10/01/2015

CHSS027C - Health Services Encounter Page 2 of 6

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 28 of 139
016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/2015

017 Chronic 

Conditions Asthma

Unspecified 

asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/2015

018 Communicable 

Diseases Hepatitis C

Chronic viral 

hepatitis C 

[B18.2]

Assessed 11/16/2015

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/2015

020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 

- Cervical 

root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/2016

Related Allergies/Health Problems/Conditions 

ID Number Category Type National HIE Code(s) Diagnosis Code Status Status Date

No Rows Found

Assessment Notes

CSP disc bulging with foraminal impingment

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 6 of 6)

View MAR Summary

Prescription/Medication National HIE 

Code(s) 

Effective

Date Dosage Frequency Expiration Status

ALBUTEROL HFA 

(8.5GM) INHA/90 Mcg 

RxNorm: 

745752 -

200 

ACTUAT 

Albuterol 

0.09 

MG/ACTUAT 

Metered 

Dose 

Inhaler 

[ProAir 

HFA]; &...

05/24/2016 2 

puffs

TWICE 

DAILY AS 

NEEDED

10/25/2016

Received 

from 

Pharmacy

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 29 of 139
GABAPENTIN 

CAPS/300 Mg 

RxNorm: 

310431 -

gabapentin 

300 MG 

Oral 

Capsule; 

04/29/2016 2 

tab

TWICE 

DAILY 08/27/2016

Received 

from 

Pharmacy

MELOXICAM TABS/15 

Mg 

RxNorm: 

152695 -

meloxicam 

15 MG Oral 

Tablet; 

03/28/2016 1 

tab

EVERY 

DAY 09/24/2016

Order 

Accepted 

at 

Pharmacy 

Vendor 

(SC)

NORTRIPTYLINE HCL 

CAPS/75 Mg 03/28/2016 1 

tab

EVERY 

EVENING 09/24/2016

Order 

Accepted 

at 

Pharmacy 

Vendor 

(SC)

LEVOTHYROXINE SOD 

TABS/0.075 Mg 

RxNorm: 

966171 -

Synthroid 

75 MCG 

Oral 

Tablet; 

02/12/2016 1 EVERY 

MORNING 08/10/2016

Received 

from 

Pharmacy

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 

855671 -

Phenytoin 

sodium 100 

MG 

Extended 

Release 

Capsule; 

02/28/2016 2 TWICE 

DAILY 08/10/2016

Received 

from 

Pharmacy

Ordered Drug Prescriptions 

Prescription/Medication National HIE Code(s) Effective

Date Dosage Frequency Expiration Status

No Rows Found

Lab Test Orders 

Lab Test Type National HIE Code(s) Priority Status Results Value

No Rows Found

X-Ray Orders 

X-Ray Body Area Priority Status

No Rows Found

Consultation Request (1 - 1 of 1)

Request Type Service Type Priority Status

Off-site Clinic Pain Clinic Routine Consult Occurred

Follow-up Appointments

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 30 of 139
Date Time Type Staff Location

No Rows Found

Patient Transfer Holds (1 - 1 of 1)

Type Expiration Date Status

Medical Hold 07/05/2016 Removed

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comments

No Rows Found

Plan Notes

CSP disc bulging with foraminal impingment- continue meds, request consult with pain mgmt. for 

possible spinal injections, f/u PRN, may need PT in the future also.

Patient Education

Patient Education Notes

notify medical for worsening or change in s/s

Meaningful Use Measurement

 Demographic Information in Patient Header verified

 Current Medical Problem List verified (or Patient has no Medical Problems)

 Current Medications List verified (or Patient has no Medical Medications) Medications List NOT 

verified 

 Medication Allergies List verified (or Patient is not allergic to any Medications)

Health Classification

Medical: 2

Mental: 3D-Outpatient-Recently Off Meds-Monitoring Only Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Encounter Orders Review 

Review Type*: Pending Nurses Order Review Staff: Smith, Christine, RN

Review Date: 06/20/2016 Review Time: 20:45:55

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 31 of 139
Review Notes

Reviewed 

TimeStamp: 20 June 2016 20:47:57 --- User: Christine Smith (CSMITH)

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms

Type Staff

No Rows Found

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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 4

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 33 of 139
Dinesh Chlnlhagada, MD Brian Page, DO

SusanBill!€Y.FNP-C LindsayBurk PA-C

,.iohl"liee.l'Jm, ~NP-C Amelia Campbell, H.,JP-C

NICholsBrown,FNP.c KellyCarr.FNP-C

Maya Vaysbrot, MD

Carmen Carrahis, FNP-C

Hlab~I~1 Colman, FNP·C

Nathan Franke, PA-C

Gregory Zakas, DO

MomsBruceHamburg,ANP·C

Leslie K<:)ISiS,ANP·C

Yvonne Mclemore, FNP-C

2016-07-26 11:24:23 (GMT -07:00) Page 2/6

Phone: 523.456.6350 Fax:623518.6389

COMING SOON!

GUNDM_L ,W0NDAL[ CE['FP..4.L 'J CHHnN. AHWA,TUKEE MESA (HANl)lEG: $1_IRPPISE N,PH:':.'SCOTT:,DAlE

l~.)\ ",;'-X': .."'·'_'''.\'' ·'<;'fhl<l\-.'((,':" ',~,:(,:x,:··>r,:~"r,:>

I.:)!':,"~;T( ',T;::~·.' f.;';:-i::-''''\'fl>~ <lli3~ ~~"i('~ :,1:~1:;~

CLi:f:,lAlr._':"?,~;::.!r:~i'1~()U;;\ tl")(;,I-': t.: ,3:,~<V- I>"'W(\':'\JfJ~II!.f)~84-' Mt;·,\'.2 (1;;2,1 (\.ii\l·r':1~f I,;'_C!:<;:~ '" :~r;::;:.;:,"2 W'P'.

Patient:

Date of Birth:

JAY PEMBER

07/2111966

Visit Date:

Attending Provide,':

07/26/2016

Brian Page DO

Patient Visit Note

Referring Provider:

ASPCEyman

Active Problems

• Cervical Radiculopathy

ReasonForVisit

New patient consultation and evaluation.

History of Present Illness

This is a 50 year old Male

PositiveSymptoms. Neckpain.

Pertinent negativesymptoms:

Nochills, nofever, no chest pain or discomfort, no dyspnea, no heartburn, normal

appetite, nodysphagia, no diarrhea, no nausea, no vomiting, novertigo, no motor

disturbances, no dizzinessand no fainting

Other History

• Pastmedical history reviewed.• Medicationlist reviewed.

Patient is seenfor pain management consultation and evaluation. Pt presents stating

severecervical and left arm pain, numbnessand tingling since2005 when he was"

stomped in the neck". He hada recent MRI which shows a disc bulge at C5 C6. He

was seenby a neurosurgeonwho recommendedcervical epidural injections. Hehas

not had PT.

Painis severe without pain medications. With pain medications pain is moderate.

Patient is able to function with pain medications and brings pain to a tolerable level

without significant sideeffects.

Painimpacts quality of life which includesactivity, walking, bending, standing.

Patient has tried iceand heat. Patient has tried NSAIDS.

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 34 of 139
)MFax 2016-07-26 11:24:23 (GMT -07:00) Page 3/6

Patient Name:JAY PEMBER

Date of Birth: 07/21/1966

Date: 07/26/2016

Patient denies any history of over dosing on medications. Deniesany history of

substanceabuse.

I discussedwith patient that this is an interventional practice.

Allergies

• Tegretol (Carbamazepine) Reaction: swelling in throat

Medication History

• Albuterol 90 mcg Tablet 0 days, 0 refills

• Gabapentin 300 MGCapsule 0 days, 0 refills

• Levothyroxine Sodium 75 MCGTablet 0 days, 0 refills

• Meloxicam 15 MGTablet 0 days, 0 refills

• Nortriptyline HCI75 MGCapsule 0 days, 0 refills

• Phenytoin Sodium Extended 100 MGCapsule 0 days, 0 refills

Past Medical/Surgical History

Diagnoses:

Hepatic disorders C

Hepatitis

History of Asthma.

Surgical History: The patient reports no past surgical history.

Physical Findings

• Vitals taken 07/26/2016 09:38 am

BP-Sitting L

BPCuff Size

Pulse Rate-Sitting

Respiration Rate

Temp-Temporal

Height

Weight

Body MassIndex

Body SurfaceArea

Oxygen Saturation

126/78 mmHg

Regular

83 bpm

18 per min

97.5 F

69 in

220 Ibs

32.5 kgjm2

2.15 m2

98 %

Previous Therapy

• History of psychiatric therapy

Social History

Nothing reported.

Family History

The patient reports no family history

ReviewOf Systems

Systemic: Nofever and no chills.

Cardiovascular: Nochest pain or discomfort.

Pulmonary: Nodyspnea.

Gastrointestinal: Normal appetite, nodysphagia, and no heartburn. Nonausea, no

vomiting, and nodiarrhea.

Neurological: Nodizziness, no vertigo, no fainting, and no motor disturbances.

GeneralAppearance:

• General appearance: 0 Alert. 0 Well hydrated.

Head:

Page 2 of 5

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 35 of 139
2016-07-26 11:24:23 (GMT -07:00) Page 4/6

Patient Name:JAYPEMBER

Date of Birth: 07/21/1966

Date: 07/26/2016

Appearance: 0 Noexternal occipital swellingof the head was observed.

Lungs:

o Clear to auscultation.

Cardiovascular:

Heart RateAnd Rhythm: 0 Normal.

Heart Sounds: 0 Normal.

Abdomen:

o Normal.

Musculoskeletal System:

Shoulder:

General/bilateral: 0 Shoulderjoints havefull range of motion.

Cervical Spine:

General/bilateral: • Cervical spine showedtenderness on palpation of the

spinous process.• Cervical spinedid not show full range of motion.• A

foraminal compressiontest of the cervical spine was performed.

o Occipital protuberance (inion) was not tender on palpation.

Thoracic Spine:

General/bilateral: 0 Thoracic spineexhibited no tenderness on palpation.

Thoracolumbar Spine (Motion):

General/bilateral: 0 Thoracolumbar spinedemonstrated full range of motion.

Lumbar / Lumbosacral Spine:

General/bilateral: 0 Lumbosacral spineexhibited no tenderness on palpation.

o Lumbosacral spinedemonstrated full range of motion. 0 A straight-leg

raising test was negative.

Pelvis:

General/bilateral: 0 Both sacroiliacjoints did not show tenderness on

palpation.

Knee:

Right Knee: • Examined. 0 Medialaspect was not tender on palpation.

o Lateral aspect was not tender on palpation.

Left Knee: • Examined. 0 Medial aspect was not tender on palpation.

o Lateral aspect was not tender on palpation.

Neurological:

o Oriented to time, place, and person.

Gait And Stance: 0 Normal.

Reflexes: 0 Deeptendon reflexes were normal. 0 Biceps reflex was normal +2/4.

o Brachioradialis reflex was normal +2/4, 0 Triceps reflex was normal +2/4.

Skin:

o Normal.

Assessment/ Impression

• Cervical radiculopathy

PROCEDURE

Epidurography was performed

PROCEDURE:Epidurogram

PREOPDIAGNOSIS: Cervical disc bulge

POSTOPDIAGNOSIS:Same

SURGEON:Brian Page, DO

COMPLICATIONS:None

EBL: Minimal

INFORMEDCONSENT:After explanation of the risks, benefits, alternatives and

possiblecomplications, written and verbal consent was obtained from the patient and

placed in the chart.

Page 3 of 5

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 36 of 139
2016-07-26 11:24:23 (GMT -07:00) Page 5/6

Patient Name: JAY PEMBER

Date of Birth: 07/21/1966

Date: 07/26/2016

PROCEDUREIN DETAIL:The patient underwent cervical epidural steroid injection

today. The epidural was observed at the level of C5-C6under APand lateral

fluoroscopic guidance. 2cc of Omnipaque240 contrast was injected that evenly

spreadfrom level C5to C7 level with posterior-anterior dye spread bilaterally at level

of C5-C6and C6-C7.The intervertebral disc height at the level of C5-C6 was slightly

less than normal and intervertebral disc height at the level of C6-C7was slightly less

than normal. The neural foramen appeared to be patent.

Conclusion: Goodepidural dye containment from C5-C7. Hardcopies of the

images are on file.

Administered nerve block into the left C5-C6disc spaceby transforaminal

epidural approach

PROCEDURE:CervicalTransforaminal Epidural Steroid Injection

PREOPDIAGNOSIS: Sameas Assessment

POSTOPDIAGNOSIS:Same

SURGEON:Brian Page, DO

COMPLICATIONS:None

EBL: Minimal

INFORMEDCONSENT- Cervical Transforaminal Epidural Steroid Injection - The

nature of the procedure was explained in detail to the patient. Riskswere explained

including the possibility of dural puncture, subsequent postdural puncture headache,

at times severeand disabling for weeks, rarer possibility of infection, bleeding, nerve

injury or spinal cord injury and allergic reaction to medication. The patient has also

had an explanation of the sideeffects of corticosteroid. Possibleallergies to

iodinated radiocontrast dye, iodinated skin preparation solution, corticosteroids, and

local anesthetic haveall beenasked about and are negative by history. The patient

has signeda procedure-specific consent. The patient has hadan opportunity to have

all questions answered both on the day of initial consultation and again today. The

patient wishes to proceed.

PROCEDUREIN DETAIL:After informed consent was obtained and all of patient's

questions were answered, the patient was taken to the procedure room and placedin

the supine position with the head rotated to the opposite side. The cervical area was

prepped with Betadineand sterile drapes were placed. Icc of 1% lidocaine was

infused for local anesthesia at each location. An oblique fluoroscopy view was

obtained and a 22 gauge, 3.5 inch spinal needle was placedinto the cervical foramen

at the C5-C6level on the left using direct fluoroscopic guidance. lcc of Omnipaque

300 dye was infused at each location to rule out intravascular injection. lOmg of

dexamethasone mixed with lcc of preservative free saline was infused at each

location. The needles were removed. The patient tolerated the procedure well and

there were nocomplications noted.

Treatment Plan

• Radiculopathy, cervical region

CORRESPONDENCE: CCTO REFERRINGPHYSICIAN

• Educationand instructions for pain management were discussed.The

importance of taking the medication was discussedas well as possibleside effects

including constipation or sedation. If sudden loss of bowel or bladder function, or

severe weaknessof extremities occurs, seek emergent medical treatment

• Return to the clinic if condition worsens or new symptoms arise, otherwise

schedule follow up or treatment as noted. Noother concerns noted

Page 4 of 5

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 37 of 139
)MFax 2016-07-26 11:24:23 (GMT -07:00) Page 6/6

Patient Name: JAY PEMBER

Date of Birth: 07/21/1966

Date: 07/26/2016

I reviewed patient's AZ pharmacy board report, referring physician notes, and

imaging studies sent over.

Ireviewed our pain and urine drug screen agreement. Patient verbalized

understanding and signed.

Thank you for this referral.

Today I proceeded with a cervical transforaminal epidural at C5 C6on the left. He

should return in 4 weeks for a second injection.

The patient receiveda 25mg 1M injection of Demerol given in R Deltoid

Lot #095386 Exp 09/2017

Administered by Jim T, Lpn

Health Reminders

• Assess BMI satisfied 07/26/2016.

Note faxed to ASPCEyman and ASPCFlorence (cb)

Brian Page DO

Electronically signed by: Brian Page Date:07/26/201610:44

Page 5 of 5

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 38 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 5

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 39 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 22, 2018 

10:47:54

Encounter Header

Date*: 11/07/2016 Start Time*: 14:37:33

End Date*: 11/07/2016 End Time*: 14:54:19

Category: Medical Provider

Type*: Practitioner - Chronic Care Encounter Close Date: 11/15/2016

Location*: ASPC-E BROWNING STG [A52] Encounter Close Time: 13:56:33

Setting*: Clinic

Staff Member*: Salyer, Nick C

Title: Physician Assistant

Form Type:

Subjective

Related Health Service Requests (1 - 2 of 2)

Request Date Area of Interest Request Type Status

09/01/2016 Provider Not Required to be Seen Encounter Held

11/03/2016 Provider Duplicate HNR Encounter Held

Subjective Notes

Request Date: 11/03/2016

Wants to See Provider About Pain Management. Was Scheduled 10/20/16 and Not Seen.

Request Date: 09/01/2016

Wants Status of Pain management Regimen

Patient Was Seeing Pain Management Clinic For Spinal cervical Steroid Injections Had One Several 

Months Ago, Staes Suppose To F/U @ Pain Management Clinic For Series Of Injections.

Continued Pain especially 4-6 Hours After Current Rx Regimens Makes Him Restless, and Anxious @ 

Night 7-9 Pains Left Neck Upper Back Radiates Down Left Arm.

Denies Recent SZs, and Asthma Attacks Since last Visit. Denies SXs Of Hep C.

Objective

Vital Signs (1 - 1 of 1)

Taken By Time Temp Pulse Resp HeightWeight BP

Systolic

BP

Diastolic

Blood

Sugar Comments

Salyer, Nick C, PA 14:38 97.5 88 18 5 9 223 140 80 NA

Objective Notes

See MRI, and Pain management Clinic Injections.

A+Ox4, Mild Discomfort Today, Fully Lucid, and Cognitive. Mildly Anxious Mood, and Affect.

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 40 of 139
CNsII-XII Grossly Intact.

PERLA, EOMI OUs.

Very Mild Left lateral cervical Neck Muscle Atrophy, Left Shoulder Muscle Atrophy, and Left Upper, 

and Lower Arm Muscle Atrophy. Patient In Side Restraints, Mild Weak Left Shoulder Shrug, and 

Moderately Weak Left Arm Hand Strength. decreased DTRs Left Arm. decreased Sharp Dull and 

Monofilament Testing Sensations Left Hand Mostly First Three Digits.

Symmetrical Wrist Pulses 4/4. Good Capillary Refill All Digits Bilateral hands.

No Nucchal Cervical Spinal Rigidity.

Lungs CTA, and Normal Symmetrical Excursions Bilaterally.

Heart Has RRR W/O Murmurs.

Abdomen Is W/O Ascites, NT W/O Gross Hepatosplenomegaly.

Non-Tender Lumbar sacral AROM W/O Rigidity.

Negative SLRs Bilateral LEs.

Tandem gait W/IO Foot Drop.

Assessment

Medical Diagnosis/Complaint

ICD Code Diagnosis/Complaint

No Rows Found

Chronic Conditions Being Treated

Asthma NOS [493.90]: Mild intermittent asthma, 

uncomplicated [J45.20]:

Unspecified asthma, 

uncomplicated [J45.909]: Coronary Artery Disease (CAD):

Diabetes Type I: Diabetes Type II:

Dyslipidemia: Chronic viral hepatitis C [B18.2]:

HIV/AIDS: Hypertension:

Multiple Sclerosis (MS): Convulsions NEC [780.39]:

Unspecified convulsions [R56.9]: Sickle Cell:

Tuberculosis Active (TB): Tuberculosis Latent Inactive (LTBI):

Hypothyroidism NOS [244.9]: Hypothyroidism, unspecified 

[E03.9]:

Active Allergies/Health Problems/Conditions (1 - 16 of 16)

ID 

Number Category Type National HIE 

Code(s) Diagnosis Code Status Status Date

001 Chronic 

Conditions Asthma Assessed 10/02/2013

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/2013

003 Communicable 

Diseases Hepatitis C Assessed 10/02/2013

004 Allergies -

Medication Carbamazepine Assessed 08/04/2014

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 41 of 139
005 Mental Health Mental Health Assessed 08/04/2014

006 Mental Health Mental Health

Bipolar 

disorder NOS 

[296.80]

Assessed 08/04/2014

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/2014

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/2014

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/2014

010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/2015

011 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism 

NOS [244.9] Assessed 09/30/2015

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/2015

013 Chronic 

Conditions Asthma Asthma NOS 

[493.90] Assessed 09/30/2015

016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/2015

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/2015

020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 

- Cervical 

root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/2016

Related Allergies/Health Problems/Conditions (1 - 4 of 4)

ID 

Number Category Type

National 

HIE Code

(s)

Diagnosis Code Status Status Date

014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions [R56.9] Assessed 10/01/2015

015 Other Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified [E03.9] Assessed 10/01/2015

017 Chronic 

Conditions Asthma

Unspecified asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/2015

018 Communicable Hepatitis C Chronic viral Assessed 11/16/2015

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 42 of 139
Diseases hepatitis C [B18.2]

Assessment Notes

Asthma, and SZs Under Good Control @ Goal.

Hep C Fair Control, Unchanged APRI=0.67

Hypothyroid Therapy @ Goal.

Chronic Neuropathic pain Due To Cervical Spinal Stenosis Under Pain Management.

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 6 of 6)

View MAR Summary

Prescription/Medication National HIE 

Code(s) 

Effective

Date Dosage Frequency Expiration Status

CROMOLYN NASAL 

SPRAY (26) INHA/4% 

RxNorm: 

746341 -

200 

ACTUAT 

Cromolyn 

Sodium 5.2 

MG/ACTUAT 

Nasal 

Inhaler; 

09/17/2016 1 

spray

FOUR 

TIMES 

DAILY

03/15/2017

Received 

from 

Pharmacy

MELOXICAM TABS/15 

Mg 

RxNorm: 

152695 -

meloxicam 

15 MG Oral 

Tablet; 

09/25/2016 1 EVERY 

DAY 03/23/2017

Received 

from 

Pharmacy

LEVOTHYROXINE SOD 

TABS/0.075 Mg 

RxNorm: 

966171 -

Synthroid 

75 MCG 

Oral 

Tablet; 

08/09/2016 1 EVERY 

MORNING 02/05/2017

Received 

from 

Pharmacy

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 

855671 -

Phenytoin 

sodium 100 

MG 

Extended 

Release 

Capsule; 

08/08/2016 2 TWICE 

DAILY 02/04/2017

Received 

from 

Pharmacy

NORTRIPTYLINE HCL 

CAPS/75 Mg 08/04/2016 1 EVERY 

EVENING 01/31/2017

Received 

from 

Pharmacy

GABAPENTIN 

08/04/2016 2 tab

TWICE 

12/02/2016 Received 

from 

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 43 of 139
CAPS/300 Mg DAILY Pharmacy

Ordered Drug Prescriptions (1 - 1 of 1)

Prescription/Medication

National 

HIE Code

(s)

Effective

Date Dosage Frequency Expiration Status

GABAPENTIN CAPS/300 

Mg 11/07/2016 3 TWICE 

DAILY 03/06/2017 Discontinued 

- Other

Lab Test Orders (1 - 3 of 3)

Lab Test Type National HIE Code(s) Priority Status Results Value

URINALYSIS 

(UA) 

LOINC: 5794-3 - Hgb Ur Ql 

Strip; 58450-8 - Bilirubin 

Confirm., Ur; 20454-5 -

P...

Rout (Draw10days;Rslts48hrs) Completed -

Results 

Reviewed 

See 

Report

From 

Vendor

PSA Total 

LOINC: 35741-8 - PSA 

SerPl DL<=0.01 ng/mLmCnc; 

Rout (Draw10days;Rslts48hrs) Completed -

Results 

Reviewed 

See 

Report

From 

Vendor

Diagnostic 

Panel 2 

LOINC: 3050-2 - T3 Uptake 

(T3U); 2085-9 - HDL 

CHOL., DIRECT; 3026-2 -

Thyroxin...

Rout (Draw10days;Rslts48hrs) Completed -

Results 

Reviewed 

See 

Report

From 

Vendor

X-Ray Orders 

X-Ray Body Area Priority Status

No Rows Found

Consultation Request (1 - 1 of 1)

Request Type Service Type Priority Status

Off-site Clinic Pain Clinic Routine Consult Completed- Practitioner Reviewed

Follow-up Appointments (1 - 3 of 3)

Date Time Type Staff Location

11/17/2016 02:37:34 Health Services Salyer, Nick C ASPC-E BROWNING STG

11/17/2016 02:37:35 Health Services Salyer, Nick C ASPC-E BROWNING STG

11/17/2016 14:37:33 Health Services Salyer, Nick C ASPC-E BROWNING STG

Patient Transfer Holds

Type Expiration Date Status

No Rows Found

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comments

No Rows Found

Plan Notes

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 44 of 139
1) Consult to Pain Management Clinic For Follow Up Spinal Injections requesting Approval**

2) Requesting NFDR To Increase Gabapentin To 900 MG PO BID DOT**

3) F/U Chronic care, and Pain Management in Feb 2017 or Via HNR PRN**

4) labs**

Patient Education

Patient Education Notes

Patient Ed To Avoid Heavy Lifting, and No Behind The Head Situps, and No Jumping Exercises.

May Do Gentle AROM, and Gentle Stretching Exercises Only For Now**

Meaningful Use Measurement

 Demographic Information in Patient Header verified

 Current Medical Problem List verified (or Patient has no Medical Problems)

 Current Medications List verified (or Patient has no Medical Medications) Medications List NOT 

verified 

 Medication Allergies List verified (or Patient is not allergic to any Medications)

Health Classification

Medical: 3

Mental: 3E-Not on meds > 6 months with 30 day follow-up Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Encounter Orders Review 

Review Type*: Pending Nurses Order Review Staff: Gowey, Catherine, RN

Review Date: 11/07/2016 Review Time: 22:58:02

Review Notes

See Plan, Labs, Consult, and RX Changes**

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms (1 - 1 of 1)

Type Staff

Lab Test Order Monz, Jamilyn K

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 45 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 6

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 46 of 139
CHSS027J - Condensed Health Services Encounter 8/22/18, 12'28 PM

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CHSS027J Condensed Health Services Encounter Wednesday August 22, 2018 12:25:31 PM

ADC #: 067165 Inmate Name: PEMBER, JAY L. 

ENCOUNTER DATE: 12/29/2016 TIME: 12:59:16 DURATION: minutes TYPE: Provider - Follow

Up Care

LOCATION: ASPC-E BROWNING STG [A52] SETTING: Clinic

S NOTES: 

Pt here to ask why he hasn't had a follow up epidural injection for his neck and arm pain. He states

they are supposed to be every 3 months. His neck pain, described as burning is 8/10 and starts in

the back of his neck and radiates down his L arm. He states that the previous epidural injections

gave him relief for approx. 2 weeks. He states that at one point surgery was discussed to remove

the disc and readjust the bones in his neck. He doesn't think the Nortriptyline is helping his pain and

says he is having more urinary issues, specifically starting a stream since starting the med. He is

asking for an increase in his Gabapentin, stating that seems to help and thinks a higher dose may

decrease the burning more.

He wants to discuss his R ankle pain which is associated with an old gun shot wound. He describes

the pain as burning, tingling and numbness. 

He also wants to discuss his PSA lab results, stating that his dad died of prostate CA in his 60's.

O PREV: 12:28:02 TEMP: 97.5 PULSE: 89 RP: 16 BP: 128/85 HT: 5 ft. 9 in. WT: 220 lb

BLOOD SUGAR: NA + 

02 SAT: 99.00% SOURCE: Room Air

NOTES: 

GEN: alert and oriented x 3, NAD,cooperative

MSK: Neck is tender to palpation, arm strength 3/5 bilat, ROM intact but painful, no recent x-rays of

neck

R ankle with surgical scar present on medial aspect

A RELATED PROBLEM: Other Diagnosis: Other Diagnosis Spinal stenosis, cervical region

[M48.02]

MEDICAL DIAGNOSIS: Spinal stenosis, cervical region [M48.02]

NOTES: Spinal stenosis, cervical region

P X-RAY ORDERED: Cervical, 3V VERBAL BY: Hutchinson, Julie

APPT SCHEDULED: X-Ray WITH: Hutchinson, Julie

ON: 01/08/2017 AT: 12:59:16

APPT SCHEDULED: Provider - Follow Up Care WITH: Hutchinson, Julie

ON: 01/27/2017 AT: 14:56:00

NOTES: 

Nortriptyline discontinued

Pt scheduled for cervical injection next week

follow up in 1 month to assess pain

Consider increasing Gabapentin if indicated

E NOTES: 

pathophysiology of Degenerative Disc disease and it's effect on the spine discussed. Medication side

effects discussed. PSA results discussed.

H/S MH Status: Outpatient-Regular MH Contact

STAFF: Hutchinson, Julie

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 47 of 139
CHSS027J - Condensed Health Services Encounter 8/22/18, 12'28 PM

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 48 of 139
CHSS027J - Condensed Health Services Encounter 8/22/18, 12'28 PM

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Clinical Orders

ADC #: 067165 Inmate Name: PEMBER, JAY L. 

Encounter Date: 12/29/2016 Encounter Time: 12:59:16

X-RAY: ORDERED: Cervical, 3V VERBAL BY: Hutchinson, Julie

APPT SCHEDULED: X-Ray WITH: Hutchinson, Julie

ON: 01/08/2017 AT: 12:59:16

APPT SCHEDULED: Provider - Follow Up Care WITH: Hutchinson, Julie

ON: 01/27/2017 AT: 14:56:00

PROVIDER SIGNATURE: _________________________________________________

Hutchinson, Julie

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 49 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 7

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 50 of 139
c_.mzoN ....- HEALTW' - •._

Reference # G~ ,d(.ol(i,''Vl Date of Service \/~Jll

Patient. . -\,em'oe~ ._,_".....,.., ~_~o....1 . Patient 10:(011 G,S DOB: 11a.\ Iv~

Facility: t'iNur) Facility 10: '~~",\l'\ Phone:

practition~: ~~\lC(\cz.~ ~l{\ C.\\\\4 Practitioner Type: ~c,,\{l C.\ \.,,\L(_

--.J

locationi'2_\ ..R ~(A \{

*** See Attached Consultation Request for Health Services Authorized ***

Forsecurity reasons inmates must NOTbe informed of recommended treatment or possible hospitalization. Due to

security considerations, 0/1 recommended tests and treatments are to be scheduled by Corizon.

Review of Case (Chief complaint, exam findings, etc.):

PI f>I-- <f7 eM 1'-1 e ,.vcr: -'( r- @ _4--1"N) p.lf />:

Lfd/v P~/r/ ;Z-rv- / r p: rP""""'"'

v('jl fi PI (J~,.(I1-

Diagnosis and Prescription Suggestions (To be reviewed by Corizon Medical Director):

- f}176 ~vt- (7-C

I-- 1- »» Cell.//c 1t EPI.D L{P1-er rf7p~

Can equivalent medication substitution be used? IrYes r No jFOliow-uP needed?~eS rNO

If follow up needed, explain:

#~_e: OS Cfwl) 5 tf!-tfJ EP'-?~!71JL /,_/

~

(J, j>~~~ /t-~

~ Il'!') Practitionerr Name (Print) Ira910ner Signature Date

To be completed by Corizo! ractitioner

Recommendation after review of consultant's report: 1r: No fu~e r action r Imolement the followineImplement:

Conzon Practitioner Name (Print) Corlzon Practitioner Signature Date

Practitioner Consultation Report

(Complete and return in SEALEDenvelope with Correctional Officer)

UM002 - 401C Page1 of Z © 2015Corizon Health, Inc. All rights reserved.

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 51 of 139
Pl'1Fax 2017-01-04 15:57:18 {GMT -07:00} Page 2/4

Patient: JAY PEMBER

Date of Birth: 07/2111966

Visit Date: (J1/0.312017

Attending Provider: Brian Page DO

Patient Visit Note

Referring Provider;

ASPCEyman

Active Problems

• Cervical Radiculopathy

History of Present Illness

This is a 50 year old Male

Patient is seen in follow up today for his second cervical transforaminal epidural

steroid injection C5 C6 on the left

Allergies

• Tegretol (Carbamazepine) Reaction: swelling in throat

Medication History

• Albuterol 90 meg Tablet 0 days, 0 refills

• Gabapentin 300 MG Capsule CAPS, 0 days, 0 refills

• Lcvothyroxinc Sodium 75 MCGTablet 0 days, 0 refills

• Meloxicarn 15 MG Tablet 0 days, 0 refills

• Nortriptyline HCI 75 MG Capsule CAPS, 0 days, 0 refills

• Phenytoin Sodium Extended 100 MG Capsule CAPS, 0 days, 0 refills

Past Medical/Surgical History

Diagnoses:

Hepatic disorders C

Hepatitis

Surgical History: The patient reports no past surgical history.

Phvsical Findings

General Appearance:

o Normal. 0 Well hydrated.

Lungs:

...............

-

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 52 of 139
PMFax 2017-01-04 19:33:58 (GMT -07:00) Page 2/4

Patient:

Date of Birth:

JAY PEMBER

07/2lf1966

Visit Dote:

Attending Provider:

01l113/21H7

Brian Page DO

Patient Visit Note

Referring Provider:

ASPC Eyman

Active Problems

• Cervical Radiculopathy

History of Present Illness

This is a 50 year old Male

Patient is seen in follow up today for his second cervical transtoramlnal epidural

steroid injection C5 C6 on the left

Allergies

• Tegretol (Carbarnazepine) Reaction: swelling in throat

Medication History

• Albuterol 90 mcg Tablet 0 days, 0 refills

• Gabapentin 300 MG Capsule CAPS, 0 days, 0 refills

• Lcvothvroxinc Sodium 75 MeG Tablet a days, 0 refills

• Mcioxicam 15 MGTablet 0 days, 0 refills

• Nortriptyline HC! 75 MG Capsule CAPS, 0 days, 0 refills

• Phenytoin Sodium Extended 100 MGCapsule CAPS, 0 days, 0 refills

Past Medical/Surgical History

Diagnoses:

Hepatic disorders C

Hepatitis

Surgical History: The patient reports no past surgical history.

Physical Findings

General Appearance:

o Normal. 0 Well hydrated.

Lungs:

.....- . -, ................., ..

u~."

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 53 of 139
PMFax 2017-01-04 19:34:04 (GMT -07:00) Page 3/4

Patient Name; JAY PEMBER.

Date Df Birth: 07/21/1966

Date: 01/03/2017

o Clear to auscultation.

Cardiovascular:

Heart Rate And Rhythm: 0 Normal.

Heart Sounds: 0 Normal.

Abdomen:

D Normal.

Musculoskeletal System:

Cervical Spine:

General/bilateral: 0 Cervical spine had a normal appearance. 0 Cervical spine

showed no tenderness on palpation.

Lumbar I Lumbosacral Spine: .

General/bilateral: 0 Lumbosacral spine exhibited no tenderness on palpation.

o Lumbosacral spine motion was normal.

Neurological:

D Oriented to time, place, and person.

Assessment/Impression

• Cervical radiculopathy

PROCEDURE

Epidurography was performed

PROCEDURE: Epidurogram

PREOPDIAGNOSIS: Cervical disc bulge

POSTOP DIAGNOSIS: Same

SURGEON: Brian Page, DO

COMPLICAT10NS: None

EBL: Minimal

INFORMED CONSENT: After explanation of the risks, benefits, alternatives and

possible complications, written and verbal consent was obtained from the patient and

placed in the chart.

PROCEDUREIN DETAIL: The patient underwent cervical epidural steroid injection

today. The epidural was observed at the level of C5-C6 under AP and lateral

fluoroscopic guidance. 2ec of Omnipaque 240 contrast was injected that evenly

spread from level CS to C7 level with posterior-anterior dye spread bilaterally at level

of CS-C6 and C6-C7. The intervertebral disc height at the level of C5-C6 was slightly

less than normal and intervertebral disc height at the level of C6-C7 was slightly less

than normal. The neural foramen appeared to be patent.

Conclusion: Good epidural dye containment from C5-C7. Hard copies of the

images are on file.

Administration of anesthesia for procedures; Monitored Anesthesia Care - See

Anesthesia Record •

. Adm'nistered nerve block into the left C5-C6 disc space by transforamintll

epidural approach

PROCED~RE: Cervical Transforaminal Epidural Steroid Injection

PREOP DlAGNOSIS; Same as Assessment

POSTOP DIAGNOSIS; Same

SURGEON: Brian Page, DO

COMPLICATIONS: None

EBL: Minimal

Page 2 of 3

..-_,,-

....-,~-

....&......

.---..~,,-...

-____

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 54 of 139
PMFax 2017-01-04 18:34:04 (GMT -07:00) Page 4/4

Date: 01/03/2017

Patient Name: lAY PEMBER

Date of Birth: 07/21/1966

INFORMEDCONSENT- Cervical Transforaminal Epidural Steroid Injection - The

nature of the procedure was explained In detail to the patient. Risks were explained

including the possibility of dural puncture, subsequent postdural puncture headache,

at times severe and disabling for weeks, rarer possibility of infection, bleeding, nerve

injury or spinal LOrd injury and allergic reaction to medication. The patient has also

had an explanation of the side effects of corticosteroid. possible allergies to

iodinated radiocontrast dye, iodinated skin preparation solution, corticosteroids, and

local anesthetic have 011 been asked about and are negative by history. The patient

has signed a procedure-specific consent. The patient has had an opportunity to have

all questions answered both on the day of initial consultation and again today. The

patient wishes to proceed. PROCEDUREIN DETAIL: After informed consent was obtained and all of patient's

questions were answered, the patient was taken to the procedure room and placed in

the supine position with the head rotated to the opposite side. The cervlca I area was

prepped with Betadine and sterile drapes were placed. 1cc of 1% lidocaine was

Infused for local anesthesia at each location. An oblique fluoroscopy view was

obtained and a 22 gauge, 3.5 inch spinal needle was placed into the cervical foramen

at the CS C6 level on the left using direct fluoroscopic guidance. tee of Omnipaque

300 dye was infused at each location to rule out intravascular injection. 10mg of

dexamethasone mixed with lcc of preservative free saline was infused at each

location. The needles were removed. The patient tolerated the procedure well and

there were no complications noted.

Treatment Plan

• Radic:ulopathy, cervical region

CORRESPONDENCE:CCTO REFERRINGPHYSICIAN

Patient is to call the office if any signs of bleeding or infection occur.

Patient to follow up in 2 weeks

Post Op Note: Patient stable ad' II .

pending anesthesia assessmentan~U~?~~~a~g~Pp~o~.naiehfor discharge to home

anesthesia recovery and has met criteria for discharqe. as been evaluated for

The patient received a 25m 1M" .

Lot # 026370 exp 2/18 g injection of Demerol given in right delt

Administered by Esther L MA

Brian Page DO

Electronically signed by: Brian Page Date: 01104/2017 07:12

Page 3 of 3

--

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 55 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 8

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 56 of 139
C~RIZON _..- .-~-..

He:ALTHPractitioner Consultation Report .-

(Complete and return in SEALEDenvelope with Correctional Officer)

Reference1# C"K'r)k.

.

a.lc·~~o'-\ Dateof Service a·"'..'l

Patient: ~ '('(\~-,:: .'0. Patient10: {ol Hi::> DOB:]- d\-vl::-

~V'\

-'

Facility: Facility10: ~\'t\~ Phone:

r: ~\1CI,'Cl\II.}I._ \b.,,,,- (\'" Practitioner Type:~c..\C\ C\\ {\, l

J

Practttioru Location:C, 'e~\(

... SeeAttached Consultation Requestfor Health ServicesAuthorized ***

Forsee ~rity reasons inmates must NOT be informed of recommended treatment or possible hospitalization. Due to

security considerations, all recommended tests and treatments are to be scheduled by Corizon.

Reviewof ~ase(Chiefcomplaint, examfindings,etc.):

p1 7p

Stvel~ ;VteA .". (!l A"'_' (/~//

it1~ P..t//"" j'I- tt-/ e", f//e;IVI '1Sf' / """,?Cer.~

Diagnosisand PrescriptionSuggestions(Tobereviewedby CorizonMedical Director):

p(~ ~ b'fCy" {J.... v

Canequiv~Ientmedicationsubstitution beused? lP'Yes r: No IFOIIOW-UPneeded?If\ve.s c: NO

If follow t.p needed,explain: ~"f/H~-/C. /-' l(""",..-s ,A/

~r~ '''-'

A'

o -~vC ~ h -;J_ ?iL,

Practition~rr Name (Print) 1/ ~ion~ Signature Date

Tobecompleted bv/f_r1'(practitioner

Recomm.ndation after review of consultant's report: lr/Io~urther action rImolement the followine

lmplemet t: f

I

I

!

Corizon Practitioner Name (Print) Corizon Practitioner Si&natur~ Date

UMOO2- 40 C Page lof2 (C) 2015CorizonHealth,Inc. All rights re~lIrved.

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 57 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 9

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 58 of 139
CHSS027J - Condensed Health Services Encounter 8/22/18, 12'29 PM

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CHSS027J Condensed Health Services Encounter Wednesday August 22, 2018 12:27:06 PM

ADC #: 067165 Inmate Name: PEMBER, JAY L. 

ENCOUNTER DATE: 02/23/2017 TIME: 08:09:12 DURATION: minutes TYPE: Provider - Follow

Up Care

LOCATION: ASPC-E BROWNING STG [A52] SETTING: Clinic

S Are interpreter services needed for this inmate: No 

NOTES: 

Provider visit completed form discussion of alternative therapy treatment options for ghabapentin

use as well as alternative treatment discussion regarding orthotics request. Started discussion

regarding the use of gabapentin for neuropathy pain and discomfort cervical stenosis. patient states"

I cannot be taken off gabapentin because I have grand mal seizure activity. I haven't had a seizure

since beginning this drug. informed patient about gabapentin not currently used for grand mal

seizure activity, but adjunct therapy for petite mal seizure activity. Also informed about alternative

use with other anticonvulsants which also dual actionme4deication that treats neuropathy

discomfort. next; patient with complaints of right foot deformity secondary to old injury with

multiple surgical repairs secondary to GSW. Admits some numbness and stiffness of right foot digit

3m,4 &5 non-movement. requesting ankle support for ankle. debnnies any increased swelling to

right ankle joint or open wound right foot digits.

MRI cervical (05/2016) resulted discbuldge C5-C6 region. Seen by neurosurgeon who suggested

epidural injections; received 2nd injection (01/06/2017) at C5-C6 region under folurospy.

O PREV: 07:57:06 TEMP: 97.9 PULSE: 90 RP: 16 BP: 119/81 HT: 5 ft. 9 in. WT: 218 lb

BLOOD SUGAR: NA + 

02 SAT: 98.00% SOURCE: Room Air

NOTES: 

General: no apparent distress noted

Cervical spine: trachea midline, supple, positive full range of motion noted with relation, and fluxion

and hyperextension; negative discomfort on palpation,

Lumbar spine: ambulatory in exam rom with steady gait; no deformity or limp noted ;lumbar spine

positive soft without spam noted; no spine swelling noted or muscle atrophy noted; positive full range of

motion noted with flexion, rotation and side bends and hyperextension; upper waste level

Extrem: weariing appears like new (New balances foot wear) feet without lesions, blisters, or wounds noted;

all digits nail beds pink, clear, positive range of motion noted; positive color pink, warm and dry. old scar

inner aspect right ankle well healed with minor deformity noted ambulatory with steady gait, Move all

extremity with full range of motion; positive equal grips bilateral; straight leg raises negative, strength 5/5;

good muscle tone and bulk noted all extremities; positive sensation all extremities noted

Neuro: CN II-XII grossly intact, no focal deficits noted reflexes all extremities grossly intact

A RELATED PROBLEM: Other Diagnosis: Other Diagnosis Low back pain [M54.5]

Other Diagnosis: Other Diagnosis Cervicalgia [M54.2]

Other Diagnosis: Other Diagnosis Pain in right ankle and joints of right foot

[M25.571]

MEDICAL DIAGNOSIS: Pain in right ankle and joints of right foot [M25.571]

Cervicalgia [M54.2]

Low back pain [M54.5]

NOTES: 

Lower back pains, cervicalgia:

chronic pain

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 59 of 139
CHSS027J - Condensed Health Services Encounter 8/22/18, 12'29 PM

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P NOTES: 

continue to wean off gabapentin therapy

continue NORTRIPTYLINE HCL CAPS/75 Mg

on Amitriptyline Hcl (Ud)/50 Mg at bed time for now

ankle support

E NOTES: 

medication changes

alternative treatment plan for chronic pain

ankle support for right ankle

follow up as needed

H/S MH Status: Outpatient-Regular MH Contact

STAFF: Gay, Maureen

PROVIDER SIGNATURE: _________________________________________________

Gay, Maureen

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 60 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 10

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 61 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 08, 2018 

15:27:27

Encounter Header

Date*: 03/07/2017 Start Time*: 12:48:02

End Date*: 03/07/2017 End Time*: 12:54:26

Category: Nursing

Type*: Nurse - Return From Offsite Encounter Close Date: 03/13/2017

Location*: ASPC-E BROWNING STG [A52] Encounter Close Time: 11:17:37

Setting*: Clinic

Staff Member*: Ortiz, Carol

Title: Registered Nurse

Form Type: Continuous Progress Record - Inmate Returning from Hospital

Subjective

Are interpreter services needed for this inmate*: No

What type of interpreter services were used for the encounter*: 

Related Health Service Requests (1 - 1 of 1)

Request Date Area of Interest Request Type Statu

03/06/2017 Nursing Routine Encounter Held

Subjective Notes

Request Date: 03/06/2017

Severe pain

Inmate stated he got Epidural shot left side of neck, C5-C6. 

Objective

Vital Signs (1 - 1 of 1)

Rev #: 359

Continuous Progress Record - Subjective

Inmate return from: Scheduled appointment or procedure 

 Emergency transport and/or admission 

Copy of SOAP to ASOII: Y N 

Inmate returned from:Advanced Pain Management at 06:49:00

For (describe): Treatment of severe cervical pain

CHSS027C - Health Services Encounter Page 1 of 7

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 62 of 139
Taken By Time Temp Pulse Resp Height Weight BP

Systolic

BP

Diastolic

Blood

Sugar Comments

Ortiz, Carol, RN 12:49 98.1 80 16 5 9 220 118 82 NA

Objective Notes

None

Assessment

Active Allergies/Health Problems/Conditions (1 - 27 of 27)

ID 

Number Category Type National HIE 

Code(s) Diagnosis Code Status Status D

001 Chronic 

Conditions Asthma Assessed 10/02/20

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/20

003 Communicable 

Diseases Hepatitis C Assessed 10/02/20

004 Allergies -

Medication Carbamazepine Assessed 08/04/20

005 Mental Health Mental Health Assessed 08/04/20

006 Mental Health Mental Health Bipolar disorder 

NOS [296.80] Assessed 08/04/20

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/20

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/20

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/20

Rev #: 359

Continuous Progress Record - Objective

Discharge orders/recommendations:

Describe:

Describe:

Location:

Describe:

Dressing: Y N Location:

Dressing changes required: Y N 

Sutures: Y N 

Complaints: Y N 

CHSS027C - Health Services Encounter Page 2 of 7

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 63 of 139
010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/20

011 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism 

NOS [244.9] Assessed 09/30/20

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/20

013 Chronic 

Conditions Asthma Asthma NOS 

[493.90] Assessed 09/30/20

014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions 

[R56.9]

Assessed 10/01/20

015 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 10/01/20

016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/20

017 Chronic 

Conditions Asthma

Unspecified 

asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/20

018 Communicable 

Diseases Hepatitis C

Chronic viral 

hepatitis C 

[B18.2]

Assessed 11/16/20

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/20

020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 -

Cervical root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/20

021 Mental Health Mental Health

SNOMED: 

55668003 -

Adjustment 

disorder with 

mixed 

emotional 

features 

(disorder)

Adjustment 

disorder with 

mixed anxiety 

and depressed 

mood [F43.23]

Assessed 11/08/20

022 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

83561009 -

Spinal stenosis 

in cervical 

region 

(disorder)

Spinal stenosis, 

cervical region 

[M48.02]

Assessed 12/29/20

023 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

11049006 -

Cervical 

Radiculopathy, 

cervical region 

Assessed 01/27/20

CHSS027C - Health Services Encounter Page 3 of 7

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 64 of 139
radiculitis 

(disorder)

[M54.12]

024 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

813001 - Ankle 

instability 

(finding)

Injury of other 

nerves at ankle 

and foot level, 

right leg, 

sequela 

[S94.8X1S]

Assessed 01/27/20

025 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

134407002 -

Chronic back 

pain (finding)

Low back pain 

[M54.5] Assessed 02/23/20

026 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

1121000119107 

- Chronic neck 

pain (finding)

Cervicalgia 

[M54.2] Assessed 02/23/20

027 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

299447008 -

Ankle joint -

painful on 

movement 

(finding)

Pain in right 

ankle and joints 

of right foot 

[M25.571]

Assessed 02/23/20

Related Allergies/Health Problems/Conditions 

ID Number Category Type National HIE Code(s) Diagnosis Code Status Status Da

No Rows Found

Assessment Notes

Altered comfort

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 7 of 7)

View MAR Summary

Prescription/Medication National HIE 

Code(s) 

Effective

Date Dosage Frequency Expiration Status

RxNorm: 

Rev #: 359

Continuous Progress Record - Assessment

 Stable 

 Unstable 

CHSS027C - Health Services Encounter Page 4 of 7

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 65 of 139
LEVOTHYROXINE SOD 

TABS/0.075 Mg 

966171 -

Synthroid 75 

MCG Oral 

Tablet; 

02/24/2017 1 EVERY 

DAY 08/22/2017

Received 

from 

Pharmacy

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 

855671 -

Phenytoin 

sodium 100 

MG Extended 

Release 

Capsule; 

02/10/2017 2 

caps

TWICE 

DAILY 06/09/2017

Received 

from 

Pharmacy

Amitriptyline Hcl 

(Ud)/50 Mg 

RxNorm: 

856845 -

Amitriptyline 

Hydrochloride 

50 MG Oral 

Tablet; 

01/27/2017 1 EVERY 

BEDTIME 05/26/2017

Received 

from 

Pharmacy

NORTRIPTYLINE HCL 

CAPS/75 Mg 02/01/2017 1 EVERY 

EVENING 07/30/2017

Received 

from 

Pharmacy

PAROXETINE HCL 

TABS/40 Mg 

RxNorm: 

312244 -

Paroxetine 40 

MG Oral 

Tablet; 

11/15/2016 1 EVERY 

EVENING 05/13/2017

Received 

from 

Pharmacy

CROMOLYN NASAL 

SPRAY (26) INHA/4% 

RxNorm: 

746341 - 200 

ACTUAT 

Cromolyn 

Sodium 5.2 

MG/ACTUAT 

Nasal 

Inhaler; 

09/17/2016 1 

spray

FOUR 

TIMES 

DAILY

03/15/2017

Received 

from 

Pharmacy

MELOXICAM TABS/15 

Mg 

RxNorm: 

152695 -

meloxicam 

15 MG Oral 

Tablet; 

09/25/2016 1 EVERY 

DAY 03/23/2017

Received 

from 

Pharmacy

Ordered Drug Prescriptions 

Prescription/Medication National HIE Code(s) Effective

Date Dosage Frequency Expiration Statu

No Rows Found

Lab Test Orders 

Lab Test Type National HIE Code(s) Priority Status Results Value

No Rows Found

X-Ray Orders 

X-Ray Body Area Priority Status

No Rows Found

CHSS027C - Health Services Encounter Page 5 of 7

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 66 of 139
Consultation Request 

Request Type Service Type Priority

No Rows Found

Follow-up Appointments (1 - 1 of 1)

Date Time Type Staff Locatio

03/13/2017 09:57:00 Health Services Gay, Maureen ASPC-E BROWNING 

Patient Transfer Holds

Type Expiration Date Sta

No Rows Found

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comm

No Rows Found

Plan Notes

None at this time as no report to medical from that facility. They told him if it continuous in pain it could e

nerve burn for therapy.

Patient Education

Patient Education Notes

Submit an HNR for medical issues as needed.

Meaningful Use Measurement

 Demographic Information in Patient Header verified

 Current Medical Problem List verified (or Patient has no Medical Problems)

Rev #: 359

Continuous Progress Record - Plan

Returned with medications: Y N 

On call practitioner notified for medication order: Y N 

Verbal medication orders entered into system: Y N 

Copy of consultation report to clinical coordinator: Y N 

Returned to unit at: 21:45:00

CHSS027C - Health Services Encounter Page 6 of 7

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 67 of 139
 Current Medications List verified (or Patient has no Medical Medications) Medications List NOT 

verified 

 Medication Allergies List verified (or Patient is not allergic to any Medications)

Health Classification

Medical: 3

Mental: 3B-Outpatient-Regular MH Contact Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Encounter Orders Review 

Review Type*: Practitioner Review Review Staff: Gay, Maureen

Review Date: 03/13/2017 Review Time: 11:17:37

Review Notes

agree with current plan 

TimeStamp: 13 March 2017 11:18:28 --- User: Maureen Gay (GAYMA01)

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms

Type Staff

No Rows Found

CHSS027C - Health Services Encounter Page 7 of 7

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 68 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 11

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 69 of 139
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CHSS027J Condensed Health Services Encounter Wednesday August 22, 2018 12:28:10 PM

ADC #: 067165 Inmate Name: PEMBER, JAY L. 

ENCOUNTER DATE: 05/12/2017 TIME: 12:31:13 DURATION: minutes TYPE: Provider - Follow

Up Care

LOCATION: ASPC-E BROWNING STG [A52] SETTING: Clinic

S Are interpreter services needed for this inmate: No 

NOTES: 

Seen today for outside consultation follow up visit after pain management and medication changes for

cervical radiculopathy. Patient states positive reaction to Cymbalta stating tongue swelling, nausea,

depression or increase suppression. States are all SSRIs calls increase oppression whenever taken. Please

see refusal side in chart. Admits positive continue pain and discomfort posterior neck and left arm

radiculopathy noted. Requesting medication changes for neuropathy such as gabapentin therapy. Discussion

took place about gabapentin and the medication will not be returned for changes in alternative therapy and

treatment options on this yard. Suggested other alternative therapy. current taking amitriptyline and

nortripylin po. Patient refused medications stating it does not work. Offered trileptal as alternative therapy

option today. Patient denies any changes in physical condition records cervical pain except for intensity

number 8/10 most days however at night 10/10 pain level.

Patient also requested podiatry visit for possible darkened Nail right foot second nail bed. States positive

black toes and tenderness on right foot. Education provided to patient about podiatry consultation and

medical necessity. Patient a form at this time this no clinical reason to send the podiatry.

Next complaints patient discussion regarding alternative treatment plan for the request of medical footwear.

Patient according to documents does not meet criteria at this time. Patient verbalized understanding at time

of visit.

O PREV: 12:04:00 TEMP: 98.6 PULSE: 68 RP: 16 BP: 112/74 HT: 5 ft. 9 in. WT: 218 lb

BLOOD SUGAR: NA + 

02 SAT: 98.00% SOURCE: Room Air

NOTES: 

General: no apparent distress noted; cuffed with security during exam

Skin: Intact, 

Neck: trachea midline; supple without lesion, no stridor, pain or lymphadenopathy noted; positive rotation

without pain or stiffness noted

CV: S1S2, RRR, no S3, gallops, clicks, or murmurs heard; no chest discomfort on palpation, no guarding

noted

Pulm: equal chest expansion bilateral, clear bilaterally, no wheezes, rales or rhonchi noted; no lesions felt

right sternal rib cage at this time. 

Gastro: non-distended abdomen, BSx4, soft, non-tenderness noted, no rebound tenderness or guarding

noted, no masses, CVA tenderness or hernias noted

Extrem: right foot, nail bed slightly darkened small portion of nail bed color is pink of the digit, warm, dry

positive full range of motion and left foot. Ambulatory with steady gait, positive pedal pulse noted, move all

extremity with full range of motion; positive equal grips bilateral; strength 5/5; good muscle tone and bulk

noted all extremities; positive sensation all extremities noted

Neuro: awake, alert, oriented times x; CN II-XII intact; speech clear and appropriate, no focal deficits

noted, reflexes all extremities grossly intact.

A RELATED PROBLEM: Other Diagnosis: Other Diagnosis Nail disorder, unspecified [L60.9]

MEDICAL DIAGNOSIS: Nail disorder, unspecified [L60.9]

Cervicalgia [M54.2]

NOTES: Cervicalgia: offered Trileptal; discuss will started low dose and titrate upward as needed

nail disorder; darkened slightly darkened nail bed right foot, continue self-care afoot at this time

P DRUG PRESCRIPTION: OXCARBAZEPINE (UD) TABS/300 Mg VERBAL BY: Gay, Maureen

EFFECTIVE DT: 05/12/2017 RT: PO DOSE: 1 STRENGTH: 300 Mg METHOD: Normal Dose

FREQ: QHS FOR: 14 DAYS EXPIRATION DATE: 05/25/2017 REFILLS: 0 STATUS: Received from

Pharmacy

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 70 of 139
CHSS027J - Condensed Health Services Encounter 8/22/18, 12'30 PM

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DRUG PRESCRIPTION: OXCARBAZEPINE (UD) TABS/300 Mg VERBAL BY: Gay, Maureen

EFFECTIVE DT: 05/26/2017 RT: PO DOSE: 1 STRENGTH: 300 Mg METHOD: Normal Dose

FREQ: BID FOR: 180 DAYS EXPIRATION DATE: 11/21/2017 REFILLS: 5 STATUS: Discontinued

- Other

NOTES: Discontinue Cymbalta PO; patient states reaction

offered Trileptal 300 mg at bedtime for 14 days

then increase Cymbalta to 600 twice daily

continue home exercise program

continue warm water/compress lower back or cervical area door showers

E NOTES: See above plan written as per above

a follow-up health unit as needed or next chronic care visit

education provided regarding alternative and planned for medical shoes requests

education provided regarding not met criteria for podiatry exam visit; continue self-care foot at this

time

H/S MH Status: Outpatient-Regular MH Contact

STAFF: Gay, Maureen

Clinical Orders

ADC #: 067165 Inmate Name: PEMBER, JAY L. 

Encounter Date: 05/12/2017 Encounter Time: 12:31:13

DRUG PRESCRIPTION: OXCARBAZEPINE (UD) TABS/300 Mg

VERBAL BY: Gay, Maureen

EFFECTIVE DT: 05/12/2017 RT: PO DOSE: 1 STRENGTH: 300 Mg

METHOD: Normal Dose

FREQ: QHS FOR: 14; DAYS EXPIRATION DATE: 05/25/2017

REFILLS: 0 STATUS: Received from Pharmacy

Status Date: 05/15/2017

Status: Received from

Pharmacy User: Peat,

Mark

Set Date: 05/15/2017

Set Time: 13:13:22

Status Date: 05/13/2017

Status: Order Accepted at

Pharmacy Vendor (SC)

User: EOIR880

Set Date: 05/13/2017

Set Time: 05:50:31

Status Date: 05/12/2017

Status: Approved/Approval

User: Gay, Maureen

Set Date: 05/12/2017

Set Time: 12:35:21

Verbal By: Gay, Maureen

DRUG PRESCRIPTION: OXCARBAZEPINE (UD) TABS/300 Mg

VERBAL BY: Gay, Maureen

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 71 of 139
CHSS027J - Condensed Health Services Encounter 8/22/18, 12'30 PM

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EFFECTIVE DT: 05/26/2017 RT: PO DOSE: 1 STRENGTH: 300 Mg

METHOD: Normal Dose

FREQ: BID FOR: 180; DAYS EXPIRATION DATE: 11/21/2017

REFILLS: 5 STATUS: Discontinued - Other

DRUG COMMENTS: At 06/22/2017 01:40:49 a prescription order message

from the Pharmacy, with a status of "Order Discontinued at Pharmacy Vendor

(DR)", was not processed because the prescription status in eOMIS was

"Discontinued - Other" at the time the pharmacy message was received. At

06/22/2017 01:25:20 a prescription order message from the Pharmacy, with

a status of "Order Discontinued at Pharmacy Vendor (DR)", was not

processed because the prescription status in eOMIS was "Discontinued -

Other" at the time the pharmacy message was received.

Status Date: 06/21/2017

Status: Discontinued -

Other User: Watson, Jan

Set Date: 06/21/2017

Set Time: 16:16:45

Verbal By: Watson, Jan

Status Date: 05/15/2017

Status: Received from

Pharmacy User: Peat,

Mark

Set Date: 05/15/2017

Set Time: 13:13:27

Status Date: 05/13/2017

Status: Order Accepted at

Pharmacy Vendor (SC)

User: EOIR880

Set Date: 05/13/2017

Set Time: 06:05:58

Status Date: 05/12/2017

Status: Approved/Approval

User: Gay, Maureen

Set Date: 05/12/2017

Set Time: 12:36:12

Verbal By: Gay, Maureen

PROVIDER SIGNATURE: _________________________________________________

Gay, Maureen

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 72 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 12

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 73 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 08, 2018 

15:31:59

Encounter Header

Date*: 06/21/2017 Start Time*: 15:53:54

End Date*: 06/21/2017 End Time*: 15:54:30

Category: Medical Provider

Type*: Provider - Sick Call - Scheduled Encounter Close Date: 06/22/2017

Location*: ASPC-E BROWNING STG [A52] Encounter Close Time: 11:15:19

Setting*: Clinic Addendum Added

Staff Member*: Watson, Jan

Title: Medical Doctor

Form Type:

Subjective

Are interpreter services needed for this inmate*: No

What type of interpreter services were used for the encounter*: 

Related Health Service Requests

Request Date Area of Interest Request Type Status

No Rows Found

Subjective Notes

Pain in his neck, which has had for 8 years.

Objective

Vital Signs (1 - 1 of 1)

Taken By Time Temp Pulse Resp Height Weight BP

Systolic

BP

Diastolic

Blood

Sugar Comments

Corliss, Victoria 15:53 97.8 67 16 5 9 215 116 79 NA

Objective Notes

At the level of C2-C3, satisfactory anatomic findings are noted. At the level of 

C3-C4, there is moderate left foraminal narrowing. 

At the level of C4-C5, the anatomic findings are within normal limits. 

At the level C5-C6 there is marked left foraminal narrowing with a 3.0 mm 

central posterior disc bulge which slightly impresses upon the thecal sac. 

At the levels of C6-C7, and C7-T1, satisfactory anatomic findings are noted. 

Muscular and soft tissue signal and appearance is within normal limits. 

IMPRESSIONS: 

1. Straightening of the cervical spinal loss of lordosis is noted and may be 

secondary to cervical myositis. 

2. At the level of C5-C6, there is moderate degenerative spurring anteriorly 

with bridging as well as a 3.0 mm central posterior disc bulge with slight 

impression upon the thecal sac and marked left foraminal impingement. 

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3. At the level of C3-C4, moderate left foraminal impingement is noted.

Assessment

Medical Diagnosis/Complaint

ICD Code Diagnosis/Complaint

No Rows Found

Active Allergies/Health Problems/Conditions (1 - 28 of 28)

ID 

Number Category Type National HIE Code(s) Diagnosis Code Status Status D

001 Chronic 

Conditions Asthma Assessed 10/02/20

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/20

003 Communicable 

Diseases Hepatitis C Assessed 10/02/20

004 Allergies -

Medication Carbamazepine Assessed 08/04/20

005 Mental Health Mental Health Assessed 08/04/20

006 Mental Health Mental Health Bipolar disorder 

NOS [296.80] Assessed 08/04/20

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/20

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/20

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/20

010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/20

011 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism 

NOS [244.9] Assessed 09/30/20

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/20

013 Chronic 

Conditions Asthma Asthma NOS [493.90] Assessed 09/30/20

014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions 

[R56.9]

Assessed 10/01/20

015 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 10/01/20

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016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/20

017 Chronic 

Conditions Asthma

Unspecified 

asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/20

018 Communicable 

Diseases Hepatitis C

Chronic viral 

hepatitis C 

[B18.2]

Assessed 11/16/20

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/20

020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 -

Cervical root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/20

021 Mental Health Mental Health

SNOMED: 

55668003 -

Adjustment 

disorder with 

mixed 

emotional 

features 

(disorder)

Adjustment 

disorder with 

mixed anxiety 

and depressed 

mood [F43.23]

Assessed 11/08/20

022 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

83561009 -

Spinal stenosis 

in cervical 

region 

(disorder)

Spinal stenosis, 

cervical region 

[M48.02]

Assessed 12/29/20

023 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

11049006 -

Cervical 

radiculitis 

(disorder)

Radiculopathy, 

cervical region 

[M54.12]

Assessed 01/27/20

024 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

813001 - Ankle 

instability 

(finding)

Injury of other 

nerves at ankle 

and foot level, 

right leg, 

sequela 

[S94.8X1S]

Assessed 01/27/20

025 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

134407002 -

Chronic back 

pain (finding)

Low back pain 

[M54.5] Assessed 02/23/20

026 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

1121000119107 

- Chronic neck 

pain (finding)

Cervicalgia 

[M54.2] Assessed 02/23/20

SNOMED: 

299447008 - Pain in right 

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 76 of 139
027 Other 

Diagnosis

Other 

Diagnosis

Ankle joint -

painful on 

movement 

(finding)

ankle and joints 

of right foot 

[M25.571] Assessed 02/23/20

028 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

17790008 -

Disorder of nail 

(disorder)

Nail disorder, 

unspecified 

[L60.9]

Assessed 05/12/20

Related Allergies/Health Problems/Conditions 

ID Number Category Type National HIE Code(s) Diagnosis Code Status Status Da

No Rows Found

Assessment Notes

None

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 5 of 5)

View MAR Summary

Prescription/Medication National HIE Code

(s) 

Effective

Date DosageFrequency Expiration Status

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 855671 

- DPH sodium 

100 MG 

Extended 

Release Oral 

Capsule; 

06/13/2017 2 TWICE 

DAILY 12/09/2017

Receive

from 

Pharma

OXCARBAZEPINE (UD) 

TABS/300 Mg 

RxNorm: 312137 

- OXcarbazepine 

300 MG Oral 

Tablet; 

05/26/2017 1 TWICE 

DAILY 11/21/2017

Receive

from 

Pharma

ALBUTEROL HFA 

(8.5GM) INHA/90 Mcg 

RxNorm: 745679 

- 200 ACTUAT 

Albuterol 0.09 

MG/ACTUAT 

Metered Dose 

Inhaler; 745752 

-...

05/11/2017 2 

puffs

TWICE 

DAILY 

AS 

NEEDED

11/06/2017

Receive

from 

Pharma

APAP-ASA-CAFF 

TABS/250-250-65 Mg 

RxNorm: 209468 

- Acetaminophen 

250 MG / Aspirin 

250 MG / 

Caffeine 65 MG 

Oral Tablet 

[Excedrin]; ...

04/25/2017 2 

tabs

TWICE 

DAILY 07/23/2017

Order 

Accepte

at 

Pharma

Vendor 

(SC)

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 77 of 139
LEVOTHYROXINE SOD 

TABS/0.075 Mg 

RxNorm: 966171 

- Synthroid 75 

MCG Oral 

Tablet; 

02/24/2017 1 EVERY 

DAY 08/22/2017

Receive

from 

Pharma

Ordered Drug Prescriptions (1 - 2 of 2)

Prescription/Medication National HIE 

Code(s)

Effective

Date Dosage Frequency Expiration Statu

FLUTICASONE PROP 

NASAL (16) 

SUSP/0.05% 

RxNorm: 

1797907 -

Fluticasone 

propionate 0.05 

MG/ACTUAT 

Metered Dose 

Nasal Spray; 

06/21/2017 2 

sprays

EVERY 

DAY 10/18/2017

Receive

from 

Pharma

IBUPROFEN (UD) 

TABS/600 Mg 

RxNorm: 

197806 -

Ibuprofen 600 

MG Oral 

Tablet; 316077 

- Ibuprofen 600 

MG; &nbs...

06/21/2017 1

FOUR 

TIMES 

DAILY 

AS 

NEEDED

10/18/2017

Receive

from 

Pharma

Lab Test Orders 

Lab Test Type National HIE Code(s) Priority Status Results Val

No Rows Found

X-Ray Orders 

X-Ray Body Area Priority Status

No Rows Found

Consultation Request 

Request Type Service Type Priority Status

No Rows Found

Follow-up Appointments

Date Time Type Staff Location

No Rows Found

Patient Transfer Holds

Type Expiration Date Status

No Rows Found

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comments

No Rows Found

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Plan Notes

MEDICATION DISCONTINUED VIA THIS ENCOUNTER- Medication Name: 'OXCARBAZEPINE (UD) TABS', 

Order Number: 1130045, Authorized By: Watson, Jan. Timestamp: 06/21/2017 16:16:45

Patient Education

Patient Education Notes

.

Health Classification

Medical: 3

Mental: 3D-Outpatient-Recently Off Meds-Monitoring Only Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Encounter Orders Review 

Review Type*: Pending Nurses Order Review Staff: Nash, Craig, LPN

Review Date: 06/21/2017 Review Time: 19:26:25

Review Notes

TimeStamp: 21 June 2017 19:27:55 --- User: Craig Nash (NASCR01)

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms

Type Staff

No Rows Found

Prior Addendums

06/22/2017 11:21:56 Watson, Jan 

He has pain in multiple joints, not just his cervical spine. Examination of his knees and ankle is 

unremarkable. 

Assessment he may have degenerative changes in his knees and ankle.

Plan xrays of knees and right ankle.

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 79 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 13

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 80 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 08, 2018 

15:35:30

Encounter Header

Date*: 07/29/2017 Start Time*: 08:53:32

End Date*: 07/29/2017 End Time*: 09:05:26

Category: Medical Provider

Type*: Practitioner - Chronic Care Encounter Close Date: 07/29/2017

Location*: ASPC-E BROWNING STG [A52] Encounter Close Time: 09:05:26

Setting*: Clinic

Staff Member*: Gay, Maureen

Title: Nurse Practitioner

Form Type: Chronic Care Clinic

Subjective

Are interpreter services needed for this inmate*: No

What type of interpreter services were used for the encounter*: 

Related Health Service Requests (1 - 1 of 1)

Request Date Area of Interest Request Type Status

05/14/2017 Provider Not Required to be Seen Encounter Held

Subjective Notes

Request Date: 05/14/2017

"This is the third time you have dismissed me in the middle of a appointment without finishing the 

appointment. The first two times I though I miss something so I made it a point to ask questions. But 

when you are combative, condescending, call other staff liars and walk out of the appointment there 

is a issue. You said nothing to me or CO II Lake and had NA Adams tell us I was done while you hid 

in NA office. Everyone was confused. Clearly you are doing bare minimum to say you seen me, 

prescribed a med to comply with Parsons. You are doctoring the books. I want to be seen by another 

provider."

Forwarded to HCP

chronic care visit completed for hypothyroid, asthma, seizure disorder

seizures history noted for the past two years. Lassies positive grand mal seizure activity. Last seizure 

activity noted to be one month ago without reporting to him health unit. Maintain all medications at 

this time

asthma diagnosed childhood. Denies hospital stays or intubation history. Stays last attack several 

years ago maintained on albuterol MDI uses three times weekly as needed. No not no night Tom 

asthma symptoms noted per patient.

Hypothyroid; diagnosed 2010. While in prison last lab levels within normal limits. Maintained on level 

thyroxine 0.075 mg daily neck.

Hepatitis C; Denis anyfever, chills, rice abdominal pain, gray color stool's. Does admit intimate 

Nikons was but a crib contribute to at thyroid disease. Last AST 40 ALT 44 other liver enzymes within 

normal limits.

P.E

GEN: A&OX3, NAD, ambulates w/ steady gait, balance symmet, well-nourished, good color 

CNS: CN II-XII grossly intact bilat.; VSS; NC/AT 

HEENT: NT sinuses; PERRLA; ANICTERIC; good dentition with molars intact. NT pinna and tragus 

manipulation, ear canal without erythema, swelling or drainage. TM appears intact without erythema 

or buldging; (-)Nasal d/c with normal turbinate size bilateral; Throat clear w/o exudates, tonsils +1 

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without erythema, swelling or exudate 

NECK: Supple; NT; no LAD; no JVD, no thyromegaly 

CVS: S1S2,RRR, no MRG, no clicks 

RESP: lung sounds clear Sym Expansion; No W/R/R/Cough/Pleural rub; 1:2 chest expansion equal, resp ef

easy/non-labored, no accessories muscles used 

ABDO: Soft/NT/ND/BSX4/ No Ascites, no HSM 

Extremity: ambulatory with steady gait; full AROM <2sec cap refill; Gross sensation intact distally, 2 + DT

edema, 5/5 strength, no muscular atrophy 

INTEG: Skin Dry, Clean, Intact, no jaundice 

Assessment:

1. Hepatitis C. Need updated labs for a Apri escort updated. Most recent APRI score 0.73, five fourscore 1

update labs.

2. asthma: mild intermittent stable at this time continue albuterol admitted have treatments. Will update p

vaccine

3. Seizure disorder; no medications at this time however is maintained on Trileptal possibly for pain manag

4. hypothyroid; TSH 1.49 T-3 uptake 285 free T4 two point for all labs within normal limits continue level t

ordered:

Chronic Care Clinic Subjective

History: 



Risk factors: Obesity: Y N Alcohol: Y N Family history of heart disease: Y 

Smoker: Rare/None Current Former 

Amount/Length: Less than 10 pk yrs 10-20 pk yrs More than 20 pk yrs 

Diseases:

Last eye exam date: Retinopathy: N Y Problems with vision: N 

Pulmonary: Age of onset: Frequency of inhaler use:

Last attack:

Prior hospitalization for asthma: Y N History of intubation: Y N 

Prior corticosteroids: Y N 

Aggravating factors for asthma: Change in season Pollen Exercise Dust

 Cold Other:

Night time awakenings with asthma within the last 30 days:

Seizures: Type: Generalized Tonic Clonic(Grand Mal) Complex(partial) Absence(Petit M

Approximate date of first seizure: Date of last seizure:

Frequency:

Seizure related to: Alcohol Drug use Head injury Other:

Infectious diseases:

Infectious disease Hx:

CAD: Y N PVD: Y N CVA: Y N CRD: Y N 

Hx DKA: Y N N/A Other:

History Y N Needle Y 

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Objective

Vital Signs (1 - 1 of 1)

Taken By Time Temp Pulse Resp Height Weight BP

Systolic

BP

Diastolic

Blood

Sugar

Marino, Mary, RN 08:40 98.6 58 17 5 9 211 128 68 NA

Objective Notes

see above

Rev #: 735

Infectious disease Hx: History Needle

Injectable drug use: Y N Blood Transfusion before 1990: Y N 

Alcohol Abuse: Y N 

 N Y: 

Nasal drug use: Y N Cough: Y N 

Night sweats: Y N Fever: Y N Headaches: Y N 

Diarrhea: D Y N Neurologic Change: Y ysphagia/Odynophagia: Y N 

Visual Disturbance: Y N PPD Conversion: Y N 

Incomplete previous TB Rx: Y N Recent exposure to Active TB: Y N 

Recent weight loss/cachexia: N Y 

Other complaints:

Sickle Cell Disease:

Pain: N Y: Long bone(pre-tibial) Hand and foot Joint Abdominal

 Chest Describe:

Fever: N Y: 

Recent trauma N Y: :

Nausea and vomiting: N Y: 

Sortness of breath: N Y: 

Headache: N Y: 

Visual changes: N Y: 

Fatigue: N Y: 

Other symptoms: N Y: 

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Assessment

Medical Diagnosis/Complaint (1 - 4 of 4)

ICD Code Diagnosis/Complaint

B18.2 Chronic viral hepatitis C

Rev #: 735

Chronic Care Clinic Objective

HEENT: Nystagmus (SZ): N Y 

Gingival hyperplasia (SZ): N Y 

Ataxia: N Y 

Eyes: Conjunctiva pale: N Y 

Sclera icteric: N Y 

Neck: Carotid bruit (Optional less than 50/Required greater than 50): Y N 

Thyroid NL: N Y Cervical lymph nodes NL: Y N 

Heart: Regular Rhythm: Y N Murmur Present: Y N 

Gallop: Y N 

Lungs: Wheezing: Y N Rales: Y N Rhonchi: Y N 

Other:

Abdomen: Tenderness: Y N Mass: Y N Hepatomegaly: Y N 

Bowel Sounds: Y N Soft: Y N Splenomegaly: Y N 

Ext.: Pedal pulse palpable: Y N Peripheral edema: Y N 

Foot exam unremarkable: Y N 

Neuro: Motor deficits: Y N Sensory deficits Y N 

Monofilament testing: Y N NA 

Skin:

Spine:

Additional findings / description of fundi if visualized:

Studies: Ordered at this visit Review of previously completed with patient

Annual Lab/Immunizations: LFT TSH Flu Pneumo (5 years)





Leg ulcers: N Y 

Skin Pallor: N Y: 

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 84 of 139
E03.9 Hypothyroidism, unspecified

G40.89 Other seizures

J45.20 Mild intermittent asthma, uncomplicated

Chronic Conditions Being Treated

Asthma NOS [493.90]: Mild intermittent asthma, 

uncomplicated [J45.20]:

Unspecified asthma, uncomplicated 

[J45.909]: Coronary Artery Disease (CAD):

Diabetes Type I: Diabetes Type II:

Dyslipidemia: Chronic viral hepatitis C [B18.2]:

HIV/AIDS: Hypertension:

Multiple Sclerosis (MS): Convulsions NEC [780.39]:

Unspecified convulsions [R56.9]: Sickle Cell:

Tuberculosis Active (TB): Tuberculosis Latent Inactive (LTBI):

Hypothyroidism NOS [244.9]: Hypothyroidism, unspecified [E03.9]:

Active Allergies/Health Problems/Conditions (1 - 30 of 30)

ID 

Number Category Type National HIE Code(s) Diagnosis Code Status Status D

001 Chronic 

Conditions Asthma Assessed 10/02/20

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/20

003 Communicable 

Diseases Hepatitis C Assessed 10/02/20

004 Allergies -

Medication Carbamazepine Assessed 08/04/20

005 Mental Health Mental Health Assessed 08/04/20

006 Mental Health Mental Health Bipolar disorder 

NOS [296.80] Assessed 08/04/20

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/20

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/20

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/20

010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/20

Other Pt. Specific Hypothyroidism 

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 85 of 139
011 Diagnosis Chronic 

Condition

NOS [244.9] Assessed 09/30/20

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/20

013 Chronic 

Conditions Asthma Asthma NOS [493.90] Assessed 09/30/20

014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions 

[R56.9]

Assessed 10/01/20

015 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 10/01/20

016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/20

017 Chronic 

Conditions Asthma

Unspecified 

asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/20

018 Communicable 

Diseases Hepatitis C

Chronic viral 

hepatitis C 

[B18.2]

Assessed 11/16/20

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/20

020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 -

Cervical root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/20

021 Mental Health Mental Health

SNOMED: 

55668003 -

Adjustment 

disorder with 

mixed 

emotional 

features 

(disorder)

Adjustment 

disorder with 

mixed anxiety 

and depressed 

mood [F43.23]

Assessed 11/08/20

022 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

83561009 -

Spinal stenosis 

in cervical 

region 

(disorder)

Spinal stenosis, 

cervical region 

[M48.02]

Assessed 12/29/20

023 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

11049006 -

Cervical 

radiculitis 

(disorder)

Radiculopathy, 

cervical region 

[M54.12]

Assessed 01/27/20

SNOMED: 

Injury of other 

nerves at ankle 

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 86 of 139
024 Other 

Diagnosis

Other 

Diagnosis

813001 - Ankle 

instability 

(finding)

and foot level, 

right leg, 

sequela 

[S94.8X1S]

Assessed 01/27/20

025 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

134407002 -

Chronic back 

pain (finding)

Low back pain 

[M54.5] Assessed 02/23/20

026 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

1121000119107 

- Chronic neck 

pain (finding)

Cervicalgia 

[M54.2] Assessed 02/23/20

027 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

299447008 -

Ankle joint -

painful on 

movement 

(finding)

Pain in right 

ankle and joints 

of right foot 

[M25.571]

Assessed 02/23/20

028 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

17790008 -

Disorder of nail 

(disorder)

Nail disorder, 

unspecified 

[L60.9]

Assessed 05/12/20

029 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

10601006 -

Pain in lower 

limb (finding)

Pain in left knee 

[M25.562] Assessed 06/22/20

030 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

47933007 -

Foot pain 

(finding)

Superficial 

foreign body, 

right foot, 

sequela 

[S90.851S]

Assessed 06/29/20

Related Allergies/Health Problems/Conditions (1 - 3 of 3)

ID 

Number Category Type National HIE Code(s) Diagnosis Code Status Status D

031 Chronic 

Conditions Asthma

SNOMED: 

195967001 -

Asthma (disorder)

Mild intermittent 

asthma, 

uncomplicated 

[J45.20]

Assessed 07/29/20

032 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

128613002 -

Seizure disorder 

(disorder)

Other seizures 

[G40.89] Assessed 07/29/20

033 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

40930008 -

Hypothyroidism 

(disorder)

Hypothyroidism, 

unspecified [E03.9] Assessed 07/29/20

Assessment Notes

1. Hepatitis C. Need updated labs for a Apri escort updated. Most recent APRI score 0.73, five fourscore 1.

labs. 

2. asthma: mild intermittent stable at this time continue albuterol admitted have treatments. Will update p

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 87 of 139
vaccine 

3. Seizure disorder; no medications at this time however is maintained on Trileptal possibly for pain manag

4. hypothyroid; TSH 1.49 T-3 uptake 285 free T4 two point for all labs within normal limits continue level t

ordered 

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 7 of 7)

View MAR Summary

Prescription/Medication National HIE Code

(s) 

Effective

Date Dosage Frequency Expiration Stat

APAP-ASA-CAFF 

TABS/250-250-65 Mg 

RxNorm: 209468 

- Acetaminophen 

250 MG / Aspirin 

250 MG / 

Caffeine 65 MG 

Oral Tablet 

[Excedrin]; ...

07/24/2017 2 tabs TWICE 

DAILY 10/21/2017

Receiv

from 

Pharm

CODEINE/APAP (UD) 

TABS/30-300 Mg 

RxNorm: 993781 

- Acetaminophen 

300 MG / 

Codeine 

Phosphate 30 MG 

Oral Tablet; 

06/29/2017 2

TWICE 

DAILY 

AS 

NEEDED

10/26/2017 Refill 

Ordere

FLUTICASONE PROP 

NASAL (16) 

SUSP/0.05% 

RxNorm: 

1797907 -

Fluticasone 

propionate 0.05 

MG/ACTUAT 

Metered Dose 

Nasal Spray; 

06/21/2017 2 

sprays

EVERY 

DAY 10/18/2017

Receiv

from 

Pharm

IBUPROFEN (UD) 

TABS/600 Mg 

RxNorm: 197806 

- Ibuprofen 600 

MG Oral 

Tablet; 316077 

- Ibuprofen 600 

MG; &nbs...

06/21/2017 1

FOUR 

TIMES 

DAILY 

AS 

NEEDED

10/18/2017

Receiv

from 

Pharm

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 855671 

- DPH sodium 

100 MG 

Extended 

06/13/2017 2 TWICE 

DAILY 12/09/2017

Receiv

from 

Rev #: 735

Chronic Care Clinic Assessment

Has the MPL been updated? yes

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 88 of 139
Release Oral 

Capsule; 

Pharm

ALBUTEROL HFA 

(8.5GM) INHA/90 Mcg 

RxNorm: 745679 

- 200 ACTUAT 

Albuterol 0.09 

MG/ACTUAT 

Metered Dose 

Inhaler; 745752 

-...

05/11/2017 2 

puffs

TWICE 

DAILY 

AS 

NEEDED

11/06/2017

Receiv

from 

Pharm

LEVOTHYROXINE SOD 

TABS/0.075 Mg 

RxNorm: 966171 

- Synthroid 75 

MCG Oral 

Tablet; 

02/24/2017 1 EVERY 

DAY 08/22/2017 Refill 

Ordere

Ordered Drug Prescriptions 

Prescription/Medication National HIE Code(s) Effective

Date Dosage Frequency Expiration St

No Rows Found

Lab Test Orders (1 - 1 of 1)

Lab Test Type National HIE Code(s) Priority Status Results Val

Diagnostic 

Panel 2 

LOINC: 3050-2 - T3 Uptake 

(T3U); 2085-9 - HDL CHOL., 

DIRECT; 3026-2 - Thyroxin...

Rout (Draw10days;Rslts48hrs) Completed -

Results 

Reviewed 

See 

Report

From

Vend

X-Ray Orders 

X-Ray Body Area Priority Status

No Rows Found

Consultation Request 

Request Type Service Type Priority Status

No Rows Found

Follow-up Appointments (1 - 1 of 1)

Date Time Type Staff Location

08/08/2017 08:53:32 Health Services Gay, Maureen ASPC-E BROWNING STG

Patient Transfer Holds

Type Expiration Date Status

No Rows Found

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comments

No Rows Found

Plan Notes

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 89 of 139
Continue medication therapy; no changes for now

labs every 3 months

chronic care follow up in 90 days

Patient Education

Patient Education Notes

see above plan

Meaningful Use Measurement

 Demographic Information in Patient Header verified

 Current Medical Problem List verified (or Patient has no Medical Problems)

 Current Medications List verified (or Patient has no Medical Medications) Medications List NOT 

verified 

 Medication Allergies List verified (or Patient is not allergic to any Medications)

Health Classification

Medical: 3

Mental: 3D-Outpatient-Recently Off Meds-Monitoring Only Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Rev #: 735

Chronic Care Clinic Plan

Management goals for this patient (Justification needed if you deviate from protocol):





met

Change meds: N Y: (see orders)

Rev #: 735

Chronic Care Clinic Patient Education

Education (correctional adaptation): Diet/Nutrition Smoking Med Info Exercise

PIFs to patient:

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 90 of 139
Encounter Orders Review 

Review Type*: Pending Nurses Order Review Staff: Nodar, Donna

Review Date: 07/29/2017 Review Time: 19:00:36

Review Notes

Chronic care follow up in 90 days, labs ordered by provider

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms

Type Staff

No Rows Found

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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 14

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CHSS027J Condensed Health Services Encounter Wednesday August 22, 2018 12:28:39 PM

ADC #: 067165 Inmate Name: PEMBER, JAY L. 

ENCOUNTER DATE: 12/27/2017 TIME: 12:29:30 DURATION: minutes TYPE: Provider - Sick Call

- Scheduled

LOCATION: ASPC-E BROWNING STG [A52] SETTING: Clinic

S Are interpreter services needed for this inmate: No 

NOTES: 

Pt with c/o ibuprofen and Excedrine causing gastric irritation. He reports being on meloxicam in the

past with good results and no side effects. He would also like to start something for his herniated

disc, C5 - C6. Pt states he suffered a neck injury in 2004. He states he started having pain in 2009.

 Pt states that gabapentin was the best medication for his pain symptoms. A review of his records

indicates he has tried ibuprofen, Excedrine migraine, T3, oxcarbazepine, Duloxetine, Amitriptyline

and Nortiptyline. He states that none of these medications made him feel better. 

Pt states he jogs and walks for exercise 3 times a week. 

O PREV: 12:26:51 TEMP: 98.1 PULSE: 69 RP: 18 BP: 129/81 HT: 5 ft. 9 in. WT: 198 lb

BLOOD SUGAR: NA + 

02 SAT: 99.00% SOURCE: Room Air

NOTES: 

AVSS 

G- a/o x 4, NAD 

Neck - moves neck spontaneously in all directed, no indication of pain or limited ROM during

interview

E - PERRLA, EOMI, Sclera non-icteric 

H- RRR, no murmur, rub or gallop 

L- CTA b/l no wheeze, rales or rhonchi 

A- s/nt/nd +BS, no rebound tenderness, rigidity or guarding 

ext- w/d no clubbing, cyanosis or edema, grips equal b/l, no loss of sensation in either hand or arm. 

Strength 5/5 b/l UE and LE's. Well developed musculature throughout. 

A NOTES: Cervicalgia

P DRUG PRESCRIPTION: MELOXICAM (UD) TABS/7.5 Mg VERBAL BY: Johnson, Chris, D.O.

EFFECTIVE DT: 12/27/2017 RT: PO DOSE: 1 STRENGTH: 7.5 Mg METHOD: Normal Dose

FREQ: BID FOR: 180 DAYS EXPIRATION DATE: 06/24/2018 REFILLS: 5 STATUS: Order

Discontinued at Pharmacy Vendor (DR)

DRUG PRESCRIPTION: ZONISAMIDE CAPS/25 Mg VERBAL BY: Johnson, Chris, D.O.

EFFECTIVE DT: 12/27/2017 RT: PO DOSE: 1 STRENGTH: 25 Mg METHOD: Normal Dose

FREQ: BID FOR: 120 DAYS EXPIRATION DATE: 04/25/2018 REFILLS: 3 STATUS: Discontinued

- Other

NOTES: 

Cervicalgia - Will try zonisamide, and restart meloxicam per the patient's request. 

MEDICATION DISCONTINUED VIA THIS ENCOUNTER- Medication Name: 'APAP-ASA-CAFF TABS',

Order Number: 1296848, Authorized By: Johnson, Chris. Timestamp: 12/27/2017 12:33:41

MEDICATION DISCONTINUED VIA THIS ENCOUNTER- Medication Name: 'IBUPROFEN (UD) TABS',

Order Number: 1290771, Authorized By: Johnson, Chris. Timestamp: 12/27/2017 12:34:00

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 93 of 139
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E NOTES: 

Take medications as directed. Make medical needs known via HNR.

H/S MH Status: Not on meds > 6 months with 30 day follow-up

STAFF: Johnson, Chris, D.O.

Clinical Orders

ADC #: 067165 Inmate Name: PEMBER, JAY L. 

Encounter Date: 12/27/2017 Encounter Time: 12:29:30

DRUG PRESCRIPTION: MELOXICAM (UD) TABS/7.5 Mg

VERBAL BY: Johnson, Chris, D.O.

EFFECTIVE DT: 12/27/2017 RT: PO DOSE: 1 STRENGTH: 7.5 Mg

METHOD: Normal Dose

FREQ: BID FOR: 180; DAYS EXPIRATION DATE: 06/24/2018

REFILLS: 5 STATUS: Order Discontinued at Pharmacy Vendor (DR)

DRUG COMMENTS: 

KOP

take one tablet twice a day

Status Date: 06/24/2018

Status: Order Discontinued

at Pharmacy Vendor (DR)

User: EOIR880

Set Date: 06/24/2018

Set Time: 22:04:39

Status Date: 05/31/2018

Status: Received from

Pharmacy User: MILER01

Set Date: 05/31/2018

Set Time: 15:56:57

Status Date: 05/30/2018

Status: Order Accepted at

Pharmacy Vendor (SC)

User: EOIR880

Set Date: 05/30/2018

Set Time: 18:06:37

Status Date: 05/30/2018

Status: Refill Ordered

User: Sedlar, Lisa

Set Date: 05/30/2018

Set Time: 08:59:32

Status Date: 04/25/2018

Status: Received from

Pharmacy User: Owens,

Julia V

Set Date: 04/25/2018

Set Time: 15:04:17

Status Date: 04/24/2018

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Status: Refill Ordered

User: Owens, Julia V

Set Date: 04/24/2018

Set Time: 08:52:13

Status Date: 04/02/2018

Status: Received from

Pharmacy User: Owens,

Julia V

Set Date: 04/02/2018

Set Time: 12:32:30

Status Date: 03/30/2018

Status: Refill Ordered

User: Owens, Julia V

Set Date: 03/30/2018

Set Time: 14:24:39

Status Date: 02/27/2018

Status: Received from

Pharmacy User: Owens,

Julia V

Set Date: 02/27/2018

Set Time: 12:20:26

Status Date: 02/26/2018

Status: Refill Ordered

User: Owens, Julia V

Set Date: 02/26/2018

Set Time: 12:03:10

Status Date: 01/18/2018

Status: Received from

Pharmacy User: Owens,

Julia V

Set Date: 01/18/2018

Set Time: 13:54:17

Status Date: 01/18/2018

Status: Order Accepted at

Pharmacy Vendor (SC)

User: EOIR880

Set Date: 01/18/2018

Set Time: 01:36:27

Status Date: 12/28/2017

Status: Received from

Pharmacy User: King,

Martha J

Set Date: 12/28/2017

Set Time: 13:39:39

Status Date: 12/28/2017

Status: Order Accepted at

Pharmacy Vendor (SC)

User: EOIR880

Set Date: 12/28/2017

Set Time: 01:45:22

Status Date: 12/27/2017

Status: Approved/Approval

User: Johnson, Chris

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 95 of 139
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Set Date: 12/27/2017

Set Time: 12:37:11

Verbal By: Johnson, Chris,

D.O.

DRUG PRESCRIPTION: ZONISAMIDE CAPS/25 Mg VERBAL BY: Johnson,

Chris, D.O.

EFFECTIVE DT: 12/27/2017 RT: PO DOSE: 1 STRENGTH: 25 Mg

METHOD: Normal Dose

FREQ: BID FOR: 120; DAYS EXPIRATION DATE: 04/25/2018

REFILLS: 3 STATUS: Discontinued - Other

DRUG COMMENTS: At 04/19/2018 12:38:54 a prescription order message

from the Pharmacy, with a status of "Order Discontinued at Pharmacy Vendor

(DR)", was not processed because the prescription status in eOMIS was

"Discontinued - Other" at the time the pharmacy message was received. At

04/19/2018 12:23:20 a prescription order message from the Pharmacy, with

a status of "Order Discontinued at Pharmacy Vendor (DR)", was not

processed because the prescription status in eOMIS was "Discontinued -

Other" at the time the pharmacy message was received.

DOT

Why must this drug be used instead of one included on the formulary? Pt has

failed all formulary options for pain management since Gabapentin was

discontinued.

What formulary drugs have been tried? Ibuprofen, Excedrine migraine, T3,

Oxcarbazepine, Duloxetine, Gabapentin, Amitriptyline, Nortiptyine

What was outcome? Continued cervical pain

Medication discontinued as patient refuses to take it. 

Status Date: 04/18/2018

Status: Discontinued -

Other User: Johnson,

Chris

Set Date: 04/18/2018

Set Time: 09:16:31

Verbal By: Johnson, Chris,

D.O.

Status Date: 03/26/2018

Status: Received from

Pharmacy User: King,

Martha J

Set Date: 03/26/2018

Set Time: 12:52:48

Status Date: 03/22/2018

Status: Refill Ordered

User: Owens, Julia V

Set Date: 03/22/2018

Set Time: 08:51:05

Status Date: 02/28/2018

Status: Received from

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Pharmacy User: Owens,

Julia V

Set Date: 02/28/2018

Set Time: 14:56:32

Status Date: 02/27/2018

Status: Refill Ordered

User: Owens, Julia V

Set Date: 02/27/2018

Set Time: 10:10:29

Status Date: 01/19/2018

Status: Received from

Pharmacy User: Owens,

Julia V

Set Date: 01/19/2018

Set Time: 13:48:23

Status Date: 01/19/2018

Status: Order Accepted at

Pharmacy Vendor (SC)

User: EOIR880

Set Date: 01/19/2018

Set Time: 01:57:43

Status Date: 01/18/2018

Status: Refill Ordered

User: Owens, Julia V

Set Date: 01/18/2018

Set Time: 08:38:28

Status Date: 12/28/2017

Status: Received from

Pharmacy User: King,

Martha J

Set Date: 12/28/2017

Set Time: 13:33:20

Status Date: 12/28/2017

Status: Order Accepted at

Pharmacy Vendor (SC)

User: EOIR880

Set Date: 12/28/2017

Set Time: 01:56:26

Status Date: 12/27/2017

Status: Approved/Approval

User: Mustain, Dawn

Set Date: 12/27/2017

Set Time: 14:12:49

Verbal By: Johnson, Chris,

D.O.

Status Date: 12/27/2017

Status: Pending Approval

User: Johnson, Chris

Set Date: 12/27/2017

Set Time: 13:03:42

PROVIDER SIGNATURE: _________________________________________________

Johnson, Chris, D.O.

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 97 of 139
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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 15

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 99 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 08, 2018 

16:01:39

Encounter Header

Date*: 01/27/2018 Start Time*: 08:03:14

End Date*: 01/27/2018 End Time*: 08:07:10

Category: Nursing

Type*: Nurse - Sick Call - Scheduled Encounter Close Date: 01/27/2018

Location*: ASPC-E BROWNING STG [A52] Encounter Close Time: 10:27:37

Setting*: Clinic

Staff Member*: Vegara, Lourdes

Title: Mental Health RN

Form Type: NET-Musculoskeletal

Subjective

Are interpreter services needed for this inmate*: No

What type of interpreter services were used for the encounter*: 

Related Health Service Requests

Request Date Area of Interest Request Type

No Rows Found

Subjective Notes

HNR - Requesting pain medication change. Inmates states that zonizamide is not working. States Meloxica

be helping with arthritis.

NET-Musculoskeletal - Subjective

Chief complaint: Pain medication not working. 

Onset Date:

 Trauma Describe injury:

 Difficulty breathing

 Pain Chronic Acute Dull Sharp Achy Burning

Pain scale is now: 8 /10 At worst: 10 /10

What makes it better: Gabapentin

What makes it worse:

 Radiation Describe:

Associated Factors:

 Urinary incontinence Painful urination Fecal incontinence 

 Tingling Nausea/vomiting 

Abdominal pain Fever

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 100 of 139
Objective

Vital Signs (1 - 1 of 1)

Taken By Time Temp Pulse Resp Height Weight BP

Systolic

BP

Diastolic

Blood

Suga

Vegara, Lourdes, RN 08:05 97.8 70 18 5 9 204 118 74 NA

Objective Notes

A/Ox3. Ambulating w/o deficit. Inmate reports pain is at 8/10. No grimacing observed. Inmate is smiling a

at times when appropriate. VS WNL.

Rev #: 926

Abdominal pain 

 Numbness: 

 Weakness: 

 Weight change

 Impaired mobility Impaired ADLs

 Chronic Acute Describe:

 Chronic Acute Describe:

 Gain Loss

Current Medications: Steroids NSAIDS Anticoagulants

 New medication in the past 30 days? What medication:

Pertinent Medical Conditions:

 Arthritis Cancer Osteoporosis Kidney disease/stones

 Back surgery Working lifting heavy objects

 Recent weight lifting Other:

Explain:

lbs.

Tetanus Booster >5 years: Y N Unknown 

Ever had a Tdap: Y N Unknown 

NET-Musculoskeletal - Objective

Skin: Warm Dry Pale Red

 Cold Clammy Scratching Bruising

Abdomen: Normal Pulsatile mass in abdomen Lumps Redness

Extremities:

 Pedal pulse: Radial pulse: R L R L

 Handgrips equal and strong

Call practitioner if T>100, P>100, or SBP <100.

Chronic care clinic: Y N What clinic(s):

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 101 of 139
Assessment

Active Allergies/Health Problems/Conditions (1 - 33 of 33)

ID 

Number Category Type National HIE 

Code(s) Diagnosis Code Status Status D

001 Chronic 

Conditions Asthma Assessed 10/02/20

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/20

003 Communicable 

Diseases Hepatitis C Assessed 10/02/20

004 Allergies -

Medication Carbamazepine Assessed 08/04/20

005 Mental Health Mental Health Assessed 08/04/20

006 Mental Health Mental Health Bipolar disorder Assessed 08/04/20

Rev #: 926

 Handgrips unequal and weak

 Tender to touch

 Straight leg raise equal and strong

 Straight leg raise unequal and weak

 Posture erect

 Posture not erect

 Gait symmetrical

 Gait not symmetrical

 Able to walk heel to toe

 Able to squat and rise

Describe:

Describe:

Describe:

Describe:

Describe:

Tests:

Record fingerstick results for diabetics in the vital signs section of this encounter.

Record Dipstick U/A order and results in the lab orders section of this encounter.

(Back pain or excessive exercise)

Comments:





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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 102 of 139
NOS [296.80]

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/20

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/20

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/20

010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/20

011 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism 

NOS [244.9] Assessed 09/30/20

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/20

013 Chronic 

Conditions Asthma Asthma NOS 

[493.90] Assessed 09/30/20

014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions 

[R56.9]

Assessed 10/01/20

015 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 10/01/20

016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/20

017 Chronic 

Conditions Asthma

Unspecified 

asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/20

018 Communicable 

Diseases Hepatitis C

Chronic viral 

hepatitis C 

[B18.2]

Assessed 11/16/20

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/20

020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 -

Cervical root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/20

021 Mental Health Mental Health

SNOMED: 

55668003 -

Adjustment 

disorder with 

mixed 

emotional 

features 

Adjustment 

disorder with 

mixed anxiety 

and depressed 

mood [F43.23]

Assessed 11/08/20

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 103 of 139
(disorder)

022 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

83561009 -

Spinal stenosis 

in cervical 

region 

(disorder)

Spinal stenosis, 

cervical region 

[M48.02]

Assessed 12/29/20

023 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

11049006 -

Cervical 

radiculitis 

(disorder)

Radiculopathy, 

cervical region 

[M54.12]

Assessed 01/27/20

024 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

813001 - Ankle 

instability 

(finding)

Injury of other 

nerves at ankle 

and foot level, 

right leg, 

sequela 

[S94.8X1S]

Assessed 01/27/20

025 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

134407002 -

Chronic back 

pain (finding)

Low back pain 

[M54.5] Assessed 02/23/20

026 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

1121000119107 

- Chronic neck 

pain (finding)

Cervicalgia 

[M54.2] Assessed 02/23/20

027 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

299447008 -

Ankle joint -

painful on 

movement 

(finding)

Pain in right 

ankle and joints 

of right foot 

[M25.571]

Assessed 02/23/20

028 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

17790008 -

Disorder of nail 

(disorder)

Nail disorder, 

unspecified 

[L60.9]

Assessed 05/12/20

029 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

10601006 -

Pain in lower 

limb (finding)

Pain in left knee 

[M25.562] Assessed 06/22/20

030 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

47933007 -

Foot pain 

(finding)

Superficial 

foreign body, 

right foot, 

sequela 

[S90.851S]

Assessed 06/29/20

031 Chronic 

Conditions Asthma

SNOMED: 

195967001 -

Asthma 

(disorder)

Mild 

intermittent 

asthma, 

uncomplicated 

[J45.20]

Assessed 07/29/20

032 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

128613002 -

Seizure disorder 

(disorder)

Other seizures 

[G40.89] Assessed 07/29/20

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 104 of 139
033 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

40930008 -

Hypothyroidism 

(disorder)

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 07/29/20

Related Allergies/Health Problems/Conditions 

ID Number Category Type National HIE Code(s) Diagnosis Code Status Status Da

No Rows Found

Assessment Notes

Alteration in comfort

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 5 of 5)

View MAR Summary

Prescription/Medication National HIE Code

(s) 

Effective

Date Dosage Frequency Expiration Stat

MELOXICAM (UD) 

TABS/7.5 Mg 

RxNorm: 311486 

- meloxicam 7.5 

MG Oral 

Tablet; 

12/27/2017 1 TWICE 

DAILY 06/24/2018

Receiv

from 

Pharm

ZONISAMIDE CAPS/25 

Mg 

RxNorm: 403966 

- zonisamide 25 

MG Oral 

Capsule; 

12/27/2017 1 TWICE 

DAILY 04/25/2018

Receiv

from 

Pharm

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 855671 

- DPH sodium 

100 MG 

Extended 

Release Oral 

Capsule; 

12/01/2017 2 TWICE 

DAILY 05/29/2018

Receiv

from 

Pharm

ALBUTEROL HFA 

(8.5GM) INHA/90 Mcg 

RxNorm: 745679 

- 200 ACTUAT 

Albuterol 0.09 

MG/ACTUAT 

Metered Dose 

Inhaler; 745752 

-...

11/09/2017 2puff

FOUR 

TIMES 

DAILY 

AS 

NEEDED

05/07/2018

Receiv

from 

Pharm

FLUTICASONE PROP 

NASAL (16) 

SUSP/0.05% 

RxNorm: 

1797907 -

Fluticasone 

propionate 0.05 

MG/ACTUAT 

Metered Dose 

10/18/2017 2 

sprays

EVERY 

DAY 02/14/2018

Receiv

from 

Pharm

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 105 of 139
Nasal Spray; 

Ordered Drug Prescriptions 

Prescription/Medication National HIE Code(s) Effective

Date Dosage Frequency Expira

No Rows Found

Lab Test Orders 

Lab Test Type National HIE Code(s) Priority Status Result

No Rows Found

X-Ray Orders 

X-Ray Body Area Priority S

No Rows Found

Consultation Request 

Request Type Service Type Priority

No Rows Found

Follow-up Appointments (1 - 1 of 1)

Date Time Type Staff Locatio

02/10/2018 10:00:00 Health Services Gay, Maureen ASPC-E BROWNING 

Patient Transfer Holds

Type Expiration Date Sta

No Rows Found

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comm

No Rows Found

Plan Notes

Referred to HCP for f/u.

NET-Musculoskeletal - Plan/Intervention

 Emergent Intervention

Practitioner notified: Time:

If CPR or AED is initiated use Emergency Response Form.

EMS activated: EMS arrival:

EMS transport: Facility transported to:

Other:

Comments:

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 106 of 139
Comments:





 Urgent Intervention-Contact Practitioner

Practitioner contact required due to:

 Abnormal vital signs (Rule of 100s)T>100, P>100, SBP<100

 Abnormal abdominal exam Positive straight leg raise Numbness/weakness (acute

 Decreased ROM Obvious deformity Uncontrolled bleeding

 Absence of pedal or radial pulse Abnormal fingerstick, Diabetic <70 or >240

 Abnormal dipstick UA Other:

Reviewed with practitioner: MAR Medical record

 Seen by practitioner

 Contacted practitioner

Name:

Name:

Time:

Time:

Practitioner Orders Received: Y N Read back practitioner orders

Disposition: Return to unit Monitor/Observation Admit to infirmary

 Other:

Comments:





 Nursing Intervention

Continuity of Care:

 Nurse follow up scheduled Referral to practitioner for current presenting complaint

 Custody notified of special needs No further follow up needed at this time

Medication:

 Seen by practitioner Name: Time:

 Contacted practitioner Name: Time:

Practitioner orders received Y N Read back practitioner orders

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 107 of 139
Patient Education

Patient Education Notes

Inmate educated on HCP referral process/protocol. Verbalized understanding. 

Health Classification

Medical: 3

Mental: 2-Previously received MH services Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Rev #: 926

Medication:

 O2 @

 OTC medication per site guideline

 KOP Medication administered Medication noted on MAR

LPM via

List: Acetaminophen, Ibuprofen

Comments:





Rev #: 926

NET-Musculoskeletal - Patient Education

Patient Education:

 Patient educated to contact medical if symptoms develop or worsen

 Education given Written information provided Verbal education given

 The patient demonstrates an understanding of self-care, symptoms to report, and when to return

for follow-up care

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 108 of 139
Encounter Orders Review 

Review Type*: No Review Required Review Staff: Unknown

Review Notes

None

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms

Type Staff

No Rows Found

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 109 of 139
 

Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 16

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 110 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 08, 2018 

14:16:01

Encounter Header

Date*: 02/10/2018 Start Time*: 15:33:16

End Date*: 02/10/2018 End Time*: 15:43:12

Category: Medical Provider

Type*: Provider - Follow Up Care Encounter Close Date: 02/10/2018

Location*: ASPC-E BROWNING STG [A52] Encounter Close Time: 15:46:20

Setting*: Clinic

Staff Member*: Gay, Maureen

Title: Nurse Practitioner

Form Type:

Subjective

Are interpreter services needed for this inmate*: No

What type of interpreter services were used for the encounter*: 

Related Health Service Requests

Request Date Area of Interest Request Type Status

No Rows Found

Subjective Notes

 Seen today for discussion of treatment plan augmentations. Claims current regimen provided 

meloxicam 7.5mg bid and Zonisamide po ineffective for pain management. Now states medication 

causes gastric upset with worsening symptoms for numbness involving entire hand left side as well 

as weakness left hand with grips. Denies any inability to participate in activity of daily living except 

exercises. In addition, states pain involving lower lumbar spine regions. patient is now requesting 

pain management returned visit for injections cervical regions or discectomy as suggested by 

neurologists 2014. lengthy discussion provided to patient about current and past tr5eamtnets 

provided for pains relief. Discussion included about short course narcotic use with tramadol. Patient 

stated, tramadol causes seizures in the past. patient then stated discectomy options cancelled after 

litigations about other health issues. 

 .

According to old record history: Dr. Marsella on 07/17/2012 after his EMG. Per his report, "nerve 

conduction shows very mild bilateral median neuropathy, but no radiculopathy, plexopathy, or 

peripheral neuropathy. States was involved in a prison riot in 2004 and someone stepped on the back 

of his neck as he was lying on the floor. Per records, pt had MRI on 07/2009 of his neck which 

showed C5-6 disk herniation. He saw Dr. Abhay Sanan (neurosurgery) on 10/15/2009 who 

recommended a c5-6 anterior cervical diskectomy and arthrodesis. At that time, he complained of 

RUE pain that shoots to his fingers, deltoid and biceps muscle atrophy, fasciculations of the deltoid 

and numbness/tingling to fingers. he was sent for a repeat MRI and neurosurgical eval in 09/2011 by 

Dr. Marco Marsella. His assessment showed mild R wrist dorsiflexion weakness and diminished 

sensatiuon to radial nerve tract, hypoactive DTRs symmetrically. His MRI showed mild diffuse facet 

joint hypertrophy consistent with arthritic changes. mild C5-6 degenerative disc disease with slight 

uplifting of posterior longitudinal ligament, maybe consistent with prior disc herniation, which is no 

longer visible. diffuse minimal foraminal stenosis. Recommendations by Dr. Marsella, "symptoms 

consistent with combination of radial and ulnar neuropathy. no focal abnormality that requires 

surgical correction. Nerve conduction study and EMG recommended to confirm diagnosis and 

determine extent of nerve damage. if they felt nerve entrapment syndrome will be detected then 

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surgical decompression may be recommended." he then had a f/u visit with Dr. Marsella on 

07/17/2012 after his EMG. Per his report, "nerve conduction shows very mild bilateral median 

neuropathy, but no radiculopathy, plexopathy, or peripheral neuropathy. given normal findings, do 

not advise surgical intervention at this time. discharged from surgical care. 

Updated MRI completed 2016 showed: 1. Straightening of the cervical spinal loss of lordosis is noted 

and may be secondary to cervical myositis.2. At the level of C5-C6, there is moderate degenerative 

spurring anteriorly with bridging as well as a 3.0 mm central posterior disc bulge with slight 

impression upon the thecal sac and marked left foraminal impingement. 3. At the level of C3-C4, 

moderate left foraminal impingement is noted. 

2017; received injection received January, February and March 03/18/2017; states lasted 2 months. 

Admits increased discomfort post cervical spine regions with increased numbness located post left 

arm involving left hand all digits . with increased weakness grip left hand. 

Continue HEP as ordered 

Objective

Vital Signs (1 - 1 of 1)

Taken By Time Temp Pulse Resp HeightWeight BP

Systolic

BP

Diastolic

Blood

Sugar Comments

Adams, Cheyenne 13:45 98.3 57 16 5 9 203 144 70 NA

Objective Notes

Physical exam: 

GENERAL: 

Gen. no apparent distress cuffed with security in room 

CERVIAL SPINE: no cervical tenderness on palpations, positive full range of motion noted with 

rotations flexion and hyper extension positive point tenderness left lateral scalene, splenius capitus 

muscle and trapezius muscle without cervical spine bulging or edema noted 

bilateral shoulders are symmetric no scars noted no deformities noted, no point tenderness noted at 

the glenohumeral joint anterior bicep muscle and the supraspinatinus muscle; no joint after the war 

muscle atrophy noted were joint swelling noted positive full range of motion with decreased range of 

motion abduction and in turn rotation. Apley's scratch test unable to perform without discomfort, 

apprehension test positive discomfort at the glenohumeral joint area grips slightly weaker than right, 

colors pink, warm, dry radial pulses positive, positive sensation 

neurologic exam reflexes bilateral upper extremities grossly intact 

Assessment

Medical Diagnosis/Complaint (1 - 2 of 2)

ICD Code Diagnosis/Complaint

M54.2 Cervicalgia

R51 Headache

Active Allergies/Health Problems/Conditions (1 - 33 of 33)

ID 

Number Category Type National HIE Code(s) Diagnosis Code Status Status D

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 112 of 139
001 Chronic 

Conditions Asthma Assessed 10/02/20

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/20

003 Communicable 

Diseases Hepatitis C Assessed 10/02/20

004 Allergies -

Medication Carbamazepine Assessed 08/04/20

005 Mental Health Mental Health Assessed 08/04/20

006 Mental Health Mental Health Bipolar disorder 

NOS [296.80] Assessed 08/04/20

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/20

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/20

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/20

010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/20

011 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism 

NOS [244.9] Assessed 09/30/20

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/20

013 Chronic 

Conditions Asthma Asthma NOS 

[493.90] Assessed 09/30/20

014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions 

[R56.9]

Assessed 10/01/20

015 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 10/01/20

016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/20

017 Chronic 

Conditions Asthma

Unspecified 

asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/20

018 Communicable 

Diseases Hepatitis C

Chronic viral 

hepatitis C 

[B18.2]

Assessed 11/16/20

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/20

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 113 of 139
020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 -

Cervical root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/20

021 Mental Health Mental Health

SNOMED: 

55668003 -

Adjustment 

disorder with 

mixed 

emotional 

features 

(disorder)

Adjustment 

disorder with 

mixed anxiety 

and depressed 

mood [F43.23]

Assessed 11/08/20

022 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

83561009 -

Spinal stenosis 

in cervical 

region 

(disorder)

Spinal stenosis, 

cervical region 

[M48.02]

Assessed 12/29/20

023 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

11049006 -

Cervical 

radiculitis 

(disorder)

Radiculopathy, 

cervical region 

[M54.12]

Assessed 01/27/20

024 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

813001 - Ankle 

instability 

(finding)

Injury of other 

nerves at ankle 

and foot level, 

right leg, 

sequela 

[S94.8X1S]

Assessed 01/27/20

025 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

134407002 -

Chronic back 

pain (finding)

Low back pain 

[M54.5] Assessed 02/23/20

026 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

1121000119107 

- Chronic neck 

pain (finding)

Cervicalgia 

[M54.2] Assessed 02/23/20

027 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

299447008 -

Ankle joint -

painful on 

movement 

(finding)

Pain in right 

ankle and joints 

of right foot 

[M25.571]

Assessed 02/23/20

028 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

17790008 -

Disorder of nail 

(disorder)

Nail disorder, 

unspecified 

[L60.9]

Assessed 05/12/20

029 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

10601006 -

Pain in lower 

limb (finding)

Pain in left knee 

[M25.562] Assessed 06/22/20

Other Other 

SNOMED: 

47933007 -

Superficial 

foreign body, 

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 114 of 139
030

Diagnosis Diagnosis Foot pain 

(finding)

right foot, 

sequela 

[S90.851S]

Assessed 06/29/20

031 Chronic 

Conditions Asthma

SNOMED: 

195967001 -

Asthma 

(disorder)

Mild 

intermittent 

asthma, 

uncomplicated 

[J45.20]

Assessed 07/29/20

032 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

128613002 -

Seizure disorder 

(disorder)

Other seizures 

[G40.89] Assessed 07/29/20

033 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

40930008 -

Hypothyroidism 

(disorder)

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 07/29/20

Related Allergies/Health Problems/Conditions (1 - 1 of 1)

ID 

Number Category Type National HIE Code(s) Diagnosis Code Status Status D

034 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 162299003 -

Generalized headache 

(finding)

Headache 

[R51] Assessed 02/10/20

Assessment Notes

Assessment; 

1. Cervicalgia: 

2. Tension type headache: 

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 6 of 6)

View MAR Summary

Prescription/Medication National HIE Code

(s) 

Effective

Date Dosage Frequency Expiration Stat

LEVOTHYROXINE SOD 

TABS/0.075 Mg 

RxNorm: 966171 

- Levothyroxine 

Sodium 0.075 

MG Oral Tablet 

[Synthroid]; 

02/01/2018 1 EVERY 

DAY 07/30/2018

Receiv

from 

Pharm

MELOXICAM (UD) 

TABS/7.5 Mg 

RxNorm: 311486 

- meloxicam 7.5 

MG Oral 

Tablet; 

12/27/2017 1 TWICE 

DAILY 06/24/2018

Receiv

from 

Pharm

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 115 of 139
ZONISAMIDE CAPS/25 

Mg 

RxNorm: 403966 

- zonisamide 25 

MG Oral 

Capsule; 

12/27/2017 1 TWICE 

DAILY 04/25/2018

Receiv

from 

Pharm

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 855671 

- DPH sodium 

100 MG 

Extended 

Release Oral 

Capsule; 

12/01/2017 2 TWICE 

DAILY 05/29/2018

Receiv

from 

Pharm

ALBUTEROL HFA 

(8.5GM) INHA/90 Mcg 

RxNorm: 745679 

- 200 ACTUAT 

Albuterol 0.09 

MG/ACTUAT 

Metered Dose 

Inhaler; 745752 

-...

11/09/2017 2puff

FOUR 

TIMES 

DAILY 

AS 

NEEDED

05/07/2018

Receiv

from 

Pharm

FLUTICASONE PROP 

NASAL (16) 

SUSP/0.05% 

RxNorm: 

1797907 -

Fluticasone 

propionate 0.05 

MG/ACTUAT 

Metered Dose 

Nasal Spray; 

10/18/2017 2 

sprays

EVERY 

DAY 02/14/2018

Receiv

from 

Pharm

Ordered Drug Prescriptions (1 - 1 of 1)

Prescription/Medication National HIE Code

(s)

Effective

Date Dosage Frequency Expiration Statu

APAP (BOX OF 24) 

TABS/325 Mg 

RxNorm: 313782 

- Acetaminophen 

325 MG Oral 

Tablet; 

02/10/2018 1

TWICE 

DAILY 

AS 

NEEDED

03/11/2018

Receiv

from 

Pharma

Lab Test Orders 

Lab Test Type National HIE Code(s) Priority Status Results Va

No Rows Found

X-Ray Orders 

X-Ray Body Area Priority Status

No Rows Found

Consultation Request 

Request Type Service Type Priority Status

No Rows Found

Follow-up Appointments

Date Time Type Staff Location

No Rows Found

Patient Transfer Holds

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 116 of 139
Type Expiration Date Status

No Rows Found

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comments

No Rows Found

Plan Notes

Plan: 

1. add Tylenol 325mg bid as needed 

2. Continue current therapy for now until long term treatment options has been developed. allow at least 7

days for discussion about further treatment options to be discussed.

Patient Education

Patient Education Notes

1. add reviewed multiple records for review 

2. Reviewed medications; option, need approval for additional medications offered

Meaningful Use Measurement

 Demographic Information in Patient Header verified

 Current Medical Problem List verified (or Patient has no Medical Problems)

 Current Medications List verified (or Patient has no Medical Medications) Medications List NOT 

verified 

 Medication Allergies List verified (or Patient is not allergic to any Medications)

Health Classification

Medical: 3

Mental: 2-Previously received MH services Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Encounter Orders Review 

Review Type*: Pending Nurses Order Review Staff: Vallejo, Jose, LPN

Review Date: 02/11/2018 Review Time: 04:22:37

Review Notes

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TimeStamp: 11 February 2018 04:25:33 --- User: Jose Vallejo (VALJO01)

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms

Type Staff

No Rows Found

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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 17

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 119 of 139
CHSS027C

Health Services 

Encounter

Wednesday August 08, 2018 

14:33:55

Encounter Header

Date*: 03/15/2018 Start Time*: 13:58:16

End Date*: 03/15/2018 End Time*: 14:58:13

Category: Medical Provider

Type*: Provider - Sick Call - Scheduled Encounter Close Date: 03/15/2018

Location*: ASPC-E BROWNING STG [A52] Encounter Close Time: 16:00:48

Setting*: Clinic

Staff Member*: Stewart, Rodney

Title: Medical Doctor

Form Type:

Subjective

Are interpreter services needed for this inmate*: No

What type of interpreter services were used for the encounter*: 

Related Health Service Requests (1 - 1 of 1)

Request Date Area of Interest Request Type Status

02/22/2017 Provider Routine Encounter Held

Subjective Notes

Request Date: 02/22/2017

Asking why his gabapentin dosage was reduced without discussing it with him

INMATE PRESENTS FOR ASSESSMENT AND DISCUSSION OF DISCONTINUEATION OF 

GABAPENTIN. DISCUSSED WITH PATIENT THAT WE HAVE REDUCED GABBAPENTIN USAGE EXCEPT 

IN TWO MEDICAL INSTANCES. THESE WEREE EXPLAINED TO THINMATE. WE DISCUSSED 

CONSISTENT TREATMENT IN POLICY ACROSS ALL LINES AND THAT WE CAN NOT USE GABAPENTIN 

IN HIS CASE. 

THE PATIENT STATES HE WOULD NOT REFUSE ANYTHING AT THIS TIME. HE IS INTERESTED IN 

SURGERY AT THIS TIME. SYMPTOMS ORIGINALLY CAUSED RIGHT SIDE WEAKNESS AND ATROPHY. 

HE NOTES THAT OVER THE LAST NEARLY 9 YEARS SYMPTOMS HAVE CHANGED FROM RIGHT 

WEAKNESS AND ATROPHY TO LEFT SIDE WEAKNESS AND NERVE PAIN. 

Objective

Vital Signs 

Taken By Time Temp Pulse Resp Height Weight BP

Systolic

BP

Diastolic

Blood

Sugar Comments

Not Taken

Objective Notes

VITALS STABLE 

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LUNG CTA

HEART RRR, NO M/R/G

ABD SOFT NT BS+ ND

EXT NO EDEMA

NEURO CN II-XII ARE INTACT; POSITIVE BUT SUBTLE WEAKNESS IN LEFT UPPER EXT 

COMPARED TO THE RIGHT. PATIENT WITH MINOR WEAKNESS IN THE LEWFT LOWER EXT BUT 

POSITIVE WITH SENSORY DEFICITS. NO LEG LIFT PAIN.

Assessment

Medical Diagnosis/Complaint

ICD Code Diagnosis/Complaint

No Rows Found

Active Allergies/Health Problems/Conditions (1 - 34 of 34)

ID 

Number Category Type National HIE Code(s) Diagnosis Code Status Status D

001 Chronic 

Conditions Asthma Assessed 10/02/20

002 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Assessed 10/02/20

003 Communicable 

Diseases Hepatitis C Assessed 10/02/20

004 Allergies -

Medication Carbamazepine Assessed 08/04/20

005 Mental Health Mental Health Assessed 08/04/20

006 Mental Health Mental Health Bipolar disorder 

NOS [296.80] Assessed 08/04/20

007 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Epilepsy NOS w 

intr epil 

[345.91]

Assessed 10/01/20

008 Other 

Diagnosis

Other 

Diagnosis

Hand injury 

NOS [959.4] Assessed 10/15/20

009 Other 

Diagnosis

Other 

Diagnosis

Other postop 

infection 

[998.59]

Assessed 11/04/20

010 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Convulsions 

NEC [780.39] Assessed 09/30/20

011 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism 

NOS [244.9] Assessed 09/30/20

012 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[338.4]

Assessed 09/30/20

013 Chronic 

Conditions Asthma Asthma NOS 

[493.90] Assessed 09/30/20

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014 Chronic 

Conditions

Seizures, 

Epilepsy, or 

Convul.

Unspecified 

convulsions 

[R56.9]

Assessed 10/01/20

015 Other 

Diagnosis

Pt. Specific 

Chronic 

Condition

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 10/01/20

016 Other 

Diagnosis

Other 

Diagnosis

Chronic pain 

syndrome 

[G89.4]

Assessed 10/01/20

017 Chronic 

Conditions Asthma

Unspecified 

asthma, 

uncomplicated 

[J45.909]

Assessed 10/01/20

018 Communicable 

Diseases Hepatitis C

Chronic viral 

hepatitis C 

[B18.2]

Assessed 11/16/20

019 Mental Health Mental Health

Bipolar 

disorder, 

unspecified 

[F31.9]

Assessed 12/03/20

020 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

202776005 -

Cervical root 

syndrome 

(disorder)

Cervical root 

disorders, not 

elsewhere 

classified 

[G54.2]

Assessed 03/28/20

021 Mental Health Mental Health

SNOMED: 

55668003 -

Adjustment 

disorder with 

mixed 

emotional 

features 

(disorder)

Adjustment 

disorder with 

mixed anxiety 

and depressed 

mood [F43.23]

Assessed 11/08/20

022 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

83561009 -

Spinal stenosis 

in cervical 

region 

(disorder)

Spinal stenosis, 

cervical region 

[M48.02]

Assessed 12/29/20

023 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

11049006 -

Cervical 

radiculitis 

(disorder)

Radiculopathy, 

cervical region 

[M54.12]

Assessed 01/27/20

024 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

813001 - Ankle 

instability 

(finding)

Injury of other 

nerves at ankle 

and foot level, 

right leg, 

sequela 

[S94.8X1S]

Assessed 01/27/20

025 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

134407002 -

Chronic back 

pain (finding)

Low back pain 

[M54.5] Assessed 02/23/20

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026 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

1121000119107 

- Chronic neck 

pain (finding)

Cervicalgia 

[M54.2] Assessed 02/23/20

027 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

299447008 -

Ankle joint -

painful on 

movement 

(finding)

Pain in right 

ankle and joints 

of right foot 

[M25.571]

Assessed 02/23/20

028 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

17790008 -

Disorder of nail 

(disorder)

Nail disorder, 

unspecified 

[L60.9]

Assessed 05/12/20

029 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

10601006 -

Pain in lower 

limb (finding)

Pain in left knee 

[M25.562] Assessed 06/22/20

030 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

47933007 -

Foot pain 

(finding)

Superficial 

foreign body, 

right foot, 

sequela 

[S90.851S]

Assessed 06/29/20

031 Chronic 

Conditions Asthma

SNOMED: 

195967001 -

Asthma 

(disorder)

Mild 

intermittent 

asthma, 

uncomplicated 

[J45.20]

Assessed 07/29/20

032 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

128613002 -

Seizure disorder 

(disorder)

Other seizures 

[G40.89] Assessed 07/29/20

033 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

40930008 -

Hypothyroidism 

(disorder)

Hypothyroidism, 

unspecified 

[E03.9]

Assessed 07/29/20

034 Other 

Diagnosis

Other 

Diagnosis

SNOMED: 

162299003 -

Generalized 

headache 

(finding)

Headache [R51] Assessed 02/10/20

Related Allergies/Health Problems/Conditions 

ID Number Category Type National HIE Code(s) Diagnosis Code Status Status Da

No Rows Found

Assessment Notes

LEFT NEUROPATHIC RADICULOPATHY PAIN IN UPPER AND LOWER EXTREMITIES

PREVIOUS HISTORY OF CERVICAL HNP. 

LAST MRI IN 2016 SHOWED MARKED FORMINAL LEFT INPINGMENT AT C5-6 AND C3-4. C5-6 ALSO HAD S

SAC INPINGEMENT. 

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EPILEPSY

HYPOTHYROIDISM

Plan

Treatment Orders 

Category Type Frequency For Days Specify Comments

No Rows Found

Active Drug Prescription Orders (1 - 8 of 8)

View MAR Summary

Prescription/Medication National HIE Code

(s) 

Effective

Date Dosage Frequency Expiration Sta

CODEINE/APAP 

TABS/30-300 Mg 03/15/2018 2 TWICE 

DAILY 04/13/2018

Orde

Acce

at 

Phar

Vend

(SC)

APAP TABS/325 Mg 

RxNorm: 209375 -

Acetaminophen 

325 MG Oral 

Tablet 

[Mapap]; 313782 

- Acetaminophen 

3...

03/12/2018 1

TWICE 

DAILY 

AS 

NEEDED

04/10/2018

Rece

from

Phar

FLUTICASONE PROP 

NASAL (16) 

SUSP/0.05% 

RxNorm: 1797907 

- Fluticasone 

propionate 0.05 

MG/ACTUAT 

Metered Dose 

Nasal Spray; 

02/15/2018 2 

sprays

EVERY 

DAY 06/14/2018

Rece

from

Phar

LEVOTHYROXINE SOD 

TABS/0.075 Mg 

RxNorm: 966171 -

Levothyroxine 

Sodium 0.075 MG 

Oral Tablet 

[Synthroid]; 

02/01/2018 1 EVERY 

DAY 07/30/2018

Rece

from

Phar

MELOXICAM (UD) 

TABS/7.5 Mg 

RxNorm: 311486 -

meloxicam 7.5 MG 

Oral Tablet; 

12/27/2017 1 TWICE 

DAILY 06/24/2018

Rece

from

Phar

ZONISAMIDE CAPS/25 

Mg 

RxNorm: 403966 -

zonisamide 25 MG 

Oral Capsule; 

12/27/2017 1 TWICE 

DAILY 04/25/2018

Rece

from

Phar

PHENYTOIN SOD 

*EXT* CAPS/100 Mg 

RxNorm: 855671 -

DPH sodium 100 

MG Extended 

Release Oral 

Capsule; 

12/01/2017 2 TWICE 

DAILY 05/29/2018

Rece

from

Phar

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ALBUTEROL HFA 

(8.5GM) INHA/90 Mcg 

RxNorm: 745679 -

200 ACTUAT 

Albuterol 0.09 

MG/ACTUAT 

Metered Dose 

Inhaler; 745752 

-...

11/09/2017 2puff

FOUR 

TIMES 

DAILY 

AS 

NEEDED

05/07/2018

Rece

from

Phar

Ordered Drug Prescriptions (1 - 1 of 1)

Prescription/Medication National HIE Code

(s)

Effective

Date Dosage Frequency Expiration Sta

CODEINE/APAP 

TABS/30-300 Mg 

RxNorm: 993781 -

Acetaminophen 300 

MG / Codeine 

Phosphate 30 MG 

Oral Tablet; 

03/15/2018 2 

TABS

TWICE 

DAILY 04/13/2018 Ref

Ord

Lab Test Orders 

Lab Test Type National HIE Code(s) Priority Status Results V

No Rows Found

X-Ray Orders 

X-Ray Body Area Priority Status

No Rows Found

Consultation Request (1 - 1 of 1)

Request Type Service Type Priority Status

Off-site Clinic Neuro Surgery Routine Consult Completed -Results Received

Follow-up Appointments

Date Time Type Staff Location

No Rows Found

Patient Transfer Holds

Type Expiration Date Status

No Rows Found

Other Actions/Procedures

Group Type Approximate

Begin Date

Approximate

End Date Specify Comments

No Rows Found

Plan Notes

TYLENOL -3 FOR PAIN X30 DAYS

NEURO SURGICAL CONSULT FOR REPAIR OF KNOWN CERVICAL DISEASE, IF IT WILL CHANGE SYMPTOMS

THAT HAVE BEEN PRESENT FOR YEARS 

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MAY NEED REPEAT MRI AS HERNIATED DISC CAN RESOLVE. SYMPTOMS AND EXAM REMAIN 

CONSISTENT WITH LAST MRI FINDINGS

Patient Education

Patient Education Notes

DISCUSSED PLAN WITH INMATE

Meaningful Use Measurement

 Demographic Information in Patient Header verified

 Current Medical Problem List verified (or Patient has no Medical Problems)

 Current Medications List verified (or Patient has no Medical Medications) Medications List NOT 

verified 

 Medication Allergies List verified (or Patient is not allergic to any Medications)

Health Classification

Medical: 3

Mental: 2-Previously received MH services Prognosis: Improvable Condition

SMI: N-No

Dental: U-Unknown (Conversion)

Classification and Security Notes

None

Encounter Orders Review 

Review Type*: No Review Required Review Staff: Generic, Clinic Nurse

Review Notes

None

Scanned Documents/Photos

Document Type Date Scanned Title Source Privacy Level 

No Rows Found

Standard Forms

Type Staff

No Rows Found

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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 18

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 127 of 139
OCSS011P Condensed Consultation Request Wednesday August 08, 2018 

14:29:43

ADC#: 067165 INMATE NAME: PEMBER, JAY L. 

ADC#: 067165 INMATE NAME: PEMBER, JAY L. DOB: 07/21/1966 

ADMISSION: 08/28/2003 DISCHARGE: 04/10/2025

REQUEST DATE: 03/15/2018 REQUEST TIME: 13:58:16 SEQ#: 001

ENCOUNTER TYPE: Provider - Sick Call - Scheduled LOCATION: ASPC-E BROWNING STG 

[A52] STATUS: Consult Completed -Results Received

BY STAFF MEMBER: Stewart, Rodney

VERBAL BY: None

REQUEST TYPE: Off-site Clinic PRIORITY: Routine

SERVICE TYPE: Neuro Surgery PROCEDURE REQUESTED: 

OffSite Location: Offsite Location Offsite Provider: Offsite, Provider

PRESUMED DIAGNOSIS: 

PROCEDURE REQUESTED COMMENTS: 

PATIENT IS A 51 YO WHITE MALE WITH HISTORY OF PREVIOUS CERVICAL INJURY AND MRI 2016 

SHOWING C5-6 AND C3-4 FORAMINAL IMPINGEMENT AND THECAL INPINGEMENT AT C5-6. HE 

IS NOTING INCREASING PAIN DOWN THE LEFT ARM AND LEFT LEG AND FOOT. HE IS NOTING 

PROGRESSIVE WORSENING AS HE IS UNABLE TO TOLERATE SYMPTOMS ANY LONGER AND IS 

HAVING DIFFICULTY WITH SLEEP. NEURO EXAM FINDINGS SHOW A STOCKING GLOVE SENSORY 

DEFICIT IN LEFT UYPPER AND LEFT LOWER EXT. HE HAS WEAKNESS IN LEFT UPPER EXT BUT 

NOT LOWER EXT WHEN COMPARED TO RIGHT.

PLEASE INCLUDE PREVIOUS MRI. 

PLEASE INCLUDE PREVIOUS NOTES AND SURDICAL EVALUATIONS 

SUBJECTIVE NOTES: 

Request Date: 02/22/2017

Asking why his gabapentin dosage was reduced without discussing it with him

INMATE PRESENTS FOR ASSESSMENT AND DISCUSSION OF DISCONTINUEATION OF 

GABAPENTIN. DISCUSSED WITH PATIENT THAT WE HAVE REDUCED GABBAPENTIN USAGE 

EXCEPT IN TWO MEDICAL INSTANCES. THESE WEREE EXPLAINED TO THINMATE. WE 

DISCUSSED CONSISTENT TREATMENT IN POLICY ACROSS ALL LINES AND THAT WE CAN NOT USE 

GABAPENTIN IN HIS CASE. 

THE PATIENT STATES HE WOULD NOT REFUSE ANYTHING AT THIS TIME. HE IS INTERESTED IN 

SURGERY AT THIS TIME. SYMPTOMS ORIGINALLY CAUSED RIGHT SIDE WEAKNESS AND 

ATROPHY. HE NOTES THAT OVER THE LAST NEARLY 9 YEARS SYMPTOMS HAVE CHANGED FROM 

RIGHT WEAKNESS AND ATROPHY TO LEFT SIDE WEAKNESS AND NERVE PAIN. 

SIGNS/SYMPTOMS SUGGESTING DIAGNOSIS COMMENTS: 

VITALS STABLE 

LUNG CTA

HEART RRR, NO M/R/G

ABD SOFT NT BS+ ND

EXT NO EDEMA

NEURO CN II-XII ARE INTACT; POSITIVE BUT SUBTLE WEAKNESS IN LEFT UPPER EXT 

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Electronically signed by: Stewart, Rodney on 03/15/2018 at 13:58:16.

CPT® copyright 2018 American Medical Association. All rights reserved.

COMPARED TO THE RIGHT. PATIENT WITH MINOR WEAKNESS IN THE LEWFT LOWER EXT BUT 

POSITIVE WITH SENSORY DEFICITS. NO LEG LIFT PAIN.

ACTIVE PROBLEMS CONDITIONS COMMENTS: 

Chronic Conditions - Asthma

Chronic Conditions - Seizures, Epilepsy, or Convul.

Communicable Diseases - Hepatitis C

Allergies - Medication - Carbamazepine

Chronic Conditions - Seizures, Epilepsy, or Convul. - Epilepsy NOS w intr epil [345.91]

Hand injury NOS [959.4]

Other postop infection [998.59]

Chronic Conditions - Seizures, Epilepsy, or Convul. - Unspecified convulsions [R56.9]

Hypothyroidism, unspecified [E03.9]

Chronic pain syndrome [G89.4]

Chronic Conditions - Asthma - Unspecified asthma, uncomplicated [J45.909]

Communicable Diseases - Hepatitis C - Chronic viral hepatitis C [B18.2]

Cervical root disorders, not elsewhere classified [G54.2]

Mental Health - Adjustment disorder with mixed anxiety and depressed mood [F43.23]

Spinal stenosis, cervical region [M48.02]

Radiculopathy, cervical region [M54.12]

Injury of other nerves at ankle and foot level, right leg, sequela [S94.8X1S]

Low back pain [M54.5]

Cervicalgia [M54.2]

Pain in right ankle and joints of right foot [M25.571]

Nail disorder, unspecified [L60.9]

Pain in left knee [M25.562]

Superficial foreign body, right foot, sequela [S90.851S]

Chronic Conditions - Asthma - Mild intermittent asthma, uncomplicated [J45.20]

Other seizures [G40.89]

Hypothyroidism, unspecified [E03.9]

Headache [R51]

CURRENT MEDICATIONS COMMENTS: 

CODEINE/APAP TABS/30-300 Mg;APAP TABS/325 Mg;FLUTICASONE PROP NASAL (16) 

SUSP/0.05%;LEVOTHYROXINE SOD TABS/0.075 Mg;MELOXICAM (UD) TABS/7.5 Mg;ZONISAMIDE 

CAPS/25 Mg;PHENYTOIN SOD *EXT* CAPS/100 Mg;ALBUTEROL HFA (8.5GM) INHA/90 Mcg;

FAILED THERAPIES COMMENTS: 

None

RELATED LAB TEST COMMENTS: 

None

RELATED XRAY COMMENTS: 

None

ACTION TAKEN: 

DATE: 08/06/2018 TIME: 09:35:10 TYPE: Consult Completed -Results 

Received REASON: Consult Completed - Results Received BY STAFF: McClary, Paula, CNA

DATE: 06/01/2018 TIME: 08:35:05 TYPE: Consult - Rescheduled REASON: See Comments BY 

STAFF: Ramirez, Martha

DATE: 04/16/2018 TIME: 16:18:25 TYPE: External Consult Scheduled REASON: Scheduled BY 

STAFF: Ramirez, Martha

DATE: 04/04/2018 TIME: 14:30:43 TYPE: Referred to UM Team for Review REASON: See 

Comments BY STAFF: Ramirez, Martha

SCANNED DOCUMENTS: 

SCANNED DOCUMENT/PHOTO TYPE: Consults TITLE: 2018_08_03 CHC Neurosurgery

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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 19

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Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 132 of 139
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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 20

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 134 of 139
Show Last Updated Information

OCSS011D Consultation Request ActionMonday August 20, 2018 01:56:39 PM

Consult Request

Name: JAY L. PEMBER ADC #: 067165

Request Date: 03/15/2018 Request Time: 13:58:16

Encounter Type: Provider - Sick Call - Scheduled Location: ASPC-E BROWNING STG [A52

Title: Medical Doctor Status: Consult Completed- Practitione

Request Type: Off-site Clinic Priority: Routine

Service Type: Neuro Surgery In-house Location: 

In-house Provider: Offsite Location: Offsite Location

Offsite Provider: Offsite, Provider

Action Date: 08/09/2018 Time: 17:15:03

Staff: Johnson, Chris, D.O.

Action Type: Consult Completed- Practitioner Reviewed

Reason: Consult Completed- Practitioner Reviewed

2nd: 

3rd: 

Forward Staff: 

Action Taken Comments

Recommendations reviewed. EMG, MRI for cervical and thoracic spine and PT ordered. Will request f/u 

with neuro after these have been completed. 

TimeStamp: 9 August 2018 17:18:11 --- User: Chris Johnson (Joh01)

Prior Page

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Q U I N T A I R O S, P R I E T O, W O O D & B O Y E R, P.A.

Exhibit 21

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 136 of 139
 

NOT FOR PUBLICATION

UNITED STATES COURT OF APPEALS

FOR THE NINTH CIRCUIT

JAY LYNN PEMBER, 

Plaintiff-Appellant, 

 v. 

AL RAMOS; et al., 

Defendants-Appellees. 

No. 15-15627 

D.C. No. 2:11-cv-02332-SMM 

MEMORANDUM*

Appeal from the United States District Court

for the District of Arizona

Stephen M. McNamee, District Judge, Presiding

Submitted August 16, 2016**

San Francisco, California

Before: O’SCANNLAIN, LEAVY, and CLIFTON, Circuit Judges.

Arizona state prisoner Jay Lynn Pember appeals pro se from the district

court’s summary judgment in his 42 U.S.C. § 1983 action alleging constitutional 

claims. We have jurisdiction under 28 U.S.C. § 1291. We review de novo.

 

* This disposition is not appropriate for publication and is not precedent 

except as provided by Ninth Circuit Rule 36-3.

** The panel unanimously concludes this case is suitable for decision 

without oral argument. See Fed. R. App. P. 34(a)(2).

FILED

MAR 6 2017

MOLLY C. DWYER, CLERK

U.S. COURT OF APPEALS

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 137 of 139 Case: 15-15627, 03/06/2017, ID: 10343924, DktEntry: 34-1, Page 1 of 3
 2 15-15627 

Lemire v. Cal. Dep’t of Corr. & Rehab., 726 F.3d 1062, 1074 (9th Cir. 2013). We

affirm in part, reverse in part, and remand.

The district court granted summary judgment for defendant Dr. Baird. 

However, Defendants’ argument that there was a difference of medical opinion 

regarding Pember’s need for surgery was unsupported by admissible evidence. See 

Nissan Fire & Marine Ins. Co. v. Fritz Cos., 210 F.3d 1099, 1102 (9th Cir. 2000) 

(“A moving party without the ultimate burden of persuasion at trial . . . has both 

the initial burden of production and the ultimate burden of persuasion on a motion 

for summary judgment.”); see also Orr v. Bank of Am., NT & SA, 285 F.3d 764, 

773 (9th Cir. 2002) (“A trial court can only consider admissible evidence in ruling 

on a motion for summary judgment . . . [and] authentication is a condition 

precedent to admissibility.” (citations and internal quotation marks omitted)). 

None of the exhibits cited by Defendants were authenticated, and there were no 

declarations by Dr. Baird, Dr. Marsella, or anyone else, or any explanation for the 

failure to submit such evidence. More broadly, the original recommendation for

surgery was rendered in 2009. The different medical opinion (assuming that the 

exhibits could be authenticated) was not rendered until two years later in 2011. 

There was no explanation for the delay, during which time there was no opinion 

identified to us other than the one recommending surgery. It could be concluded 

that the failure to perform the surgery or to obtain any other medical opinion 

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 138 of 139 Case: 15-15627, 03/06/2017, ID: 10343924, DktEntry: 34-1, Page 2 of 3
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during that extended period constituted deliberate indifference. See Jackson v. 

McIntosh, 90 F.3d 330, 332 (9th Cir. 1996) (plaintiff can show deliberate 

indifference if “the course of treatment the doctors chose was medically 

unacceptable under the circumstances”). Accordingly, we reverse the judgment for 

Dr. Baird and remand for further proceedings.

Because Pember only challenges summary judgment on his deliberate

indifference claim against Dr. Baird, we affirm the remainder of the district court’s 

summary judgment.

The parties shall bear their own costs on appeal.

AFFIRMED in part, REVERSED in part, and REMANDED.

Case 2:17-cv-04069-JJT-JFM Document 41 Filed 08/22/18 Page 139 of 139 Case: 15-15627, 03/06/2017, ID: 10343924, DktEntry: 34-1, Page 3 of 3