                                                                     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

                            NANCY MARIE PECK,
                                Appellant,

                                         V.

                             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<l.. r--~t<
Experienced Side effects from your medications such
as nausea, vomiting, constipation, Itching, mental
cloudiness, sweating, fatigue, drowsiness
RR-000113
Date: 09/16/2011
Pl~le ~· wo · that describe your pain: ~· ~ · ConsU. _ . . Numbing. ~ ~
Sharp Stabbing Tinglihg ~ramp!~ ~- ~ging
Vomiting
Diarrhea
Fever
Joint pain
Memory changes
RR-000114

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<a:.r spine as w~ll as both legs. She alsc has parn
l n her neck and arms. We discussed how the spinal cor-d stimulator cculd
potentially treat the l ower thoracic lumbar and leg pain. Beyor.d ::hat, it is
difficult to predict what t11e st.i rnulator will cover in terms of pain
RR-000179

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
