Here are the results from my C&P exam for depression, let me know what ya'll think, and what my possible rating might be. Thanks
These are blue button download notes, so not in exactly easy to read format.
Print Done
T========================== Date/Time: 03 Nov 2015 @ 0800 Note Title: COMPENSATION & PENSION NOTE Location: Lebanon VA Medical Center Signed By: VONRAGO,LAWRENCE L Co-signed By: VONRAGO,LAWRENCE L Date/Time Signed: 03 Nov 2015 @ 1032 ------------------------------------------------------------------------- LOCAL TITLE: COMPENSATION & PENSION NOTE STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: NOV 03, 2015@08:00 ENTRY DATE: NOV 03, 2015@10:32:49 AUTHOR: VONRAGO,LAWRENCE L EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Name of patient/Veteran SECTION I: ---------- 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes[ ] No If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Major Depression, chronic Comments, if any: Patient reports that he has been depressed throughout his military career and never felt depressed prior to joining the military. After leaving the military, he remained with chronic clinical depression which is never resolved. He never received day treatment until recently. Mental Disorder Diagnosis #2: history of alcohol use disorder in partial remission versus full remission b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 2. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ] Not shown in records reviewed 3. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[ ] No[X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ a. Medical record review: Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: cprs and vbms were reviewed. b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: cprs and vbms were reviewed. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Re: Section 2.0, please refer to section 6.0 below b. Relevant Occupational and Educational history (pre-military, military, and post-military): No response provided. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): No response provided. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): No response provided. e. Relevant Substance abuse history (pre-military, military, and post-military): No response provided. f. Other, if any: No response provided. 3. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Chronic sleep impairment [X] Disturbances of motivation and mood 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [ ] Yes[X] No 5. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 6. Remarks (including any testing results), if any: --------------------------------------------------- Please note the following regarding Compensation and Pension exam documentation: 1. The examiner is a poor typist and no longer has access to a transcriptionist for dictating reports; however, parts of the report will be automatically typed via transcription software or dragon software. This dragon software is prone to error, therefore there may be typos in the body of the report. Important documentation considered vital, such as diagnosis and recommendations, will be proofread before submitting. 2. In order to maximize face-to-face time with the veteran the following measures will be taken: 1.) with regards to the grammar, syntax, structure, etcetera in this report, only the assessment, diagnostic formulations, and conclusion of the report will be thoroughly proofread. The non-essential parts of the report will NOT be thoroughly edited and WILL contain typographical and organizational errors (the body of the report may not be well-written, 2.) select parts of the exam may be dictated in the spoken language of the veteran or will be paraphrased; when the author types in the first person, assume the sentence is likely a quotation. When deemed essential to understanding the context of a statement, quotations will be included in the report. 3. An ACE examination was not completed today. The veteran was present for this examination. Acronyms used in report: hx =history abuse x 3 = physical/sexual/verbal abuse pt = patient asap = as soon as possible sx = sympto m bc = because fx = function d/a or D&A = drug and alcohol fxing (functioning) s/p = status post si/hi = suicide homicide cfs = pt is able to contract for his/her safety CIP/cip = crisis intervention protoco mh = mental health hs = high school or at bedtime avh = auditory visual hallucination c/o = complains of FH = family history c/w = consistent with Rx = medication rship relationship dx = diagnosis nm= nightmares N= no Y= yes s = without c = with re: = regarding XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX IDENTIFYING DATA: . He presents today for a compensation and pension exam. He offers no cc. He provides a document in support of his argument that his chronic depression is caused by his chronic pain which is caused by a leg injury he had during the military. PAST PSYCHIATRIC HX: 1. Inpatient psychiatric treatment? none 2. Counseling hx? + 3. Psychiatric Rx Tx? no 4. Family psych. Hx? none known 5. Legal Hx? non 6. Drug Abuse Hx? 7. Alcohol abuse/dependence? He abused alcohol most of his military career per patient. I "think I started drinking regularly for sleep?He then reported excessive drinking throughout the military and he had one article 15 for etoh abuse. He has not been drunk since 22 years old. He continues to use etoh as a "sleep aid". I only drink 2 beers nightly. Denies cage and problematic drinking patterns. 8. Behavioral Hx? neg 9. SI/HI Hx? He tried to cut himself in the military. He talked to a chaplain, but had no mh treatment otherwise. He has suffered from chronic suicidal. SUICIDE HX: The veteran presents a chronic history of suicidal ideation. He indicates that in the context of his pain primarily, and his resultant depression, he was on the verge of cutting his wrist in order to end his life. Just when he was about to do this, someone intervened. He has not subsequent had suicide attempts, but he reports that he has suffered from chronic, intermittent, suicidal ideation, which she reports waxes and wanes. He reports that this seems to present with stress but can occur out of the blue. He has been able to contract for his own safety with his current counselor and he denies any current intent, plans, wishes, or goals to harm himself. He expressed an excellent understanding of crisis intervention protocol (cip) and expressed a good understanding of how to initiate cip if need be. The patient is able to contract for safety and will not act on any SI/HI if it subsequently presents. If the patient exhibits warning signs/symptoms of worsening MH problems, e.g. becomes increasingly depressed or anxious etcetera, the veteran promises to notify the treatment team. The patient reports he is safe and does not need to be in the hospital and indicates that this is been going on for years. The patient appears reliable at this time regarding the above and seems aware of which symptoms warrant contacting the treatment team so that the risk of si/hi is minimized. The patient is seen as lower risk for acting out, but in the context of this being so chronic, one would be advised to monitor this for worsening. In the context of the obtained clinical history and the mental status examination, there are no significant signs of acuity today that would suggest or indicate that the veteran is in imminent risk for acting out regarding si/hi. On exit interview, the veteran did not appear to be in any acute distress nor was suicidal/homicidal issues deemed to have been provoked. The veteran denied any acute SI/HI symptoms at the conclusion of the evaluation. Re: guns/weapons, the veteran was counseled to avoid any access to firearms and other dangerous weapons/devices, etc., due to the increased risks associated with access. PAST MEDICAL HISTORY: see chart/records CURRENT STRESSORS: "dealing with the VA". He had a couple claims denied. They were mostly resolved. " Life in general". CURRENT FUNCTIONING: 1. INTERPERSONAL- FRIENDS, FAMILY: Per patient, he has less than adequate relationships in general, which he believes is related to his depression. He says that he has no true friends. He admits to having acquaintances. 2. WORK HX : good relationships at work. Good work hx. he has never been officially fired. 3. TYPICAL DAY : I don't do anything for fun. I go home, I work a 10 hour shift. When I am off I sit around. I like doing yardwork. He report watching TV. He and his wife are financially struggling so they don't go out to eat much. He reports no friendships. He had no true friendships in childhood either. "I was a military brat". I don't do social events. He has only recently started counseling despite the fact that he has been depressed most of his life. He has a 9 yo and a 14 yo. He will do activities with his children. His relationship with his wife is , well, it is not great but not horrible either. He variably indicated that he argues a lot with her. Counseling records seem to describe the relationship as being strained MATERIALS REVIEWED? VBMS was reviewed. CPRS was reviewed. The veteran was examined. The computer records were reviewed. Military Hx: no combat hx. Served in the military x 6 yrs. HPI : The veteran self-reports that he was a fairly normal kid. He indicates that he never had any kinds of mental health problems whatsoever. He was easy-going. He does not recall having any problems sleeping or being a nervous anxious person etc. He seems to have excellent mental health per the patient. Once he got into the military and injured his leg, everything seemed to go downhill. He indicates that he injured his leg and needed to wear a brace for about 8 days. He indicates that ever since that time he developed problems sleeping which she then self-medicated with alcohol. Because he self-medicated with alcohol to sleep this then caused his alcohol problem. Although he never sought any treatment for his depression, he believes the depression directly resulted from his leg pain and his insomnia, the latter of which caused was the cause of his alcohol problems. He does not take personal responsibility for his alcohol problems, indicating it was a result of his insomnia. He indicated that he wore a leg brace for 8 days and then was sent back to active duty. He reports that he has suffered from a lifetime of pain which is caused his problems. He indicates his pain ranges and now he has pain in the number of different places. He indicates his pain average to be falling in the range of 6 through 8. The veteran currently reports feeling depressed and indicates that he has been depressed throughout his military career and throughout his life. Although he feels strongly that his leg pain caused his depression, he does admit with questioning that there were other stressors. One of the stressors he indicated was the fact that there was stress in the military. He was in the Marines I believe and indicated that they had strict standards. At one point he was afraid that he was going to have to buy new uniforms because of something a commander said to him.. He reports that would take a full paycheck. He believes this was the trigger when he was going to commit suicide by cutting his wrists. With further questioning, he did admit that he had a girlfriend who developed cancer. Psych clear what happened but her family lied to him and told him that she died. He subsequent found out that that was alive. Regarding the patient's depression, he feels depressed, chronically, and admits to neuro vegetative symptoms of depression such as feeling angry and irritable frequently, having trouble concentrating and focusing, having no desire to do things at times. He indicates it's hard for him to enjoy things. He has trouble sleeping at night which he relates is secondary to his mind racing. He does not endorse bipolar problems. He does not endorse psychotic problems. He does not endorse drug problems. He does indicate that he has had alcohol abuse problems, but he self-reports now that all he drinks are to light beers per night, no more low less. He reports that he had been clearly abusing alcohol in the military and in fact received an article 15 for alcohol related charges. He described out of control drinking, drinking most days of the week and really feeling out of control. He was able to stop this when he left the military at some point and currently has maintained a pattern of only 2 drinks per night to, per patient, help him fall sleep. He denies any abuse. He denies people being concerned about his drinking patterns, or other him symptoms suggestive of alcohol problems. No history of panic. He does describe feeling stressed and anxious but does not feel he is a worrier. He does not endorse social phobias or any other type of OCD/anxious based disorder. No other comorbidities were noted. There is no history of significant trauma. Regarding the patient's history of insonmina he does suffer from chronic depression which most often is connected with sle with sleep problems. The veteran does not recall having any sleep problems whatsoever as a child or adolescent. His sleep problems began when he joined the military, as did his clinical depression. He has been diagnosed with sleep apnea, and vividly recalls being a heavy snorer when he was in the military. He does not recall having any problems with being us nor prior to joining the military. I don't see any clear military connection for sleep apnea although he reports that his sleep apnea may have started in the military as well. Since there was heavy drinking during this time period and again there is no documentation, I do not believe there is any grounds to suggest that his current sleep apnea is military related. Sleep apnea could itself be one of the many risk factors for development of depression. PERSONAL HX: CHILDHOOD, SCHOOL, PARENTS The veteran reports having an unremarkable (history seems to fall WNL) childhood hx. 1. Hx of abuse x 3 : n 2. Hx of MH problems : n 3. D/A hx : n 4. Academic hx: n MSE: unremarkable. No si/hi/avh/del. 1. Is the examiner concerned with imminent si/hi ? N 2. Is the examiner concerned re: avh/del/psychomotor agitation/mania/mixed/manic sx's? N 3. On exit assessment, are there any imminent concerns noticed that need acutely addressed? N 4. Re: safety issues, is the examiner sufficiently concerned re: reliability of the candidates hx? N General Overview re: Compensation and Pension exam-- In this checkbox formulated template report, although a veteran may endorse experiencing certain symptoms, one may not see a symptom checked off on the provided diagnostic checkbox list of symptoms. Any symptom reported by the veteran but not checked off on the checkbox list indicates that the symptom(s) is not deemed to be clinically significant. This means that the symptom(s) reported has not been determined to represent psychopathology (an aberrant symptom(s)) but rather, the symptom is deemed to fall within the normal limits of human experience). The examiner's role in this process is to determine which symptoms represent abnormal or pathologic mental health states vs. those symptoms that fall within the normal limits of human experience. The presence of psychological symptoms can be considered "normal" depending on various factors. For example, it is not necessarily pathologic (a mental illness) for one to feel sad, angry, anxious, depressed, etc. Experiencing such symptoms does not mean that one is suffering from a clinical depression or has mental illness ( e.g. psychopathologic depression). It is within the range of normal human experience to feel "emotional", sad, angry, or even anguished at times when thinking of friends, fellow soldiers, or innocent victims that have been injured or killed; merely experiencing such an emotion does not constitute psychopathology. In some individuals, feeling intermittently emotional about past traumatic experiences can fall well within normal limits, even if symptoms surface on and off for many years. Feeling strong emotions at times does not necessarily mean that you are mentally ill (experience psychopathology). Discussion: The veteran feels strongly that his clinical depression which has been present throughout most of his adult life has been caused by a leg injury that he had in the military. He did not seek out any help for his depression in the military because he was ashamed. When he left the military, even though he continued to be remain moderately to severely depressed dailiy, he never sought any form of treatment and has no documentation of clinical depression. He only recently started clinical treatment. Findings: The veteran describes chronic depressed mood, with no history of meaningful clinical improvement and certainly no remission. He reports feeling depressed daily, and ranks his depression as being moderate (7 on a scale of 1-10 for depression). He describes neurovegetative symptoms of depression including problems with chronic suicidal ideations. Typically, depression is considered to be multifactorial. There can be genetic influence often times but not always. Clinical depression is very common in general oftentimes there are multifactorial elements, which play a role in so far as etiology. In this veteran, there is no documentation supporting that he suffered from depression while he was in the military. He indicates that he was so severely depressed that he had been seconds away from attempting suicide but never sought any treatment throughout. He did indicate that he talked to religious counselor once I believe. There is no evidence of any specific cause of his depression which hes has felt throughout his adult life. There are multiple clinical factors that are believed to be prominent triggers for depression such as of low self-esteem, unfulfilling relationships, chronic use of alcohol, which we know now is a risk factor for depression. Although the veteran believes his pain has specifically caused his clinical depression, however depression is most often determined to be multifactorial. In the examiner's opinion, there is insufficient evidence to suggest that in this particular case his clinical depression is solely secondary to his leg pain. That is, the examiner believes that there is a greater chance than not that other factors played substantial roles in his chronic clinical depression and in the absence of clinical evidence i.e. documentation, to suggest otherwise, there is not sufficient evidence to support his own belief that his pain is ultimately the sole cause of his chronic depression. By his history and per records there've been multiple stressors throughout his life that could play a significant etiologic role. With regards to there being a military stressor large enough to provoke clinical depression while in the military, it is unlikely that a minor injury (an injury that required a leg brace for 8 days and then back to duty) would be sufficient grounds to cause clinical depression, particularly since there were numerous stressors including relationship issues and legal problems. xx /es/ LAWRENCE L VONRAGO M.D./STAFF PSYCHIATRIST Signed: 11/03/2015 10:32 -------------------------------------------------------------------------
Question
Andyman73
Here are the results from my C&P exam for depression, let me know what ya'll think, and what my possible rating might be. Thanks
These are blue button download notes, so not in exactly easy to read format.
Print Done
T========================== Date/Time: 03 Nov 2015 @ 0800 Note Title: COMPENSATION & PENSION NOTE Location: Lebanon VA Medical Center Signed By: VONRAGO,LAWRENCE L Co-signed By: VONRAGO,LAWRENCE L Date/Time Signed: 03 Nov 2015 @ 1032 ------------------------------------------------------------------------- LOCAL TITLE: COMPENSATION & PENSION NOTE STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: NOV 03, 2015@08:00 ENTRY DATE: NOV 03, 2015@10:32:49 AUTHOR: VONRAGO,LAWRENCE L EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Name of patient/Veteran SECTION I: ---------- 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes[ ] No If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Major Depression, chronic Comments, if any: Patient reports that he has been depressed throughout his military career and never felt depressed prior to joining the military. After leaving the military, he remained with chronic clinical depression which is never resolved. He never received day treatment until recently. Mental Disorder Diagnosis #2: history of alcohol use disorder in partial remission versus full remission b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 2. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ] Not shown in records reviewed 3. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[ ] No[X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ a. Medical record review: Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: cprs and vbms were reviewed. b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: cprs and vbms were reviewed. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Re: Section 2.0, please refer to section 6.0 below b. Relevant Occupational and Educational history (pre-military, military, and post-military): No response provided. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): No response provided. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): No response provided. e. Relevant Substance abuse history (pre-military, military, and post-military): No response provided. f. Other, if any: No response provided. 3. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Chronic sleep impairment [X] Disturbances of motivation and mood 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [ ] Yes[X] No 5. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 6. Remarks (including any testing results), if any: --------------------------------------------------- Please note the following regarding Compensation and Pension exam documentation: 1. The examiner is a poor typist and no longer has access to a transcriptionist for dictating reports; however, parts of the report will be automatically typed via transcription software or dragon software. This dragon software is prone to error, therefore there may be typos in the body of the report. Important documentation considered vital, such as diagnosis and recommendations, will be proofread before submitting. 2. In order to maximize face-to-face time with the veteran the following measures will be taken: 1.) with regards to the grammar, syntax, structure, etcetera in this report, only the assessment, diagnostic formulations, and conclusion of the report will be thoroughly proofread. The non-essential parts of the report will NOT be thoroughly edited and WILL contain typographical and organizational errors (the body of the report may not be well-written, 2.) select parts of the exam may be dictated in the spoken language of the veteran or will be paraphrased; when the author types in the first person, assume the sentence is likely a quotation. When deemed essential to understanding the context of a statement, quotations will be included in the report. 3. An ACE examination was not completed today. The veteran was present for this examination. Acronyms used in report: hx =history abuse x 3 = physical/sexual/verbal abuse pt = patient asap = as soon as possible sx = sympto m bc = because fx = function d/a or D&A = drug and alcohol fxing (functioning) s/p = status post si/hi = suicide homicide cfs = pt is able to contract for his/her safety CIP/cip = crisis intervention protoco mh = mental health hs = high school or at bedtime avh = auditory visual hallucination c/o = complains of FH = family history c/w = consistent with Rx = medication rship relationship dx = diagnosis nm= nightmares N= no Y= yes s = without c = with re: = regarding XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX IDENTIFYING DATA: . He presents today for a compensation and pension exam. He offers no cc. He provides a document in support of his argument that his chronic depression is caused by his chronic pain which is caused by a leg injury he had during the military. PAST PSYCHIATRIC HX: 1. Inpatient psychiatric treatment? none 2. Counseling hx? + 3. Psychiatric Rx Tx? no 4. Family psych. Hx? none known 5. Legal Hx? non 6. Drug Abuse Hx? 7. Alcohol abuse/dependence? He abused alcohol most of his military career per patient. I "think I started drinking regularly for sleep?He then reported excessive drinking throughout the military and he had one article 15 for etoh abuse. He has not been drunk since 22 years old. He continues to use etoh as a "sleep aid". I only drink 2 beers nightly. Denies cage and problematic drinking patterns. 8. Behavioral Hx? neg 9. SI/HI Hx? He tried to cut himself in the military. He talked to a chaplain, but had no mh treatment otherwise. He has suffered from chronic suicidal. SUICIDE HX: The veteran presents a chronic history of suicidal ideation. He indicates that in the context of his pain primarily, and his resultant depression, he was on the verge of cutting his wrist in order to end his life. Just when he was about to do this, someone intervened. He has not subsequent had suicide attempts, but he reports that he has suffered from chronic, intermittent, suicidal ideation, which she reports waxes and wanes. He reports that this seems to present with stress but can occur out of the blue. He has been able to contract for his own safety with his current counselor and he denies any current intent, plans, wishes, or goals to harm himself. He expressed an excellent understanding of crisis intervention protocol (cip) and expressed a good understanding of how to initiate cip if need be. The patient is able to contract for safety and will not act on any SI/HI if it subsequently presents. If the patient exhibits warning signs/symptoms of worsening MH problems, e.g. becomes increasingly depressed or anxious etcetera, the veteran promises to notify the treatment team. The patient reports he is safe and does not need to be in the hospital and indicates that this is been going on for years. The patient appears reliable at this time regarding the above and seems aware of which symptoms warrant contacting the treatment team so that the risk of si/hi is minimized. The patient is seen as lower risk for acting out, but in the context of this being so chronic, one would be advised to monitor this for worsening. In the context of the obtained clinical history and the mental status examination, there are no significant signs of acuity today that would suggest or indicate that the veteran is in imminent risk for acting out regarding si/hi. On exit interview, the veteran did not appear to be in any acute distress nor was suicidal/homicidal issues deemed to have been provoked. The veteran denied any acute SI/HI symptoms at the conclusion of the evaluation. Re: guns/weapons, the veteran was counseled to avoid any access to firearms and other dangerous weapons/devices, etc., due to the increased risks associated with access. PAST MEDICAL HISTORY: see chart/records CURRENT STRESSORS: "dealing with the VA". He had a couple claims denied. They were mostly resolved. " Life in general". CURRENT FUNCTIONING: 1. INTERPERSONAL- FRIENDS, FAMILY: Per patient, he has less than adequate relationships in general, which he believes is related to his depression. He says that he has no true friends. He admits to having acquaintances. 2. WORK HX : good relationships at work. Good work hx. he has never been officially fired. 3. TYPICAL DAY : I don't do anything for fun. I go home, I work a 10 hour shift. When I am off I sit around. I like doing yardwork. He report watching TV. He and his wife are financially struggling so they don't go out to eat much. He reports no friendships. He had no true friendships in childhood either. "I was a military brat". I don't do social events. He has only recently started counseling despite the fact that he has been depressed most of his life. He has a 9 yo and a 14 yo. He will do activities with his children. His relationship with his wife is , well, it is not great but not horrible either. He variably indicated that he argues a lot with her. Counseling records seem to describe the relationship as being strained MATERIALS REVIEWED? VBMS was reviewed. CPRS was reviewed. The veteran was examined. The computer records were reviewed. Military Hx: no combat hx. Served in the military x 6 yrs. HPI : The veteran self-reports that he was a fairly normal kid. He indicates that he never had any kinds of mental health problems whatsoever. He was easy-going. He does not recall having any problems sleeping or being a nervous anxious person etc. He seems to have excellent mental health per the patient. Once he got into the military and injured his leg, everything seemed to go downhill. He indicates that he injured his leg and needed to wear a brace for about 8 days. He indicates that ever since that time he developed problems sleeping which she then self-medicated with alcohol. Because he self-medicated with alcohol to sleep this then caused his alcohol problem. Although he never sought any treatment for his depression, he believes the depression directly resulted from his leg pain and his insomnia, the latter of which caused was the cause of his alcohol problems. He does not take personal responsibility for his alcohol problems, indicating it was a result of his insomnia. He indicated that he wore a leg brace for 8 days and then was sent back to active duty. He reports that he has suffered from a lifetime of pain which is caused his problems. He indicates his pain ranges and now he has pain in the number of different places. He indicates his pain average to be falling in the range of 6 through 8. The veteran currently reports feeling depressed and indicates that he has been depressed throughout his military career and throughout his life. Although he feels strongly that his leg pain caused his depression, he does admit with questioning that there were other stressors. One of the stressors he indicated was the fact that there was stress in the military. He was in the Marines I believe and indicated that they had strict standards. At one point he was afraid that he was going to have to buy new uniforms because of something a commander said to him.. He reports that would take a full paycheck. He believes this was the trigger when he was going to commit suicide by cutting his wrists. With further questioning, he did admit that he had a girlfriend who developed cancer. Psych clear what happened but her family lied to him and told him that she died. He subsequent found out that that was alive. Regarding the patient's depression, he feels depressed, chronically, and admits to neuro vegetative symptoms of depression such as feeling angry and irritable frequently, having trouble concentrating and focusing, having no desire to do things at times. He indicates it's hard for him to enjoy things. He has trouble sleeping at night which he relates is secondary to his mind racing. He does not endorse bipolar problems. He does not endorse psychotic problems. He does not endorse drug problems. He does indicate that he has had alcohol abuse problems, but he self-reports now that all he drinks are to light beers per night, no more low less. He reports that he had been clearly abusing alcohol in the military and in fact received an article 15 for alcohol related charges. He described out of control drinking, drinking most days of the week and really feeling out of control. He was able to stop this when he left the military at some point and currently has maintained a pattern of only 2 drinks per night to, per patient, help him fall sleep. He denies any abuse. He denies people being concerned about his drinking patterns, or other him symptoms suggestive of alcohol problems. No history of panic. He does describe feeling stressed and anxious but does not feel he is a worrier. He does not endorse social phobias or any other type of OCD/anxious based disorder. No other comorbidities were noted. There is no history of significant trauma. Regarding the patient's history of insonmina he does suffer from chronic depression which most often is connected with sle with sleep problems. The veteran does not recall having any sleep problems whatsoever as a child or adolescent. His sleep problems began when he joined the military, as did his clinical depression. He has been diagnosed with sleep apnea, and vividly recalls being a heavy snorer when he was in the military. He does not recall having any problems with being us nor prior to joining the military. I don't see any clear military connection for sleep apnea although he reports that his sleep apnea may have started in the military as well. Since there was heavy drinking during this time period and again there is no documentation, I do not believe there is any grounds to suggest that his current sleep apnea is military related. Sleep apnea could itself be one of the many risk factors for development of depression. PERSONAL HX: CHILDHOOD, SCHOOL, PARENTS The veteran reports having an unremarkable (history seems to fall WNL) childhood hx. 1. Hx of abuse x 3 : n 2. Hx of MH problems : n 3. D/A hx : n 4. Academic hx: n MSE: unremarkable. No si/hi/avh/del. 1. Is the examiner concerned with imminent si/hi ? N 2. Is the examiner concerned re: avh/del/psychomotor agitation/mania/mixed/manic sx's? N 3. On exit assessment, are there any imminent concerns noticed that need acutely addressed? N 4. Re: safety issues, is the examiner sufficiently concerned re: reliability of the candidates hx? N General Overview re: Compensation and Pension exam-- In this checkbox formulated template report, although a veteran may endorse experiencing certain symptoms, one may not see a symptom checked off on the provided diagnostic checkbox list of symptoms. Any symptom reported by the veteran but not checked off on the checkbox list indicates that the symptom(s) is not deemed to be clinically significant. This means that the symptom(s) reported has not been determined to represent psychopathology (an aberrant symptom(s)) but rather, the symptom is deemed to fall within the normal limits of human experience). The examiner's role in this process is to determine which symptoms represent abnormal or pathologic mental health states vs. those symptoms that fall within the normal limits of human experience. The presence of psychological symptoms can be considered "normal" depending on various factors. For example, it is not necessarily pathologic (a mental illness) for one to feel sad, angry, anxious, depressed, etc. Experiencing such symptoms does not mean that one is suffering from a clinical depression or has mental illness ( e.g. psychopathologic depression). It is within the range of normal human experience to feel "emotional", sad, angry, or even anguished at times when thinking of friends, fellow soldiers, or innocent victims that have been injured or killed; merely experiencing such an emotion does not constitute psychopathology. In some individuals, feeling intermittently emotional about past traumatic experiences can fall well within normal limits, even if symptoms surface on and off for many years. Feeling strong emotions at times does not necessarily mean that you are mentally ill (experience psychopathology). Discussion: The veteran feels strongly that his clinical depression which has been present throughout most of his adult life has been caused by a leg injury that he had in the military. He did not seek out any help for his depression in the military because he was ashamed. When he left the military, even though he continued to be remain moderately to severely depressed dailiy, he never sought any form of treatment and has no documentation of clinical depression. He only recently started clinical treatment. Findings: The veteran describes chronic depressed mood, with no history of meaningful clinical improvement and certainly no remission. He reports feeling depressed daily, and ranks his depression as being moderate (7 on a scale of 1-10 for depression). He describes neurovegetative symptoms of depression including problems with chronic suicidal ideations. Typically, depression is considered to be multifactorial. There can be genetic influence often times but not always. Clinical depression is very common in general oftentimes there are multifactorial elements, which play a role in so far as etiology. In this veteran, there is no documentation supporting that he suffered from depression while he was in the military. He indicates that he was so severely depressed that he had been seconds away from attempting suicide but never sought any treatment throughout. He did indicate that he talked to religious counselor once I believe. There is no evidence of any specific cause of his depression which hes has felt throughout his adult life. There are multiple clinical factors that are believed to be prominent triggers for depression such as of low self-esteem, unfulfilling relationships, chronic use of alcohol, which we know now is a risk factor for depression. Although the veteran believes his pain has specifically caused his clinical depression, however depression is most often determined to be multifactorial. In the examiner's opinion, there is insufficient evidence to suggest that in this particular case his clinical depression is solely secondary to his leg pain. That is, the examiner believes that there is a greater chance than not that other factors played substantial roles in his chronic clinical depression and in the absence of clinical evidence i.e. documentation, to suggest otherwise, there is not sufficient evidence to support his own belief that his pain is ultimately the sole cause of his chronic depression. By his history and per records there've been multiple stressors throughout his life that could play a significant etiologic role. With regards to there being a military stressor large enough to provoke clinical depression while in the military, it is unlikely that a minor injury (an injury that required a leg brace for 8 days and then back to duty) would be sufficient grounds to cause clinical depression, particularly since there were numerous stressors including relationship issues and legal problems. xx /es/ LAWRENCE L VONRAGO M.D./STAFF PSYCHIATRIST Signed: 11/03/2015 10:32 -------------------------------------------------------------------------
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Buck52
Andyman to be honest it don't look to good...maybe SC but probably not a rating but we never know how the rater will see this? or it could just be denied on bases of what this examiner mention about
iceturkee
i would be concerned reading the doctors last comments as there is no nexus or eval from a va mh practioner. i had both plus the all important it is at least as likely as not. i got 30 percent. hope g
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