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Question
wes1
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21 Nov 2015 @ 1604
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like an opinion
Name: ------------------------ DOWNLOAD REQUEST SUMMARY -----------------------
System Request Date/Time: 21 Nov 2015 @ 1604
File Name:
Date Range Selected: 06 Nov 2015 to 06 Nov 2015
Data Types Selected:
My HealtheVet Account Summary
VA Notes
--------------------- MY HEALTHEVET ACCOUNT SUMMARY ---------------------
Source: VA
Authentication Status: Authenticated
Authentication Date: 20 Apr 2011
Authentication Facility ID: 656
Authentication Facility Name: St Cloud VA Health Care System
VA Treating Facility Type
-------------------- ------
Tomah WI VAMC na
Minneapolis VA Hlth Syst VAMC na
VBA BRLS na
St Cloud VA Health Care System na
VETERANS ID CARD SYSTEM na
VBA CORP na
DEPARTMENT OF DEFENSE DEERS na
AUSTIN MHV na
ENROLLMENT SYSTEM REENGINEERING na
------------------------------- VA NOTES --------------------------------
Source: VA
Last Updated: 21 Nov 2015 @ 1354
Sorted By: Date/Time (Descending)
VA Notes from January 1, 2013 forward are available 3 calendar days after
they have been completed and signed by all required members of your VA
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visit the FAQs or contact your VA health care team.
=========================================================================
Date/Time: 06 Nov 2015 @ 1430
Note Title: C&P EXAMINATION
Location: Minneapolis VA Hlth Syst VAMC
Signed By: KING,LINDSAY T
Co-signed By: KING,LINDSAY T
Date/Time Signed: 18 Nov 2015 @ 1356
-------------------------------------------------------------------------
LOCAL TITLE: C&P EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: NOV 06, 2015@14:30 ENTRY DATE: NOV 18, 2015@13:56:49
AUTHOR: KING,LINDSAY T EXP COSIGNER:
URGENCY: STATUS: COMPLETED
COMPENSATION AND PENSION EXAMINATION REPORT (FREE TEXT)
=======================================================
Mental Disorders (other than PTSD and Eating Disorders)
Disability Benefits Questionnaire
NAME of VETERAN:
Your patient is applying to the U.S. Department of Veterans Affairs (VA) for
disability benefits. VA will consider the information you provide on this
questionnaire as part of their evaluation in processing the Veteran's claim.
Please note that this questionnaire is for disability evaluation, not for
treatment purposes.
NOTE: If the Veteran experiences a mental health emergency during the
interview, please terminate the interview and obtain help, using local resources
as appropriate. You may also contact the Veterans Crisis Line at
1-800-273-TALK(8255). Stay on the Crisis Line until help can link the Veteran to
emergency care.
NOTE: In order to conduct an initial examination for mental disorders, the
examiner must meet one of the following criteria: a board-certified or
board-eligible psychiatrist; a licensed doctorate-level psychologist; a
doctorate-level mental health provider under the close supervision of a
board-certified or board-eligible psychiatrist or licensed doctorate-level
psychologist; a psychiatry resident under close supervision of a board-certified
or board-eligible psychiatrist or licensed doctorate-level psychologist; or a
clinical or counseling psychologist completing a one-year internship or
residency
(for purposes of a doctorate-level degree) under close supervision of a
board-certified or board-eligible psychiatrist or licensed doctorate-level
psychologist.
In order to conduct a review examination for mental disorders, the examiner
must meet one of the criteria above, OR be a licensed clinical social worker
(LCSW), a nurse practitioner, a clinical nurse specialist, or a physician
assistant, under close supervision of a board-certified or board-eligible
psychiatrist or licensed doctorate-level psychologist.
This Questionnaire is to be completed for both initial and review mental
disorder(s) claims.
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
NOTE: If the Veteran has a diagnosis of an eating disorder, complete the
Eating Disorders Questionnaire in lieu of this Questionnaire.
NOTE: If the Veteran has a diagnosis of PTSD, the Initial PTSD Questionnaire
must be completed by a VHA staff or contract examiner in lieu of
this Questionnaire.
If the Veteran currently has one or more mental disorders that conform to
DSM-V criteria, provide all diagnoses:
Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Adjustment Disorder, with mixed anxiety and
depressed mood, chronic
ICD code:
Comments, if any (including causation/exacerbation):
Mental Disorder Diagnosis #2: Alcohol Use Disorder, in early remission
ICD code:
Comments, if any (including causation/exacerbation):
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): N/A
ICD code:
Comments, if any:
2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [ ] No
If yes, complete the following question:
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[X] Yes [ ] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis:
If yes, list which symptoms are attributable to each diagnosis:
Veteran is not currently exhibiting any symptoms of alcohol use disorder.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[X] Yes [ ] No [ ] Not shown in records reviewed
Comments, if any:
If yes, complete the following question:
d. Is it possible to differentiate what symptom(s) indicated above is/are
attributable to each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis:
There is no scientific method to differentiate what portion of each symptom is
attributable to each diagnosis.
If yes, list which symptoms are attributable to each diagnosis:
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)
[ ] No mental order diagnosis
[ ] 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
[ ] Occupational and social impairment due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication
[ ] Occupational and social impairment with occasional decrease in work
efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily,
with normal routine behavior, self-care and conversation
[ ] Occupational and social impairment with reduced reliability and
productivity
[X] Occupational and social impairment with deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood
[ ] Total occupational and social impairment
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 [X] No [ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social
impairment is attributable to each diagnosis:
There is no proven scientific method to delineate the level of impairment that
results from each diagnosis.
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
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 [X] No [ ] No diagnosis of TBI
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social
impairment is attributable to each diagnosis:
There is no proven s
cientific method to delineate the level of impairment that
results from each diagnosis.
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence review
------------------
If any records (evidence) were reviewed, please list here:
From C-file (including Service Treatment Records): Reviewed via VBMS.
Veteran was seen for a Mental Disorders C&P exam on 12/17/13 by Dr. O'Neil.
Diagnostic impression was: Dissociative Disorder, NOS, with depressive features;
Alcohol Dependence, in full sustained remission. GAF was 45.
From CPRS: Reviewed.
Veteran participates in MH treatment at Minneapolis VAHCS. Diagnostic impression
is: Complex neurobehavioral disorder with disturbance of mood (Organic Affective
Disorder).
Veteran underwent a neuropsychological evaluation on 06/13/13 by Dr. Eidson.
Summary was: "Although the possibility of cognitive impairment secondary to a
longstanding and
intractable seizure disorder is quite possible, especially given the noted
temporal lobe onset of his recent seizure activity, the extent of his true
cognitive dysfunction is unclear given his performance on measures of effort and
test validity. Keeping the possibility of reduced effort in mind, Mr. Eitel does
demonstrate a slightly lateralized neuropsychological profile, with severely
impaired verbal recall and intact recall for visuospatial material noted. A
lateralized profile would not be expected if results were due solely to poor
effort, and may reflect his longstanding seizure disorder. Recent MRI results
also indicate hippocampal asymmetry. In addition to the noted impairment on
cognitive testing, Mr. Eitel appears to be in significant psychological distress
at this time (although MMPI-2 was rendered invalid due to the possibility of
over-reporting). Problem areas endorsed included symptoms of depression,
anxiety, somatic complaints, social avoidance, and bizarre sensory experiences.
Thus, It is likely that both psychological and neurological factors are
reflected in his current cognitive presentation.
Other: None.
2. History (since 12/17/13)
----------
NOTE: Initial examinations require pre-military, military, and post-military
history. If this is a review examination only indicate any relevant history
since
prior exam.
A. RELEVANT SOCIAL/MARITAL/FAMILY HISTORY (PRE-MILITARY, MILITARY,
POST-MILITARY):
Veteran lives with a male roommate in River Falls, WI. His roommate was his
sponsor in AA. This gentleman owns the home and veteran has been renting from
him
for 5 years. No current significant other.
Two children, ages 30 and 28. Two grandchildren. Has not seen his children "in
years."
Mother is still living, but he has no contact with her. Has two brothers and one
sister. Has "very little" contact with them.
Has a "pretty good" relationship with his sponsor. No other close friends.
B. RELEVANT OCCUPATIONAL AND EDUCATIONAL HISTORY (PRE-MILITARY, MILITARY,
POST-MILITARY):
Last worked 4 years ago. He had been a manager of collection agency for four
years.
Current sources of income: SSDI and VA disability.
C. RELEVANT MENTAL HEALTH HISTORY, TO INCLUDE PRESCRIBED MEDICATIONS AND FAMILY
MENTAL HEALTH (PRE-MILITARY, MILITARY, POST-MILITARY):
Sees Dr. NcNairy for medication management. Current medication is clonazepam.
Numerous psychiatric hospitalizations. Says he has been to "every hospital in
Wisconsin." Attended a civil commitment hearing approximately 4 months ago.
D. RELEVANT LEGAL AND BEHAVIORAL HISTORY (PRE-MILITARY, MILITARY,
POST-MILITARY):
None.
E. RELEVANT SUBSTANCE ABUSE HISTORY (PRE-MILITARY, MILITARY, POST-MILITARY):
Veteran reports being sober from alcohol since March 2011. Had "one slip" four
months ago. Per MH note dated 08/04/15 by Dr. McNairy: "Reviewed his single
episode of drinking 'with old friends' who happened by and took him to local bar
for old times. 'I was lonely...I don't recall what happened or how much I drank,
(BAL .133 in local ED) Was told I was disruptive and needed to be restrained, I
am so ashamed. Have been going to AA 3x week ever since and sponsor contact
daily.' Recall being in MH unit Ashland WI and court where judge denied petition
to extend 72 hour hold. 'I told him rationally what I recalled and the mistake I
made that wont happen again.'"
F. RELEVANT MEDICAL (NON Mental health) HISTORY (PRE-MILITARY, MILITARY,
POST-MILITARY):
Veteran reports that he has a seizure disorder. Says he has "big" seizures and
"little" seizures. He can go one week without seizures and then have 3-4 in a
row. Big ones come during his sleep. Per CPRS,
1. Alcohol Abuse
2. Seizure Disorder
- comment made in records of possible pseudo seizure
3. Tobacco Use Disorder *
4. Alcohol Depend, Unspec
5. Affective/Mood Disorder
6. Organic Anxiety Syndrome
7. Presbyopia
8. Myopia
9. General Anxiety Disorder
10. Other and unspecified alcohol dependence, in remission
11. Hyperlipidemia *
12. Pain in joint involving upper arm
13. Tremor *
14. Drug-induced delirium
15. Dissociative Disorder NOS *
16. Status epilepticus (SNOMED CT 230456007)
G. SENTINEL EVENT(S) (other than stressors):
H. OTHER, IF ANY:
3. Symptoms
-----------
For VA purposes, check all symptoms that apply to the Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[ ] Suspiciousness
[ ] Panic attacks that occur weekly or less often
[ ] Panic attacks more than once a week
[ ] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[ ] Mild memory loss, such as forgetting names, directions or recent events
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[ ] Memory loss for names of close relatives, own occupation, or own name
[ ] Flattened affect
[ ] Circumstantial, circumlocutory or stereotyped speech
[ ] Speech intermittently illogical, obscure, or irrelevant
[ ] Difficulty in understanding complex commands
[ ] Impaired judgment
[ ] Impaired abstract thinking
[ ] Gross impairment in thought processes or communication
[ ] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or a
Work-like setting
[ ] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[ ] Compulsive rituals or obsessive thoughts which interfere with routine
activities
[X] Impaired impulse control, such as unprovoked irritability with periods
of violence
[ ] Spatial disorientation
[ ] Persistent delusions or hallucinations
[ ] Grossly inappropriate behavior
[ ] Persistent danger of hurting self or others
[ ] Neglect of personal appearance and hygiene
[ ] Intermittent inability to perform activities of daily living,
including maintenance of minimal personal hygiene
[ ] Disorientation to time or place
[ X] Feelings of hopelessness
[ ] Feelings of guilt or worthlessness
[ ] Appetite disturbance or weight loss
[ ] Thoughts of harming others
[ ] Elevated or euphoric mood
4. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes [X] No
If yes, describe:
5. Mental Status and Behavioral Observations
--------------------------------------------
Veteran presented for the evaluation as alert and oriented to person, place, and
time. He was seated in a wheelchair and displayed bilateral tremors. Eye
contact
was poor as he often looked down during the exam. Speech was loud, at times.
Thought processes were logical and coherent. Responses were terse. Observed
affect was extremely irritable. He describes his general mood as "life sucks."
Experiences anxiety "on and off." Intermittent irritability. Feels depressed
"most of the time." Lost my house, my wife, my friends (6 years). Says he has
"no
motivation." When asked about sleep, he says "I don't." He says he sleeps two
hours at night. Then he takes a nap for 1-2 hours during the day. He can go 2-3
days without sleep. He is easily awakened by slight noises. He says he has
"weird
dreams." Concentration and memory are "terrible." Says he is "absent-minded."
Cannot create an Excel spreadsheet for his budget. He says at one time he had a
"photographic memory." He could multi-task well. Appetite is variable. Stable
weight. Feelings of worthlessness and hopelessness "come and go." Endorses
chronic SI. Says he has "no more ego." Denies current intent or plan. No signs
of
thought disorder, hallucinations, or delusions. He completed serial 7s with one
error (93, 95, 88, 81, 75, 68, 61).
6. Reliability and credibility of self-report:
---------------------------------------------
There are notable concerns about the credibility of the veteran's self-report
and
clinical presentation. First, psychometric testing (MMPI-2/MMPI-2-RF) has shown
significant symptom over-endorsement, both in his 2013 C&P exam and his 2011
neuropsychological evaluation. Second, veteran performed within the "invalid"
range on effort measures embedded in his 2013 neuropsychological evaluation.
Third, there are questions about the etiology of the veteran's seizures. Per
Neuropsychology Consult dated 08/29/11: "He was brought to the Minneapolis VA
Emergency Room (see notes dated 8/31/11) for a tremor and persistent headache
after a self-reported seizure; notes from a neurology consult conducted at that
time, state that the history of the event was not consistent with an epileptic
seizure and was more likely attributable to a psychological process." Finally,
there are significant concerns about the nature and nexus of the veteran's
psychological symptoms. He reports unusual (e.g. low base rate) symptoms,
including a history of bilateral tremors which he says doctors have told him are
related to anxiety and "black outs"/dissociative episodes. He also has a history
of chronic severe alcohol use which complicates his clinical picture even more.
Seizures, tremors and black outs can be negative consequences associated with
chronic several alcohol use.
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
If no, explain:
8. Remarks, if any (include additional rationale and explanation of diagnoses
and
conclusions not already included above):
Veteran reports numerous and severe psychiatric symptoms, including depression,
anxiety, and dissociative episodes, in the context of multiple medical issues,
including a seizure condition. There are notable concerns about the credibility
of the veteran's self-report and clinical presentation, including the nature and
nexus of both physiological and psychological symptoms (see above). Giving him
the benefit the benefit of the doubt, veteran meets criteria for Adjustment
Disorder, with mixed anxiety and depressed mood, which is at least as likely as
not related to his medical conditions, including his seizure condition. Given
the
duration of symptoms is greater than six months, the adjustment disorder is
chronic.
9. The purpose of the evaluation and limits of confidentiality were discussed
and
the veteran gave informed consent. [X] Yes [ ] No
10. Veteran was told that the examiner would be typing their information into a
computerized record during the interview and did not raise objects to that.
11. Time spent in evaluation:
Clinical interview: 50 minutes
Record review: 120 minutes
Additional report preparation (after interview): 60 minutes
NOTE: VA may request additional medical information, including additional
Examinations if necessary to complete VA's review of the Veteran's application.
/es/ LINDSAY T KING
Psychologist
Signed: 11/18/2015 13:56
-------------------------------------------------------------------------
=========================================================================
Date/Time: 06 Nov 2015 @ 0900
Note Title: C&P EXAMINATION
Location: Minneapolis VA Hlth Syst VAMC
Signed By: MOLENAAR,DONALD M
Co-signed By: MOLENAAR,DONALD M
Date/Time Signed: 06 Nov 2015 @ 1046
-------------------------------------------------------------------------
LOCAL TITLE: C&P EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: NOV 06, 2015@09:00 ENTRY DATE: NOV 06, 2015@10:46:17
AUTHOR: MOLENAAR,DONALD M EXP COSIGNER:
URGENCY: STATUS: COMPLETED
COMPENSATION AND PENSION EXAMINATION REPORT (FREE TEXT)
=======================================================
An in-person examination is required for the following exam(s).
ACE process must not be used to complete the DBQ.
DBQ Medical Opinion 1
DBQ NEURO Headaches (including migraine headaches)
DBQ NEURO Seizure disorders (Epilepsy)
DBQ PSYCH Mental disorders
_________________________________________________________________
____________________
The following contentions need to be examined:
traumatic brain injury
migraine headaches
temporal lobe epilepsy
organic affective disorder, with history of anxiety, depression
and psychosis and substance abuse, in remission
Active duty service dates:
MEDICAL OPINION REQUEST based on TBI examination on 07/10/2015.
Examiner failed to complete the DBQs for seizures and migraines,
which were determined to be residuals of TBI. Moreover, motor
abnormalities were noted, but not associated or identified with
an etiology, i.e, are the tremors residuals of TBI. Also, the
veteran has co-existing mental health conditions, which
previously examiners have related to his seizure disorder, which
will be service connected, as the examiner related the seizure
disorder to in-service TBI. Therefore, a mental health
examination is required, and the examiner must delineate which
neurobehavioral symptoms and findings noted on TBI exam are
attributable to TBI versus to his mental health condition.
OPINION:
Please keep in mind that the disability caused by each TBI-
related symptom many only be considered ONCE, as either part of a
diagnosed disability OR as part of a facet. Each symptom
reported by the veteran must be discussed.
If both a Mental Health exam and a TBI exam are being conducted,
please specify which mental health symptoms, to include cognitive
symptoms and sleep disturbance symptoms, are related to a
diagnosed mental health disability.
To aid in this undertaking, please provide the following
information for each symptom reported by the veteran:
1. Is the symptom a residual of TBI? If not, please explain.
2. Is the symptom related to a diagnosed disability?
3. If so, please specify the diagnosis.
4. Is the diagnosis a residual of TBI?
5. If the symptom is not related to a diagnosed disability,
which FACET best classifies the impairment caused by the symptom.
Please choose only one facet for each symptom.
6. Please use the exam worksheet to determine the severity
of each facet. See #14: ASSESSMENT OF COGNITIVE IMPAIRMENT AND
OTHER RESIDUALS OF TBI NOT OTHERWISE CLASSIFIED. Choose one of
the evaluation levels under each facet.
Rationale must be provided in the appropriate section.
*****************************************************************
DBQ NEURO Headaches (including migraine headaches):
The Veteran will be service connected for migraine headaches.
Please evaluate for the current level of severity of the
Veteran's service connected disability. If the diagnosis rendered
is different from the disability for which the Veteran is service
connected, please indicate whether the Veteran's current
diagnosis is a progression of the service connected disability or
the original diagnosis was in error.
*************************************************************
DBQ NEURO Seizure disorders (Epilepsy):
The Veteran will be service connected for temporal lobe epilepsy.
Please evaluate for the current level of severity of the
Veteran's service connected disability. If the diagnosis rendered
is different from the disability for which the Veteran is service
connected, please indicate whether the Veteran's current
diagnosis is a progression of the service connected disability or
the original diagnosis was in error.
*****************************************************************
Please direct any questions regarding this request to:
Wendy Kasper
Phone number: 414-902-5165
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed? No
If no, check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment
records)
MEDICAL OPINION SUMMARY
-----------------------
"
Please keep in mind that the disability caused by each TBI-
related symptom many only be considered ONCE, as either part of a
diagnosed disability OR as part of a facet. Each symptom
reported by the veteran must be discussed.
If both a Mental Health exam and a TBI exam are being conducted,
please specify which mental health symptoms, to include cognitive
symptoms and sleep disturbance symptoms, are related to a
diagnosed mental health disability.
To aid in this undertaking, please provide the following
information for each symptom reported by the veteran:
1. Is the symptom a residual of TBI? If not, please explain.
2. Is the symptom related to a diagnosed disability?
3. If so, please specify the diagnosis.
4. Is the diagnosis a residual of TBI?
5. If the symptom is not related to a diagnosed disability,
which FACET best classifies the impairment caused by the symptom.
Please choose only one facet for each symptom.
6. Please use the exam worksheet to determine the severity
of each facet. See #14: ASSESSMENT OF COGNITIVE IMPAIRMENT AND
OTHER RESIDUALS OF TBI NOT OTHERWISE CLASSIFIED. Choose one of
the evaluation levels under each facet. "
**************************************
NOTE ALOTTED TIME 2 HOURS.
OPINION: VA EXAMINER IS NOT VES EXAMINER AND CANNOT INTERPRET EXAMINATION
FINDINGS/DIAGNOSES OR LACK THEROF. VA EXAMINER IS NOT A VA QUALIFIED TBI
EXAMINER AND NO OPINION RE MANIFESTATIONS OF TBI INJURIES/SYMPTOMS/RESIDUALS
CAN BE PROVIDED.
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: **CLAIM TYPE: SUPPLEMENTAL
**SPECIAL CONSIDERATIONS: NOT APPLICABLE
**INSUFFICIENT EXAM: NO
ELECTRONIC CLAIMS FOLDER AVAILABLE.
REMAND, PLEASE EXPEDITE
This request is associated with a pending appeal and is not
considered a part of any of the priority categories.
An in-pe
rson examination is required for the following exam(s).
ACE process must not be used to complete the DBQ.
DBQ Medical Opinion 1
DBQ NEURO Headaches (including migraine headaches)
DBQ NEURO Seizure disorders (Epilepsy)
DBQ PSYCH Mental disorders
_________________________________________________________________
____________________
The following contentions need to be examined:
traumatic brain injury
migraine headaches
temporal lobe epilepsy
organic affective disorder, with history of anxiety, depression
and psychosis and substance abuse, in remission
Active duty service dates:
Branch: Air Force
EOD: 06/06/1979
RAD: 04/02/1985
DBQ Medical Opinion 1:
The Veteran has important information in his or her electronic
claims folder in VBMS and Virtual VA. Please review both folders
and state that they were reviewed in your report.
MEDICAL OPINION REQUEST based on TBI examination on 07/10/2015.
Examiner failed to complete the DBQs for seizures and migraines,
which were determined to be residuals of TBI. Moreover, motor
abnormalities were noted, but not associated or identified with
an etiology, i.e, are the tremors residuals of TBI. Also, the
veteran has co-existing mental health conditions, which
previously examiners have related to his seizure disorder, which
will be service connected, as the examiner related the seizure
disorder to in-service TBI. Therefore, a mental health
examination is required, and the examiner must delineate which
neurobehavioral symptoms and findings noted on TBI exam are
attributable to TBI versus to his mental health condition.
OPINION:
Please keep in mind that the disability caused by each TBI-
related symptom many only be considered ONCE, as either part of a
diagnosed disability OR as part of a facet. Each symptom
reported by the veteran must be discussed.
If both a Mental Health exam and a TBI exam are being conducted,
please specify which mental health symptoms, to include cognitive
symptoms and sleep disturbance symptoms, are related to a
diagnosed mental health disability.
To aid in this undertaking, please provide the following
information for each symptom reported by the veteran:
1. Is the symptom a residual of TBI? If not, please explain.
2. Is the symptom related to a diagnosed disability?
3. If so, please specify the diagnosis.
4. Is the diagnosis a residual of TBI?
5. If the symptom is not related to a diagnosed disability,
which FACET best classifies the impairment caused by the symptom.
Please choose only one facet for each symptom.
6. Please use the exam worksheet to determine the severity
of each facet. See #14: ASSESSMENT OF COGNITIVE IMPAIRMENT AND
OTHER RESIDUALS OF TBI NOT OTHERWISE CLASSIFIED. Choose one of
the evaluation levels under each facet.
Rationale must be provided in the appropriate section.
*****************************************************************
********************
DBQ NEURO Headaches (including migraine headaches):
The Veteran will be service connected for migraine headaches.
Please evaluate for the current level of severity of the
Veteran's service connected disability. If the diagnosis rendered
is different from the disability for which the Veteran is service
connected, please indicate whether the Veteran's current
diagnosis is a progression of the service connected disability or
the original diagnosis was in error.
*****************************************************************
********************
DBQ NEURO Seizure disorders (Epilepsy):
The Veteran will be service connected for temporal lobe epilepsy.
Please evaluate for the current level of severity of the
Veteran's service connected disability. If the diagnosis rendered
is different from the disability for which the Veteran is service
connected, please indicate whether the Veteran's current
diagnosis is a progression of the service connected disability or
the original diagnosis was in error.
*****************************************************************
********************
DBQ PSYCH Mental disorders:
The Veteran has important information in his or her electronic
claims folder in VBMS and Virtual VA. Please review both folders
and state that they were reviewed in your report.
The Veteran will be service connected for organic affective
disorder, with history of anxiety, depression and psychosis.
Please evaluate for the current level of severity of the
Veteran's service connected disability. If the diagnosis rendered
is different from the disability for which the Veteran is service
connected, please indicate whether the Veteran's current
diagnosis is a progression of the service connected disability or
the original diagnosis was in error. Please address whether the
veteran's substance abuse is at least as likely as not caused by
his service related mental health condition. If not, please
state whether it has been permanently aggravated beyond natural
progression by the mental health condition; and, if so, please
provide the date of aggravation by citing the date of the medical
evidence that supports your determination. Please provide full,
detailed rationale.
If more than one mental disorder is diagnosed please comment on
their relationship to one another and, if possible, please state
which symptoms are attributed to each disorder.
Please direct any questions regarding this request to:
Wendy Kasper
Phone number: 414-902-5165
b. Indicate type of exam for which opinion has been requested: TBT Residuals
*************************************************************************
****************************************************************************
Headaches (including Migraine Headaches)
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
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
[X] 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
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a headache
condition?
[X] Yes [ ] No
[X] Migraine including migraine variants
ICD code: SC Date of diagnosis: SC
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
headache conditions (brief summary):
Active duty service dates:
Branch: Air Force
EOD: 06/06/1979
RAD: 04/02/1985
The Veteran will be service connected for migraine headaches per VBA
and have asked to evaluate for the current level of severity of this
service connected isability. When asked, do you get headaches, the
veteranss response is "I do not get headaches" but the "f...'rs will
explode in my head. ....When I was in the service they used to give me
good drugs and cover for me so I did not get into trouble". He does
have
a documeted prescription for SUMATRIPTAN SUCCINATE 50MG TAB TAKE 1/2
TABLET TO ONE ACTIVE TABLET BY MOUTH ONCE AS NEEDED FOR SEVERE
HEADACHE.... which does not help. Symptoms may be relieved in part by
placing and ice pack on his forehead/eyes. He states " I wish you guys
would fix this s..."" When asked what he means by that the pt states, I
want my life back... as " I have lost everything and when I go in
public
I look like a freak". He has had this feeling since " they laughed at
me
at my last job interview about 3 yrs ago as a mgr at a collection
agency".
SEEN VAMC STANDARD TITLE: PSYCHIATRY E & M NOTE DATE OF NOTE: APR 16,
2015@12:21
. ASSESSMENT:Tremor very pronounced at todays visit. Note that Oxcarb.
was reduced after last set of A/E levels in early April. Still thinks
he
is having nocturnal SZ as he has awakening with swollen, bitten tongue
several times past month.He defines his waking problems as "memory,
balance and tremors...without improvement I can not work again.
Active Outpatient Medications SUMATRIPTAN SUCCINATE 50MG TAB TAKE 1/2
TABLET TO ONE ACTIVE
TABLET BY MOUTH ONCE AS NEEDED FOR SEVERE HEADACHE. Active problems -
Computerized Problem List is the source for the following: 1. Alcohol
Abuse 2. Seizure Disorder - comment made in records of possible
pseudoseizure 3. Tobacco Use Disorder * 4. Alcohol Depend, Unspec 5.
Affective/Mood Disorder 6. Organic Anxiety Syndrome 8. Myopia 9.
General Anxiety Disorder10. Other and unspecified alcohol dependence,
in
remission 11. Hyperlipidemia * 12. Pain in joint involving upper arm
13. Tremor * 14. Drug-induced delirium 15. Dissociative Disorder NOS *
16. Status epilepticus (SNOMED CT 230456007). PLAN: Pt seen in RN/MD
clinic for psychiatric evaluation and medication management. While
awaiting resutls of movement consult in May will offer pt ,low dose
clonazepam on days 0.5mg bid in addtion to 1mg hs. takes it
infrequently by his account. but whatever visitng RN sets up for him
he
follows.Referral to Health Buddy to allow for online contact and
tacking
of freq. of sz due to poor recall at interval visits. RTC:2 months.
RECORDS
VBMS
"You do not have sufficient security access for this file".
CPRS
****
LOCAL TITLE: H&P HISTORY & PHYSICAL
STANDARD TITLE: H & P NOTE
DATE OF NOTE: JUN 10, 2013@13:12 ENTRY DATE: JUN 10, 2013@13:12:35
Chief Complaint(s), Reason for Admission and History of Present
Illness:
This 51 year old MALE w/ seizure disorder, mood disorder followed by
Dr
McNairy
and sore R shoulder admitted to CLC for med mgmt, rehab and discharge
planning.
Admitted fm ED 5/11/2013 w/ presumed dehydration for further evaluation
of
imbalance and confusion. He had recently been seen by neurology for his
seizure
disorder, and phenytoin added to his zonisamide QHS. He continued to
have spells
several times per week. On admit, head CT negative for acute pathology.
Ethanol,
UTox negative. No lab or VS abnormalities. He required soft restraints
for
agitation and abusiveness towards staff, but eventually became calm.
Phenytoin
level was found to be significantly elevated at ~50.
Past Medical History (based on Computerized Problem List):
1. Alcohol Abuse - sober 2011
2. Seizure Disorder
3. Tobacco Use Disorder (no desire to cut down or quit)
4. R shoulder injury/chronic pain
5. Affective/Mood Disorder
6. Anxiety disorder
7. Presbyopia
8. Myopia
9. Hyperlipidemia
10. Bipolar Disorder
11. tremor
12. Dissociative Disorder (5/2013 Dr McNairy)
Diagnosis/Treatment Plan: see admit note per Dr West
06/10/2013 ADDENDUM STATUS: COMPLETED
51 yo with intractable partial complex seizures, despite trials of
multiple
AEDs, was brought to ED May 11 by his roommate who was unable to
provide
any
history as VA police escorted him off the premises due to his behavior.
In the
ED pt was confused, agitated, weak and had an unsteady gait. Head CT
showed no
pathology. He had been started on DPH recently, in addition to his
Zonisamide,
and DPH level was around 50. DPH was stopped, etiology of elevated
level never
determined (possibly pt is a slow metabolizer along the CYP pathway);
once the
DPH level was sub-therapeutic he had recurrent seizure activity and
neuro
recommended starting Carbamazepine. On May 16 pt refused all meds; a
video EEG
monitor was started, pt had a t-c seizure recorded and when that was
shown to
the pt he agreed to resume taking meds.
MRI of the brain May 31 was unremarkable.
Carbamazepine level June 7 was 9.4 (4-12) and the metabolite level was
1.9 (0.2-
2).
His confusion, angry outbursts and uncooperativeness have all improved
over the
past week and his gait is more steady.
He transfers to CLC for on-going rehab and for help finding a safe
living
situation.
A/P:
1. Intractable seizures - possible slow metabolizer of drugs. Cont
Carbamazepine with monitoring of metabolite levels. No known seizure
activity
past week or more
2. Confusion - unclear how much this was related to medication
toxicity,
vs
seizures vs underlying cognitive impairment. Need OT and neuropsych
testing to
help characterize deficits. ? progressive supranuclear palsy given
upward gaze
palsy.
3. Mood disorder with dissociative episodes esp at night: on-going f/up
by Dr
McNairy. On Quetiapine per psychiatry for mood disorder and agitation.
Psych
felt he lacked decision making capacity the first several weeks of this
admit
but now feel he is at his baseline mental status and they feel he does
have
capacity for most decisions at this time.
4.Tremor - cont Primadone started this admit
5. R shoulder pain - chronic - trial Lidocaine ointment
6. RUL cavitary lesion - had neg TB eval in 2012; CXR now shows
scarring
RUL and
no progression of cavity
*********************
LOCAL TITLE: C&P EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: SEP 09, 2011@13:10 ENTRY DATE: SEP 09, 2011@13:02:44
COMPENSATION AND PENSION EXAMINATION
MISCELLANEOUS NEUROLOGICAL DISORDERS
====================================
PROBLEM SUMMARY
===============
PROBLEM: HEADACHES
DATE OF ONSET: 1981
CIRCUMSTANCES AND INITIAL MANIFESTATIONS: THINKS DX WITH MIGRAINES
1981 RX ASA
AND PAIN KILLERS DOES NOT KNOW THE NAME
SELF REPORTS ALWAYS CONSISTENT FROM THAT TIME ON 2-3 TIME PER WEEK
NOW I GET SHOTS STARTED 4 YEARS AGO, THAT TAKES CARE OF THEM
IMMEDIATELY
HEADACHES OCCUR START IN THE BACK AND WORK WAY UP FRONT BEHIND
EYES
LAST WITH MEDS 25-30 MINUTES
COURSE SINCE ONSET: Improved
CURRENT TREATMENT FOR THIS CONDITION: Medication
DESCRIBE CURRENT TREATMENT(S): IMITREX
RESPONSE TO TREATMENT: Good
SIDE EFFECTS FROM CURRENT TREATMENT(S): Yes
DESCRIBE SIDE EFFECTS FROM CURRENT TREATMENT(S): UNCOMFORTABLE
FEELING ACROSS
WHOLE BODY WHEN IT HAPPENS
*********************
MEDICAL HISTORY
===============
NO HISTORY OF: Neurologic related Hospitalization or Surgery;
Neurologic
Neoplasm.
DISORDER(S) BEING EVALUATED
---------------------------
MIGRAINE HEADACHE
-----------------
FREQUENCY DURING PAST 12 MONTHS: Weekly
HEADACHE SEVERITY: Most attacks are prostrating
TREATED WITH CONTINUOUS MEDICATION: No
USUAL DURATION OF HEADACHE: Minutes
LIST MEDICATIONS, DOSAGES, AND SCHEDULES:
IMITREX
PHYSICAL EXAMINATION
====================
NORMAL FUNDOSCOPIC EXAM? Yes
NORMAL MENTAL STATUS? Yes
ARE ALL CRANIAL NERVES INTACT? Yes
IS CEREBELLAR EXAM NORMAL? Yes
IS THERE EVIDENCE OF CHOREA? No
IS A CAROTID BRUIT PRESENT? No carotid bruits
TESTS
=====
DIAGNOSIS SECTION
=================
SUMMARY OF PROBLEMS, DIAGNOSES, AND FUNCTIONAL EFFECTS
------------------------------------------------------
DIAGNOSIS: MIGRAINES
PROBLEM ASSOCIATED WITH THE DIAGNOSIS: HEADACHES
EFFECT(S) ON USUAL OCCUPATION AND RESULTING WORK PROBLEM(S):
Increased absenteeism.
EFFECT(S) ON OCCUPATIONAL ACTIVITIES: Pain.
ARE THERE EFFECTS OF THE PROBLEM ON USUAL DAILY ACTIVITIES?
Yes
DESCRIPTION OF THE EFFECTS OF THE PROBLEM ON USUAL DAILY
ACTIVITIES: I ADLS AVOIDS NORMAL ACTIVITIES WITH
MIGRAINES
************************************************************
EMPLOYMENT HISTORY
------------------
USUAL OCCUPATION: MANAGER OF AGENCIES
VETERAN IS CURRENTLY NOT EMPLOYED.
VETERAN IS NOT RETIRED.
IS VETERAN UNEMPLOYED BUT NOT RETIRED? Yes
DURATION OF CURRENT UNEMPLOYMENT: Less than 1 year
REASONS GIVEN FOR UNEMPLOYMENT: UNABLE TO PERFORM HIS JOB
**************************************************
COMMENTS:
BASED UPON EXAMINATION AND AVAILABLE INFORMATION IT IS LESS LIKELY
THAN NOT THE
VETERANS MIGRAINE CONDITION IS DIE TO OR AGGRAVATED BY MILITARY
SERVICE
RATIONALE: NO DOCUMENTATION OF TREATMENT FOR A MIGRAINE CONDITION IN
THE MILITARY
************************************************************************
*********
b. Does the Veteran's treatment plan include taking medication for the
diagnosed condition?
[X] Yes [ ] No
If yes, describe treatment (list only those medications used for the
diagnosed condition):
SUMATRIPTAN SUCCINATE 50MG TAB TAKE 1/2 TABLET TO ONE ACTIVE
TABLET BY MOUTH ONCE AS NEEDED FOR SEVERE HEADACHE
3. Symptoms
-----------
a. Does the Veteran experience headache pain?
[X] Yes [ ] No
[X] Pain on both sides of the head
b. Does the Veteran experience non-headache symptoms associated with
headaches? (including symptoms associated with an aura prior to headache
pain)
[ ] Yes [X] No
c. Indicate duration of typical head pain
[X] Other, describe:
not consistent per veteran
d. Indicate location of typical head pain
[X] Both sides of head
4. Prostrating attacks of headache pain
---------------------------------------
a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating
attacks of migraine / non-migraine headache pain?
[ ] Yes [X] No
5. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms
-----------------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
conditions
listed in the Diagnosis section above?
[X] Yes [ ] No
If yes, describe (brief summary):
see Seizure DBQ.
6. Diagnostic testing
---------------------
Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
7. Functional impact
--------------------
Does the Veteran's headache condition impact his or her ability to work?
[ ] Yes [X] No
8. Remarks, if any:
-------------------
OPINION: NONE REQUESTED.
The Veteran's current diagnosis is NOT CLEARLY ESTABLISHED IN VAMC
RECORDS, AND THERE IS NO DOCUMENTATION OF PROGRESSION OF MIGRAINE
HEADACHES .
****************************************************************************
Seizure Disorders (Epilepsy)
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
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
[X] 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
[ ] Other:
1. Diagnosis
------------
Does the Veteran have or has he/she ever been diagnosed with a seizure
disorder (epilepsy)? (This is the condition the Veteran is claiming or for
which an exam has been requested)
[X] Yes [ ] No
[X] Psychomotor epilepsy (complex partial seizures, temporal lobe
seizures)
ICD code: VAMC Date of diagnosis: SC
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
seizure
disorder (epilepsy) (brief summary):
Active duty service dates:
Branch: Air Force
EOD: 06/06/1979
RAD: 04/02/1985
***************
53-year-old with intractable complex partial epilepsy, frequent
hospitalizations for medication toxicity as well as history of
nonepileptic events and continuous tremor presents in a wheechair,
with
a noticeable tremor at rest and which appears to be aggravated by his
emotions, and emotional lability but of seemingly clear mind. The
Veteran will be service connected for temporal lobe epilepsy per VBA
and is being seen, among otehr reasons, to assess the current level of
severity of the Veteran's service connected disability. He opines that
these seizures commenced in about 1982 when hit in the head with a
pool
cube during a brawland which vary in their freqeuncy... about every
2-3
weeks, or, for several days in a row the last being about 3 days ago.
He is currently on Trileptal 300/750 and then Lacosamide 100/200.
Says
that his seizures are occurring every week or two and are reported to
be associated with amnesia and post eizure stiffness/confusion. When
his balance is fine he can stand but at otehr times he descibes it as
terrible. He no longer drives x ~ 7 yrs, performs limited cooking and
showers when he "feels like it". He uses a walker to get into his
trailer home. He no longer reads beucause of difficulty following text
and because " they smile in your face and stb you in the back". He
lives with his roomate. DIAGNOSIS: TLE with complicated behavioral and
cognitive disorders.
SEEN LOCAL TITLE: C&P EXAMINATION ENTRY DATE: JUL 10,
2015@13:53:38... VES... .C&P DEM CONTRACT VES EXAM AVAILABLE IN VISTA
IMAGING AND IN THE NATIONAL SHARE POINT FOLDER FOR YOUR RO. TBI
examination on 07/10/2015. Examiner failed to complete the DBQs for
seizures and migraines, which were determined to be residuals of TBI.
Moreover, motor abnormalities were noted, but not associated or
identified with an etiology, i.e, are the tremors residuals of TBI.
Also, the veteran has co-existing mental health conditions, which
previously examiners have related to his seizure disorder, which will
be service connected, as the examiner related the seizure disorder to
in-service TBI. Therefore, a mental health
examination is required, and the examiner must delineate which
neurobehavioral symptoms and findings noted on TBI exam are
attributable to TBI versus to his mental health condition.
SEEN LOCAL TITLE: EEG NEUROLOGY CONSULT DATE OF NOTE: JUN 11,
2014@08:30. HISTORY: the patient has a history of epileptic and
nonepileptic events and is admitted with Carbamazepine toxicity and
intubated in the MICU. During much of the recording, the patient is
on
Propofol due to control agitation.IMPRESSION: this three day video
EEG
recording in the MICU is abnormal due to the presence of moderate
generalized slowing consistent with a moderate diffuse
encephalopathy.
NO seizures are seen. The patient's
medications may be contributing to the abnormalities seen. NO seizures
are seen.
SEEN LOCAL TITLE: C&P EXAMINATION ENTRY DATE: SEP 27,
2011@16:16:40.COMPENSATION AND PENSION EXAMINATION EPILEPSY AND
NARCOLEPSY.( frm Neuro note). The patient is a 49 year old with
alcohol
abuse and abnormal spells. He is currently on Dilantin 300 in the
morning with a level of 2.3 this morning and Depakote 500 q.h.s. with
a level of 19.3 this morning. His first seizure started several years
ago. He was followed by primary care provider. He apparently
somewhere around February was started on Dilantin and he was started
on the Depakote about a month ago by Mental Health for possible
bipolar
disorder. He has not previously been evaluated by Neurology. He has
had a head CT but no MRI and no EEG. He has had a hand tremor and
been knocked out for an hour; however, the relationship to alcohol is
not clear. He states that, however, for his first seizure which was
more a major motor, occurred when he had not drank for a year.
EXAM:
On exam he has a significant postural tremor which he states is
longstanding. IMPRESSION: 49 year old with alcohol abuse and
abnormal
events that are suspicious for complex partial epilepsy. He should not
drive until seizure free for 3 mo.
RECORDS
VBMS
"You do not have sufficient security access for this file".
CPRS
****
LOCAL TITLE: NEUROLOGY CLINIC STAFF NOTE
STANDARD TITLE: NEUROLOGY ATTENDING NOTE
DATE OF NOTE: SEP 03, 2015@11:30 ENTRY DATE: SEP 04, 2015@12:13:58
SUBJECTIVE:
The patient is a 53-year-old with intractable complex partial epilepsy,
as well as history of nonepileptic events and continuous tremor. He is
currently on Trileptal 300/750 and then Lacosamide 100/200.
Since last seen on 05/07/2015, he continues to have primarily nocturnal
events, he reports several times a week and often with a bit tongue. In
the last several days, he had a daytime event.
The patient also has continuous body tremor. Has been seen by Dr.
Bushara, but has not had a follow-up.
IMPRESSION AND PLAN:
This is a 53-year-old with intractable right temporal complex partial
epilepsy, as well as some nonepileptic events. The patient has recently
contacted his ex-wife and she states that he had nocturnal shaking
spells
when they were married, so his seizures may date back to the 1990s.
He continues to have abnormal events, which are likely seizures. He has
been very sensitive to medicines, but overall is tolerating his current
medications.
In the last several visits, we had discussed possible vagus nerve
stimulator. We had previously also discussed that he does have a right
temporal abnormality on his MRI; however, it is not classical mesial
temporal sclerosis. Given his mental health history and prior
discussions, he is not interested in and would not likely be a good
surgical candidate.
The patient has reviewed the literature. He has also discussed it with
vagus nerve stimulator representatives, as well as talked to many
people
that have had vagus nerve stimulators placed. He still has some
concerns
about it, which we discussed further. I think it is a reasonable
option
and his Mental Health providers think it may help as well, for his
mental
health issues, since depression may be a component of it. We discussed
that after the placement, we increase the stimulation gradually as
tolerated, that it can cause interruption of speaking and/or coughing.
After the discussion, he would like to move forward with this and we
placed a consult to Dr. Gapany in ENT for vagus nerve stimulator
placement. We will see him in follow-up in a couple months or depending
on vagus nerve stimulator placement time, follow-up with turning on the
stimulator and subsequently adjusting it.
******************************************
LOCAL TITLE: NEUROLOGY CLINIC STAFF NOTE
STANDARD TITLE: NEUROLOGY ATTENDING NOTE
DATE OF NOTE: JAN 15, 2015@10:30 ENTRY DATE: JAN 16, 2015@07:06:49
CHIEF COMPLAINT:
The patient is a 53 year old followed for intractable complex partial
epilepsy.
HISTORY OF PRESENT ILLNESS:
He is on Trileptal 300-600 and Lamictal 100-100. The patient was last
seen several months ago in November 2014. He says that his seizures
are
less frequent occurring every week or two. He does note that they are
different and that rather than observed to be stiff he finds himself
in
a
new room. He continues to be confused after that. He also notes that
for
days after he has these brief episodes where he pauses and is unable
to
function but aware of what is going on.
He was on Trileptal 600-600. His Trileptal level has been high and
although there are no clear notes, according to him the dose has been
reduced to the 300-600 and he does not complain of double vision. He
does
complain of some blurriness but can see Ophthalmology before.
The patient has a long history of multiple hospitalizations with toxic
levels indicating compliance has been an issue but it overall has
improved. He does occasionally miss his morning medications once or
twice
a week.
PHYSICAL EXAM:
On exam, extraocular muscles are intact. He has a tremor which
involves
shaking of his hands, sometimes symmetrical and sometimes alternating.
He
has a simultaneously scissoring of his legs. He, when doing this, has
increased tone or more stiffness of his arms. It reduces somewhat
when
he
is doing activities such as unlocking his wheelchair. Again it may be
non
physiological.
IMPRESSION:
This is a 53-year-old with complex partial epilepsy and non-epileptic
events. Overall he has been doing better with Trileptal and
lacosamide
with carbamazepine. I think with variable compliance he sometimes
would
have toxic levels due to auto induction and it is less likely with the
Trileptal and he is doing well. He has had high levels even though he
is
on a relatively low dose. However, we have reduced the dose somewhat.
He
still has some incomplete seizure control. Again compliance may be a
factor, however, I think we can try increasing perhaps the lacosamide
and
in the past when it was higher, he was tired but since his seizures
are
primarily occurring at night we will increase it to 100-200. If he is
excessively tired during the day or has new double vision or other
side
effects, he should contact us and we will reduce it to 150 at bedtime.
We
will also check levels today and encourage levels to be obtained
whenever
he is in the hospital so we can better monitor and avoid
hospitalizations.
His tremor is a big issue for him today. He says it interferes with
his
ability to go back to work. It has many characteristics of a non
physiological tremor. I think it is unlikely that the antiepileptic
medications are a significant factor since he has had the tremor
essentially unchanged when on a variety of different medicines and
even
when on toxic levels such as Dilantin. I will ask a movement disorder
specialist to possibly make any recommendations that may help. I also
think that he may benefit from physical therapy since he uses a walker
and
the tremor is apparently a factor in limiting his ambulation. Perhaps
with physical therapist and concentrating on gait that the tremor may
improve as well as his ambulation.
*************************************************************
LOCAL TITLE: MH PSYCHIATRIC EVALUATION & MANAGEMENT
STANDARD TITLE: PSYCHIATRY E & M NOTE
DATE OF NOTE: JAN 15, 2015@11:55 ENTRY DATE: JAN 15, 2015@11:55:26
ID: 53 year old male with history of Organic Mood Disorder; TLE
intractable
Seizures; Cognitive disorder who presents for psychiatric follow up.
Patient was
last seen for psychiatric follow up 11/2014 after hospital discharge
due to
seizure.
ASSESSMENT: 53 y/o male with history of mood disorder, TLE, alcohol
use
disorder
in full remission, and cognitive disorder who presents for psychiatric
follow up
after appointment with Neurology. Patient reports seizure control
remains
concern, explains increase to one of his seizure medications likely.
He
reports
depressive symptoms continue as feels reality setting in more at times
regarding
his tremor, memory concerns, and inability to walk safely with balance
concerns.
He reports has had hope the tremor would somehow go away but feels
today he has
to face reality it may never go away. He reports upcoming visit per
Neurology
with specialist to look at more of his current physical concerns with
tremor. He
relates again past poor response to antidepressant medication and is
not
interested in at this time. He reports use of clonazepam for sleep but
with
report of continued poor sleep. He reports home health RN helps to set
up his
medication on weekly basis and has helped eliminate confusion to
anti-epileptic
dosing as history of previous hospital admissions due to anti-epileptic
toxicities. He will follow up with psychiatry in one month hopefully
at
time of
concurrent medical visit.
DIAGNOSIS:
1. Organic Mood Disorder.
2. Cognitive Disorder. Recent MOCA 20/30 in 9/2014.
3. Alcohol use disorder, in remission.
4. Tobacco use disorder, severe.
5. Intractable right temporal complex partial epilepsy.
6. Non-epileptic events.
7. Tremor.
8. Unintentional medication overdose of oxcarbazepine and likely
clonazepam, per
patient report 11/2014. Resolved.
9. Altered mental status secondary to carbamazepine toxicity,
resolved.
10. Hyperlipidemia.
11. Hyperammonemic encephalopathy secondary to valproic acid, resolved
9/17/2014.
PLAN: Pt seen in MD clinic for psychiatric evaluation and medication
management.
1. Continue clonazepam for sleep 1-2 mg hs prn.
2. Patient to return to clinic in one month and try to coordinate at
time of
other appointments. Patient is psychiatrically stable, denies
SI/HI/AH/VH.
3. Patient will go to lab for anti-epileptic drug levels per Neurology.
4. Patient to call clinic with concerns prior to next follow up
appointment.
5. Risk, benefit, side effect of the medications were discussed with
patient.
6. ROI obtained for Riverfalls and Hudson hospital records prior to
2012.
INTERVAL HISTORY/CURRENT FUNCTIONING:
New medical symptoms: Seizure control continues to be challenge for
patient.
Reports Neurology may be increasing one of his medications after
Neurology visit
this AM.
General/Mood: Patient report feels "hopeless" as he is beginning to
think his
tremor on bilateral hands is never going to go away and his memory is
poor. He
reports is more difficult to walk or use a walker as balance is poor.
Patient
reports difficulty with gait and ability to walk has been present past
few years
only. He reports frustration as feels he can no longer be productive
member to
society. He reports last employment around 2012 for debt collection
agency. He
denies any suicidal ideation or intent to act on suicidal plan. He
reports
history of passive suicidal ideation with no increase at this time. He
reports
daily low mood. He denies any HI/AH/VH. He has history of mood
instability with
seizure disorder on anti-epileptic medications. He denies anxiety or
panic
concern at this time.
Sleep: Reports sleep always a problem, even when young. Reports only
obtains a
few hours of sleep per night. Reports klonopin only helps a little.
Drug/alcohol use: Denies any alcohol use concern, denies alcohol
craving.
Reports last use of alcohol 4 years ago. He denies other substance use.
CURRENT MEDS (include OTC and use of herbs): * Review for Accuracy.*
MENTAL STATUS EXAM:
MENTAL STATUS EXAM:
General: Casually dressed, well groomed, adequate hygiene
Gait: in wheelchair
Motor: Tremor noted bilateral UE and at time in bilateral LE
Orientation: Alert to person, place and time
Cognition/Memory: Intact, memory problems more concern in past few
years
Eye Contact: good
Speech: Normal volume, at times with pause as if attempting to
remember
words,
pressured speech when recall past unfavorable events
Mood: "ok, wish this tremor would just go away and my memory"
Affect: easily angered at times due to unexplained reasons for his
tremor,
memory difficulty, inability to safely walk/bear weight
Thought Content/SI/HI: Denies SI/HI, no delusions or hallucinations
Insight/Judgment: Intact and fair.
DIAGNOSIS: TLE with complicated behavioral and cognitive disorders
**************************************************
LOCAL TITLE: NEUROLOGY INPT RESIDENT NOTE
STANDARD TITLE: NEUROLOGY RESIDENT NOTE
DATE OF NOTE: NOV 06, 2014@17:03 ENTRY DATE: NOV 06, 2014@17:03:50
HPI: This 53 year old gentleman has a history of a poorly controlled
seizure
disorder. He was admitted to United hopsital after an overdose of
anti-
epileptics, including carbamazepine which was part of his prior
anti-epileptic
program. he required two days of intubation, was confused afterwards,
and is now
recovering at the VA. he himself denies any recollection of overdose
or of
intent to harm himself, he has a known history of a great deal of
trouble taking
his medications as directed.
ROS: He feels a sense of unreality which he says warms him that a
seizure may be
coming on, otherwise he has no positive on ROS.
PMH: he has temporal lobe epilepsy manifested by partial complex
seizures. He
is known for having aggressive and agitated states following seizures.
He often
has seizures at night, and says he knows by feeling unwell when he
gets
up or
because his room will be a mess. he has been on zonisamide, dilantin,
and
lamotrigine in the past and failed these medicines. he was most
recently on
carbamazepine and depakote. He had a similar presentation here in
september,
and was switched to oxcarbazapine and lacosamide. This was due to
concerns
about the auto-induction activity of caramazepine with his eratic
compliance,
and due to elevated ammonias on depakote.
He reports that he was doing well on the new program. It seems he was
only
taking 50 mg of lacosamide bid, rather than the 100 mg bid that was
intended.
He was taking 600 mg of oxcarbazepine as prescribed. he had levels
from late
september than suggested compliance.
he feels his seizure frequency has been lower on the new meds. he
has
not had
any day time seizures recently and has only had one or two night time
seizures
in the last two weeks.
Social Hx: lives with a roomate. smokes. denies alcohol use although
has been
positive on lab testing.
Exam:
VS unremarkable.
he is in no distress. He has a subtle tremor with nonphysiologic
characteristics. he has no nystagmus. Upward gaze is slightly
limited. he has
no cranial neuropathies. No focal weakness, drift.
A/P: Would continue the prescribed program of 100 mg lacosamide bid
and
600 mg
oxcarbazepine bid. Please notify Dr. Holloway prior to his DC so
levels can be
ordered that will route back to seizure clinic. he should definitely
have a
medications nurse help him with his pills from here on out. he seems
more
agreeable to this than he has in the past.
***************************
LOCAL TITLE: EEG NEUROLOGY CONSULT
STANDARD TITLE: NEUROLOGY CONSULT
DATE OF NOTE: JUN 11, 2014@08:30 ENTRY DATE: JUN 17, 2014@15:53:59
HISTORY: the patient has a history of epileptic and nonepileptic
events
and is admitted with Carbamazepine toxicity and intubated in the MICU.
During much of the recording, the patient is on Propofol due to control
agitation.IMPRESSION: this three day video EEG recording in the MICU
is abnormal
due to the presence of moderate generalized slowing consistent with a
moderate diffuse encephalopathy. NO seizures are seen. The patient's
medications may be contributing to the abnormalities seen. NO seizures
are
seen.
***************************************************************
LOCAL TITLE: C&P EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: SEP 09, 2011@13:10 ENTRY DATE: SEP 27, 2011@16:16:40
COMPENSATION AND PENSION EXAMINATION
EPILEPSY AND NARCOLEPSY
====================================
COMMENTS:
based upon examination and available information It is less likely
than not the
veteran current eplipesy condition is related to military service
rationale: review of C file STR documentation, discharge exam no
seizure disorder
noted, unable to find documentation in STR's of an ongoing siezure
disorder
treated from incident date to separation
had testing (MMPI. Shipley, substance completion) Kurt High in
chronolgical
records care note stamped/dated August 80
note ends underlined No Evidence of Seizure Disorder with an
exclamation mark.
There are no outside medical records found in C file
It is more likely the Veteran's current seizure disorder are
related to past ETOH
use and mental health issues
b. Is continuous medication required for control of epilepsy or seizure
activity?
[X] Yes [ ] No
If yes, list only those medications required for the Veteran's
epilepsy or seizure activity:
Trileptal 300/750 and then Lacosamide 100/200
c. Has the Veteran had any other treatment (such as surgery) for epilepsy or
seizure activity?
[ ] Yes [X] No
d. Has the diagnosis of a seizure disorder been confirmed?
[X] Yes [ ] No
If yes, describe:
SEE HPI
e. Has the Veteran had a witnessed seizure?
[X] Yes [ ] No
If yes, describe, including relationship of witnesses to Veteran:
WIFE (FORMER)
f. Has the Veteran had a confirmed diagnosis of epilepsy with a history of
seizures?
[ ] Yes [X] No
3. Findings, signs and symptoms
-------------------------------
Does the Veteran have or has he or she had any findings, signs or symptoms
attributable to seizure disorder (epilepsy) activity?
[X] Yes [ ] No
If yes, check all that apply:
[X] Episodes of abnormalities of mood
[X] Episodes of tremors
[X] Other
For all checked conditions, describe:
"He continues to have abnormal events, which are likely seizures. He has
been very sensitive to medicines, but overall is tolerating his current
medications."
4. Type and frequency of seizure activity
------------------------------------------
Does the Veteran have or has he/she ever had any type of seizure activity,
including major, minor, petit mal or psychomotor seizure activity?
[X] Yes [ ] No
If yes, complete the following section:
a. Approximate date of first seizure activity: 1980's
Date of most recent seizure activity: 2-3 D AGO
b. Has the Veteran ever had minor seizures (characterized by a brief
interruption in consciousness or conscious control associated with
staring or rhythmic blinking of the eyes or nodding of the head
("pure"
petit mal) or sudden jerking movements of the arms, trunk or head
(myoclonic type) or sudden loss of postural control (akinetic type))?
No response provided.
c. Has the Veteran ever had major seizures (characterized by the
generalized tonic-clonic convulsion with unconsciousness)?
No response provided.
d. Has the Veteran ever had minor psychomotor seizures (characterized by
brief transient episodes of random motor movements, hallucinations,
perceptual illusions, abnormalities of thinking, memory or mood, or
autonomic disturbances)?
No response provided.
e. Has the Veteran ever had major psychomotor seizures (major psychomotor
seizures are characterized by automatic states and/or generalized
convulsions with unconsciousness)?
No response provided.
f. Has the Veteran ever had epilepsy associated with a nonpsychotic
organic brain syndrome?
No response provided.
g. Has the Veteran ever had epilepsy associated with a psychotic
disorder,
psychoneurotic disorder, or personality disorder?
[X] Yes [ ] No
5. Other pertinent physical findings, scars, complications, conditions,
signs
and/or symptoms
-----------------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
conditions
listed in the Diagnosis section above?
[ ] Yes [X] No
6. Diagnostic testing
---------------------
a. Have any imaging studies or diagnostic procedures been performed?
[X] Yes [ ] No
If yes, check all that apply:
[X] Magnetic resonance imaging (MRI)
Date: MAR 30, 2015@12:57
Results:
Impression:
1. Again seen is slight asymmetric prominence of
the head of the
right hippocampal complex. This is stable dating
back to 2011,
and is of uncertain clinical significance. No
progressive lesion
is identified.
2. No abnormal intracranial IV gadolinium
enhancement, with
special attention to this area.
[X] Computed tomography (CT)
Date: SEP 14, 2014@02:30
Results:
Impression:
1. No acute intracranial abnormality is seen.
2. Please note, hyperacute ischemia can remain
occult on CT. If
ischemia is clinically suspected, MRI is
recommended for further
evaluation.
[X] Electroencephalography (EEG)
Date: JUN 11, 2014@08:30
Results:
IMPRESSION: this three day video EEG recording in the
MICU is abnormal
due to the presence of moderate generalized slowing
consistent with a
moderate diffuse encephalopathy. No seizures are seen.
The patient's
medications may be contributing to the abnormalities
seen. No seizures are
seen.
b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
7. Functional impact
---------------------
Does the Veteran's epilepsy or seizure (epilepsy) disorder impact his or her
ability to work?
[X] Yes [ ] No
If yes, describe the impact of the Veteran's seizure (epilepsy) disorder,
providing one or more examples:
see HPI. His tremor interferes with his ability to go back to work.
8. Remarks, if any:
-------------------
OPINION: SEE MO.
DBQ SEIZURE QUERIES MAY BE LEFT BLANK WHERE QUESTIONS MAY FORCE FIT
IMPPROPER ANSWERS AND/OR WHERE ANSWER IS NOT KNOWN OR NOT CLEAR.
/es/ DONALD M MOLENAAR MD
STAFF PHYSICIAN C&P
Signed: 11/06/2015 10:46
-------------------------------------------------------------------------
----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------
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I am sorry for the long file, Its the only way I knew to get it there. I would add the new TBI exam from the contractor but don't know how to convert the file. Thank you for taking the time to look a
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