Nancy Marie Peck v. Wayne Cody Peck

• Court: Court of Appeals of Texas
• Decided: December 30, 2014
• Docket: 03-14-00440-CV
• Status: Published

Opinion

ACCEPTED 03-14-00440-CV 3622487 THIRD COURT OF APPEALS AUSTIN, TEXAS 12/30/2014 5:26:19 PM JEFFREY D. KYLE CLERK No. 03-14-00440-CV

IN THE COURT OF APPEALS FILED IN 3rd COURT OF APPEALS THIRD JUDICIAL DISTRICT AUSTIN, TEXAS AUSTIN, TEXAS 12/30/2014 5:26:19 PM JEFFREY D. KYLE Clerk _________________________________

NANCY MARIE PECK, Appellant,

V.

WAYNE CODY PECK, Appellee. ________________________________

Appealed from the County Court at Law No. 4 Williamson County, Texas

APPELLANT’S BRIEF

John J. Hindera, J.D., Ph.D. Texas Bar No. 24036782 THE HINDERA LAW FIRM 4425 S. MoPac Expressway Building 2, Suite 107 Austin, Texas 78735 Tel: (512) 899-3631 Fax: (512) 899-3618 Email: john@hinderalaw.com

ATTORNEY FOR APPELLANT, NANCY MARIE PECK

APPELLANT REQUESTS ORAL ARGUMENT No. 03-14-00440-CV

WAYNE CODY PECK, APPELLEE.

_____________________________________

IDENTITY OF PARTIES & COUNSEL _____________________________________

Nancy Marie Peck, Appellant herein, brings this appeal seeking relief from the Third Court of Appeals. In order that the Court may determine disqualification and recusal under Rule 16 of the Texas Rules of Appellate Procedure, Appellant certifies the following is a complete list of the parties, attorney, the trial court judge, and any other person who had an interest in the outcome of the underlying lawsuit.

Appellant Appellee Nancy Marie Peck Wayne Cody Peck Petitioner in 13-0926-FC4 Respondent in 13-0926-FC4

Attorney for Appellant Attorney for Appellee John J. Hindera, J.D., Ph.D. Felix Rippy Texas Bar No. 24037682 Texas Bar No. 16937400 THE HINDERA LAW FIRM RIPPY & TAYLOR, PC 4425 S. MoPac Expressway 3000 Joe Dimaggio Blvd., Ste. 4 Building 2, Suite 107 Round Rock, Texas 78665 Austin, Texas 78735 Tel: (512) 310-9500 Tel: (512) 899-3631 Fax: (512) 310-2580 Fax: (512) 899-3618 Email: felixrippy@aol.com Email: john@hinderalaw.com PAGE 2 OF 21 TABLE OF CONTENTS

IDENTITY OF PARTIES & COUNSEL..................................................................2

TABLE OF CONTENTS...........................................................................................3

INDEX OF AUTHORITIES......................................................................................4

STATEMENT OF THE CASE..................................................................................6

ISSUES PRESENTED..............................................................................................7

STATEMENT OF FACTS........................................................................................8

SUMMARY OF THE ARGUMENT.......................................................................10

ARGUMENT

Issue 1: The trial court abused its discretion by holding against the great weight of the evidence that Appellant’s ability to provide for her minimum reasonable needs is not substantially or totally diminished because of a physical or mental disability.............11

Issue 2: The trial court abused its discretion by not requiring Appellee to prove by clear and convincing evidence that a certain monies are effectively separate property...............................................16

PRAYER..................................................................................................................19

CERTIFICATE OF SERVICE................................................................................21

RULE 9.4(I)(3) CERTIFICATION.........................................................................21

APPENDIX

Summary of Exhibit 2 Medical Records.......................................EXHIBIT A

PAGE 3 OF 21 Summary of Exhibit 3 Medical Records.......................................EXHIBIT B

Summary of Exhibits 17, 20, 21, and 22 Medical Records...........EXHIBIT C

Summary of Exhibit 23 Medical Records......................................EXHIBIT D

INDEX OF AUTHORITIES

CASES Boyd v. Boyd, 131 S.W.3d 605, 616-17 (Tex.App.–Fort Worth 2004, no pet.) ....................................................................................................................17

Brooks v. Brooks, 257 S.W.3d 418, 425-26 (Tex.App–Fort Worth 2008, pet. denied.......................................................................................................................11

Carlin v. Carlin, 92 S.W.3d 902, 910 (Tex.App–Beaumont 2002, no pet.) ..................................................................................................................................15

City of Keller v. Wilson, 168 S.W.3d 802 (Tex. 2005)...........................................14

In re M.E.C., 66 S.W.3d 449, 457 (Tex.App–Waco 2001, no pet.)........................15

McCann v. McCann, 22 S.W.3d 21, 24 (Tex.App.–Houston [14th Dist.] 2000, pet. denied)…………………………………………………………………………….17

McKinley v. McKinley, 496 S.W.2d 540, 543 (Tex. 1973)....................................17

Pace v. Pace, 160 S.W.3d 706, 714 (Tex.App.– Dallas 2005, pet. denied).............18

Pickens v. Pickens, 62 S.W.3d 212, 215 (Tex.App–Dallas 2001, pet. denied)…...11

Smith v. Smith, 115 S.W.3d 303, 309 (Tex.App–Corpus Christi 2003, no pet.)....11

Stavinoha v. Stavinoha, 126 S.W.3d 604, 608 (Tex.App–Houston [14th Dist.] 2004) …………………………………………………………………………………….17

PAGE 4 OF 21 RULES TEX. R. APP. P. 16 ………………….……………………………………………..2

TEX R. EVID. 605......................................................................................................15

STATUTES TEX. FAM. CODE § 3.003(a)......................................................................................17

TEX. FAM. CODE § 3.003(b).....................................................................................17

TEX. FAM. CODE § 6.711..........................................................................................16

TEX. FAM. CODE § 8.051..........................................................................................11

TEX. FAM. CODE § 8.051(2)(A)................................................................................11

PAGE 5 OF 21 STATEMENT OF THE CASE

This is an appeal from a divorce without children lawsuit. After a two-day

bench trial, the court found that Appellant was not disabled for purposes of

awarding spousal maintenance and that Appellee should be awarded all the monies

in a Morgan Stanley account. Those were the only disputed issues presented to the

trial court.

PAGE 6 OF 21 ISSUES PRESENTED

Issue 1: The trial court abused its discretion by holding against the great

weight of the evidence that Appellant’s ability to provide for her

minimum reasonable needs is not substantially or totally diminished

because of a physical or mental disability.

Issue 2: The trial court abused its discretion by not requiring Appellee to prove

by clear and convincing evidence that a certain monies are effectively

separate property.

PAGE 7 OF 21 STATEMENT OF FACTS

Appellant and Appellee were married on June 24, 1989, and Appellee

graduated from the U.S. Army Academy thereafter. At all times relevant to the

underlying divorce lawsuit, Appellee was an officer in the United States Army.

In approximately 2002, Appellant became unable to work at her chosen

profession as a registered nurse because of several chronic physical illnesses and

mental disorders. Those debilitating mental and physical maladies continue to the

present day.

Beginning is the Fall of 2011, Appellee began to threaten Appellant that if

she did not give him everything in the marital estate, he would divorce her and thus

deny her the lifetime medical care available to spouses of retired military

personnel. Toward that end, in December 2011 Appellee convinced Appellant that

if she would leave the marital residence for two weeks it would strengthen the

marital relationship. Instead, once Appellant removed herself from the marital

residence, Appellee changed the locks and Appellant was not able to retrieve her

personal items until late February 2012.

On February 20, 2012, a mediated agreement was reached that allowed

Appellant to retrieve some of her clothes and personal items. Of more importance,

in exchange for Appellee remaining in the marital residence, it was agreed that the

PAGE 8 OF 21 parties would not be divorced until Appellant was fully qualified for Tri-Care – i.e.

lifetime medical care. Although Appellee twice attempted to set aside the

mediated agreement, the trial court held the parties to their agreement.

The case came on to be heard in a bench trial on March 17-18, 2014, but the

trial court failed to grant the parties their divorce. Subsequently, a hearing was

held on May 8, 2014, at which time the court clarified the distribution of marital

assets and liabilities, and granted the divorce.

PAGE 9 OF 21 SUMMARY OF THE ARGUMENT

Appellant’s first argument challenges the sufficiency of the evidence

supporting the trial court’s finding that “it’s the court’s experience with this

particular mixture of medicine” that causes Appellant to be unable to work, instead

of the multitude of physical and mental ailments suffered by Appellant, as

evidenced in over a thousand pages of medical records introduced at trial.

Moreover, Appellant’s uncontroverted expert testimony was that the Mayo Clinic

determined that she is disabled.

Appellant’s second argument is that Appellee’s evidence was grossly

insufficient to afford the trial court to award him the entirety of a Smith Barney

account. Appellee asserted that the account only contained monies inherited from

his father, but the only evidence he introduced other than his own controverted

testimony was a copy of his father’s last will and testament that named him as a

beneficiary. No other documentary evidence was introduced, and the trial court

awarded Appellee all the monies in the account, but specifically refused to

characterize the account as either separate property or community property.

PAGE 10 OF 21 ARGUMENT

Issue 1: The trial court abused its discretion by holding against the great weight of the evidence that Appellant’s ability to provide for her minimum reasonable needs is not substantially or totally diminished because of a physical or mental disability.

Appellant pleadings requested the trial court to order that she receive spousal

maintenance from Appellee in order to meet her minimum reasonable needs. TEX.

FAM. CODE § 8.051. In order to prove she is eligible to receive spousal

maintenance, Appellant is required to prove she is unable to earn sufficient income

to provide for her minimum reasonable needs because of an incapacitating physical

or mental disability. TEX. FAM. CODE § 8.051(2)(A). Toward that end, Appellant

introduced almost 1200 pages of medical records replete with references to severe

to extreme physical and mental impairment, as well as her own expert testimony

about her disabling physical and mental condition. Vol. 2 at 37:5-10. These

debilitating conditions are summarized in Exhibits A-D, which are undergirded by

the corresponding exhibits introduced at trial.

Appellant’s disability can be inferred from circumstantial evidence, from

lay-witness testimony, or from expert opinion. Smith v. Smith, 115 S.W.3d 303,

309 (Tex.App–Corpus Christi 2003, no pet.); Pickens v. Pickens, 62 S.W.2d 212,

215 (Tex.App–Dallas 2001, pet. denied); Brooks v. Brooks, 257 S.W.3d 418, 425-

PAGE 11 OF 21 26 (Tex.App–Fort Worth 2008, pet. denied). Appellant testified that she has a

diagnosis of Ehlers-Danlo Syndrome, a genetic deficit in her connective tissue that

results in chronic pain. Vol. 3 at 44:18-19 and 45:7-14. Moreover, various

physicians have ruled out other diagnoses, but have made a “definitive diagnosis of

Ehlers-Danlos Syndrome.” Vol. 3 at 58:13-17. Ehlers-Danlo Syndrome is

“progressive genetic syndrome” that results in chronic fatigue and chronic pain.

Vol. 3 at 58:20-59:9.

Appellant was treated for her chronic pain by Austin Pain Associates. Vol. 5

at 9-586. The medical records of Austin Pain Associates reveal that Appellant

suffers from thoracic spondylosis, lumbosacral neuritis, osteoarthritis, chronic pain

syndrome, fibromyaligia, osteoarthritis, cervical disc displacement without

myelopathy, as well as Ehlers-Danlo Syndrome. Id. In total, the Austin Pain

Associate records evidence well over 100 entries over almost a decade of treatment

that conclusively prove Appellant’s physical pain and infirmities. Exhibit B.

Those records stand in stark contrast to the trial court’s conclusion:

“Now, I do not find that Mrs. Peck is disabled. I do find that she is on

a very distressing combination of medicine. I do believe that that may

be a factor in her employment possibilities as the currently exist. And

it might do her well to confer with one physician about her issues,

PAGE 12 OF 21 because it’s the Court’s experience with this particular mixture of

medicine causing problems in cases similiarly situated to this one.”

Vol. 3 at 44:2-10. (emphasis added)

There was absolutely no evidence introduce at trial regarding the causal effects of

the prescription medicines taken by Appellant. Accordingly, the trial court’s

conclusion is without factual support.

Appellant was treated for depression, anxiety, and memory impairment. Vol.

5 at 624-978; Exhibit A. The records of Claudia Ghio contain over 100

observations that Appellant’s suffers from severe to extreme psychological

distress. Exhibit A. The records establish that Appellant’s memory skills are “well

below the expected level relative to the results on the intellectual testing.” Vol. 5

at 894. Moreover, Appellant’s “index score on the General Memory suggests an

overall memory impairment as this index is considered the best measure of the

types of abilities that are critical to effective memory in day-to-day tasks.” Vol. 5

at 895. Finally, “[t]he results of achievement test are negative for learning

diabilities.” Vol. 5 at 896. The foregoing are just a sample of the dozens and

dozens of professional observations that attest to Appellant’s impaired mental

functioning and emotional distress. Again, they stand in stark contrast to the trial

court’s unfounded conclusion that “it’s the Court’s experience with this particular

PAGE 13 OF 21 mixture of medicine causing problems in cases similarly situated to this one.” Vol.

3 at 44:2-10. It cannot be overstated that not a single scintilla of evidence was

introduced at trial to support the trial court’s attribution of Appellant’s inability to

work to the medication she was prescribed rather than the obvious fact of her

afflictions.

Appellant’s chronic fatigue, pain and memory impairment are also evident in

the records of Medical Clinic of North Texas. Vol. 6 and Exhibit C. Those

records establish that Appellant suffers from hypermobility syndrome and fatigue.

Vol. 6 at 1012. The records also reveal that Appellant’s “immediate recall score is

mildly impaired and her delayed recall score is severely impaired.” Vol. 6 at 1035.

Again, this is evidence of Appellant’s inability to be gainfully employed. Yet, the

trial court attributed Appellant’s inability to work and support herself to the

medications she is prescribed.

A trial court may not go outside the evidence introduced at trial. City of

Keller v. Wilson, 168 S.W.3d 802 (Tex. 2005). Absolutely no evidence was

introduced at trial regarding the physiological or psychological effects of the

medications Appellant was prescribed by her treating physicians and health care

professionals. Moreover, Appellant’s testimony concerning her physical and

mental infirmities was uncontroverted by any testimonial or documentary evidence

PAGE 14 OF 21 introduced by Appellee. Trial courts must credit undisputed testimony that is clear,

positive, direct, otherwise credible, free from contradictions and inconsistencies,

and which could have been readily controverted. Id. at 814. Finally, the conclusion

based on the trial court’s previous “experience with this particular mixture of

medicine causing problems” violates Texas Rule of Evidence 605, because it “is

the functional equivalent of witness testimony.” In re M.E.C., 66 S,W,3d 449, 457

(Tex.App–Waco 2001, no pet.); TEX R. EVID. 605. In the end, Appellant’s

uncontroverted evidence established far beyond a preponderance of the evidence

that Appellant suffers from disabling physical and mental conditions.

Appellant’s disability is incapacitating to the point that it prevents her from

earning a sufficient income to meet her minimum reasonable needs. Vol. 3 at 55:6-

10 and 69:15-71:19. Because Appellant cannot perform day-to-day activities

required to work, she cannot provide for her minimum reasonable needs. Carlin v.

Carlin, 92 S.W.3d 902, 910 (Tex.App–Beaumont 2002, no pet.).

The evidence introduced at trial overwhelmingly established that Appellant

cannot work due to a variety of physical and emotional ailments and conditions.

The trial court ignored the evidence of Appellant’s physical and emotional

disabilities and instead relied on its own “experience with this particular mixture of

medicine causing problems.” Vol. 3 at 44:2-10. Texas law does not permit a trial

PAGE 15 OF 21 to render judgment that disregards the evidence and relies on the trial court’s

experience outside the record. Accordingly, the Court should reverse the trial

court’s judgment and render judgment that Appellant should receive spousal

maintenance because she is unable to earn sufficient income to provide for her

minimum reasonable needs because of an incapacitating physical or mental

disability. In the alternative, the Court should reverse and remand for further

evidence of Appellants physical and mental conditions and the effects on those

conditions of the medicines she has been prescribed.

Issue 2: The trial court abused its discretion by not requiring Appellee to prove by clear and convincing evidence that a certain monies are effectively separate property.

Appellant and Appellee stipulated to the character and distribution of the

marital assets, with the sole exception of a certain Morgan Stanley account that

Appellee claimed was separate property because it only contained funds from an

inheritance. Vol. 2 at 7:15-8:13. It was also stipulated that Appellant had a

separate property interest in a Smith Barney account that contained funds gifted to

her by her parents. Vol. 2 at 8:6-9.

The character of marital property is a mixed question of law and fact. TEX.

FAM. CODE § 6.711. Further, the Texas Family Code creates a statutory

presumption that all property possessed by a spouse during or upon dissolution of

PAGE 16 OF 21 marriage is community property. TEX. FAM. CODE § 3.003(a). The presumption

applies to both real and personal property. Stanley v. Stanley, 294 S.W.2d 132,

136 (Tex.App.–Amarillo 1956, writ ref’d n.r.e.). The community-property

presumption is rebutted when a party introduces evidence indicating that the

property should be characterized as separate property. McCann v. McCann, 22

S.W.3d 21, 24 (Tex.App.–Houston [14th Dist.] 2000, pet. denied). The party

seeking to rebut the community-property presumption must present clear and

convincing evidence or the property’s separate character. TEX. FAM. CODE

§3.003(b); McKinley v. McKinley, 496 S.W.2d 540, 543 (Tex. 1973). The clear

and convincing standard requires evidence on which “a reasonable trier of fact

could have formed a firm belief or conviction that its finding was true.” Stavinoha

v. Stavinoha, 126 S.W.3d 604, 608 (Tex.App–Houston [14th Dist.] 2004, no pet.).

The heightened standard of proof requires evidence that establishes the time and

manner in which the property was acquired (i.e. inception of title) and all of its

mutations (i.e. tracing). Boyd v. Boyd, 131 S.W.3d 605, 616-17 (Tex.App.–Fort

Worth 2004, no pet.).

The testimony at trial concerning the inception and character of the funds in

the Morgan Stanely account Appellee claimed was his separate property was

controverted. Appellee testified that “around $69,000" he received pursuant to his

PAGE 17 OF 21 father’s estate was held in a Morgan Stanley account. Vol. 3 at 17:14-23. The

account number was never identified at trial. Contrarily, Appellant testified that

the funds in the Morgan Stanley account were originally deposited in a joint

checking account at NCNB Bank in New York. Vol. 2 at 79:6-80:9. The only

documentary evidence introduced regarding the disputed monies was the last will

and testament of Appellant’s father. Vol. 3 at 14:9-15:19. It is noteworthy that

Appellant’s counsel objected to the document’s admission because it had not been

produced in response to specific discovery requests propounded by Appellant.

Vol. 3 at 14:20-24 and 15:10-12. That is the sum total of evidence Appellee

introduced at trial to prove the separate character of the property.

A spouse’s uncorroborated testimony that is contradicted is not sufficient to

constitute clear and convincing evidence. Pace v. Pace, 160 S.W.3d 706, 714

(Tex.App.– Dallas 2005, pet. denied). Appellant did not introduce and evidence of

the date the Morgan Stanley account was opened, the amount of funds deposited to

open the account, nor the source of the funds. Moreover, the link between

Appellant’s father’s last will and testament and the funds currently on deposit in

the Morgan Stanley account was never established by any evidence. Thus,

Appellant failed in his stated attempt to prove the separate property character of the

funds. Nonetheless, the trial court awarded the entire funds in the account to

PAGE 18 OF 21 Appellant, stating:

“I believe that, regardless of the classification of the property held in

the Morgan Stanley account, I’m awarding it in its entirety to him.

Regardless of the classification of the property contained in her

account that she says is her separate property, I will award entirely to

her.”

This ruling ignores the stipulation at trial that the monies in the Smith Barney

account were solely gifts to Appellant from her parents. The trial court’s ruling

effectively, if not expressly, characterized the funds in the Morgan Stanley account

as separate property without making Appellee meet his burden of proof by clear

and convincing evidence. Accordingly, the Court should reverse the trial court’s

ruling and remand the issue in order that Appellee have the opportunity to either

meet his burden of proof or so that the property can be characterized according to

its presumed community property status.

PRAYER

Appellant introduced uncontroverted evidence that she is unable to earn

sufficient income to provide for her minimum reasonable needs because of an

incapacitating physical or mental disability. Thus, this Court should reverse the

trial court’s order that was based on his personal experience outside the record at

PAGE 19 OF 21 trial. Appellee failed to meet his burden of proof that the disputed property was his

separate property. The trial court’s order that effectively characterized the disputed

funds as Appellee’s separate property should be reversed.

Respectfully submitted,

/s/ John J. Hindera John J. Hindera, J.D., Ph.D. Texas Bar No. 24037682 THE HINDERA LAW FIRM 4425 S. MoPac Expressway Building 2, Suite 107 Austin, Texas 78735 Tel: (512) 899-3631 Fax: (512) 899-3618 Email: john@hinderalaw.com

PAGE 20 OF 21 CERTIFICATE OF SERVICE

I certify that on December 23, 2014, a true and correct copy of the foregoing

Appellant’s Brief was served on Appellee, Wayne Code Peck, by and through his

attorney of record, Felix Rippy, by certified U.S. mail, return receipt requested, to

3000 Joe Dimaggio Boulevard, Suite 4, Round Rock, Texas 78665.

____/s/__John J. Hindera__________ John J. Hindera. J.D., Ph.D. Texas Bar No. 24036782

RULE 9.4(I)(3) CERTIFICATION

By my signature below, I certify that this document contains 3,278 words. I have relied on the word count of Microsoft Word to prepare this Certification.

____/s/__John J. Hindera__________ John J. Hindera. J.D., Ph.D. Texas Bar No. 24036782

PAGE 21 OF 21 EXHIBIT A PETITIONER’S EXHIBIT NO. 2

(Exhibit 2 consists of weekly Psychology visits and reports from Claudia Ghio, LP.A., LS.S.P from 2008- 2011. Most progress reports have same outcome with patients level of distress severe/depressed. Below is a list of the dates of visits and coordinating bate stamps.)

PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/12/11 Clients level of distressed impairment: Severe 000624 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/19/11 Clients level of distressed impairment: extreme 000626 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/20/11 Clients level of distressed impairment: severe 000628 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/26/11 Clients level of distressed impairment: severe 000630 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/27/11 Clients level of distressed impairment: severe 000632 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/31/11 Clients level of distressed impairment: severe 000634 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/10/11 Clients level of distressed impairment: severe 000636 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/2/11 Clients level of distressed impairment: severe 000638 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/3/11 Clients level of distressed impairment: severe 000640 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/17/11 Clients level of distressed impairment: moderate 000642 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/10/11 Clients level of distressed impairment: moderate 000644 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/24/11 Clients level of distressed impairment: severe 000646 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/31/11 Clients level of distressed impairment: severe 000648 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/13/11 Clients level of distressed impairment: moderate 000650 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/21/11 Clients level of distressed impairment: severe 000652 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/27/11 Clients level of distressed impairment: severe 000654 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/28/11 Clients level of distressed impairment: severe 000656 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 5/4/11 Clients level of distressed impairment: severe 000658 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 5/5/11 Clients level of distressed impairment: severe 000660 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/1/11 Clients level of distressed impairment: severe 000662 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/8/11 Clients level of distressed impairment: severe 000664 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/9/11 Clients level of distressed impairment: severe 000666 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/15/11 Clients level of distressed impairment: severe 000668 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/16/11 Clients level of distressed impairment: severe 000670 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/29/11 Clients level of distressed impairment: moderate 000672 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/6/11 Clients level of distressed impairment: severe 000674 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/7/11 Clients level of distressed impairment: severe 000676 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/14/11 Clients level of distressed impairment: severe 000678 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/7/11 Clients level of distressed impairment: severe 000680 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/8/11 Clients level of distressed impairment: severe 000682 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/22/11 Clients level of distressed impairment: moderate 000684 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/20/11 Clients level of distressed impairment: severe 000686 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/27/11 Clients level of distressed impairment: severe 000688 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/3/11 Clients level of distressed impairment: severe 000690 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/22/11 Clients level of distressed impairment: severe 000692 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P February 03, 2011 REASON FOR REFERRAL: NANCY PECK 09/24/1964 46-4 01/19/11 & 01/24/11 Dr. Robert P. Wills referred Mrs. Peck for a presurgical evaluation for a Spinal Cord Stimulator (SCS). A diagnostic interview, the Minnesota Multiphasic-Personality Inventory- 2 Restructured Form (MMPI-2 RF) and the Coping Strategies QuestionnaireRevised, (CSQ-R) were completed as part of a psychological evaluation. This presurgical evaluation is being performed to rule out the presence of a mental disorder or other psychological factors that may be related to the decreased likelihood of success from surgery. A secondary purpose of this evaluation is to recommend any additional needed treatment to aid with pain management. The evaluation results are based on the assumption that Mrs. Peck provided accurate personal data during the interview and testing procedures. 000697 PSYCHIATRIC IDSTORY/CURRENT SYMPTOMS: Mrs. Peck past history of psychiatric/ psychological intervention include two hospitalizations for depression and suicidal ideation. She is currently in psychological therapy and marriage therapy. Presently she reports severe depression, hopelessness, low energy, diminish interest in almost all activities, severe psychomotor retardation, severe fatigue, feeling of worthlessness, inappropriate guilt, diminished ability to think and concentrate, and apprehensive expectation and excessive worry. She reports severe symptoms of insomnia and loss of libido which she ascribes to the pain. Mrs. Peck reports her social support system consists mainly of her parents when they are in Texas. She reports social support is weak when they leave. Socialization has been significantly reduced due to her pain, loss of energy, depression, and shame. At the present she denies any suicidal ideation. ASSESSMENT: The following findings are based on the clinical interview, the MMPI-2 and the CSQ-R. Mrs. Peck's approached the test in a manner that suggests she may be over-representing her psychological distress. However, the patient may have approached the test in a manner that reflects an open admission of significant psychological difficulties. Since the patient has corroborating evidence of concurrent psychological difficulties, the test is likely valid and an accurate reflection of the patients emotional functioning at this time. 000700 The patient is reporting significant somatic concerns, including gastrointestinal complaints, neurological complaints, head pain complaints, and cognitive difficulties. There is likely a psychological component to her somatic difficulties in that she may be prone to develop physical problems under stress. She may also be somatically focused and may prefer medical explanations rather than psychological explanations for her current distress. She may be at risk for suicidality given the extreme psychological distress and lack of positive emotions experienced by this patient. She does not directly endorse suicidal ideation; however, a careful assessment of potential feelings of hopelessness and depression should be assessed. Her thinking may be marked with negative preoccupations and ruminations and she may have difficulty managing her thoughts. While her thinking is not disordered, the patient may have difficulties with controlling her thoughts. In addition to somatic concerns, the patient is endorsing significant difficulties with family relationships and social support. Mrs. Peck scores on the CSQ-R suggest that she utilizes equally effective and ineffective coping strategies for coping with her pain. She is more likely to use catastrophizing when confronted with pain, but she also uses in a lesser manner, distraction and coping selfstatements. Given the overall level of psychological distress, somatization, lack of social support, and cognitive difficulties; this patient is not good presurgical candidate for an SCS trial at this time. DSM-IV-TR DIAGNOSES: Axis I: Axis II: Axis III: Axis IV: AxisV: Pain Disorder Associated With Both Psychological Factors and a General Medical Condition. Chronic Major Depressive Disorder, Recurrent Episode, Severe. Cognitive Disorder, NOS No Diagnosis. Deferred to Physician. Severity of Psychosocial Stressors: 4-Severe Current GAF: 50 RECOMMENDATIONS: Mrs. Peck has a POOR prognosis for a surgical outcome. She is experiencing extreme psychological distress, cognitive difficulties, and few positive emotions. Additionally, Mrs. Peck uses mainly ineffective coping strategies for coping with her pain as she has a 000701 tendency to catastrophize when confronted with pain. Her social support is moderate in relation to the presence of her parents, but at home she has very little support. Mrs. Peck's thinking appears to be marked with negative preoccupations about her health and although she reports to have realistic expectations from the surgery, she is not very hopeful about the outcome. Mrs. Peck is under significant stress at the present. Stressors include her pain, her deteriorating symptoms reportedly post ECT's, serious marital problems, and her son's mental health and poor functioning. Mrs. Peck should continue to receive psychotherapy to help her cope with stress-related pain symptoms and increase her use of effective coping skills to cope with pain. 000702 Date 11/17/11 Clients level of distressed impairment: severe 000703 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/1/11 Clients level of distressed impairment: severe 000705 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/6/11 Clients level of distressed impairment: severe 000707 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/15/11 Clients level of distressed impairment: severe 000709 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/29/11 Clients level of distressed impairment: severe 000711 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/7/10 Clients level of distressed impairment: severe 000713 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/8/10 Clients level of distressed impairment: severe 000715 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/11/10 Clients level of distressed impairment: severe 000717 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/11/10 Clients level of distressed impairment: severe 000719 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/18/10 Clients level of distressed impairment: severe 000721 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/25/10 Clients level of distressed impairment: severe 000723 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/31/10 Clients level of distressed impairment: severe to extreme 000725 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/1/10 Clients level of distressed impairment: severe to extreme 000727 PROGRESS NOTE -Claudia Ghio, LP.A., LS.S.P Date 4/7/10 Clients level of distressed impairment: severe 000729 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/8/10 Clients level of distressed impairment: severe 000731 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/8/10 Clients level of distressed impairment: severe 000733 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/14/10 Clients level of distressed impairment: severe 000735 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/21/10 Clients level of distressed impairment: severe 000737 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/22/10 Clients level of distressed impairment: moderate 000739 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/28/10 Clients level of distressed impairment: severe 000741 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 5/20/10 Clients level of distressed impairment: moderate to severe 000743 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 5/26/10 Clients level of distressed impairment: moderate 000745 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/2/10 Clients level of distressed impairment: sever 00074 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/3/10 Clients level of distressed impairment: minimal 000749 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/9/10 Clients level of distressed impairment: sever 000751 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/16/10 Clients level of distressed impairment: moderate to severe 000753 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/17/10 Clients level of distressed impairment: severe 000755 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/23/10 Clients level of distressed impairment: severe 000757 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/30/10 Clients level of distressed impairment: severe 000759 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/7/10 Clients level of distressed impairment: severe 000761 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/14/10 Clients level of distressed impairment: severe 000763 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/21/10 Clients level of distressed impairment: severe 000765 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/28/10 Clients level of distressed impairment: severe 000767 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/29/10 Clients level of distressed impairment: severe 000769 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/4/10 Clients level of distressed impairment: severe 000771 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/5/10 Clients level of distressed impairment: severe 000773 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/11/10 Clients level of distressed impairment: severe 000775 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/29/10 Clients level of distressed impairment: severe 000777 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/30/10 Clients level of distressed impairment: severe 000779 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/6/10 Clients level of distressed impairment: severe 000781 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/7/10 Clients level of distressed impairment: severe 000783 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/13/10 Clients level of distressed impairment: severe 000785 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/14/10 Clients level of distressed impairment: severe 000787 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/19/10 Clients level of distressed impairment: severe 000789 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/20/20 000791 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/27/10 Clients level of distressed impairment: severe 000793 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/28/10 Clients level of distressed impairment: severe 000795 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/04/10 Clients level of distressed impairment: severe 000798 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/10/10 Clients level of distressed impairment: moderate 000801 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/11/10 Clients level of distressed impairment: moderate 000803 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date11/17/10 Clients level of distressed impairment: moderate 000805 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/18/10 Clients level of distressed impairment: moderate 000807 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/1/10 Clients level of distressed impairment: severe 000809 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/2/10 Clients level of distressed impairment:moderate 000811 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/8/10 Clients level of distressed impairment: severe Increase of neurological symptoms 000811 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/16/10 Clients level of distressed impairment: severe 000816 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 1/22/09 Clients level of distressed impairment: moderate 000826 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/12/09 Clients level of distressed impairment: moderate 000832 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/26/09 Clients level of distressed impairment: moderate 000838 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/4/09 Clients level of distressed impairment: severe 000846 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/18/09 Clients level of distressed impairment: severe 000848 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/30/09 Clients level of distressed impairment: severe 000850 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/6/09 Clients level of distressed impairment: severe 000852 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/17/09 Clients level of distressed impairment: moderate 000854 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/24/09 Clients level of distressed impairment: severe 000856 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/15/09 Clients level of distressed impairment: severe 000858 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/22/09 Clients level of distressed impairment: severe 000860 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/29/09 Clients level of distressed impairment: severe 000862 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/05/09 Clients level of distressed impairment: severe 000864 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/19/09 Clients level of distressed impairment: severe 000866 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/18/09 Clients level of distressed impairment: severe 000868 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/3/09 Clients level of distressed impairment: severe 000870 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/17/09 Clients level of distressed impairment: severe 000872 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 2/8/08 Clients level of distressed impairment: severe Progress notes of pain from Nancy to Psychologist 000874 000875 Symptom Checklist 000876 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/4/08 Clients level of distressed impairment: severe 000878 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 3/11/08 Clients level of distressed impairment: severe 000880 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/8/08 Clients level of distressed impairment: mild 000882 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/15/08 Clients level of distressed impairment: moderate 000884 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/22/08 Clients level of distressed impairment: severe 000886 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 4/29/08 Clients level of distressed impairment: severe 000888 Psychological Evaluation-Claudia Ghio, LP.A., LS.S.P Date 5/5/2008 000890 Past Medical History: 000892 Test Results and Behavioral Observations: Mrs. Peck is a right-handed, well-nourished, Caucasian woman who appeared to be her stated age. She was clean, well-groomed, and casually dressed. Gait was normal. Eye contact was maintained adequately. Speech exhibited some deficits in fluency, but was well elaborated, and well articulated. Psychomotor activity was decreased . Mood was dysphoric and affect generally sad, but appropriate to situation, and wide in range. Mrs. Peck was oriented x three . Social judgment was adequate. Attention and concentration were normal. Language comprehension was below average. Mrs. Peck denied any hallucinations, delusions, or any other form of psychosis, and none were evident. During the three sessions involved in Mrs. Peck' testing, she was polite, very well motivated, and she invested a lot of effort in each and every task given. She was keenly aware of time limits and she became increasingly nervous, when allowed time was soon to be over. She, however, took reassurance adequately. She required frequent repetition, and clarification Mrs. Peck was able to maintain effort independently. Most noticeable test behavior was Mrs. Peck' marked discouragement when confronted with difficult tasks and possible failure. In those instances, she needed repeated encouragement to sustain effort. This was especially observed when Mrs. Peck knew her answer was not correct. On the other hand, Mrs. Peck became very enthusiastic when she was successful, and her success motivated her to increase her effort. Mrs. Peck' attention and concentration varied according to task: she was more attentive during those tasks which involved doing something with her hands; however, on the verbal tests, her attention and concentration were easily lost. Overall, Mrs. Peck invested a lot of effort in completing the present evaluation. She was welJmotivated and results obtained are thought to be valid. 000893 Wechsler Memory Scale-Ill The WMS-Ill is a comprehensive set of individually administered battery oflearning, memory, and working memory measures. These results, with the exception of Visual Immediate Memory and Working memory, are below the expected level relative to the results on the intellectual testing. The pattern of scores across the individual subtests suggests a marked reduction in auditory memory and in the initial encoding quality. Compared to her own mean, she has two significant 000894 On the other hand, Mrs. Peck index score on General Memory suggests an overall memory impairment as this index is considered the best measure of the types of abilities that are critical to effective memory in day-to-day tasks. The results also suggest that Mrs. Peck will be able to retain information better if is presented in a multi modal approach. 000895 SUMMARY: The results of achievement test are negative for learning disabilities. However, scores obtained are lower than expected from a person who was in pre-med and held a 4.0 GPA while in College. This is especially seen in the area of Spelling, a subject she reports experiencing problems. This lower than expected achievement suggests the presence of deteriorative signs of undetermined etiology. The results of the neuropsychological screening tests suggest the presence of a Mild dysfunction in the areas of psychomotor speed, sequencing, and attention Mrs. Peck index score in General Memory suggests the present of a clinically significant diminished memory capacity. There is a marked reduction in immediate and delayed auditory memory which suggests that this memory deficit is of phonological origin. The fact that when she uses visual information, her memory improves, is further evidence of this as the brain when processing visual information it converts it into a phonological format. It is very possible that inattention is contributing for the loss of information experienced. There is a rapid loss of information when a person is distracted as is never encoded properly. It is clear that Mrs. Peck is currently suffering from clinically significant memory impairment, most likely associated with an organic etiology. She also suffers from chronic pain, loss of motor tone, paresthesias, migraine headaches, and fatigue. These symptoms have not yet been linked to a definite diagnosis or etiology and Mrs. Peck has become increasingly depressed, hopeless, and withdrawn. It also seems clear that her ongoing depressive symptoms have been the result, in large part, of not knowing what is afflicting her and the anxiety and apprehension about her illness becoming increasingly worse. With this in view, it is felt that efforts should be made to rule out the presence of 000896 past suggested probable causes, such a Multiple Sclerosis, a reaction to the vaccinatio:i received shortly before her initial episode of neurological symptoms, "Persian Gulf Syndrome'', as well as others diagnoses mentioned. DSM-IV-TR DIAGNOSES: Axis I: Major Depressive Disorder, Single Episode. Cognitive Disorder, NOS Axis II: No Diagnosis. Axis III: Deferred to Physician. Axis IV: Severity of Psychosocial Stressors: 4- Severe. Axis V: Current GAF: 62 RECOMMENDATIONS: 1. It is recommended that a more comprehensive neuropsychological evaluation be done. 2. Given Mrs. Peck's difficulty in retaining information solely presented audibly, an auditory test to rule out a hearing loss is recommende 000897 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 5/6/08 Clients level of distressed impairment: severe 000898 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 5/22/08 Clients level of distressed impairment: severe 000902 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 5/22/08 Clients level of distressed impairment: severe 000902 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/3/08 Clients level of distressed impairment: moderate 000904 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 6/10/08 Clients level of distressed impairment: severe 000908 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/8/08 Clients level of distressed impairment: moderate 000918 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 710/08 Clients level of distressed impairment: moderate 000920 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/17/08 Clients level of distressed impairment: moderate 000922 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/22/08 Clients level of distressed impairment: In Pain again 000924 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/24/08 Clients level of distressed impairment: mild 000926 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 7/29/08 Clients level of distressed impairment: severe 000928 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/5/08 Clients level of distressed impairment: severe 000932 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/7/08 Clients level of distressed impairment: moderate 000934 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/12/08 Clients level of distressed impairment: severe 000936 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/14/08 Clients level of distressed impairment: severe 000938 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/15/08 Clients level of distressed impairment: severe 000940 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 8/26/08 Clients level of distressed impairment: mild 000942 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/11/08 Clients level of distressed impairment: severe 000944 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 9/16/08 Clients level of distressed impairment: mild 000946 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/9/08 Clients level of distressed impairment: mild 000948 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/14/08 Clients level of distressed impairment: severe 000950 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/16/08 Clients level of distressed impairment: mild Neural and verbal memory 000952 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/21/08 Clients level of distressed impairment: moderate 000954 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/28/08 Clients level of distressed impairment: moderate 000956 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 10/30/08 Clients level of distressed impairment: moderate 000958 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/04/08 Clients level of distressed impairment: memory 000960 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/06/08 Clients level of distressed impairment: EON- MEM 000962 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/11/08 Clients level of distressed impairment: memory 000964 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11-20-08 Clients level of distressed impairment: severe 000966 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 11/25/08 Clients level of distressed impairment: severe 000968 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/02/08 Clients level of distressed impairment: moderate Neuro/ memory 000970 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/3/08 000972 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/4/08 Clients level of distressed impairment: moderate 000974 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/9/08 Clients level of distressed impairment: severe/ Pain 000976 PROGRESS NOTE-Claudia Ghio, LP.A., LS.S.P Date 12/16/08 Clients level of distressed impairment: mild Neuro Rehabilitation of Memory 000978 EXHIBIT B Summary of Comments- Exhibit 3

Page: 1 Date: 9/26/14

12/15/2011 CHIEF COMPLAINT: joint pain HISTORY OF PRESENT ILLNESS: Ms. Peck states that her midback pain is stable; however, she does continue to have that band-like feeling around her chest area due to her spinal cord stimulator. She does continue to have multiple joint complaints. Today she mentions her bilateral hips. As noted before, she has been diagnosed with Ehlers-Danlos syndrome. Her rheumatologist has ordered aqua therapy for her to start.. I discussed spinal cord reprogramming with this patient and since Hunter, the Medtronic representative, was the one who initially programmed her stimulator, I will try to request him to do a reprogramming on her stimulator again to see if he can give her midback good coverage without causing the band-like feeling around her chest. The patient indicates that her medications give her between 30% and 50% relief, her urine drug screens have been consistent. RR-000009

Complains of nausea, diarrhea. RESPIRATORY: Complains of cough. MUSCULOSKELETAL: Complains of stiffness, bone pain, joint pain. She has tenderness over the mid thoracic paraspinal muscles with spasm noted. Patient has normal range of motion in her thoracic and lumbar spine with minimal pain. She has mild tenderness over the bilateral greater trochanters. Straight leg raise is negative bilaterally. RR-000010

Page: 11 THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) OSTEOARTHROSIS - GENERALIZED MULTIPLE SITES (ICD-715.09) RR-000011

CHIEF COMPLAINT: Mid back pain Ms. Peck continues to have midback pain as well as complaints of arthritis in her hands, knees, feet, and hips. She has been diagnosed with Ehlers-Danlos syndrome by a rheumatologist in Denton, Dr. Luciano. She states that the spinal cord stimulator reprogramming on 09/18 did not get rid of the bandlike feeling that she has in her chest area, but it is still helping approximately 25%. She said that her Zanafiex is helping with her muscle spasms at night and letting her sleep, She states that the hydrocodone is effective, but she takes 1 twice a day and it is not lasting the whole 12 hours. Her urine drug screens have been consistent CHRONIC PROBLEM LIST: ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD~V58.69) CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721 .1 RR-000012

She has tendemess over the mid thoracic paraspinal muscles with spasm noted .. Patient has normal range of motion in her thoracic and lumbar spine with minimal pain. There is tenderness to palpation over the joints in the bilateral hands RR-000013

DIAGNOSIS: THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) OSTEOARTHRITIS - HAND (ICD-715.94) CHRONIC PAIN SYNDROME (ICD-338.4) RR-000014

09/16/2011 DIAGNOSIS: CHRONIC PAIN SYNDROME (ICD-338.4), THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4), THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) RR-000015

09/16/2011 CHIEF COMPLAINT: Mid back pain HISTORY OF PRESENT ILLNESS: Ms. Peck had her Medtronic spinal cord reprogrammed today. She cannot tell yet if it is helping. The representative told her to give it a few days. Right now her unit is turned off. She continues to have pain in the thoracic spine area. She also complains of arthritis in her hands, knees, and feet. She has a history of congenital hip dysplasia. She saw a rheumatological specialist in Denton, Texas who officially diagnosed her with Ehlers- Danlos syndrome. This doctor's name is Dr. Luciano and the patient has a follow up appointment with her in October. She said that the hydrocodone added at last visit for breakthrough pain is helping. The Zanaflex that she takes at night is helping with her sleep. RR-000016 Complains of vomiting, diarrhea. Complains of stiffness, joint pain. She has tenderness over the mid thoracic paraspinal muscles with spasm noted. There is tenderness to palpation over the joints in the bilateral hands RR-000017

DIAGNOSIS THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) MFPS/FIBROMYALGIA (ICD-729.1) ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD-V58.69) RR-000018

08/18/2011 CHIEF COMPLAINT: Mid back pain HISTORY OF PRESENT ILLNESS: Ms. Peck has a Medtronic spinal cord stimulator for her mid back pain. She says that overall it decreases her pain in that area approximately 25%. She states this is not as effective as it has been previously. She says she has not had any reprogramming done on the device. She also has an lnterStim implanted in the sacral area for urinary incontinence. Ms. Peck says that since her stimulator is not giving her as good coverage for her pain, she feels that the tramadol for breakthrough pain is not as effective and she is asking for something a little stronger. She says her long acting Ultramcontinues to work well. Her urine drug screens have been consistent CHRONIC PROBLEM LIST: ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD-V58.69) CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (lCD-721.2} CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000019

She has some tenderness over the mid thoracic paraspinal muscles with some spasm noted. RR-000020

05/23/2011 CHIEF COMPLAINT: back pain CHRONIC PROBLEM LIST: ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS {ICD-V58.69) CHRONIC PAIN SYNDROME {ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721 .1) RR-000022

Complains of palpitations, chest pain. Complains of diarrhea. Complains of stiffness,joint pain, bone pain. Complains of memory changes, weakness. RR-000023

DIAGNOSIS: ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD-V58.69) CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) RR-000024

HISTORY OF PRESENT ILLNESS Nancy has been recovering from her bladder stim implant. She is having some discomfort along the right hip from the battery placement. She feels that it was placed a little higher than the battery for her spinal cord stimulator which is in the left buttock region. She is following up with Dr Antonini soon to discuss this issue. 04/21/2011 CHIEF COMPLAINT: back pain CHRONIC PROBLEM LIST: ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD-V58.69) CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYE!-OPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000026 Complains of chest pain Complains of stiffness, joint pain. RR-000027

DIAGNOSIS: ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD-V58.69) CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) OSTEOARTHRITIS - HAND (ICD-715.94) RR-000028

HISTORY OF PRESENT ILLNESS: Ms Peck had her thoracic epidural spinal cord stimulator implanted with Dr Loftus less than 2 weeks ago, She was hospitalized overnight for 2 days. She was having problems with low blood pressure in the hospital. He has prescribed her Percocet 10/325 and Flexeril, which have been helpful for pain. She is requiring Percocet at about 6 a day. She is also scheduled to have her lnterStim unit surgically implanted with Dr Antonini on April 4th, The battery will be implanted into the right buttock. She is requesting we manage her postoperative pain for that surgery. She is not currently taking the tramadol 50 mg for breakthrough pain since her surgery as she found the right 1st MCP injection Dr Wills did slightly decrease the frequency of her thumb locking up, but she does continue to have some issues with this. Her medication usage appears to be appropriate and she appears emotionally more stable than she has in this past year. She is hopeful that when the swelling goes down, the thoracic epidural stimulator will significantly help with her mid back pain. She is a little sore from it at this time. 03/28/2011 CHIEF COMPLAINT: Mid back pain CHRONIC PROBLEM LIST: ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD-V58.69) CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENTW/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000030

Complains of fever. Complains of nausea, diarrhea. Complains of stiffness Complains of headaches, weakness, numbness RR-000031 ENCOUNTER FOR LONG-TERM USE OF OTHER MEDICATIONS (ICD-V58.69) CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11 RR-000032

DIAGNOSIS: Thoracic spondylosis without myelopathy · Mfps/fibromyalg ia PROCEDURE PERFORMED: Radiofrequency Thermocoagulation Neurotomy, Right TS Facet Joint Medial Branch Nerve Radiofrequency Thermocoagulation Neurotomy, Right T6, T?, T8 Facet Joint Medial Branch Nerve Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1118 End: 1126 ) DATE OF PROCEDURE: 09/28/2009 RR-000034

DATE OF PROCEDURE: 03/23/2011 DIAGNOSIS Generalized osteoarthritis, involving hand PROCEDURE Right Metacarpophalangeal Intra-articular Joint Injection of the 1st Digit Ultrasound Needle Guidance Supervision of Moderate Sedation (Start: 1440 End: 1444 RR-000036

DATE OF PROCEDURE: 03/09/2011 DIAGNOSIS Osteoarthritis of the Right Hand PROCEDURE Right Metacarpophalangeal Intra-articular Joint Injection of the 1st Digit Ultrasound Needle Guidance Supervision of Moderate Sedation (Start: 1510 End: 1517) RR-000039

HISTORY OF PRESENT ILLNESS: Established Patient Office Visit Wills ESTABLISHED PATIENT OFFICE VISIT Ms. Peck returns to the clinic today for a routine office visit. She has completed her thoracic RFTC at the T5, T6, T7, TB levels and noted greater than 75% relief of her pain. She is now also in physical therapy and feels stronger. However, she has been noticing some soreness over her upper arm. She has been advised to discuss this further with her physical therapist. She is using light weights which may need to be adjusted. She is apprehensive about the length of time she will note an improvement. She is aware that this is unknown. She will be meeting with a psychologist, Dr. Claudia Byrne, later in February and has been placedon Lamictal by her psychiatrist and feels that it is working better than her other psychotropic medications. Her family has noted improvement in her mood. Date: 01/28/2008 CHIEF COMPLAINT: Thoracic back pain. CHRONIC PROBLEM LIST: 721.2 - Thoracic Spondyfosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000042

DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000043

Date: 11/29/2007 CHIEF COMPLAINT: Thoracic back pain, total body pain. HISTORY OF PRESENT ILLNESS: Ms. Peck returns to the clinic today for a routine office visit. She has completed her series of three thoracic medial branch block injections and has noted a reduction of her pain for at least 2-3 days. She also finds that the Lidoderm patch is effective in reducing her pain which she places on in the evening. We discussed how she should continue with placement of the patch until at least noon to determine during the day if it does help to continue to reduce her pain. She states that when she awakens in the morning her pain level is less and as the day progresses her pain level increases. She has also been under the care of her psychiatrist who has recently taken her off Effexor and due to blood pressure elevation. She was placed on Lamictal. She states there is a family history of bipolar disorder. She has been on it for a short term and has difficulty assessing if it has been effective. She has never started the Lyrica. Her physician has recommended that she not start the Lyrica until her blood pressure and psychological condition improve. She is requesting psychological therapy but has limited reso•Jrces due to her insurance of TriCare Remote. We will try to find a therapist who can work with her regarding her depression and chronic pain issues. CHRONIC PROBLEM LIST: 721 .2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000045

She has tenderness over the facet areas from the approximately the T6 through T9 levels. It is aggravated with thoracic lumbar extension. She does note some tightness over the thoracic paraspinals. DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000046

HISTORY OF PRESENT ILLNESS: Ms. Peck reports that she got very good relief of her axial back pain with the spinal cord stimulator trial. It was an unusual trial in that we had to get the distal electrode all the way up to T5 to try to see if we could get coverage of the thoracic spine pain. She did also get some costal margin paresthesias which she felt were uncomfortable. I explained that there was no way to guarantee that she would not get these with surgical implantation of a paddle lead. She reports that when she turned the trial stimulator down to where she could not feel it along her ribs she still had some relief in her back. When she turned it all the way off, she felt the back pain return. This is actually a pretty good objective result for the trial. 02128/2011 CHIEF COMPLAINT: Back pain. CHRONIC PROBLEM LIST: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000048

Complains of chest pain Complains of nausea, diarrhea Complains of stiffness, joint pain Complains of weakness Thoracic spine exam reveals paravertebral spasm from the mid-thoracic spine down to the thoracolumbar junction with tenderness over the facet joints at multiple levels. RR-000049

PLAN: 1. Based on the above discussion and information, I would recommend proceeding with a surgical consultation with Dr. Loftus to discuss the pros and cons of proceeding with implantation of a spinal cord stimulator. 2. Continue current medications as presently prescribed. 3. Return visit in one month or sooner on an as-needed basis. IMPRESSION: 1. Chronic intractable pain which is multifactorial in nature. 2. Chronic thoracic radiculopathy RR-000050

DATE OF PROCEDURE: 02/22/2011 DIAGNOSIS Osteoarthritis of the Right Hand PROCEDURE Right Metacarpophalangeal Intra-articular Joint Injection of the 1st Digit Ultrasound Needle Guidance Supervision of Moderate Sedation (Start: 0953 End: 0956) RR-000051

02/21/2011 Chronic Problems: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721 .1) RR-000056

Nancy was seen today for post-op to SCS Trial. Nancy states that she received 50-75% pain relief during her trial. Pt would like to wait for a few days on proceeding with the implants. Pt is undecided. During the visit today the patient was afebrile, the tape was removed, the lead was removed with tip intact, the leads were removed with tips intact, the area was cleaned with alcohol, antibiotic ointment was applied, bandaids were applied, no swelling or drainage was noted, and no signs of infection were noted. Pt said that overall it worked for her. She did some activities. Pt reported also that she decreased the medication. Pt informed that the only thing that bothered her was the feeling in the ribs, she said that she was having a tingling and pressure in her ribs. Pt reported also that she had a hard time sitting down but had no problems with her legs. 02/21/2011 RR-000058

DIAGNOSIS: Chronic pain syndrome Lumbar/thoracic radiculopathy Thoracic Spondylosis without Myelopathy PROCEDURE PERFORMED: Right Lumbar Epidural Eight Electrode Array, Percutaneous Spinal Cord Stimulator Lead Placement Left Lumbar Epidural Eight Electrode Array, Percutaneous Spinal Cord Stimulator Lead Placement Fluoroscopic Needle Guidance IPG interrogation and reprogramming Supervision of Moderate Sedation (Start: 1204 End: 1235) DATE OF PROCEDURE: 02/15/2011 RR-000059

C: DISCUSSION AND PLAN: The patient will be scheduled for follow-up in 5 - 7 days to remove the leads and assess the success of the trial. The patient was instructed to keep a diary of visual analog scale pain levels, use of opioid pain medications, and changes in usual level of function. Based on this, we will make recommendations regarding implantation of a permanent system. RR-000060

02/10/2011 Nancy was seen today for pre-op to SCS Trial. Patient was prescribed KEFLEX 500 MG CAPS (CEPHALEXIN) Take 1 twice daily starting on the day of the procedure. RR-000061

01112/2011 CHIEF COMPLAINT: Back pain, leg pain. Ms. Peck is here to discuss spinal cord stimulation. She saw Dr. Loftus who recommended this approach rather than surgery. She has pain in her thoracic and lumbar spine as well as both legs. She also has pain in her neck and arms.We discussed how the spinal cord stimulator could potentially treat the lower thoracic lumbar and leg pain. Beyond that, it is difficult to predict what the stimulator will cover in terms of pain pattern. However, this is why we do the trial first to see what we can get in terms of coverage. At that point, we can make the decision about proceeding with a permanent implant. She is also seeing a urogynecologist and is considering having a bladder stim implant as well. Her medications are providing significant pain relief and maintenance of function. She is here today with her father who has questions that are answered regarding the stimulator trial as well as the chronic fatigue and depression. We went over all of this in a lot of detail today going through each medication one at a time and discussing its purpose as well as potential side effects and drug interactions. CHRONIC PROBLEM LIST: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENTW/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000062

Complains of visual changes Complains of chest pain. Complains of nausea. Complains of incontinence Complains of stiffness, joint pain, bone pain Complains of memory changes, weakness, numbness. Thoracic spine exam reveals tenderness and paravertebral spasm in the mid- and lower segments down into the lumbar region. Trigger points are present diffusely in the paraspinals, latissimus dorsi, and lumbar paraspinal muscles. RR-000063

PLAN: 1. As discussed above, we will proceed with a spinal cord stimulator trial utilizing two 1 x8 leads. 2. Continue current medications as presently prescribed. 3. We will have her go back to see either Jason or Claudia for the behavioral health evaluation prior to the trial. 4. Return visit in one month. RR-000064

HISTORY OF PRESENT ILLNESS: ESTABLISHED PATIENT OFFICE VISIT Ms. Peck is here for a foilow up visit accompanied by her father. She continues to have considerable mid back pain with radiation into her abdomen on both sides. She has known disk protrusions at T5-6 and T7-8 in addition to facet degeneration. Her pain has been interfering with her activities of daily living including doing her dishes, folding her clothes and cooking. She would like to have a more active lifestyle if she could get better control of her pain. She did recently schedule a follow up visit with Thomas Loftus, MD, a surgeon she has seen in the past. He did discuss with her the possibility of doing a spinal cord stimulator trial that would cover her thoracic pain that radiates into her abdomen. We hadan extensive discussion today regarding the risks and benefits of the spinal cord stimulator trial including the psychological testing that would be involved. 12/17/2010

CHIEF COMPLAINT: Mid back pain CHRONIC PROBLEM LIST: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000065

Complains of stiffness, joint pain. Increased pain with thoracic back flexion equal to extension. DIAGNOSIS: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) RR-000066

HISTORY OF PRESENT ILLNESS: ESTABLISHED PATIENT OFFICE VISIT Ms. Peck presents today for a followup visit. She completed a series of TS, T6, T7 TFESls with Dr. Wills. She still cannot tell how much these injections have helped her. as she has been spending 75% of the day in bed due to her orthostatic hypertension. Ms. Peck did say that she had some functional improvements on one day where she sat and organized her home office for about 3 hours, more work than she has done in a couple of years she states. However, she had a significant flare of her pain after these activities. She feels dizzy, weak and unsteady. Her gastroenterologist recently prescribed her Marinol as she has lost 50 pounds in the past several months. She has no appetite. She has found thatthe Marinol is helpful in increasing her appetite and also helps with some of her fibromyalgia symptoms. Ms. Peck does take her medications as prescribed.Ms. Peck has been frustrated as she did have significant reduction in her mid back pain in the past though it was temporary after diagnostic medial branch blocks from TS to T7. Unfortunately the radiofrequency procedure was no longer being approved by TRICARE. I have informed.Ms. Peck that we were informed by ASIPP that they were now reconsidering the radiofrequency nerve ablation procedure. She is tearful with the thought of getting similar reduction in her pain that she experienced during the diagnostic phase of these prior medial branch blocks. 10/18/2010 CHIEF COMPLAINT: Mid back pain CHRONIC PROBLEM LIST: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721 .1) RR-000068

Significant tenderness to palpation along the paraspinal muscles of the thoracic spine from TS toT7. She has increased pain with thoracic back extension greater than flexion. Also, has increased pain with lateral bending to both sides. She has diffuse tenderness to palpation of her bilateral upper and lower extremities as well as musculature of her entire spine consistent with fibromyalgia. DIAGNOSIS: THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) CHRONIC PAIN SYNDROME (ICD-338.4) MFPS/FIBROMYALGIA (ICD-729.1) OSTEOARTHRITIS - HAND (ICD-715.94) PLAN: 1. We will re-request radiofrequency nerve ablation of the bilateral T5-T7 facet joint medial branch blqcks given that she has had positive diagnostic response to these injections and we have been informed from ASIPP that she would now be a candidate for radiofrequency nerve ablation. We hope this will allow her to improve her quality of life by decreasing her pain and increasing her level of functioning. 2. Continue medications at their current strength and dose. 3. Discussed gradually increasing home exercise program. Cautioned about fall risk with her orthostatic hypertension, but she is continuing to work on this with her primary care physician RR-000069

DATE OF PROCEDURE: 10/05/2010 DIAGNOSIS: Thoracic spondylosis without myelopathy Mf ps/fibromyalgia PROCEDURE: Bilateral T5, T6, T7 Transforaminal Epidural Steroid Injection Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1435 End: 1440) RR-000071

DATE OF PROCEDURE: 09/23/2010 DIAGNOSIS: Thoracic spondylosis without myelopathy Mfps/fibromyalg ia PROCEDURE: Bilateral T5, T6, T7 Transforaminal Epidural Steroid Injection Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1145 End: 1149) RR-000073 09/21/2010 CHIEF COMPLAINT: back pain HISTORY OF PRESENT ILLNESS: Nancy is here for a followup office visit. She had a bilateral TS, T6, T7 transforaminal epidural injection done on September 7. She states that she cannot tell at all if it helped because she has been in bed because of her orthostatic hypotension. Her hands are doing well. Her medications are doing well. She had the understanding that she would need an office visit for medications which is not the case with the medications that she is on. She is not on any C2 prescriptions right now CHRONIC PROBLEM LIST: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000075

DIAGNOSIS: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) THORACIC DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.11 RR-000076

DATE OF PROCEDURE: 09/07/2010 Cervical spondylosis with myelopathy Thoracic spondylosis without myelopathy PROCEDURE: Bilateral T5, T6, T? Transforaminal Epidural Steroid Injection Epidurogram and Interpretation Supervision of Moderate Sedation (Start: 1421 End: 1427 RR-000078

Change in work status RR-000087

Date: 02/13/2012 Fever Stiffness Joint pain Abnormal heart beat Chest pains RR-000088

Osteoarthritis, Hypermobility Sydrome, Ehlers Oanlos. Syndrome. Orthostatic Hypotention PAST SURGICAL HISTORY: Cholecystectomy; Anal Fistula repair ; Left foot Surgery; Anal Fistula repair ; T & A; Neurostimulator implant; lnterstim Implant RR-000093

status Resumed any hobbies or activities- no Ability to perfonn daily chores-no Change In work status RR-000097

Fever Stiffness~ :Bone pain Abnormal heart beat Chest pains Memory changes .Headaches’ Shortness. Of breath RR-000098

Date: 11/17/2011 X-Ray t\ (\tvTr -*e-c..k ~ RR-000105

Fever Stiffness Joint pain Abnormal heart beat Headaches Shortness of breath RR-000106

Date: 09/16/2011 Increased Pain Physical Therapy X-Ray \-\-Ai\'DL ~t\~ne

Date: 09/16/2011 Increased Pain Physical Therapy X-Ray \4-Af\1)_.L Fe:t\_LKne Experi~ side ehcts frCm your medications such as nausea1 wmiting, constipation, Itching, mental cloudiness, sweating, fatigue, drowsiness RR-000118

Vomiting Fever Diarrhea Stiffness Joint pain Memory changes RR-000119

Date : 08/1812011 Increased P-ain Physical Therapy RR-000130

Date: 08118 120 ·~ 1 ~h-~.; ('"i5~if> (consta~' \ Burnifig· _c;;n~pir)g <~~-~-~-~~~;i Fever Diarrhea Stiff e-: s Chest pains RR-000131

May 13. 2011 HISTOnY: Nancy is approximately 8 weeks status post upper thoracic epidural spinal cordstimulator implant with left buttock rechargeable generator. She states she is getting stimulation to the thoracic spine and around the bilateral ribcage and foels that the stimulator to hdping w decrease her pain overall. She does state she would like more stimulati.on to the thoracic spine and less stimulation to the bilateral ribcage. She does .state she has not reprogrammed with Medtronic yet .since .having the stimulator implan:reQ, $he did just have an interstitial stimulator implanted on April 9th with Dr. Antonini and' st.llt~s that she did very wdl with this. She states she is no longer getting the spasms to the thoracie spine that she was. getting a1 ht:r previous office visit. She is currently taking tramadol, extended releast:, 100 mg J pill daily and Mobic and feels tha1 her current medications help to reduce t111Y of her postoperative pain. She denies any falls, trauma fever, or t:hills. Overall she is doing well and is very pleased with her sLirgir.:al outcome. PLAN: Resu:ictions and I.imitations ongoing were discussed with the patient today. She wasadvised to follow up with the Medtronic represe11tative for rcprognìnming of ber stimulator. Thepatient did discuss with D.r. Loftus today tj,in she does have symptoms suggestive of Ehler- RR-000132

Danlos sytidrome. '·Ji./e will have the patient return Lu the clinic on an as-needed hasis w l"ollow up with Dr. Loftus RR-000133

Date: 0512312011 Experienced side effects from your medications suchas nausea. \Omiting, constipation, itching, mental 0cloudiness, sweating, fatigue, drowsinass RR-000136

Date: 05/23/2011 .,,., s_f_i:a_·r_~... ..;. / '.°,.,.C~;-~plng ''" /'Radiating Nausea omiting Difficulty controlling urine Stiffness Joint pain Bone pain Chest pains Abnormal heart beat N\ernory chan9e<:. Weakness RR-000137

Date: 05/23/2011 as nausea, \(Jmiling, constipation, itching. mental /\' cloudiness, sweating, ratigue, drowsiness Diarrhea Difficulty controlling urine Stiffness Joint pain Bone pain Chest pains ~ 0 Abnormal heart tv\ern ory change~. W eaknP..ss RR-000144

March 31, 2011 HISTORY: Nancy is 2 weeks status post upper thoracic epidural spinal cord stimuJator implant with left buttock rechargeable generator. She states she is getting coverage to the thoracic spine and bilateral ribcage to tbe areas where she desires to have coverage. She does describe that she is having musde ·spasms around bet in.cision sit~~ She states the more active she is, the more spasm she has in this area. She states she is currently taking Pcrcocet, up to 6 per day and taking Flexeril at 2 per day. She denk:s any fa.lb, trauma, fever or .chills postoperatively. She states she does have .surgery scheduled for implantation of her interstitial stimulator on April 9, with Dr. Antonini. She states overall she is getting cove?rage with the stimulator to the areas of pain \Vitb pain reduction. She states at this time her incision pain is most problematic postopt!ratively. RR-000153

Match 15. 2011 I had the Qpponunity to see Nancy Peck in my clinic today for evaluation of thoracic spinal cord stimulator implant for her thoracic spine pain. Please see attached clil)ic note. She had a very good response to the trial undm- the direction of Or. Wills recently with a lead implant at approximately the T5 level. She is willing to move forward with permanent implantation. I have scheduled her to undergo an upper thoracic epidural stimulator implant with left bullock rechargeable generatorplaoement an March 16. 1 will keep you apprised of her progress after surgery. RR-000156

Page: 157 :l3/l 7/ll ADM DAT!:: DIAGNOSIS: Chronic pain syndrome l''ROCC:DUF.E: : Upper thoracic e9idural $pinal cord sti..-nulat::>r with le!t btittock recl1a.rqcuble generator. HISTORY OF PRESENT ILLN£SS: The ;:;>atient !.s a 46-year-old female who p?:"esents to the off.ice w.i.Lh a. prima::-y complair.t of -::.hor.acic and bilateral rib cage radicul.opattiy symptoms. St1f'! describes her thoracic pain ~s a :tharp .stabbing pain that will radia-n!. anwnd the ~:.lateral .rib cages and ma.l::e it difficult for her to breath. She stares that certain acti ¥1 ties suer. as washing di.!lnes or folding laundry or any kind of activities wa.th her bi:ateral upper extremities -:.bat i.nvolves reaching or s-:ret.chinq wil.1 usually exacerbat:e her th.ora.ci:c pa·in. She does state that she ::ollcws up wi-::h Dr. Wells in pain :management and ha~ had approximately 2-3 P-ì.i.d~ral steroid .i.njec-.:.ions to thoracic !!pine that she .feel~ has helped some tc decrease her thora:::.i.c pair; b>.1t not siqnificantly and only last for a short pe.riod of time. It t1as been recommended by Dr. Wil·ls in the past to do a radiofrequency to the ~horacic spine but ":his was denLed by her insurance. Sr.e !·:as dls;:i completed physical therapy in the past wit!': short term bene.fi t:.. She does describe ;m inc.;ident in 01./11 .where s .he was ho.sp·ita.li.:ted for approximate.ly 30 days for a ne!:Vous breakdown. Sh~ estates that when ;she was inpl!.tient she ::lid have shoe~ treatments t::>r depression. She stat.es th1JL s.ince having tl-.e shock t:::ea::.ments she nas he.d qi.fficulty with coqnition €IS well as h~d some problems witt:. b J. a.dcter and. bowel incontinence. She does state that she has follcwed up with an urogynecologist, Dr. Antonini and is pl.a.nr:ing on having .,n int:erstitial .st.inr.Jlator iJr,planted on 4/9 by er. Antonini !or her bowel and bladder :..ncontinence. The pa.ti.ent did 'Complete a spinal corct s .timula:::or trial with Dr. \Hlls at t.he end of February and states that she did ha·ve ~dequate coverage with the stimulator to her thoracic spine and around her rib cages during t.he ~rial and felt that overall it helped to decrease her thoracic and rib c~gc pain by greater ·:han 50%. She also· states tt.at during the trial. she felt t:hat. it also helped w:i.t:h some of he!: bowel incontinence. She felt that she had more regular bowel movement..o:i du!'." .ing the t.::lal and she did no~. :"lave as nu;ch diarrhea and cons~ipati~n. She states t .hat she ff.ll t. thi!t she was mo::e active during the ·trial and was a.b,le to dO more activities wi.t.hm;t pd.in :Jve.::a.l l . She wa.s very pleased. with i::.he t.rial and is int:eres;;:ed in mov!:ng forward wi. th permaner:t imFlantat ion ot; the -spinal ccrd stilri(ll.ato.r. Chronic pain, fatigue, hiatal hernia, anxiety, depression, gastritis, slee:;: RR-000157

Page: 158 d i sonie!", hyperLenainn, ini;Cl!ll1.:.a, alle:rgic r.t·-.initis, asthlr.a, sle·ep ciprcea .ar.d no'::.tole:?:ating CPA? machine. RR-000158

Page: 159 She ~·as m.ild ·tend~rness to pal pat.ion to -:;he r.:i,.q;it thoracic pa:r-aspin;.l musculature f;om approximately T5-TI regitm. 'l'his patient is a 46-year-old female with .a pri.m.ary comp.Laint of thoracic ::ain ::::adiati:'lg around the ·bil ateral r:.b cages. Based upon ::he cii!lical findi:lgs, the faill:re of conservative measi.:.res to -::reat this pe1tient 's pain, as well as tne patient's excellent response· with the ·spinal cord st:..mulator trial where she had greater than a 5:>"1! reduct.ion in her thoraci.c and bil.at.eral rib:::age pair:. as wel l as increa.se i:'l he!: act.i.vir.ies of daily living d.u::ing the trial. we ::-1ave deemed this pa.tient a viable candidate ! ·or surgi.cal intervention. Ne have recommended an upper thoracic epidural 3pinEll cord stimulator with left buLLock rechargeable neurolcgic deficit, be:no.c:rhage, stroke, no': .fo.rmi.:..lating de.flnitive diaqnosis, possi ble nP.ed for oper<>tion .:.n the future, infection or deat:h RR-000159

Date: 03/28/2011 RR-000170 Nausea Diarrhea Fever Stiffness Headaches Weakness Numbness RR-000171

DATE: 03/21/2011 REASON FOR HEFERRAL: D1SPLCMT THOR DISC W/O MY:ELOPATHY RR-000178

03/16/2011 She saw Dr . Loftus. who recommended this .approach rather than s .urgery. . She hc;ts oain in her thora:c1c and luIJib

D Nausea, Diarrhea, S~ffnes~ ':;:I<( 0 Joint pam Chest pains Weakness RR-000193

DATE: 02/17/2011 P.E.l\SON FOR REFERRAL: OSTEOARTHROS UNSPEC GEN/LOC HAND RR-000201

DATE: 02/09/2010 She ti.as had an MRI scan of the thoracic spine which does reveal TS-6 and 17-8 disc abhormalities. She is wanting to pursue interventional procedures rather than surgical t reatment. Hee pain. starts in the middle of her back between her shoulders blades and radiates around her chest wall. He.r: wors t pain is in a thoracic axial pattern . RR-000332

01/13/2010 Int.erventional Procedures 1. Bilateral TS, T6 and T7 Media l Branch Nerve (Facet Joint) Block x 3 2. Procedure li teratu.r.e was given to patient. . Fo llow-up Appointments Office visit in 1 mon::h. REASON FOR REFERRAL: THOR SPONDYLOSIS WITHOUT MYELOPATHY RR-000335

11/30/20U9 She completed her RFTC. to the right T5-T8 levels as well a:s trigger point injections . She h~ .s noted at 1easi:t a 20-3-0% r~duction of pain to her thoraci c spine an~ feels that. it has allowe'd her to :sl~ep at ni11ht. She has been pleased in general with the results. She cont1nu·es to incorporate 01 tracet t wice a Glay. RR-000336

10/06/2003 She tad a thoracic media: b~an~h RFTC at TS, T6, 17 ~nd TB on 9/14. She sta~es t hat the day af t er her procedure she started running a :.ow grade temperatuL·e ranging from ~9.0 to 100.4 daily . RR-000337

09/13/2001 Interventional Procedures 1. Right L2, 13, 14 and L:· Thermal Radicfrequency Neurc.l Ablation 2. Procedure literature was given to patient. Physica:. Therapy/Rehabilitation Continue home exercise program REASON FOR REFERRAL: LUMBOSAC SPCNDYLOSIS W/O MYElOPll.TH': RR-000338

09/04/2001 Ms . Peck i s having a retu.rn of pain in her t:-1or::1cic spine, left greater than right, radiating along her left ribcage. She occasiona:ly has statbing pa j n that she fe.els underneath her left bre.ast. .She also has neck pain in an axial pattern as well as internit~ent low back pai~ . RR-000339

~---------- Dull or Cramping Please list any physical activities; that you hope your pain management program will help you tocontinue or resume. Please be as specific as possible. hobbies; exercises, part time work etc RR-000341

11/09/2007 REASON FOR REFERRAL: THOR SPONDYLOSIS WITHOUT MYELO RR-000342 12/0S/OS MIU LtJMJWl SPlNt Wl'l'HO'U'I' CON'l'RASTi Back pala. Cblllps of disc deticcatian oh miJd degree are present It T12-Ll and Ll·L2. Mild bulging of the annulus is present Disc dcliccatiOD ii present at LS-Sl. Slight posterior lmWlar bulains ii. prcemt. High sianat intensity along the postmor dilc mugin near the midline and 1lona tho left pnoentraJ dilc lllllJin i• consistent with annular tear RR-000343

09/20/2007 Ms. Peck has a 13-year history of chronic pain syndrome. The pain is centered in her mid-thoracic spine ·area. She demonstrates an area just below her bra strap where she feels severe pain that radiates along her ribcage and also up and down her spine. REASON FOR RBFBRRAL: THOR SPONDYLOSIS WITHOUT MYBLO RR-000345

;OS/0212007 PROCEDURE: MRI Of THE BRAIN RR-000347

e:05/02J2007 PROCEDURE.! MRI OF THE 'rHOAACIC SPINE RR-000348 1. Please describe the location of your pain: ~ 4 e..-4.

.Please list any physical activities .• •. etc th~lf hope your pain management program will help you tocontinue or resume. Please be as specific as possible hobbies, exercise part time work RR-000350 RR-000351

May 5, 2008 Mrs. Peckreports that on Febniary 1995~ while Jiving in Abu D~bi (United Arab Emirates) where her husband was.stationed, she ~x.periencedasudden, intense pain on the right side ofher body> including f~, arm,, and leg. She al5o noted difficult with vision in the right eye and occasional douhle·vision. Following this incident, she began. to have periods of intense fatigue, parllStbesias, and muscle pain in both sides of body. Initially these periods were fat apart from ea;ch other, now they have become increasingly closer to each other. Presently, the etiology of her symptoms is not clear and a diagnosis has not been made.Mrs. Peck reports that since the above described incid~, she has been having severememory deficits involving· finding the right word, significant trouble remembering names and numbers, and frequently niissing parts of infonnation presented either visually, orverbally. Family members complain about her repeating the same questions or .:.J'om11ttion, after only a few minutes of delay. When writing, she made grammatical and RR-000353 spelling errors that she never did before. She believes her vocabul~ finds herself making simple mistakes like missing the letter "r'' (i.e. "your") or writing the letter "e" for "I" and vice versa. She has had from husband and friends about her increasing spelling and gramma Mrs. Peck has a :Saclielor degree in Psychology and Pre-Med. She I in nursing and a Master in Health Services Management. For the p~ legal nurse consultan~ sub contracting for lawyers 01 insurance con: cases where she has to report her findings in writing. She reports tt. would mot be re-hired anq W3$ told this was due to her spelling and cont:.ained in her reports. She reports that she graduated Magna Cur these-types of problems before. Presently, her pain has become almost constant. In addition to havi long muscles1 now she has .Pain in knees, joints, and palms. News~ teeth pain, headache pain which appears associated to her teeth pair heaviness of right side of body and feelings of "a needle being stucl feet or hands". Many times $he trips while she is in pain. Additioru increasing loss- of concentration .and trouble sequencmg and organh Mrs. Peck has been.repeatedly evaluated by Neurologists who have for her symptoms. Their findings included: dysesthesias, possible d: of questionable etiology, anomia, difficulty with vision, right facial migraine equivalent syndrome, and possible medication reaction. Ji her early consults~ Dr. Wayne H. Gordon raised the possibility of '"l I Syndrome,'~ a diagnosis never again suggested. ! Mrs. Peck has had a CT scan of the brain done.in Abu Dhabi and 5 studies had yielded results consistent with Multiple Sclerosis or a st rested for syphilis, Lyme disease$ and heavy metal poisoning. all of· Prior to her move to Abu Dh.$bi. Mrs. Peck received sev~al immWJ included MMR, hepatitis A, hepatitis B, PPD, malaria, typhoid feve meningococcal, and flu. The immunizations were given prior to th( fatigue and right side ~rasthesias, and lasted for two weeks. Mrs. Peck has had trigger point injections, 2 cortisone injections, bt physical therapy to alleviate her Chronic pain. She reports very litt11 and only for short periods of tim~. RR-000354

PAST MEDICAL IDSTORY: History of hypothyroidism. Possible Toxic Shock Syndrome as a teenager. Chronic n:ctal fissure. Left foot neuroma. Removed. Hemanuia of questionable etiology. Cholecystectomy, 2003 or 2004. RR-000355

These results, with the exception of Visual Immediate Memory and Working memory, are below the expected level relative to the results on the intellectual testing RR-000357

On tb.e Recall part of this measure she obtained a Stan.dard Score of'83 indicating that her visu,al recall memory is impaired RR-000358

The results of achievement test are negative for learning disabilities. However, scores obtained are lower than expected from a person who was in p~med and held a 4.0 GPA while in College. This is C$pecially seen in the area of Spelling, a subject she reports experiencing problems. This lower than expected achievement suggests the presence of deteriorative signs of undetermined etiolog. Mrs. Peck index score in General Memory suggests the present of a clinically significant diminished memory capacity. There is a marked reduction in immediate and delayed auditory memory which suggests that this memory deficit is ·of phonological origin It is clear that Mrs . . :Peck is currently suffering from clinically significant memory intpairm~ most likely associat~d. With an organic etiology. She also suffers from chronic pain, loss of motor to~, paresthesias, migraine headaches, and fatigue . These symptoms have not yet been linked to a defiu,ite diagnosis or etiology and Mrs. Peck has become increasingly depressed, hopeless, and withdrawn. It also seems clear that her ongoing depressive symptoms have been the result, in large part, of not knowing what is afflicting her and the anxiety and apprehension about her illness becoming increasingly w()rse. With this in view, it is felt that efforts should be made to rule out the presence of RR-000359 past suggested pro~ble causes~ stlch a Multiple Sclerosis, a reaction to the vaccination received shortly before her 4iitial episode Qf neurological symptoms, "Persian Gulf Syndrome'\ as well as others diagnoses mtmtioned. RR-000360

12'0.W5 MRI TBORAac SPINI WITJIOlJT CON'l'llAST: RR-000361 Page: 365 05/10/2007 PT NBBDS PAIN SPBC FOR PAIN, Mot.TIPLB SITBS RBASON FOR RBFBRRAL: PAIN IN JOINT, MULTIPLE SJ:TBS RR-000365 Page: 369 ~ Physical Therapy RR-000369

Pain Assessment Questionnaire 9 - I - 01 RR-000370 RR-000372 ~ Vomiting ~ ~ ~ List other activities you would like to return to doing: parttime work RR-000374 If you are unemployed or employed part-time, is this due to your present pain conditior: yes RR-000376

DATE: 07/24/2008 REASON FOR REFERRAL: THOR SPONDYLOSIS WITHOUT MYELO RR-000378

Date: 5 I LI 0 \- l.Please list any physical activities, hobbles, exercises, that you hope your pain management program will help you to: part time work RR-000379

09/07/2010 DIAGNOSIS: Cervical spondylosis with myelopathy Thoracic spondylosis without myelopathy PROCEDURE PERFORMED: Epidurogram and Interpretation INDICATIONS FOR PROCEDURE: This patient is under my care for intractable pain. As part of the plan of treatment, this epidurogram is being performed in conjunction with an epidural steroid injection to assist in diagnosing any epidural abnormalities that might contribute to the pain etiology, and to guide further treatment. RR-000380

HISTORY OF PRESENT ILLNESS: ESTABLISHED PATIENT OFFICE VISIT Ms. Peck presents today for a follow-up visit. She continues to have considerable mid- back pain that is now interfering with her ability to grocery shop. When she leans foiward on the cart, it typically increases her mid-back pain. At its worst, it radiates around into her chest on both sides. She is concerned that the disc herniations she was told about in the past are causing this pain. 08/27/2010 CHIEF COMPLAINT: mid back CHRONIC PROBLEM LIST: CHRONIC PAIN SYNDROME (ICD-338.4) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) THORACIC DISC DISPLACEMENT W /0 MYELOPATHY (ICD-722.11) OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721 .1) RR-000382

Complains of stiffness, joint pain. She has tenderness to palpation along the paraspinal muscles of her thoracic spine from T5-T10. She has increased pain with thoracic back flexion greater than extension. DIAGNOSIS: THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) THORACIC/LUMBOSACRAL NEURITIS/RADICULITIS UNSPEC (ICD-724.4) MFPS/FIBROMYALGIA (ICD-729.1) CHRONIC PAIN SYNDROME (ICD-338.4) IMPRESSION: This is a 45-year-old female with thoracic disc degeneration with protrusions predominantly at the TS-6 and T7-8 levels who has elements of discogenic pain concordant with these radiology findings. RR-000383

DATE OF PROCEDURE: 08/10/2010 DIAGNOSIS Generalized osteoarthrosis, involving hand PROCEDURE Right Intra-articular Joint Injection of the 1st Digit Left Intra-articular Joint Injection of the 1st Digit Ultrasound Needle Guidance Supervision of Moderate Sedation (Start: 1052 End: 1059 ) RR-000385

HISTORY OF PRESENT ILLNESS: ESTABLISHED PATIENT OFFICE VISIT Ms. Peck presents today for a follow-up visit. She has purchased her wrist extension braces which she thinks may be helping a little bit. She also had her first intraarticular injections which have helped some with the pain in her thumbs, but she continues to have some "catching" first thing in the morning when she has difficulty flexing the joint. 08/02/2010 CHIEF COMPLAINT: bilateral han CHRONIC PROBLEM LIST: OSTEOARTHRITIS - HAND (ICD-715.94) DISTURBANCE OF SKIN SENSATION (ICD-782.0) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721 .2) CERVICAL SPONDYLOSIS WITH MYELOPATHY (ICD-721.1) RR-000387

Complains of stiffness Complains of memory changes. DIAGNOSIS: OSTEOARTHRITIS- HAND (ICD-715.94) CERVICAL DISC DISPLACEMENT W/O MYELOPATHY (ICD-722.0) MFPS/FIBROMYALGIA (ICD-729.1) THORACIC SPONDYLOSIS WITHOUT MYELOPATHY (ICD-721.2) RR-000388

DATE OF PROCEDURE: 07/27/2010 DIAGNOSIS Generalized osteoarthrosis, involving hand PROCEDURE Right Intra-articular Joint Injection of the 1st Digit Left Intra-articular Joint Injection of the 1st Digit Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1028 End: 1034 RR-000390

DATE: 07-09-2010 RR-000392 Date: 07/09/2010 CHIEF COMPLAINT: Hand pain, mid-back pain. Ms. Peck presents today for a follow-up visit. She continues to find pain around the areas of her bilateral thumbs and her mid-back. She is awaiting approval of a repeat RFTC procedure to address the pain related to her mid-back spondylosis. She has had this procedure before and it provided her with a significant reduction in her pain. She feels as though poorly controlled pain worsens her depression and anxiety. She is hopeful that they will approve this procedure. She has an extensive medical history. She describes to me an adverse reaction to an ECT procedure she had in the past which she states worsened her memor RR-000394

Tenderness to palpation of the paraspinal muscles of her thoracic spine bilaterally consistent with facet tenderness DIAGNOSIS: 715.04 - Generalized osteoarthrosis, involving hand 721.2 - Thoracic spondylosis without myelopathy 729.1 - MFPS/Fibromyalgia 721 .1 - Cervical spondylosis with myelopathy RR-000395 DATE: 06-07-2010

RR-000397 MEDICATION REQUESTED: 1. Ultram ER 200 mgs CLINICAL: LMN-Ultracet LETTER OF MEDICAL NECESSITY The above listed patient is under my care for chronic intractable pain. As part of the treatment for this condition, they have been prescribed Ultram ER. Ultram ER is a potent, non-narcotic analgesic that is being used to reduce the patient's level of pain and increase their level of function. The patient is using the medication appropriately, without misuse or abuse behavior, and it is a medically necessary part of the overall treatment plan. The duration of use will likely be long-term. DATE: June 7, 2010 RR-000398 06/07/2010 DIAGNOSIS: Thoracic facet arthropathy Thoracic facet radiofrequency thermocoagulation. CLINICAL HISTORY: Ms. Peck is under my care for intractable pain related in part to multilevel thoracic spondylosis and facet arthropathy. She recently underwent a series of thoracic facet injections at the T5-6 and T6-7 levels. It is our standard of practice and also the standard of care in our region to perform radiofrequency ablation of the medial branch nerves when temporary but not sustained relief is achieved with facet medial branch nerve blocks. RR-000400 Page: 402 Date: 06/07/2010 CHRONIC PROBLEM LIST: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy 715.04 - Generalized osteoarthrosis, involving han RR-000402

Page: 403 extremities;MUSCULOSKELETAL: Thoracic spine exam reveals point tenderness over the mid- and lower facet column with overlying paravertebral spasm DIAGNOSIS: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic spondylosis without myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myefopathy IMPRESSION: 1. Multilevel thoracic spondyfosis and degenerative disc disease. 2. Bilateral metacarpal phalangeal arthritis. She does have tenderness to palpation over the first and second MCP joints with erythema or swelling. 3. Cervical spondylosis and degenerative disc disease. RR-000403

Page: 406 DATE: 05-18-2010 Recommendations Bilateral carpal/metacarpal joint injections. RR-000406

Page: 407 DATE OF EXAM: 05/18/2010 1. The bilateral median distal sensory latencies are borderline abnormal. RR-000407

Page: 411 DATE OF PROCEDURE: 05/13/2010 HISTORY: Chief Complaint/Present Illness: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000411

Page: 413 DATE: 05-05-2010 lnterventional Procedures 1. Bilateral TS, T6 and T7 Thermal Radiofrequency Neural Ablation 2. Trigger Point Injections Bilateral Thumbs x2 3. Procedure literature was given to patient. RR-000413

Page: 415 CHIEF COMPLAINT: Hand pain, back pain. HISTORY OF PRESENT ILLNESS: Ms. Peck is concerned about his hand. She has had increasing pain in her thumbs as well as in her wrists and she has noted swelling. Topamax has been helping, and she wants to go up on this dosage upon the recommendation of her allergist. She would also like to go up on the dosage of her Mobic on the recommendation of her primary care physician. She would like to proceed with thoracic facet injections for the thoracic pain which has been increasing in severity over the last couple of months. She also is reporting occasional tingling and numbness in her fingers. Date: 05/05/2010 CHRONIC PROBLEM LIST: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000415 Page: 416 Tenderness is present in the MP joints of the first digit bilaterally. Thoracic spine exam reveals tenderness over the facet joints at T5-6, T6-7, T7-8 with overlying paravertebral spasm DIAGNOSIS: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic spondylosis without myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy IMPRESSION: 1. Chronic intractable pain which is multifactorial in nature. 2. Thoracic facet arthropathy. 3. Possible inflammatory arthritis versus osteoarthritis. 4. Possible carpal tunnel syndrome. RR-000416

Page: 420 DATE OF PROCEDURE: 04/15/2010 Chief Complaint/Present Illness: 721.1 - Cervical spondylosis with myelopathy 721 .2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000420 PLANNED PROCEDURE/OPERATIVE PERMIT: Bilateral T5, T6 and T7 Medial Branch Block (Facet Joint) RR-000421 Page: 422 DATE OF PROCEDURE: 04/15/2010 DIAGNOSIS: Thoracic spondylosis without myelopathy PROCEDURE: Bilateral T5, T6, Tl Facet Joint Medial Branch Nerve Block Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 0924 End: 0926) RR-000422 Page: 424 DATE: 04-05-2010 lnterventional Procedures 1. Bilateral T5, T6 and T7 Medial Branch Nerve (Facet Joint) Block x1 RR-000424 Page: 425 Date: 04/05/2610 CHIEF COMPLAINT: Back pain, thoracic pain. HISTORY OF PRESENT ILLNESS: Ms. Peck spent a month in the hospital for severe depression. She had electroconvulsive therapy. She has been discharged on her usual medications with an increase in her extended-release Ultram to 200 mg q. day. Her medicines are providing her relief. ~ She does have burning neuropathic pain in her thoracic area. She did et good temporary relief with thoracic facet medial branch blocks. These were interrupted with the hospitalization, and she would like to proceed and finish the series and consider RFTC. CHRONIC PROBLEM LIST: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic Spondylosis without Myelopathy 729. 1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000425 Page: 426 MUSCULOSKELETAL: Thoracic spine exam reveals point tenderness at the facet joints at TS-6 and T6-7 aggravated with extension. Paravertebral spasm extends down to the lower thoracic paraspinals. DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy IMPRESSION: 1. Multilevel thoracic spondylosis with facet arthropathy. 2. Cervical spondylosis. 3. Regional myofascial syndrome. 4. Major depression. RR-000426 Page: 428 03/24/2010 Patient called to schedule an OV with Dr. Wills. Patient was last seen on 2/9/10 for a procedure. The patient had been scheduled for her final MBB Facet injection in a series of 3 on 2/23, but it was canceled due to the patient being admitted to the hospital for depression. The patient was discharged from the hospital yesterday (3/23). She was given a months worth of medication . The patient thin ks it's the same type of medication that we have been prescribing her, but she is unsu r e. She said her memory has really become bad lately. I scheduled the pa tie nt for an OV with Dr. Wills at the. south office on 4/5 at 2PM. I instructed t he patient to bring an updated list of her meds and any pills for pain that she ha s been prescribed. RR-000428

Page: 429 DATE OF PROCEDURE: 02/09/2010 DIAGNOSIS: Thoracic spondylosis without myelopathy PROCEDURE: Bilateral TS, T6, T7 Facet Joint Medial Branch Nerve Block, Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1037 End: 1042 ) RR-000429 Page: 431 DATE: 02-09-2010 RR-000431 Page: 432 HISTORY OF PRESENT ILLNESS: OFFICE VISIT Ms. Peck returns to the clinic today for a routine office visit. Later this morning she will complete her second thoracic medial branch block injections. She had her first completed on January 21 and had difficulty distinguishing if her pain level regressed. She states that she has been in bed more secondary to abdominal pain. Earlier in the month she had an EGO completed which revealed she has a large hiatal hernia. She states that she was started on new medication and has a follow-up scheduled. Date: 02/09/2010 CHIEF COMPLAINT: Thoracic back pain. RR-000432 Page: 433 DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 789.06 - Abdominal pain, epigastric · IMPRESSION: 1. Multilevel thoracic spondylosis and facet arthropathy most prominent at the T5-6 and T6-7 levels. 2. Cervical spondylosis/ degenerative disc disease. 3. Regional myofascial pain syndrome. RR-000433

Page: 439 DATE OF PROCEDURE: 01/21/2010 Chief Complaint/Present Illness: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000439 Page: 441 DATE OF PROCEDURE: 01/21/2010 DIAGNOSIS: Thoracic spondylosis without myelopathy . PROCEDURE: Bilateral TS, T6, T7 Facet Joint Medial Branch Nerve Block, Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1020 End: 1021 ) RR-000441 Page: 444 01/11/2010 RR-000444 Page: 446 01/11/2010 RR-000446 Page: 448 01-11-2010 lnterventional Procedures 1. Bilateral TS, T6 and T7 Medial Branch Nerve (Facet Joint) Block x3 RR-000448 Page: 449 Date: 01/11/2010 CHIEF COMPLAINT: Thoracic pain. Her pain starts in the middle of her back between her shoulders blades and radiates around her chest wall. Her worst pain is in a thoracic axial pattern. She has a sense of "weakness" in hermid- and upper back. CHRONIC PROBLEM LIST: 721. 1 - Cervical spondylosis with myelopathy 721.2 • Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000449 Page: 450 Thoracic spine exam reveals marked point tenderness over the facet column at multiple levels, essentially over the TS-6, T6-7, T?-8 joints aggravated to some degree with end range axial rotation and extension. Overlying paravertebral spasm is present that extends into the latissimus dorsi musculature and up into the rhomboid musculature. Cervical spine exam reveals tenderness in the mid- and lower segments with mildly restricted range of motion. DIAGNOSIS: 721.1 - Cervical spondylosis with myelopathy 721.2 - Thoracic spondylosis without myelopathy 729.1 - MFPS/Fibromyalgia IMPRESSION: 1. Multilevel thoracic spondylosis and facet arthropathy most prominent at the TS-6, T6- 7 levels. 2. Multilevel cervical spondylosis and degenerative disc disease. RR-000450

Page: 452 DATE: 12-14-2009 RR-000452 Page: 453 HISTORY OF PRESENT ILLNESS: OFFICE VISIT Ms. Peck returns to the clinic today after approximately a two-month absence. In that interim, she has had a thoracic MRI completed which indicated a new disc herniation at T7-8 as well as a disc protrusion that was present on prior studies at the TS-6 level. Transforaminal epidural steroid injections were recommended by Dr. Wills. However, the patient does not have transportation to the Austin area until February when her husband finishes his tour of duty in Iraq. He also recommended that she meet with a neurosurgeon. A referral has been placed with Dr. Loftus. We discussed options, and she will try to meet with Dr. Loftus before considering interventional injections. There was a discussion regarding possible breast reduction since they feel that perhaps her breast size is causing more pressure on her thoracic spine. She cannot recall the name of the plastic surgeon available for reduction surgery. TriCare has recommended that she meet with a neurosurgeon before a plastic surgeon. Date: 12/ 14/2009 CHIEF COMPLAINT: Thoracic back pain. RR-000453 Page: 454 The patient is experiencing tenderness at the T7-8 level at the midline as well as over to the paravertebral facet joint region. The patient does experience slight discomfort with extension. RR-000454 Page: 455 1. Chronic intractable pain which is multifactorial in nature. 2. Thoracic disc displacement/ spondylosis. The patient will be meeting with neurosurgeon Dr. Loftus to discuss her pathology before proceeding with interventional injections. Transforaminal epidural steroid injections have been recommended. 3. Myofascial pain syndrome/fibromyalgia. RR-000455 Page: 463 DATE: 10-15-2009 Diagnostic Tests Imaging Studies MRI without contrast of the thoracic spine RR-000463 Page: 464 Date: 10/15/2009 CHIEF COMPLAINT: Thoracic back pain. CHRONIC PROBLEM LIST: 721 .2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000464 Page: 465 DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000465 Page: 469 DATE OF PROCEDURE: 10/13/2009 DIAGNOSIS: MFPS/Fibromyalgia PROCEDURE: Trigger Point Injection, three or more muscle groups RR-000469 Page: 473 DATE OF PROCEDURE: 09/28/2009 DIAGNOSIS: MFPS/Fibromyalgia PROCEDURE: Trigger Point Injection, three or more muscle groups RR-000473

DATE OF PROCEDURE: 09/28/2009 RR-000475 HISTORY: Chief Complaint/Present Illness: 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia · 722.0 - Cervical Disc Displacement w/o myelopathy DATE OF PROCEDURE: 09/28/2009 RR-000477

Plan Of Treatment PLAN OF TREATMENT

DATE: 09-17-2009 RR-000479 Page: 480 HISTORY OF PRESENT ILLNESS: OFFICE VISIT Patient is here for follow up and medication refills. She had a thoracic medial branch RFTC at T5, T6, T7 and TB on 9/14. She states that the day after her procedure she started running a low grade temperature ranging from 99.0 to 100.4 daily. When we took her temperature in the office today it was back down to normal. She states that she does not feel sick and is not having any systemic problems or any pain at the procedure site. She states that she will just get very hot suddenly and will take her temperature and it will be elevated. She states that she had a siginificant reduction in her back pain following the procedure. Her second procedure is scheduled for 9/28. She has been taking the Ultracet up to twice per day, but states that she is taking it more for her knee pain than her back pain. She is needing a refill of the Ultracet today. Date: 09/17/2009 CHIEF COMPLAINT: Thoracic pain

CHRONIC PROBLEM LIST: 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000480

DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000481

9/15/09 Returned call. Pt states she is running a fever of 100.1 but she thinks it may be higher if she weren't taking Ultracet. She has no other sx other than slight pain at injection site for which she is using ice. Advised pt to monitor her temp and call tomorrow morning if it increases. She will take OTC ibuprofen as needed this evening. RR-000483

DATE OF PROCEDURE: 09/14/2009 DIAGNOSIS: MFPS/Fibromyalgia PROCEDURE: Trigger Point Injection, three or more muscle groups RR-000484

DATE OF PROCEDURE: 09/14/2009 HISTORY: Chief Complaint/Present Illness: 721 .2 -·Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000488 PROCEDURE PERFORMED: Radiofrequency Thermocoagulation Neurotomy, Left TS Facet Joint Medial Branch Nerve Radiofrequency Thermocoagulation Neurotomy, Left T6, T7, TB Facet Joint Medial Branch Nerve Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1153 End: 1201 ) DATE OF PROCEDURE: 09/14/2009 DIAGNOSIS: Thoracic spondylosis without myelopathy Mf ps/fibromyalg ia RR-000490

09/04/2009 S/w pt who is scheduled for RFTC on 9/14 and OVon 9/15. She is worried she will not be able to come in on 9/15 because she will be recovering. Pt RR-000492

Date: 08/17/2009 CHIEF COMPLAINT: Neck pain, chest pain, back pain. HISTORY OF PRESENT ILLNESS: Ms. Peck is having a return of pain in her thoracic spine, left greater than right, radiating along her left ribcage. She occasionally has stabbing pain that she feels underneath her left breast. She also has neck pain in an axial pattern as well as intermittent low back pain CHRONIC PROBLEM LIST: 721 .2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000494

Thoracic spine exam reveals tenderness over the facet joints at the T5-6, T6-7, T7-8 levels as well as in the lower cervical spineaggravated with extension and lateral bending. Trigger points are present throughout the lower cervical and mid- and lower thoracic and upper lumbar paraspinal musculature. There is also some tenderness along the left costal margin DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy IMPRESSION: 1. Multilevel thoracic spondylosis and degenerative disc disease, previously responsive to thoracic facet injections and radiofrequency ablation. 2. Multilevel cervical spondylosis and degenerative disc disease. 3. Lumbar degenerative disc disease. RR-000497

DATE: 08-17-2009 lnterventional Procedures 1. Bilateral T6, T7, TB and T9 Thermal Radiofrequency Neural Ablation 2. Procedure literature was given to patient. RR-000503 01 /29/2009 Trigger Point Injection RR-000504 01/29/2009 RR-000506 01/29/2009 RR-000508 DATE: 01-29-2009 lnterventional Procedures 1. Left TS, T6, T7 and TB Thermal Radiofrequency Neural Ablation 2. Trigger Point Injections Bilateral Thoracic Spine Region, Latissimus Dorsi and Rhomboids 3. Procedure literature was given to patient RR-000510

Date: 01 /29/2009 CHIEF COMPLAINT: Thoracic back pain. CHRONIC PROBLEM LIST: 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 • Cervical Disc Displacement w/o myelopathy RR-000511

She has tenderness in the T3 to approximately T8 level at the midline as well as over her facet areas. She has positive tenderness down her latissimus dorsi of her thoracic spine and her suprascapular rhomboid area DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000512

PLAN OF TREATMENT Date: 07/31/2008 RR-000515

Date: 07/31/2008 CHIEF COMPLAINT: Thoracic back pain. CHRONIC PROBLEM LIST: 721 .2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - CeNical Disc Displacement w/o myelopathy RR-000516

DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000517

PLAN OF TREATMENT DATE: 05-02-2008 RR-000519 Date: 05/02/2008 CHIEF COMPLAINT: Thoracic back pain. RR-000520

Tenderness in the T5-T10 level at the midline; not over the facet areas; it is not aggravated with lumbar extension, actually provides some relief, DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000521

PLAN OF TREATMENT DATE: 01-28-2008 RR-000524

DATE OF PROCEDURE: 01/14/2008 DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia PROCEDURE: Trigger Point Injection, three or more muscle groups Supervision of Moderate Sedation (Start: 0923 End: 0933) RR-000525 DATE OF PROCEDURE: 01/14/2008 Chief Complaint/Present Illness: 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000529 PLANNED PROCEDURE/OPERATIVE PERMIT: Left TS, T6, T7 and T8 Thermal Radiofrequency Neural Ablation Bilateral Thoracic Paraspinals Trigger Point Injections #2/2 DATE OF PROCEDURE: 01/14/2008 DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia PROCEDURE PERFORMED: Radiofrequency Thermocoagulation Neurotomy, Left TS Facet Joint Medial Branch Nerve Radiofrequency Thermocoagulation Neurotomy, Left T6, T7, TB Facet Joint Medial Branch Nerve Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 0923 End: 0933) RR-000531

DATE OF PROCEDURE: 12/31/2007 DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia PROCEDURE: Trigger Point Injection, three or more muscle groups Supervision of Moderate Sedation (Start: 0857 End: 0907 RR-000533 DATE OF PROCEDURE: 12/31/2007 DATE OF PROCEDURE: 12/31/2007 HISTORY: Chief Complaint/Present Illness: 721 .2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000537 DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia PROCEDURE PERFORMED: Radiofrequency Thermocoagulation Neurotomy, Right T5 Facet Joint Medial Branch Nerve Radiofrequency Thermocoagulation Neurotomy, Right T6, T7, T8 Facet Joint Medial Branch Nerve Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 0857 End: 0907 ) DATE OF PROCEDURE: 12/31/2007 RR-000539

DATE: 11/29/2007 Radio Frequency Thermocoagulation RR-000541 DATE: 11-29-2007 Medications Continue: LIDODERM PATCH - 1 patch 18 hours on, 6 hours off lnterventional Procedures 1. Right TS, T6, T7 and T8 Thermal Radiofrequency Neural Ablation, then Left side RR-000545

DATE OF PROCEDURE: 10/23/2007 DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia PROCEDURE: Trigger Point Injection, three or more muscle groups Supervision of Moderate Sedation (Start: 1049 End: 1052 RR-000549

DATE OF PROCEDURE: 10/23/2007 RR-000551 DATE OF PROCEDURE: 10/23/2007 Chief Complaint/Present Illness: 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000553 DATE OF PROCEDURE: 10/23/2007 DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia PROCEDURE: Bilateral T6, T7, TB, T9 Facet Joint Medial Branch Nerve Block, Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1049 End: 1052) RR-000555

DATE OF PROCEDURE: 10/09/2007 DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia 721.0 - Cervical spondylosis without myelopathy PROCEDURE: Trigger Point Injection, three or more muscle groups Supervision of Moderate Sedation (Start: 1027 End: 1035 RR-000557 HISTORY: Chief Complaint/Present Illness: 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy DATE OF PROCEDURE: 10/09/2007 RR-000561 DATE OF PROCEDURE: 10/09/2007 DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729. 1 - Mfps/fibromyalgia 721 .0 - Cervical spondylosis without myelopathy PROCEDURE: Bilateral T6, T7, TB, T9 Facet Joint Medial Branch Nerve Block, Fluoroscopic Needle Guidance Supervision of Moderate Sedation (Start: 1027 End: 1035 ) RR-000563

PLAN OF TREATMENT DATE: 10-04-2007 Start/Change: LIDODERM PATCH - 2 patch 17 hours on, 7 hours off L YRICA 75mg - 1 tab twice a day RR-000566 Page: 567 Date: 10/04/2007 CHIEF COMPLAINT: Thoracic back pain, total body pain. She has been having increased pain to her midthoracic spine area. She has completed her first thoracic medial branch block injection at the T6- 7, T7-8 , TB-9 levels and has noticed a reduction of her pain for a number of days. She also finds that the Lidoderm patch has been effective in helping to reduce her pain. She has never started the Lyrica. She was having problems with elevated blood pressure and feared that this may aggravate her blood pressure. Sleep has been problematic, and she was placed on Seroquel at h.s. and states that she feels it had side effects and since then has discontinue it. She feels somewhat fatigued and would like to await a number of days before she starts introducing the Lyrica into her regimen. CHRONIC PROBLEM LIST: 721 .2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy RR-000567

DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia RR-000568 Page: 570 DATE OF PROCEDURE: 09/25/2007 DIAGNOSIS: 7212 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia 721.0 - Cervical spondylosis without myelopathy 728.85 - Spasm of muscle PROCEDURE: Trigger Point Injection, three or more muscle groups Supervision of Moderate Sedation RR-000570 DATE OF PROCEDURE: 09/25/2007 Chief Complaint/Present Illness: 721.2 - Thoracic Spondylosis without Myelopathy 729.1 - MFPS/Fibromyalgia 722 .0 - Cervical Disc Displacement w/o myelopathy RR-000574 PLANNED PROCEDURE/OPERATIVE PERMIT: Bilateral T6, T7, T8 and T9 Medial Branch Block (Facet Joint) #1 Bilateral Trapezius and Thoracic Paraspinals Trigger Point Injections #1 RR-000575 DATE OF PROCEDURE: 09/25/2007 DIAGNOSIS: 721.2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia PROCEDURE: Bilateral T6, T7, TB, T9 Facet Joint Medial Branch Nerve Block, Fluoroscopic Needle Guidance Supervision of Moderate Sedation RR-000576

09/05/2007 Trigger Point Injection The cause of your muscle pain or spasms may be one or more trigger points. Your doctor may decide to inject the painful spots to relax the muscle. This can help relieve your pain. Relaxing the muscle can also make movement easier. You may then be able to exercise to strengthen the muscle and help it heal. RR-000578 DATE: 09/05/2007 Facet Joint Injection Back or neck pain may be caused by a problem with your facet joints. If so, a facet joint injection may help. With this treatment, medication is injected into certain facet joints. The injection can help your doctor find problem joints. It may also relieve your pain. RR-000580 DATE: 09-05-2007 Medications Start/Change: L YRICA 75MG -- 1 pill twice daily LIDODERM PATCH 5% -- Apply 1 patch to affected area, 18hrs on 6hrs off, may repeat as needed Procedures 1. Bilateral T6, T7, T8 and T9 Medial Branch Nerve (Facet Joint) Block 2. Trigger Point Injection Bilateral trapezius and thoracic paraspinals RR-000582 HISTORY OF PRESENT ILLNESS: Ms. Peck has a 13-year history of chronic pain syndrome. The pain is centered in her mid-thoracic spine area .She demonstrates an area just below her bra strap where she feels severe pain that radiates along her ribcage and also up and down her spine. She also has a headache, arm pain and tingling, foot pain and tingling, and occasional stabbing pains. She relates a history that 13 years ago she had what sounds like a possible migrainous stroke or TIA where she developed right-sided weakness in her extremities and required extensive neurologic workup. She was in the military at that time and stationed overseas. Since that time, she has had cyclical recurrence of these neurologic symptoms about every six months. She continues to have an extensive workup including infectious disease, neurology, and rheumatology without a clear diagnosis yet determined. She has now developed to the point where she has essentially daily chronic pain as described above. She is very sensitive to medications and presently is not taking a specific analgesic agent. She was prescribed Lyrica last year and was just started on Effexor. Effexor has been helping some with her depression and pain levels. She has not had any interventional therapy. She had an MRI scan of her brain last year done in San Antonio. She is not clear is she had an MRI scan of her spine. She has not had any recent physical therapy. She denies any progressive neurologic symptoms or bowel or bladder sphincter dysfunction. Date: 09/05/2007 CHIEF COMPLAINT: Back pain, total body pain. RR-000584

MUSCULOSKELETAL: Thoracic spine exam reveals point tenderness over the facet joints in the mid segments essentially from T6-7 through T8-9 aggravated with thoracolumbar extension.Paravertebral spasm is present to a marked degree in this area that extends up towards the cervical region. Cervical spine exam reveals decreased range of motion in axial rotation with negative Spurling's maneuver.Trigger points are present in the trapezius, rhomboid and cervical paraspinal musculature as well as the occipital musculature. DIAGNOSIS: 721 .2 - Thoracic spondylosis without myelopathy 729.1 - Mfps/fibromyalgia 722.0 - Cervical Disc Displacement w/o myelopathy PLAN/DISCUSSION: 1. In terms of the clinical appearance of thoracic facet syndrome, I would recommend diagnostic and potentially therapeutic facet injections at the T6-7, T7-8, TB-9 levels utilizing a medial branch technique. Depending on the degree and duration of relief she may be a candidate for radiofrequency ablation of the involved medial branch nerves. I would also recommend trigger point injections to the above-identified myofascial trigger point regions at the time of her facet blocks. 2. I would also recommend physical therapy for cervical and thoracic spine strengthening and stabilization and development of a home exercise program. 3. In terms of her diagnostics, as discussed above, we will go ahead with MRI scan imaging of the cervical and thoracic spine. This might change our injection target. 4. In terms of medications, I would recommend reinitiating a trial of Lyrica 75 mg b.i.d. along with a trial of Lidoderm patch which she can apply to various areas of pain on a daily basis. 5. Return visit in one month or after her third injection, whichever comes first. RR-000586 EXHIBIT C Summary of Comments on 14-440-CV 092214 Petitioner's Exhibit No. 17, 20, 21, 22 (981-1075)

Exhibit No. 17 (Exhibit No. 17 includes Psychological Evaluations/visits from Jason Booth M.A., L.P.A)

Jason Booth Licensed Psychological Associate Dates: 7/01/10- 3/24/11 -Help Managing Pain and interpersonal relationships with family RR000989- RR001005

Exhibit No. 20 ( Exhibit No. 20 includes visits from Medical Clinic of North Texas P.A. Denton Rheumatology & Endo) 09/14/2011 This is a 46 Years old Caucasian Female presenting for a(n) NP Evaluation visit. History of Presenting Illness Complaint: Generic Additional Comments Patient lives 3 112 hrs away. Here to RIO Ehlers Danlohs Syndrome Past Medical History Previous Illnesses I Conditions: I. Fibromyalgia-729 .1 4. Osteopenia-733.90 Assessment I Chronic Condition Status HYPERMOBILfiY SYNDROME (728.5) OA, GENERALIZED, MULTIPLE SITES (715.09) FATIGUE/MALAISE (780.79) RR 001012 Page: 34 Encounter Date: 10/12/20113: History of Presenting Illness Complaint # 1: Generic Additional Comments Patient comes today for follow up visit to discussed Test Results. All x-rays are normal. She still hurting all over. The pain is worse in the morning. She is having difficulty writting. RR 001014 10/12/2011 Past Medical History Previous Illnesses I Conditions: 1. Fibromyalgia-729.1 2. Tachycardia, NOS 785.0 3. FX Toe(s) of 1-foot-826.0 4. Osteopenia-733.90 5. Hypotension 6. Cystocele 7. Nervous Breakdown 8. FX Ankle Closed-824.8 9. Rectocele 10. cong. Hip Dysplasia 11. Gastritis-535.50 13. Incontinence of feces-787 14. Hiatal Hernia Hospitalizations: 1. several surgeries Surgical History I. Tonsillectomy 2. Lt foot Neuroma in 2003 3. Interstim implant (bowel&bladder) in 2011 4. Adenoidectomy 5. Cholecystectomy in 2003 6. Neurostimulator Inplant Thorax in 2011 7. Fissure Repair, anal 2003 11. Fistula, anal 2008 RR 001015 10/12/2011 Assessment I Chronic Condition Status HYPERMOBILITY SYNDROME (728.5) FffiROMY ALGIA, MYALGIA (729.1) Mrs Peck has evidence ofhypermobitlity and chronic pain syndrome. Plan Continue current medications and therapy E&MCoding 99213 - Level 3 Exam, Established Patient RR 001016 01/31/2012 History of Presenting lllness Complaint # 1: Generic Additional Comments Patient comes today for follow up visit for the management of hypennobility syndrome and chronic pain syndrome. She has tried lyrica and cymbalta and both not well tolerated. I gave her a trial of Savella and it made her nauseated. It was discontinued. Patient is not doing well. She has severe fatigue, weakness generalized, pain in thoracic spine, also in bilat hip going down lateral thighs. Hands still in pain, more in right hand than left. Patient is spending majority of her time in bed. Exhausted when running errands. She is stiff in the mornings for about 1-2 hours. She is very anxious her husband wants to divorce her, more stress. RR 001017 01/31/2012 Musculoskeletal: Comments: -Passive apposition of thumb to forearm bilateral - Passive hyperextension of fingers -Active hyperextension of elbow> 10 degree 18/18 tender points . tender mcp's RR 001018 Assessment I Chronic Condition Status FffiROMY ALGIA, MYALGIA (729.1) HYPERMOBILITY SYNDROME (728.5) FATIGUE/MALAISE (780.79) OA, GENERALIZED, MULTIPLE SITES 715.09 01131/2012 1. Fibromyalgia: Mrs Peck meets criteria for Fibromyalgia, widespread pain, > 11 tender points, fatigue and poor night sleep. She has tried lyrica and cymbalta with no success. She was advised to start a yoga and/or pilates. A trial of savella was given could not tolerated either. I will choose a nonpharmacological approach. 2. Hypermobility syndrome: meets criteria for hypermobility, however, I can't make the diagnosis of Ehlers Danlos with the clinical evidence I have. If she still wants to pursue the diagnosis she will need to be refer to a geneticist for further testing. Hypermobility Syndrome can cause OA over time and physical therapy for strengthening exercises is the goal of therapy. 3.Fatigue: Multifactorial. Fibromyalgia anxiety and depression is also causing some of her fatigue. Poor night sleep. 4. OA: I think some of her joint pain could be related to some early OA. X- rays are all normal. 01131/2012 RR 001019 Study Date: 10/11/11 Indication: Palpitations (786.1 ), Hypertension (401 .1), Mitral Valve Disorder (424.0) IMPRESSIONS: 1. No evidence of mitral valve prolapse. 2.. OVerall LV systolic function Is normal. LV EJection fraction Is 68 %. 3. Estimated pulmonary artery systolic preasures ere normal. 4. Trece tricuspid valve regurgitation . RR 001020 26 Apr 2011 BONE DENSITOMETRY, HIP AND SPINE: 4/26/2011 CLINICAL HISTORY: Premenopausal. Family history of osteoporosis .. Taking seizure medication INTERPRETATION: The FRAX algorittuns give the 10 year probability of fracture. The output is a 10 year probability of hip fracture and the 10 year probability of a major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture). IMPRESSION: . %. The 10 year probability of hip fracture is 0.8%. RR 001021 09/14/2011 CLINICAL HISTORY: Pain, arthritis. 1 FINDINGS: The joints are well maintained. There is no evidence of a fracture or dislocation. he bone density appears normal. There is no evidence of an effusion or periostitis/bony destructive lesion. IMPRESSION: Negative left knee. RR 001022 9/1412011 CLINICAL HISTORY: Pain, arthritis. 09/1412011 CLINICAL HISTORY: Pain, arthritis. TECHNIQUE: Three views of the right wrist. FINDINGS: The joints are well maintained. There is no evidence of a fracture or dislocation. e bone density appears nonnal. There is no evidence of an effusion or periostitis/bony destructive lesion. IMPRESSION: Negative right wrist. RR 001024 Page: 45 09/14/2011 CLINICAL HISTORY: Pain, arthritis. TECHNIQUE: Three views of the right hand. FINDINGS: The joints are well maintained. There is no evidence of a fracture or dislocation. her bone density appears normal. There is no evidence of an effusion or periostitis/bony destructive lesion. IMPRESSION: Negative right hand. RR 001025 Page: 46 09/14/2011 CLINICAL HISTORY: Pain, arthritis TECHNIQUE: Three views of the left wrist. FINDINGS: The joints are well maintained. There is no evidence of a fracture or dislocation. e bone density appears normal. There is no evidence of an effusion or periostitis/bony destructive lesion. IMPRESSION: Negative left wrist. RR 001026 DATE OF EX M: 09/14/'2011 CLINICAL IDSTORY: Pain, arthritis. IMPRESSION: Negative left hand. RR 001027 Page: 48 CLINICAL HISTORY: Pain, arthritis. TECHNIQUE: Three views ofthe left wrist. DATEOFEX M: DOB: MRN#: 09/14/2011 09124/1964 175646 IMPRESSION: Negative left wrist. 09/14/2011 RR 001028 Page: 49 09/14/2011 CLINICAL HISTORY: Pain, arthritis. TECHNIQUE: Three views of the left hand. FINDINGS: The joints are well maintained. There Is no evidence of a fracture or dislocation. e bone density appears nonnal. There is no evidence of an effusion or periostitis/bony destructive lesion. IMPRESSION: Negative left hand. RR 001029 Test Date: 8/27/08 Presenting Problem Nancy Peck is a 43~year~old female who is referred for neuropsychological evaluation. She has provided details of her medical history in the form of an outline that she prepared, and sothat detailed information will not be repeated here. Ms. Peck reports that she recently had a psychological evaluation performed by her counselor, which revealed a "significant verbal memory deficit", which "explains a lot of what has been going on over the last 12 years". For a period of time in the past, Ms. Peck lived in the Middle East until about 13 years ago. Towards the end of her stay there she had an episode in which she developed a right side paresthesia accompanied by a bad headache that lasted approximately a week. Prior to that event, she had had no history of neurological problems, but had had some anxiety and PMS. Ever since that event, she has been unable towork, unable to enjoy life, and has been depressed. She reports that she developed "optical migraines" about three years following the event. In describing the details of the event, Ms. Peck states that the right side of her head, her right extremities-- basically the whole right side of her body-- had reduced tactile perception and felt tingly or prickly. Her right eyelid was droopy and she generally felt weak on her right side. This improved over the course of the next few days but she continued to feel very fatigued. She observed no effect on her speech and language functioning, and no one else noticed anything out of the ordinary. Regarding educational history, Ms. Peck is a high school graduate from New York, with high school grades that were generally B's. Throughout school she never repeated a grade, and was never in any kind of special education, speech and language or occupational therapy, and had no behavior problems. After high school, Ms. Peck attended a community college in New York, completing a two year RN program, and then obtained a bachelor's degree from the State University ofNew York in psychology/premed, with a 4.0 GPA during her last two years. Later, she obtained a master's degree in health services management from Webster University. Ms. Peck is currently not employed. Her last regular full-time employment was with Blue Cross Blue Shield as a utilization management nurse, in the late 1990s for several years. Before that, she had worked in the Middle East teaching English as a second language. Regarding medical history, Ms. Peck is the product of a normal pregnancy and delivery. She had congenital hip dysplasia. She has been hospitalized for a tonsillectomy, gallbladder removal, colon/rectal surgery, and for the birth of her son who is now 16 years of age. She reports that she was once briefly knocked out when she struck her head while at work, but RR 001033 there were no sequelae from this injury. She denies any problems with alcohol or drug use. Regarding sleep history, she reports that for a long time she had problems falling asleep, and these difficulties increased following her event. She describes herself as being a light sleeper who hears everything that goes on around her while she's asleep. She sleeps all the way through the night when she uses Lunesta. She has had three sleep studies done, and apparently they have all showed multiple arousals and the most recent one also indicates restless leg syndrome. She is taking Mirapex and also Provigil. Regarding psychological and psychiatric treatment, Ms. Peck's first professional mental health contact occurred in 1995 in the context of some marital counseling. Since then, she has seen a psychiatrist for treatment of anxiety and depression resulting from all of her health problems. Her family history is positive for hyperactivity, anxiety, and possibly bipolar disorder. Behavioral Observations: Ms. Peck presents with good grooming and hygiene. Her attire was casual and appropriate. She was cooperative and compliant with the examiner. Her mood was neutral to positive and upbeat, and her affect was normal for range and congruence. Attention and concentration were average to below average. Motivation and persistence were normal. Expressive and receptive language appeared normal. Stream of thought was normal for pace, content, and structure. Motor skills appeared dexterous and coordinated. She displayed a normal !evel of baseline motor activity during the testing. Test Results: (Index and standard scores have a mean of I 00 and a standard deviation of I5. Scaled scores have a mean of I 0 and a standard deviation of 3.) Ms. Peck was administered the Reynolds Intellectual Assessment Scales, with the following results: Subject: Highlight Date: 11/29/14, 4:02:05 PM Verbal Intelligence 107 68 Nonverbal Intelligence 111 77 Composite Intelligence (IQ) 109 73 Composite Memory 98 45 These scores place Ms. Peck at the top of the Average range of intellectual functioning, at the 73rd percentile relative to age peers. The Composite Memory Index, which is a screening measure based on immediate auditory story recall and immediate visual object recognition, falls near the middle of the average range, at the 45th percentile, with no significant difference in performance on the verbal versus the nonverbal subtests. To examine achievement levels, Ms. Peck was administered selected subtests from the woodcock Johnson-Third Edition achievement battery which were scored relative to age peers using the normative update, with the following results: · 2 RR 001034 Page: 55 AREA Letter-Word Identification Reading Fluency Calculation Math Fluency Spelling Reading Comprehension STD SCORE 92 92 100 83 98 92 William A. Dailey, Ph.D. PERCENTILE 30 29 50 13 45 31 GRADEEQUIV 8.9 8.8 11.0 6.6 13.0 7.9 The math calculation score is at the expected level although the fluency score is significantly lower, indicating inefficient application of formal arithmetic skills. The verbal scores, generally speaking, are lower than expected relative to this patient's educational history and intellectual level. To examine memory function, Ms. Peck was administered the Neuropsychological Assessment Battery, memory module, which was then scored relative to other individuals of her same age, sex, and educational level. This produced a Memory Index Standard Score of 68, which falls at the 2nd percentile, and is moderately impaired. On the auditory verbal list learning test, the rate of acquisition is impaired, and there is slightly greater than expected forgetting across the delay intervals, and the delayed forced choice recognition score remains impaired. On an auditory verbal story learning test, the acquisition of specific phrase content is average and the acquisition ofthematic content is high average. Retention of thematic content is normal, but there is slightly greater than expected forgetting of specific phrase content. On a visual shape learning test, the rate of acquisition is slower than average but her terminal acquisition level is at the 50th percentile. Performance on the delayed recognition trial is average, and performance on the forced choice delayed recognition trial is high average. On a test of acquisition and retention of information from daily living activities, Ms. Peck's immediate recall score is mildly impaired and her delayed recall score is severely impaired, but she demonstrates average performance on the delayed recognition trial. In general, these results on the memory testing demonstrate problems with acquisition and retrieval, and only minimal retention difficulties. To further examine memory performance, Ms. Peck was administered the Logical Memory subtest from the Wechsler Memory Scale-Third Edition. On this story memory test, her overall immediate recall score is low average for specific content, and her thematic recall score is low. These findings represent some variance from those reported above. Ms. Peck was also administered the California Verbal Learning Test-Second Edition, which is a verbal list learning test with acquisition across repeated trials followed by short and long delay free and cued recall trials. She shows very inefficient acquisition of the list, with an overall acquisition score that is 2.2 standard deviations below the mean. Her short and long delay free and cued recall scores indicate no forgetting across the delay intervals, and no benefit from recall cueing, with a long delay free recall score that is 2.5 standard deviations below the mean. The serial position curve indicates a significant recency effect. On the delayed yes/no recognition trial, Ms. Peck's score was five standard deviations below the mean, but on a forced choice recognition test she demonstrated perfect recognition accuracy. RR 001035 To examine visual memory, Ms. Peck was administered the Rey Complex Figure Test and Recognition Trial, which uses a complex geometric figure as the stimulus. Her immediate and delayed recall scores are at the 62nd and 54th percentiles, respectively. On the delayed multiple choice recognition trial, her score is at the 50th percentile. Various measures of executive function were administered as follows. On the Trail Making Test, which provides measures of visual scanning speed, sequencing ability, and response set flexibility, Ms. Peck's scores were normal. On the Wisconsin Card Sorting Test, which provides a measure of visual abstraction and problem solving using a trial and error learning procedure, relative to age and education peers, Ms. Peck's scores are all average. She completed six out of six categories, requiring only 12 trials to complete the first category, and with only one failure to maintain response set. Various tests were administered from the Delis-Kaplan Executive Function System, as follows. On the Verbal Fluency Test, Ms. Peck displays low productivity on the letter fluency and category fluency trials, but high average productivity and accuracy on the category switching trial. On the Design Fluency Test, Ms. Peck displays low average to average productivity across the three trials, with average performance on the switching trial, and average design accuracy. On the 20 Questions Test, Ms. Peck's overall score is high average. On the Tower Test, which provides a measure ofvisuospatial planning and problem solving, Ms. Peck's overall score is upper average, with normal performance efficiency and normal move accuracy. On the Proverbs Test, Ms. Peck's overall score is average, with a normal abstraction level. To examine language function, Ms. Peck was administered the Aphasia Screening Exam, on which she demonstrates intact naming, spelling, reading, writing, repetition, articulation, comprehension, and computational ability. Her drawing productions are all normal, with no dyspraxic features. Results on the motor exam are as follows. Ms. Peck is right hand, right eye, and right foot dominant. She shows normal right-left orientation. Motor speed is mildly impaired and appropriately lateralized. Motor strength is in the borderline range and appropriately lateralized. Performance on the Grooved Pegboard Test, which provides a measure of speeded fine motor dexterity and coordination, is high average, and bilaterally equal. Alternating movements were performed well. Luria was performed well. On the Sensory Perceptual Exam, Ms. Peck displays perfect responding in the tactile, auditory, and visual modalities. Performance on the finger agnosia and dysgraphesthesia exams is perfect. Visual fields appear full to simple confrontation stimulation. To examine attention and concentration, Ms. Peck was administered the Ruff2 and 7 Selective Attention Test, which provides a measure of selective attention and processing speed using a visual cancellation procedure under low and high distraction conditions. Under the low distraction condition, her speed score is at the 8th percentile and her accuracy is at the 19th percentile. Under the more challenging high distraction condition, her speed RR 001036 increases to the 12th percentile and her accuracy improves to the 70th percentile. This increase in accuracy is, statistically, a highly significant change.To examine level oftask engagement, Ms. Peck was administered the Medical Symptom Validity Test, which resulted in passing scores on all of the effort trials. Ms. Peck completed the Beck Depression Inventory-Second Edition, obtaining a total score that falls in the severely depressed range. Ms. Peck completed the Personality Assessment Inventory, producing a valid profile. Individuals with this type of profile are reporting an unusually high number of physical symptoms and health concerns. Ms. Peck is reporting a relatively high level of depressive symptomatology, accompanied by a high level of anxiety and tension. The profile suggests an unusually harsh negative self evaluation, and suggests that typically, she tends to be veryself-critical, pessimistic, and self-blaming. Impression: This is an abnormal set of neuropsychological test results because of very impaired performance across most of the memory testing, primarily reflecting inefficient acquisition and retrieval, but with sometimes perfect recovery of information on recognition testing, and also with completely normal performance on a complex visual memory test. On a number of tests include including fluency and selective attention measures, Ms. Peck's performances are significantly better on the more difficult trials. The depression inventory score falls in the severely depressed range, and the personality inventory profile indicates high levels of depression, along with anxiety and numerous somatic complaints and concerns, and a pattern that suggests significant somatization tendencies. Diagnostically, the results are consistent with considerable psychological distress and dysfunction, sleep dysfunction, and reduced cognitive functioning, as a result of these factors. The test results are not diagnostic for any type of specific neurological condition including age- related dementia, such as Alzheimer's disease. From a treatment standpoint, continued psychiatric monitoring would be appropriate. Further efforts may be necessary to address this patient's sleep problems to achieve adequate restorative sleep. Individual psychotherapy is strongly recommended, exploring the possibility that there is a substantial psychological contribution to her numerous health problems and concerns about her cognitive decline. These results have been reviewed in detail with Ms. Peck. WAD:ds RR 001037

PETITIONER’S EXHIBIT NO. 22 Robert K. Burlingame, M.D.P.C. General Psychiatry Progress Notes 12/14/01-4/19/02 RR 001044

12/14/01

RR001050

4/30/2001 She has not been doing well, Serzone has been making her drowsy, lethargic. Severe Migraine after visual auras, flashes, as migraine clears she develops the fatigue and overall pain, mostly extremities, is virtually non functional for weeks. 001057 4/12/01-Depression and Anxiety. 001058 3/23/01 depression, anxiety, lethargy 001059 3/1/01 depression, 001060 2/15/01 anxiety, depression 001061 1/25/01 ANDREW V. CHARLES M.D. ·~ Patient Initial Evaluation- migranes 001066 1/25/01 Nancy Peck self reported signs and symptoms **Parerethisis RT side head to toes **Migraines *Rt eye pain **Weakness **Aches and pains joints and muscles. Especially hand and arm, shoulders feet, legs, hips, back) **Back pain {Trapezoids, cervical, mid thoracic, and lower lumber.) **Foot Pain **Memory changes **Speech changes - trouble finding a word or saying wrong word Chest pain occasionally left lower **Teeth sensitivity, teeth and jaw pains **Scalp sensitivity Weight gain **Depression **Anxiety **Clumsiness (sometimes tipping to the right side, bumping into things, tripping over right foot, and dropping things) **Fatigue after minimal exertion Increased facial hair 001073 **Increased sleeping. Current medications cause insomnia occasionally. Anal fissure which doesn't seem to heal Hemorrhoids * Stress Urinary incontinence intermittently- not currently *Visual Changes- not currently * Heavy eyelids? * * Upper right neck pain, stiffuess, and increased pressure. ** Increased breathing and heart rate after minimal exertion **Frequent day dreaming ("zoning out") Subject: Highlight Date: 11/29/14, 4:27:02 PM Updated 2/02 Occur during an episode Worsen during an episode RR 001074 EXHIBIT D