In Re Briggs A WLS Employee 12-22560

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Supreme Court No. 61 057
INTHE MATTER OF DISCIPLINE OF
JEFFERY A. BRIGGS, ESQ.
BAR NO. 5884
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LEMONS, GRI
& EISENBE
6005 PLUMil
SUITE 300
RENO, NV 8951 9
(775) 786-6868
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J U L 1 7 2 0 1 2
TRACIE K. LINDEMAN
CLERK OF SUPREME COURT
DEPUTY CLERK
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IN THE SU PREME COU RT OF THE STATE OF NEVADA
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MOTION TO REMAND FOR HEARING
JefferyA. Briggs herebymoves this court for anorder remandingthis
matter to State Bar of Nevadafor afull hearing. He was unable to participate,
physicallyor mentallyduringthe time leadingup to the scheduledformal
hearingheldApril 1 8, 201 2. The bar proceededinhis absence. Mr. Briggs is
informedthat the State Bar does not oppose this motion.
Mr. Briggs is chargedwithunauthorizedpractice of lawfor acceptinga
retainer near the endof afive-monthperiodof inactive status imposedbecause
he didnot complywithNevada's continuingeducationrequirement for lawyers.
Recordof DisciplinaryProceedings, Pleadings andTranscript of Hearing("RDP" 2,
VO). He was returnedto active status inDecember, 201 0. (Id.). The panel has
recommendedasuspensionof Mr. Briggs for six months andadaybasedinpart
uponhis failure to participate inthe hearing. RDP 24. The panel also refusedto
accept Mr. Briggs' unsupportedstatements set forthinhis Answer regardinghis
disabilityfactors. (Id.).
A. U nderlying Grievance and Complaint
JefferyA. Briggs was the subject of a bar grievance filedonMarch29,
201 1 . The grievance informedthe bar that DavidThompsonhadbeeninvolved
inongoinglitigationinYeringtonandsought to hire Briggs. Thompsonretained
Briggs November 3, 201 0 andBriggs substitutedinas counsel inthe case on
Nov time of the initial contact andhis entryinto the case,
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LEMONS, GRI
& E1 SENBE
6005 Pump
SUITE 300
RENO, NV 8951 9
(775) 786-6868
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Briggs was onsuspensionfor failuretocomplywithhis mandatoryCLE
requirements. (RDP 2). HissuspensionbeganonJuly21 , 201 0. Hewasreturned
toactivestatus onDecember 9, 201 0, shortlyafter his retentionbyThompson
(Id.).
Thompsonsubmittedhis grievanceonMarch29, 201 1 (Id.). Briggs
respondedwithaletter of explanation, admittingandapologizingfor hiserror in
takingafeewhilesuspended. (RDP 75). His explanationinvolvedaveryshort
versionof his ongoingmedical andpsychological troubles, thedetails of which
thedisciplinarypanel never learned. (Id.). Thereafter, as his medical condition,
financial positionandpersonal relationshipsdeteriorated, Jeff Briggswassimply
unabletoput together andpresent his defensetothebar. (Briggs Declaration,
Exhibit 1). Hedidnot fileanAnswer totheFormal Complaint anddidnot
participateinhis owndisciplinaryhearinginApril, despitereceivingnotices
thereof.
What thepanel andbar counsel didn't know, becauseMr. Briggs didnot
inform them, is that duringthelast twoyears hehas beenseriouslyimpairedin
his abilitytofunctionintheordinarycourseof his life. This impairment arose
from his steadyuseof painmedications arisingfrom aserious spinal condition
that manifesteditself in2000. (Exh. 1 , p.1 ). His conditionwas soserious that he
underwent atwo-level surgical fusionof his lower vertebraein2001 , whenhe
was32 yearsold. (Id., p.2). Thoughthesurgerysuccessfullystabilizedhisspine,
hehas ever sincecontinuedtoexperiencechronicandexcruciatingpain,
radiatingintohislegs. (Medical Recordsof AndrewC. Wesley, M.D.,
Exhibit 2). 1 -
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'See, e.g., HistoryandPhysical Report No. 8, 6/21 /201 1 : "Thepatient statesthat
thepainhas sometimes made[him] tenseor anxious, made[him] depressedor
discouragedandmade[him] irritableandupset.... Thepainofteninterferes
withgoingtowork, sleep andappetite.... depression/anxietyarestill ongoing
issuesheisworkingon".
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LEMONS, GRI
8 z EISENBE
6005 PLUMP
SUITE 300
RENO, NV 8951 9
(775) 786-6868
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His health problems affected his work and his personal life. During the relevant
times applicable to this grievance/bar complaint, he was also going through a
divorce and separation fromhis children. (See, RDP 75). He was also unable to
meet his financial obligations, including compliance with his state bar CLE
requirement. (Exh. 1 , p.1 ).
During the same time, his lawpractice had virtually disappeared. (Id.) He
lost his medical insurance coverage during a time in which he desperately
needed health insurance. (Id., p.2). He ultimately closed his one-roomrented
office, to do what work he had out of his home. (Id.) These and other factors
caused his pain specialist, AndrewWeseley, M.D., to conclude that Briggs was
experiencing "uncontrolled pain" even with recent epidural injections, an
implanted electric spinal stimulator and narcotic medications.
2 His marriage and
family therapist believes his emotional status during the recent past was
"moderately impairing his every day functioning."3 For these reasons, Mr. Briggs
did not participate in the disciplinary process after his initial letter of explanation
to the bar. When the Formal Hearing Panel met, it was without the input and
participation of Mr. Briggs. RPD, p. 1 9.
Mr. Briggs was referred to the undersigned counsel in late May by his
employer, Paul Elcano, Executive Director of Washoe Legal Services. When
Briggs learned that he was about to be suspended, he disclosed to his boss, Mr.
Elcano, that he would soon be unable to practice as a child advocate in indigent
cases for WLS. Mr. Elcano has since been instrumental in supporting Mr. Briggs
and trying to salvage Mr. Briggs' career. (See, Elcano Declaration,
Exhibit 4).
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2 See, Note of Dr. Weseley, March 20, 201 2, Exhibit 2, p. Briggs 1 3).
3 See, letter fromKathleen Milbeck, M.A., M.F.T. dated June 28, 201 2,
Exhibit 3.
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LEMONS, GRI
& EISENBE
6005 PLUMP
SUITE 300
RENO, NV 89519
(775) 786-6868
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Indeed, Mr. Elcano indicates that Mr. Briggs has become a very valuable
lawyer in a difficult, hard to fill position as a male child advocate. He has been
effective in that position, and positive comments fromjudicial officers in the
Washoe Family Court. (Id.).
Mr. Briggs contacted and retained the undersigned counsel on May 31,
2012. The next day Mr. Grundy conferred with Bar Counsel David Clark. At that
time, the panel's Decision had been prepared and signed, but not yet
transmitted to the court. The discussion between counsel and Mr. Clark resulted
in an understanding that Mr. Briggs may submit a motion for reconsideration to
the bar and request a newhearing. However, shortly thereafter, through no
fault of anyone at the Bar office, the panel Decision was filed with this court. We
have had further discussions with bar counsel and have been advised that bar
counsel will not oppose this motion. (See, Declaration of David R. Grundy,
Exhibit 5).
B. Evidence to be offered at rehearing would be beneficial to the Bar
and to this Court
If given the opportunity to have this matter heard by a new, or even the
original, Disciplinary Panel, this court would have the benefit and record of a full
hearing. Respondent fully understands that he alone has placed himself in the
position of peril in which he finds himself. However, this court has previously
recognized the benefit in discipline cases of having a fact-finding hearing and a
recommendation of its disciplinary committee. SCR 105; (a panel's findings are
not binding upon the court, but they are "persuasive." In Re Discipline of Droz,
123 Nev. 163, 168, 160 P.3d 881, 884 (2007). Of course, this court may and has
remanded cases to the state bar when it determines that "additional evidentiary
proceedings before the hearing panel would assist the court in resolving issues
on appeal." In Re Discipline of Drakulich, 111 Nev. 1556, 1563, 908 P.2d 709, 713
(1995).
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LEMONS, GRI
& EISENBE
6005 PLUMP
SUITE 300
RENO, NV 8951 9
(775) 786-6868
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Mr. Briggswasadmittedtothebar in1 996. Prior tothepending
Compliant hehadnoprior public discipline. RDP 20. Duetoacombinationof
eventsincludingafailingmarriage, continuingchronic painresultingfroma
spinal injury in1 988, andhisinability tomaintainanactivepracticeandsupport
himself andhisfamily, Mr. Briggswasunabletofulfill hisContinuingLegal
Educationobligations. (Exh. 1 , p.2). Moreimportantly, thesesamepressures
weredevelopingintoaseriousmedical andpsychological predicament forMr.
Briggsthat imposedimmensepressureuponhim, resultingintheadmitted
errorsof judgment of whichhehasbeencharged. (Id.).
Inorder tounderstandtheinterplay betweentheeventssurroundinghis
CLE inactivestatusandhishealthandpersonal problems, wehaveprepareda
Timelinewhichisconsistent withtheevidencecontainedwithintheexhibitsto
thisMotionandtherecordbeforethecourt. That TimelineisattachedasExhibit
In201 0, Mr. Briggs' lawpracticehaddeclinedsoastobenearly non-
existent. Hehadleasedasmall, one-roomofficeat 200 SouthVirginiainReno.
Hehadnoemployeesandfewclients. Hisleaseranout inthesummerof 201 1
andhegaveupthisofficetooperateout of hishome, until hebecameemployed
last Novemberat WashoeLegal Services. (Id.).
In201 0, Mr. Briggs' 21 -year marriagewasfailingaswell. After
considerablestrife, Mr. Briggsmovedout of thefamily homeinDecember, 201 0.
Briggsbeganaseriesof therapy sessionswithaMarriageandFamily Counselor,
whomhecontinuedtoseesporadically until April of thisyear. Hehastwoboys,
aged1 8 and1 3 withwhomhewasvery close. His1 8 year-oldwasat Texas
ChristianUniversity whohadtowithdrawfromschool becauseof thelack of
fundsfor tuitionandexpenses. Mr. Briggsmovedout of hisfamily homeand
intoanapartment inDecember, 201 0. (Exh. 1, p.2). Thecouple'sdivorcebecame
final inApril, 201 1 . Custody disputescontinue. (Id.). Theseeventsframedthe
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LEMONS, GRI
& EISENBE
6005 PLUMP
SUITE 300
RENO, NV 8951 9
(775) 786-6868
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circumstances during which Mr. Thompson contacted Briggs and offered hima
fee retainer.
In 201 1 , leading up to the bar hearing, Mr. Briggs was dealing with
worsening symptoms related to his prior back injury. By the end of 201 1 , the
stimulator installed in 2007 had effectively ceased working. (Exh. 6). Mr. Briggs
tried desperately to avoid narcotic drugs throughout this lengthy period. For the
most part, he has been successful, though when the spinal stimulator stopped
providing sufficient pain relief, he did accept prescription pain relief fromhis
chronic pain specialist for a period in 201 1 . (Id.). Indeed, between the date of
the Notice of Formal Hearing and the hearing itself was the time during which
Dr. Weseley was reporting that Mr. Briggs' pain was "uncontrolled." (Id.).
However, Dr. Weseley more recently reports that Jeff stopped taking
oxycodone all together in May of this year and wanted to remain off these
drugs. On June 5, 201 2, the doctor reported that Jeff wants to be off all
controlled substances; will discharge him; only option left is infusion device;
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he's in fair amount of pain now. (Exhibit 2, p. Briggs 2; Dr. Weseley's records for
June 5, 201 2).
We have had some difficulty getting records fromone of the doctors,
which we would certainly have by the time of any newformal hearing.
C. Recent Developments
Respondent Jeffery A. Briggs has recovered somewhat fromthe pressures
he was under in 201 1 and early this year. As indicated, he is taking positive steps
to wean himself off the heavy medications that have challenged himin the past.
His relations with his family have also improved.
One of the most significant events in Mr. Briggs' recent past occurred last
October, when he was hired to become a child advocate for VVashoe Legal
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4 An infusion device would provide the patient with a continuous dosage of medication
automaticallyat a predetermined rate.
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Services. Between October and May, 201 2, Mr. Briggs has made a very positive
impression upon Mr. Elcano, and apparently some of the judges in Family Court.
Mr. Elcano has provided a declaration in support of Mr. Briggs.
(Exhibit 4). He is
quite anxious to participate in any further bar proceedings in support of Mr.
Briggs. He also is confident that Mr. Briggs has become an important part of the
services provided by Washoe Legal Services to indigent clients, mostly minors
with troubles of their own. Along the way, this newlegal position may be helping
Jeff Briggs as well.
On behalf of Mr. Briggs, we would ask this court to remand so that a full
evidentiary hearing be held and that substantive recommendations be made to
this court as to what, if any discipline should be imposed. We are currently in the
process of gathering additional medical records to present to this court or a new
panel. Mr. Briggs is also in the process of withdrawing money fromhis 401 k plan
with which to make restitution to Mr. Thompson and pay the expenses he owes
for the first hearing.
However, at this time, Jeffery Briggs requests that this court remand this
matter to the State Bar to conduct a newhearing and enter newFindings of
Fact, Conclusions of Lawand Decision in this matter. This court would thereafter
have much more substantive information for its reviewand ultimate decision.
On his behalf, I thank the State Bar in not opposing this Motion and this court for
being willing to consider this request.
DATEDthis 1 6 day of Jul
BY:
avid R. Grundy
LEMONS, GRUNDY & EISEN BERG
6005 Plumas Street, Suite 300
Reno, NV 8951 9
(775) 786-6868
LEMONS, GRI
& EISENBE
6005PLUMP
SUITE300
RENO, NV8951 9
(775) 786-6868
28
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CERTIFICATE OF MAILING
Pursuant to FRAP 5(b), I certify that I am an employee of Lemons, Grundy
& Eisenberg and that on July 17, 2012, I deposited in the United States Mail, with
postage fully prepaid, a true and correct copy of the within MOTION TO
REMAND FOR HEARING addressed to the following:
Patrick King, Esq.
Assistant Bar Counsel
State Bar of Nevada
9456 Double R Blvd., Suite B
Reno, NV 89521
DATED this 17t h day of July, 2012.
t acy Keliison
LEMONS, GR1
& EISENBE
6005 PLUMP
SUITE 300
RENO, NV 89519
(775) 786-6868
28
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# OF PAGES EXHIBIT # DESCRIPTION
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EXHIBIT LIST
1 Declaration of Jeffrey Briggs
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2 Medical records of Andrew Weseley
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3 Letter from Kathleen Mil - beck, M.A., M.F.T. dated June 28, 1
2012
4 Dec aration o Paul Elcano
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5 Dec aration o David Grundy
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6 Timeline
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LEMONS, GRI
& EISENBE
6005 PLUMP
SUITE 300
RENO, NV 89519
(775) 786-6868
28

EXHIBIT 1
EXHIBIT 1
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LEMONS, GRUNDY 28
& EISENBERG
6005 PLUMAS ST.
THIRD FLOOR
RENO, NV 89519
(775) 786-6868
DECLARATION OF JEFFREY BRIGGS
I, JEFFREY BRIGGS, hereby declare under penalty of perjury that the following
statements are true to the best of my knowledge and belief.
1. I am Respondent herein and tender this Declaration in support of my Motion to
Remand for further proceedings before the State Bar of Nevada.
2. During the last two years I have been impaired in my ability to function in the
ordinary course of my life. This impairment arose from my steady use of pain medications
arising from a serious spinal condition that manifested itself in the mid 1990's.
3. My condition was so serious that I underwent a two-level surgical fusion of my
lower vertebrae in 2001, when I was 32 years old. Though the surgery successfully stabilized
my spine, I have ever since continued to experience varying degrees of chronic and
excruciating pain, radiating into my legs.
4. In 2010 and 2011 I was unable to meet some of my financial obligations,
including compliance with my state bar CLE requirement. During that time, my construction
lawpractice had virtually disappeared. I lost my medical insurance coverage during a time in
which I desperately needed health insurance. Dr. Weseley even continued to treat me
through his Physician's Assistant as an accommodation to my financial needs. I ultimately
closed my one-room rented office, to do what work I had out of my home.
5. When I learned that I was about to be suspended, I disclosed these events to
my boss, Paul Elcano. He expressed concern that I would soon be unable to practice as a child
advocate in dependency cases for WLS. Mr. Elcano has since been instrumental in supporting
me and trying to help me salvage my career.
6. When David Thompson contacted me in November, 2010 I was attempting to
complete my CLE requirement and expected that my status would be returned to active
forthwith. I expected to be able to complete my representation of him as an active lawyer.
7. When I learned that I was about to be suspended, I disclosed to my boss, Mr.
Elcano, that I would soon be unable to practice as a child advocate in dependency cases for
WLS.
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LEMONS, GRUNDY
& EISENBERG
6005 PLUMAS ST.
THIRD FLOOR
RENO, NV 89519
(775) 786-6868
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8. I was admitted to the bar in 1996. Prior to the pending Compliant I have had no
prior discipline of any kind.
9. My inability to fulfill my CLE requirements were due to a combination of events
including a failing marriage, continuing chronic pain resulting from a spinal injury in 1988, and
my inability to maintain an active practice and support myself and my family. These same
pressures were developing into a serious medical and psychological predicament for me that
imposed immense pressure upon me, resulting in several errors of judgment with respect to
my agreement to represent Mr. Thompson. He came to me and asked me to help him. When I
agreed, I knew that I was going to be able to complete my coursework and would be
reinstated immediately thereafter. Though I am not certain, I believe I used some of the fees
that Mr. Thompson paid me to pay the fine to become active again.
10. In 2010, my law practice had declined so as to be nearly non-existent. I had
leased a small, one-room office at 200 South Virginia in Reno. I had no employees and few
clients. My lease ran out in the fall of 2011 and I gave up this office to operate out of my
home, until he became employed last November at Washoe Legal Services.
11. In 2010, my 21-year marriage was failing as well. After considerable strife, I
moved out of the family home in December, 2010. I immediately began a series of therapy
sessions with a Marriage and Family Counselor, whom I continued to see sporadically until
April of this year. I have two boys, aged 19 and 13 with whom I am very close. My then 18
year-old was at Texas Christian University when he had to withdraw from school because of
the lack of funds for tuition and expenses. My divorce became final in April, 2011. Custody
disputes continue.
12. In addition, I was dealing with continuing problems with my lower back. In
1988 I suffered a severe accident in which two lumbar vertebrae were crushed in a work-
related accident. I received a permanent disability rating in the early 1990's. After years of
conservative treatment, I re-injured my back in 2000 and underwent spinal surgery with
fusions at two levels in 2001. My symptoms persisted and have worsened in the years since. In
2007, my chronic pain specialist prescribed a spinal stimulator device which was installed
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JEFFREY BRIG
surgically. This device remained in place until May, 2012, when it was removed. I tried
desperately to avoid narcotic drugs throughout this lengthy period. For the most part, I was
successful, though when the spinal stimulator stopped providing sufficient pain relief, I did
accept prescription pain relief for a period in 2011.
13.
I became employed at Washoe Legal Services in October, 2011. In that position
I have enjoyed the work assigned and have become very dedicated to the children I represent
who are in difficult circumstances. I believe that I afford good services to this group of very
under-represented clients. I believe that my supervisor, Paul Elcano, is supportive of my
efforts to continue my ability to serve in my current capacity.
The statements contained in this Declaration are made under penalty of perjury, and
are true and correct, except as to those matters made upon information and belief, which I
believe are true and correct.
DATED: This 16t h day of July, 2012.
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LEMONS, GRUNDY
& EISENBERG
6005 PLUMAS Si.
THIRDFLOOR
RENO, NV 89519
(775) 786-6868
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EXHIBIT 2
EXHIBIT 2
Z79 5. 74filizio-t e 4 J 74 1/1.
Rod, IVY 55s- o/
, aye ic 4 - 1,t ri;2_ Purpose of
Addrdss
Entire Medical Record
History & Physical
Operative/Procedure Reports
Lab/X- Ray/EKG/EMG/Tests
onsultation
Date
Date
vi
Signature of Paiient
Signature of Parent/Legal Guardian/Representative
Relationship to Patient
E,6a) Date
Signature of Witness
AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION
FROM NEVADA PAIN & SPINE SPECIALISTS
Patient Name' - - </CFF
32(66S
/
Date of Birth 01/2 /70
Information to be released from: Nevada Pain & Spine Specialists (must have signed transfer of records
from Sierra Anesthesia/Sierra Pain Consultants- if records requested are prior to November 2006.)
Address: 605 Sierra Rose Drive,Suite -Fign
to:
Name/Aeency
Information to,be'releas
oe/6,6's
BACTES
J U NO 7 7 01 2
COPIED
INITIAL each item of information to be released.
Psychiatric/Psychological/Mental Health Records
Drug and/or Alcohol Abuse Records
Billing
Other
AIDS- related information (full signature required)
This aut horizat ion is e ffe ct ive imme diat e ly and is subje ct t o re vocat ion in writ ing at any t ime , e xce pt t o t he
e xt e nt t hat act ion has alre ady be e n t oke n in re liance t he re on. O t he rwise , t his Aut horizat ion e xpire s nine t y (90)
days from t he dat e of signing.
I furt he r re le ase my at t e nding provide r and e mploye e s of Ne vada Pain & Spine Spe cialist s from any liabilit y
arising from t he re le ase of inforraatr:gat o.t he pe rson/age ncy de signat e d above .
/
Briggs- 1
History & Physical Report #24
Jeff Briggs
6/5/2012 11:00 AM
Location: Nevada Pain & Spine Specialists
Patient #: 15206
DOB: 1/21/1970
Married/ Language: Un defin ed / Race: Undefined
Male
History of Present Ilnem (Andrew C West*, MD; 6/5(2 012 11:26 AM)
The patient is a 42 year old malewho is here for follow up. Patient is here for a wound check Patient's pan is located in the lower back.
and in beft leg(s). The patient describes the pain as sharp, stabbing, dull, puling and shooting. Pain scores include a current pain level of 7/10
and this is wthout medicabons. The patient describes symptoms as worsening. Patient recently had (a/n) 5(5 extrmtion (5/14/12). Recent
evaluations inckide (a/n) visit to the emergency room (NNMC-Opnbalta wkhdraw and spinal fluid). Current treatment Includes home exercises
(yoga). Sleep: averages about 5 hrs of sleep per night. Medication concerns: none at this bme. Reference patient's intake form for todaYs
encountif under manned documents. Note for '0V Follow up':
The patient Is here fa a wound check. When I last saw him, he had developed sime swelling around his spinal incision site, possibly secondary
to increased activity shcrtly after surgery. In any event, I examned hirn today everything looks fine. There is no swelling. The incision is well-
healed.
At this point, Jeff wants to be off all controlled substances. He Is in a fair amount of pain, but wants to let things settle in his personal life,
before he reconside rs further treatments. Honestly, the next step would be to trial/consider 1005 therapy. F-or now well discharge him from
regular visits, but he knows he can call us for foRowup at any bme.
Problem List/Past Medical (Jayme Dwicee, MA; 6/5(2012 11:08 AM)
Last UDS. 11/29/11
Contracts Updated. 9/20/11
Lest DEA. 7114/11
DISORDER, ADJUSTMENT 1N/DEPRESSED MOOD (309,0)
DEPENDENCE, OPIOID, UNSPECIFIED (304.00)
LUMBAR POSTLAMINECTOMY(722.83)
LUMBAR RADICULITIS (722.2). history cf fusion from 14-51
Last seen by NPSS M.D.. Dr Wesehl 6/21/11
Medication History (Jayme Durkee, MA; 6/5/2012 11:10 AM)
Tylenol Arthnlis Paln (650MG Tablet ER 2 Oral as needed) Active. (Not wrkten by NPSS)
Naprosyn (250 MG Tablet 2 Oral as needed) Active. (Not written by NPSS)
Advil (200MG Tablet 4 Oral as needed) Active. (Not wrtten by NP5S)
Alergies (Jayrne Durkee, Mk, 6/5P012 11:08 AM)
No Known Allergies
Social History ()ayme Durkee, MA; 6/5/201211:08 AM)
Most recent prirnary occupation. Professional specialty. ATTORNEY
No akohol use
Marital status. Married.
Non smoker/ no tobacco use
Current work status. Full-time.
Highest Education Level Attained. JURIS DOCTOR
Children
Famiy History (Jayme Durkee, MA; 6/5/2012 11:08 AM)
No pertinent family history
Past Surgical History (Jayme Durkee, MA; 6/5(2012 11:08 NI)
Spinal Fusion. 2001 14-5 and 15-S1 posterior fusion with cage
2007 SPINAL CORD ST1M.
Epidural Injection Lumbar). 9/15/2010, 1/11/2010, AND 10/1512008.
Epidural Iniedion Lumbar). Date: 1/30/2012, Inpatient, Left, L5-51.
EXPLANTATION 0 SPINAL ELECTRODE ARRAY. 05/14/2012
Diagnostic Studies History ()ayrne Durkee, MA; 615/2012 11:08 AM)
CB C (Complete Blood Count) w/diffe rentlal. 8/13P007 AND 8/7/2007.
Other Problems (Jayme Durkee, MA; 6/512012 11:08 AM)
depression
Review of Systems (Jayme Durkee, MA; 6/5/2012 11:08 AM)
General: Present- Weirght Loss. Not Present- Fatioue and Weight Gan.
06/06/2012 03:38 pin Jeff Briggs DOB 01/2111970
Page 4/52
Briggs-2
Skin: Present- Excessive Sweating. Not Present- Rash, Pigmentation, Change in Hair Growth or Loss, Nail Changes, Skin Color Changes,
Bruising, Hair Growth and Hair Loss.
HEENT: Not Present- Visual Loss, Hearing Loss, Glaucoma, Nose Bleed and Hoarseness.
Respiratory: Not Present- Bloody sputum, Cough,Whee7ing and Shortness of Breath.
Cardiovascular: Not Present- Chest Pain, Fainting, Swelling cf Extremities and Irregular Heart Beat
Gastrointestinal: Not Present- Abd om hal Pain, Constipation, Nausea, Vomiting and Incontinence of Stool.
Musculoskeletal: Prrsent- Musde Weakness, Back Pain and Physical Disability. Not Present- Joint Pain, Fractures, Muscle Pain, Muscle
Cramps and bint Swelf
Neurologicak Present-Weakness. Not Present- Trouble walking, Balance Problems and Headaches.
Psychiatric: Present- Trouble Falling Asleep.
Endocrine: Present- Cold Intolerance and Heat Intolerance.
Vitals (Jayme Durkee, MA; 6/5/201211:04 AM)
D5 012 11:91 AM
Waiht: 175 b Height 75 in
We t was reported by pa bent
Ile'ght was moorted by patient
Body Surface Area: 2.05 m3 Body 11 ass Index: 21.87 kg/m2
Pain Level: 7/10
Tempo.: 98.4 F
BP: 142/84 (Sitting , Left Arm, Standard)
NO ASSISTIVE DEVICE
Asq.ssrnent Or Plan (Andrew C WEsely, MD; 6/5/2012 12:00 PM)
DEPENDENCE, OPIOID. UNSPECIFIED (3 04.00)
Current Plans
I Follow up with Dr. Wesely
I FOLLOW-UP AS NEEDED
DISORDER. ADJUSTMENT W/DEPRESSED MOOD (3 09.0)
LUMBAR POSTLAMINECTOMY(722.83 )
WMBAR RADICUUT1S (722.2)
Story: history of fusion from L4-51
Signed electronicany by Andrew C WeseY, MD (6/5/2012 12:00 PM)
Page 5/52
06/06/2012 03:30 pm Jeff Briggs DOB 01/21/1920
Briggs-3
Jeff Briggs
5/22/2012 8:08 AM
Location: Nevada Pan &Spine Spec ialists
Patient #: 15206
DOB: 1/2111970
Married / Language: Undefined / Race: Undefined
Male
History of Present lines (Andrew C Wesely, MD; 5(22/20129:04 AM)
The patient is a42 year old malewho is here for foiow up. Patient is hee for post procedure. Patient's pain is located in the lower back
The patient describes the pan as aching. Pain gores include a current pain level of 0/10 and this is without medications. The patient describes
symptoms as unchanged. Patent recently had (a/n) SCS explant (5(14112). The pain increased after the procedure. Patient has had no recent
evaluations.. Sleep: ave-ages about 2-3 firs of sleep per night. Medication concerns: none at this tine. Reference patient's Intake form for
today's encounter under scanned documents. Note for 'OY Folow up':
3eif is here for postop wound check_ 1 removed his staples. His incision tines lock g cod. There is no signs of infection. lie went on a camping
trip with his son yesterday, and was sleeping on the ground and on a cot. lie tells me over the last 12 hours he developed sweling under the
sweat Incision int, whih 1 noticed today. 1 think this wit settle down with him using the abdominal binder I prescribed, and the minis his
activity unti folowup in 2 weeks.
On a separate note, lust stopped his oxycodone akogether. He is about 24-48 hours out, and is feeling a title bit of discomfort from withdrawal
symptoms. 1 offeed him some 'listen! to he him sleep. His goal at this point is to come off opioids altogether. He would like to trial the fat
few months completely Odd free and see how he does. We will hold off on pursuing ION therapy for now.
Problern List/Past Medical ()ayme Durkee, MA; 5(22/2012 8:11 AM)
DISORDER, ADJUSTMENT W/DEPRESSED HOOD (309.0)
LUMBAR POSTIAMINECTOMY(722.83)
DEPENDENCE, OPIOM, UNSPECIFIED (304.00)
LUMBAR RADICULITIS (722.2). history d fusion from14-51
Last seen by NPSS M.D.. Dr Wes* 6/21111
Last DEA. 7714/11
Last UDS. 11/29/11
Medication History ()ayme Durkee, MA; 5/22/2012 8:11 N4)
No Current Mediations.
Alergies(Jayme Durkee, MA; 5/22/2012 8:11 AM)
No Known Allergies
Socii History (Jayrne Durkee, MA; 5/22(2012 8:11 N4)
Non smoker ! no tobacco use
arital status. Married.
Children
Most recent primary occupation. Professional specialty. ATTORNEY
No akohol use
Famiy History (layme Durkee, MA; 5/22/20128:11 AM)
Past Surgical Hi skiry ()ayme Durkee, MA; 5/22/2012 8:11 AM)
Spinal Fusion. 200114-5 and 1S-S1 posterior fusion with cage
2007 SPINAL CORD ST114.
Epidural IlectionFilumbar). 9/15/2010, 1/11(2010, AND 10/15/2008.
Epidural In ection Lumbar). Date: 1/30/2012, Inpatient, Left, L5-51.
EXPLANTA ION 0 SPINA t. ELECTRODE ARRAY. 05/14/2012
Diagnostic Studks History Oayrne Durkee, MA; 5(22/2012 8:11 AM)
CBC (Complete Blood Count) w/differential. 8/13/2007 AND 8/7/2007.
Other Problems (Jayrne Durkee, MA;
5(22/20128:11
AM)
depression
Review of Systems (Jayme Durkee, MA; 5/22/2012 8:12 AM)
General: Present- Weight Loss, Medication Changes and Tiredness. Not Present- Fatigue and Wecht Gain.
Skin: Present- Excessive Sweating. Not Present- Rash, Pigmentation, Change In Hair Growth or Loss, Nail Changes, Skin Color Changes,
ruisine. Hair Growth and Hair loss.
Page 6152
06/06/2012 03:38 pm Jeff Briggs DOB 01121/1970
Briggs-4
Respiratory: Not Present- Bloody sputum, Cough, Wheezing and Shortness of Breath.
Cardiovascular: Not Present- Chest Pain, Fainting, Swelling cf Extremities and Irregular Heart Beat
Gastrointestinal: Present- Constipation. Not Present- Abdominal Pan, Nausea, Vomitino and Incon tinence of Stool.
Musculoskeletal: Present-Joint Pain and Musde Weakness. Not Present- Fractures, Muscle Pain, Muscle Cramps and Joint Swelling.
Neurologicat Not Present- Trouble walking, Balance Problems and Headaches.
Wats (Jayme Durkee, PA; 5122/2012 8:11 AM)
8:10 AM
Weight: eight 75
We9 t was reported by pa bent
Heght was reported by patient.
Body Surface Area: 2.05 ma Body Mass Index: 21,87 kg/ma
Pain Level: 0/10
Temp.: 98.5 F
NO ASSISTIVE DEVICES
Physical Exam (Andrew C Wesely, MD; 5/22/2012 8:48 AM)
The physical exam findings are as follows:
Note:1 removed the staples without dfficulty. Prepped the incision line with benzoin and appied Steri-Strips.
Assessment Et Plan (Andrew C Wisely, MD; 5/22/2012 9:27 AM)
WMBAR POSTLAM1NECTOMY(722.83)
Current Plans
I Vistard 25MG, 1-2 Capsule at bedtine, *20, 30 days starting 05/22/2012, Rd. xl. Active.
fa- sleep
I Follow up with Dr- Weselv
I Folow up In 1 month or as needed
I Post-txocedure follow up
Note: Followup in 2 weeks for wound check to make sure her swelling is going down.
Addendum Note (Andrew C Wesely, MD; 5/22(2012 9:30 AM)
Jeff wil fu in 2 weeks with Don M. for a wound check.
Signed electronically by Andrew C Wesely, MD (5/22/2012 9:28 AM)
Page 7/52
06/06/2012 03:38 pm left Briggs DOB 01/21/1
970
Briggs-5
Jeff Briggs
5/15/2012 10:19 AM
Location: Nevada Pain & Spine Spec bfists
Patent #: 15206
D013: 1/21/1970
Male
History of Present !loess (Judy Lopez, RN;
5/15/201211:14 AM)
The patient is a 42 year old malewho is here for folow up. Patient is he for one day post op (S(S removal). Patients pain is located in
the lower back Pain scores include a current pan level of 4/10 (post op pain.). Current treatment includes medication. Patient reports that stress
level is increased. Sleep: patent averages 6 hours pe night. MedkatIon concerns: none at this time. Reference patients Intake form for todaYs
encountEr under xannrsi documents.
Note: post op
Problem Lot/Past Medical (Bite Thornpson; 5/15/201210:20 AM)
Last seen by NPSS M.D.. Dr Wesel), 6/21/11
Last DIA. 7/14/11
LUMBAR POSTLAMINECTOMY(7 22.83)
DISORDER, ADJUSTMENT W/DEPRESSED MOOD (309.0)
LUMBAR RADICULITIS (722.2). history d fusion from L4-51
Last UDS. 11/29/11
Alerg les (Billie Thompson; 5/15/2012 10:20 AM)
No Known Allergies
Social History (Billie Thompson; 5/15/2012 10:20 AM)
No akohol use
Children
Marital status. Marred.
Non smoker / no tobacco use
Highest Education level Attained. AIMS DOCTOR
Famiy history (Bilie Thompson; 5/15/2012 10:20 AM)
Past Surgical History (Billie Thompson; 5/15/2012 10:20 AM)
Epidural Injection (Lumbar). Date: 1/30/2012, Inpatient, Left, 15-51.
Spinal Fusion. 200114-5 and l5-51 posterer fusion with cage
2007 SPINAL CORD STIM.
Epidural Injection (Lumbar). 9/15/2010, 1/11/2010, AND 10/15/2008.
Diagnostic Stud es History (Billie Thompson; 5/1512012 10:20 AM)
CB C (Complete Blood Count) w/differential. 8/13/2007 AND 8/7/2007.
Other Problems (Bile Thompson; 5/1512012 10:20 AM)
depression
Review of Systems (Billie Thompson; 5/15/2012 1026 AM)
General: Present- Medkation Changes (increased oxycodone to 10 mg pest op).
Gastrointestinak Present- Constipation.
Musculosketetab Present- Back Pain.
Vials(BilieThompscn; 5/15/2012 10:31 AM)
,511q912 1Q_28
W ht: 175 b Height 75 in
Wetr t was reported by patient
Heght vas reported by patient
Body Surface Area: 2_05 m2 Body Mass Index: 21.87 kg/m2
Pain Level; 8/10
Temp.: 98.4 F (Temporal) Pulse: 64 (Regular)
06/06/2012 03:38 pm leff Briggs DOB 01/21/1970
Page 9/52
Briggs-6
06/06/2012 03:38 pm Jeff Briggs 00801/21/1970
Page 9/52
Jeff Briggs
5/15/2012 10:19 AM
Patient #:15206
008: 1/21/1970
Male
History of Pres.ent Mess (Judy Lope:, RN; 5/15/2012 11:14 AM)
The patient is a 42 year old malewho is here for folow up. Patient is he for one day post op (SCS removal). Patients pain is located in
the lower back. Pain scores include a current pan level of 4/10 (post cc pain.). Current treatrnent includes medkation. Patient reports that stress
level is increased. Sleep: patent averages 6 hours per night Med katbn concerns: none at this time. Reference patients intake fonn for todaYs
encounter under scanned documents.
Note: post op
Problem List/Past Medical (Bile Thompson; 5/15/2012 10:20 AM)
Last seen by NPSS M.D.. Dr VVesely 6/21/11
Last DEA. 7/14/11
LUMBARPOSTLAMINECTOMY(7 22.83)
LUMBAR RAI)ICULITIS (722.2). history of fusion from L4-51
Last UDS. 11/29/11
Allergies (Billie Thompson; 5/15/2012 10:20 AM)
No Known Allergies
Social History (Balk Thompson; 5/15/2012 10:20 AM)
No alcohol use
Children
Famly history (Bile Thompson; 5/15/2012 10:20 AM)
Past Surgical Misibly (Hie Thompson; 5/15/2012 10:20 AM)
Epidural Infection (Lumbar)._ Date: 1/30/2012, Inpatient, left, 15-51.
Spinal Fusion. 200114-5 and 16-S1 posterior fusion with cage
Diagnostic Studies History (Bilie Thompson; 5/15/2012 10:20 AM)
CB C (Compk te Blood Count) w/diffe rential. 8/13/2007 AND 8/7/2007.
Other Problerns (Bile Thompson; 5/15/2012 10:20 AM)
depression
Review of Systems (Bilk Thompson; 5/15/2012 1016 AM)
General: Present-Medication Changes (increased oxycodone to 10 mg post op).
Gastrointestinak Present-Constipation.
Mus CUloskeletak Present- Back Pain.
Endoainer Present- Cold Intolerance and Heat Intolerance.
Vials (Bilie Thompscn; 5/15/2012 10:31 AM)
511312,012 10B
Weight: 175 b Height 75 in
Weght was reported by patient
He.ght was reported by patient
Body Surface Area: 2.05 m2 Body Mass Index: 21.87 kg/m1
Pain Level: 8/10
Temp.: 981.4F (Temporal) Pulse: 64 (Regular)
BP: 112/72 (Sftig , Left Arm, Standard)
Briggs-7
,ei..ve

Physical Exam ()udy Lopez, RN; 5/15/2012 11:14 AM)
Note: NURSING ASSESSMENT
General
Mental Status - Alert. General A ppearance - Cooperatrve and Well groomed. Orientation - Or ie nted X3. Build & Nutrition - We
nourished. Postu le - Norm al posture. Gait - Norms.
Integumentary
Problem ttl:
Location: Back - Note: mid back Assessment of Surgical Indsion - consistent wth normal anticipated wound healing. Incision - Dry,
Intact, edges well approximated, pain (minimal) and staples intact, no signs of dehiscence, no drainage premnt, no signs ci infection, no
redness, no swelling and no warmth to the touch.
Problem #2: Assessment of Surgical I ndsion - consistent wkh normal anticipated wound heaEng. Incision - Dry, Intact Edges well
approximated, pain (mhimal) and staples Intact, no signs of dehiscence, no drainage present, no signs of infection, no redness, no swelling and
no warmth to the touch.
Eye
Pupa - Bilateral - Normal. Put:Ilia ry Size -Bilateral - 3.0mm.
Assessment & Plan (Judy Lopez, RN; 5/15/2012 10:52 AM)
DISORDER. ADJUSTMENT W/DEPRESSED MOOD (309.01
LUMBAR POS1LAMINEC1OMY(722.83)
WMBAR RADICULITIS (722_2)
Story: history of fusion from 14-51
Impression: spiral cord stimulator in place with plans for exolantation.
Current Plans
I Fclow UD as scheduled with Dr. Wesely and CX Canof s med manaement on th 17th
I dont get dressIne wet, take antibiotics and f/u with Wesel,/
Signed electronically by Judy Lopez, RN (5/15/2012 11:15 AM)
Jeff Briggs 008 01(21/1970
Page 10/52
06/06/2012 03:38 pm
Jeff Briggs
5/7120124:37 PM
Location: Nevada Pan & Sone Specialists
Patient it: 15206
DOB: 1/21/1970
Male
History of Present I Iness (Carol B Hayne, PA-C; 5/712012 4:50 PM)
The patient is a 42 year old male who prents for a pre-op visit The procedure scheduled is spinal cord stimulator ex pla nt on 5114/12.
The surgeon for the procedure wit be Dr Wesely. Recent symptoms include nausea (from the pain in the mornings), while recent symptoms do
not Include fever, chits, fatigue, chest pain, cough, dyspnea. , dysuria, urinary frequency, vomiting, diarrhea, abdominal pain, easy bruising, lo.ver
extremty swelling or poor exercise tolerance (haven't exercised in a bng tme). Diagnostic tests include laboratory tests (Renown 2 weeksa go).
Note for NPSS Pre-Op. Feeling well Strnulator with inadequate analgesia and poor tolerance to stimulation. Fie is scheduled for
explantation in one week.
Feels well. No cough, cold or voiding symptoms.
Contemplating intrathecal pump for pain management in the future to alow him to be off of narootk therapy.
Problem List/Past Medical (Carol B Mayne, PA-C; 517/2012 452 PM)
Last UDS. 11(29/11
DISORDER, AD)USTMENT W/DEPRESSED MOOD (309.0)
LUMBAR RADICULITIS (722.2). history d fusion horn 14-51
Last seen by NPSS M.D.. Dr Wesey 6/21/11
Last DEA. 7/14/11
Medication History (Becky Gates; 5/712012 4:41 PM)
FentaNYL (75MCGIHR Patch 72HR 1 Transdermal every 72 hours, Taken starting 04/19/2012) Active. (every 72 hours)
Oxycodone-Acetaminophen (7.5-325MG Tablet 1 Oral every 4 to 6 hours, Taken starting 04/19/2012) Active
Cyrnballa (60MG Capsule DR Part 1 Oral daily, Taken starting 04/30/2012) Active. (for pain and depression)
Allergies (Becky Gates; 5/7/2012 4:41 PM)
No Known Allergies
Sod History (Beck/ Gates; 5/7/20124:41 PM)
Most recent primary occupation. Professbrial specalty. ATTORNEY
Children
No akohei use
Highest Education Level Attained. JUR1S DOCTOR
Family History (Becky Gates; 5/7/20174:41 PM)
Past Surgical History (Becky Gates; 5/7/2012 4:41 PM)
Epidural Injedlon (Lumbar) . 9/15/2010, 1/11/2010, AND 10/15/2008.
Spinal Fusion. 200114-5 and 15-51 posteror fusion with cage
Epidural Injection (Lumbar). Date: 1/30/2012, Inpatient, Left, 15-51.
Diagnostic Studies History (Becky Gates; 5/7/2 012 4:41 PM)
CBC (Complete Blood Count) w/differentlal. 8/13/2007 AND 8/7(2007.
Other Problems (Carol B Hayne s PA-C; 5/7/20124:52 PM)
depression
Review of Systems (Becky Gates; 5/7/2012 4:41 PM)
Generals Present- Tredness. Not Present- Fatigue, Weight Gain and Weight Loss.
Skin: Present-Excessive Sweating. Not Present- Rash, Pigmentation, Change in Hai Growth or Loss, Nail Changes, Skin Color Changes
Bruising Hair Growth and Hair loss.
HEEPITt' Not Present- Visual Loss, Hearing Loss, Glaucoma, Nose Bleed and Hoarseness.
Respiratory s Not Present- Bloody sputum, Cough, Wheezing and Shortness of Breath.
Cardiovascular: Not Present- Chest Pain, Fainting. Syvelina of Extremities and I rreoular Heart Beat
Page 11/52
06/06/2012 03:38 pm let/ Briggs DOB 01/21/1970
Briggs-9
Gastrointestinal: Present- Constipation and Nausea. Not Present- Abdominal Pain, Vomiting and Incontinence of Stool.
Musculoskeletal: Present- Musde Weakness and Back Pain. Not Present- Joint Pain, Fractures, Mu le Pan, Muscle Cramps and /mint
Swelhng.
Neurologkah Present- Numbness, Weakness and Ting brig. Not Present- Balance Problems and Headaches.
Psychiatric: Present- InabBity to Concentrate and 'Trouble Failing Asleep.
Encloainei Present- Cold Intolerance and Heat Intolerance.
Vials (Becky Gates; 5j7/2012 4:43 PM)
VeiriV:41`g Eli el gh t 75 h
Wag t was reported by pabent
Heght was reported by patient.
Body Surface Area: 2.05 m2 Body Mau index: 21.87 kg/ms
Pain Levels 8/10
Temp.: 98.2 F (Tympank) Pulse: 85 (Regular) P.OX: 98% (Room air)
BP: 122/80 (Siftrig, Left Arm, Standat)
NO ASSISTIVE DEVICES
LABS DONE AT REN0114V
Physical Exam (Carol B Mayne, PA-C; 5/7120124:51 PM)
General
-
Mental Status - Alert. General Appearance - Cooperative and Well groomed. Orientation -Oriented X3. Build & Nutrition -Wen
nourished and Well devebped. Posture - Normal posture. Galt - Normal.
Integumentary
General Charadteristicsi Overall oamination of the patient's skin reveals - no rashes and no bruises. Color - normal coloration of skin. Skin
Moisture - normal skin moisture. Temperature - normal warrnth is noted.
Read anti Netk
Head - norrnocephalic, atraum atic wth no lesions or palpable masses.
ChestandLa.rngExasn
Chest aid lung exam reveals - normal excursion with symmetric chest walls, quiet, even and easy respiratory effort with no use of accessory
muscles and on auscultation, normal breath sounds, no adventitious sounds and normal vocal resonance.
Cardiovascular
Cardiovascular examination reveals - normal heart sounds, regular rate and rhythm with no murmurs and carotid auscultation reveals no bruits.
Abdomen
Inspeclion: Inspection of the abdomen reveals - No Visible peristalsis and No Abnormal pulsations.
Neurologic
Neurologic evaluatbn reveals - normal sensation and normal coordination.
Neuropsychlatic
Mental status exam performed with Endings of - no evidence of hallucinations, delusions, obsessions or hornki
daVsuicidal ideation and attention
span and abilty to concentrate are normal.

Asmssment & Plan (Carol B Mayne, PA-C; 5/7/20124-33
PM)
LUMBAR POSILAMINECTOMY(722.831
DISORDER. ADJUSTMENT W/DEPRESSED 14300 (309.01
DEPENDENCE. OP10113, UNSPECIFIED (304.00)
LUMBAR RADICULITIS (722.2)
Story: history of fusion from 14-51
Impression: spina cord stimulator in place with plans for explanation.
Current Plans
BID CNT, COhIPL (BC W/AUTO DI FF WBC (85025)
METABOLIC PANEL COMPREHENSIVE (80053)
PT (PROTHROMBIN TIME) (85610)
PTT (ACTIVATED PARTIAL THROMBOPLASTIN TIME) (85730)
URINALYSIS WMICROSCOPY (81000)
Kellex SOONG, 1 Capsule three times d4V, #15, 5 days starting 05/13/2012, No Refill. Active.
beain the day Ma to planned Procedure.
Page 12/52
06/06/2012 03:38 pm 3eff Briggs DOB 01[21/1970
Briggs-10
Jeff Briggs
4/19/2012 8:02 AM
Location: Nevada Pain &Spine Specialists
Patient #: 15206
DOB: 1/21/1970
MarnedJ 1.2inguage : Undefined / Pace: Undefined
Male
History of Present I Iness (Andrew C Wesely, MD; 4119/2012 8:44 AM)
The patient is a 42 year old male here for blow up. . Patient is here for a discussion about reomving the SCS and doing a pump possibly or
and epidural and medication ma nag erneni Patient's pain is located in the lower back and in left leg(s). The quaity is described - as aching,
throbbing, sharp, stabbing, tinging and dull Pain scores iodide a current pain level of 8/10 and this is with medications. The patient descrbes
symptoms as worsening and medications are not helpful Patent has had no recent evaluations.. Medication concerns: his body is getting used
to the pain medications so they are no longer working. Current treatment includes SCS system and intermittent injections. Reference pabent's
intake form for today's encounter under scanned documents. Note for 'OFFICE VISIT':
I an seeing 3eff today, to evaluate his spinal stimulator system. We placed this several years ago for chronic back and bilateral leg pain,
secondary to postlammec tomy pain syndrome. He had good reief wth this device for a while, but gradually, o'er tine, it's become less
effective for him. At this locint it is no bnger helpful viehen he has it on. When he turns it off, he continues to experience intermittent tinging in
his thighs, wkhout any obvious source. The device is been looked at it appears to be functioning properly.
3eff continues to do the best he can, working as an attorney. He is currently representing disadvantaged chiciren. He is raising his 13-year-old
along. He is now divorced and his wife was in Ca ikornia. .
Tried many forms of treatment wth left the past Al one point we we weaned hin off narcotics altogether, but his quaity of life Is so poor that
we need to reinstitute medications. He typically does well for a while, and he needs to have dcse advances to maintain pan relief. Eventually
he developed side effects. At one point, he probably also probably had coroisting dependence issue with oxycodone.
For now, I think we need to explant his spinal stimulator since It is no longer helpful, and causing him side effects. Well continue his
medications as prevbusly outkned. Add followup, we will discuss whether or not proceeding intrathecal infusion wouki be a good option for him.
He may be worth trialing with ziconitide.
Problem List/Past Medical (Jayme Durkee, MA; 4/1912012 8:06 AM)
DISORDER, ADJUSTMENT W /DEPRESSED MOOD (309.0)
LUMBAR RADICUUTIS (722.2). history el fusion from 14-51
Last DEA. 7/14/11
Last seen by NPSS M.D.. Dr VVesety 6/21/11
Last UDS. 11/29/11
Medication History (3ayrne Durkee, HA 4/19/2012 8:06 All)
Cymbalta (60MG Capsule DR Part 1 Oral daily, Taken starting 03/20/2012) Active. (for pain and depression)
FentaNYL (75MCG/HR Patch 72HR 1 Transdermal every 72 hours, Taken starting 03/20(2012) Active. (every 72 hours)
Oxycodone-Acetaminophen (7.5-325MG Tablet 1 Oral every 4 to 6 hours, Taken starting 03(20/2012 )Active.
Alergies ()ayrne Durkee, MA; 4/19/2012 8:06 AM)
No Known Allergies
Social History (layme Durkee, MA; 4/19/2012 8:06 N4)
Highest Education Level Attained. 3URIS DOCTOR
Curse ntworkstatus. Full-time.
No alcohol use
Children
Fan* History (layme Durkee, MA; 4/19/2012 8:06 AM)
Past Surgical History (3ayme Durkee, MA; 4/19/20128:06 AM)
Spinal Fusion. 200114-5 and 15-51 posterior fusion with cage
2007 SPINAL CORD 571M.
Epidural Injedlon (Lumbar). 9/15/2010, 1/11/2010, AND 10/15/2008.
Epidural Injedion (Lumbar). Date: 1/30/2012, Inpatient, Left, 13-51.
Diagnostic Studies History (Jayne Durkee, MA; 4/19(2012 8:06 AM)
CSC (Compkte Blood Count) w/dIfferential. 8/13/2007 AND 8/7/2007.
06/06(2012 03:38 pm Jeff Briggs DOB 01/21)1970
Page 19/52
Briggs- 11
06/06/2012 03:38 pm
Jeff 01. 1
99s DOB 01/21/1970
Page 15/52
Other Problems (Jayne Durkee, MA; 4/1912012 8:06 AM)
depression
Review of Systems Chyme Durkee, MA; 4/19/2012 8:06 AM)
General: Not Present- Fatigue, Weight Gain and Weght loss.
Skim Not Present- Excessive Sweating, Rash, Pigmentation, Change in Hair Growth or Less, Nail Changes, Skin Color Changes, Bruising, Hair
Growth and Hair Loss.
Cardiovascular: Not Present- Chest Pain, Fainting, Sweling & Extremtles and Irregular Heart Beat
Gastroirrtestinak Present- Constipation. Not Present- Abdominal Pain, Nausea, Vomiting and Incontinence of StooL
Musculoskeletak Present- Musde Weakness, Back Pain and Physical Disability. Not Present-Joint Pain, Fractures, Muscle Pain, Muscle
Cramps and Joint Sweling.
Neurological: Present-Trouble waking. Nct Present- Balance Problems and Headaches.
Psychiatric: Present- InabOlty to Concentrate and Trouble Falling Asleep.
Vials (Jayne Durkee, MA; 4/19/2012 8:07 AM)
4/19/2012_8, .06_Ati
Weight: 175 b HelOb 75 in
Weght was reported by pabent
Meg/it was reported by patient.
Body Surface Areal 2.05 m 2 Body Mass Index: 21.87 kg/rn 2
Temp.: 98.S F
BP: 114/72 (Sitting, Left Arm, Standard)
NO ASSIST1VE DEVICES
Assessment & Plan (Andrew C Wesely, MD; 4/19/2012 9:00 AM)
DISORDER. ADJUSTMENT W/DEPRESSED MOOD (309.0)
LUMBAR POSTLAMI N(CTOMY(722.83)
Current Plans
I Cymbal ta 60MG, 1 Capsrle DR Part daily, R60, 60 days starting 04/19[2012, Ref. xl. Active.
for pain and depression
I FentaNYL 75MCG/HR, 1 Patch 72IIR every 72 hours, 10 Pat h 721IR, 30 days starting 04/19/2012, No Refill. Active.
every 72 hours
I Or/codone-AcetaninoPhen 73-325MG. 1 Tablet every 4 to 6 hours, #100,30 days starling 04119/2012, No Refill. Active.
WMBAR RADICULITIS (722.2)
Story: history of fusi3n horn 14-51
DEPENDENCE, OPIOID. UNSPECIFIED (304.00)
Current Plans
CBC W/DIFFERENTIAL (85025)
COMPLETE METABOUC PROFILE (80053)
PT (PROTHROMBIN TIME) (85610)
PTT (85730)
Folow UD with Dr.Weselv
Folow up in 1 month or as needed
Post-procedure follow up
Request authorization for Removal of Electrodes using fboroscopy (63661).
Note: Procedures explantation of spinal stimulator system. Followup per protocol
Signed electronically by Andrew C Wesely, MD (4/19/2012 9:01 AM)
Briggs-12
Jeff Briggs
3/20/20U 12 33 PM
location: Nevada Pan & Spine Specialists
Patient*: 15206
DOB: 1/21/1970
Married / Language: Un dein ed / Race: Undefined
Male
History of Present Ilness (Carol B Mayne, PA-C; 3/20/20121:18 PM)
The patient is a 42 year old male is here for follow up. Patient is here for medication management Patient's pain is located In the low
back and in left leg(s). The patient describes the pain as tearing, burning, sharp, stabbing, numbness and dull Pain scores Include a current pain
level of 7/10 and the is with medic ation s. The patient describes symptoms as worsening and medicabons are helpful Patient recently had Cain)
epidural steroid, lumbar. The pain was diminished by 50% after the procedure, pen relief duration was? weeks and patient decreased
medication use. Patient has had no recent evaluations.. Current treatment includes medication. Patient reports that stress level is unchanged.
Sleep: sleep moderatdy. Medication side effects include constipation. The patent dates that the pain has never made them borrow addibonal
pain medication, never made them run out early of ther pain medication, never made them take more than prescribed of their pain metlication
and neves made them need to use alcohnV manwan a/ other Mit substances The patient states that the pain has sometimes made them tense
or anxious, sometimes made them depressed or discouraged and sometin es made them 'nibble or upset. The patient states that the pain never
interferes with Yard wait or shopping, never interferes with Having sexual relations and never interferes with Appetite The patient states that
the pain sometimes interferes with Gong to work, sometimes interf eres with Socializing with friends, sometimes interferes with Recreation and
hobbies and sorndimes interferes with sleep. The patient states that the pain often interferes with performing household chores and often
interferes with physical aercise. Note for 'Office Visit Follow Up': leff is here today with uncontrolled pain desp te epidural Injection, spinal cord
stimulator and narcotic medication. He Is status post fusion at 14-5 and L5-51. Pam radbtes to his left leg. Epidural beneficial for only 6 weeks.
Problem List/Past Medical (Carol B Mayne, PA-C; 3/20/2012 1:23 PM)
Last seen by NPSS M.D.. Dr Wes* 6/21/11
Last DEA. 7/14/11
Contracts Updated 9/20/11
DISORDER, ADRISTM ENT W/DEPRESSED MOOD (309.0)
LUMBAR RADICULITIS (722.2). history cf fusion from 1.4-51
Last UDS. 11/29/11
Medication History (Becloy Gates; 3/20/2012 1:01 PM)
Cyrnbaita (60MG Capsule DR Part 1 Oral daily, Taken starting 02_/23/2012) Active. (for pain and depression)
FentaNTL (50MCG/HR Patch 72HR 1 Transdermal every 48 hrs, -Taken starting 02/23/2012) Active. (every 72 hours)
Oxycodone-Acetaminophen (7.5-325MG Tablet 1 Oral every 4 to 6 hours, Taken starting 02/23/2012 ) Active.
Allergies (Becky Gates; 3/20(2012 1:01 PM)
No Known Allergies
Social History (Becky Gates; 3/20/2012 1:01 PM)
Current work status. Pull-time.
Children
No akohol use
Highest Education Level Attained. JURLS DOCTOR
Non srnoker / no tobacco use
Past Surgical History (Becky Gates; 3/20)2012 1:01 PM)
Epidural Injection Lumbar). Date: 1/30/2012, Inpatient, Left, l3-51.
Epidural Injection Lumbar . 9/15/2010, 1/11/2010, AND 10/15/2008.
Spinal Fusion. 200 14-5 an 15-S1 posterior fusion with cage
Diagnostic Studies History (Becky Gates; 3/20/2012 1:01 PM)
CBC (Complete Blood Count) w/differential. 8/13/2007 AND 8j7/2007.
Other Problems (Card B Mayne, PA-C; 3120/2012 1:23 PM)
depression
Review of Systems (Becky Gates; 312012012 1:01 PM)
06/06/2 01 2 03:38 pmJeff Briggs DOB 01/21/1970
Page 17/52
Briggs-13
Skin: Present- Excessive Sweating.
HEENT: Present- Headache.
Gastrointestinal: Present- Constipation.
Muscu loske letal: Present- Muscle Weakness and Back Pain.
Neurologicak Present- Numbness, Trouble walking, Weakness and Tingling.
Psychiatric: Present- Amdety and Ina biity to Concentrate.
Endoaine: Present- Cold Intolerance and Heat Intolerance.
Vtals (Becky Gates; 3/20/2012 1:03 PM)
3120/7.0 1 2 1 : 02 PM
W t: 175 b Hel9ht 75 in
Wet t was reported by pa pent
Heght was reported by patient
Becht Surface Area: 105 m2 Body Mass Index: 21.87 kg/m3
Pain Level: 7/10
Temp.: 98.3 F (Temporal) Pulse: 79 (Rergular)
no assist device
no recent studies
Physical Exam (Carol B Mayne, PA-C; 3/20/2012 1:18 PM)
General
Menta I Status -Alert. Ge nera I Appearance - Cooperative. Posture - Normal posture. Gait - Normal.
Integumentary
General C bar aderistics: Overall examination of the patent's slOn reveals - no rashes, no suspicious lesions and no bruises.
Head and Neck
Head - normocephalic, atraumatic with no lesions or palpable masses
Eye
NTH - Bilateral - Normal. Pupillary Size - Bilateral - 3.0mm.
Chest and Lung Exam
Inspection: Shape - Normal and Symmetric- Movements -Normal and SyrnmetricaL Accessory muscles - No use of accessory muscles in
breathing.
Cardiovascular
Abdomen
Palpation/ Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No Rebound tenderness.
Peripheral Vascular
Lower Extremity:
Palpation: Temperature - Bilateral - Normal. Homan's sign - Bilateral - Negative (normal). Do rsalls pedls pulse - Bilateral - Normal.
Posterior tibial pulse - Bilateral - Normal.
Neurologic
Mental Status: Thought co ntent/perce ption - Normal.
Neuropsychlatric
Examination of related systems reveals- The patient is wet-nourished and well-groomed. Mental status exam performed wth findings of -
Oriented X3 with appropriate mood and affect and able to articulate well with normal speech/language, rate, volume and coherence.
Associations -Intact. Judgment and Insight - insight is appropriate concerning matters relevant to self.
useulgske !eta 1
Trig9er Point Examination: Back & Lower Extremity - Bilateral - trigger points palpated, Gluteus maxinus, 1 tocostalis lumborum,
Long Issimus lumborum, Multifidus and Quadratus lumborum.
Spine/Ribs/ Pelvis
Pelvic Region: Functiona !Testing - Sacroliac compression test negative.
lumbosacral Spine:
Inspection and Palpation: Tenderness -No tenderness to palpation.
Repeated Movements Assessment: Retraction/ Extension,supine - does not affect pain. Rotation, (R) - does not affect pain. Rotation,
(1) - does not affect pain. Repeated flexion - does not affect pain. Extension - does not affect pain. Defonnites/Maralignments/Discrepancies -
lumbar lordosis positive.
Functional Testing - Straight Leg Raising Test negative.
Lower Extremity
Hip: Examination of the right hip reveals- normal range of motion, no crepitus. Examination of the left hip reveals - normal range of motion, no
crepitus.
Fibrornyalgia Exam - Bilateral - fibromyakgia sites nontender.
Assessment & Plan (Carol B Mayne, PA-C; 3/20/2012 1:53 PM)
Page 1 8/52
06/06/2 01 2 03 :3 8 pm left Briggs DOB 01 /2 1 /1 970
Briggs-1 4
Current Plans
1 Fe ntahlY L 75MCG/11R, 1 Patch 72HR every 72 hours, 10 Patch 72H R, 30 days staffing 03/2012012, No Refill. Active.
every 72 hours
I Oxycodone-ketaminophen 7.5-325MG, 1 Tablet every 4 to 6 hours. 0100, 30 days starano 03/2012012. No Refit Active.
Impression: Secondary to chronic pain problem
subaxone was "a niohtmere' with psycholoolcal problems and he failed methadone
Impression: on CYmbalta.
Current Plans
I Cymballa 60MG, 1 Capsule DR Part daiY, *60, 60 days starting 03/20/2012, Ref. xl. Active.
fcr Pain and deoression
LUMBAR RADICULTTIS (722.2)
Story; history of fusbn from 14-51
Impression: svmMoms of L5-51 left iadiculitls with 000d response to LES1 short term.
Current Plans
I Follow up in 1 month or as needed with Dr Weselv to discuss removal of spinal cord stimulator and further therapy at this juncture.
Note: failed back syndrome with pain recurrent following LESI. He is not benefitting fromspinal cord stimulator and would like to have this
removed as he feels 'ghost" pan.
wi1 have the patient see Dr Wesely again to discuss removal of stimulator and further management options at this point.
WE increase dose of Fentanyl in the mean time for uncontrolled pain.
Faled adjuvant therapy in the past, Lyrics and Neuronfin.
e k f r e 6 . 1 4
r
.f/i - c
Signed electronically by Carol B Hayne, PA-C (3/2012012 1:53 PM)
Page 19/52
06/06/2012 03:38pmJeff Briggs 00801121/1970
Briggs-15
Jeff Briggs
2/23/2012 8:25 AM
Location: Nevada Pain &Spine Specialists
Patent 15206
006: 112111970
Married! Language: Undef in ed / Race: Undefined
Male
History of Present llness (Carol B Mayne, PA-C; 2/2312012 8:47 AM)
The patient is a 42 year old male is here for follow up. Patient is here for medication management and a post-block follow up. Patent's
pain Is located in the low back and in left leg(s). The patient descrlies the pain as stabbing and shooting. Pain scores include a current pain eve'
of 4/10 and this is with medications. The patient descrbes symptoms as kr proving and medications are helpful. Patient recently had (a/n)
epidural steroid, lumbar. The pain was diminished by 50% after the procedure and pain relief duration is indeterminate at this time.. Patent has
had no recent evaluations.. Current treatment includes medication. Patient reports that stress level is unchanged. Sleep: sleep moderately. The
patient states that the pain has never made them borrow additional pain medication, never made them run out early of th or pain medication,
never made them take more than prescribed of their pain medication and never made them need to use alcohoV marijuana/ other ilicit
substances. The patient states that the pain has sometimes made them tenw or anxious, sometimes made them depressed or discouraged and
sometimes made them irritable or upset. The patient slates that the pain never Interferes with Going to work, lever interferes with Yard work or
shopping, never interferes with Socializing with friends, never interferes with Recreation and hobbies, near interferes wth Having sexual
retatens, never interferes with sleep and never interferes with Appetite. The patient states that the pain sometimes interferes with performing
household chores. The patient slates that the pain often interferes with physical exercise. Note for "Offke 14st Follow Up': Currant regiment is
working well. He has much less discomfort with epidural performed 1/30/12. Able to change fentanyl patch every 3 days now. Using
oxycotfone pm generally four daily.
Problem List/Past Medical (Carol El Hayne, PA-C; 2/23/2012 8:50 AM)
Last UPS. 11/29/11
DISORDER, AIMUSTMENT W/DEPRESSED MOOD (309.0)
LUMBAR RADICULMS (722.2). history of fusion from 14-S1
LUMBAR POSTLAMINECTOMY(722.83). stimulator in place,
Last DEA. 7/14/11
Last seen by NPSS M.D.. Dr Wesel/ 6/21/11
Medication History (Becky Gates; 2/23/2012 8:31 AM)
FentaNYL (SOMCG/HR Patch 72HR 1 Transdermal every 48 hrs, Taken starling 01/27/2012) Active. (Use every 48 hrs as hist -tic ted.)
Oxycodone-Acetaminophen (7.5-325MG Tablet 1 Oral every 4 bi 6 hours, Taken starting 01127/2012) Active.
Cymbalta (60MG Capsule DR Part 1 Oral daily, Taken starting 02/23/2012) Active. (for pain and depression)
Allergies (Becky Gates; 2/23/2012 8:30 AM)
No Known Allergies
Social History (Becky Gates; 2/23/2012 8:33 AM)
No alcohol use
Children
Non smoker J no tobacco use
Highest Education Level Attained. 3URIS DOCTOR
Current work status. Full-lame_
Past Surgical History (Becky Gates; 2/23/2012 8:30AM)
Epidural Injedlon (Lumbar). Date: 1M/2012, Inpatient, Left, LS-S1.
Spina I Fusion. 2001 14-5 and 15-51 posterior fusion with cage
Diagnostic Studies History (Becky Gates; 2/23/2012 8:30 AM)
CBC (Complete Blood Count) w/differential. 8/13/2007 AND 817(2007.
Other Problems (Card B Mayne, PA-C; 2/23/2012 8:50 AM)
depression
Review of Systems (Becky Gates; 2/2312012 8:30 AM)
Genera k Present- Tiredness.
Skin: Present-Excessive Sweating.
GastroIntestinat Present- Constgatian,
Endocrine: Present- Heat Intderance-
Vitals (Becky Gates; 2/23/2012 8:33 AM)
06/06/2012 03:38 pm leff Briggs DOB 01121/1970
Page 20/52
Briggs-16

2a3/29112_8:31 AM
Weight: 175Ei Height 75in
Weght was reported by patient
Hoght was moorted by patient
Body Surface Area: 205m, Body Mass Index: 21.67kg/m,
Pain Level: 4/10
Pulse; 86 (Regular)
BP: 140/90(Sitting, Left Arm, Standard)
no assist devi- e
no recefit studies
Physical Exam(Carol B Hayne, PA-C; 2/23/2012 8:47AM)
Thephysical examfindings are as follows:
General
Mental Status - Alert. General Appearance - Cocpeative. Posture - Normal posture. Galt - Normal.
Integumentary
General Characteristics: Overall examinationof thepatient's skinreveals - no rashes, no suspicious lesions and no bruises.
Head and Neck
Head - normocephalic, atraumatic wthno lesions or palpable masses.
Eye
Pupil - Bilateral - Normal. Pupillary Sire - Bilateral - 3.0mm.
Chest and Lung Exam
Inspedion: Shape - Normal and Symmetric. Movements - Normal and Symmetrical. Accessory muscles - No use of accessory muscles in
breathing.
Cardiovascular
Cardiovascular examinationreveals - normal heart sounds, regular rateand rhythmWithno murmurs and carotid auscultationreveals no bruits.
Abdomen
Palpation! Percussion: Palpationand Percussionof theabdomenreveal - NonTender and No Rebound tenderness.
Peripheral Vascular
Lower Extremity:
Palpation: Temperature Bilateral - Normal. Homan's sign - Bilateral - Negative (normal). Dorsalls pedls pulse - Bilateral - Normal.
Neurologic
Mental Status: Thought content/perception - Normal.
Neuropsychla tic
Examination of related systems reveals-The patient is well-nourished and well-groomed. Mental status exam performed wth fn dings of -
Associations -inbct. ludgrnent and Insight - insight Is appropriate concerning mattes relevant to self.
ffusculoskielgil
Trigger Point Examination: Back & Lower E:dr amity - Bilateral - trigger points palpated, Gluteus maxinus,liocostalis lumborum,
Long issimus lumborum, Mullifidus and Quadratus lumborom.
Spine/Ribs! Pelvis
Pelvic Region: Functional Te sting - Sacroiliac compressiontest negative.
Lumbosacral Spne:
Inspection and Palpation: Tenderness No tenderness to palpation.
Repeated Movements AstAssment Retractbni Extenslorksupine - does not affect pain. Rotation, (R) - does not affect pain. Rotation,
(1) - does not affect pain. Repeated flexion - does not affect pain. Extension- does not affect pain. ODefOrmities/Malalignments/Discrepmcies -
lumbar lordosis postive.
Functional Testing - Straght LegRaisingTest negative.
Lower Extremity
Hip: Examination of the right hip reveals- normal range of motion, no creptus Examination of the left hip reveals - normal range of motion, no
crepitus.
Flbromyalgia Exam - Bilateral - hbromyalgia sites nontender.
Asssment & Plan (Carol BHayne, PA-C; 2/23/2012 8:51 AM)
Page 21/52
06/06/2012 03:38 pin Jeff Briggs COB 01/21/1970
Briggs-17
Impression: on Cvmba la.
Current Plans
I Cymbalta 60MG, 1 Capsu le DR Part daily, #60, 60 days startng 0212312012, No Refit. Active.
fa vain and depression
LUMBAR RADIC1111115 (722.2)
Story: history of fusim from 14-51
Impression: sym ptoms of 5-51 left radicatis with 000d response to 1E51.
Current Plans
I FentaNYL 50MCG/MR, 1 Patch 7211R every 48 hrs, 10 Path 72HR, 30 days starting 02/23P012, No Refill. Active.
every 72 hours
I Oxycodone-Acetaninoohen 7.5-32 5MG, 1 Tablet every 4 to 6 hours. #100.30 days star:Ono 02123/2012. No Refll Active.
1 F- olow up in 4 weeks with Carol Mayne PA-C
I Follow-Up for Medication Manacement
I Referral: PhysicalTheraPv
Note: Intolerant of methadone and suboxone, back on fentanyl with percocet with stable doses
stimulatcr in place, not using with any regularly as it causes muscle spasms
& , . ?
l i A r
. - c
Signed electronically by Carol 8 liayne, PA-C (2123/2012 8:52 AM)
Page 22/52
06/06/2012 03:38 pm 3eff Briggs DOB 01/21/1970
Bri ggs- 18
Jeff Briggs
1/27/2012 11:13 AM
Patient*: 15206
DOB: 1/21/1970
Married! Language: Undefined / Race: Undefined
Male
History of Present liness (Carol B Hare, PA-C; 1(27(2012 11:37 AM)
Patient words:1 haven't used my SCS at all over the last few months. It leaves 'ghost" electronic impulses that cause muscle spasms and
vibration in my leg.
The patient is a 42 year old male Is here for follow up. Patient is here for medication management Patients pain is located in the mid to
lower back, In left leg(s) and in left hip(s). The patient descrbes the pain as aching, burning, throbbing, sharp, stabbing, numbness, dull and
shooting. Pain scores include a current pain level of 8/10, this Is w itti medications and an average pain level of 7/10. The patient describes
symptoms as unchanged and medications are helpful Patient has had no recent evaluations.. Current treatment includes medication and Boston
Scientific spinal cord stimulator. Patient reports that stress level is decreased. Sleep: averages 4 hours Interrupted. Medication concerns Patient
reports severe tiredness with combination of Oxycodone and Fentanyl. Medication side effects Include drowsiness . (severe).The patient states
that the pain has never made them borrow additional pain medication, never made them run out early of their pain medication, never made
them take more than prescribed of their pain medicatbn and never made them need to use alcohoV marijuana/ other licit substances. The
patient states that the pain has sometimes made them tense or anxious and sometimes made them irritable or upset. The patient states that the
pan has frequenty made them depressed or discouraged. The patient states that the pain never interferes with Having sexual relations. The
patient states that the paln sometimes Interferes wth Yard work or shopping, sometimes interferes velh Socializing wth friends, sometimes
interferes with Recreation and hobbies and sometimes interferes with Appetite. The patient states that the pain often interferes with Going to
work_often interferes with performing household chores, often interferes with physical exercise and often interferes with deep. Note for '011fice
Visit Follow Up": He is not using his 5C-S despite having reprogramming in October. He Is annoyed with his legs spasning and the sensation of
vibration after turning off his Simulator. Would like to consider explanting this.
His pain Is poorly controlled but he will have lf SI performed next month. REmeron Is making him too tired during the daytime.
Hewitt be seeing his primary care provider again and viii discuss management of depression with him. He has been on various antidepressant
medications in the past.
Review of Systems (Leah Cobb, MA; 1/27/2012 11:18 AM)
General: Present-Tiredness.
Skin; Present- Excessive Sweating.
Gastrointestinal: Present- Constipation and Nausea.
Musculoakeletals Present- Muscle Weakness and Back Pan.
Neurologicah Present- Numbness, Trouble walking, Weakness and Balance Problems.
Psychiatric: Present- Depression, Anxiety, Inability to Concentrate and Trouble Falfing Asleep.
Endoaine: Present- Heat Intderance.
Vitals (Leah Cobb, MA; 1/2712012 11:20 AM)
1a712012.11,19 A M
erg ' tit: 175'b Height 75 in
Weight was reported by patient
Height was reported by patient.
Body Surface Arta: 2,05 m' Body Mass Index 21.87 kg/m2
Pain Level: 8/10
Temp.: 97.9F Pulse: 84 (Regular)
BP; 106/70 (Sitting, Left Ann, Standard)
NO ASSISTIVF DEVICES
pan score with mels
Physical Exam (Carol B Hayne, PA-C; 1/27/2012 11:37 AM)
The physical cam findings are as folovvs:
General
Mental Status - Alert. General A ppearance - Cooperative and Well groomed. Build & Nutrition -Lean and Wet nourished.
Integumentary
General Characteristics: Overall examination of the patient's skin reveals - no rashes and no bruises. Color - normal coloration of skin. SkIn
Moisture - normal skin moisture. Temperature - normal warmth is noted.
ptad and Neck
Head- normocephalic, atraumatic with no lesions or palpable masses
Eye
Pupil - Bilateral -Normal and Equal. Pupillary Size - Bilateral - 3.0mm.
Chest and Lung Exam
Chest aid lung exam reveals - normal excursion with symmetric chest walls and quiet, even and easy respiratory effort with no use of accessory
muscles.
06/06/2012 03:38 pm Jeff Briggs 005 01/23/1970
Page 24/52
Briggs-19
Cardiovascular
Cardiovascular examinabon reveals - normal heart sounds, regular rate and rhythm with no murmurs arid carotid auscultaton reveals no bruits.
Abdomen
Palpation/Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No Rebound tenderness.
Peripheral Vascular
Lower Extremity;
Palpation: Temperature - Bilateral - Normal. Homan's sign - Bilateral - Negative (normal). Dorsalis pedls pulse - Bilateral- Normal.
Neurologic
Neurologk evaluation reveals - alert and oriented x 3 wth no impairment cf recent or remote memory and normal card ination.
Sensory;
Ught Touch: - No Abnormalities.
Pain: - Normal pain sensation.
Temperature: - No Abn orrn aides.
Overall Assessment of Muscle Strength and Tone reveals:
Lower Extremities: Right Illopsoas - 5/5. Left Iliopsoas - 5/5. Right Quadriceps - 5/5. Left Quadriceps - 5/5. Right Tibialis
Anterior - 5/5. Left TIbialis Anterior - 5/5. Right Gastroc-Scieus - 5/5. Left Gastroc-Sok us - 5/5. Right EHL - 5/5. left EHL - 5/5.
Reflexes (Dermatom es): 0/2 Absent Left knee (L2-4). 2/2 Normal - Left Achiles (15-52), Right Achiles (L5-52) and Right Knee (12-
4). Gait - Normal.
Neuropsychiatrlo
Mental status exan performed with fridings of - Oriented X3 wth appropriate mood and al fect, no evidence of hallucinations, delusions,
obsessions or homiadal/sulcid al Ideation and attention span and a biity to concentrate are normal.
Busculoskeletal
Trigger Point Examination: Back & Lower Extremity - Bilateral - trgger points palpated,
Gluteus maximus, I bocostalis lumborum,
Longrssimus lumborum, Kilbhdus and Quadratus lumborum.
Spine/Ribs/ Pelvis
Pelvic Region: Functional Testing - Sacroiiac compression test negative.
Lumbosacral Spine:
Inspection and Palpation: Tenderness - No tenderness to palpation.
Repeated Movements Assessment: Retraction/ Extension,sepine - does not affect pain. Rotation, (R) -
does not affect pain. Rotation,.
(L) - does not affect pain. Repeated flexion - does not affect pain. Extension - does not affect pan. Deformities/Malalignments/Discrepancies -
lumbar lordosis costive.
Lower Extremity
Hip: E x a mination of the right hip reveals- normal range of motion, no oreptus. Examination of the left hip reveals - normal range of motion, no
crepibis.
Fibromyalgia Exam - Bilateral - fibromyagia sites nontender.
Assessment & Plan (Carol BMayne, PA-C; 1127/2012 11:39 AM)
Impression: will change te Remeren from Cvm bait&
LUMBAR PO5TLAMDECTOMY(722.83)
Story: stimulate in place,
Impression: awatno LEL
Impression: Secondary b chronic pain problem
Intolerant of methadone and siboxone, back on fentanYI wth uncertain benefit. consider addition of pm morphine.
LUMBAR RADICUIJTIS (722.2)
Story; history of fusion from L4-51
Impression: syrn ptoms of 13-51 left radiculitis with good response to LESI lithe past. S CS precluded MI. exam does not document weakness
but patient describes intermittent weaknessof doisiflecbn of the Wt ankle when he walks up and down sta .'s.
Current Plans
FentaltYL 50MCG/HR, 1 Patch 72KR every 48 his, 15 Path 72MR, 30 days starting 01/27/2012, No Refit. Active,
Use every 48 his as instructed.
I Oxvcodone-Acetarninophen 7.5-325MG, 1 Tablet every 4 to 6 hours, #100. 30 days startino 01/27/2012. No Refit. Active.
depression
Impression: poor response to Remeron (chose this to increa the patients appette) and will give 2 west's of Cymbata samples sufficient to
last until he is seen by Dr Brian fitCormick.
- C
Signed electronkally by Carol BHayne, PA-C (1/2712012 11:40 AM)
06/06/2012 03:38 pm Jeff Briggs DOB01/21/1970
Page 25/52
Briggs-20
Jeff Briggs
12/29/2011 12-23 PM
Location: Nevada Pain & Spine $pec lalists
Patient 1:15206
DOB: 112111970
Male
History of Present I Iness (Carol B Mayne, PA-C; 12/2912011 12:33 PM)
The patient is a 41 year old male is here for follow up. Patient is he for medication management Patient's pain is located in the mid to
low back and in left leg(s). The patient describes the pain as aching, burning, throbbing, sharp, stabbing, tingling, dul, pulling and shooting. Pain
scores include a current pain level of 7/10 and this is with m edications. The patient descrbes symptoms as unchanged and medications are
helpful. Patient has had no recent evaluations.. Current treatment includes medication. Patient reports that stress level Is unchanged. Steep: -
sleep moderately. The patient states that the pain has never made them borrow additional pain medication, never made them run out early of
their . pain medication, never Made them take more than prescribed of ther pain medication and never made them need to use alcohoY
malijuan a/ other Wird substances.T he patient states that the pain has frequently made them tense or anxious, frequently made them depressed
or d scouraged and frequently made them irritable or upset_ The patient states that the pain never interferes with Going to work and never
interferes with Having sexual relations. The patient slates that the pain sometimes interferes with Recreation and hobbies and sometines
interferes with sleep. The patient states that the pain often interferes with performing household chores, often interferes with Yard work or
shopping, often interferes with socializing with friends and often interferes with physical exercise. Note for 'Office Visit Follow Up': He is getting
along better with Cyrnbata than originally when he felt suicil al. He is loosing weight. Patch is working for his pain but not adequately. He
contrues to have moderate pain.
Problem List/Past Medical (Carol B Mayne, PA-C; 32(29/201112:36 PM)
LUMBAR RADICULITIS (727.2). history cf fusion from 14-S1
LUMBAR POSTLAHINECTOMY(722.83)._ stimulator in pbce,
DISORDER, ADIUSTMENT W /DEPRESSED MOOD (309.0)
Last seen by NPSS M.D.. Dr WeseV 6/21/11
Last UDS. 5/3/11
Last DEA. 7114/11
Contracts Updat ed. 9/20/11
Medication History (Carol 8 Mayne, PA-C; 12/29/2011 12:24 PM)
FentaNYL (50MCG/HR Patch 7211R 1 Transderrnal every 48 hrs, Taken starting 11/29/2011) Active. (Use every 48
his as instructed.)
Cyrnbalta (60MG Capsule DR Pat 1 Oral daily, Taken starting 11/29/2011) Active. (for pain and depression)
Atergies (Carol B Mayne, PA-C; 12)29/20111224 PM)
No Known A Be rgks
Social History (Carol B Mayne, PA-C; 12/29/2011 12:24 PM)
Highest Education Level Attaine d. JURIS DOCTOR
Non smoker / no tobacos use
Current work siztus. Full-time.
Children
No alcohol use
Past Surgical History (Carol 8 Mayne, PA-C; 12(29/2011 1224 PM)
Epidural Infedion (Lumbar). 9/15/2010, 1/11/2010, AND 10/15/2008.
Spinal Fusion. 2001. 4-5 and 15-S1 posterior fusion with cage
Diagnostic Studies History (Carol B Mayne, PA-C; 12/29/201112:24 PM)
CBC (Complete Blood Count) w/diffe rential. 8/13/2007 AND 8/712007.
Review of Systems (Becky Gates; 12/29(201112:26 PM)
General: Present-Weight Loss and Tiredness.
Skin: Present- E XassNe Sweating.
Gastrointestinal: Present- Constipation and Nausea.
Musculoskeletak Present- Muscle Weakness and Back Pain.
Psychiatric: Present- Depression, Anxiety, Inability to Concentrate and Trouble Falling Asleep.
Endocrine: Present- Heat Intolerance_
Vitals (Becky Gates;
12(29/201112:26
PM)
12129/2011 I22.PM
e t: 175 1Tit 75 in
Wet i/'1 was reported by patient
tiespht was reported by patrent.
06/06/2012 03:38 pm )eff Briggs DOB 01/21/1970
Page 26/52
Briggs-21
Body Surface Area: 2.05 rn' Body Mass Index: 21.87 kg/m,
Pain Level: 7/10
no assrst devre
no recent studies
Physical Exam (Carol B Hayne, PA-C; 12/29/2011 1.233 PM)
The physical exa m findings are as follows:
General
Mental Status - Alert. General Appearance - Cooperative and Well groomed. Build & Nutrition - Lean and Wet nourished.
Integumentary
General Charade ristks: Overall examination of the patent's skin reveals - no rashes and no bruises. Color - normal coloration of skin. Skin
pead_and Neck
Head - normoce ober, atraurnatic wt h no lesions or palpable masses
Eye
Pupil - Bilateral - Normal and Equal. Pupillary Size - Bilateral - 3.0mm.
Chest and Lung Exam
Chest and lung exam reveals - normal excursion with symmetric chest walls and quiet, even and easy respiratory effort with no use of accessory
muscles.
Cardiovascular
Cardiovascular examination reveals - normal heart sounds, regulx rate and rhythm with no murmurs and carotid auscultation reveals no bruits.
Abdomen
Palpation/ Percussion: Palpation and Percussbn of the abdomen reveal - Non Tender and No Rebound tenderness.
Peripheral Vascular
Lower Extremity:
Palpation: Temperature - Bilateral - Normal. Homan's sign - Bilateral - Negative (normal). Dorsalis pedis pulse - Bilateral - Normal.
Neurologic
Neurologic evaluation reveal - alert and oriented x 3 wth no impairment d recent or remote memory and normal coordination.
Sensory:
Light Touch: -No Abncrmalifies.
Pain: - Normal pain sensation.
Temperature: - No Abn GM: aities.
Overa I Assessment of Muscle Strength and Tone reveals:
Lower Extremities: Right Iliopsoas - 5/5. Left Iliopsoas - 5/5. Right Quadriceps 5/5. Left Quadriceps - 5/5. Right Tiblalis
Anterior -5/5. Left Tibialls Anterior - 5/5. Right Gastroc-Soieus - 5/5. Left Gastroc-Soieus -3/5. Right EHL - 5/5. Left EHL - 5/5.
Reflexes (De rmatomes): 0/2 Absent - Left Knee (12-4). 2/2 Normal - Left Achiles (15-52), Right Achiles (15-52) and Right Knee (L2-
4). Galt - Normal.
Neuropsychlatric
Mental status examperformed with findings of - Oriented X3 wth appropriate mood and affect, no evidence cf hallucinations, delusions,
obsessions or homiodal/suic.idal ideation and attention span and absity to concentrate are normal.
Mussulsolligletal
Trigger Point Examination: Back & Lower Extremity - Bilateral - trigger ports palpated, Gluteus maximus, Ibocostalis lumborum,
Long isslmus iumborum, Multifidus and Quadratic lumborurn.
Spine/Ribs/ Pelvis
Pelvic Region: Functional Te sting - Sacmiiac compression test negative.
Lurnbosacral Spite:
Inspection and Palpation: Tenderness- No tenderness to palpation.
Repeated Movements Assessment: Retraction/ Extenslon,supine - does not affect pain. Rotation, (R) - does not affect pain. Rotation,
(I) - does not affectpain. Repeated flexion -does not affect pain. Extension - does not affect pain. Deformities/Melalignments/DistrePancies -
lumbar lordosis postNe.
Lower Extremity
Hip: Examination of the right hip reveals - normal range of motion, no creptus. Examination of the left hip reveals - normal range of motion, no
crepitus.
Fibromyalgla Exam- Bilateral - fibronryaigia sites nontender.
Assessment & Plan (Carol B Hayne, PA-C; 12/29/2011 12:39 PM)
06/06/2012 03:38 pm left BlIggs COB 01/21/1970
Page 27/52
Briggs-22
LUMBAR RADICUI1TIS (722.2
Story: history of fusion frorn. L4-51
Impression: symptoms of L5-51 left radiculitis with good response to LEST in the past. SCS precluded MI. exam does not document weakness
but patent describes intermittent weakness of dorsiflex ion of the left ankle when he waks up and do,vn stars.
Current Plans
I FeritaNYl 50MCG/HR, 1 Patch 72HR every 48 hrs, 15 Path 72H R, 30 days starting 12/29/2011, No Refit. Active.
Use every 48 hrs as instructed.
I Oxycodone-Acetaminophen 7.5-32 SMG. I Tabld every 4 to 6 hours. #100, 30 days startino 12129/2011. No Refit Active.
I Folow up in 4 weeks with Carol Mayne PA-C
Conbnue current medication - with chance
I Folow-Up for Medication Management
DEPENDENCE, MID, UNSPEOFIED(304.00)
Intolerant of methadone and sr boxone. back on fentanyl wth uncertain benefit. consider addition of Pm morphine.
UJ MBAR POS11AM I NECTOMY(722.83)
Stow stimubtcr in place,
Impression: wit trial on ES1 when he has insurance in January, minimal benefit from increase in dose of Fentanvl.
DISORDER, ADJUSTMENT VV/DEPRESSED MOOD (309.0)
Impression: will chanoe to Remeroi from Cyrn bait&
Current Plans
I Remeron ISMG. 1-2 Tablet at bedtime for mood. #60.30 days startiia 12129/2011, Ref. xl. Active.
Signed electronically by Carol B Mayne, PA-C (12129/2011 1241 PM)
)e f? Biggs 006 01/21/1970
Page 28/52
06/06/2012 03:38 pm
Jeff
11/29/2011 10:42 AM
Location: Nevada Pain & Sp ne Specialists
Patient #: 15206
DOB: 1/21/1970
Married I language: Undefined / Race: Undefined
Male
History of Present lIness (Carol B Hayne, PA-C; 11/29/2011 11:10 AM)
Thepatient is a 41 year old male is here for follow up. Patient is here for medcation management Patient's pain is located in the low
back, in left leg(s) and in left foot(s). The patient describes the pain as aching, burning, throbbing, sharp, stabbing, numbness, dull and
shooting. Pain scores include a current pan level of 8/10 arid this Is wth mead cations.lh The patient descrb es symptoms as worsening and.
medicabons are not helpful. Patient has had no recent evaluations.. Current treatment includes medication. Patient reports that stress level is
unchanged. Sleep: sleep moderately. The patient states that the pain has never made them borrow additional pan medication, never made them
run out early of their pai n medication, never made them take more than prescribed of their pain medication and never made them need to use
alcohol/ mamuana/ other illicit substances. The patient states that the pain has sometimes made them tense or anxious. The patient states that
the pan has frequently made them irritable or upset. The patient states that the pain never Interferes with Going to work aid never interferes
with Having sexual relations. The patient states that the pain often interferes with performing household chores, often interferes with Yard work
or shoppng, often interferes with sociaIting with friends, often
interferes with recreation and hobbies, often interferes with physical exercise,
often Interferes with sleep end often interferes with appetite. Note for 'Office visit follow up":
More pain over the past few months with developing of weakness In the left leg and he has numbness in the distal leg periodically as well. tie
is having symptoms siniliar to prior to his surgery in the past. He has SCS in place. Fie has pan radlabng to the left foot.
Now working with chldren thmugh the Washoe County Advocacy Center
Problem List/Past Medical (Becky Gates; 13129/201110:46 AM)
Last UDS. 5/3/11
Last DEA. 7/14111
Last seen by NPSS M.D.. Dr Wesel,/ 6/21/11
DEPENDENCE., OPIOID, UNSPECIFIED (304.00)
DISORDER, A1)3USTMENT W/DEPRESSED MOOD (309.0)
LUMBAR POSTLANINECTOMY(722.83). stimulator In place, failed lumbar epidurals on medication management.
Medication History (Becky Gates; 11/29/2011 10/17 AM)
FentaNYL (25MCG(HR Patch 72HR 1 Transderrnal every 48 hrs, Taken starting 09/20/2011) Active. (Use every 48 hrs as instructed.)
Allergies (Becky Gates; 11/29/2011 10:46 AM)
No Known Allergies
Social History (Beck/ Gates; 11(29/2011 10/16 AM)
No alcohol use
Children
Hight Education Level Attained. )URIS DOCTOR
Most recent primary occupation. Professional specalty. ATTORNEY
Past Surgical History (Carol B Mayne, PA -C; 11/29/201110 -39 AM)
Epidural Injection (Lumbar). 9115/2010, 1/11/2010, AND 10115/2008.
Spinal Fus ion. 2001 14-5 arid 15-51 posterior fusion with cage
Diagnostic Studies History (Becky Gates; 11/29/2011 1046 AM)
CBC (Complete Blood Count) w/differential. 8/13/2007 AND 8/7/2007.
Review of Systems (Becky Gates; 11/29/201110:46 NA)
General: Present- Weight Gain and Tiredness.
M usculoskeleta Present- Muscle Weakness, Back Pain and Physical Disability.
Neurobgica b Present- Numbness, Trouble walking, Weakness and Tingling.
Psychiatric: Present- Depression, Anxiety, Inability to Concentrate and Trouble FalIng Asleep.
V kals (Becky Gates; 1 V29/2011 10:48 AM)
1,1a9/20,1e 0:4 _M
Pulse: 70 Regular)
BP: 100/8 (Sitting, Left Arm, Standard )
06/06/2012 03:38 pin Jeff Briggs COB 01/21/1970
Page 29/52
Briggs-24
affect pain. Rotation, (R) - does not affect pain. Rotation,
- does not affect pain. Deformities/Malalignments/Discrepancies -
Examination
of the left hip reveals - normal range of motion, no
Physkal Exam (Carol B Hayne, PA-C; 11/29/2011 11135 AM)
General
M entail Status - Alert. General Appearance - Cooperative and Well groomed. Build & Nutrition - Well nourished and Wet developed.
Integumentary
General Charaderistics: Overall examination of the patient's skin reveals - no rashes and no bruises.
Color - normal coloration of skin. Skin
Ileac( and Neck
Head - normocephalk, atraumatic wl h no lesions or palpable masses
Eye
Pupil - Bilateral - Normal and Equal. Pupil la ry Sire - Bilateral - 3.0mm.
Chest and Lung Exam
Chest and lung exam reveals - normal excursion with symmetric chest walls and quiet, even and easy respiratory effort with no use of accessory
muscles.
Cardiovascular
Abdomen
Palpation/ Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No Rebound tenderness.
Peripheral Vascular
Lower Extremity:
Palpation: Temperature - Bilateral - Normal. Homan's sign - Bilateral - Negative (normal). Dorsalis pedls pulse - Bilateral - Normal.
Posterior tibial puke - Bilateral - Normal.
Neurologic
Neurologic evakiation reveals - alert and oriented x 3 wkh no impairment o f
recent or remote memory and normal coordination.
Sensory:
Ught Touch: -No Abncrrnalities.
Pains - Normal pain sensation.
Temperature: - No Abnorrnaibes.
OveraI Assessment of Muscle Strength and Tone reveals:
Lower Extremities: Right Illopsoas - 5/5. Left Illopsoas -5/5. Right Quadriceps -5/5. Left Quadriceps -5/5. Right Tibialls
Anterior - 5/5. Left Tibralls Anterior - 5/5. Right Gastroc-Soleus - 5/5. Left Gastroc-Sole us -5/5. Right EHL - 5/5. Left (ML -5/5.
Reflexes (Dermatom es): 0/2 Absent - Left knee (U-4). 2/2 Normal - Left Achiles (15-52), Right Achiles (1.5-52) and Right Knee (12-
4). Galt - Normal.
Neuropsychiat ic
Mental status exam performed with fndings of - Oriented X3 wth appropriate mood and affect, no evidence
cf hallucinations, delusions,
obsessions or homicidal/suicidal ideation and attention span and ablity to concentrate are normal.
Moculoskeletal
Trigger Point Examination: Back & Lowe r Extremity - Bilateral - trigger
Longissimus lumborum, Multifidus and Quadratus lumborum.
Spine/Ribs/ Pelvis
Pelvic Region: Functional Testing - Sacroaiac compression test negative.
mbosacral Spine:
Repeated Movements Assessment: Retraction/ Extenslon,supine - does not
(L) - does not affect pain. Repeated flexion - does not affect pain. Extension
lumbar lordosis poslive.
Functional Testing -Straight Leg Raising Test negative.
Lower Extremity
Hip: Examinabon of the right hip reveals- normal range of moticn, no crept us.
crepitus.
Fibranyalgla Exam - Bilateral - fibromyaigia sites nontender.
points palpated, Gluteus maxinus,llocostalis lumborum,
Assessment & Plan (Carol B Mayne, PA-C; 11/29/201111:13 AM)
06/06/2012 03:38 pin 3eff Briggs DOB 01121/1970
Page 30/52
Briggs-25
response to LES1 in the past. SCS precluded MR1. exam does not document weakness
of the left ankle.
fkioro for needle location (77003).
DEPENDENCE, MID, UNSPECIFIED (304.00)
Impression: Secondary 9:i chronic pain problem
intolerant of methadone, back on fentany1 with Good results.
1in or esslon: did better on effexor, will (live samples of Cy mbatta today.
UJMBAR POSTLAMINECTOMY,(722.83)
Storyt stimulator in place,
Impression: will trial on ES1 again and increme dose of FentanVL
Current Plans
FentaNYL 50MCG/HR, I Patch 72HR every 48 his, 15 Patch 72HR, 30 days starting 11/29/2011, No Refill. Active.
Cymbalta 6014G, 1 Capsule DR Part daily, #60, 60 days starting 11/29/2011, No Refil. Active.
!Samples Given)
Ice pain and depression
Follow up in 4 weeks with Carol Havne PA-C
with >50% of time spent counseling the patient and coordination of care.
The patient was counselled on medicabods) administered
Follow-Up for Medication Management
WMBAR RADICULITIS (722.2)
Story' history of fusion from 14-S1
Impression: symptoms of LS-S1 left radicuiltis with good
but patient describes intermittent weakness of dorsiflec on
Current Plans
I t.5
I 5 I
I Left
I Request au thorization for Lumbar TF ES! (644 83)with
Signed electronicalty by Carol B Mayne, PA-C (11/29/2011 11-15 AM)
06/06/2012 03:38 pin left Briggs 008 0112111970
Page 31/52
Jeff Briggs
9/20/20111:35 PM
Locatian: Nevada Pan & Spine Spec ialists
Patient #: 15206
008: 1/2111970
Married! Language: Undefin el / Race: Undefined
Ma le
History of Present !Inez (Carol B Mayne, PA-C; 9/20/2011 2:04 PM)
The patient is a 41 year old male is here for follow up.. Patient is here for medkation management. Patient's pain is located in the lower
back and in left leg(s). The patient descnbes the pain as aching, burning, sharp, stabbing, numbness, dull and pulling. Pain scores include a
current pain level o14/10 and this Is without medkations (been out d patches for couple of days
). The patient describes symptoms as unchanged and medications are h elpfu L Current treatment includes medkation. The patient states that the
pain has never made them depressed a. discouraged, never made them borrow additional pan medication, never made them run out 83r11/ of
their pain medication, never made them take more than prescribed of their pain medication and never made them need to use alcohol/
marquan a/ other stint substances. The patient states that the pain has sometimes made then tense or anxious and sometimes made them
irriable or upset The patient states that the pain never interferes with Yard work or shopping, never Interferes with Socializing !rah friends,
never Interferes with Recreation and hobbies, never interferes with Having sexual relations and never interferes with Appetite. The
. patient states
that the pain sometimes interferes with perforrning household chores, mmetimes interferes with Physical exercise and sometimes interferes with
sleep. Note for 'Office vidt folow up': He has tapered off effexor withcut dificulty. Methadone caused sedatbn and men tal clouding with pan
now improved with fentanyl patches. He feels very well
Problem List/Past Medical (Becky Gates; 9120/2011 1:35 PM)
DEPEND ENOE, OP1OID, UNSPECIFIED (304.00)
LUMBAR POSTLAMINECTOMY(722.83). stimulator in place, failed lumbar epidurals on medication management.
DISORDER, ADJUSTMEtff W/DEPRESSED MOOD (309.0)
Medication History (Becky Gates; 9/20/2011 1:36 PM)
Veilafaxine HO (75MG Tablet 1 Oral twice a day, Taken 07/1912011 to 09/01/2011) Discontinued.
Allergies (Becky Gates; 9(20/2011 1:35 PM)
No Known Allergies
Social History (Becky Gates; 9(20/20111:35 PM)
Children
No akohol use
Highest Edusation Level Att Dined. )URIS DOCTOR
Past Surgical History (Becky Gates; 9(20/2011 1:35 PM)
Epidural Injection (Lumbar). 9/1512010, 1/11/2010, AND 10/15/2008.
Spinal Fusion. 2001.
Diagnostic Studies History (Becky Gates; 9/20/20111:35 PM)
CBC (Complete Blood Count) w/differential. 8/13/2007 AND 817/2007.
Reviewof Systems (Becky Gates; 9/20/20111:40 PM)
General: Present-Weight Gain and Medication Changes (no bnger taking an tidepressants).
Skin; Present- E xcessive Sweating.
Muscu loskeleta h Present- Back Pain.
Neurological: Present-Weakness.
Vitals (Becky Gates; 9/20(2011 1:42 PM)
91420/V11 L:40 PM
Weph t was reportedby patient
Heigh t was reportedby patient
Body Surface Areas 2.05 ml Body Mass Index: 21.87 kg/m2
Pain Levels 4110
Temp-. 37 C (Temporal) Pulse: 68 (Regular)
no assist devke
no recent studies
06/06/2012 03:313 pm )eft Briggs DOB 01/21/1970
Page 33/52
Briggs-27

Physical Exam (Carol B Mayne, PA-C; 912012011 2:04 PM)
General
M entail Status -Alert. General Appearance - Cooperative Posture - Normal posture. Gait - Normal.
Integumentary
Ge octal Charade ristics: Overall examinabon of the patent's skin reveals -no rashes, no suspicious lesions and no bruises.
Eye
Pupil - Bilateral - Normal. Pupiltary Size - Bilateral - 3.0mm.
Chest and Lung Exam
Inspedion: Shape -Normal and Syrn metric. Movements - Normal and Symmetrical Accessory muscles - No use of accessory muscles in
breathing.
He
Neuropsychlatric
Examination of related systems re/eals- The patient is wet-nourished and well-groomed. Mental status exam performed with findings of -
Oriented X3 with appropnate mood and affect and able to articulate well with normal speech/language, rate, volume and coherence.
Associations - intact. Judgment and Insight - insight is appropriate concerning matters relevant to self.
Assessment &Plan (Carol B Mayne, PA-C; 9120/2011 2:08 PM)

DISORDER, ADJUSTMENTW/DEPRESSED MOOD (309.0)
Impression: minimal symptoms today, he has a newrelationship and his mood is very upbeat without effexor.
Intolerant of methadone. back on fentanyl with 000d results.
LUMBAR RADICULITIS 02121
W MBAR POSTLAMINECTOMY(722.83)
Story: stimulator in place. faied lumbar epidurals on medication management.
Current Plans
FentaWL 25MCG/HR, 1 Patch 72HR every 48 hrs, 15 Path 72HR, 30 days stating 09/20(2011, No Refill. Active.
Use every 48 hrs as instructed.
Follow-Up for Medication Manaoement
Sioned medication agreement
Sianed consent for medication manaoement
Sianed NP5S polity
Followup in 2 months with Carol Mayne PA-C
Signed electronically by AndrewC Wesely, MO(9/2912011 11:41 AM)
Page 34/52
06/06/2012 03:38 pin left Briggs COB 01121/1970
Briggs-28
06/06/2012 03:38 pm Jeff BrIggs DOB 01n1/1970
Page 35/52

Jeff Brig's
7/29/2011 8:53 AM
Patient #: 15206
DOB: 1121/1970
Male
History of Present Illness (Carol B Mayne, PA-C; 7P9/2011 9:09 AM)
The patient is a 41 year old male is here for follow up. Patient Is here for medication management Patients pain is located In the low
back and in left leg(s). The patient describes the pain as dull, aching, burning, numbness, shooting, stabbing, throbbing and dngling. Pain scores
include a current pain level of 3/10 and this is with medications. The patient states that the pain has never made them borrow additional pain
medication, never made them run out early of their pain medication, never made them take more than prescribed of their pain medication and
never made them need to use akohol/ marijuana/ other illicit substances. The patient states that the pain has sometimes made them tense or
anxious and sometimes mad e then irritable orupset. The patient states that the pain has freguentW made them depressed or discouraged. The
patient states that the pain sometimes Interferes with Appetke. The patient states that the pan often interferes with Going to work often
Interferes with perfomung household chores, often interferes with Yard work or shopping, often interferes with social/mg with friends, often
interferes with recreation and hobbies, cften interferes with physical exercise and often interferes with sleep. Note for "Office visit follow up":
tie
missed work last week due to his profound fatigue. lie had problems wth insomnia intermittently in the past but he has not had daytime
sleepiness which he has since starting methadone. His pain is stable on the methadone transfer from Fentanyl.
Problem List/Past Medical (Ashley Lesco; 7/29/2011 8:56 AM)
DISORDER ADJUSTMENT W/ DEPRESSED MOOD (309.0)
LUMBAR RADICULrfIS (722.2)
LUMBAR POSTI.AMINECTOMY(722.83). stimulator in place, failed lumbar epidurals on medicabon manzgement.
Medication History (Ashley Lesco; 7/29/2011 8:57 AM)
Savella (25MG Tablet 1 Oral, Taken starting 01/07/2011) Active.
FentaNYL (25MCG/11R Patch 7211R I Transdermal every 48 bra, Taken starting 06/21/2011) Active. (Use every 48 hrs as instructed.)
Methadone MCI (5 MG Tablet 1 Oral three times daN Taken startkig 07/19/2011) Active.
Venlafaxine MCI (75VG Tablet 1 Oral twice a day, Taken starting 07/1912011) Active.
Xanax (IMG Tablet 1 Oral daily) Active. (Not written by NP55)
Cymballa (60MG Capsule DR Part I Oral daily) Active. (Not wrkten by NPSS)
Reguip (0.25MG Tablet 1 Oral at bedtime) Acbve. (Not written by NP 55)
Allerg ies (Ashley Lesco; 7/29(20118:56 AM)
No Known Allergies
Social History (Ashley Lest(); 7/29/20118:56 AM)
Most recent primary occupation. Professbnal wecialty. ATTORNEY
Maritsl status. Married.
No alcohol use
Children
Past Surgical History (Ashley Lesco; 7/29/2011 8:56 AM)
Spinal Fusbn. 2001.
2007 SPINAL CORDST1M
Diagnostic Studies History (Ashley Lesco; 7n9/2011 8:56 AM)
CBC (Complete Blood Count) w/diffe re ntlal. 8/13/2007 AND 81712007.
Revien of Systems (Ashley Lesco; 7/29/2011 8:56 AM)
General: Present-Medication Changes and Ti-edness.
Skin: Present-Excessive Sweating.
Gast r ointestina k Present-Constipation.
Musculoskeleta Present- Back Pain and Physical Disablity.
Neurological: Present- Numbness, Weakness and Tinging.
Psychiatrk: Present- Depression, Anxiety, Inability to Concentrate, Memcry Loss and Trouble fang Asleep.
Vials (Ashley Lesco; 7/29/2011 8:58 AM)
el #216:11$MeIght 75 in
Wevht wa s reporte d by pa bent.
Herght Was 'wa rted by pa tient.
Body Surface Area t 2.05 m2 Body Mass Index: 21.87 ko/m2
Briggs-29
Pain Level: 3/10
Temp.: 98 F Pulse; 70 (Regular)
no essst devke
no recent studies
Physical Exam (Carol B Mayne, PA-C; 7/29/2011 9:09 AM)
General
Menbl Status -Aiert General Appearance - Cocperative. Posture - Normal posture. Gait - Norm al.
Integumentary
Ge nera I Chars de ristics: Overall examinat3on of the patient's skin reveals - no rashes, no suspicious lesions and no bruises.
Eye
Pupil - Bilateral - Normal. Pupillary Slu - Bilateral - 3.0 min.
Chest and Lung Exam
Inspection: Shape - Normal and Symmetric Movements - Normal and Symmetrical Accessory muscles - No use of accessory muscles in
breathing.
Neurologic
M enta I Status: Thought content/perce ption - Normal.
Neuropsychiabic
Examination of related systems reveals- The patient is well-nourished and well-groomed. Mental status exam performed wkh findings of -
Associations - intact. )1,dg-trent and Insight - Insight is appropriate concerning matters relevant to self.
Assessment & Plan (Kenneth W Plman, MD; 7/29/2011 445 PM)
DEPENDENCE, OP1010, UNSPECIFIED (304.00)
Charmed to methadone from Fentanyt excessive somnolence from methadone, will cut back on dose and tkrate slowly.
Current Plans
I Methadone HO SMG, 1 Tablet at bedtime for 2 weeks then twice a day, #42. 30 days starting 0712912011, No Refill. Active.
I Follow uo in 4 weeks wkh Carol Mayne PA-C
I Folovv-Up for Medication Manaoement
LUMBAR POSTLAM1NECTOMY(722. 83)
Story: stimulator in Place. faked lumbar epidurals on medication rna naoernent.
W MBAR RAD1C1JLITIS (722.2)
DISORDER, ADRIS11ENT W/DEPRESSED MOOD (309.0)
Impression: on Effexor for noradrenernic /serotonin benefit for mood and pain
Signed electronically by Kenneth W PitrnaL MD (7/29P011 445 PM)
Page 36/52
06/06/2012 03:38pm3eff Briggs DOB 0112111970
Briggs-30
Jeff Briggs
7/19/2011 8:44 AM
Location; Nevada Pain &Spine Specialists
Patient 0: 15206
DOB: 1/21/1970
Male
History of Present Ilness (Carol B Mayne, PA-C; 7/1912011 9:10 AM)
The patient is a 41 year old male is here for follow up. Patient is here for medication management Patents pain is located in the low
back and in left leg(s). The patient describes the pain as sharp, dull, aching, burning, numbness, shooting, stabbing and tingling. Pain g ores
include a current pain level of 4/10 and this Is with medications. The patient states that the pdn has never made them borrow additional pain .
medication, made them run out early of their pain medication, made them take more than prescribed of their pain medication and made them
need to use alcohol/ marijuana/ other fttt substances to control th. The patient states that the pain has sometenes made them tense or
anxious, made them depressed or de,cou raged and made them irritable or upset The patient states that the pain does not interfere with yard
work or shopping and Having sexual relations. The patient states that the pain sometimes interferes with Going to work, performing household
chores, Socialtzing wth Mends, Recreation and hobbies, Physical exercise, sleep and Appette. Note for "Office visit foltivi up': Medication
management of failed back syndrome with stable course on 25 Fentanyi patch. On Pristiq as wdl. No short acting pain medication. He wit
loose insurance the first of August Ile has a stimulator in place with marginal beneft.
DISORDER, ADVSTMENT W/DEPRES5ED MOOD (309.0)
LUMBAR POSTLAMINECTO1.CY(722.83)
LUMBAR RADICULMS (722-2)
Medication History (Ashley Le.co; 7/19/2011 8:46 NI)
Gabapentin (100MG Capsule 1 Oral 1-3 po qhs, Taken starting 10/14/2010) Active.
Savelta (25MG Tablet 1 Oral, Taken starting 01/07/2011) Active.
FentaNYL (25MCG/HR Patch 72HR 1 Transdermal ever/ 48 hrs, Taken starting 06/21/2011) Active. (Use every 48, bra as insti
- ucted.)
Xanax (1MG Tablet 1 Oral daily) Active. (Not written by NPSS)
Cyrnbalta (60MG Capsule DR Part 1 Oral daily) Ac bye. (Not written by NPSS)
Requip (0.25M Tablet 1 Oral at bedtime) Active. (Not written by NPSS)
Review of Systems (Ashley Lesco; 7/19/2011 8:46 AM)
General: Present- Weight Loss.
Musculoskeletak Present-Back Pain.
Neurologkak Present- Numbness, Weakness and Ting fog.
Psychiatric Present- Depression, Anxiety, Inability to Concentrate, Memory Loss and Trouble Failing Asleep.
Vitals (Ashley Lesco; 7/19/2011 8:48 AM)
7 r q - u - 8 , 1 1 6 - A U e t: 1 _ _eight 75 in
t was reported by patient
Height was rrported by patimt
Body Surface Area: 2.05 rn 2 Boa/ Mass Index: 21.87 kg/m2
Temp.: 98.3 F Pulse: 74 (Regular)
BP: 120/7E1 (Sitting, Left A rm, Standard)
no assist devke
no rerent studies
Aswssment & Plan (Carol B Hayne, PA-C; 7/19/2011 9:14 AM)
Story: stimulator in place. faired lumbar epidurals on medication management.
Current Plans
I Venlafaxine HO 75MG. 1 Tablet twke a day. #60, 30 days starting 07/19/2011, Rd. x2. Active.
LUMBAR RADICUUTIS (7212)
Impression: secondary to chronic pain problem
Will trial on meth adone in Ieu of Fentanyt for cost advantaoe.
Current Plans
Methadone HO NG. 1 Tablet three tines defy. *90. 30 days starting 07/19/2011, No Refill. Active.
I Fotow up in
Page 37/52
06/06/2012 03:38 pmJeff Briggs DOB01/21/1970
Briggs-31
Signed electronally by Andrew C Wesely, MD (7/21/2011 7:58 AM)
Page 38/52
06/0612012 03:38 pmleft Briggs DOB01/21/1970
Briggs-32
Jeff Briggs
6/21/2011 8:46 AM
Patient it: 15206
D08: 1/21/1970
Married / language: Un defined / Pace: Undefined
Male
History of Present 11 ness (Andrew C Wesety, MD; 6121/2011 8:57 AM)
The patient is a 41 year old male is here for follow up. Patient is here for 1 month f/u appt and medication management Patient's pain is
located in the lower bark and in left leg(s) (knee and foot). The patient describes the pain as due, aching, burning, shooting, stabbing, throbbing
and tingling. Pam scores include a current pain level of 3/10 and this is with medications. The patient describes symptoms as improving and
medications are helpful. Patient has had no recent evaluations. Current treatment includes medication. Slew: averages about 5 tirs of - sleep per
night Medication concerns: none at this time. The patient states that the pain has never made them think that they would be better off dead, or
of hurting themsei in so, made them bon- ow additonal pan medication, made them run out eariy of their pain medication, made them take
more than prescribed of their pain medication and made them need to use alcohol/ marijuana/ other ilticit substances to control tin. The patient
states that the pain has sometimes made them tense or anxious, made them depressed or discouraged and made them irritable or upset. The
patient states that the pain does not interfere with Yard work or shopping, Sociaizng with friends and Having sexual relations. The patient
states that the pain sometimes interferes with performing household chores, Recreation and hobbies and Physical exercise The patient states
that the pain often interferes with Going to work, sleep and Appetite. Note for 'Office visit follow up":
overall doing fairly well on present regime working on behavioral issues. depression/anxiety are still ongoing issues he is working on. .
Revievv of Systems (layme Durkee, MA; 6/21/2011 8:52 AM)
General: Present- Weight Loss. Not Present- Fatigue and Weight Gain.
SkimNot Present- Excessive Sweating, Rash, Pigmentation, Change in Hair Growth or Loss, Nail Changes, Skin Color Changes, Bruising, Hair
Growth and Hair LDS&
HUNT: Not Present- Visual Loss, Hearing Loss, Glaucoma, Nose Bleed and Hoarseness.
Cardiovascular: Not Present- Chest Pain, Fainting, Sweling d Extremities and Irregular Heart Beat
Gastrointestinal: Present- Constipation. Not Present-Abdominal Pain, Nausea, Vomiting and Incontinence of Stool
Musculoskeletali Present- Back Pain. Not Present- Joint Pain, Muwle Weakness, Fractures, Muscle Pain, Muscle Cramps and Joint Swetling.
Neurological: Present- Numbness, Weakness and Tingling. Not Present- Trouble walking, Balance Problems and Headaches.
Psychiatric: Present- Depression, Anxiety, Inablity to Concentrate, Memory Loss and Trouble Falling Asleep.
\gals (.3ayme Durkee, MA; 6/21/20118:49 AM)
6/21/2911iLlq AM
Weight: 175b Height 75in
Weght was reportedby patent
Height was reportedby patient
Body Surface Area: 105ml Body Mass Index: 21.87kg/m2
Pain Level: 3/10
Temp.: 98.5 F
BM 142/82(Sitting, left Arm, Standard)
NO ASSISTIPE DEWCES
General
ental Status - Alert. Ge ner a I A ppearance - Cooperative Posture Normal posture. Gait - Normal .
Integumentary
General Characteristics: Overall examination of the patient's skin reveals - no rashes, no suspicious lesions and no bruises.
Eye
Pupil -Bilateral - Normal. Pupilla ry Sire - Bilateral - 3.0mm.
Chest and Lung Exam
Inspection: Shape - Normal and Symmetric. Movements - Normal and Symmetrical Accessory muscles -No use of accessory muscles in
breathing.
Neuroberic
Neuropsychlatric
Examination of related systems reveals - The patient is well-nourished and well-groomed. Mental status vam perforrned wth findings of -
Oriented X3 withappropriate mood and affect and able to articulate well withnormal speech/language, rate, volume and coherence.
Associations -intact. 3udgrnent and Insight - insight is appropriate concerning mattes relevant to self.
Assessment & Plan (Andrew C Wesely, MD; 6/21/2011 8:59AM)
06/061201203:38 pm Jeff Briggs 008 01/21/1970 Page 39/52
Briggs-33

LUMBAR RAD1CULITIS (722.2)
Current Plans
I FentaNYL 25MCG/HR, 1 Patch 72HR every 48 his, 15 Patch 72HR, 30 days starting 06/2112011, No Refil. Active.
I Folhavv UD With Dr. VVeselY
Folowup in 1 month or as needed
I FOLLOWUP WITHMIDLEVEL
DISORDER. ACOUSTMENT W/DEPRESSED MOOD (309.0)
Signed electronically by AndrewC Wesey, MD (6/21/2011 9:02 AM)
Page 40/52
06106/2012 03:38 pmJeff Briggs DOB 01121/1970
Briggs-34
Jeff Briggs
5/24/2011 8:41 AM
Locaton: Nevada Pain & Spine Sp&ialiets
Patent 47: 15206
DOB: 1/21/1970
Male
History of Present Illness (Andrew C Wesely, MD; 5125/2011 7:49 AM)
The patient e a41 year old male is here for follow up. Patient is ha-e for revievv imaging and medication mane/gement. Patients pain is
located in the low back and in left leg(s). The patient desubes the pain as burning, stabbing and tingling. Pain scores include a current pain
level of 6/10, this is with medicatbns and an aver -age pain level of 8/10. The patient describes symptoms as improving and medicatians are
helpful. Recent evaluations include (a/n) kw back x-ray. Current treatment includes medication and home exercises. Sleep: averages about?
hours cf sleep per night. Medication concerns: the path is only bsting 2 days. Note for Folow Up":
doing much better on patch, but it only lasts two days. UDT was OX. I
reviewed films. He has mild DOD above fusion at 134, and I see a bit
more angulation into flexion, but nothing dramatic (about 5-10 degrees). No cravings. No euphoria with path es. Mood much better.
Problem List/Past Medical )ayme Durkee, MA; 5/24/2011 8:45 AM)
LUMBAR RADI CULI TI S (722.2)
LUMBAR POSTLAMI NECTOMY(722.133)
DI SORDER, AD3USTMENT W/DEPRESSED MOOD (309.0)
Medication History ()erne Durkee, MA; 5/24/2011 8:45 AM)
Gabapentin (100MG Capsule 1 Oral 1-3 po qhs, Taken starting 10/14(2010) Active.
Savella (25ftC Tablet 1 Oral, Taken starting 01107/2011)ActNe.
FentaNYL (25MCG/HR Patch 72HR 1 Transdermal three times a week, Taken starting M/29/2011) Active.
Cymbalta (GCMG Capsule DR Pat 1 Oral daily) Active. (Not written by NPSS)
Requti (0.25MG Tablet 1 Oral at bedtime) Active. (Not written by NPSS)
Allergies (layrne Durkee, MA; 5/24/20118:45 AM)
No Known Allergies
Social History (Jayrne Durkee, MA; 5124/2011 8:45 AM)
Children
No akohol use
Non smoker/ no tobacco use
Past Surgical History ()ayme Durkee, MA; 5/24/2011 8:45 AM)
Epidural I njection (Lumbar). 9/15/2010, 1/11/2010, AND 10/15/2008.
Diagnostk Studies History (law* Durkee, MA; 5/24/2011 8:45 AM)
CB C (Complete Blood Count) w/diffe mntial. 8/13(2007 AND 8/7/2007.
Review of Systems (layme Durkee, MA; 5/24/2011 8:45 AM)
Generale Present-Weight Loss, Medication Changes and Tiredness. Not Present- Fatigue and Weight Gain.
Skin: Present-Excessive Sweating. Not Present- New Lesions, Rash and Skin Color Changes.
HEENT: Not Present- Visual Loss, Hearing Loss, Headache and Blurred Visbn.
Neck: Not Present Neck Pan and Neck Stiffness.
Respiratory: Not Present- Bloody sputum, Coug h, Difficulty Breathing and Wheezing.
Cardiovascular: Not Present- Chest Pain, FaI nbng, Shortness of Breath and Swelling of Extras I les.
Gastrointestinal: Present- Nausea and Van I tin42. Not Present- Bloody Stool, Abdominal Pain and Constipation.
Musculoskeletzilt Present- Musde Weakness. Not Present- Joint Pan, Back Pain and Physical Disability.
Neurological: Present-Trouble walking, Weakness and Tingling. Not Present- Numbness.
Psychiatric: Present- Depression, Anxiety, I nability to Concentrate, Memory Loss and Trouble Falling Asleep.
Endocrine: Present- Heat I ntolerance. Not Present- Cold I ntolerance, Excessive Sweating,
Lido Change and Sexual Dysfunction.
Vitals (layme Durkee, MA; 5/24/2011 8:43 AM)
5/24/2011 8:41 AM
06/06/2012 03:38 pm ler? Briggs DOB 01/21/1970
Page 41/52
Briggs-35

Weight: 175bHeir/lb75n
We:ght was reported by pa bent
Heght was moorted by patient.
Body Surface Area: 2.05m2 Body Mass Index: 21.87kg/m2
PainLevel: 6/10
Temp.: 97.9F Pulse: 60 (Regular)
NO ASSISTIVE DivrcEs
Physical Exam(Andrew C VVesely, MD; 5/24/20119:04 AM)
Thephysical examfindings areas follows:
General
Mental Status -Alert. General Appearance - Cooperative. Posture - Normal posture. Gak - Normal.
Integumentary
General Charaderistics: Overall examinationof thepatent's skinreveals - no rashes, no suspicious lesions and no bruises.
Eye
Pupil - Bilateral - Normal. Pupillary S172 -Bilateral - 3.0mm.
Chest and LungExam
Inspection: Shape - Normal and Syrnmetic. Movements - Normal and Symmetrical Accessory muscles - No useof accessory musclein
breathing.
Neurologic
Menta I Status: Thought content/perception- Normal.
Neuropsychlatric
Examinationof related systems meals- Thepatient is well-nourished and well-groomed. Mental status examperformed withfindings of -
Oriented X3 withappropriatemood and affect and ableto articulatewell withnormal speech/language, rate, volumeand coherence.
Associations - intact. Judgment and Insight - insight is appropriate concerningmattes relevant to self.
Akqessment & Plan(Andrew C Wesely, MD; 5/24/20119:06 AM)
LUMBARRADICULTT1S(722.2)
Current Plans
I FentaNYL25MCG/HR, 1 Patch72HRevery 48 bra, 15Path72HR, 30 days stating05/24/2011, No Refil. Active.
Useevery 48 hrs as instructed.
I Folow up withDr. Wesel,/
I Folow uo in1monthor as needed
I Medicationtitration
LUMBARPOS1IAMINECTOMY(722.831
DISORDER. ADJUSTMENTW/DEPRESSED MOOD (309.0)
Note: stirnsill coveringlegs whenneeded. I don't think hardwareremoval is a good ideal right now.
k
ote...404fits;;;--
7
Signed electronically by Andrew C Wesely, MD (5/25/20117:50 AM)
06/0612012 03136 pmJeff Eltiggs DOB0112111970
Page42(52
Briggs-36
Jeff Briggs
4129/20113:52 PM
Patient*: 1 5206
008: 1/21/1970
Male
History of Present II ness (Sara Mueller, MA; 412912011 3:57 PM)
The patient is a 41 year old male is here for follow up. Patient is here for mediation management Patient's pain is located in the low
back The patient describes the pah as burning, stabbing and tinging. Pan scores include a current pain level of 8/10 and an average pain level'
of 8/10. The patient describes symptoms as worsening and medications are not helpful (taking iliprofen and gabapentin). Recent evaluations
include (a/n) visit to the emergency room (went to the Northern Nevada ER on 4/27 for ncreased pain). Current treatment includes medication.
Patient reports that stress level is increawd (depression has worsened but is seeing a Psychologist and is able to take less of the Xanax). Sleep:
less than 4 hours. Mediation concerns: failed suboxcne, medications are not contrclling pan.
Problem List/Past Medical (Sara Mueller, MA; 4/29/2011 3:58 PM)
LUMBAR RADICULIIIS (722.2)
LUMBAR POSTLAMINECTOMY(7 22.83)
DISORDER, AD3USIMENT W/DEPRESS ED P4000 (309.0)
Medication History (Sara Mueller, MA; 4/29/2011 3:57 PM)
Savella (25MG Tablet 1 Oral, Taken starting 01/07/2011) Actrve.
Cymbalta (60MG Capsule DR Part 1 Oral daily) Active. (Not wrtten by NPSS)
Requip (0.25MG Tablet 1 Oral at bedtime) Active. (Not written by NPSS)
Oats (Sara Mueller, MA; 4/29/2011 4:00 PM)
4ae9l itigg?7it P eIght 75 in
Wep t was reported y pa bent
Heght W35 reported' by patient
Body Surface Area: 2.05 ma Body mass Index: 21.87 kg/ma
Pain Level: 7/10
Temp.: 98.8 F Pulse: 68 (Regular) Resp.: 16 (Unlabored)
BP: 148/96 (Sitting, Left Arm, Standard )
pain level is at a 7, pain score with meds
Physical Exam (Sara Mueller, MA; 4/29/2011 3 57 PM)
Note: depressed.
Genera l
M ental Status - Alert. General Appears nc e - Cooperative. Posture -Normal posture. GaR - Normal.
Integumentary
General Characteristics: Overall examination of the patient's skin reveals - no rashes, no suspicious lesions and no bruises.
Eye
Pupil -Bilateral -Normal. Pupilta ry Slre - Bilateral - 3.0mm.
Chest and Lung Exam
Inspection: Shape-Normal and Symmetric. Movements - Normal and Symmetrical Accessory muscles -Na use of accessory muscles in
breathing.
Neurologic
Mental Status: Thought content/perce ptl on - Normal.
Neuropsychiatric
Examination of related systems reveals - The patient is well-nourished and well-groomed. Mental status exam performed with findings of -
Associations -Intact. 3udgment and Insight - insight is appropriate concerning matters relevant to self.
Iv-qesment & Plan (Andrew C Wesely, MD; 4/29/2011 4:41 PM)
06/0612012 03:38 pm .1 eft Briggs COB 01/21/1970
Page 43/52
Briggs-37
Current Plans
DIAGNOSTIC RADIOGRAPHY, FLEXION AND/OR EXTENSION STUDIES
NPSS Urine Ouick Test (Inhouse) (80101)
Fe ntaNY L 25MCG1HR. 1 Patch 721- IR three times a week. 10 Patch 72HR, 30 days startina 0412912011, No Refill. Actwe.
Medication manazement (stable)
Folow up with Dr. Wesel,/
Folow up In 1 month or as needed
X-RAY EXAM OF LONER SPINE. COMPUTE (72114)
W MB AR PO STIA M INE CTO MY(722. 83)
DISORDER, ADJUSTMENT 1N/DEPRESSED MOOD (309.0)
Note: SEE DICTATION FOR TODAY'S VISIT
Signed electronically by Andrew C Wesey, MD (5/2/2011 9:23 AM)
Laboratories
NP SS Urine Qukk Test enhe us e) (80101) Ordered
Diagnosis: LUMBAR RADICUUTIS (722.2)
procedures
DIAGNOSTIC RADIOGRAPHY, RDUON AND/OR EXTENSION STUDIES
Performed: 04/2912011 (Ordered)
X-RAY EXAM OF LOWER SPINE, COMPLETE (72fl4) Performed: 04/29/2011 (Ordered)
Page 49/52
Briggs-38
Jeff BliggS
211120117:59 AM
lotaten: Nevada Pain & Spine Specialists
Patient*: 15206
008: 1/21/1970
Male
The patient es a41 year old Male.
Assessment & Plan (Andrew C Wesel', MD; 2/1/2011 8:29 AM)
DISORDER, ADJUSTMENT W/DEPRESSED M000 (309.0)
k
eeer.re--7
Signed electronicaly by Andrew C Wesely, MD (2/112011 6:47 PM)
Page 95/52
0610E42012 03:38 pm left Briggs DOB 01/21/1970
Briggs-39
History 8t Physical Report #4
Jeff Briggs
1/26/2011 10 29 AM
Location: 75NPSS FLUORO
Patent a: 15206
DOB: 1/21/1970
Married / Language: Un dein ed / Race: Undefined
Male
History of Present Illness (Andrew C Weseiy, MD; 1/27/2011 5:05 PM)
The patient is a 41 year old male is here for follow up. Patient is he for medication management (Pt had bad reaction lo suboxone, feels
like he has paricinsons due to muscle spasms.). Patient's pain is located in the low back. The patient descnbes the pain as burring, stabbing and
tingling. Pain scores irickide a current pain level of 4/10 and this S without medications. The patient describes s - ymptoms as worsening. Patient
has had no recent evaluations.. The patient S not currently being treated for this problem. Note for 'Follow Up :
failed suboxone. depression may heve been worsened. developed `blotches" cn skin, possbly representing allergic reaction. pain was a bit
better but overall not beneficial.
Problem List/Past Medical payme Durkee, MA;
1/26/2011 10:35 AM)
LUMBAR RADICUUTIS (122.2)
LUMBAR POSTLAMINEC10MY(722.113)
DISORDER, ADJUSTMENT W/DEPRESS ED MOOD (309.0)
Medication History (Jayme Durkee, MA; 1/26/201110:35 AM)
Suboxone (8-2MG Tab Subbngual 1 Subingual daiy, Taken starting 01/18/2011) Active.
Savelb (25MG Tablet I Oral, Taken starting 01(07/2 011) Active.
Gabapentin (100MG Capsule 1 Oral 1-3 pa ohs, Taken starting 10/14/2010) Active_
Xanax (1MG Tablet 1 Oral daily) Active. (Not written by NFSS)
Cymbaita (60MG Capsule DR Part 1 Oral daily) Active. (Not wrtten by NPSS)
Requip (0.25M Tablet 1 Oral at bedtime) Active. (Not written by NPSS)
Allergies (3ayme Durkee, MA; 1/26/201110:35 AM)
No Known Allergies
Social History ()ayne Durkee, MA; 1/26/201110:35 AM)
No akohol use
Currentwork status. Full-time.
Children
Non anoker / no tobacco use
Most recent primary occupation. Professional specially. ATTORNEY
Past Surgical History (layme Durkee, MA; 1/26/2011 10:35 AM)
Spinal Fusion 2001.
2007 SPINAL CORD ST114.
Diagnostic Studieshistory (hyme Durkee, MA; 1/26/2011 10:35 AM)
CBC (Complete Blood Count) w/dIffe mntial. 8/13/2007 AND 8/7/2007.
Review of Systems (lame Durkee, MA; 1/26/201110:34 AM)
General: Present-Weight Loss, Medication Changes and Tiredness. Not Present- Fatigue and Weight Gain.
Skin: Present- Excessive Sweating. Not Present- New Lesions, Rash and Skin Color Changes.
HEENTi Not Present- Visual loss, Hearing loss, Headache and Blurred Msion.
Neckt Not Present- Neck Pain and Neck Stiffness.
Respiratory: Not Present- Bloody sputum, Cough, Difficulty Breathing and Wheezing.
Cardiovascular: Not Present. Chest Pain, Fainting, Shortness of Breath and Sweling of Extrernkies.
Gastrointestinak Present- Nausea and Yorniting. Not Present- Bloody Stool, Abdominal Pain and Constipation.
Muscukskektak Present- Musde Weakness. Not Present-Joint Pain, B a c k Pain and Physical Disabdity.
Neurological Present-Trouble walking, Weakness and Tingling. Not Present- Numbness.
Psychiatric: Present- Depression, Anxiety, Inability to Concentrate, Memory Loss and Trouble Falling Asleep.
Endocrine: Present- Heat Intolerance. Not Present- Cold Intolerance, Excessive Sweating, libido Change and Sexual Dysfunction.
Vitals payme Durkee, MA; 1P6/2011 10 32 AM)
1/26/2911 LQ:11
Weight was reported by patient
Height was reported by patient
Page 46/52
06/06/201203:38 pm /eft Briggs DOB 01/21/1970
Briggs-40
Body Surface Area: 2.05 m2 Body Mass Index, 21.87 kg/m2
Temp.: 98.2 F Pulse: 60 (Regular)
no asstive devre
Physical Exam (Andrew C Wenely, MD; 1/27/2011 5:05 PM)
Note: depressed.
General
Mental Status - Alert. Ge ner al Appearance Cooperative Posture - Normal pasture. Gat - Norm al.
Integumentary
General Charade ristks: Overall examination of the patent's skin reveals - no rashes, no suspicious lesens and no bruises.
Eye
Pupil - Bilateral - Normd. Pupillary Size - Bilateral - 3.0mm.
Chest and Lung Exam
Inspection: Shape - Normal and Symmetric. Movements - Normal and Symmetrical Accessory muscles - No use of accessory muscles in
breathing.
Neurologic
He uropsychlatic
Examination of related systems reveals- The .patient is wel-nourishedt and well-groomed. Mental status exam performed with fin dins of -
Oriented X3 with appropriate mood and affect and able to articulate well with normal specch/language, rate, volume and coherence.
Associations - intact. 3ud7nent and Insight - insight is appropriate concerning matters relevant to self
Assessment & Plan (Andrew C Wesely, MD; 112712011 5:07 PM)
WM8AR POSTLAMINECTOMY(722.83)
Note: I don't have much more to offer for now. He may eventualy consider IDSS with oriel, but I think intractable depression is a big obstacle
to success wth pain management he will fu pm.
Signed electronically by Andrew C Wesely, MD (1/27/2011 5:07 PM)
Page 47/52
06/06/2 012 03:38 pmJeff Briggs DoB 01/21/1970
Briggs-41
Jeff Briggs
1/18/2011 7:59 AM
Location: Nevada Fain & Spine Specialists
Patient SI: 15206
DOB: 1/21/1970
Mal e
History of Present Illness (Andrew C Wesely, MD; 1/18/2011 8:29 AM)
The patient is a 40year old male is here for follow up. Patient is here for medication management and review d test results. Patient's
pan Is located in the low back. The patient descnbes the pan as burning, stabbing and tingling. Pain scores in aide a current pain level of 7/10
and this is with medications. Note for Follow Up':
not sure I savella is the right choice. it has only been two weeks, but sue dal thoughts have increased a bit. workng with behavioral health
and these issues are being worked on. I'm incined to stop savella and get back on celexa, which he has been stable on for a w hae we spent
quite some time talking about suboxone for pain. His testosterone level was acceptable.
Medication History (Ashley Lesco; 1/18/2011 8:03 PM)
Gabapenbn (100MG Capsule 1 Oral 1-3 po qhs, Taken starting 10/14/2010) Active-
Savella (25MG Tablet 1 Oral, Taken starting 01/07(2011) Active.
Cymbafta (60MG Capsule DR Pat 1 Oral daiy) Ac (Not written by NPSS)
Requp (0.25MG Tablet 1 Oral at bedtime) Active. (Not written by NPSS)
Alergies (Ashley Lesco; 1/18/2011 8:03 AM)
No Known A Nets*,
Social History (Ashley taco; 1/1812011 8:03 AM)
M arital stet us. Married.
Children
No alcohol use
Past Surgical History (Ashley Lesto; 1/18/2011 8:03 AM)
Epidural injection (Lumbar). 9/15/2010, 1/11/2010, AND 10/15/2008.
Diagnostic Studies history (Ashley Lesco; 1/18(2011 8:03 AM)
CB C (Complete Blood Count) widiffe re ntbl. 8/13/2007 AND 8[7/2007.
Review of Systems (Ashley Lesco; 1/18/2011 8:03 AM)
General: Not Present- Fatigue, Weight Gain, Weight Loss, Medication Changes and Tiredness.
Skin: Not Present- Excessive Sweating,. New Lesions, Rash and Skin Color (lenges.
HEENT: Not Present- Visual Loss, Hearing Loss, Headache and Blurred Msion.
Neck: Not Present- Neck Pain arid Neck Stiffness.
Respiratory: Not Present- Bloody sputum, Cough, Difficulty Breathing and Wheezing.
Cardiovascular: Not Present- Chest Pain, Fainting, Shortness of Breath and Sweling of Extrem ties.
Gastrointestinal: Not Present- Bloody Stod, Abdominal Pain, ConstPation, Nausea and Vcmting.
Musculoskeletak Not Present- Joint Pain, Muscle Weakness, Back Pan and Physical Disabilty.
Neurological: Not Present- Numbness, Trouble walking, Weakness and Tinging.
Psychiatric: Not Present- Depression, Anxiety, Inability to Concentrate, Memory Loss and Trou bie Falling Asleep.
Endocrine: Not Present- Cold Intolerance, Excessive Sweating, Heat Intolerance, Libido Change and Sem al Dysfunction.
Vials (Ashley Lesco; 1/18/2011 8:06 AM)
//1812011 8'0 AM
Pain Level: 7/10
Temp.: 97.6F Pulse: BO (Regular)
no assist elevke
no recent pacer/um
Testosterone Labs available
06/06/2012 03:38 pm Jeff Briggs COB 01/21/1970
Page 48/52
Briggs-42
pt notes be is havilg increase ii sue idal thoughts widi the med change
Note: not actively suicidal. ow stable.
General
M enta I Status - Alert. Ge neral Appearance - Cooperative. Posture - Normal posture. Gait - Normal.
Integumentary
General Characte ristks I Overall examination of the patient's skin reveals - no rashes, no - suspicious lesions and no bruises.
Eye
Pupil - Bilateral- Normal. Pupillary Size - Bilateral - 3.0mm.
Chest and Lung Exam
breathing.
Neurologic
M enta I Status: Thought content/perception - Normal.
Neuropsychlatric
Examination of related systems renals patient is we1-nourished and welkyoomed. Mental status exam performed wkh fn dings of -
Associations - Intact. Judgment and Insight - Insight is appropriate concerning matters relevant to self.
Assessment & Plan (Andrew C VVesely, MD; 1/18/2011 13:38 AM)
WMBAR RADICUUTIS (722.2)
LUMBAR POS1LAM1NECTOMY(722.83)
Current Plans
Suboxone13-2MG, 1 Tab Sublinoual daily. 30 Tab Sublinoual. 30 days startino 01/18/2011. No Refill Active
Note: We are triaing suboxone for pain control. Opiod dependence is NOT an issue in this case. He is presently NOT using op ioids. Akhough
an off label use, this medications presents certain advantages tor his particular clinical situation. fu in in two weeks.
k
eAleder-c--7
Sgned electronically by Andrew C Wesely, MD (1118/2011 3:20 PM)
Page 49/52
06/0612022 03:38 pm Jeff Briggs DOB 01/21/1970
Briggs-43
Jeff Briggs
1/7/201110:00 AM
Locaton: 75NPSS FLUORO
Patent #: 15206
DOB: 1/21/1970
Male
History of Present Ilness (Andrew C WeseY, MD; 1/712013 11:52 AM)
The patient is a 40 year old male who presents with chronic pain. Patient is here for medication.management Patient's pain is located in
the Lower back and in Biateral leg(s). The patient describes the pain as sharp, dull, aching, burning, numbness, crampy, shooting, stabbing,
stinging, throbbing and constant. Pain scores include a current pain level of 8/10 and this is without medications. Patient has had no recent
evaluations.. Medication concerns: none at this time. Note for "Follow Up':
spoke with wife a while ago. stimulator st0I helping but not enough to prevent functional decline, and progressive depression. Has struggled
with opicid dePendence and alcoholism in the past making him very leery of habtuating substances. sti1wit, top and bilateral leg pain following
instrumented decompression/fusion.
stringing for work as attorney, recently separated from wife, quite depressed and seeing psychologist. on 55R1 from PCP (mccorma;k).
Problem List/Past Medical (Danielle Hassler, MA; 1/71201110:06 AM)
Medication History (Danielletlassler, MA; 1/7/2011 10)36AM)
Cymbalta (60MG Capsule DR Part 1 Oral daily) Active. (Not wrtten by NPSS)
Requip (0.25MG Tablet 1 Oral at bedtime) Active. (Not written by NPSS)
Review of Systems (Danielle Hassler, MA;
1/7/201110:06
NI)
General: Present- Weight LOSS, Medication Changes and Tiredness. Not Present- Fatigue and Weight Gain.
Skin: Not Present- Excessive Sweating, New Lesions, Rash and Skin Color Changes.
HUNT: Not Present- 14sual Loss Heanng Loss, Headache and Blurred Vision.
Neck: Not Present- Neck Pain and Neck Stiffness.
Respiratory: Not PresentBloody sputum, Cough, Difficulty Breathing and Wheezing.
Cardiovascular: Not Present- Chest Pain, Fainbng, Shortness of Breath and Sweling of Extremities.
GastroIntestInak Not Present- Bloody Stool, Abdominal Pain, Constpation Nausea and Waiting. and
Present- Back Pain. Not Present- Joint Pan, Muscle Weakne ss and Physical Disabliti.
Neurologicak Not Present- Numbness, Trouble walking, Weakness and Tinging.
Psychlatrk: Present- Depression, Arodety. Inability to Concentrate, f4ernory loss and Trouble Falling Asleep.
Endocrine: Not Present- Cold intolerance, Excessive Sweating, Heat intolerance, Libido Change and Sexual Dysfunction.
Physical Exam (Andrew C Wesely, MD;
1/7/201111:47 AM)
Note: le neuro grossly htact. a bit depressed with lack of hope. separated frcrn wife at this time.
General
Mental Status - Anxious. General Ap pea ranee -Cooperative. Pasture - Normal posture. Galt - Normal.
Integumentary
General Charaderistks: Overall examination of the patient's skin reveals - no rashes, no suspicious lesions and no bruises.
Eye
Pupil - Bilateral -Normal. Pupillary Size - Bilateral - 3.0mm.
Chest and Lung Exam
breathing.
Neuro logk
Mental Status: Tho ught content/perception - Normal,
Neuropsychiatrk
Examination of related systems reieals- The patient is wet-nourished and well-groomed. Mental status exam pc-formed with
In dogs of -
Oriented X3 with appropriate mood and affect and able to articulate weil with normal speech/language, rate, volume
and coherence.
Associations - intact. Judgment and Insight - insight is appropriate concerning matters relevant to self.
Assessment & Plan (Andrew C Wendy, MD; 1/7/201111:50 AM)
Page 51/52
Briggs-44
DISORDER, AD)USTMENT W/DEPRESSED MOOD (309.0)
Cur- rent Plans
I TOTAL TESTOSTERONE (84403)
I Save!la 25VG. Active.
Note: trial saveila starter pack. screen for hypogonadism. stop celexa while trialing savela. consider low risk opoid-type meds for improved
pain control: suboxone, tramadol, nucynta (urn two weeks
k
izegiole
Signed electrontally by Andrew C Wesely, MD (1/7(2011 12:04 PM)
Laboratories
TOTAL TESTOSTERONE (84403) Ordered
Diagnosis: DISORDER, ADJUSTMENT W/DEPRESSED MOOD (309.0)
Page 52/52
06/06/2012 03:38 pm eft' Briggs DOB 01/21/1970
Briggs-45
Jeff Briggs
02/23/2012 08:25 AM
Patient #: 15206
DOB: 01/21/1970
Marital status: Married / Language: Undefined / Race: Undefined / Ethnicity: Undefined
Gender: Male
History of Present Illness fcarda Ha" PA-0O2/23/2012 08:47"
The patient Is a 42 year old male Is here for follow up. Patient is here for medication management and a post-
block follow up. Patient's pain is located in the low back and In left leg(s). The patient describes the pain as
stabbing and shooting. Pain scores include a current pain level of 4/10 and this is with medications. The patient
describes symptoms as Improving and medications are helpful. Patient recently had (a/n) epidural steroid, lumbar.
The pain was diminished by 50 % after the procedure and pain relief duration Is Indeterminate at this time.. Patient
has had no recent evaluations.. Current treatment includes medication. Patient reports that stress level Is
unchanged. Sleep: sleep moderately. The patient states that the pain has never made them borrow additional pain
medication, never made them run out early of their pain medication, never made them take more than prescribed of
their pain medication and never made them need to use alcohol/ marijuana/ other Illicit substances. The patient
states that the pain has sometimes made them tense or anxious, sometimes made them depressed or discouraged
and sometimes made them irritable or upset. The patient states that the pain never interferes with Going to work,
never Interferes with Yard work or shopping, never interferes with Socializing with friends, never interferes with
Recreation and hobbies, never interferes with Having sexual relations, never Interferes with sleep and never
interferes with Appetite. The patient states that the pain sometimes Interferes with performing household chores.
The patient states that the pain often Interferes with physical exercise. Note for *Office Visit Follow Up": Current
regiment Is working well. He has much less discomfort with epidural performed 1/30/12. Able to change fentanyl
patch every 3 days now. Using oxycodone pm generally four daily.
Alleraies Karp/a Ha" PA-C 02/23/1011 aesso "
No Known Allergies
Past Medical History (Carol 8 name PA-C. 01,2. 52011 0850 Am)
Last UDS: 12/29/11
LUMBAR RADICULMS (722.2): history of fusion from 1.4-51
LUMBAR POSTLAMINECTOMY(722.83); stimulator In place.
Last DEA; 7/14/11
Contracts Updated: 9/20/11
Last seen by NPSS M.D.; Dr Weselv 6/21/11
Sodal History (Carol Harm. PA-C 02/23/2011 08:50 AM)
No alcohol use
Children
Marital status
Highest Education Level Attained: JURIS DOCTOR
Most recent primary occupation: ATTORNEY
Current work status
Medication History (OW 13 Mayne. PA-C 01/23/1012 011:50 AM)
FentaNYL (50MCG/HR Patch 72HR 1 Transdermal every 48 hrs, Taken starting 01/27/2012) Active - Hx Entry. (Use
every 48 hrs as instructed.)
Oxycodone-Acetamlnophen (7.5-325MG Tablet 1 Oral every 4 to 6 hours, Taken starting 01127/2012) Active -
Hx
Entry.
Cyrnbalta (60MG Capsule DR Part 1 Oral daily, Taken starting 02/23/2012) Active - fix Entry. (for pain and
depression)
Other Problems Komi Horne, PA-C 01/23/201208. 10 AM)
depression
Past Surgical (Ord B Ha" PA-C 02/23/2011 08:50 Am)
Epidural Inlection (Lumbar)
Spinal Fusion; 200114-5 and 15-51 posterior fusion with cage
Epidural Injection (Lumbar); 9/15/2010. 1/11/2010, AND 10/15/2008.
Wednesday, June 6, 2012
Page 1 / 4
Briggs-46
Diagnostic Studies (Carol 8 Marne PA-C 02/21/70.11 oalo Am)
CBC (Complete Blood Count) w/differential; 8/13/2007 AND 8/7/2007.
Review of Systems (8ecity Gatrs; 0212317012 08 30 API)
General: Present- Tiredness.
Skin: Present- Excessive Sweating.
Gastrointestinal: Present- Constipation.
Endocrine: Present- Heat Intolerance.
Vitals (Bedy Gates; 02/732012 08:33
02123/2012 08:31 AM
Weight: 175 lb Height: 75 In
Body Surface Area: 2.05 m2 Body Mass Index: 21.87 kg/m2
Pa in level: 4/10
Pulse: 86 (Regular)
BP: 140/90 Manual (Sitting, Left Aim, Standard)
no assist device
no recent studies
Physical Exam (Oro/ 8 Hayne, PA-C 0217317012 (i8:47 Am)
General
Mental Status - Alert. General Appearance - Cooperative. Posture - Normal posture. Gait - Normal.
Integumentary
General Characteristics: Overall examination of the patient's skin reveals - no rashes, no suspicious lesions and
no bruises.
Head and Neck
Head - normocephalic, atraumatic with no lesions or palpable masses.
Eye
Pupil - Bilateral - Normal. Pupillary Size - Bilateral - 3.0mm.
Chest and Lung Exam
Inspection: Shape - Normal and Symmetric. Movements - Normal and Symmetrical. Accessory muscles - No
use of accessory muscles in breathing.
Cardiovascular
Cardiovascular examination reveals - normal heart sounds, regular rate and rhythm with no murmurs and carotid
auscultation reveals no bruits.
Abdomen
Palpation/Percussion: Palpation and Percussion of the abdomen reveal - Non Tender and No Rebound
tenderness.
Peripheral Vascular
Lower Extremity:
Palpation: Temperature - Bilateral - Normal. Homan's sign - Bilateral - Negative (normal). Dorsalis pedis
pulse - Bilateral - Normal. Posterior tibial pulse - Bilateral - Normal.
Page 2 / 4
Briggs-47
Neurologic
Neuropsychlatric
Examination of related systems reveals - The patient is welt-nourished and well-groomed. Mental status exam
performed with findings of - Oriented X3 with appropriate mood and affect and ableto articulate well with normal
speech/language, rate, volume and coherence. Associations - intact. Judgment and Insight - insight is
appropriate concerning matters relevant to self.
Mysculoskeletal
Trigger Point Examination: Back & Lower Extremity - Bilateral - trigger points palpated, Gluteus maximus,
Iliocostalis lumborum, longissimus lumborum, MuMMus and Quadrates lumborum.
Spine/Ribs/Pelvis
Pelvic Region: Functional Testing - Sacroiliac compression test negative.
Lumbosacral Spine:
Repeated Movements Assessment: Retraction/Extension,supine - does not affect pain.
Rotation, (R) - does
not affect pain. Rotation, (L) - does not affect pain. Repeated flexion - does not affect pain. Extension - does
not affect pain. Deformities/Malalignments/Discrepancies - lumbar lordosis positive.
Lower Extremity
Hip: Examination of the right hip reveals - normal range of motion, no crepitus. Examination of the left hip reveals
- normal range of motion, no crepitus.
Fibromyalgia Exam - Bilateral - fibrornyalgia sites nontender.
Assessment & Plan (Cord B /lame, PA-C 02/23/201208:51 AM)
Today's Impression: Secondary to chronic pain problem
Current Plans:
Today's Impression: on Cymbalta.
Current Plans:
Cymbalta 60MG, 1 Capsule DR Part daily, #60, 60 days starting 02/23/2012, No Refill. Active.
Current Plans:
Problem Story: history of fusion from 14-51
Today's Impression: symptoms of 15-S1 left radiculitis with good response to LES'.
Current Plans:
Oxycodone-Acetaminophen 7.5-325MG, 3 Tablet every 4 to 6 hours, 4/100, 30 days starting 02/23/2012, No
Refill. Active.
FentaNYL 50MCG/HR, 1 Patch 72HR every 48 hrs, 10 Patch 72HR, 30 days starting 02/23/2012, No Refill.
Active.
Follow up in 4 weeks with Carol Hayne PA-C
Follow-Up for Medication Management
Referral: Physical Therapy
Intolerant of methadone and suboxone, back on fentanyl with perrocet with stable doses
stimulator in place, not using with any regularity as it causes muscle spasms.
Page 3/4
Briggs-48
Page 4 / 4
ek t . t , e: g( r
Carol B Hayne PA-C
Briggs-49
H lt1 511912012: 09: 10PMPAOE1/003FaxServer
RENOWN SOUTH MEADOWSMEDICAL CENTER BRIGGS,JEFF
10101 DOUBLER BLVD Mr:1N:309t D11
RENOWN SOUTH MEADOWSMEDICAL CENTER BRIGGS,JEFF
10101 DOUBLER BLVD MRN:3091011
RENO, NV 89521-3149DOB:121/1970, Sex:PA
Aorn:6/14/2012 D/C:5/14/2012
**"*This report has not been reviewed orauthenticated by theresponsibleprovider.
EncounterInformation
Encounter I:dolt/Imam
C,SNit -Pociity , Adntit Cote:- ::.! DischargeDate
11500572824 RENOWN SOUTH MEADOWSMEDICAL CENTER May 14, 2012may 14.2012
OR Surgeon flied by Andrew C Wesely, M.D. I Draft: Not Electronically Shred
Author: AndrewC Wanly, M.D. Se:vice: (none) AuthorType:Physician
Red: 05/141121317 NoteTime:05111/121009
DATE OF OPERATION: 0914/2012
PREOPERATIVE DIAGNOSES:
1. Failed back surgery syndrome
2. spinal cord stimulator system implantation, several years ago.
3. Failure ol spinal cord stimulator system without acceptable side
ettects.
POSTOPERATIVE DIAGNOSIS:
OPERATION PERFORMED:
1. Explantation or spinal electrode array.
2. Explantallon of right &teal IPG.
3. Fluoroscopic guidance.
SURGEON: Andrew C. Wesely. M.D.
ASSISTANT:
ANESTHESIOLOGIST:
ANESTHESIA:
INFORMED CONSENT: The risks. benefits. indications and alternatives
to todays Injection treatment were reviewed with the patent.
Specifically mentioned was the very small but theoretically possible
chance of bleecing, infection, vascular injury, neurobgical injury,
paralysis. seizure, lung puncture C m collapse, allergic reaction,
worsentng of pain, orlack of Improvement in pain. Although extremety
rare, such events could posmbly lead to death. The potient agreed to
proceed.
NARRATIVE: The patient was brought In today for explantation of his
Boston Scientific spinal cord stimulator system. Although thedevice
worked very well forhimtorseveral years, overlimeit became
Renown.
06/061201203:45pin Jeff Briggs DOB 01/21/1970
Pt.NameGriggs, Jell (MR4:3091011) Page1
2/4
Briggs-50
Pt.NarneBriggs,JeIt (MRN:3091011) Page 2
HIM 5114/20124:09:10 PM PAOE2/003 FaxServer
RENOWN SOUTH MEADOWS MEDICAL CENTER
10101 DOUBLER BLVD
RENO, NV 89521-3149
BRIGGS,JEFF
MRN: 3001011
0013: 1/2111910, Sex: M
Adrn:6/14/2012,D/OVI 4/2012
Encounter Inlormation (continued)
gradually ess effective. Ultimately. heperceived thetingling to be
otherthan analgesic. Heultmately stopped using thedevice
attOgether. Heis hereforexplantation.
DETAILSOFPROCEDURE: Alterdismissing thecasepreoperatively with
him, Starding obtaining en informed consent priorto any sedation, he
was brought in to theoperating mom. Prophylactic antibiotics were
administered perprotocol. Hewas anesthetized supineand then placed
In theproneposition. Pressurepoints werechecked pertheOR staff
and Anesthesia.
His tow back was sterilety prepped and draped. FlUoroscopy was used
to Identify at thedevices and components of thespinal cord
stimulatorsystem. A 5 crn horizontal incision was carried out over
his cold IPG scarin the right gluteal area. Blunt dissection was used
to mobile. theIPG device, and it was removed uneventfully. The
electrodes entering theIPG pocket wereIdentified and snaps were
applied.
A spinal incision was then carried out overtheprevious siteof
Insertion, again approximately 5 an in length. Blunt dissection was
carded out subcutaneously to exposethestimulatorwires, the
restraining loop, and theanchorsites. Thesewere811 mobilized and
theelectrodes wereeasily removed horn theepidural space.
Fluoroscopy was used to makeabsolutely sureall components of the
spinal cord stimulator system werecompletely removed.
Both wounds werecopiously Irrigated with badtracIn solution and
hemoetaeiewas achieved wah electromutery, as needed. Thewounds
werethen closet, in 2 layers with interrupted Vicryls bringing the
deepersubcutaneous and cutaneous layers together, and staples were
applied to theskin edges. Thewounds weredressed with Xeroform
gauzeand Tegaderm dressing overasterile 4x4.
Theprocedurewas weetolerated. Therewereno apparent
compications. Hewas dscharg cd to therecovery room alteremergence
from general anesthesiaperanesthetic record.
Andrew C. Wesety, M.D.
ACW/MEDO
DD: 05114/2012 1009 AM
DT: 05/14(20121:11 PM
2017493 Jobe: 513839573
cc: ANDREW C. WESELY, M.D.
3/4
06/06/201203:45 pin Jeff Briggs DOB 01121/1970
Briggs-51
PI.NameStiggs. Jett (ARN:3091011) Page 3
HIM 5/14/2012 4:09:10 PH PAOE 3/003 FaxServer
RENOWN SOUTH MEADOWS MEDICAL CENTER BRIGGS,JEFF
10101 DOUBLE R BLVD MRN:aossoi I
RENO. NV89521-3149 DOB: 121/1970, Sex: M
Adm:5)14/2012JM5/1412012
EncounterInformation (continued)
4/4 06/06/2012 03:45 pm Jeff Briggs BOB 01/21/1970
Briggs-52
Reitown.
PI NaneBrigos, Jell (MRN:3091011) Page I
U,11 HIM 1131/20126:44:16 AM PAGE 11002FaxServer
RGNOVIN GOUT H ME.ADOWSMEDICAL CENTER BRIGGSAFF
10101 DOUBLE R BLVD MRN. 3094011
RENO, NV 89521-3149 DOB: 112111970, Sex: M
Adm:1/30.2012, DIcy30/2012
This report has not been reviewed Or authenticated by the responsible provider.
Encountet Information
Encounter Information
2 t 0599011 RENOWN SOUTH MEADOWSAEDICAL CENTER Jan 30, 2012
.:rINsr_nsrge tee
Jan !0, 2012
Procedures Mad by Andrew C Wesely,11.13 ;Draft: Hot Electronically Sianed
Autnor: Andrew C wasely, M.D. Service: 'none) Author Type: Physician
Filed: 01/31/120643 Nolo Time: 011301121710
DATE OFPROCEDURE: 01/3012012
DIAGNOSES:
I. Failed back surgery syndrome.
2. Chronic klmbosacral radicu this.
3. Flistory of favorable response to epidural steroid Injections in
the past.
PROCEDURES:
1. inleriaminar lumbar epidural steroid Injection on the left at L.5-
St .
2. Needle guidance Using fluoroscopy.
INFORMED CONSENT: The risks, benefits. Indications and alternatives
to toclay's Injection treatment were reviewed with
Specific:ay rnentbned was the very small but theoreticalty portable
chance at bleeding, Infection, vascular injury, neurological injury,
paralysis, seizure, lung puncture or collapse, allergic reaction,
Worsening of pain, or lack of improvement in paln. Although extremely
rare, ouch events could possibly lead to death. The patient agreed to
proceed.
NARRATIVE: Alter the patient was placed prone In the operative suite.
his low back was sterilely prepped and draped. After the sidn was
anesthetized, an epidural injection was carried out at an area where
he did not appear to previously have fusion. Multiplanar needle ot
lip evaluation was carried out per protocol. Visualization was a bit
difticut because of extensive previous surgery and hardware in place.
Nevertheless. a good epidurogram was achieved and the epidural space
was Infiltrated with 6cc containing 80 mg of Depo-Medrol and the
temaining volume of 03% Edocaine.
06/06/2012 03:41 pm
lefi Briggs COB 01/21/1970 2/3
Briggs-53
it. C 3 1 0Vrtx. . .
NarrieBriggs, Jeff (MRN:3091011) Page 2
HIM 1/31/2012 6:4416AM PAGE2/002 FaxServer
RENOWN SOUTH MEADOWSMEDICAL CENTER
10101 DOUBLER BLVD
RENO, NV 89521-3149
BRIGGS,JEFF
MRN. nes 011
DOB: 1/2111370. Sex: M
Ad/n:1/30/2012, 0/0:1 /3 0/201 2
Encounter IntormaIlon (continued)
Procedure was well tolerated. No apparent corn pkations. He was
discharged home in stable condition after uneventful recovery.
Andrew C. Wesely, MD.
ACW/MEDO
DD: 01/30/2012 5;10 PM
DT: 011312012 siaam
D: 1809450 John: 499431276
cc: ANDREW C. WESELY. M.D.
06/06/2012 03:41 pm
Jeff Briggs 003 01121/1970 3/3
Briggs-54
PAIN MANAGEMENT FOLLOW-UP REPORT
CC:
Andrew C. Wesely, M.D.
PATIENT: BRIGGS, JEFF ID#: 15206 DATE: 52no11
INTERVAL HISTORY:
Jeff comes back in for a followup. His situation is unchanged significantly from before although his pain
has progressively worsened. He is requesting to go back onto chronic opioid analgesic therapy to control
his pain. He has a well-established diagnosis of failed back surgery syndrome having previously
undergone instrumented decompression and fusion by Dr. Blakey back in 2001. He subsequently went on
to have a spinal cord stimulator placed in 2007 which was helpful in relieving his back and leg pain at the
time. Unfortunately the device is not clearly helping him anymore although when he does turn it on it
does get stimulation to his back and legs.
He recently had a pain flare and went to the emergency room. He was given some Percocet and Toradol,
and felt much better.
He has not had any new imaging for many years although he has not had any obvious intervening history.
REVIEW OF SYSTEMS:
He denies any trouble with bowel or bladder control problems or saddle anesthesia. There are no
problems of lower extremity numbness, weakness or paralysis.
PHYSICAL EXAM:
Jeff walks in today with a normal gait. He is not using any assistive devices. He is not limping. Motor,
sensory, and reflex functions are all intact. There are no sciatic tension signs. He does have tight
hamstrings, from probably lack of stretching.
He has diffuse pain across the lumbosacral junction mostly over the left side in the sacroiliac sulcus and a
little bit of left sciatic notch tenderness.
ASSESSMENT:
I. Post-larninectomy pain syndrome with chronic lumbosacral radiculitis without evidence of frank
radiculopathy.
2. Desire to go on COAT for pain control and improved function.
3. I note recent failure in buprenorphine trial.
4. History of reasonable, but only temporary benefit with injection therapies.
5. Presence of spinal cord stimulator device, questionable benefit at this time.
NEVADA PAIN St SPINE SPECIALISTS
605 SIERRA ROSE DRIVE, SUITE 4
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
PATIENT NAME: BRIGGS, JEFF
PHYSICIAN: ANDREW C. WESELY, M.D.
MEDREC#: 15206
OUTPATIENT: PAIN MANAGEMENT CLINIC
PAGE: 1 0F2
Briggs-55
PLAN:
I. I had a long talk with Jeff today. The risks of going on COAT were reviewed with him, but may be
a reasonable option presently given his circumstances. We will begin him with Duragesic at 25
mcg an hour, hopefully avoiding the use of breakthrough pain medicine and short-acting agents.
Other options do include methadone and MS Contin which have not yet been trialed. He continues
to use gabapentin but is not sure if it is helping him or not. I suggested he trial a withdrawal from
the medicine and see what happens.
2. I will get standing x-rays including flexion and extension views to make sure there are not any
obvious degenerative changes above his fusion. If there is any suspicion of this, then we may need
to explant his stimulator device in order to get an MRI to reassess him.
3. Baseline UDT today and follomp in two weeks with one of our nurses.
4. I would like to see him back in a month for data review.
5. He will continue to work with his psychologist. His primary psychological struggle continues to be
depression, which probably is significantly associated with his chronic pain problem.
P s 1 4 , 9 w - t o
ACW/crn
Job t h 53935558
Date Dictated: 5/2/2011
Date Transcribed: 5/2/2011
(Transcribed and sent without review to expedite mailing)
NEVADA PAIN & SPINE SPECIALISTS
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775)689-5432
PHYSICIAN: ANDREW C. \VESELY, M.D.
MEDRECO: 15206
PAGE: 2 OF 2
Briggs-56
CC:
PATIENT: BRIGGS, JEFF ID#: 15206 DATE: 9/1512010
INTERVAL HISTORY:
I saw Jeff today and carried out bilateral SI selective nerve root infiltrations. He did very well. I also
spot checked his electrode array and although there was a bit of a dislodgement as noted previously, his
electrodes are certainly in an acceptable position with them in the midline, staggered on top of one
another straddling from about T9 through T12. He continues to get good slim. He will followup with
Katie Toledo, A.P.N. as scheduled.
ACW/cm
Job t 46638374
Date Dictated: 911512010
Date Transcribed: 9/1612010

RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
MEDREC#: 15206
PAGE: 1 OF 1
Briggs-57
cc: Andrew Wesely, M.D.
Brian McCormack, M.D.(Autofax)
Pamela Hassler, PA-C
PATIENT: BRIGGS, JEFF IDN: 15206 DATE: 2/1112010
DATE OF BIRTH: 1121/1970
INTERVAL HISTORY:
Jeff comes in today for post-block followup. He had an lumbar epidural steroid infiltration on
01/11/2010. He states that it was helpful for his leg pain which has improved approximately 80% but he
has had no improvement of his low back pain. He has episodic "spasms" where he "locks up" with a
sharp, dull, aching, burning, numbing, cramping, and shooting pain. He has had two episodes since the
procedure. He did try his Lidoderm patches which helped him. He would like to try a prescription for
this. He rates his pain as averaging 7 out of 10.
CURRENT MEDICATIONS:
His primary care provider has given him Cymbalta 60 mg which he has been on for one week. He has not
noticed any significant changes. He does continue to take alprazolam approximately 0.5 mg b.i.d.
PHYSICAL EXAMINATION:
The patient is alert and oriented, answers questions appropriately. He walks with no assistive devices.
His pupils are equal and reactive. Blood pressure 108/71, pulse 87, and temperature 98.3. He does have
diffuse myofascial tenderness over the entire lumbar region. Limited range of motion with both flexion
and twisting bilaterally.
ASSESSMENT:
I. Post-laminectomy syndrome lumbar with myofascial component.
2. Status post lumbar epidural steroid injection.
TREATMENT PLAN:
I. The patient was given samples of Voltaren gel and Lidoderm patches x2. He is also given a
prescription for the Lidoderm patches. He will call us if he would like a prescription for the
Voltaren.
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
PHYSICIAN: PAMELA HASSLER, PA-C
MEDRECN: 15206
PAGE: 1 0F2
Briggs-58
2. He will followup in one month with Dr. Wesely.
Pamela Hassler, PA-C
PH/cm
Job 40339469
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775)689-5432
PHYSICIAN: PAMELA HASSLER, PA-C
MEDREC#: 15206
PAGE: 2 OF 2
Briggs-59
CC:
PATIENT: BRIGGS, JEFF IDN: 15206 DATE: 1/1112010
INTERVAL HISTORY:
Jeff is here for a followup visit. Jeff has a stimulator in place for failed back surgery syndrome and
chronic left-sided lurnbosacral radiculitis. He is doing well and then this fall was doing some lifting and
had a flare in his loW back and left leg pain. He also took up karate and it sounds like he was doing some
sparring type activity and again had a flare in his symptoms. He has had fusions from L4 through SI
which appears stable.
REVIEW OF SYSTEMS:
He has not had any persistent paralysis, bowel or bladder control problems or saddle analgesia. He does
have some aching left leg pain which is more in the sciatic type distribution, into his posterior calf and
lateral foot.
PHYSICAL EXAM:
On exam today Jeff is neurologically intact and walks in without any gait abnormalities. Blood pressure
118/74, pulse 66, temperature 98_8.
He has mild sciatic tension signs on the left but otherwise appears neurologically intact.
ASSESSMENT:
1. Probable pain flare following increased activity.
2. Significant disk herniation above fusion unlikely based on exam and history.
3. He continues to get good stimulation into his distribution of pain, suggesting that significant lead
dislodgement of lead migration is unlikely.
PLAN:
I. Trial left SI epidural steroid infiltration.
2. Spot films today to confirm electrode array positioning.
3. Followup in one month for review and re-evaluation.
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
MEDREC#: 15206
PAGE: 1 0F2
ADDENDUM:
X-ray evaluation of electrode placement: Jeffs left stimulator electrode array has dropped down a bit,
about one segment from its original position. He is still getting good stimulation without any significant
changes in perception of his current programs. We will keep this in mind and continue to follow him.
AlAvv,we
Andrew C. Vesely, M.D.
ACW/cm
Job #: 39436152
RENO, NEVADA 89511
PHONE: (775)689-5410
FAX: (775) 689-5432
MEDREC#: 15206
PAGE: 2 OF 2
Briggs-61
Kimberlee M. Bayless, APN
PATIENT: BRIGGS, JEFF
CHIEF COMPLAINT:
Low back pain.
IDN: 15206 DATE: 10/1612007
INTERVAL HISTORY:
Jeff is a patient of Dr. Wesely who comes in today for a scheduled office visit. His pain is better. He
does not have pain per se in the back or in his legs. He has great coverage of his spinal cord stim.
He is currently on detox off of his Percocet, which he is currently at 3 a day. We will continue to wean
him off his oxycodone.
RECENT PROCEDURES:
He has had no recent procedures.
REVIEW OF SYSTEMS:
He denies any new medical problems.
SOCIAL HISTORY:
He works full time. He has been busier than he has been. His functional level has increased. He is
sleeping better at night. He is more happy in his relationship with his family.
Temperature 97.3, pulse 66 and blood pressure 120/80. He is alert, oriented and in no acute distress. He
does not appear sedated under medication standpoint. He ambulates without any use of assistive devices.
His pupils are 3 mm bilaterally.
ASSESSMENT:
1. Failed back surgery syndrome.
2. Status post palliation with spinal cord stim. No need to reprogram today.
TREATMENT PLAN:
I. Continue weaning of his Percocet. We will go down to two pills a day for a week and one tablet a
day for a week and then off.
2. He can reprogram as needed. I have instructed the patient that he can call Gabby from Advance
RENO, NEVADA 89511
PHONE: (775)689-5410
FAX: (775)689-5432
PHYSICIAN: KIMBERLEE M. BAYLESS, APN
MEDRECN: 15206
PAGE: 1 OF 2
Briggs-62
Bionics through our office and we will set up reprogramming.
3. He will follow up as needed.
4. The only withdrawal symptom he is having is that he is having some irritability on the weekends
when he does go through withdrawals; however, this is manageable.
9Wayk, 1119 Q
KMB/01/57
Job #: 19250206
Date Dictated: 10/1612007
RENO, NEVADA 89511
PHONE: (775)689-5410
FAX: (775)689-5432
PHYSICIAN: K1MBERLEE M. BAYLESS, APN
MEDFtECH: 15206
PAGE: 2 OF 2
Briggs-63
CC:
PATIENT: BRIGGS, JEFF IDN: 15206 DATE: 9/13/2007
INTERVAL HISTORY:
Jeff is here for a followup visit. He is doing very well with his stimulator and has began diminishing his
Percocet use. We had a talk today about realistic expectations. He is also concerned about potential
addiction to the medications. I suggested that we begin a weaning program but have realistic
expectations. If Jeff can put boundaries on the use of his opioids and limit them in a reasonable fashion
then small intermittent doses may still be reasonable.
He occasionally gets a bit of swelling around the spinal incision site with increased activity.
PHYSICAL EXAM:
Blood pressure 100/75, pulse 72 and temperature 98. His incisions look clean, dry and are well healed.
ASSESSMENT:
1. Failed back surgery syndrome.
2. Successful symptom palliation with spinal cord stimulator.
PLAN:
I. Begin opioid weaning. We will take him from 6 to 5 pills a day for 1 week, then 4 tablets a day for
1 week and then 3 tablets a day for the next 2 weeks.
2. Follow up in I month.
NA/gtm-NW41
ACW/ml
Job #: 18650373
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
MEDREC#: 15206
PAGE: 1 OF 1
CC:
PATIENT: BRIGGS, JEFF 15206 DATE: 8/21/2007
INTERVAL HISTORY:
Jeff is here for a followup/postop visit. We inspected his incision and it is healing nicely. We removed
the staples and applied Steri-Strips. He has a bit of bruising on the right gluteal site but it is healing well.
The wounds are dry.
PHYSICAL EXAM:
Blood pressure 110/64, pulse 86, temperature 98.3.
ASSESSMENT:
I. Successful placement of spinal cord stimulator system.
2. Improved pain control.
PLAN:
I. We will see Jeff back in a month. He is to finish his antibiotic regimen. He can go ahead and
shower, but I told him to avoid soaking in a tub. I gave him some more Percocet and we will begin
a weaning program at the followup visit. He may decide to begin weaning himself earlier as
possible. I explained to him he will still have some soreness for the next few weeks.
P s 1 4 9 - v m - N e o , i
Andrew C. \Vesely, M.D.
ACW/cm
Job #: 18241066
NEVADA PAJN & SPINE SPECIALISTS
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775)689-5432
MEDREC#: 15206
PAGE: 1 OF 1
Briggs-65
Kimberiee M. Bayless, APN
PATIENT: BRIGGS, JEFF IDti: 15206 DATE: 81712007
CHIEF COMPLAINT:
Low back pain.
INTERVAL HISTORY:
Jeff is a patient of Dr. Wesely who comes in today for a preop visit for spinal cord stimulation
implantation. The doctor is Dr. Wesely. The patient states that he had .a successful trial. In regard to
general health, he did have an epidural done yesterday by Dr. Wesely which did seem to aggravate some
of his pain complaints. He is sore down into that area. His pain is sharp, dull and aching. It is the same.
It is an 8/10.
Oxycodone and Cymbalta.
NEW MEDICAL PROBLEMS:
The patient does not report any new medical problems or injuries.
SOCIAL HISTORY:
The patient does work full time as a lawyer.
Temperature 97.5, pulse 74 and blood pressure 136/78. The patient is alert and oriented, and in no acute
distress. The patient does not appear sedated under any medication standpoint. The patient ambulates
without the use of assistive devices. Pupils are 3 mm
ASSESSMENT:
2. Successful spinal cord slim trial.
TREATMENT PLAN:
1. I have given him preoperative labs including CBC, CMP, PT, PTT, and UA.
2. He does have a prescription for Percocet already.
RENO, NEVADA 89511
PHONE: (775)689-5410
FAX: (775) 689-5432
PHYSICIAN: KIMBEFtLEE M. BAYLESS, APN
MEDRE01: 15206
PAGE: OF 2
Briggs-66
3. 1 have given him postoperative antibiotics Keflex 700 mg onc three times a day for 21 days.
4. He will follow up as scheduled for spinal cord stim implantation.
oWay k, f i c Q
KMB/03/e2
Job th 18002618
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
MEDRECti: 15206
PAGE: 2 0F2
Briggs-67
CC:
PATIENT: BRIGGS, JEFF ID#: 15206 DATE: 7/5/2007
INTERVAL HISTORY: Jeff is here for a followup visit. He is interested in proceeding with spinal cord
stimulator therapy to treat his failed back surgery syndrome.
Unfortunately, I have some documentation he provided showing that Blue Cross Blue Shield has denied
his stimulator trial after previously authorizing it a month earlier. This puts in the question whether there
will be some difficulty proceeding with a permanent implant despite the fact that all reasonable criteria for
Jeff has been met.
In the meantime, we will go ahead and manage Jeff medically and keep his symptoms in check as best as
possible. As soon as we have authorization to proceed with an implant, we will do so.
PHYSICAL EXAM:
Jeff is alert and oriented. No signs of medication toxicity. He has no trouble with
his speech or his gait. Blood pressure 141/86, temperature 98.4, pulse 74.
ASSESSMENT:
2.
Successful spinal cord stimulator trial with desire to proceed with an implant.
3. Insurance denial.
PLAN:
I. I re-prescribed his medications today.
2. He will follow up in one month with Kim Bayless.
3. Re-request implantation based on the results of successful trial, a good diagnosis known to be
responsive to this treatment, and psychological clearance.
P P 4 i b u o - N &
4 ,
)
ACW/ml
Job #: 17463955
Date Dictated: 7/512007
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
IVIJEDREC#: 15206
PAGE: 1 OF 1
Briggs-68
CC:
INTERVAL HISTORY:
Jeff is here for a followup visit. He is also here for electrode removal after his spinal cord stimulator
trial.
After the site dressing was removed, the stitches were snipped, the electrodes were withdrawn intact. The
site looked clean and dry without any signs of infection. Band-Aids were placed over the puncture
wounds.
With regard to the trial, Jeff did have substantial leg pain relief. Nevertheless, he did not have quite as
much back pain relief as he would have desired. He is fairly sure that he would like to proceed with
implantation but at this point would like to think about it for one more week and have some time to
compare his pain levels without the device in place.
Blood pressure 124T70, temperature 98.2, pulse 64.
ASSESSMENT:
I. Post laminectomy pain syndrome with chronic lumbosacral radiculitis.
2. Mostly successful spinal cord stimulator trial.
PLAN:
1. Followup in two weeks for re-evaluation and to decide whether to proceed with permanent implant.
kriAvvAAytaiw.4i
ACW/cm
Job #: 17256892
RENO, NEVADA 89511
PHONE: (775)689-5410
FAX: (775) 689-5432
MEDRECN: 15206
PAGE: I OF 1
Briggs-69
11'sfTERVAL HISTORY:
Jeff comes in one day post spinal cord stimulator implantation using Advanced Bionics System by Dr.
Wesely. The patient states that he had 100% coverage of his bilateral lower extremity; however, they
have been unable to capture his low back area. The patient states that he has been using less of his pain
medication. Gabi from Advanced Bionics is not here at this time, able to call the the patient and set up
the time to come in and hopefully reprogram the patient to hopefully get coverage in his low back area.
Temperature 98.2, pulse 76, and blood pressure 112180. The patient is alert and oriented, and in no acute
distress. The patient does not appear sedated on medication standpoint. The patient ambulates without
the use of assistive devices. Pupils are 3 mm bilaterally. The patient does have a dressing on his midback
that does have two spots of old bloody drainage. The dressing is intact and the leads are in placed.
ASSESSMENT:
1. One day post spinal cord stimulator trial.
2. Failed back surgery syndrome with chronic lumbosacral radiculitis, left greater than the right
TREATMENT PLAN:
1. We will have him follow up with Advanced Bionics with Gabi for reprogramming.
2. He will continue with the medications as prescribed.
3. He will follow up in one month's time with Dr. Wesely for a seven-day post trial for lead removal.
cbteayk,
KMB/ae/e2
Job #: 17132600
RENO, NEVADA 89511
PHONE: (775)689-5410
FAX: (775) 689-5432
MEDREC#: 15206
PAGE: 1 OF 1
Briggs-70
PAIN MANAGEMENT PREOPERATIVE HISTORY AND PHYSICAL
PATIENT: BRIGGS, JEFF ID#: 15206 DATE: 61812007
PHYSICIAN:
Andrew Wesely, M.D.
CHIEF COMPLAINT:
Low back and left leg pain.
DIAGNOSES:
I. Failed back surgery syndrome with chronic lumbosacral radiculitis, left greater than the right.
2. A psychological evaluation by Dr. Lewandowslci states he is a good candidate.
MEDICATION:
Oxycodone 5/325 mg one tablet three times a day as needed.
ALLERGIES:
No known allergies.
Temperature 97.4, pulse 66, and blood pressure 118/82. The patient is alert and oriented, in no acute
distress. The patient does not appear sedated under any medication standpoint. The patient ambulates
without the use assistive devices. Pupils are 3 mm bilaterally. Heart, regular rate and rhythm. SI and
S2 heard - without any murmurs, rubs, or gallops. Pulmonary is clear to auscultation, anterior and
posterior.
ASSESSMENT:
1. Failed back surgery syndrome with chronic lumbosacral radieulitis, left greater than right.
2. Failure of conservative treatments including numerous medication regimens.
3. History of reasonable symptom palliation with epidural steroid infiltrations but only on a
temporary basis.
TREATMENT PLAN:
1. I will give him prescription for his antibiotics, Keflex 500 mg one tablet three times a day for
seven days. He has already received his lab work that came back and Dr. Wesely has reviewed
this.
RENO, NEVADA 89511
PHONE: (775) 689- 5410
FAX: (775) 689- 5432
PHYSICIAN: K1MBERLEE M. BAYLESS, APN
MEDRECti: 15206
PAGE: 1 OF 2
PAIN MANAGEMENT PREOPERATIVE HISTORY AND PHYSICAL
Briggs- 71
2. Consent was reviewed and signed by the patient.
3. The patient does have medications for postoperative pain.
4. He will follow up as scheduled for post spinal cord stimulator trial.
5. Gabby from Medtronics is in the room with the patient for education.
ADDENDUM:
The patient has been meeting with Dr. Lewandowski, has noticed some depression. He would like to
know if he could start on the medication and if we have any samples. We will go ahead and trial him on
Cymbalta 30 mg once a day. I have given him a two weeks' supply of samples and we can increase up
to the 60 rug as tolerated and consider Cymbalta if no improvement.
ch416#3, ) 1 P 3
Kimberlee M. Bayless, AP N
KMB/ae/ml
Job it: 1 7047035
NEVADA P AIN & SP INE SP ECIALISTS
RENO, NEVADA 8951 1
P HONE: (775) 689-541 0
FAX: (775) 689-5432
P ATIENT NAME: BRIGGS, JEFF
P HYSICIAN: K1 MBERLEE M. BAYLESS, AP N
MEDRECN: 1 5206
OUTP ATIENT: P AIN MANAGEMENT CLINIC
P AGE: 2 OF 2
P AIN MANAGEMENT P REOP ERATIVE HISTORY AND P HYSICAL
Briggs-72
CC:
PATIENT: BRIGGS, JEFF MTh 15206 DATE: 5/1712007
INTERVAL HISTORY:
Jeff is here for followup visit. Unfortunately, he is still having trouble with intractable pain.
The Percocet is helping him somewhat, but he is still very symptomatic, especially with his leg
symptoms.
He did see Dr. Michael Lewandowski who thought he was a reasonable candidate for a spinal cord
stimulator trial. Jeff reviewed the educational literature and had his questions answered. At thi point, he
would like to go forward with the trial and see if this will give him any good treatment option for his back
and bilateral leg pain.
PHYSICAL EXAM:
Jcff is alert and oriented today. No signs of medication toxicity or intoxication. Blood pressure 138/66.
Temperature 98.5. Pulse 80.
ASSESSMENT:
1. Failed back surgery syndrome with chronic lurnbosacral radiculltis, left greater than right.
2. Failure of conservative treatments including numerous medication regimens.
3. History of reasonable symptom palliation with epidural steroid infiltrations, but only on a
temporary basis.
PLAN:
I. Obtain insurance authorization for spinal cord stimulator trial using a dual-lead Advanced Bionic
system.
2. I gave le ff a prescription for his preoperative labs today and they will fax us the results.
3. We will obtain authorization for a series of two caudal epidural infiltrations to help control the
RENO, NEVADA 89511
PHONE: (775)689-5410
FAX: (775)689-5432
MEDRECti: 15206
PAGE: 1 OF 2
Briggs-73
symptoms until we can proceed with the trial.
4. Continue Percocet for pain relief purposes.
iteati
ACW/sc
Job tt: 16697269
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
PHYSICIAN: ANDREW C. %VESELY, M.D.
MEDREC#: 15206
PAGE: 2 OF 2
Briggs-74
PAIN MANAGEMENT CONSULTATION REPORT
cc: Jason S. McKenzie, D.0.(Autofax)
PATIENT: BRIGGS, JEFF ID: 15206 DATE: 5/1/2007
REFERRING PHYSICIAN:
Jason McKenzie, D.O.
CHIEF COMPLAINT:
Back and bilateral leg pain.
HISTORY OF PRESENT ILLNESS:
Jeff Briggs is kindly referred by Dr. Jason McKenzie for interventional pain management consultation.
He is a pleasant 37-year-old white man who has a chief complaint of back and bilateral leg pain which
began in January of 2006 without any history of trauma.
He has a long history of low back pain going back to the mid 1990s. He ultimately underwent pedicle
screw decompression and fixation at L4 through SI by Dr. Richard Blakey in 2001. Afterward he was
completely pain free and was doing extremely well functionally without any limitations until this past
January. I note that in the past he has also been on numerous pain medication management regimens,
and the medications were somewhat problematic for him.
CURRENT STATUS:
He states his pain averages 9 and ranges from 8-9.5. It is fairly constant. It is primarily localized in his
low back, both his legs of equal degrees. His pain is made worse with mechanical activities such as
walking, lifting, sitting, coughing or sneezing, and stress.
REVIEW OF SYSTEMS:
He denies any bowel or bladder control problems or saddle analgesia. No history of fever, sweats, chills
or weight loss. He denies any persistent lower extremity numbness, weakness or paralysis but he
occasionally gets tingling in his feet and the back of his calves. He has also struggled with difficulty
with sleep, frustration, anger and depression over the chronicity of his symptoms.
Aleve, Tylenol, Advil.
ALLERGIES: None.
PAST TREATMENTS:
Previous oral analgesics include OxyContin, Neurontin, Lyrica, antidepressants, anti-inflammatories,
and muscle relaxant agents.
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
MEDRECN: 15206
PAGE: 1 OF 3
Briggs-75
FAMILY HISTORY:
Negative.
SOCIAL HISTORY:
He lives with his wife and two children. He does not use tobacco. He drinks casually.
OCCUPATIONAL HISTORY:
He continues to work full-time as an attorney, although his practice has slowed down a bit because of
his pain symptoms.
IMAGING REVIEW:
had a chance to look at a CT of his lumbar spine from February 2006. He has hardware in at L4
through Si with pedicle screw fixation. Alignment and hardware location appear satisfactory. There is
no obvious neurological compression. The L3-4 disk, above his fusion, has a very minor bulge but there
is no neuroforaminal compromise or central stenosis.
Jeff is alert and oriented. No signs of medication toxicity. He walks about with a normal gait. He can
heel and toe walk without any difficulty. He can squat to the floor and get back up without any
assistance.
Blood pressure 116/89, pulse 92, temperature 97.6, height 6'3", weight 175.
Jeff can bend forward about 20 degrees and he starts getting some increased back and hamstring pain.
Deflexion is not painful.
There are no sciatic tension signs with straight leg raising. Reflexes are intact at knees and ankles.
There are no sensory deficits. Peripheral pulses are full. Mobilization of the hips is not painful. SI shear
testing is not painful.
Palpatory examination shows fairly benign back without any significant pain at the sacroiliac sulci, or
areas of myofascial tenderness. He does have mild sciatic notch tenderness bilaterally.
ASSESSMENT:
2. No signs of new instability or neurological compression on recent MRIs.
3. History of marginal response to epidural injections.
4. Desire to avoid surgery and medications if at all possible.
5. Chronic back and bilateral lumbosacral radiculitis without any signs of radiculopathy or
myelopathy.
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775)689-5432
MEDFtECM: 15206
PAGE: 2 OF 3
Briggs-76
RECOMMENDATIONS/DISCUSSION:
1. I had a long talk with Jeff today. He think spinal cord stimulation is a reasonable option to be
considered. His other nonsurgical option would be to resume oral analgesics and use of injections
on an intermittent basis for palliative purposes. We will give him some Percocet for symptom
control until he can decide how he would like to proceed.
2. We provided Jeff with some literature today so he can think about the stim as a treatment option.
We also will go ahead and obtain a psychological evaluation per protocol.
PstkgvAA- Ne e d ,i
ACW/cm
Job N : 16416318
RENO, NEVADA 89511
PHONE: (775) 689-5410
FAX: (775) 689-5432
MEDRECH: 15206
PAGE: 3 OF 3
Briggs- 77

EXHIBIT 3

EXHIBIT 3
KATHLEEN A. MILBECK, M.A.
Licensed Marriage & Family Therapist
460 South Sierra St.
Reno, NV 89501
06.28.12
Dave Grurdy
Attorney at Law
6005 Plumas Ave.
Reno, NV 89501
RE: Jeff Briggs
D.O.B: 01.21.70
I am writing this at the request of your dient, Jeff Briggs. He has asked that I inform you of the medical
and emotional difficulties he was experiencing which brought him to seek psychotherapy last year.
He sought therapy in December of 2010 and continued until April 2012. He was primarily seen on a bi-
monthly basis.
He was experiencing a great deal of anxiety and depressive symptoms related to his separation and later
divorce from his wife of over 20 years. Along with these issues Jeff was dealing with the emotional
difficulties of a long-standing back injury, which has left him with chronic pain. I would suggest that his
emotional status was moderately impairing his every day functioning.
Should you have any other questions, please don't hesitate to contact me at 786-2424.
Sincerely,

EXHIBIT 4

EXHIBIT 4
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DECLARATION OF PAUL ELCANO
I, PAULELCANO, hereby declare under penalty of perjury that the following
statements are true tothe best of myknowledge andbelief.
1. I am Executive Director of Washoe Legal Services, inReno, Nevada. I give this
declarationinsupport of JefferyA. Briggs, anemployee of WLS since October, 2011.
2. Mr. Brigg's work has beenexcellent, ina difficult positionas a childadvocate. I
have receivedreports from twojudicial officers inthe FamilyCourt whoconfirm that his work
there is excellent. One has commented that she has seen Mr. Briggs interact with his young
clients andit is a pleasure towatchthat interaction.
3. His work is excellent, he is reliable andmaintains goodrelations withme and
his co-workers.
4. If he were suspended for any period of time, it would be difficult to replace
him, as there are very fewcandidates who are willing to work at our pay scale who have his
skills. We would expect it would take at least 2-3 months to find and retain a replacement
child advocate. In addition, males, especially are hard to find in this field, and there are
certainlycases that benefit from a male role model.
5. I believe Jeff is committedtohelpingthese childrenwhobecome his clients.
6. Although Jeff has had personal and health challenges since he came to work
here, these conditions have not interferedwithhis work or our desire tokeephim.
7. The statements contained in this Declaration are made under penalty of
perjury, and are true and correct, except as to those matters made upon information and
belief, whichI believe are true andcorrect.
DATED: This 16
t h
dayof July, 2012.
PAULD. ELCANO
Executive Director
26
27
LEMONS, GRUNDY 28
& EISENBERG
6005 PLUMAS ST.
THIRDFLOOR
RENO, NV 89519
(775) 786-6868
I
EXHIBIT 5
EXHIBIT 5
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DECLARATION OF DAVID R. GRUNDY
I, DAVIDR. GRUNDY, hereby declare under penalty of perjury that the
following statements are true to the best of my knowledge and belief.
1 . I amcounsel of record for Jeffery Briggs, Respondent.
2. I was contacted by Mr. Briggs and retained on May 31 , 201 2. The
next day I conferred with Bar Counsel David Clark. At that time, the panel's
Decision had been prepared and signed, but not yet transmitted to the court.
The discussion between counsel and Mr. Clark resulted in an understanding that
Mr. Brooks may submit a motion for reconsideration to the bar and request a
newhearing. However, shortly thereafter, through no fault of anyone at the Bar
office, the panel Decision was filed with this court.
3. Thereafter, I have had further discussions with assistant bar counsel
Patrick King and have been advised that bar counsel will not oppose this motion.
4. The statements contained in this Declaration are made under
penalty of perjury, and are true and correct, except as to those matters made
upon information and belief, which I believe are true and correct.
DATED: This 1 6t h day of July, 20
DAVIDR. GRUNDY,
20
21
22
23
24
25
26
27
LEMONS, GRUNDY
& EISENBERG
6005 PLUMAS ST.
THIRDFLOOR
RENO, NV8951 9
(775) 786-6868
28

EXHIBIT 6

EXHIBIT 6
TIMELINE
Briggs Bar Grievance
20071 Diagnosed with "Failed spine syndrome with chronic
radiculopathy"is prescribed a spinal cord stimulator to be
implanted in his back (by Dr. Bayless), also epidural steroid injections.
201 0 Began taking anti-depressants (Dr. McCormick)
Feb. 11 Spasms in legs, using Lidoderm patches and steroid injections to his
back.
,..!.
nsferred to S.Ct. Order
Sept. 15, Nerve Root Infusions
Nov. 3 Briggs retained by David Thompson
Nov. 12 Substitution of attorneys, Thompson pro per
Dec. 3 Thompson learns of inactive status
Dec. 9 Briggs returned to active status after completing CLE
Dec. 14 Moves out of house to apartment on Desert Fox Drive
2011
Jan. begins treatment with Dr. Wesley, pain management; stimulator
installed in 2007 not enough to prevent "functional decline;"
"struggling for work as an attorney, recently separate from wife;
quite depressed and seeing a psychologist; "suicidal thoughts
increased a bit"
Feb. 1
Mar. 29
diagnosis: Adjustment disorder with depressed mood (Wesley)
Thompson grievance filedfor return of $3,500 retainer
1 . Medical treatment in black type.
Grievant David Thompson actions in red,
State Bar Actions in Woe
SBN n otitie ?vance
April ? stops taking antidepressants (coverage lapses)
April 11 Divorce filed in Douglas County
June 21 "Pain interferes with work, play; depression/anxiety are ongoing
issues"
iggs respondr. , ,:drilits suspended when consulted
Summer Office lease at 200 S. Virginia expires; maintains no office but home
July 19 Will lose health insurance in August (Wesley note)
July 29 Begins methadone treatments in lieu of Fentanyl patches
Sept. 20 Changes back to Fentanyl as methadone makes him drowsy, off
methadone
Complaint filed by SBN
ieee
Nov. 29
Dec. 1
Dec. 29
2012
Jan. 27
Mar, 16
Mar. 20
A
Pain and numbness similar to pre-surgery with numbness and
weakness in legs; tries another patch (Wesley)
Notice of intent to Proceed on Default Basis
Changes medication for depression to another drug that causes side
effects (Wesley)
legs spasming; pain poorly controlled; will have steroid injection next
month (Wesley)
Notice of Formal Hearing (on April 18, 2012)
"Uncontrolled pain" even with recent epidural injection, spinal
stimulator and narcotic medications.
Format Hearing

May 14 Spinal Stimulator in place since 2007 removed in surgical procedure
11
May-June Reconciliation treatment with wife; failed

In Re Briggs A WLS Employee 12-22560

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