--------------- MY HEALTHEVET PERSONAL INFORMATION REPORT --------------- *************CONFIDENTIAL************* Produced by the VA Blue Button (v12.10) 03 Jan 2017 @ 1457 This summary is a copy of information from your My HealtheVet Personal Health Record. Your summary may include: - information that you entered (self reported) - information from your VA health record - your military service information from the department of defense (DoD). ***Note: Your health care team may not have all of the information from your Personal Health Record unless you share it with them. Contact your health care team if you have questions about your health information.*** Key: Double dashes (--) mean there is no information to display. Name: SANDOVAL, EDGAR JULIAN Date of Birth: 10 Feb 1978 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 03 Jan 2017 @ 1457 File Name: mhv_SANDOVAL_20170103_1457.txt Date Range Selected: 03 Jan 2016 to 03 Jan 2017 Data Types Selected: My HealtheVet Account Summary Self Reported Demographics VA Demographics Self Reported Health Care Providers Self Reported Treatment Facilities Self Reported Health Insurance VA Wellness Reminders VA Appointments (Future) VA Appointments (Limited to past 2 years) VA Allergies Self Reported Allergies VA Medication History Self Reported Medications and Supplements VA Problem List VA Admissions and Discharges VA Notes Self Reported Medical Events VA Immunizations Self Reported Immunizations VA Laboratory Results: Chemistry/Hematology/Microbiology VA Pathology Reports: Surgical Pathology/Cytology/Electron Microscopy Self Reported Labs and Tests VA Vitals and Readings Self Reported Vitals and Readings VA Radiology Reports VA Electrocardiogram (EKG) Reports Self Reported Family Health History Self Reported Military Health History Self Reported Activity Journal Self Reported Food Journal DoD Military Service Information Self Reported My Goals Current Self Reported My Goals Completed --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 07 May 2014 Authentication Facility ID: 740 Authentication Facility Name: VA Texas Valley Coastal HCS VA Treating Facility Type -------------------- ------ VBA BRLS na VBA CORP na VETERANS ID CARD SYSTEM na ENROLLMENT SYSTEM REENGINEERING na DEPARTMENT OF DEFENSE DEERS na Richmond VA na AUSTIN MHV na AUSTIN na VA Texas Valley Coastal HCS na VA S. Texas Health Care System na Temple TX VAMC na ---------------------- SELF REPORTED DEMOGRAPHICS ----------------------- Source: Self-Entered Your self-entered information saved in My HealtheVet is not shared with other sources. First Name: EDGAR Middle Initial: J Last Name: SANDOVAL Suffix: Alias: Relationship to VA: Patient, Veteran Gender: Male Blood Type: A+ Organ Donor: No Date of Birth: 10 Feb 1978 Marital Status: Current Occupation: student Mailing or Destination Address: 2314 E. 21st street Mailing or Destination Address2: Mailing or Destination City: Missoin Mailing or Destination State: TX Mailing or Destination Country: United States Mailing or Destination Province: Mailing or Destination Zip/Postal Code: 78572 Home Phone Number: 956-802-8945 Work Phone Number: 956-802-8945 Pager Number: Cell Phone Number: 956-802-8945 FAX Number: Email Address: edgar_sandoval2000@yahoo.com Preferred Method of Contact: Email EMERGENCY CONTACTS Contact First Name: Marissa Contact Last Name: Sandoval Relationship: Home Phone Number: Work Phone Number: Extension: Cell Phone Number: 956-802-8971 Address Line 1: 4401 W. IVY Ave. Address Line 2: McAllen City: McAllen State: TX Country: United States Province: Zip/Post Code: 78501 Email Address: ---------------------------- VA DEMOGRAPHICS ---------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 Sorted By: VA Treating Facility Your information in My HealtheVet is not transferred to your VA Health Record. Also, VA Demographic information is not updated between VA treating facilities. If you have any questions or updates, please contact your VA health care team. ========================================================================= VA Treating Facility: VA Texas Valley Coastal HCS ------------------------------------------------------------------------- First Name: EDGAR Middle Name: JULIAN Last Name: SANDOVAL Religion: -- Ethnicity: -- Date of Birth: 10 Feb 1978 Place of Birth: WESLACO, TEXAS Age: 38 Gender: Male Marital Status: MARRIED ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 2314 E 21ST STREET Work Phone Number: -- City: MISSION State: TEXAS Zip Code: 78572 County: 215 Country: USA Home Phone Number: -- Work Phone Number: -- Cell Phone Number: -- Email Address: edgar_sandoval2000@yahoo.com ------------------------------------------------------------------------- ELIGIBILITY Primary Eligibility Code: -- Service Connected Percentage: 80 EMPLOYMENT Employment Status: NOT EMPLOYED Employer Name: -- ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: -- Effective Date: -- Expiration Date: -- Group Name: -- Group Number: -- Subscriber ID: -- Subscriber Name: -- Subscriber Relationship: -- ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: SANDOVAL,FLOR MARISSA Street Address: 2314 E 21ST STREET City: MISSION State: TEXAS Zip Code: 78572 Home Phone Number: 956-802-8971 Work Phone Number: 000-000-0000 ------------------------------------------------------------------------- EMERGENCY CONTACT Name: SANDOVAL,FLOR MARISSA Street Address: 2314 E 21ST STREET City: MISSION State: TEXAS Zip Code: 78572 Home Phone Number: 956-802-8971 Work Phone Number: -- ------------------------------------------------------------------------- VA GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- CIVIL GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- ------------------------------------------------------------------------- ========================================================================= VA Treating Facility: VA S. Texas Health Care System ------------------------------------------------------------------------- First Name: EDGAR Middle Name: JULIAN Last Name: SANDOVAL Religion: -- Ethnicity: -- Date of Birth: 10 Feb 1978 Place of Birth: WESLACO, TEXAS Age: 38 Gender: Male Marital Status: MARRIED ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 2314 E 21ST STREET Work Phone Number: -- City: MISSION State: TEXAS Zip Code: 78572 County: 215 Country: USA Home Phone Number: -- Work Phone Number: -- Cell Phone Number: -- Email Address: edgar_sandoval2000@yahoo.com ------------------------------------------------------------------------- ELIGIBILITY Primary Eligibility Code: -- Service Connected Percentage: 80 EMPLOYMENT Employment Status: NOT EMPLOYED Employer Name: -- ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: BC BS TX Effective Date: 01 May 2009 Expiration Date: -- Group Name: 25893 - CITY OF MCALLEN Group Number: 009141 Subscriber ID: ZGP839679735 Subscriber Name: SANDOVAL,EDGAR J Subscriber Relationship: PATIENT ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: SANDOVAL,FLOR MARISSA Street Address: 2314 E 21ST STREET City: MISSION State: TEXAS Zip Code: 78572 Home Phone Number: 956-802-8971 Work Phone Number: 000-000-0000 ------------------------------------------------------------------------- EMERGENCY CONTACT Name: SANDOVAL,FLOR MARISSA Street Address: 2314 E 21ST STREET City: MISSION State: TEXAS Zip Code: 78572 Home Phone Number: 956-802-8971 Work Phone Number: -- ------------------------------------------------------------------------- VA GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- CIVIL GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- ------------------------------------------------------------------------- ========================================================================= VA Treating Facility: Temple TX VAMC ------------------------------------------------------------------------- First Name: EDGAR Middle Name: JULIAN Last Name: SANDOVAL Religion: -- Ethnicity: -- Date of Birth: 10 Feb 1978 Place of Birth: WESLACO, TEXAS Age: 38 Gender: Male Marital Status: MARRIED ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 2314 E 21ST STREET Work Phone Number: -- City: MISSION State: TEXAS Zip Code: 78572 County: 215 Country: USA Home Phone Number: -- Work Phone Number: -- Cell Phone Number: -- Email Address: edgar_sandoval2000@yahoo.com ------------------------------------------------------------------------- ELIGIBILITY Primary Eligibility Code: -- Service Connected Percentage: 80 EMPLOYMENT Employment Status: NOT EMPLOYED Employer Name: -- ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: -- Effective Date: -- Expiration Date: -- Group Name: -- Group Number: -- Subscriber ID: -- Subscriber Name: -- Subscriber Relationship: -- ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: SANDOVAL,FLOR MARISSA Street Address: 2314 E 21ST STREET City: MISSION State: TEXAS Zip Code: 78572 Home Phone Number: 956-802-8971 Work Phone Number: 000-000-0000 ------------------------------------------------------------------------- EMERGENCY CONTACT Name: SANDOVAL,FLOR MARISSA Street Address: 2314 E 21ST STREET City: MISSION State: TEXAS Zip Code: 78572 Home Phone Number: 956-802-8971 Work Phone Number: -- ------------------------------------------------------------------------- VA GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- CIVIL GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- ------------------------------------------------------------------------- ========================================================================= VA Treating Facility: Richmond VA ------------------------------------------------------------------------- First Name: EDGAR Middle Name: JULIAN Last Name: SANDOVAL Religion: -- Ethnicity: -- Date of Birth: 10 Feb 1978 Place of Birth: WESLACO, TEXAS Age: 38 Gender: Male Marital Status: DIVORCED ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 700 24TH ST Work Phone Number: -- City: FORT LEE State: VIRGINIA Zip Code: 23801 County: 149 Country: USA Home Phone Number: -- Work Phone Number: -- Cell Phone Number: -- Email Address: -- ------------------------------------------------------------------------- ELIGIBILITY Primary Eligibility Code: -- Service Connected Percentage: 80 EMPLOYMENT Employment Status: NOT EMPLOYED Employer Name: -- ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: -- Effective Date: -- Expiration Date: -- Group Name: -- Group Number: -- Subscriber ID: -- Subscriber Name: -- Subscriber Relationship: -- ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: SANDOVAL,MARIA M Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: 956-783-6980 Work Phone Number: -- ------------------------------------------------------------------------- EMERGENCY CONTACT Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- VA GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- CIVIL GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- ------------------ SELF REPORTED HEALTH CARE PROVIDERS ------------------ Source: Self-Entered No information was available that matched your selection. ------------------ SELF REPORTED TREATMENT FACILITIES-------------------- Source: Self-Entered No information was available that matched your selection. ------------------- SELF REPORTED HEALTH INSURANCE ---------------------- Source: Self-Entered No information was available that matched your selection. --------------------------- VA WELLNESS REMINDERS ----------------------- Source: VA Last Updated: 03 Jan 2017 @ 1439 Wellness Reminder Due Date Last Completed Location ------------------------------------------------------------------------- Pneumonia Vaccine DUE NOW UNKNOWN VA Texas Val Lipid Measurement (Cholesterol) DUE NOW UNKNOWN VA S. Texas Lipid Measurement (Cholesterol) DUE NOW UNKNOWN VA S. Texas Influenza Vaccine DUE NOW UNKNOWN Temple TX VA Body Mass Index more than 25 DUE NOW UNKNOWN VA Texas Val Influenza Vaccine DUE NOW UNKNOWN VA Texas Val Influenza Vaccine DUE NOW UNKNOWN VA S. Texas Hypertension (High Blood Pressure) DUE NOW UNKNOWN VA Texas Val Lipid Measurement (Cholesterol) 18 Jul 2021 18 Jul 2016 VA Texas Val Influenza Vaccine DUE NOW UNKNOWN Richmond VA Lipid Measurement (Cholesterol) DUE NOW UNKNOWN Richmond VA Body Mass Index more than 25 DUE NOW UNKNOWN VA S. Texas Learn more about these Wellness Reminders by visiting My HealtheVet. Please contact your health care team with any questions about your VA Wellness Reminders. --------------------------- VA APPOINTMENTS ----------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1439 Sort By: Date (Descending) All future VA Appointments are shown below. Past VA Appointments are limited to two years from the date of your download request. To cancel, change or request an appointment with your VA health care team, please contact your local VA facility. FUTURE APPOINTMENTS: -------------------- Date/Time: 13 Feb 2017 @ 0930 Location: MCALLEN OPC Status: FUTURE Clinic: MCA PACT BLUE TEAM Phone Number: (956)618-7100 Date/Time: 06 Feb 2017 @ 0930 Location: MCALLEN OPC Status: FUTURE Clinic: MCA LABORATORY Phone Number: (956)618-7100 Date/Time: 27 Jan 2017 @ 0930 Location: MCA BHIP 2 PHARM Status: FUTURE Clinic: MCA BHIP 2 PHARM Phone Number: 956 618 7100 PAST APPOINTMENTS: -------------------- Date/Time: 16 Dec 2016 @ 1100 Location: MCA BHIP 2 PHARM Status: APPOINTMENT KEPT Clinic: MCA BHIP 2 PHARM Phone Number: 956 618 7100 Date/Time: 09 Dec 2016 @ 1130 Location: MCA BHIP 2 PHARM Status: CANCELLED Clinic: MCA BHIP 2 PHARM Phone Number: 956 618 7100 Date/Time: 02 Dec 2016 @ 1400 Location: MCA BHIP 2 PHARM Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP 2 PHARM Phone Number: 956 618 7100 Date/Time: 22 Nov 2016 @ 0800 Location: MCA PSY C&P PSY 2 Status: APPOINTMENT KEPT Clinic: MCA PSY C&P PSY 2 Phone Number: 956 618 7100 Date/Time: 17 Oct 2016 @ 1300 Location: MCA BHIP GRP Status: CANCELLED Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 07 Oct 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: CANCELLED Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 03 Oct 2016 @ 1300 Location: MCA BHIP GRP Status: CANCELLED Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 30 Sep 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: CANCELLED Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 26 Sep 2016 @ 1300 Location: MCA BHIP GRP Status: CANCELLED Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 23 Sep 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 19 Sep 2016 @ 1300 Location: MCA BHIP GRP Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 16 Sep 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 12 Sep 2016 @ 1300 Location: MCA BHIP GRP Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 09 Sep 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: CANCELLED Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 29 Aug 2016 @ 1300 Location: MCA BHIP GRP Status: CANCELLED Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 26 Aug 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: CANCELLED Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 22 Aug 2016 @ 1300 Location: MCA BHIP GRP Status: APPOINTMENT KEPT Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 19 Aug 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: APPOINTMENT KEPT Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 15 Aug 2016 @ 1300 Location: MCA BHIP GRP Status: APPOINTMENT KEPT Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 12 Aug 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: APPOINTMENT KEPT Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 08 Aug 2016 @ 1300 Location: MCA BHIP GRP Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 05 Aug 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: CANCELLED Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 02 Aug 2016 @ 1300 Location: MCA BHIP 2 LPMHC Status: APPOINTMENT KEPT Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 01 Aug 2016 @ 1300 Location: MCA BHIP GRP Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 29 Jul 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: APPOINTMENT KEPT Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 25 Jul 2016 @ 1300 Location: MCA BHIP GRP Status: APPOINTMENT KEPT Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 25 Jul 2016 @ 1030 Location: MCALLEN OPC Status: APPOINTMENT KEPT Clinic: MCA PACT BLUE TEAM Phone Number: (956)618-7100 Date/Time: 22 Jul 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: CANCELLED Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 18 Jul 2016 @ 1300 Location: MCA BHIP GRP Status: CANCELLED Clinic: MCA BHIP GRP Phone Number: (956)618-7100 Date/Time: 18 Jul 2016 @ 0830 Location: MCALLEN OPC Status: UPDATE IN PROGRESS Clinic: MCA LABORATORY Phone Number: (956)618-7100 Date/Time: 09 Jun 2016 @ 1500 Location: MCA TMH VPTT PSY GRP REM Status: APPOINTMENT KEPT Clinic: MCA TMH VPTT PSY GRP REM Phone Number: 619 7100 Date/Time: 02 Jun 2016 @ 1500 Location: MCA TMH VPTT PSY GRP REM Status: APPOINTMENT KEPT Clinic: MCA TMH VPTT PSY GRP REM Phone Number: 619 7100 Date/Time: 31 May 2016 @ 0930 Location: MCALLEN OPC Status: APPOINTMENT KEPT Clinic: MCA PACT BLUE RES TEAM Phone Number: (956)618-7100 Date/Time: 31 May 2016 @ 0900 Location: MCALLEN OPC Status: APPOINTMENT KEPT Clinic: MCA PACT BLUE TEAM NURSE Phone Number: (956)618-7100 Date/Time: 26 May 2016 @ 1300 Location: MCA PSY C&P PSY Status: APPOINTMENT KEPT Clinic: MCA PSY C&P PSY Phone Number: (956)618-7100 Type: Compensation and Pension Appointment Date/Time: 26 May 2016 @ 1100 Location: MCALLEN OPC Status: APPOINTMENT KEPT Clinic: MCA TMH VPTT PSY 2 Phone Number: 956 618 7100 Date/Time: 26 May 2016 @ 1000 Location: MCALLEN OPC Status: CANCELLED Clinic: MCA TMH VPTT PSY 2 Phone Number: 956 618 7100 Date/Time: 18 May 2016 @ 1000 Location: MCA C&P GMED 3 Status: APPOINTMENT KEPT Clinic: MCA C&P GMED 3 Phone Number: (956)618-7100 Type: Compensation and Pension Appointment Date/Time: 09 May 2016 @ 1400 Location: MCALLEN OPC Status: APPOINTMENT NOT KEPT Clinic: MCA TMH VPTT PSY 2 Phone Number: 956 618 7100 Date/Time: 03 May 2016 @ 1300 Location: MCALLEN OPC Status: CANCELLED Clinic: MCA TMH VPTT PSY 2 Phone Number: 956 618 7100 Date/Time: 02 May 2016 @ 0900 Location: MCALLEN OPC Status: APPOINTMENT NOT KEPT Clinic: MCA TMH VPTT PSY 2 Phone Number: 956 618 7100 Date/Time: 29 Mar 2016 @ 1500 Location: MCALLEN OPC Status: CANCELLED Clinic: MCA TMH VPTT PSY 2 Phone Number: 956 618 7100 Date/Time: 24 Feb 2016 @ 1000 Location: MCA BHIP 1 LMFT Status: APPOINTMENT NOT KEPT Clinic: MCA BHIP 1 LMFT Phone Number: (956)618-7100 Date/Time: 23 Feb 2016 @ 1300 Location: MCALLEN OPC Status: APPOINTMENT KEPT Clinic: MCA TMH VPTT PSY 2 Phone Number: 956 618 7100 Date/Time: 10 Feb 2016 @ 1000 Location: MCA BHIP 2 LPMHC Status: APPOINTMENT KEPT Clinic: MCA BHIP 2 LPMHC Phone Number: (956)618-7100 Date/Time: 10 Feb 2016 @ 0900 Location: MCA PCMHI PSY 2 Status: APPOINTMENT KEPT Clinic: MCA PCMHI PSY 2 Phone Number: (956)618-7100 Date/Time: 03 Feb 2016 @ 1000 Location: MCA BHIP 2 PSY Status: CANCELLED Clinic: MCA BHIP 2 PSY Phone Number: (956)618-7100 Date/Time: 27 Jan 2016 @ 1000 Location: MCA PCMHI PSY 2 Status: APPOINTMENT KEPT Clinic: MCA PCMHI PSY 2 Phone Number: (956)618-7100 Date/Time: 19 Jan 2016 @ 1000 Location: MCA PCMHI PSY 2 Status: APPOINTMENT KEPT Clinic: MCA PCMHI PSY 2 Phone Number: (956)618-7100 Date/Time: 19 Jan 2016 @ 0900 Location: MCALLEN OPC Status: APPOINTMENT KEPT Clinic: MCA PACT BLUE RES TEAM Phone Number: (956)618-7100 ----------------------------- VA ALLERGIES ------------------------------ Source: VA Last Updated: 03 Jan 2017 @ 1439 Remember to share all information about your allergies with your health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Allergy Name: TUNA Location: VA S. Texas Health Care System Date Entered: 16 May 2005 Reaction: HIVES Allergy Type: DRUG, FOOD VA Drug Class: -- Observed/Historical: HISTORICAL Comments: -- Allergy Name: TUNA Location: VA Texas Valley Coastal HCS Date Entered: 16 May 2005 Reaction: URTICARIA Allergy Type: DRUG, FOOD VA Drug Class: -- Observed/Historical: HISTORICAL Comments: -- Remember to share all information about your allergies with your health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Allergy information. -------------------------- SELF REPORTED ALLERGIES -------------------- Source: Self-Entered No information was available that matched your selection. -------------------------- VA MEDICATION HISTORY ---------------------- Source: VA Last Updated: 20 Dec 2016 @ 0940 Sorted By: Last Filled On (Descending) Remember to share all information about your medications or updates with your VA health care team. Also, check information in your VA Allergies and your Self Reported Allergies. This may let you know if you had a reaction to a medication you received. If you have any questions about your information please visit the FAQs or contact your VA health care team. Medication: MEDICATION ORGANIZER 7 DAY Instructions: USE 1 BOX (SUPPLY ITEM) AS DIRECTED FOR MEDICATION Status: Active Refills Remaining: 0 Last Filled On: 16 Dec 2016 Initially Ordered On: 16 Dec 2016 Quantity: 1 Days Supply: 90 Pharmacy: MCALLEN Prescription Number: 50374418 Medication: OMEPRAZOLE 20MG EC CAP Instructions: TAKE ONE CAPSULE BY MOUTH EVERY DAY Status: Refill in Process Refills Remaining: 1 Last Filled On: 11 Jan 2017 Initially Ordered On: 25 Jul 2016 Quantity: 90 Days Supply: 90 Pharmacy: MCALLEN Prescription Number: 50343935 Medication: BUSPIRONE HCL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH THREE TIMES A DAY FOR ANXIETY FOR MOOD Status: Submitted Refills Remaining: 3 Last Filled On: 16 Dec 2016 Initially Ordered On: 16 Dec 2016 Quantity: 270 Days Supply: 90 Pharmacy: MCALLEN Prescription Number: 50374404 Medication: CITALOPRAM HYDROBROMIDE 40MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR 7 DAYS, THEN TAKE ONE Status: Submitted Refills Remaining: 1 Last Filled On: 16 Dec 2016 Initially Ordered On: 16 Dec 2016 Quantity: 87 Days Supply: 90 Pharmacy: MCALLEN Prescription Number: 50374405 Medication: LISINOPRIL 20MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE Status: Submitted Refills Remaining: 2 Last Filled On: 25 Nov 2016 Initially Ordered On: 25 Jul 2016 Quantity: 15 Days Supply: 30 Pharmacy: MCALLEN Prescription Number: 50343936 Medication: LISINOPRIL 20MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH DAILY FOR BLOOD PRESSURE Status: Expired Refills Remaining: 0 Last Filled On: 03 Aug 2016 Initially Ordered On: 03 Aug 2016 Quantity: 5 Days Supply: 10 Pharmacy: AUSTIN Prescription Number: 6447582 Medication: BUSPIRONE HCL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH THREE TIMES A DAY AS NEEDED FOR ANXIETY Status: Discontinued Refills Remaining: 0 Last Filled On: 25 Jul 2016 Initially Ordered On: 05 Jan 2016 Quantity: 90 Days Supply: 30 Pharmacy: MCALLEN Prescription Number: 50299932 Medication: LISINOPRIL 20MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE Status: Discontinued Refills Remaining: 2 Last Filled On: 07 Jul 2016 Initially Ordered On: 22 Mar 2016 Quantity: 45 Days Supply: 90 Pharmacy: MCALLEN Prescription Number: 50316531 Medication: THROAT LOZENGE W/BENZOCAINE,MENTHOL Instructions: DISSOLVE 1 LOZENGE IN MOUTH EVERY 6 HOURS Status: Expired Refills Remaining: 0 Last Filled On: 31 May 2016 Initially Ordered On: 31 May 2016 Quantity: 18 Days Supply: 5 Pharmacy: MCALLEN Prescription Number: 50331804 Medication: IBUPROFEN 400MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY 6 HOURS FOR PAIN OR INFLAMMATION. TAKE WITH FOOD OR MILK. Status: Expired Refills Remaining: 0 Last Filled On: 31 May 2016 Initially Ordered On: 31 May 2016 Quantity: 40 Days Supply: 10 Pharmacy: MCALLEN Prescription Number: 50331794 Medication: THROAT LOZENGE W/BENZOCAINE,MENTHOL Instructions: DISSOLVE 1 LOZENGE IN MOUTH EVERY 6 HOURS Status: Discontinued Refills Remaining: 0 Last Filled On: 31 May 2016 Initially Ordered On: 31 May 2016 Quantity: 18 Days Supply: 5 Pharmacy: MCALLEN Prescription Number: 50331795 Medication: AMOXICILLIN 500MG CAP Instructions: TAKE ONE CAPSULE BY MOUTH TWICE A DAY FOR INFECTION Status: Expired Refills Remaining: 0 Last Filled On: 31 May 2016 Initially Ordered On: 31 May 2016 Quantity: 20 Days Supply: 10 Pharmacy: MCALLEN Prescription Number: 50331793 Medication: OMEPRAZOLE 20MG EC CAP Instructions: TAKE ONE CAPSULE BY MOUTH EVERY DAY AS NEEDED TAKE 30 TO 60 MINUTES BEFORE A MEAL. FOR REFLUX - SHORT TERM THERAPY - 90 DAYS Status: Expired Refills Remaining: 0 Last Filled On: 22 Mar 2016 Initially Ordered On: 22 Mar 2016 Quantity: 90 Days Supply: 90 Pharmacy: MCALLEN Prescription Number: 50316534 ----------------- SELF REPORTED MEDICATIONS AND SUPPLEMENTS ------------- Source: Self-Entered No information was available that matched your selection. ---------------------------- VA PROBLEM LIST ---------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 Sorted By: Date/Time Entered (Descending) then alphabetically by Problem Your VA Problem List contains active health problems your VA providers are helping you to manage. This information is available 3 calendar days after it has been entered. It may not contain active problems managed by non-VA health care providers. If you have any questions about your information, visit the FAQs or contact your VA health care team. Problem: Major depressive disorder (SCT 370143000) Date/Time Entered: 16 Dec 2016 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: PAN,ISAAC Comments: -- Problem: Hypertension (SCT 38341003) Date/Time Entered: 25 Jul 2016 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: VEGA,OLYMPIA C Comments: -- Problem: Obstructive sleep apnea syndrome (SCT 78275009) Date/Time Entered: 25 Jul 2016 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: VEGA,OLYMPIA C Comments: presumptive; sleep study requested Problem: Stress and adjustment reaction (SCT 271952001) Date/Time Entered: 23 Feb 2016 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: VON LINDEN,MEGHAN I Comments: -- Problem: Cholelithiasis without obstruction (ICD-9-CM 574.20) Date/Time Entered: 30 Jul 2014 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: PAREJA,HEIDI Y Comments: -- Problem: Obesity (ICD-9-CM 278.00) Date/Time Entered: 30 Jul 2014 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: PAREJA,HEIDI Y Comments: -- Problem: Paroxysmal nocturnal dyspnea (ICD-9-CM 786.09) Date/Time Entered: 30 Jul 2014 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: PAREJA,HEIDI Y Comments: -- Problem: Gastroenteritis (ICD-9-CM 558.9) Date/Time Entered: 06 Jun 2012 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: CASTILLO,ROGELIO Comments: -- Problem: Knee Pain (ICD-9-CM 719.46) Date/Time Entered: 06 Jun 2012 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: CASTILLO,ROGELIO Comments: -- Problem: Contact dermatitis and other eczema (ICD-9-CM 692.9) Date/Time Entered: 10 Jun 2011 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: IZQUIERDO,WILSON Comments: since return from Iraq Problem: Dehydration (ICD-9-CM 276.51) Date/Time Entered: 10 Jun 2011 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: IZQUIERDO,WILSON Comments: -- Problem: Dysthymic Disorder (ICD-9-CM 300.4) Date/Time Entered: 10 Jun 2011 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: IZQUIERDO,WILSON Comments: -- Problem: Hearing loss (ICD-9-CM 389.9) Date/Time Entered: 10 Jun 2011 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: IZQUIERDO,WILSON Comments: -- Problem: Lumbago (ICD-9-CM 724.2) Date/Time Entered: 10 Jun 2011 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: IZQUIERDO,WILSON Comments: Lifting up a pipe >100 pounds, March 2003 Problem: Male erectile disorder (ICD-9-CM 302.72) Date/Time Entered: 10 Jun 2011 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: IZQUIERDO,WILSON Comments: -- Problem: Other specified gastritis, without mention of hemorrhage (ICD-9-CM 535.40) Date/Time Entered: 10 Jun 2011 @ 1200 Location: VA Texas Valley Coastal HCS Status: ACTIVE Provider: IZQUIERDO,WILSON Comments: : on upper GI series, mild gastritis, negative barium swallo Problem: Unspecified internal derangement of knee (ICD-9-CM 717.9) Date/Time Entered: 20 Aug 2010 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: PEREZ,RICHARD W Comments: -- Problem: Other ankle sprain (ICD-9-CM 845.09) Date/Time Entered: 15 Sep 2009 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: PEREZ,RICHARD W Comments: -- Problem: Contusion of knee (ICD-9-CM 924.11) Date/Time Entered: 13 Jul 2009 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: PETERSON,CECIL B Comments: -- Problem: Health Maintenance (ICD-9-CM V65.9) Date/Time Entered: 13 Jul 2009 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: GUAJARDO,SOILA Comments: -- Problem: Contusions (ICD-9-CM 924.9) Date/Time Entered: 07 Jul 2009 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: PETERSON,CECIL B Comments: -- Problem: Hearing loss (ICD-9-CM 389.9) Date/Time Entered: 26 Jul 2007 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: BARREIRO,MARIBEL B Comments: -- Problem: Other specified gastritis, without mention of hemorrhage (ICD-9-CM 535.40) Date/Time Entered: 13 Mar 2007 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: BARREIRO,MARIBEL B Comments: on upper GI series, mild gastritis, negative barium swallow Problem: Male erectile disorder (ICD-9-CM 302.72) Date/Time Entered: 23 Feb 2007 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: CANALES,LAYRA ZOEE Comments: -- Problem: Other specified gastritis, without mention of hemorrhage (ICD-9-CM 535.40) Date/Time Entered: 23 Feb 2007 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: CANALES,LAYRA ZOEE Comments: -- Problem: Chronic Low Back Pain (ICD-9-CM 724.2) Date/Time Entered: 16 May 2005 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: BARREIRO,MARIBEL B Comments: Lifting up a pipe >100 pounds, March 2003 Problem: Depression (ICD-9-CM 300.4) Date/Time Entered: 16 May 2005 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: BARREIRO,MARIBEL B Comments: -- Problem: Dermatitis (ICD-9-CM 692.9) Date/Time Entered: 16 May 2005 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: BARREIRO,MARIBEL B Comments: since return from Iraq Problem: Hypertension (ICD-9-CM 401.9) Date/Time Entered: 16 May 2005 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: BARREIRO,MARIBEL B Comments: -- Problem: Posttraumatic Stress Disorder (ICD-9-CM 309.81) Date/Time Entered: 16 May 2005 @ 1200 Location: VA S. Texas Health Care System Status: ACTIVE Provider: BARREIRO,MARIBEL B Comments: -- --------------------- VA ADMISSIONS AND DISCHARGES ---------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 No information was available that matched your selection. However if you were recently discharged, your summary may be available 3 calendar days after it is completed. ------------------------------- VA NOTES -------------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 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 health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Date/Time: 16 Dec 2016 @ 1107 Note Title: PSYCH PHARMD NOTE Location: VA Texas Valley Coastal HCS Signed By: PAN,ISAAC Co-signed By: PAN,ISAAC Date/Time Signed: 16 Dec 2016 @ 1219 ------------------------------------------------------------------------- LOCAL TITLE: PSYCH PHARMD NOTE STANDARD TITLE: PHARMACY CLINICAL NOTE DATE OF NOTE: DEC 16, 2016@11:07 ENTRY DATE: DEC 16, 2016@11:08:03 AUTHOR: PAN,ISAAC EXP COSIGNER: URGENCY: STATUS: COMPLETED *** PSYCH PHARMD NOTE Has ADDENDA *** Date: 12/16/16 11:00 SANDOVAL,EDGAR JULIAN, 457-65-1840 38 year old WHITE MALE with MDD and unspecified trauma/stressor related disorder seen for medication management, for which he is taking: -Buspirone 10 mg TID PRN CC:"Anger" HPI: Today pt arrives to appointment early. States he works for maintance for HEB. Notes work keeps busy. Reports having relationship problem with wife, who stays home and take cares of their son, who's 8 yo. Notes having irritability and anger toward wife and son. Also reports recenlty his next-door neighbor was broken-in, and notes he has become more "on guard" after the incident. Reports moderate depressive sxs (PHQ-9=13), including dysphoria, anhedonia, sleep disturbance, guilt feeling. Denies current SI/HI, attempt, plan. Reports significant sxs related to PTSD, including intrusive thoughts, nightmares, , irritability, avoidance, and hypervigilance. Reports he has been on citalopram with good response. --Specific symptoms as reported below. Depressive symptoms: Sleep- endorses sleep disturbance, including difficulty of sleep intiation Interest- endorses anhedonia Excess guilt- endorses Energy- endorses anergia sometimes Concentration- endorses difficulty of concentrating sometimes Eating/appetite- endorses "overeating" Irritability- endorsers irritability toward wife and son Depressed mood- endorses PTSD symptoms: Intrusion- endorses nightmares, flashbacks, and intrusive thoughts Avoidance- endorses Negative alterations in cognitions/mood- endorses Alterations in arousal and reactivity- endorses "on guard" and hypervigilance Safety: [-] suicidal/homicidal ideation- denies current or recent SI/HI. [-] access to firearms- reports having no firearms Habits: T: denies E: 2-3 beers a week illicit: denies PSYCHOSOCIAL: New stressors: none Employment: gainfully employed at a friend's company that does maintenance for HEB Marital status: married, reported marital issues Children: has one 8yo son Housing: stable Other: reports lost of both parents recently this year (mother Aug 2016, and father Oct 2016) Past psych med (only max dose listed) -Citalopram 40 mg dialy 2009, 2011 -Diazepam 2 mg one time dose 2007 -Fluoxetine 40 mg daily 2015-2016 -Hydroxyzine 50 mg HS PRN 2007 -Sertraline 50 mg daily 2005 Allergies: TUNA Active Outpatient Medications (excluding Supplies): Active Outpatient Medications Status ========================================================================= 1) BUSPIRONE HCL 10MG TAB TAKE ONE TABLET BY MOUTH THREE ACTIVE (S) TIMES A DAY FOR ANXIETY FOR MOOD 2) CITALOPRAM HYDROBROMIDE 40MG TAB TAKE ONE-HALF TABLET ACTIVE (S) BY MOUTH EVERY DAY FOR 7 DAYS, THEN TAKE ONE TABLET EVERY DAY FOR MOOD 3) LISINOPRIL 20MG TAB TAKE ONE-HALF TABLET BY MOUTH ACTIVE EVERY DAY FOR BLOOD PRESSURE 4) OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE (S) EVERY DAY Reviewed home meds with patient/caregiver and NO discrepancies found. AMSIT: A 38 year old WHITE MALE appeared as stated age. dressed casually in hat, red t-shirt, shorts, and blue sneakers. tatoos on both arms and legs. poor EC. speech in normal rate/volume. polite and cooperative. PMA wnl M Euthymic with appropriate affect, normal range/intensity. no lability observed S A&Ox3 I Average (vocab) T C/L/GD -AH/VH/D/IOR/T -SI/HI Assessment: 38 year old WHITE MALE with MDD and unspecified Veteran is not well controlled on current therapy. Denies side effects. Will optimize buspirone dosage. Re-start citalopram which has been effective Educated Veteran on indication of medications, possible side effects and what to expect from medications. Discussed risk vs benefits of medications and potential medication interactions. Last diagnostic tests reviewed and discussed with Veteran. Veteran agreed and understood treatment plan. Plan: 1. Medication: -change buspirone to 10 mg TID (scheduled) -re-start citalopram 20 mg daily for 7 days, then increase to 40 mg daily 2. (MAS) RTC 6 weeks for medication management 3. Medication Reconciliation: completed 4. Veteran to seek Tx in local ER or may RTC as a walk-in prn for questions/concerns regarding tx/sx/dx/meds/SE's/HI/SI or any other issue concerning to Veteran. Veteran is aware of, acknowledges and agrees with this safety and Tx plan. Veteran is also capable of and agrees to activate it if necessary. Veteran was provided the national VA suicide hotline number. Time spent with patient: 30 min CLINICAL REMINDER ACTIVITY PBM PharmD Pharmacotherapy Rem V8: ASSESSMENT AND PLAN: Mental Health Conditions Addressed: DEPRESSION Medication Intervention(s) Adjust dose or frequency of current medication Initiate new medication POST-TRAUMATIC STRESS DISORDER (PTSD) Medication Intervention(s) Initiate new medication /es/ ISAAC PAN, PHARMD Clinical Pharmacy Specialist Signed: 12/16/2016 12:19 Receipt Acknowledged By: 12/17/2016 09:33 /es/ NORI MARTINEZ MSA 12/16/2016 ADDENDUM STATUS: COMPLETED Family counseling? Resume psychotherapy/counseling with Ms. Campo? CPT group? /es/ ISAAC PAN, PHARMD Clinical Pharmacy Specialist Signed: 12/16/2016 12:19 12/16/2016 ADDENDUM STATUS: COMPLETED Please assist pt in re-engaging in psychotherapy/counseling Pt seen today for medication management. Reported moderate depressive sxs and significant sxs that are consisted with PTSD. Reported ongoing stressors from family. Previous seen by Ms. Campo for psychotherapy/counseling. Session discontinued due to no-shows and cancelling. Spoken with pt about counseling/psychotherapy. Pt expressed williness to re- engage. Noted he is available on Friday for appointments (off on Friday for work), but also noted being flexible on other days if he requested medical leaves ahead of time. thank you. /es/ ISAAC PAN, PHARMD Clinical Pharmacy Specialist Signed: 12/16/2016 12:24 Receipt Acknowledged By: 12/19/2016 09:20 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor 12/19/2016 ADDENDUM STATUS: COMPLETED 12/192016 9:20 am Undersigned contacted veteran via telephone regarding veteran's request to resume Individual Therapy. Veteran agreed to come in on 1/24/2017 @ 10:00 am. /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 12/19/2016 09:23 ------------------------------------------------------------------------- ========================================================================= Date/Time: 16 Dec 2016 @ 1058 Note Title: MED RECONCILIATION Location: VA Texas Valley Coastal HCS Signed By: PAN,ISAAC Co-signed By: PAN,ISAAC Date/Time Signed: 16 Dec 2016 @ 1105 ------------------------------------------------------------------------- LOCAL TITLE: MED RECONCILIATION STANDARD TITLE: MEDICATION MGT NOTE DATE OF NOTE: DEC 16, 2016@10:58 ENTRY DATE: DEC 16, 2016@10:58:32 AUTHOR: PAN,ISAAC EXP COSIGNER: URGENCY: STATUS: COMPLETED EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 PATIENT PHONE - 956 802 8945 AGE: 38 SEX: MALE WEIGHT:196.6 lb [89.4 kg] (07/25/2016 10:04) SELECTED CLINICAL REMINDERS DUE: --STATUS-- --DUE DATE-- --LAST DONE-- V17 ALL Influenza Immunization DUE NOW DUE NOW unknown Pneumococcal PPSV23 (Pneumovax) DUE NOW DUE NOW unknown VACCINES OF RECORD IN VCB CPRS: Immunization Series Date Facility Reaction Info INFLUENZA, UNSPECIFIED FORMULATIO* 09/18/2008 MCALLEN OP* TDAP 07/30/2014 MCALLEN OP* Medicine Reconciliation Medication List: DEC 16, 2016 10:58 Allergies: TUNA =========================================================== No Active Remote Medications for this patient =========================================================== Active Medications ============================================================ 1) Lisinopril 20Mg Tab Take one-half tablet by mouth every day for blood pressure 2) Omeprazole 20Mg Ec Cap Take one capsule by mouth every day You have 2 active medications Here are NEW AND/OR CHANGED MEDICATIONS that your provider has prescribed: 1) Buspirone Hcl 10Mg Tab Take One Tablet By Mouth Three Times A Day For MOOD 2) Citalopram Hydrobromide 40Mg Tab Take One-half Tablet By Mouth Every Day For 7 Days, Then Take One Tablet Every Day For Mood _______________________________________________________________________ Your provider has NOT discontinued any of your medications today. Consults/procedures/supplies that were ordered today: NO recent pending Consults found. Imaging studies,lab tests and previously scheduled appointments: NO recent pending Radiology found. No pending labs. CVF - Future Clinic Visits 12/16/2016 11:00 MCA BHIP 2 PHARM Today your provider was: ISAAC PAN, PHARMD Clinical Pharmacy Specialist Medication education and counseling for new medications(if added today) was provided to the Veteran based on their individual needs. This included why the medication was prescribed, how they should take it and for how long, what to expect from it, and what happens if the medication is not taken as prescribed. By signing this note I certify that patient or caregiver or family member understood my instructions. MEDICATION RECONCILIATION PAPER COPY GIVEN TO PATIENT The patient/caregiver was instructed to always carry an updated Medication Reconciliation list to their next appointment whether with a VA or Non-VA provider and to discard any old lists. If after hours, weekends, holidays or long distance, call Telecare: 1-888-252-9970 VETERANS CRISIS LINE Phone: 1-800-273(TALK) 8255,push 1 to reach a VA mental health clinician. For medication refills call the automated medication refill line at 1-877-752-0650. ------------------------------------------------------------------------- ========================================================================= Date/Time: 02 Dec 2016 @ 1526 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: PAN,ISAAC Co-signed By: PAN,ISAAC Date/Time Signed: 02 Dec 2016 @ 1528 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: DEC 02, 2016@15:26 ENTRY DATE: DEC 02, 2016@15:27:01 AUTHOR: PAN,ISAAC EXP COSIGNER: URGENCY: STATUS: COMPLETED *** NO SHOW NOTE MENTAL HEALTH Has ADDENDA *** NO SHOW IN Mental Health Clinic. Veteran did not present for his/her follow-up appointment and I was not able to contact Veteran by phone x3 of his main phone. Veteran's wife's listed phone number has been discontinued. MSA: Please call Veteran to reschedule. Thank you. /es/ ISAAC PAN, PHARMD Clinical Pharmacy Specialist Signed: 12/02/2016 15:28 Receipt Acknowledged By: 12/06/2016 10:05 /es/ JUAN O DUARTE MH MSA 12/05/2016 08:54 /es/ NORI MARTINEZ MSA 12/05/2016 ADDENDUM STATUS: COMPLETED MSA called veteran to schedule appointment No showed per provider alert. There was no answer. MSA left a detailed HIPPA compliant message on veteran's voice mail to call the MH Clinic back to schedule the appointment. Phone number and extensions were provided in the voice message. /es/ NORI MARTINEZ MSA Signed: 12/05/2016 08:54 ------------------------------------------------------------------------- ========================================================================= Date/Time: 22 Nov 2016 @ 0800 Note Title: C&P EXAMINATION Location: VA Texas Valley Coastal HCS Signed By: LOFLIN,PAUL M Co-signed By: LOFLIN,PAUL M Date/Time Signed: 23 Nov 2016 @ 1221 ------------------------------------------------------------------------- LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: NOV 22, 2016@08:00 ENTRY DATE: NOV 23, 2016@12:21:58 AUTHOR: LOFLIN,PAUL M EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: Edgar Sandoval SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: unspecified trauma-and stressor-related disorder ICD code: F43.9 Mental Disorder Diagnosis #2: persistent depressive disorder ICD code: F34.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): deferred to medical 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) 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 and discuss whether there is any clinical association between these diagnoses: symptom overlap c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. 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] 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 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: symptom overlap 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 ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): He was born in Weslaco, Texas and raised in Alamo by his biological parents. He has one brother. He stated that his father was an alcoholic and would "talk down at [him]." He was also physically abusive. He got along with peers and teachers and played sports in school. The veteran was living with his wife, daughter, age two and 8-year-old son, but they separated and he is now living with a friend. He visits with his children regularly. He stated that he was arguing and irritable with his spouse and that he was "swearing" in front of his children. "I was getting mad for no reason." His mother died in a nursing home with stroke (09/2016) and his father died of "alcoholism" (10/2016). He stated the symptoms of depression have increased since they died. "The whole world's on top of me." He continues to coach softball with teenage girls on the weekends. Relationships were good in the military. b. Relevant Occupational and Educational history (pre-military, military, and post-military): He graduated high school with average grades. There were no learning or attentional problems. He worked part-time at a department store during his teenage years. He was active duty Army (2002-2005) with highest rank SPC and rank at discharge of PFC due to disciplinary problem. Discharge was honorable. He received GWOT, NDSM, Global war on terrorism expeditionary medal. He was in Southwest Asia (2004). Post-military, he received a certificate for medical Assistant (2015). He has been unemployed since February 2015 after having productivity problems in a position as heavy equipment operator. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): He did not report pre-military mental health issues or family history of psychiatric problems, though his father drank heavily. Records indicate he was admitted to John Randolph Medical Center in January 2005 with "depression." Recent VA records show he has been receiving mental health treatment for trauma-related disorder and depression since January 2016. He has received both group and individual therapy. The veteran stated that symptoms of depression have been increased since his parents died 1-2 months ago. Currently, he reports symptoms of depression including feelings of guilt, decreased pleasure and interest in activities, decreased energy, irritability, tiredness, and problems sleeping. He stated that he feels guilty for not being with his parents anymore or with his family. He reports symptoms of trauma- and stressor- related disorder including occasional distressing dreams or intrusive memories, reactions to cues in the environment (seeing people with Middle Eastern clothing"), decreased interest in activities, irritability, hypervigilance, and problems sleeping. Medications: Buspirone, lisinopril. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): none e. Relevant Substance abuse history (pre-military, military, and post-military): 6-pack of beer per month. f. Other, if any: No response provided. 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: Feeling that his life was threatened during deployment with danger of being killed. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: Seeing "dead bodies" when coming back from Iraq. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: Hearing that one of his SM friends was killed. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: No response provided. Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2 [X] Stressor #3 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Chronic sleep impairment [X] 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 worklike setting 6. Behavioral Observations -------------------------- MENTAL STATUS EXAMINATION Appearance: Casual, appropriate. Behavior: cooperative. Speech: WNL Mood/Affect: WNL, appropriate to content. Orientation: Oriented to all spheres. Cognitions: WNL, not formally tested. Safety: Danger to self/others? NO Safe to return home? YES Risk Factors assessment: [NO] Patient has current thoughts of hurting or killing themselves? [NO] Patient has current thoughts of hurting or killing someone else? [NO] Patient has is looking for a way to kill themselves or has a plan? [NO] Patient has taken actions to activate plan? [NO] Patient has history of compromised impulse control? Judgment: FAIR Insight: FAIR 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- Please comment on the effect of the Veteran's service connected disabilities on his or her ability to function in an occupational environment and describe any identified functional limitations. Please refrain from opining on if the veteran is unemployable or employable; instead focus and reflect on the functional impairments and how these impairments impact occupational and employment activities. Comment: The veteran is able to function independently and engage in activities of daily living. He is able to drive an automobile and research jobs or prepare for job interviews. However, symptoms of depression and trauma-and stressor-related disorder would negatively impact his motivation. Problems sleeping and tiredness may negatively impact performance and productivity. Irritability may cause interpersonal problems on the job. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Edgar Sandoval ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Does the Veteran have a diagnosis of (a) unspecified trauma and stressor related disorder with major depressive disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) friend killed in action during service? b. Indicate type of exam for which opinion has been requested: DBQ PSYCH PTSD INITIAL TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: STRs show treatment for depression during service (2005). He served in Southwest Asia, feared for his life and found out that a SM friend of his was killed in service. He currently reports symptoms of depression and trauma-and stressor-related disorder, such as irritability, low energy, problems sleeping, intrusive memories, distressing dreams, reactions to cues in the environment. ************************************************************************* /es/ Paul Loflin, PhD Clinical Psychologist Signed: 11/23/2016 12:21 ------------------------------------------------------------------------- ========================================================================= Date/Time: 23 Sep 2016 @ 1035 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 23 Sep 2016 @ 1039 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: SEP 23, 2016@10:35 ENTRY DATE: SEP 23, 2016@10:35:58 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health Clinic. Veteran did not present for his/her follow-up appointment and I was not able to contact Veteran by phone. Undersigned attempted to make contact with veteran however was unsuccessful. Undersigned left a voice message for veteran. MSA, can you please cancel veteran's future appointments with this provider based on history of cancelled and no-show appointments. Thank you! Please send Veteran a No Show letter with offer to reschedule. /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 09/23/2016 10:39 Receipt Acknowledged By: 09/23/2016 11:19 /es/ Sean P. McGowan, Psy.D. Licensed Psychologist 09/23/2016 15:01 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 22 Sep 2016 @ 1111 Note Title: TELEPHONE NOTE Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 22 Sep 2016 @ 1111 ------------------------------------------------------------------------- LOCAL TITLE: TELEPHONE NOTE STANDARD TITLE: TELEPHONE ENCOUNTER NOTE DATE OF NOTE: SEP 22, 2016@11:11 ENTRY DATE: SEP 22, 2016@11:11:08 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED PSYCHOLOGY TELEPHONE NOTE NOTE: This document represents only the time spent on the phone with the Veteran and not time spent documenting the telephone interaction. Duration: 5-10 min (99441) Modality: Phone Clinician: Meghan Campos, LCPC Reason for Contact: Clinician attempted to make contact with veteran regarding his engagement in the CPT Combined group. Assessment: Clinician was unable to establish phone contact with Veteran. Undersigned left a voice message for veteran to call back an discuss his future engagement in CPT treatment. /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 09/22/2016 11:11 ------------------------------------------------------------------------- ========================================================================= Date/Time: 21 Sep 2016 @ 0833 Note Title: TELEPHONE NOTE Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 21 Sep 2016 @ 0835 ------------------------------------------------------------------------- LOCAL TITLE: TELEPHONE NOTE STANDARD TITLE: TELEPHONE ENCOUNTER NOTE DATE OF NOTE: SEP 21, 2016@08:33 ENTRY DATE: SEP 21, 2016@08:33:49 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED PSYCHOLOGY TELEPHONE NOTE NOTE: This document represents only the time spent on the phone with the Veteran and not time spent documenting the telephone interaction. Duration: 5-10 min (99441) Modality: Phone Clinician: Meghan Campos, LCPC Reason for Contact: Clinician attempted to make contact with veteran regarding his engagement in the CPT Combined group. Assessment: Clinician was unable to establish phone contact with Veteran. Undersigned left a voice message for veteran to call back an discuss his future engagement in CPT treatment. Plan: 1. Undersigned will attempt to make contact with veteran later on this day, 9/21/2016. /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 09/21/2016 08:35 ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Sep 2016 @ 1300 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 19 Sep 2016 @ 1710 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: SEP 19, 2016@13:00 ENTRY DATE: SEP 19, 2016@17:07:07 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health Clinic. Veteran did not present for his follow-up appointment and I was not able to contact Veteran by phone. This was the veteran's fourth no-show to the CPT- Combined Group and he also has two cancelled and one no-show to his individual CPT sessions. Undersigned attempted to contact the veteran at 4:59pm and 5:08pm without success. Undersigned left a brief, HIPPA-sensitive message on the veteran's voicemail regarding his missed appointment. MSA: Please send Veteran a No Show letter with an updated list of his future appointments. Given his four no-shows to the CPT group, please cancel the veteran's remaining MCA BHIP GRP sessions. Thank you. Ms. Campos, LPMHC: if veteran presents to his individual session, please discuss his four no-shows to the group. Given his no-shows to the group and to his individual appointments, Veteran may be a better fit for re-starting individual CPT or considering participation in the next CPT-Combined group. Thank you for your consideration. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 09/19/2016 17:10 Receipt Acknowledged By: 09/21/2016 08:33 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor 09/20/2016 15:33 /es/ NORI MARTINEZ MSA 09/19/2016 17:13 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 16 Sep 2016 @ 1031 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 16 Sep 2016 @ 1033 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: SEP 16, 2016@10:31 ENTRY DATE: SEP 16, 2016@10:31:37 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health Clinic. Veteran did not present for his/her follow-up appointment and I was not able to contact Veteran by phone. Undersigned attempted to make contact with veteran. Undersigned left a voice message for veteran to call and discuss his future appointments with this provider in addition to the CPT Group. MSA: Please send Veteran a No Show letter with offer to reschedule. /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 09/16/2016 10:33 Receipt Acknowledged By: 09/16/2016 16:59 /es/ Sean P. McGowan, Psy.D. Licensed Psychologist 09/19/2016 08:24 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 12 Sep 2016 @ 1300 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 12 Sep 2016 @ 1641 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: SEP 12, 2016@13:00 ENTRY DATE: SEP 12, 2016@16:37:51 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health Clinic. Veteran did not present for his follow-up appointment and I was not able to contact Veteran by phone. This was the veteran's third no-show to the CPT- Combined Group and he also has two cancelled individual CPT sessions. Undersigned attempted to contact the veteran at 2:47pm, 4:18pm, and 4:37pm without success. Undersigned left a brief, HIPPA-sensitive message on the veteran's voicemail regarding his missed appointment. MSA: Please send Veteran a No Show letter with an updated list of his future appointments. Thank you. Ms. Campos, LPMHC: if veteran presents to his individual session, please discuss his three no-shows to the group and his ability to commit to the remainder of the group sessions given his current circumstances. Given his no-shows to the group, Veteran may be a better fit for individual CPT at this time. Thank you for your consideration. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 09/12/2016 16:41 Receipt Acknowledged By: 09/16/2016 08:58 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor 09/12/2016 16:59 /es/ NORI MARTINEZ MSA 09/19/2016 08:23 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 22 Aug 2016 @ 1300 Note Title: CPT-COGNITIVE PROCESSING THERAPY Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 22 Aug 2016 @ 1631 ------------------------------------------------------------------------- LOCAL TITLE: CPT-COGNITIVE PROCESSING THERAPY STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: AUG 22, 2016@13:00 ENTRY DATE: AUG 22, 2016@14:56:48 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED CPT-COMBINED GROUP SESSION #4 Identification of Thoughts and Feelings GROUP THERAPY PROGRESS NOTE Clinicians: Meghan von Linden, Ph.D., Sean P. McGowan, Psy.D. Length of Session: 90 minutes Number of Participants: 6 Date: 8/22/2016 Content: Facilitators elicited the group members' reactions to completing the ABC sheets in the prior week. Group discussed challenges and benefits to completing the ABC sheets. Then, the facilitators introduced the Challenging Questions Worksheet (CQW) and went through an example based on the stuck point: "I must have done something wrong." Finally, facilitators assigned a CQW each day based on a different stuck point on their log. Participation: The Veteran indicated readiness to participate in the treatment during this session. The Veteran indicated understanding by asking relevant making appropriate comments. He was quiet for most of the session but offered responses when prompted. Veteran was actively engaged in discussing his reaction to completing the ABC sheets and working through the group CQW. Diagnosis Addressed: Other Specified Trauma and Stressor Related Disorder; Persistent Depressive Disorder (by history) Assessment/Risk Assessment: The veteran arrived early for the appointment, was dressed casually, and ambulated independently. Veteran was oriented to person, place, time and situation. Mood was euthymic with affect congruent to thought content. Thought processes were linear and goal-directed. Speech was of average rate, volume and amount. Attention, memory and concentration were not formally assessed but were intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. No SI/HI elicited. Veteran is aware that he can walk-in to the clinic, contact the Crisis Line, or go to his local emergency room if he begins to have intense, intrusive thoughts of harming himself or others. Plan: Veteran indicates understanding and agreement with the group rules, treatment goals, his role in therapy, and plan as follows: 1) Continue CPT-Combined weekly - next session 8/29/16 at 1:00pm. 2) Veteran informed of safety contact numbers. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 08/22/2016 16:31 Receipt Acknowledged By: 08/22/2016 16:39 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Aug 2016 @ 1101 Note Title: CPT-COGNITIVE PROCESSING THERAPY Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 19 Aug 2016 @ 1105 ------------------------------------------------------------------------- LOCAL TITLE: CPT-COGNITIVE PROCESSING THERAPY STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: AUG 19, 2016@11:01 ENTRY DATE: AUG 19, 2016@11:01:33 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED Cognitive Processing Therapy: Trauma Event Session Time in session (in minutes): 60 SESSION NUMBER: 4 CPT-C Combined Format SESSION FORMAT Face-to-face session: Meghan Campos, LCPC SESSION LOCATION Mental Health Clinic DIAGNOSIS: Primary (focus of treatment): PTSD ASSESSMENT: SCORES (PCL or PHQ9) PHQ-9 wad administered. The score was 14 which decreased from the previous week. PCL-5 Weekly was administered. The score was 48 which decreased from the previous week. RISK INFORMATION No new risk factors relevant to suicide or homicide were reported. Veteran did not appear to be at imminent risk of harm to self or others at this time. The Veteran specifically denied suicidal/homicidal thoughts, plan or intent. MENTAL STATUS/BEHAVIORAL OBSERVATIONS Veteran appeared oriented times 4 (person, place, time, situation) and mood/affect were congruent with the topics discussed. Thought processes were linear and goal-directed. Speech was of average rate, volume, and amount. Attention, memory, and concentration were not formally assessed but appeared intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. No SI/HI. Veteran actively participated in session. Veteran expressed his understanding of the information that was discussed. SESSION CONTENT: The Veteran completed the 4th session of Cognitive Processing Therapy (CPT) for PTSD. The following therapy components were addressed: -Therapist reviewed the completed A-B-C Worksheets with Veteran. -Therapist had Veteran read the Impact Statement aloud. -Therapist helped the Veteran go through the Impact Statement to identify stuck points using Socratic Questioning. -Therapist helped Veteran connect feelings to thoughts. PRACTICE ASSIGNMENT -Assigned additional ABC Worksheets to be completed daily PLAN Next session planned for agreed upon date/time of: 8/26/2016 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 08/19/2016 11:05 ------------------------------------------------------------------------- ========================================================================= Date/Time: 15 Aug 2016 @ 1300 Note Title: CPT-COGNITIVE PROCESSING THERAPY Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 15 Aug 2016 @ 1600 ------------------------------------------------------------------------- LOCAL TITLE: CPT-COGNITIVE PROCESSING THERAPY STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: AUG 15, 2016@13:00 ENTRY DATE: AUG 15, 2016@14:55:37 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED CPT-COMBINED GROUP SESSION #3 Identification of Thoughts and Feelings GROUP THERAPY PROGRESS NOTE Clinicians: Meghan von Linden, Ph.D., Sean P. McGowan, Psy.D. Length of Session: 90 minutes Number of Participants: 6 Date: 8/15/2016 Content: Facilitators asked about the difficulties and benefits of making phone calls to the other group members about the assignments. Facilitators then elicited the group members' reactions to completing the ABC sheets in the prior week. Then, the facilitators helped the group complete two ABC sheets, one on a typical daily event and one on a common stuck point related to the index trauma. Finally, facilitators assigned an ABC sheet each day, including one about their index trauma. Participation: The Veteran indicated readiness to participate in the treatment during this session. The Veteran indicated understanding by asking relevant questions and making appropriate comments. Veteran was actively engaged in discussing his reaction to completing the ABC sheets and working through the group ABC worksheets. He volunteered to write down group statements regarding an ABC sheet on the stuck point: "It was my fault." He also discussed how he tends to blame himself for the death of a friend who was killed in a convoy. Veteran concluded that "he should be here, not me." Diagnosis Addressed: Other Specified Trauma and Stressor Related Disorder; Persistent Depressive Disorder Assessment/Risk Assessment: The veteran arrived early for the appointment, was dressed casually, and ambulated independently. Veteran was oriented to person, place, time and situation. Mood was slightly depressed with affect congruent to thought content. Thought processes were linear and goal-directed. Speech was of average rate, volume and amount. Attention, memory and concentration were not formally assessed but were intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. No SI/HI elicited. Veteran is aware that he can walk-in to the clinic, contact the Crisis Line, or go to his local emergency room if he begins to have intense, intrusive thoughts of harming himself or others. Plan: Veteran indicates understanding and agreement with the group rules, treatment goals, his role in therapy, and plan as follows: 1) Continue CPT-Combined weekly - next session 8/22/16 at 1:00pm. 2) Veteran informed of safety contact numbers. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 08/15/2016 16:00 Receipt Acknowledged By: 08/15/2016 16:13 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor 08/15/2016 17:08 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 12 Aug 2016 @ 1332 Note Title: CPT-COGNITIVE PROCESSING THERAPY Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 12 Aug 2016 @ 1442 ------------------------------------------------------------------------- LOCAL TITLE: CPT-COGNITIVE PROCESSING THERAPY STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: AUG 12, 2016@13:32 ENTRY DATE: AUG 12, 2016@13:32:53 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED Cognitive Processing Therapy: A-B-C Worksheet Session Time in session (in minutes): 60 SESSION NUMBER: 3 CPT-C Combined SESSION FORMAT Face-to-face session: Meghan Campos, LCPC SESSION LOCATION Mental Health Clinic DIAGNOSIS: Primary (focus of treatment): PTSD ASSESSMENT: SCORES (PCL or PHQ9) PHQ-9 wad administered. The score was 16 which did not change from the previous week. PCL-5 Weekly was administered. The score was 54 which decreased from the previous week. RISK INFORMATION No new risk factors relevant to suicide or homicide were reported. Veteran did not appear to be at imminent risk of harm to self or others at this time. The Veteran specifically denied suicidal/homicidal thoughts, plan or intent. MENTAL STATUS/BEHAVIORAL OBSERVATIONS Veteran appeared oriented times 4 (person, place, time, situation) and mood/affect were congruent with the topics discussed. Thought processes were linear and goal-directed. Speech was of average rate, volume, and amount. Attention, memory, and concentration were not formally assessed but appeared intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. No SI/HI. Veteran actively participated during session. Veteran appeared to understand the material that was presented. Veteran expressed his understanding of the material and homework assignment. Veteran was reminded to bring his Impact Statement to Group on Monday. SESSION CONTENT: The Veteran completed the Thoughts and Feelings Session of the Cognitive Processing Therapy (CPT) for PTSD. The following therapy components were addressed: -Therapist reviewed homework (A-B-C Worksheets) with Veteran, and helped further differentiate between thoughts and feelings. -The Veteran did not complete any worksheets between sessions; therefore, the Veteran was asked to complete worksheets in session. Veteran was not present for Group Therapy on 8/8/2016 therefore the materials that were presented during group were presented during Individual session. -Therapist helped Veteran identify stuck points and add them to the Stuck Point Log. PRACTICE ASSIGNMENT -Therapist asked Veteran to continue using the A-B-C Worksheets, completing one each day. PLAN Next session planned for agreed upon date/time of: 8/19/2016 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 08/12/2016 14:42 ------------------------------------------------------------------------- ========================================================================= Date/Time: 08 Aug 2016 @ 1300 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 08 Aug 2016 @ 1636 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: AUG 08, 2016@13:00 ENTRY DATE: AUG 08, 2016@16:33:31 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health Clinic. Veteran did not present for his follow-up appointment and I was not able to contact Veteran by phone. This was the veteran's second consecutive no-show to the CPT-Combined Group. Undersigned attempted to contact the veteran at 2:50pm, 4:21pm, and 4:32pm without success. Undersigned left a brief, HIPPA-sensitive message on the veteran's voicemail regarding his missed appointment. MSA: Please send Veteran a No Show letter with an updated list of his future appointments. Thank you. Ms. Campos, LPMHC: if veteran presents to his individual session, please discuss his two past no-shows to the group, motivation to continue in the CPT-Combined group format, and ensure that you and he review the Impact Statement and ABC sheets for the next group session (assuming he maintains motivation for this). Thank you. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 08/08/2016 16:36 Receipt Acknowledged By: 08/08/2016 17:03 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor 08/09/2016 08:53 /es/ NORI MARTINEZ MSA 08/08/2016 16:39 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 03 Aug 2016 @ 1627 Note Title: MAS NOTE Location: Temple TX VAMC Signed By: DURGIN,ANGELA S Co-signed By: DURGIN,ANGELA S Date/Time Signed: 03 Aug 2016 @ 1630 ------------------------------------------------------------------------- LOCAL TITLE: MAS NOTE STANDARD TITLE: ADMINISTRATIVE NOTE DATE OF NOTE: AUG 03, 2016@16:27 ENTRY DATE: AUG 03, 2016@16:27:31 AUTHOR: DURGIN,ANGELA S EXP COSIGNER: URGENCY: STATUS: COMPLETED MAS NOTE Routine Received VA Form 10-10EZR, along with a copy of the Veteran's DVA Veterans ID. Veteran is passing through and here for a RX refill. Processed application and with supervisor approval referred Veteran directly to the Pharmacy. No future appointments were scheduled. /es/ ANGELA DURGIN HEALTH BENEFITS ASSISTANT Signed: 08/03/2016 16:30 ------------------------------------------------------------------------- ========================================================================= Date/Time: 02 Aug 2016 @ 1618 Note Title: CPT-COGNITIVE PROCESSING THERAPY Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 02 Aug 2016 @ 1627 ------------------------------------------------------------------------- LOCAL TITLE: CPT-COGNITIVE PROCESSING THERAPY STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: AUG 02, 2016@16:18 ENTRY DATE: AUG 02, 2016@16:18:49 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED Cognitive Processing Therapy: Meaning Session Time in session (in minutes): 60 SESSION NUMBER: 2 CPT-C Combined Format SESSION FORMAT Face-to-face session: Meghan Campos, LCPC SESSION LOCATION Mental Health Clinic DIAGNOSIS: Primary (focus of treatment): PTSD ASSESSMENT: SCORES (PCL or PHQ9) PHQ-9 wad administered. The score was 16 which increased from the previous week. PCL-5 Weekly was administered. The score was 59 which decreased from the previous week. RISK INFORMATION No new risk factors relevant to suicide or homicide were reported. Veteran did not appear to be at imminent risk of harm to self or others at this time. The Veteran specifically denied suicidal/homicidal thoughts, plan or intent. MENTAL STATUS/BEHAVIORAL OBSERVATIONS Veteran appeared oriented times 4 (person, place, time, situation) and mood/affect were congruent with the topics discussed. Thought processes were linear and goal-directed. Speech was of average rate, volume, and amount. Attention, memory, and concentration were not formally assessed but appeared intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. No SI/HI. Veteran actively participated during session. Veteran expressed his anxiety, avoidance, and feelings of self-blame as it relates to an incident that occurred during the past week. Veteran appeared to understand the material that was presented. Veteran expressed his understanding of the material and homework assignment. SESSION CONTENT: The Veteran completed the Meaning of the Event session of Cognitive Processing Therapy (CPT) for PTSD. The following therapy components were addressed: -The Veteran and therapist reviewed the Stuck Point Help Sheet and started the Stuck Point Log. -Discussed natural vs. manufactured emotions. -Discussed and introduced the Cognitive Model. -Introduced the Impact Statement with the Veteran with a focus on identifying "stuck points". PRACTICE ASSIGNMENT: -Assigned the Impact Statement. -Therapist asked the Veteran to add to the Stuck Point Log. PLAN Next session planned for agreed upon date/time of: 8/12/2016 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 08/02/2016 16:27 ------------------------------------------------------------------------- ========================================================================= Date/Time: 01 Aug 2016 @ 1300 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 01 Aug 2016 @ 1604 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: AUG 01, 2016@13:00 ENTRY DATE: AUG 01, 2016@15:55:08 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health Clinic. Veteran did not present for his follow-up appointment and I was not able to contact Veteran by phone. This was the veteran's first no-show to the CPT-Combined Group. Undersigned attempted to contact the veteran at 3:33pm, 3:54pm, and 4:04pm without success. Undersigned left a brief, HIPPA-sensitive message on the veteran's voicemail regarding his missed appointment. MSA: Please send Veteran a No Show letter with an updated list of his future appointments. Thank you. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 08/01/2016 16:04 Receipt Acknowledged By: 08/01/2016 16:32 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor 08/02/2016 08:16 /es/ NORI MARTINEZ MSA 08/01/2016 16:08 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 29 Jul 2016 @ 1421 Note Title: CPT-COGNITIVE PROCESSING THERAPY Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 29 Jul 2016 @ 1431 ------------------------------------------------------------------------- LOCAL TITLE: CPT-COGNITIVE PROCESSING THERAPY STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: JUL 29, 2016@14:21 ENTRY DATE: JUL 29, 2016@14:21:25 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED Cognitive Processing Therapy: Initial Session Time in session (in minutes): 60 SESSION NUMBER: 1 CPT-C Combined Format SESSION FORMAT Face-to-face session: Meghan Campos, LCPC SESSION LOCATION Mental Health Clinic DIAGNOSIS: Primary (focus of treatment): PTSD ASSESSMENT: SCORES (PCL or PHQ9) PHQ-9 wad administered. The score was 14. PCL-5 Weekly was administered. The score was 68. RISK INFORMATION No new risk factors relevant to suicide or homicide were reported. Veteran did not appear to be at imminent risk of harm to self or others at this time. The Veteran specifically denied suicidal/homicidal thoughts, plan or intent. MENTAL STATUS/BEHAVIORAL OBSERVATIONS Veteran appeared oriented times 4 (person, place, time, situation) and mood/affect were congruent with the topics discussed. Thought processes were linear and goal-directed. Speech was of average rate, volume, and amount. Attention, memory, and concentration were not formally assessed but appeared intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. No SI/HI. Veteran actively participated in session. Veteran expressed his understanding of the information that was discussed. SESSION CONTENT: The Veteran completed the first session of Cognitive Processing Therapy (CPT) for PTSD. The following therapeutic components were addressed: Review of PTSD symptoms marked/review 4 clusters, discussed fight/flight/freeze responses, Identify their index trauma to focus on initially, 3 goals of treatment (accept trauma happened/feel our feelings/become rational logical thinkers), discussed anticipating avoidance/encourage active practice of skills, and discussed this past week's group experience. -Facilitated a good therapeutic relationship. The following elements were utilized to help establish a collaborative, positive working relationship with the Veteran -Provided an overview of PTSD symptoms, a cognitive explanation of the development and maintenance of PTSD, and a rationale of CPT. -Discussed Veteran's readiness to engage in treatment. -Discussed and addressed Veteran's questions or concerns about treatment. Veteran expressed the following questions and/or concerns: -Asked the Veteran to describe a brief account of their most traumatic event. Veteran identified his Index Trauma as being an incident that occurred during a deployment where he witnessed the death of his good friend. Veteran did not provide additional details. PRACTICE ASSIGNMENT: -Asked Veteran to review Recovery and Non-Recovery Handout and the Stuck Point Handout. PLAN Next session planned for agreed upon date/time of: 8/2/2016. /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 07/29/2016 14:31 ------------------------------------------------------------------------- ========================================================================= Date/Time: 25 Jul 2016 @ 1300 Note Title: PSYCHOTHERAPY GROUP NOTE Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 25 Jul 2016 @ 1632 ------------------------------------------------------------------------- LOCAL TITLE: PSYCHOTHERAPY GROUP NOTE STANDARD TITLE: PSYCHOLOGY GROUP COUNSELING NOTE DATE OF NOTE: JUL 25, 2016@13:00 ENTRY DATE: JUL 25, 2016@14:53:01 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED ORIENTATION TO CPT-COMBINED GROUP SESSION COMMITMENT TO PARTICIPATION AGREEMENT GROUP THERAPY PROGRESS NOTE Clinicians: Meghan von Linden, Ph.D., Sean P. McGowan, Psy.D. Length of Session: 90 minutes Number of Participants: 6 Date: 7/25/2016 Content: The Veteran arrived for session to further identify goals he hopes to achieve in Cognitive Processing Therapy (CPT) for trauma-related symptoms. Co-leaders introduced themselves, developed goals for the group, identified group rules, clarified expectations, and thoroughly processed the commitment necessary to have the highest potential for benefit. Facilitators also provided an overview of the treatment, including: the three phases of treatment, the importance of practice assignments, and completion of measures prior to treatment. Participation: The Veteran indicated readiness to participate in the treatment during this session. The Veteran indicated understanding by asking relevant questions and making appropriate comments. Veteran stated he had been motivated to attend today's session and expressed a personal goal: improving his anger management and being more open to trusting family members. Diagnosis Addressed: Other Specified Trauma and Stressor Related Disorder Assessment/Risk Assessment: The veteran arrived early for the appointment, was dressed casually, and ambulated independently. Veteran was oriented to person, place, time and situation. Mood was anxious with affect congruent to thought content. Thought processes were linear and goal-directed. Speech was of average rate, volume and amount. Attention, memory and concentration were not formally assessed but were intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. No SI/HI elicited. Plan: Veteran indicates understanding and agreement with the group rules, treatment goals, his role in therapy, and plan as follows: 1) Continue CPT- Combined weekly - next session 8/1/16 at 1:00pm. 2) Veteran informed of safety contact numbers. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 07/25/2016 16:32 Receipt Acknowledged By: 07/25/2016 16:36 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 25 Jul 2016 @ 1027 Note Title: MED RECONCILIATION Location: VA Texas Valley Coastal HCS Signed By: VEGA,OLYMPIA C Co-signed By: VEGA,OLYMPIA C Date/Time Signed: 25 Jul 2016 @ 1027 ------------------------------------------------------------------------- LOCAL TITLE: MED RECONCILIATION STANDARD TITLE: MEDICATION MGT NOTE DATE OF NOTE: JUL 25, 2016@10:27 ENTRY DATE: JUL 25, 2016@10:27:36 AUTHOR: VEGA,OLYMPIA C EXP COSIGNER: URGENCY: STATUS: COMPLETED EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 PATIENT PHONE - 956 802 8945 AGE: 38 SEX: MALE WEIGHT:196.6 lb [89.4 kg] (07/25/2016 10:04) SELECTED CLINICAL REMINDERS DUE: --STATUS-- --DUE DATE-- --LAST DONE-- V17 ALL Influenza Immunization DUE NOW DUE NOW unknown VACCINES OF RECORD IN VCB CPRS: Immunization Series Date Facility Reaction Info INFLUENZA, UNSPECIFIED FORMULATIO* 09/18/2008 MCALLEN OP* TDAP 07/30/2014 MCALLEN OP* Medicine Reconciliation Medication List: JUL 25, 2016 10:27 Allergies: TUNA =========================================================== No Active Remote Medications for this patient =========================================================== Active Medications ============================================================ 1) Buspirone Hcl 10Mg Tab Take one tablet by mouth three times a day as needed for Anxiety 2) Lisinopril 20Mg Tab Take one-half tablet by mouth every day for blood pressure You have 2 active medications Here are NEW AND/OR CHANGED MEDICATIONS that your provider has prescribed: 1) Omeprazole 20Mg Ec Cap Take One Capsule By Mouth Every Day _______________________________________________________________________ Your provider has NOT discontinued any of your medications today. Consults/procedures/supplies that were ordered today: NO recent pending Consults found. Imaging studies,lab tests and previously scheduled appointments: NO recent pending Radiology found. PENDING LABS: URINALYSIS COMPREHENSIVE METABOLIC PNL LIPID PANEL CBC HEMOGLOBIN A1C CVF - Future Clinic Visits 07/25/2016 10:30 MCA PACT BLUE TEAM 07/25/2016 13:00 MCA BHIP GRP 07/29/2016 10:00 MCA BHIP 2 LPMHC 08/01/2016 13:00 MCA BHIP GRP 08/05/2016 10:00 MCA BHIP 2 LPMHC 08/08/2016 13:00 MCA BHIP GRP 08/12/2016 10:00 MCA BHIP 2 LPMHC 08/15/2016 13:00 MCA BHIP GRP 08/19/2016 10:00 MCA BHIP 2 LPMHC 08/22/2016 13:00 MCA BHIP GRP 08/26/2016 10:00 MCA BHIP 2 LPMHC 08/29/2016 13:00 MCA BHIP GRP 09/09/2016 10:00 MCA BHIP 2 LPMHC 09/12/2016 13:00 MCA BHIP GRP 09/16/2016 10:00 MCA BHIP 2 LPMHC 09/19/2016 13:00 MCA BHIP GRP 09/23/2016 10:00 MCA BHIP 2 LPMHC 09/26/2016 13:00 MCA BHIP GRP 09/30/2016 10:00 MCA BHIP 2 LPMHC 10/03/2016 13:00 MCA BHIP GRP 10/07/2016 10:00 MCA BHIP 2 LPMHC 10/17/2016 13:00 MCA BHIP GRP Today your provider was: OLYMPIA C VEGA Vega, Olympia , Physician Assistant Medication education and counseling for new medications(if added today) was provided to the Veteran based on their individual needs. This included why the medication was prescribed, how they should take it and for how long, what to expect from it, and what happens if the medication is not taken as prescribed. By signing this note I certify that patient or caregiver or family member understood my instructions. MEDICATION RECONCILIATION PAPER COPY GIVEN TO PATIENT The patient/caregiver was instructed to always carry an updated Medication Reconciliation list to their next appointment whether with a VA or Non-VA provider and to discard any old lists. Patient declines a paper copy of this medication reconciliation. If after hours, weekends, holidays or long distance, call Telecare: 1-888-252-9970 VETERANS CRISIS LINE Phone: 1-800-273(TALK) 8255,push 1 to reach a VA mental health clinician. For medication refills call the automated medication refill line at 1-877-752-0650. ------------------------------------------------------------------------- ========================================================================= Date/Time: 25 Jul 2016 @ 1009 Note Title: PC PROVIDER FOLLOW-UP PATIENT NOTE Location: VA Texas Valley Coastal HCS Signed By: VEGA,OLYMPIA C Co-signed By: VEGA,OLYMPIA C Date/Time Signed: 25 Jul 2016 @ 1027 ------------------------------------------------------------------------- LOCAL TITLE: PC PROVIDER FOLLOW-UP PATIENT NOTE STANDARD TITLE: PRIMARY CARE OUTPATIENT PROGRESS NOTE DATE OF NOTE: JUL 25, 2016@10:09 ENTRY DATE: JUL 25, 2016@10:09:55 AUTHOR: VEGA,OLYMPIA C EXP COSIGNER: URGENCY: STATUS: COMPLETED Reason for visit/chief complaint: Patient is a 38 year old WHITE MALE: 1: Patient in for scheduled appt Problem List was reviewed at today's appointment. Allergies: TUNA Active Medications ============================================================ 1) Buspirone Hcl 10Mg Tab Take one tablet by mouth three times a day as needed for Anxiety 2) Lisinopril 20Mg Tab Take one-half tablet by mouth every day for blood pressure You have 2 active medications Reviewed home meds with patient/caregiver and NO discrepancies found. History: HTN: On lisinopril. Denies chest pain, sob, palpitation. Positive DOE. Depression/Dysthymic d/o / PTSD: Established with MH. Denies si/hi. Tobacco user: Decreased to 2 cig per day. Gastritis: On omeprzole and doing well Sleep apnea: Using CPAP nightly Hyperlipidemia: Admits he has not been following a good diet. Review Of Systems: Denies blood in stool. Physical Exam: Vital Signs: Temperature: 98.3 F [36.8 C] (07/25/2016 10:04) Pulse: 84 (07/25/2016 10:04) Respiration: 18 (07/25/2016 10:04) BP: 131/82 (07/25/2016 10:04) Pain: 3 (07/25/2016 10:04) Height: 69 in [175.3 cm] (07/25/2016 10:04) Weight: 196.6 lb [89.4 kg] (07/25/2016 10:04) BMI: 29.1 General: No acute distress, well developed. HEENT: Normocephalic, EAC patent, TM's normal, pharynx non erythematous Neck: Supple, no masses, no lymph nodes Chest: Lungs clear, no rales, no rhonchi, no wheezes. Heart: RRR, no rubs, no gallops, no JVD Abdomen: Soft, no tenderness, no masses or organomegaly, BS normal. Back: Normal curvature, no tenderness. Extremities: No edema, no erythema, warm, well perfused Neuro: Cranial nerves grossly normal. No motor deficit. Gait: tip toes, heels: intact. Rectal: Deferred. Last diagnostic tests reviewed and discussed with patient. Assessment: 1. HTN: Meds unchanged; normal ekg. 2. Depression/Dysthymic d/o / PTSD: Keep appts with MH this afternoon. 3. Tobacco user: Encouraged tobacco cessation 4. Gastritis: continue with omeprazole, counseled on long term use. 5. Sleep apnea: Continue using CPAP machine 6. Hyperlipidemia: Encouraged diet and exercise as well as lifestyle modifications. RTC in 6months for regular follow up with pcp and prn. /es/ OLYMPIA C VEGA Vega, Olympia , Physician Assistant Signed: 07/25/2016 10:27 Receipt Acknowledged By: 07/25/2016 10:51 /es/ REBECCA BASALDUA ------------------------------------------------------------------------- ========================================================================= Date/Time: 25 Jul 2016 @ 1005 Note Title: PRIMARY CARE NURSE FOLLOW-UP NOTE Location: VA Texas Valley Coastal HCS Signed By: RINCONES,EPIFANIO Co-signed By: RINCONES,EPIFANIO Date/Time Signed: 25 Jul 2016 @ 1013 ------------------------------------------------------------------------- LOCAL TITLE: PRIMARY CARE NURSE FOLLOW-UP NOTE STANDARD TITLE: PRIMARY CARE NURSING NOTE DATE OF NOTE: JUL 25, 2016@10:05 ENTRY DATE: JUL 25, 2016@10:06 AUTHOR: RINCONES,EPIFANIO EXP COSIGNER: URGENCY: STATUS: COMPLETED SANDOVAL,EDGAR JULIAN SSN: 457-65-1840 Age:38 Sex:MALE Race:WHITE Allergies: TUNA Problem/Chief Complaint: Pt here for MD appt and labs review, pt states that he needs refills on Omeprazole and Fluoxetine, and he refilled his lisinopril and has not recieved the medication, stable gait with no assistance, alert and cooperative, states pain to bilateral knees 3/10, refer to Vega's POC. Have you traveled outside of the USA in the last 6 months? No Current Vital Signs: Temp: 98.3 F [36.8 C] (07/25/2016 10:04) Pulse: 84 (07/25/2016 10:04) Resp: 18 (07/25/2016 10:04) B/P: 131/82 (07/25/2016 10:04) Pain: 3 (07/25/2016 10:04) 7/25/16 @ 1004 PULSE OXIMETRY: 98 Height:69 in [175.3 cm] (07/25/2016 10:04) Weight:196.6 lb [89.4 kg] (07/25/2016 10:04) BMI: 29.1 Pain Screen: Pain Scale: Numeric Rating Scale (NRS). Patient has reported a pain score of 3 (07/25/2016 10:04). Chronic Pain, Acceptable level score 1-3. Location: bilateral knees Previous Learning History Learning history was reviewed,no changes were necessary. TOPICS TAUGHT: Topics taught today Discussed with: Patient The safe and effective use of medications was reviewed. Specific topic(s): take medications as prescribed Level of Understanding: Fair Referrals/Next Step in Care: Primary Care Provider Alerted: PA Vega Patient/Caregiver verbalized understanding of information and instructed to call the provider or nurse for questions or concerns. Yes Patient/Caregiver instructed that the printed medication list given to them should be taken to all future medical appointments and carried with them at all times in case of an emergency. Yes The following Clinical Nursing Reminders are due: --STATUS-- --DUE DATE-- --LAST DONE-- Nursing Annual Health History DUE SOON 01/19/2017 01/19/2016 V17 ALL Influenza Immunization DUE NOW DUE NOW unknown Pneumococcal PPSV23 (Pneumovax) DUE NOW DUE NOW unknown Nursing Clinical Reminders were reviewed today. CLINICAL REMINDER ACTIVITY V17 ALL Influenza Immunization: Primary Care Immunization Appointment prior to availability. Comment: vaccine is not available Pneumococcal PPSV23 (Pneumovax): The patient declines to receive the recommended dose of pneumococcal polysaccharide vaccine PPSV23 (Pneumovax). Comment: doesnt want vaccine right now /es/ EPIFANIO RINCONES LVN Signed: 07/25/2016 10:13 ------------------------------------------------------------------------- ========================================================================= Date/Time: 20 Jul 2016 @ 0820 Note Title: DIAGNOSTIC TEST RESULT NOTIFICATION LETTER Location: VA Texas Valley Coastal HCS Signed By: BARREIRO,MARIBEL B Co-signed By: BARREIRO,MARIBEL B Date/Time Signed: 20 Jul 2016 @ 0822 ------------------------------------------------------------------------- LOCAL TITLE: DIAGNOSTIC TEST RESULT NOTIFICATION LETTER STANDARD TITLE: LETTERS DATE OF NOTE: JUL 20, 2016@08:20 ENTRY DATE: JUL 20, 2016@08:20:20 AUTHOR: BARREIRO,MARIBEL B EXP COSIGNER: URGENCY: STATUS: COMPLETED VA Health Care Center at Harlingen 2601 Veteran's Drive Harlingen, Texas 78550 JUL 20, 2016 SANDOVAL,EDGAR JULIAN 2314 E 21ST STREET MISSION, TX 78572 Dear Mr. SANDOVAL,EDGAR JULIAN, I wanted to update you on your recent diagnostic test results: Your lab results look good. Your cholesterol is a little high, please try and eat less and move more. Future Appointments - JUL 25,2016@10:30 MCA PACT BLUE TEAM JUL 25,2016@13:00 MCA BHIP GRP JUL 29,2016@10:00 MCA BHIP 2 LPMHC AUG 1,2016@13:00 MCA BHIP GRP AUG 5,2016@10:00 MCA BHIP 2 LPMHC AUG 8,2016@13:00 MCA BHIP GRP AUG 12,2016@10:00 MCA BHIP 2 LPMHC AUG 15,2016@13:00 MCA BHIP GRP AUG 19,2016@10:00 MCA BHIP 2 LPMHC AUG 22,2016@13:00 MCA BHIP GRP AUG 26,2016@10:00 MCA BHIP 2 LPMHC AUG 29,2016@13:00 MCA BHIP GRP SEP 9,2016@10:00 MCA BHIP 2 LPMHC SEP 12,2016@13:00 MCA BHIP GRP SEP 16,2016@10:00 MCA BHIP 2 LPMHC SEP 19,2016@13:00 MCA BHIP GRP SEP 23,2016@10:00 MCA BHIP 2 LPMHC SEP 26,2016@13:00 MCA BHIP GRP SEP 30,2016@10:00 MCA BHIP 2 LPMHC OCT 3,2016@13:00 MCA BHIP GRP OCT 7,2016@10:00 MCA BHIP 2 LPMHC OCT 17,2016@13:00 MCA BHIP GRP Your blood sugar average (Hemoglobin A1c) was within goal of less than 7%. SLT - Lab Tests Selected Collection DT Specimen Test Name Result Units Ref Range 11/04/2015 10:15 BLOOD HEMOGLOBIN A1C 5.4 % 4.2 - 5.8 (LDL is the "bad" cholesterol) (HDL is the "good" cholesterol. Target is >40. Exercise can increase HDL) (TRIG = triglycerides. Target is <150. A nonfasting sample, sweets, alcohol, weight gain, and diabetes can increase these.) LIPID PROFILE Coll. dat7/18/16 08:56 CHOL 182 TRIG 91 HDL 44.2 VLDL CHOLESTEROL 18.2 Collection DT Specimen Test Name Result Units Ref Range 07/18/2016 08:56 PLASMA LDL-CHOL CALCULAT 119.6 mg/dL Ref: <100 Please continue low fat diet, low cholesterol diet Other Diagnostic Test Result(s): CBC Coll. date 7/18/16 08:56 WBC 5.9 HGB 14.6 HCT 43.2 MCV 89.9 PLT 174 CHEM 20 Coll. date 7/18/16 08:56 BUN 8 CREAT 0.86 SODIUM 137.4 K 4.3 CHLOR 101 INR - NONE FOUND PROSTATIC SPECIFIC ANTIGEN 7/18/16 08:56 0.71 Other labs: - If you need assistance after hours, weekends, holidays or long distance call Telecare: 1-888-252-9970 Sincerely, Your Valley Coastal Bend Provider: MARIBEL B BARREIRO,MD Sincerely, Your Valley Coastal Bend Provider ------------------------------------------------------------------------- ========================================================================= Date/Time: 11 Jul 2016 @ 1205 Note Title: TELEPHONE NOTE Location: VA Texas Valley Coastal HCS Signed By: MCGOWAN,SEAN P Co-signed By: MCGOWAN,SEAN P Date/Time Signed: 11 Jul 2016 @ 1213 ------------------------------------------------------------------------- LOCAL TITLE: TELEPHONE NOTE STANDARD TITLE: TELEPHONE ENCOUNTER NOTE DATE OF NOTE: JUL 11, 2016@12:05 ENTRY DATE: JUL 11, 2016@12:11:20 AUTHOR: MCGOWAN,SEAN P EXP COSIGNER: URGENCY: STATUS: COMPLETED DATE: 7/11/2016 TIME of Contact: 12:05pm Length of Contact: less than 5 minutes Provider: Sean P. McGowan, Psy.D. Modality: phone Undersigned contacted the veteran to inform him of the beginning of the CPT- Combined Group and to determine if the veteran is still interested in participation in the group and individual sessions. Veteran reported that he was still interested in engaging in the CPT-Combined group and individual sessions. Undersigned then provided the veteran with an overview of the orientation session and the nature of the subsequent sessions. Undersigned clarified that the orientation session would consist of introductions, review of the group rules, an overview of his goals, an outline of the upcoming session content, and a discussion about commitment to the group. Veteran expressed commitment to the orientation session. Veteran was alert and oriented to all spheres during the phone contact. Mood sounded euthymic. Veteran denied suicidal or homicidal ideation, plan, or intent. Veteran then was reminded that he can contact the MHC, walk-in to the clinic, call the crisis line at 1-800-273-8255, or walk-in to his local emergency room if he begins to have intense and intrusive thoughts of harming himself or others. Veteran agreed to plan. Mr. Gonzalez: please CANCEL veteran for the MCA BHIP GRP on 7/18/2016 at 1:00pm and MCA BHIP 2 LPMHC on 7/22/2016 at 10:00am (per clinic request). Thank you. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 07/11/2016 12:13 Receipt Acknowledged By: 07/12/2016 08:01 /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor 07/11/2016 13:11 /es/ GIOVANNI GONZALEZ Program Support Assitant 07/12/2016 08:15 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 08 Jul 2016 @ 1436 Note Title: TELEPHONE NOTE Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 08 Jul 2016 @ 1440 ------------------------------------------------------------------------- LOCAL TITLE: TELEPHONE NOTE STANDARD TITLE: TELEPHONE ENCOUNTER NOTE DATE OF NOTE: JUL 08, 2016@14:36 ENTRY DATE: JUL 08, 2016@14:36:37 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED PSYCHOLOGY TELEPHONE NOTE NOTE: This document represents only the time spent on the phone with the Veteran and not time spent documenting the telephone interaction. Duration: 5-10 min (99441) Modality: Phone Clinician: Meghan Campos, LCPC Reason for Contact: Clinician was alerted to Veteran's interest in the CPT Combined group. Assessment: Clinician was able to establish phone contact with Veteran. Time spent discussing the upcoming group, nature/purpose of the group, date/time of the sessions. Veteran stated interest and ACCEPTED participation. Plan: 1. MSA: Please schedule Veteran for the CPT group. [See ORDERS tab] a. CID = 07.18.2016 from 1300-1430, weekly (every Monday) for 12 weeks 2. MSA: please schedule veteran for Individual Therapy with undersigned. a. CID = 07.22.2016 @ 1000 am, weekly (every Friday) for 12 weeks /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 07/08/2016 14:40 Receipt Acknowledged By: 07/08/2016 15:05 /es/ GIOVANNI GONZALEZ Program Support Assitant ------------------------------------------------------------------------- ========================================================================= Date/Time: 09 Jun 2016 @ 1631 Note Title: PSYCHOTHERAPY GROUP NOTE Location: VA Texas Valley Coastal HCS Signed By: CROOK-ABEL,WENDY M Co-signed By: CROOK-ABEL,WENDY M Date/Time Signed: 09 Jun 2016 @ 1632 ------------------------------------------------------------------------- LOCAL TITLE: PSYCHOTHERAPY GROUP NOTE STANDARD TITLE: PSYCHOLOGY GROUP COUNSELING NOTE DATE OF NOTE: JUN 09, 2016@16:31 ENTRY DATE: JUN 09, 2016@16:31:40 AUTHOR: CROOK-ABEL,WENDY M EXP COSIGNER: URGENCY: STATUS: COMPLETED Group Title: PTSD Basic Skills Group Therapist(s):Dr. Wendy Crook-Abel Group Modality: Telehealth Session Length: 60 min Number of Participants: 4 Therapy Format/Intervention Type: Cognitive-Behavioral Skills Group Objective: To provider a basic skills foundation prior to the start of EBP for trauma. Session Title and Group Content: Provider reviewed diaphragmatic breathing and participants discussed their practice of diaphragmatic breathing the past week. Provider gave education on sleep, including sleep cycles and physiological processes involved in sleep. Provider discussed behavioral practices to improve sleep. Provider gave instruction on emotion regulation skills, including use of a strong stimulus, dive reflex, and intense exercise. Veteran's Participation: Veteran was appropriately engaged in session and participated in discussions. Diagnosis Addressed: Other Trauma- or Stressor-Related Disorder Progress Toward Objective: Veteran appears receptive to group intervention and appears to be making satisfactory progress toward objective., Veteran appeared to understand the content of today's group and participated appropriately. Risk Assessment: No new risk factors relevant to suicide or homicide were reported. Veteran did not appear to be at imminent risk of harm to self or others at this time. Intensity of Needed Services: Veteran has completed this group and no further sessions are scheduled. /es/ WENDY M CROOK-ABEL PHD Staff Psychologist Signed: 06/09/2016 16:32 ------------------------------------------------------------------------- ========================================================================= Date/Time: 06 Jun 2016 @ 0848 Note Title: PRIMARY CARE NURSE INTERIM NOTE Location: VA Texas Valley Coastal HCS Signed By: RINCONES,EPIFANIO Co-signed By: RINCONES,EPIFANIO Date/Time Signed: 06 Jun 2016 @ 0851 ------------------------------------------------------------------------- LOCAL TITLE: PRIMARY CARE NURSE INTERIM NOTE STANDARD TITLE: NURSING NOTE DATE OF NOTE: JUN 06, 2016@08:48 ENTRY DATE: JUN 06, 2016@08:48:33 AUTHOR: RINCONES,EPIFANIO EXP COSIGNER: URGENCY: STATUS: COMPLETED SANDOVAL,EDGAR JULIAN SSN: 457-65-1840 Age:38 Sex:MALE Race:WHITE Allergies: TUNA Problem/Chief Complaint: The patient was called and updated on his recent xray results of his knees are okay. That was the purpose of his scheduled visit today, If he still wanted to come in today I could administer his Flu and Pneumonia vaccines,, Pt choose to wait until next scheduled appt. Current Vital Signs: Temp: 98.6 F [37.0 C] (05/31/2016 08:30) Pulse: 84 (05/31/2016 08:30) Resp: 16 (05/31/2016 08:30) B/P: 127/82 (05/31/2016 08:30) Pain: 7 (05/31/2016 08:30) 12/23/14 @ 0844 PULSE OXIMETRY: 98 Height:68 in [172.7 cm] (05/31/2016 08:30) Weight:199.2 lb [90.5 kg] (05/31/2016 08:30) BMI: 30.4 Pain Interview Pain Scale used: Numeric Rating Scale (NRS) 0-10 Patient denies pain. Most recent pain score: 7 (05/31/2016 08:30) Previous Learning History Previous answers to learning history: LEARNING ASSESSMENT TACTILE/HANDS ON 01/19/2016 Barriers to Learning LEARNING BARRIER - HEARING 01/19/2016 Hearing-aid not available LEARNING BARRIER - VISION 01/19/2016 Wears glasses Referrals/Next Step in Care: Patient/Caregiver verbalized understanding of information and instructed to call the provider or nurse for questions or concerns. Yes Patient/Caregiver instructed that the printed medication list given to them should be taken to all future medical appointments and carried with them at all times in case of an emergency. Yes The following Clinical Nursing Reminders are due: --STATUS-- --DUE DATE-- --LAST DONE-- V17 ALL Influenza Immunization DUE NOW DUE NOW unknown Pneumococcal PPSV23 (Pneumovax) DUE NOW DUE NOW unknown Nursing Clinical Reminders were not applicable to this visit. /es/ EPIFANIO RINCONES LVN Signed: 06/06/2016 08:51 ------------------------------------------------------------------------- ========================================================================= Date/Time: 03 Jun 2016 @ 1200 Note Title: NON VA CARE CONSULT RESULT NOTE Location: VA Texas Valley Coastal HCS Signed By: SANCHEZ,VELMA D Co-signed By: SANCHEZ,VELMA D Date/Time Signed: 01 Nov 2016 @ 1457 ------------------------------------------------------------------------- LOCAL TITLE: NON VA CARE CONSULT RESULT NOTE STANDARD TITLE: NONVA CONSULT DATE OF NOTE: JUN 03, 2016 ENTRY DATE: NOV 01, 2016@14:57:18 AUTHOR: SANCHEZ,VELMA D EXP COSIGNER: URGENCY: STATUS: COMPLETED C&P VA DBQ HEARING LOSS AND TINNTUD 063016 *****Scanned document attached to this note****** Click on Tools, click on VistA Imaging Display. Now double click on the TIU Title to view the document. /es/ VELMA D SANCHEZ Signed: 11/01/2016 14:57 ------------------------------------------------------------------------- ========================================================================= Date/Time: 02 Jun 2016 @ 1705 Note Title: PSYCHOTHERAPY GROUP NOTE Location: VA Texas Valley Coastal HCS Signed By: CROOK-ABEL,WENDY M Co-signed By: CROOK-ABEL,WENDY M Date/Time Signed: 02 Jun 2016 @ 1707 ------------------------------------------------------------------------- LOCAL TITLE: PSYCHOTHERAPY GROUP NOTE STANDARD TITLE: PSYCHOLOGY GROUP COUNSELING NOTE DATE OF NOTE: JUN 02, 2016@17:05 ENTRY DATE: JUN 02, 2016@17:05:12 AUTHOR: CROOK-ABEL,WENDY M EXP COSIGNER: URGENCY: STATUS: COMPLETED Group Title: PTSD Basic Skills Group Therapist(s):Dr. Wendy Crook-Abel Group Modality: Telehealth Session Length: 60 min Number of Participants: 2 Therapy Format/Intervention Type: Cognitive-Behavioral Skills Group Objective: To provider a basic skills foundation prior to the start of EBP for trauma. Session Title and Group Content: Provider discussed the hallmark symptoms of PTSD and how PTSD is developed. Provider discussed the factors that maintain PTSD, including avoidance and escape behaviors. Provider elicited examples from participants on their avoidance and escape behaviors. Provider discussed how treatment for PTSD works and what behaviors will be targeted. Provider discussed fight or flight response. Provider gave instruction and handouts on diaphragmatic breathing. Participants were led in a breathing exercise. Instruction was also provided on relaxation techniques of visual imagery and progressive muscle relaxation. Veteran's Participation: Veteran was appropriately engaged in session and participated in discussions. Diagnosis Addressed: Other Trauma- or Stressor-Related Disorder Progress Toward Objective: Veteran appears receptive to group intervention and appears to be making satisfactory progress toward objective. Veteran appeared to understand the content of today's group and participated appropriately. Risk Assessment: No new risk factors relevant to suicide or homicide were reported. Veteran did not appear to be at imminent risk of harm to self or others at this time. Intensity of Needed Services: Veteran to continue attending group therapy per treatment plan RTC: 06-9-16 @1500; Appt already scheduled as part of a series of group appts. /es/ WENDY M CROOK-ABEL PHD Staff Psychologist Signed: 06/02/2016 17:07 ------------------------------------------------------------------------- ========================================================================= Date/Time: 02 Jun 2016 @ 1149 Note Title: TEAM CONFERENCE Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 08 Jun 2016 @ 1152 ------------------------------------------------------------------------- LOCAL TITLE: TEAM CONFERENCE STANDARD TITLE: TEAM CONFERENCE NOTE DATE OF NOTE: JUN 02, 2016@11:49 ENTRY DATE: JUN 08, 2016@11:50:03 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Clinical Report Note: Clinician: Meghan Campos, LCPC Patient: S,1840 Date of Staffing: 6/2/16 Referral Source: Dr. Moore Date of Intake: 2/10/2016 Initial Staffing: Yes Reported symptoms: PTSD symptoms, anxiety, and mild depression. Denies SI/HI. "Easily angered, snapping at my children, intense anxiety episodes, experiencing flashbacks (3-4 x's per week), nightmares, and experiencing a lot of triggers that remind him of being in Iraq/Kuwait. BDI-11: 28 Moderate depression PCL-5 Weekly: 57 Military History: (PERSIAN GULF WAR) Army From 2002-2005; MOS: 77 Foxtrot (Petroleum specialist); Honorable DE/C; E4; no disciplinary actions/loss of rank; and was deployed twice. September 2002-03 to Iraq and to Honduras for 2 months for training in 2004. Military Trauma: Combat "Patriot missiles flying over us, Mop gear for an entire week, lost friends to suicide." Primary Diagnosis: PTSD (per history) Unspecified Depressive Disorder Medications: Refer to CPRS Prior treatments and modality: Hospitalizations: Yes Suicide Attempts: No. 2004, hospitalized in Virginia, "I woke up with a knife ready to cut my wrists. I drove myself to the hospital". Was there for 2 weeks. Saw therapist from 2004- 05 on base for depression and anxiety. Treatment Goals Veteran would like to work on: 1. "To get help and stop being mad at the world and my family" 2. "To be a better man and person, to be a supportive father" EBT being considered: 1. Pharmacotherapy (PACT TEAM) 2. Individual Therapy (VPTT) 3. Group Therapy (ACT and Anger Management) 4. Couples Therapy Treatment Plan: 1. Pharmacotherapy (PACT TEAM) 2. Individual Therapy (VPTT) 3. Group Therapy (ACT and Anger Management) 4. Couples Therapy Questions/concerns: N/A Treatment team members present: Treatment team 1 members present: [x] L. Bolado [x] M. Campos [] J. Henn [x] C. Miesse [x] Dr. Dassori [] Dr. Rafols [] RN Basaluda [x] Dr. Garcia Treatment team 2 members present: [] E. Gonzalez [] S. McGowan [] M. Trevino [] M. Navarro RN Interns present: [] J. Rosado Specialty Care Providers present: [] B. Flores [x] C. Weihe [] R. Quintana [] M. Artiaga [] M. Von Linden [] M. Ojong /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 06/08/2016 11:52 Receipt Acknowledged By: 06/08/2016 13:50 /es/ LARRY BOLADO Mental Health Social Worker 06/09/2016 16:16 /es/ ALBANA M DASSORI MD 06/08/2016 13:09 /es/ HECTOR A GARCIA 06/09/2016 09:03 /es/ Colette A. Miesse, Ph.D. Staff Psychologist 06/09/2016 09:32 /es/ Marco A. Trevino, MSSW, LCSW Mental Health SW 06/08/2016 12:50 /es/ CAROL WEIHE LCMFT ------------------------------------------------------------------------- ========================================================================= Date/Time: 31 May 2016 @ 1629 Note Title: DIAGNOSTIC TEST RESULT NOTIFICATION LETTER Location: VA Texas Valley Coastal HCS Signed By: BARREIRO,MARIBEL B Co-signed By: BARREIRO,MARIBEL B Date/Time Signed: 31 May 2016 @ 1630 ------------------------------------------------------------------------- LOCAL TITLE: DIAGNOSTIC TEST RESULT NOTIFICATION LETTER STANDARD TITLE: LETTERS DATE OF NOTE: MAY 31, 2016@16:29 ENTRY DATE: MAY 31, 2016@16:29:59 AUTHOR: BARREIRO,MARIBEL B EXP COSIGNER: URGENCY: STATUS: COMPLETED VA Health Care Center at Harlingen 2601 Veteran's Drive Harlingen, Texas 78550 MAY 31, 2016 SANDOVAL,EDGAR JULIAN 2314 E 21ST STREET MISSION, TX 78572 Dear Mr. SANDOVAL,EDGAR JULIAN, I wanted to update you on your recent diagnostic test results: Your x-rays are okay. Impression: 1. Unremarkable exam. Future Appointments - JUN 2,2016@15:00 MCA TMH VPTT PSY GRP REM JUN 3,2016@10:15 MCA PACT BLUE TEAM LVN JUL 18,2016@08:30 MCA LABORATORY JUL 25,2016@10:30 MCA PACT BLUE TEAM Your blood sugar average (Hemoglobin A1c) was within goal of less than 7%. SLT - Lab Tests Selected Collection DT Specimen Test Name Result Units Ref Range 11/04/2015 10:15 BLOOD HEMOGLOBIN A1C 5.4 % 4.2 - 5.8 Other Diagnostic Test Result(s): CBC - NONE FOUND - 2W CHEM 20 - NONE FOUND - 2W INR - NONE FOUND PROSTATIC SPECIFIC ANTIGEN 11/4/15 10:15 0.78 Other labs: Sincerely, Your Valley Coastal Bend Provider: MARIBEL B BARREIRO,MD Sincerely, Your Valley Coastal Bend Provider ------------------------------------------------------------------------- ========================================================================= Date/Time: 31 May 2016 @ 0905 Note Title: MED RECONCILIATION Location: VA Texas Valley Coastal HCS Signed By: AFZAL,ZEESHAN Co-signed By: AFZAL,ZEESHAN Date/Time Signed: 31 May 2016 @ 0906 ------------------------------------------------------------------------- LOCAL TITLE: MED RECONCILIATION STANDARD TITLE: MEDICATION MGT NOTE DATE OF NOTE: MAY 31, 2016@09:05 ENTRY DATE: MAY 31, 2016@09:06:03 AUTHOR: AFZAL,ZEESHAN EXP COSIGNER: URGENCY: STATUS: COMPLETED EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 PATIENT PHONE - 956 802 8945 AGE: 38 SEX: MALE WEIGHT:199.2 lb [90.5 kg] (05/31/2016 08:30) SELECTED CLINICAL REMINDERS DUE: --STATUS-- --DUE DATE-- --LAST DONE-- V17 ALL Influenza Immunization DUE NOW DUE NOW unknown Pneumococcal PPSV23 (Pneumovax) DUE NOW DUE NOW unknown VACCINES OF RECORD IN VCB CPRS: Immunization Series Date Facility Reaction Info INFLUENZA, UNSPECIFIED FORMULATIO* 09/18/2008 MCALLEN OP* TDAP 07/30/2014 MCALLEN OP* Medicine Reconciliation Medication List: MAY 31, 2016 09:06 Allergies: TUNA =========================================================== No Active Remote Medications for this patient =========================================================== Active Medications ============================================================ 1) Buspirone Hcl 10Mg Tab Take one tablet by mouth three times a day as needed for Anxiety 2) Lisinopril 20Mg Tab Take one-half tablet by mouth every day for blood pressure 3) Omeprazole 20Mg Ec Cap Take one capsule by mouth every day as needed take 30 to 60 Minutes before a meal. For reflux - short term Therapy - 90 days You have 3 active medications Here are NEW AND/OR CHANGED MEDICATIONS that your provider has prescribed: 1) Amoxicillin 500Mg Cap Take One Capsule By Mouth Twice A Day For Infection 2) Ibuprofen 400Mg Tab Take One Tablet By Mouth Every 6 Hours For Pain Or Inflammation. Take With Food Or Milk. 3) Throat Lozenge W/benzocaine,menthol Dissolve 1 Lozenge In Mouth Every 6 Hours _______________________________________________________________________ Your provider has NOT discontinued any of your medications today. Consults or procedures that were ordered today: NO recent pending Consults found. Imaging studies,lab tests and previously scheduled appointments: Pending Radiology: KNEE 3 VIEWS No pending labs. CVF - Future Clinic Visits 05/31/2016 09:30 MCA PACT BLUE RES TEAM 06/02/2016 15:00 MCA TMH VPTT PSY GRP REM 07/18/2016 08:30 MCA LABORATORY 07/25/2016 10:30 MCA PACT BLUE TEAM Today your provider was: ZEESHAN AFZAL RESIDENT PGY1 Medication education and counseling for new medications(if added today) was provided to the Veteran based on their individual needs. This included why the medication was prescribed, how they should take it and for how long, what to expect from it, and what happens if the medication is not taken as prescribed. By signing this note I certify that patient or caregiver or family member understood my instructions. MEDICATION RECONCILIATION PAPER COPY GIVEN TO PATIENT The patient/caregiver was instructed to always carry an updated Medication Reconciliation list to their next appointment whether with a VA or Non-VA provider and to discard any old lists. If after hours, weekends, holidays or long distance, call Telecare: 1-888-252-9970 VETERANS CRISIS LINE Phone: 1-800-273(TALK) 8255,push 1 to reach a VA mental health clinician. For medication refills call the automated medication refill line at 1-877-752-0650. ------------------------------------------------------------------------- ========================================================================= Date/Time: 31 May 2016 @ 0843 Note Title: PC RESIDENT FOLLOW-UP PATIENT NOTE Location: VA Texas Valley Coastal HCS Signed By: AFZAL,ZEESHAN Co-signed By: AFZAL,ZEESHAN Date/Time Signed: 31 May 2016 @ 0904 ------------------------------------------------------------------------- LOCAL TITLE: PC RESIDENT FOLLOW-UP PATIENT NOTE STANDARD TITLE: PRIMARY CARE OUTPATIENT PROGRESS NOTE DATE OF NOTE: MAY 31, 2016@08:43 ENTRY DATE: MAY 31, 2016@08:43:40 AUTHOR: AFZAL,ZEESHAN EXP COSIGNER: BARREIRO,MARIBEL B URGENCY: STATUS: COMPLETED *** PC RESIDENT FOLLOW-UP PATIENT NOTE Has ADDENDA *** Reason for visit/chief complaint: Patient is a 38 year old WHITE MALE: 1: Sore throat for one day, Associated with chills, and pain is 7/10 on swallowing saliva or food. No N/V/D/Cough. His daughter is sick. He is c/o right knee pain for some times now. Pain is more when he walks, No previous history of arthritis or right knee trauma. No redness or swelling noticed on right knee Problem List was reviewed at today's appointment. Allergies: TUNA Active Medications ============================================================ 1) Buspirone Hcl 10Mg Tab Take one tablet by mouth three times a day as needed for Anxiety 2) Lisinopril 20Mg Tab Take one-half tablet by mouth every day for blood pressure 3) Omeprazole 20Mg Ec Cap Take one capsule by mouth every day as needed take 30 to 60 Minutes before a meal. For reflux - short term Therapy - 90 days You have 3 active medications Reviewed home meds with patient/caregiver and NO discrepancies found. REVIEW OF SYSTEMS GENERAL: Patient denies weight changes , fatigue, C/o fever, chills. HEENT: Patient denies headache, blurry vision, hearing loss, c/o nasal discharge and sore throat CARDIOVASCULAR: Patient denies chest pain, palpitations, or Shortness of Breath RESPIRATORY: Patiend denies dyspnea, orthopnea, cough or sputum production GASTROINTESTINAL: Patient denies dysphagia, reflux, nausea, vomiting, diarrhea or constipation GENITOURINARY: patient denies disuria, polyuria, olyguria, hematuria, or urinary incontinence ENDOCRINE: Patient denies heat or cold intolerance, polyphagia, polydipsia, or polyuria HEMATOLOGIC: Patient denies easy bruising, petequia, or bleeding gums, NEUROLOGIC: Patient denies numbness, tingling, weakness, paralysis, seizures or blackouts PSYCHIATRIC: Patient refers stable mood, denies anxiety or depression Vital Signs: Temperature: 98.6 F [37.0 C] (05/31/2016 08:30) Pulse: 84 (05/31/2016 08:30) Respiration: 16 (05/31/2016 08:30) BP: 127/82 (05/31/2016 08:30) Pain: 7 (05/31/2016 08:30) Height: 68 in [172.7 cm] (05/31/2016 08:30) Weight: 199.2 lb [90.5 kg] (05/31/2016 08:30) BMI: 30.4 PHYSICAL EXAM GENERAL: Patient's appareance correlates with stated age, alert, cooperative in no acute distress HEENT: Normocephalic, Atraumatic, PERRLA, no nasal discharge, Posterior pharynx and tonsills are red. NECK: Anterior cervical Lymphadnopathy. CARDIOVASCULAR: Regular Rate and Rythm, no murmurs, rubs or gallops, no peripheral edema, RESPIRATORY: Symmetric Chest, bilateral breath sounds clear to auscultation, no wheezing, ronchi or rales ABDOMEN: Soft, non tender, non distended, positive bowel sounds, no organomegaly EXTREMITIES: Right knee pain, but normal ROM'S, and strenght of 4 extremities. No lower extremity edema, pulses present, NEUROLOGIC: Cranial nerves intact, appropriate peripheral sensation and strenght, patient alert and oriented x3 Last diagnostic tests reviewed and discussed with patient. Assessment: 1. Sore throat 2. Acute pharyngitis 3. Right knee pain Plan: 1. Acute pharyngitis: Amoxicilin 500mg BID X 10 days Ibuprofen 400mg Q4-6 H prn x 10 days Chloraseptic spary Q4-6H PRN Right Knee pain: Xray righ knee. Will discuss the Xray tomorrow,if abnormal. Continue taking tylenol. Follow up in 7 days I have seen and discussed the patient with my Attending, Dr. Barreiro, who agrees with my assessment and plan. /es/ ZEESHAN AFZAL RESIDENT PGY1 Signed: 05/31/2016 09:04 /es/ MARIBEL B BARREIRO MD Cosigned: 05/31/2016 09:26 05/31/2016 ADDENDUM STATUS: COMPLETED SEEN DISCUSSED AND AGREE WITH CARE. /es/ MARIBEL B BARREIRO MD Signed: 05/31/2016 09:26 Receipt Acknowledged By: 05/31/2016 10:16 /es/ REBECCA BASALDUA 05/31/2016 ADDENDUM STATUS: COMPLETED DR PLEASE SEND OUT DX LETTER OF KNEE XRAY RESULTS ORDERED BY DR AFZAL /es/ IRVETTE V MENDOZA Irvette V Mendoza, RN Signed: 05/31/2016 16:16 Receipt Acknowledged By: 06/03/2016 09:06 /es/ MARIBEL B BARREIRO MD ------------------------------------------------------------------------- ========================================================================= Date/Time: 31 May 2016 @ 0832 Note Title: NURSING UNSCHEDULED VISIT Location: VA Texas Valley Coastal HCS Signed By: MENDOZA,IRVETTE V Co-signed By: MENDOZA,IRVETTE V Date/Time Signed: 31 May 2016 @ 0839 ------------------------------------------------------------------------- LOCAL TITLE: NURSING UNSCHEDULED VISIT STANDARD TITLE: NURSING OUTPATIENT NOTE DATE OF NOTE: MAY 31, 2016@08:32 ENTRY DATE: MAY 31, 2016@08:32:35 AUTHOR: MENDOZA,IRVETTE V EXP COSIGNER: URGENCY: STATUS: COMPLETED SANDOVAL,EDGAR JULIAN SSN: 457-65-1840 Age:38 Sex:MALE Race:WHITE Allergies: TUNA Problem/Chief Complaint: P: A&OX4, AMBULATORY, UNACCOMPANIED, WALK IN, MASKED. IN NO RESPIRATORY DISTRESS. C/O SORE THROAT X YESTERDAY AND CHILLS TODAY, BODY ACHES 2/10 1 YEAR OLD DAUGHTER SICK WITH A COLD DENIES FEVER, COUGH, CONGESTION TAKEN TYLENOL AND HALLS WHICH DID NOT HELP C/O RIGHT KNEE PAIN X 2 MONTHS WORSE AT NIGHT WHEN LEG IS STRAIGHT HAS TO WAIT A FEW MINUTES TO BE ABLE TO BEND KNEE USING OTC OINTMENT WHICH HELPS A LITTLE DENIES FALL OR TRAUMA I: REFERRED TO MD. NURSE INSTRUCTED PT ON HAND HYGEINE/INFECTION CONTROL TO PREVENT THE SPREAD OF INFECTION E: SEE MD POC. PT VERBALIZED UNDERSTANDING Current Vital Signs: Temp: 98.6 F [37.0 C] (05/31/2016 08:30) Pulse: 84 (05/31/2016 08:30) Resp: 16 (05/31/2016 08:30) B/P: 127/82 (05/31/2016 08:30) Pain: 7 (05/31/2016 08:30) 12/23/14 @ 0844 PULSE OXIMETRY: 98 Height:68 in [172.7 cm] (05/31/2016 08:30) Weight:199.2 lb [90.5 kg] (05/31/2016 08:30) BMI: 30.4 Pain Interview Pain Scale used: Numeric Rating Scale (NRS) 0-10 Acute Pain Unacceptable Most recent Pain Score is 7 (05/31/2016 08:30) When did pain start? Pain started yesterday. Where is your worst pain today? Throat Quality of Pain - How does your pain feel? Pain feels: Sore Consistency of Pain: The pattern of pain varies. Alleviating factors: What makes the pain better? No relief factors Does the patient take any prescrition medicines for pain relief? No Does the patient take any Over The Counter (OTC) medications for pain relief? Yes Comment: TYLENOL, HALLS Aggravating factors: What makes the pain worse? SWALLOWING Effects of Pain: What changes has this pain made to your life? Appetite, Sleep Pain Goal/Acceptable Pain Level What is your lowest acceptable pain level? 0 Pain review results: Provider informed of pain level 4 or higher. Previous Learning History Learning history was reviewed,no changes were necessary. TOPICS TAUGHT: Topics taught today Discussed with: Patient "In an Emergency" handout. Education provided: VA CONTRACTED HOSPITALS Level of Understanding: Good Disposition of patient: STABLE Evaluation: (Reason for visit, patient problem/chief complaint) Class IV - (Routine - the patient was assessed and categorized as routine. Patient educated on the process for calling in rather than walking in. Home and Emergency Care Instructions issued prior to discharge.) Patient educated on how to obtain medical assistance whenever an emergency arises by calling 911 or presenting to the closest local emergency department. Referrals/Next Step in Care: Patient here for: Provider notified of patient complaint and triage findings, orders received from the provider. The patient was instructed as follows: Alerted: DR BARREIRO Protocol Used: Patient/Caregiver verbalized understanding of information and instructed to call the provider or nurse for questions or concerns. Yes Patient/Caregiver instructed that the printed medication list given to them should be taken to all future medical appointments and carried with them at all times in case of an emergency. Yes CLINICAL REMINDER ACTIVITY Homelessness Screening: In the past 2 months, have you been living in stable housing that you own, rent, or stay in as part of a household? Yes - Living in stable housing. Are you worried or concerned that in the next 2 months you may NOT have stable housing that you own, rent, or stay in as part of a household? No - Not worried about housing near future V17 ALL Influenza Immunization: Instructed patient to report to nurse for vaccine. Comment: WHEN FEELING BETTER PNEUM VACCINE WHEN FEELING BETTER /es/ IRVETTE V MENDOZA Irvette V Mendoza, RN Signed: 05/31/2016 08:39 ------------------------------------------------------------------------- ========================================================================= Date/Time: 26 May 2016 @ 1359 Note Title: PSYCHOLOGY NOTE Location: VA Texas Valley Coastal HCS Signed By: ARTIAGA,MARIA T Co-signed By: ARTIAGA,MARIA T Date/Time Signed: 26 May 2016 @ 1401 ------------------------------------------------------------------------- LOCAL TITLE: PSYCHOLOGY NOTE STANDARD TITLE: PSYCHOLOGY NOTE DATE OF NOTE: MAY 26, 2016@13:59 ENTRY DATE: MAY 26, 2016@13:59:40 AUTHOR: ARTIAGA,MARIA T EXP COSIGNER: VASQUEZ,DESI A URGENCY: STATUS: COMPLETED C&P Examination for PTSD (Initial) was completed 05/26/2016 and is under review by Dr. Vasquez, Clinical Supervisor. This note serves to close encounter. Please refer to C&P Examination notes for further information. This case is supervised by the cosigning psychologist Dr. Desi Vasquez. I have discussed this case with this supervisor and he agrees with this diagnosis and treatment plan in this note or has indicated any additions/corrections in the attached addendum. **THIS IS ONLY A C&P EXAMINATION ENCOUNTER; NO TREATMENT IS RENDERED. /es/ MARIA T Artiaga, PsyD Supervised Psychology Staff Signed: 05/26/2016 14:01 /es/ DESI A. VASQUEZ, PHD SUPERVISORY PSYCHOLOGIST Cosigned: 05/30/2016 11:45 ------------------------------------------------------------------------- ========================================================================= Date/Time: 26 May 2016 @ 1300 Note Title: C&P MULTIPLE EXAM Location: VA Texas Valley Coastal HCS Signed By: ARTIAGA,MARIA T Co-signed By: ARTIAGA,MARIA T Date/Time Signed: 31 May 2016 @ 1128 ------------------------------------------------------------------------- LOCAL TITLE: C&P MULTIPLE EXAM STANDARD TITLE: C & P MULTIPLE EXAM NOTE DATE OF NOTE: MAY 26, 2016@13:00 ENTRY DATE: MAY 31, 2016@11:28:11 AUTHOR: ARTIAGA,MARIA T EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: Edgar Julian Sandoval SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Unspecified Trauma-and Stressor-Related Disorder ICD code: F43.9 (309.9) Comments, if any: Veteran's symptoms did not meet full diagnostic criteria for PTSD. Intrusive symptoms associated with traumatic stressor were sporadic, with intrusive thoughts and memories occurring "like two, three times in the past four months." Criteria was not met for negative alterations in cognitions and mood and marked changes in arousal and reactivity related to reported traumatic events. Symptoms reported by Veteran during today's, May 26, 2016, C&P Examination did meet DSM-5 diagnostic criteria for Unspecified Trauma-and Stressor-Related Disorder. Mental Disorder Diagnosis #2: Major Depressive Disorder, in partial remission ICD code: F33.41 (296.35) Comments, if any: According to November 9, 2005 C&P Evaluation, Veteran was diagnosed with Major Depression, Recurrent, Severe without Psychotic Traits. Please refer to this document for further information. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): obstructive sleep apnea; hypertension Comments, if any: Veteran has been diagnosed with obstructive sleep apnea; he stated he is not compliant with use of CPAP. He stated he uses CPAP "probably like three times a week." Please refer to Veterans Health Administration medical records (VA treatment records) for more information related to physical conditions. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) 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 and discuss whether there is any clinical association between these diagnoses: It is not possible to differentiate what portion of each symptom is attributable to each diagnosis due to the overlap in symptoms including occasional loss of interest in activities and irritability. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 4. 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] 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 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: Veteran reported that he experiences irritability with family members including his wife and son. It is not possible to differentiate what portion of each symptom is attributable to each diagnosis due to the overlap in symptoms including occasional loss of interest in activities and irritability. 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 ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. 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 yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [X] Military enlistment examination [ ] Military separation examination [X] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [X] 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: VHA medical record (CPRS) and VA e-folder (VBMS records) were reviewed. There was no physical C-File available as all documents were available in e-folder per C&P exam instructions. b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Pre-military: Veteran was born in Weslaco, Texas and raised in Alamo, Texas. He was raised by both parents and grew up with a brother. Veteran described his childhood as "okay, my mom was a stay at home mother, my dad worked, and was also an alcoholic, always talking down to me and hitting my older brother when he was drunk." Veteran reported that he got along with other children and teachers while growing up. He participated in baseball and football while in school. Military: Veteran reported that he got along "pretty good" with other soldiers. Post-military: Veteran lives with his spouse and two children, seven year-old son and one year-old daughter. Veteran and his wife have been married since 2005. He described his relationship with his wife as "married, have our ups and downs." Veteran described his relationship with his children as "nice." He spends most of his time with his daughter. His hobby is to "coach a travel selected team for softball." He stated he spends time with friends "on the weekends" barbecuing. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Pre-military: Veteran obtained a high school degree from Pharr-San Juan-Alamo High School. He reported that his grades were average and denied having any learning or attention problems. Military: Veteran served active duty in the Army from April 17, 2002 to April 16, 2005. MOS: 92F, Petroleum Supply Specialist. Rank at Discharge: E-3. Discharge: Honorable. Veteran was awarded the Army Lapel Button, National Defense Service Medal, Global War on Terrorism Expeditionary Medal, Global War on Terrorism Service Medal, Army Service Ribbon. Veteran served in Southwest Asia from February 7, 2004 to August 24, 2004. Post-military: Veteran completed a certificate for medical assistant in 2015 from Southern Careers Institute. Veteran is current unemployed; he was last employed February 2015. Veteran stated he was a heavy equipment operator for the city of Donna from December 2014 to February 2015. He stated he was fired because his "director told [him] [his] position was no longer needed." He denied having disciplinary problems at this job. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Pre-military: Veteran denied mental health history including hospitalizations for mental health problems. Veteran reported that his father was "always drinking alcohol." Military: Veteran stated that he was diagnosed with depression "January 2004." He reported that he was hospitalized for two weeks at John Randolph hospital in Virginia. Veteran reported, "When I came back from my tour in 2004, I woke up one morning and decided to cut my wrist with my Gerber knife. Then I realized what the hell I was doing, I drove myself to the local hospital in Virginia." Veteran denied seeing anyone wounded, killed or dead during deployment when he completed September 2, 2003 Post-Deployment Health Assessment. He did endorse feeling like he was in great danger of being killed. Veteran denied having little interest in doing things, feeling depressed, nightmares, avoidance behavior, hypervigilance, and feeling detached from others. He reported that his health in general was "very good." According to Report of Consultation from John Randolph Medical Center dated January 19, 2005, Veteran was "admitted to psychiatric services with depression." According to the Behavioral Health Initial Assessment from John Randolph Medical Center dated January 15, 2005, "He is in the process of getting divorced from his wife who lives in Texas. He said that he has been feeling stressed since this past weekend and yesterday he held a knife in his hand and wanted to hurt himself. He reported feeling depressed, having decreased energy, decreased appetite, decreased sleep. He has been having some flashbacks and nightmares about the war in Iraq." Post-military: Veteran is prescribed Buspirone and Fluoxetine; he stated he is compliant with psychotropic medication. Veteran attended primary care mental health integration initial appointment on January 19, 2016. He then attended mental health initial evaluation on February 10, 2016. Veteran attended VPTT Consult on February 23, 2016. He was no-show to follow-up appointment for VPTT on May 2, 2016 and May 9, 2016. Veteran denied current auditory and visual hallucinations. He denied current suicidal and homicidal ideation, intent, or plan. Nonetheless, he was provided with Veterans Crisis Line information. Veteran was instructed to monitor symptoms, including emergence of suicidal or homicidal ideation, and to utilize this number, call 911, or go to nearest ER at closest hospital, in case of mental health emergency. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Pre-military: Veteran denied legal and behavioral history. Military: Veteran reported he lost rank "for being late so many times." He denied receiving Article 15s. Post-military: Veteran denied legal and behavioral history. e. Relevant Substance abuse history (pre-military, military, and post-military): Pre-military: Veteran denied substance use including alcohol and cigarettes. Military: Veteran reported that he drank alcohol "like every weekend." He stated that he smoked cigarettes "just the weekends probably like six or seven cigarettes." Veteran denied use of other substances. Post-military: Veteran reported that he drinks "2 - 3 beers a week." He stated he is no longer smoking cigarettes. Veteran denied use of other substances. f. Other, if any: No response provided. 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: Veteran reported that he served in Kuwait and Iraq. He denied engaging in direct combat. Veteran reported, "We were, I was doing guard duty one night and we heard the patriotic missiles, there were SCUD missiles coming in," "cause we were near Camp Virginia," "and we had to put on MOPP [mission oriented protective posture] gear" "because there was blood pathogen in the air." He stated, "one of my friends getting killed" "something I heard about." "We saw some dead bodies on our way back from Iraq," "we were 50 miles close to border line, coming back to Kuwait." Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- No response provided 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- Veteran was alert and oriented x3. Dress was casual but appropriate. Attitude was cooperative and polite. Speech was clear, coherent, and relevant. Mood was "pretty good." Affect was consistent with mood and topics discussed. Thought processes were logical, linear, and goal-oriented. Thought content was WNL, with no signs or reports of A/V hallucinations, delusions, paranoia, or homicidal ideation/plan/intent. Veteran denied current suicidal ideation/plan/intent. Memory appeared intact. Judgment appeared adequate. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- Please note that level of impairment is only based on Unspecified Trauma-and Stressor-Related Disorder and Major Depressive Disorder, in partial remission. Veteran has physical impairments, which were not assessed today. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. /es/ MARIA T Artiaga, PsyD Supervised Psychology Staff Signed: 05/31/2016 11:28 Receipt Acknowledged By: 06/05/2016 16:22 /es/ DESI A. VASQUEZ, PHD SUPERVISORY PSYCHOLOGIST ------------------------------------------------------------------------- ========================================================================= Date/Time: 26 May 2016 @ 0740 Note Title: VPTT NOTE Location: VA Texas Valley Coastal HCS Signed By: VON LINDEN,MEGHAN I Co-signed By: VON LINDEN,MEGHAN I Date/Time Signed: 26 May 2016 @ 1157 ------------------------------------------------------------------------- LOCAL TITLE: VPTT NOTE STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: MAY 26, 2016@07:40 ENTRY DATE: MAY 26, 2016@07:40:54 AUTHOR: VON LINDEN,MEGHAN I EXP COSIGNER: URGENCY: STATUS: COMPLETED *** VPTT NOTE Has ADDENDA *** VPTT TREATMENT PLANNING SESSION Contact: VCB Telemental health provider (von Linden) to MCA patient for ~ 39 minutes (90834). VPTT Trauma Intake: 2/23/16 by DR VON LINDEN REASON FOR REFERRAL: Trauma consult to VPTT was requested by MS CAMPOS. SESSION CONTENT Session time was spent discussing veteran's trauma assessment at prior session, including his diagnosis of other specified trauma and stressor d/o. Provider reviewed the symptom criteria for PTSD, what symptoms veteran did and did not endorse, and processed veteran's reaction to the assessment results. He shared that he frequently has the thought that he's not a good enough person and doesn't belong here, and would like to address this in treatment. Provider described the treatment process going forward as either remaining with the PTSD treatment team and engaging in trauma focused therapies CPT/Cognitive Processing Therapy or PE/Prolonged Exposure, or returning to general mental health for other treatment options. The primary differences between the therapies was discussed, with veteran being asked about his interest level in either. Veteran expressed interest in CPT Group and Individual combined format with the below specified goals. TREATMENT GOALS: Veteran's goals for treatment: "forget about the past, be a better person to my family and friends instead of just holding everything inside of me. Friendly, trusting more people." Provider clarified the difference between "forgetting" and being at peace with past events, to which veteran was receptive. Potential obstacles to treatment: Veteran stated no expected conflicts in his ability to attend group and individual sessions. RISK INFORMATION: As of today the Veteran is not currently reporting suicidal or homicidal ideation, intentions, or plans. At present, the Veteran has sufficient ego strength and functional capacity to alert others should the experience of an escalation in crisis occur. The Veteran reported understanding being able to seek immediate medical assistance should suicidal/homicidal ideations, urges, or plans arise in the future by notifying inpatient staff, this provider, calling 911 if no other help is available. MENTAL STATUS/BEHAVORIAL OBSERVATIONS: The veteran arrived early for the appointment, was dressed casually, and ambulated independently. Veteran was oriented to person, place, time and situation. Eye contact and non-verbal behavior unremarkable. Mood appeared euthymic with affect congruent to thought content. Thought processes were linear and goal-directed. Speech was of average rate, volume and amount with adequate inflection. Attention, memory and concentration were not formally assessed but were intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. alcohol or illicit substance use: n/a DIAGNOSTIC IMPRESSIONS: other specified trauma and stressor d/o SUMMARY: Veteran is a 38 year old male referred to VPTT by MS CAMPOS for trauma- related evaluation and treatment. The Veteran and provider collaboratively discussed and agreed upon the below treatment plan: VPTT TREATMENT PLAN: [x] Trauma-Focused Group Sessions offered [x] Veteran agreed to attend: [x] CPT Group and indiv. combined format [] PTSD Basic Skills Group [] CPT Women's Group (as available by site) [] Groups above offered, but Veteran declined because: [X] Instructions for emergent care [X] Veteran instructed that he/she may present as a walk-in to MH for emergent needs [X] Veteran instructed to report to the appropriate ER for after-hours emergent care [X] Veteran provided with the 24/7 Veterans Crisis Hotline Veteran expressed understanding of and consent to this treatment plan. Veteran was provided with the clinic phone number, the crisis line phone number (1-800-273-TALK), and 911. He was instructed to monitor symptoms, including emergence of suicidal or homicidal ideation and to utilize these numbers in the case of a mental health emergency. DR CROOK-ABLE: You are being signed on this note for informational purposes given veteran's acceptance of referral to your PTSD Basic Skills Group on 6/2 and 6/9. Please contact veteran at your earliest convenience to confirm start date/time, and participation expectations. Thank you for your care of this referral. DR MCGOWAN: You are being signed on this note for informational purposes given veteran's acceptance of referral to our CPT Group starting in July. Please contact veteran at your discretion to confirm start time, group participation expectations, or other necessary preparatory matters. Thank you for your care of this veteran! /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 05/26/2016 11:57 Receipt Acknowledged By: 06/01/2016 13:08 /es/ WENDY M CROOK-ABEL PHD Staff Psychologist 05/27/2016 07:32 /es/ Sean P. McGowan, Psy.D. Licensed Psychologist 05/26/2016 ADDENDUM STATUS: COMPLETED MR GONZALEZ: Please note that veteran is engaging in CPT Group with VPTT, with first treatment date of 6/2 (Dr. Crook-Abel's grp). /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 05/26/2016 11:59 Receipt Acknowledged By: 05/26/2016 13:21 /es/ GIOVANNI GONZALEZ Program Support Assitant ------------------------------------------------------------------------- ========================================================================= Date/Time: 18 May 2016 @ 1000 Note Title: C&P EXAMINATION Location: VA Texas Valley Coastal HCS Signed By: MENCHACA,JUAN Co-signed By: MENCHACA,JUAN Date/Time Signed: 08 Jun 2016 @ 0947 ------------------------------------------------------------------------- LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAY 18, 2016@10:00 ENTRY DATE: JUN 08, 2016@09:47:58 AUTHOR: MENCHACA,JUAN EXP COSIGNER: URGENCY: STATUS: COMPLETED Hypertension Disability Benefits Questionnaire Name of patient/Veteran: Sandoval, Edgar Julian Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with hypertension or isolated systolic hypertension based on the following criteria: [X] Yes [ ] No [X] Hypertension ICD code: SCT 64715009 Date of diagnosis: 06/10/2011 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hypertension condition (brief summary): The Veteran was diagnosed with Hypertension on May 16, 2005. He received a SC of 10% for this condition on 06/02/2006. b. Does the Veteran's treatment plan include taking continuous medication for hypertension or isolated systolic hypertension? [X] Yes [ ] No c. Was the Veteran's initial diagnosis of hypertension or isolated systolic hypertension confirmed by blood pressure (BP) readings taken 2 or more times on at least 3 different days? [X] Yes [ ] No [ ] Unknown If yes, provide BP readings used to establish initial diagnosis, if known: Reading 1: 131 / 91 Date: 08/19/15 Reading 1: 130 / 84 Date: 08/31/15 Reading 1: 140 / 90 Date: 09/02/15 d. Does the Veteran have a history of a diastolic BP elevation to predominantly 100 or more? [ ] Yes [X] No 3. Current blood pressure readings ---------------------------------- Systolic Diastolic Blood pressure reading 1: 130 / 90 Date: 05/18/2016 Blood pressure reading 2: 131 / 77 Date: 05/26/2016 Blood pressure reading 3: 131 / 88 Date: 05/27/2016 Average Blood Pressure Reading: 130 / 85 4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. 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 c. Comments, if any: No response provided 5. Functional impact -------------------- Does the Veteran's hypertension or isolated systolic hypertension impact his or her ability to work? [ ] Yes [X] No 6. Remarks, if any ------------------ The Veterans Blood pressure has been slightly above normal on his visits to the clinic, however at home BP reading have been in the normal range ( 117/74 to 125/74), with occasional increases to as high as 139/75. The patient must stay on his regimen of Lisinopril 10 mg po daily to maintain normal levels. The level of severity of the Veterans Hypertension has not increased. /es/ JUAN MENCHACA Physician Signed: 06/08/2016 09:47 ------------------------------------------------------------------------- ========================================================================= Date/Time: 09 May 2016 @ 1431 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: VON LINDEN,MEGHAN I Co-signed By: VON LINDEN,MEGHAN I Date/Time Signed: 09 May 2016 @ 1432 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: MAY 09, 2016@14:31 ENTRY DATE: MAY 09, 2016@14:31:05 AUTHOR: VON LINDEN,MEGHAN I EXP COSIGNER: URGENCY: STATUS: COMPLETED *** NO SHOW NOTE MENTAL HEALTH Has ADDENDA *** NO SHOW IN Mental Health CLinic. Veteran did not present for his/her follow-up appointment and I was not able to contact Veteran by phone. Veteran was called 3 times and did not answer phone. A privacy compliant vm was left asking him to call back if interested in r/s'ing. This is veteran's second consecutive no show for VPTT feedback. PSA: Please offer 5/26 10am if veteran calls back, thank you. /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 05/09/2016 14:32 Receipt Acknowledged By: 05/09/2016 14:43 /es/ GIOVANNI GONZALEZ Program Support Assitant 05/23/2016 ADDENDUM STATUS: COMPLETED PSA: Per phone message, please cancel veteran's 10am apt on 4/26 and move to 11am on 4/26. Thank you! /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 05/23/2016 11:22 Receipt Acknowledged By: 05/23/2016 14:20 /es/ GIOVANNI GONZALEZ Program Support Assitant ------------------------------------------------------------------------- ========================================================================= Date/Time: 03 May 2016 @ 1030 Note Title: MAS ADMINISTRATIVE NOTE Location: VA Texas Valley Coastal HCS Signed By: DUARTE,JUAN O Co-signed By: DUARTE,JUAN O Date/Time Signed: 03 May 2016 @ 1031 ------------------------------------------------------------------------- LOCAL TITLE: MAS ADMINISTRATIVE NOTE STANDARD TITLE: ADMINISTRATIVE NOTE DATE OF NOTE: MAY 03, 2016@10:30 ENTRY DATE: MAY 03, 2016@10:30:54 AUTHOR: DUARTE,JUAN O EXP COSIGNER: URGENCY: STATUS: COMPLETED *** MAS ADMINISTRATIVE NOTE Has ADDENDA *** EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 Age: 38 PATIENT PHONE - 956 802 8945 LOCAL - HARLINGEN VA CLINIC (740) || MCALLEN OPC (740GB) PACT: MCA BLUE (Focus: Primary Care Only) Primary Care Provider: Barreiro,Maribel B Care Manager: Mendoza,Irvette V Clinical Associate: Alaniz,Janis N || PHONE:9566187100 Administrative Associate: Basaldua,Rebecca Clinical POC: Care Manager || Mendoza,Irvette V Administrative POC: Administrative Associate || Basaldua,Rebecca Note: Advised caller that this message is being taken by administrative staff. Patient cancelled today's appointment - please review for disposition and next step in care. Alert sent to provider's attention. /es/ JUAN O DUARTE MH MSA Signed: 05/03/2016 10:31 Receipt Acknowledged By: 05/03/2016 11:17 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist 05/03/2016 ADDENDUM STATUS: COMPLETED PSA: Please call and offer to r/s for CID 5/9 @ 2pm, thank you! /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 05/03/2016 11:18 Receipt Acknowledged By: 05/03/2016 11:26 /es/ GIOVANNI GONZALEZ Program Support Assitant ------------------------------------------------------------------------- ========================================================================= Date/Time: 02 May 2016 @ 0919 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: VON LINDEN,MEGHAN I Co-signed By: VON LINDEN,MEGHAN I Date/Time Signed: 02 May 2016 @ 0921 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: MAY 02, 2016@09:19 ENTRY DATE: MAY 02, 2016@09:19:45 AUTHOR: VON LINDEN,MEGHAN I EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health CLinic. Veteran did not present for his/her follow-up appointment and I was able to contact Veteran by phone. He stated he thought his apt was for Tues and that he is with his daughter at a doctor's visit presently. Provider offered to r/s for tomorrow at 1pm, and veteran accepted. PSA: please schedule veteran for CID 5/3 @ 1pm per patient discussion, thank you! /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 05/02/2016 09:21 Receipt Acknowledged By: 05/02/2016 11:13 /es/ GIOVANNI GONZALEZ Program Support Assitant ------------------------------------------------------------------------- ========================================================================= Date/Time: 25 Apr 2016 @ 1100 Note Title: MAS ADMINISTRATIVE NOTE Location: VA Texas Valley Coastal HCS Signed By: CANTU,VIOLETA S Co-signed By: CANTU,VIOLETA S Date/Time Signed: 25 Apr 2016 @ 1101 ------------------------------------------------------------------------- LOCAL TITLE: MAS ADMINISTRATIVE NOTE STANDARD TITLE: ADMINISTRATIVE NOTE DATE OF NOTE: APR 25, 2016@11:00 ENTRY DATE: APR 25, 2016@11:00:46 AUTHOR: CANTU,VIOLETA S EXP COSIGNER: URGENCY: STATUS: COMPLETED *** MAS ADMINISTRATIVE NOTE Has ADDENDA *** EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 Age: 38 PATIENT PHONE - 956 802 8945 LOCAL - HARLINGEN VA CLINIC (740) || MCALLEN OPC (740GB) PACT: MCA BLUE (Focus: Primary Care Only) Primary Care Provider: Barreiro,Maribel B Care Manager: Mendoza,Irvette V Clinical Associate: Gomez,Janis N || PHONE:9566187100 Administrative Associate: Basaldua,Rebecca Clinical POC: Care Manager || Mendoza,Irvette V Administrative POC: Administrative Associate || Basaldua,Rebecca Note: Advised caller that this message is being taken by administrative staff. Patient called MAS Patient states "NEEDS LAB ORDER FOR 071816, PT HAS F/U APPT 072516." /es/ VIOLETA S CANTU MSA Signed: 04/25/2016 11:01 Receipt Acknowledged By: 04/28/2016 11:53 /es/ MARIBEL B BARREIRO MD 04/29/2016 09:47 /es/ IRVETTE V MENDOZA Irvette V Mendoza, RN 04/28/2016 ADDENDUM STATUS: COMPLETED please schedule lab /es/ MARIBEL B BARREIRO MD Signed: 04/28/2016 11:54 Receipt Acknowledged By: 04/28/2016 12:19 /es/ REBECCA BASALDUA ------------------------------------------------------------------------- ========================================================================= Date/Time: 29 Mar 2016 @ 0954 Note Title: MAS ADMINISTRATIVE NOTE Location: VA Texas Valley Coastal HCS Signed By: MARTINEZ,NORI Co-signed By: MARTINEZ,NORI Date/Time Signed: 29 Mar 2016 @ 0954 ------------------------------------------------------------------------- LOCAL TITLE: MAS ADMINISTRATIVE NOTE STANDARD TITLE: ADMINISTRATIVE NOTE DATE OF NOTE: MAR 29, 2016@09:54 ENTRY DATE: MAR 29, 2016@09:54:12 AUTHOR: MARTINEZ,NORI EXP COSIGNER: URGENCY: STATUS: COMPLETED *** MAS ADMINISTRATIVE NOTE Has ADDENDA *** EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 Age: 38 PATIENT PHONE - 956 802 8945 LOCAL - HARLINGEN VA CLINIC (740) || MCALLEN OPC (740GB) PACT: MCA BLUE (Focus: Primary Care Only) Primary Care Provider: Barreiro,Maribel B Care Manager: Mendoza,Irvette V Clinical Associate: Gomez,Janis N || PHONE:9566187100 Administrative Associate: Basaldua,Rebecca Clinical POC: Care Manager || Mendoza,Irvette V Administrative POC: Administrative Associate || Basaldua,Rebecca Note: Advised caller that this message is being taken by administrative staff. VET called in today 03292016 to cancel appt. VET requesting to be resch for later date. /es/ NORI MARTINEZ MSA Signed: 03/29/2016 09:54 Receipt Acknowledged By: 03/30/2016 17:29 /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist 03/30/2016 ADDENDUM STATUS: COMPLETED PSA: Given veteran's cancellation of his apt, please call veteran and offer CID of 5/2 9am for VPTT feedback. Thank you! /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 03/30/2016 17:30 Receipt Acknowledged By: 03/31/2016 08:28 /es/ GIOVANNI GONZALEZ Program Support Assitant ------------------------------------------------------------------------- ========================================================================= Date/Time: 22 Mar 2016 @ 1231 Note Title: PRIMARY CARE SECURE MESSAGING Location: VA Texas Valley Coastal HCS Signed By: BARREIRO,MARIBEL B Co-signed By: BARREIRO,MARIBEL B Date/Time Signed: 22 Mar 2016 @ 1231 ------------------------------------------------------------------------- LOCAL TITLE: PRIMARY CARE SECURE MESSAGING STANDARD TITLE: PRIMARY CARE SECURE MESSAGING DATE OF NOTE: MAR 22, 2016@12:31:35 ENTRY DATE: MAR 22, 2016@12:31:36 AUTHOR: BARREIRO,MARIBEL B EXP COSIGNER: URGENCY: STATUS: COMPLETED ------Original Message------------------------ Sent: 03/16/2016 09:46 AM From: SANDOVAL, EDGAR To: **MOPC Dr Barreiro BLUE Team PC Subject: Medication Inquiry Good morning Doctor. This is Mr. Edgar Sandoval last four digits of my social is 1840. I motion that on my medication list on the the My Health Vet website some medications have no longer refil or expired. Like the omeprazole 20mg, and I take those daily and also lisinopril 20mg I have been taking those for a while now. Wanted to know do I have to go see you again to get another prescription. ------Original Message------------------------ Sent: 03/22/2016 01:31 PM From: BARREIRO, MARIBEL To: SANDOVAL, EDGAR Subject: Medication Inquiry I have sent them to you. Please make a appointment with me in the summer for a check up. /es/ MARIBEL B BARREIRO MD Signed: 03/22/2016 12:31 ------------------------------------------------------------------------- ========================================================================= Date/Time: 22 Mar 2016 @ 1008 Note Title: PRIMARY CARE SECURE MESSAGING Location: VA Texas Valley Coastal HCS Signed By: BARREIRO,MARIBEL B Co-signed By: BARREIRO,MARIBEL B Date/Time Signed: 22 Mar 2016 @ 1008 ------------------------------------------------------------------------- LOCAL TITLE: PRIMARY CARE SECURE MESSAGING STANDARD TITLE: PRIMARY CARE SECURE MESSAGING DATE OF NOTE: MAR 22, 2016@10:08:55 ENTRY DATE: MAR 22, 2016@10:08:56 AUTHOR: BARREIRO,MARIBEL B EXP COSIGNER: URGENCY: STATUS: COMPLETED ------Original Message------------------------ Sent: 03/21/2016 09:43 AM From: SANDOVAL, EDGAR To: **MOPC Dr Barreiro BLUE Team PC Subject: General Inquiry Good morning Doctor. This is Mr. Edgar Sandoval last four digits of my social is 1840. I motion that on my medication list on the the My Health Vet website some medications have no longer refil or expired. Like the omeprazole 20mg, and I take those daily and also lisinopril 20mg I have been taking those for a while now. Wanted to know do I have to go see you again to get another prescription. ------Original Message------------------------ Sent: 03/22/2016 11:08 AM From: BARREIRO, MARIBEL To: SANDOVAL, EDGAR Subject: General Inquiry I will mail you refills, and see you in the summer for a follow up please call in. Please take the omeprazole only as need for reflux. /es/ MARIBEL B BARREIRO MD Signed: 03/22/2016 10:08 Receipt Acknowledged By: 03/22/2016 10:19 /es/ REBECCA BASALDUA ------------------------------------------------------------------------- ========================================================================= Date/Time: 09 Mar 2016 @ 1335 Note Title: TELEPHONE NOTE Location: VA Texas Valley Coastal HCS Signed By: BOLADO,LARRY Co-signed By: BOLADO,LARRY Date/Time Signed: 09 Mar 2016 @ 1342 ------------------------------------------------------------------------- LOCAL TITLE: TELEPHONE NOTE STANDARD TITLE: TELEPHONE ENCOUNTER NOTE DATE OF NOTE: MAR 09, 2016@13:35 ENTRY DATE: MAR 09, 2016@13:35:33 AUTHOR: BOLADO,LARRY EXP COSIGNER: URGENCY: STATUS: COMPLETED Time: 10 minutes The veteran was called because this clinician was alerted by Ms. Campos LMHC. Ms. Campos informed us that this veteran would be interested in attending the Anger Management group. I called but his phone message box is not accepting messages. P- Unable to contact or leave a message for the veteran about the Anger Management group. /es/ LARRY BOLADO Mental Health Social Worker Signed: 03/09/2016 13:42 Receipt Acknowledged By: 03/14/2016 08:36 /es/ Colette A. Miesse, Ph.D. Staff Psychologist ------------------------------------------------------------------------- ========================================================================= Date/Time: 24 Feb 2016 @ 1039 Note Title: NO SHOW NOTE MENTAL HEALTH Location: VA Texas Valley Coastal HCS Signed By: WEIHE,CAROL A Co-signed By: WEIHE,CAROL A Date/Time Signed: 24 Feb 2016 @ 1053 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE MENTAL HEALTH STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: FEB 24, 2016@10:39 ENTRY DATE: FEB 24, 2016@10:39:44 AUTHOR: WEIHE,CAROL A EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW IN Mental Health Clinic. Veteran did not present for his initial MFT appointment and I was not able to contact Veteran by phone. I was unable to leave a message as the phone rang several times and then rang busy. Mr. Duarte, MSA: Please send Veteran a No Show letter with offer to reschedule. Thank you. /es/ CAROL WEIHE LCMFT Signed: 02/24/2016 10:53 Receipt Acknowledged By: 02/25/2016 10:53 /es/ JUAN O DUARTE MH MSA ------------------------------------------------------------------------- ========================================================================= Date/Time: 23 Feb 2016 @ 1303 Note Title: VPTT CONSULT RESPONSE Location: VA Texas Valley Coastal HCS Signed By: VON LINDEN,MEGHAN I Co-signed By: VON LINDEN,MEGHAN I Date/Time Signed: 23 Feb 2016 @ 1415 ------------------------------------------------------------------------- LOCAL TITLE: VPTT CONSULT RESPONSE STANDARD TITLE: CONSULT DATE OF NOTE: FEB 23, 2016@13:03 ENTRY DATE: FEB 23, 2016@13:03:11 AUTHOR: VON LINDEN,MEGHAN I EXP COSIGNER: URGENCY: STATUS: COMPLETED VPTT TRAUMA CONSULT RESPONSE Length of session: 55 minutes (90837) Psychosocial completed: 2/10/16 by MS CAMPOS REASON FOR REFERRAL: Trauma consult to VPTT was requested by MS CAMPOS. Veteran was informed of the limits of confidentiality and agreed to participate in this session. Veteran was encouraged to involve family members as appropriate in this intake assessment and subsequent treatment should he elect to engage in mental health services. PRESENTING PROBLEMS Veteran explained that he isn't the same person he used to be. "I'm trying to work at it, I make mistakes. Hoping I can get the help that I need. Stop being mad at everybody or anyone, especially my son." He continued that he wants to move on from this experience, "let it all out, not let it hold me back." MILITARY SERVICE Army March 2002-April 2005 MOS: Fueler 77foxtrot Veteran denied disciplinary actions/Article 15's/loss of rank while serving. Discharged at rank E4/Specialist. Honorable discharge, no medical. PSYCHIATRIC TREATMENT HISTORY [] Denies history of mental health treatment (including pharmacotherapy). [] Reports previous mental health treatment: [x] Reports history of psychiatric hospitalization ( )No (x) Yes: 2003 veteran stated he was hospitalized for trying to commit suicide, saw a therapist weekly for approximately 7 months. He reported it was helpful. He noted he has not been suicidal since. [] Currently utilizes the following community resources: SUBSTANCE ABUSE HISTORY Veteran stated he drinks approximately 2 beers per week. "My kids are everything to me." He denied illicit drug use. PTSD SYMPTOM ASSESSMENT BASED ON CAPS-5: Criterion A Stressor: Veteran stated that he was in OIF/OEF when "we could see the bombs coming through, and one blew up 12 miles away from us." He explained he was doing guard duty and patrolling the pump station on night duty. He stated he saw the patriotic missile intercept the Iraqi missles about 12 miles away. "It was a scary moment. Maybe God had some other plans for me to be here, I don't know. None of our battle buddies were injured." He continued that a battle buddy told him that a friend passed away on a mission. "They didn't tell us what happened, just that they were on a mission." He noted that he met this person in San Antonio when they were getting to go to base training, "we went to basic training together." Later he added that he has seen dead bodies but struggled to elaborate on it, becoming tearful when mentioning the topic. Intrusions: Regarding intrusive memories of his friend's death, he stated "not right now." He noted no dreams about his friend's death as well. He denied becoming emotionally upset at reminders because he hasn't been reminded much in the past month until today in session, when he became tearful as provider as him about his traumatic experiences. When asked instead about the day in which missiles were seen overhead, he described having unwanted memories in response to loud noises and military movies. "Last night I heard the ice machine dropping ice in the aluminum cup and I jumped up and tensed up real quick." He estimated needing 15-20 minutes to calm down, stating he will go work in the garden outside or clean the garage. "My garage is so clean, just to keep me busy." He estimated becoming upset like this 3 times in the past month. He continued that his heart will pound for 15-20 minutes during these moments. He denied dreaming and having flashbacks of this day. Avoidance: He described avoiding conversations about the military in general because it will lead to talking about his friend's death. "Every day I try to avoid it, I try to keep my mind on something. I play a lot of softball, and I have 2 kids. Every time I see em I don't want nothing to trigger what I experienced?I go to church as well." He stated he is trying to avoid "the past, wartime, trying to avoid it. It's hard especially when you're watching the news." Veteran denied avoiding people/places/situations, other than the recent time in which he saw individuals with Arab clothing on and had to exit the store. Cognitions/mood: Veteran denied difficulty remembering aspects of the trauma. He denied negative cognitions stating "I feel pretty good" about himself as a person. When asked blaming himself or others for either trauma he stated "no." He additionally denied negative mood stating "My mood is generally happy, I get along with everybody, talk to everybody." In discussing the things he enjoys doing he explained "I think I'm more active now, teaching softball, volunteering at the church. Parents love me. I think I'm doing ok." In discussing feeling connected to others he denied feeling distant or cut off from others. He noted feeling closest to his children. When asked who he would talk to about personal matters he replied "My wife," endorsing her as his social support. Regarding positive emotions, he explained "I'm a lovable person. Everything comes back to me how I was raised, treat people how you want to be treated." Arousal/reactivity: Veteran endorsed irritability towards his son for example stating "I get agitated real quick for no reason." He continued that he will start pacing, "I have a punching bag in the garage and go in there and just punch the hell out of the punching bag. My wife asks me a simple question and I just get triggered like that quick. He estimated reacting this way, including yelling and swearing, on a daily basis. "I'm not supposed to do that, I don't think it's right." When asked about vigilance he explained "Anything I hear outside I just wake up. I have the windows open at all times. I run outside?see what's going on. Anything I hear. I get up 2-3am and can't get back to sleep no more." He noted not being sure why he does this. "I'm always looking behind my shoulder to make sure no one's behind me, to make sure?" He denied startling regularly other than that above mentioned incident with his wife using the ice machine. He also denied difficulty concentrating. Regarding his sleep, he described difficulty falling asleep despite listening to music on his phone for example. He estimated going to be at 10:30pm and not falling asleep until 1a.m. "If I get 4 hours of sleep that's enough for me." He estimated sleeping 4-5 hrs per night. He noted he used to sleep 7-8 hrs a night "like 2 yrs ago." ASSESSMENT RESULTS Criterion A: met Criterion B Sev: 6 #B Sx: 3 Criterion C Sev: 4 #C Sx: 1 Criterion D Sev: 1 #D Sx: 0 Criterion E Sev: 10 #E Sx: 3 Total Severity: 21 Total #Sx: 7 Criterion F: met Criterion G Sev: 7 #G Cx: 2 "It bothers me when people talk about it, the Army Marines. I have friends that are ex-military and we BBQ at my house and they bring it up. I just don't want them to talk about it." When asked about the impact of his symptoms on his marriage he explained that his wife tells him he is different now and that he notices he also yells at her for no reason. He noted he is able to attend school and take care of his school assignments. Diss Sev: 0 #Diss Sx: 0 *unable to assess due to time constraints Patient Health Questionnaire (PHQ-9) Score= 10/27 (5-14: Physician uses clinical judgment about treatment based on patient's duration of symptoms and functiona l impairment) Posttraumatic Checklist 5 (PCL-5) Score= 45/80 (suggesting meeting DSM-5 criteria for PTSD diagnosis) **Measures are face-valid and therefore subject to over and under-reporting. Scores alone are not diagnostic and must be considered in the context of other available clinical data.** MENTAL STATUS/BEHAVIORAL OBSERVATIONS: The veteran arrived early for the appointment, was dressed casually, and ambulated independently. Veteran was oriented to person, place, time and situation. Maintained good eye contact and motor behavior unremarkable. Mood was depressed with affect congruent to thought content. Thought processes were linear and goal-directed. Speech was of average rate, volume and amount. Attention, memory and concentration were not formally assessed but were intact for the purpose of conversation. There was no evidence of hallucinations, delusions, or psychosis. RISK INFORMATION: As of today the Veteran is not currently reporting suicidal or homicidal ideation, intentions, or plans. At present, the veteran has sufficient ego strength and functional capacity to alert others should the experience of an escalation in crisis occur. The Veteran reported understanding being able to seek immediate medical assistance should suicidal/homicidal ideations, urges, or plans arise in the future by notifying inpatient staff, this provider, calling 911 if no other help is available. DIAGNOSTIC IMPRESSIONS (DSM-5): other specified trauma and stressor d/o SUMMARY: Veteran is a 38 year old male referred to VPTT by MS CAMPOS for trauma- related evaluation and treatment. Veteran completed a brief interview in addition to the CAPS-5, PCL-5 and PHQ-9. Veteran endorsed experiencing a criterion A qualifying event including threat to life, learning of the violent death of a commrade, and exposure to human remains (though he did not elaborate on the latter). Veteran endorsed intrusive memories and emotional reactions to them, significant avoidance of his traumatic experiences, as well as vigilant behaviors and irritability. Veteran denied experiencing significant negation cognitions or emotions, deying blaming himself for events or having difficult remmbering aspects of his traumas. Veteran's endorsement of symptoms on the PCL- 5 was consistent with his verbal report of symptoms as noted above. Based on the summation of these findings, it appears that a diagnosis of other specified trauma and stressor d/o is warranted at this time. PRELIMINARY TREATMENT PLAN: [x] Enroll Veteran into VPTT [x] Schedule for treatment planning session: [3/29 w/Dr von Linden] [x] Schedule for PTSD Basic Skills Group w/Dr Crook-Able [3/3 and 3/10] [x] Feedback to be given to referring provider [x] Instructions for emergent care [x] Veteran instructed that he/she may present as a walk-in to MH for emergent needs [x] Veteran instructed to report to the appropriate ER for after-hours emergent care [x] Veteran provided with the 24/7 Veterans Crisis Hotline Veteran expressed understanding of and consent to this treatment plan. Veteran was provided with the clinic phone number, the crisis line phone number (1-800-273-TALK), and 911. He was instructed to monitor symptoms, including emergence of suicidal or homicidal ideation and to utilize these numbers in the case of a mental health emergency. MAS: Please schedule veteran for 3/29 @ 3pm with this writer per patient discussion. Thank you! MS CAMPOS: You are being signed on this note for informational purposes and continuity of care given your referral of this veteran to VPTT. Please note that this veteran is being enrolled in VPTT services and will engage in treatment planning at next session. Veteran will have the choice whether to engage in trauma-focused therapy at that time. Thank you for this referral DR CROOK-ABLE: Please schedule veteran for your PTSD Basic Skills Group on 3/3 and 3/10 per patient discussion. Veteran will meet with me for VPTT feedback and treatment planning after group completion. Please contact veteran at your earliest convenience to confirm details of group time/place. Thank you! /es/ MEGHAN I VON LINDEN PHD Licensed Clinical Psychologist Signed: 02/23/2016 14:15 Receipt Acknowledged By: 02/23/2016 15:54 /es/ GIOVANNI GONZALEZ Program Support Assitant ------------------------------------------------------------------------- ========================================================================= Date/Time: 23 Feb 2016 @ 1014 Note Title: PC BEHAVIORAL HEALTH FOLLOW-UP Location: VA Texas Valley Coastal HCS Signed By: LABELLA,KERI A Co-signed By: LABELLA,KERI A Date/Time Signed: 23 Feb 2016 @ 1038 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH FOLLOW-UP STANDARD TITLE: MENTAL HEALTH INTERDISCIPLINARY NOTE DATE OF NOTE: FEB 23, 2016@10:14:05 ENTRY DATE: FEB 23, 2016@10:19:34 AUTHOR: LABELLA,KERI A EXP COSIGNER: URGENCY: STATUS: COMPLETED VA TEXAS VALLEY COASTAL BEND HCS - BEHAVIORAL HEALTH LAB FOLLOW UP REPORT CLINIC: MCOPC - Behavioral Health Lab ************************************************************ Last name: Sandoval First name: Edgar Julian Date of interview: 2/23/2016 10:14 AM Method of interview: Telephone Patient's age: 38 Patient's sex: Male ************************************************************ ACTION ITEMS / TREATMENT PLAN: Clinical intervention completed: Education, Care/Medication Management The patient will continue to be monitored. ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ####### RESULTS FOR INDIVIDUAL ASSESSMENTS ####### The remaining sections of the report contain the responses and/or summary information for each assessed domain. The individual responses are based on self-report and should be used in context with other available clinical information. ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ DEPRESSIVE SYMPTOMS (PHQ-9) 1. Little interest or pleasure: Not at all 2. Feeling down or hopeless: Several Days 3. Trouble sleeping: Several Days 4. Tired, low energy: Several Days 5. Poor appetite, over-eating: More than half the days 6. Feelings of failure, guilt: Several Days 7. Trouble concentrating: Not at all 8. Motor retardation, agitation: Several Days 9. Suicidal ideation: Not at all The PHQ-9 total score (measure of depressive symptoms) equals 7 1-4 = minimal symptoms 5-9= mild symptoms 10-14= moderate symptoms 15-19= moderately severe symptoms 20-27= severe depressive symptoms The patient stated that the depressive symptoms made it somewhat difficult to do his work, take care of things at home, or get along with others. The current symptomatology represents a decrease of 9 from the initial PHQ score completed 301 days prior. PHQ Score Over Weeks: 27-| 26-| 25-| 24-| 23-| 22-| 21-| 20-| 19-| 18-| 17-| 16-|0 15-| 37 14-| 13-| 12-| 11-| 10-| 38 9-| 8-| 7-| 43 6-| 5-| 4-| 3-| 2-| 1-| 0-| --------------------------- Visits (weeks since Baseline) 0 - 4/27/2015 37 - 1/11/2016 38 - 1/21/2016 43 - 2/23/2016 ********************************************************** ANXIETY SYMPTOMS (GAD-7) Anxiety Scale (anxiety symptoms reported in the last two weeks): 1. Feeling nervous, anxious or on edge: Nearly every day 2. Not being able to stop or control worrying: Nearly every day 3. Worrying too much about different things: Nearly every day 4. Trouble relaxing: More than half the days 5. Feeling restless (hard to sit still): Nearly every day 6. Becoming easily annoyed or irritable: More than half the days 7. Afraid as if something awful might happen: Not at all The patient stated that the anxiety symptoms made it somewhat difficult to do his/her work, take care of things at home, or get along with others. The anxiety total score (general measure of anxiety) equals 16 0-4 =minimal symptoms 5-9=mild symptoms 10-14=moderate symptoms, 15-21=severe symptoms ************************************************************ MEDICATION TREATMENT, ADHERENCE, AND SIDE EFFECTS: The patient is prescribed a psychotropic medication. He reports taking the medication as prescribed. The patient does not report symptoms suggestive of adverse effects of medication. ************************************************************ The VA Texas Valley Coastal Bend HCS - Behavioral Health Lab is directed by Jennifer Wood, Ph.D.. If you have questions please call 956-291-9125. If you have questions regarding this patient's clinical management, please contact Keri LaBella at 956-618-7100 ext 67342. ============================================================================== Mr. Sandoval was called for a follow-up PHQ-9, GAD-7, and assessment. Veteran was called as a part of care management. PHQ-9 Score: 7 Previous PHQ-9 SCORE- 10 GAD-7 Score: 16 Previous GAD-7 score 10 PHQ-9 Score today consistent with mild level of depression. GAD-7 score today consistent with severe level of anxiety. In PC MHI care management since: 4/27/2015 PROBLEM: Current medical diagnoses, concerns: Veteran denied acute concerns. Medication Concerns: Veteran denied Mental and Sleep Status Changes: Veteran states that he is sleeping 4-6 hours per night. Stressors, Strengths and Resources: Veteran stated that he quit smoking 8-9 days ago. Veteran states that he has felt more jittery and anxious lately. Veteran also noted that he has been eating more. Veteran states that he will continue to not smoke. Behavioral Activation/Pleasant Events Scheduling: Veteran is still exercising and spending time with people Other Treatment(Psychotherapy/counselling, etc.): Veteran is engaging in PTSD treatment in mental health. Suicidal Ideation: Veteran denied current active suicidal ideation/intent/plan. Patient Education: Veteran was educated about anxiety and ways to control it. RN instructed Veteran that in case of any further problems, questions or concerns, Veteran may call PC-MHI RN in this clinic during working hours. RN instructed Veteran that in case of psychiatric/emotional crisis or medical emergency, Veteran may call 911 and/or go to MMC, ERMC or McAllen Heart Hospital Emergency Room Dept. for evaluation/treatment. Veteran also has contact information for the Veterans Crisis Line 1-800-273-8255 and is aware to press 1 Impression: 1.Diagnosed: PTSD Reports: tobacco use, depression and anxiety 2.Patient identifies target symptom(s) as: smoking PLAN: 1.Follow through with PC MHI program with phone calls for assessment as indicated: 2.Patient's stated action plan: Veteran will continue to not smoke. 3. Alert MAS staff to schedule appointment for 3/15/2016 at 1000 Consults were reviewed and no needs were identified Time Spent: 16 minutes ----------------------------------------------------------------------- Mar 15,2016 is the Clinically Indicated Date for RTC. ----------------------------------------------------------------------- /es/ KERI A LABELLA BS RN PCMHI Signed: 02/23/2016 10:38 ------------------------------------------------------------------------- ========================================================================= Date/Time: 22 Feb 2016 @ 1440 Note Title: PC BEHAVIORAL HEALTH TELEPHONE Location: VA Texas Valley Coastal HCS Signed By: LABELLA,KERI A Co-signed By: LABELLA,KERI A Date/Time Signed: 22 Feb 2016 @ 1440 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH TELEPHONE STANDARD TITLE: MENTAL HEALTH TELEPHONE ENCOUNTER NOTE DATE OF NOTE: FEB 22, 2016@14:40 ENTRY DATE: FEB 22, 2016@14:40:41 AUTHOR: LABELLA,KERI A EXP COSIGNER: URGENCY: STATUS: COMPLETED Writer called Veteran to re-establish contact after a no-show. Unable to leave voice message. Letter sent to address on file. /es/ KERI A LABELLA BS RN PCMHI Signed: 02/22/2016 14:40 ------------------------------------------------------------------------- ========================================================================= Date/Time: 16 Feb 2016 @ 1025 Note Title: PC BEHAVIORAL HEALTH TELEPHONE Location: VA Texas Valley Coastal HCS Signed By: LABELLA,KERI A Co-signed By: LABELLA,KERI A Date/Time Signed: 16 Feb 2016 @ 1026 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH TELEPHONE STANDARD TITLE: MENTAL HEALTH TELEPHONE ENCOUNTER NOTE DATE OF NOTE: FEB 16, 2016@10:25 ENTRY DATE: FEB 16, 2016@10:25:50 AUTHOR: LABELLA,KERI A EXP COSIGNER: URGENCY: STATUS: COMPLETED Writer called Veteran to re-establish contact after a no-show. Unable to leave voice message. Letter sent to address on file. /es/ KERI A LABELLA BS RN PCMHI Signed: 02/16/2016 10:26 ------------------------------------------------------------------------- ========================================================================= Date/Time: 12 Feb 2016 @ 0933 Note Title: NO SHOW NOTE PRIMARY CARE Location: VA Texas Valley Coastal HCS Signed By: LABELLA,KERI A Co-signed By: LABELLA,KERI A Date/Time Signed: 12 Feb 2016 @ 0934 ------------------------------------------------------------------------- LOCAL TITLE: NO SHOW NOTE PRIMARY CARE STANDARD TITLE: NO SHOW NOTE DATE OF NOTE: FEB 12, 2016@09:33 ENTRY DATE: FEB 12, 2016@09:33:44 AUTHOR: LABELLA,KERI A EXP COSIGNER: URGENCY: STATUS: COMPLETED NO SHOW in Primary Care Clinic. MAS: Please send No Show letter. Do not reschedule appointment until patient calls. Writer called Veteran at 0901, 0913 and 0927. No voice message able to be left. Telephone line went dead. /es/ KERI A LABELLA BS RN PCMHI Signed: 02/12/2016 09:34 ------------------------------------------------------------------------- ========================================================================= Date/Time: 10 Feb 2016 @ 1635 Note Title: PC BEHAVIORAL HEALTH FOLLOW-UP Location: VA Texas Valley Coastal HCS Signed By: MOORE,SHANNON M Co-signed By: MOORE,SHANNON M Date/Time Signed: 10 Feb 2016 @ 1642 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH FOLLOW-UP STANDARD TITLE: MENTAL HEALTH INTERDISCIPLINARY NOTE DATE OF NOTE: FEB 10, 2016@16:35 ENTRY DATE: FEB 10, 2016@16:35:28 AUTHOR: MOORE,SHANNON M EXP COSIGNER: MILLER,JOHN A URGENCY: STATUS: COMPLETED PRIMARY CARE MENTAL HEALTH INTEGRATION (PCMHI) FOLLOW-UP NOTE This case is supervised by the co-signing psychologist. I have discussed this case with this Supervisor who agrees with this diagnosis and treatment plan in this note or indicated any additions/corrections in the attached addendum. DURATION OF ENCOUNTER: 15 minutes TYPE OF ENCOUNTER: Individual PURPOSE: Veteran was seen for scheduled follow-up for brief intervention with PCMHI psychologist related to: 1. Provide psychoeducation on common trauma and stressor reactions. 2. Assist with improving relaxation skills. 3. Assist with managing depression by decreasing maladaptive thoughts and behaviors. SESSION CONTENT: Briefly, met with Veteran at 0900hrs. Due to Veteran having a Behavioral Health intake today at 1100hrs, Veteran agreed to plan of cutting today's session short and following up with BH Provider. DIAGNOSTIC IMPRESSION (DSM-5/ICD-10): Unspecified Trauma and Stressor Disorder Unspecified Depressive Disorder Financial Stressors Bereavement PLAN: No follow-up needed. Facilitated linkage to BH provider. /es/ SHANNON M MOORE SUPERVISED PSYCHOLOGY STAFF Signed: 02/10/2016 16:42 /es/ John A. Miller, PhD Health Behavior Coordinator Cosigned: 02/11/2016 10:00 ------------------------------------------------------------------------- ========================================================================= Date/Time: 10 Feb 2016 @ 0953 Note Title: MENTAL HEALTH INITIAL EVALUATION CONSULT RESPONSE Location: VA Texas Valley Coastal HCS Signed By: CAMPOS,MEGHAN K Co-signed By: CAMPOS,MEGHAN K Date/Time Signed: 10 Feb 2016 @ 1110 ------------------------------------------------------------------------- LOCAL TITLE: MENTAL HEALTH INITIAL EVALUATION CONSULT RESPONSE STANDARD TITLE: MENTAL HEALTH CONSULT DATE OF NOTE: FEB 10, 2016@09:53 ENTRY DATE: FEB 10, 2016@09:53:12 AUTHOR: CAMPOS,MEGHAN K EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Health Initial Assessment Length of session: 60 minutes Veteran was referred to Mental Health by Dr. Moore for PTSD treatment. Veteran was informed of the limits of confidentiality and agreed to participate in this session. He was encouraged to involve family members as appropriate in this intake assessment and subsequent treatment should he elect to engage in Mental Health services. Chief Complaint: PTSD symptoms, anxiety, and mild depression. Denies SI/HI Assessment Results (Instrument scores alone are not diagnostic and must be interpreted in the context of other clinical data): BDI-11: 28 Moderate depression PCL-5 Weekly: 57 Reported Symptoms: "Easily angered, snapping at my children, intense anxiety episodes, experiencing flashbacks (3-4 x's per week), nightmares, and experiencing a lot of triggers that remind him of being in Iraq/Kuwait. Sleep: Difficulty sleeping due to: Nightmares; 2x's per week, nightmares are combat related. Middle Insomnia Getting 6-7 hours' sleep per night Appetite: Increased; gaining weight: Yes Gained 25 lbs. since 2005, "probably because I am not working out daily" Pain: N/A Energy Level: WNL Psychiatric Treatment History: Veteran reports previous mental health treatment: Hospitalizations: Yes Suicide Attempts: No 2004, hospitalized in Virginia, "I woke up with a knife ready to cut my wrists. I drove myself to the hospital". Was there for 2 weeks. Saw therapist from 2004-05 on base for depression and anxiety. Social History: Childhood/Development History: Raised in Weslaco, Texas by parents. Veteran has an older brother. Describes childhood as, "It was kind of hard growing up, we were poor. We went to the flea market every weekend to make money. My dad was an alcoholic." Pretty good relationship with brother and parents. Family history of mental illness: denies Family history of substance abuse: endorses Family history of suicide attempts: denies History of childhood trauma: Physical/verbal/sexual abuse: endorses Domestic violence: endorses Substance Abuse: Father alcoholic, sober since 2006. Verbal abuse from father when he was intoxicated. He would tell me that I was the reason why we are struggling. Domestic Violence: Physical abuse between father and brother, when father was intoxicated. Education: Certified Medical Assistant Marital/Relationship History: Current relationship status: married Veteran has 2 children. Veteran lives with: Married in 2007, "Marissa", and they have two children (Marlyssa 1, and Edgar 7). Describes relationship with wife as, "we have our ups and downs. I get mad at her because she doesn't do what I ask her to do. I think we'd be better with family counseling." Relationship with his children as, "Very close. I protect them, they mean the whole world to me." Socialization History: "I play softball, church on Sundays, golf, basketball? Religion/Spirituality: Very important, practicing Catholic? Cultural Preferences: N/A Primary Language/Preference: LANGUAGE PREFERENCE ENGLISH 01/19/2016 Military History: Veteran served: ARMY 04/17/2002 TO 04/16/2005 (PERSIAN GULF WAR) Army From 2002-2005; MOS: 77 Foxtrot (Petroleum specialist); Honorable DE/C; E4; no disciplinary actions/loss of rank; and was deployed twice. September 2002- 03 to Iraq and to Honduras for 2 months for training in 2004. Military Trauma History: Combat "Patriot missiles flying over us, Mop gear for an entire week, lost friends to suicide." Occupational/Financial History: Finances are inadequate and Veteran is currently unemployed VA Disability. Was working for city of McAllen, checking water meters from 2008-2012. Legal/Violence History: Veteran denies current or prior history of being arrested/incarcerated. History of Addictive Behaviors: Veteran endorses the following addictive behaviors: Alcohol, Tobacco, Caffeine Alcohol, stopped in 2010. Tobacco: cigarettes, every other day, 2 cigarettes Caffeine: coffee, daily, 1 cup per day Risk Assessment for Current Behaviors: Suicide: Denied current suicidal ideation, intent, and plan. Homicide: Denied current homicidal ideation, intent, and plan. Mental Status Examination: Veteran was alert and oriented X4; veteran?s speech was clear and coherent; he was dressed appropriately and appeared well-groomed; mood appeared euthymic and anxious; congruent affect; his thought process appeared linear, logical, and goal oriented; no signs/reports of hallucinations, delusions, paranoia, or suicidal/homicidal ideation, intent, or plan; memory appeared intact; presented with good judgement and good insight. Diagnostic Impression: PTSD (per history) Unspecified Depressive Disorder Treatment Goals Veteran's short-term goals for treatment: "To get help and stop being mad at the world and my family" Veteran's long-term goals for treatment: "To be a better man and person, to be a supportive father" Veteran's perceived strengths: "I talk to anyone and get along with people, supportive, and active" Potential obstacles to treatment: "No" Preliminary Treatment Plan: Individual Psychotherapy: Veteran's request for psychotherapy to address PTSD treatment will be Staffed next treatment team meeting for therapist assignment. Applicable EBPs explained and offered to the Veteran. Veteran ACCEPTS VPTT treatment. *** Ms. Weihe, veteran is interested in doing Couples Therapy. Thank you! *** Mr. Bolado, veteran is interested in beginning Anger Management group in March. Thank you! *** Dr. Miesse, veteran is interested in beginning ACT for Depression Group in March. Thank you! Pharmacotherapy: Veteran is currently being treated in Primary Care; no need for medication management through MH at this time. Class/Workshop/Group Sessions Veteran is interested in attending group to address the following issues: Anger Management and ACT for depression Vet Center: N/A Instructions for emergent care: Veteran instructed that he may present as a walk-in to MH for emergent needs. Veteran instructed to report to the appropriate ER for after-hours emergent care. Veteran provided with the 24/7 Veterans Crisis Line. Veteran expressed understanding of and consent to this initial treatment plan. Veteran was provided with the clinic phone number, the Veteran's Crisis Line phone number (1-800-273-8255 (TALK), press 1), and 911. Veteran was instructed to monitor symptoms, including emergence of suicidal or homicidal ideation, and to utilize these numbers in case of mental health emergency. /es/ Meghan Campos, LCPC Licensed Professional Mental Health Counselor Signed: 02/10/2016 11:10 Receipt Acknowledged By: 02/16/2016 07:53 /es/ LARRY BOLADO Mental Health Social Worker 03/02/2016 15:52 /es/ Colette A. Miesse, Ph.D. Staff Psychologist 02/10/2016 17:28 /es/ CAROL WEIHE LCMFT ------------------------------------------------------------------------- ========================================================================= Date/Time: 02 Feb 2016 @ 1626 Note Title: MAS ADMINISTRATIVE NOTE Location: VA Texas Valley Coastal HCS Signed By: DUARTE,JUAN O Co-signed By: DUARTE,JUAN O Date/Time Signed: 02 Feb 2016 @ 1629 ------------------------------------------------------------------------- LOCAL TITLE: MAS ADMINISTRATIVE NOTE STANDARD TITLE: ADMINISTRATIVE NOTE DATE OF NOTE: FEB 02, 2016@16:26 ENTRY DATE: FEB 02, 2016@16:26:33 AUTHOR: DUARTE,JUAN O EXP COSIGNER: URGENCY: STATUS: COMPLETED *** MAS ADMINISTRATIVE NOTE Has ADDENDA *** EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 Age: 37 PATIENT PHONE - 956 802 8945 LOCAL - HARLINGEN VA CLINIC (740) || MCALLEN OPC (740GB) PACT: MCA BLUE (Focus: Primary Care Only) Primary Care Provider: Barreiro,Maribel B Care Manager: Clinical Associate: Gomez,Janis N || PHONE:9566187100 Administrative Associate: Basaldua,Rebecca Clinical POC: Administrative POC: Administrative Associate || Basaldua,Rebecca Note: Advised caller that this message is being taken by administrative staff. Patient cancelled tomorrow's appointment (0203@1000)- please review for disposition and next step in care. Alert sent to provider's attention. /es/ JUAN O DUARTE MH MSA Signed: 02/02/2016 16:29 Receipt Acknowledged By: 02/03/2016 08:50 /es/ Sean P. McGowan, Psy.D. Licensed Psychologist 02/03/2016 ADDENDUM STATUS: COMPLETED Ms. Aponte: veteran cancelled his first intake appointment. Please contact veteran to reschedule the appointment based on his preference and our next availability. Thank you. /es/ Sean P. McGowan, Psy.D. Licensed Psychologist Signed: 02/03/2016 08:51 Receipt Acknowledged By: 02/05/2016 14:52 /es/ CORAZON S APONTE Program Support Assistant ------------------------------------------------------------------------- ========================================================================= Date/Time: 27 Jan 2016 @ 1653 Note Title: PC BEHAVIORAL HEALTH FOLLOW-UP Location: VA Texas Valley Coastal HCS Signed By: MOORE,SHANNON M Co-signed By: MOORE,SHANNON M Date/Time Signed: 28 Jan 2016 @ 1419 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH FOLLOW-UP STANDARD TITLE: MENTAL HEALTH INTERDISCIPLINARY NOTE DATE OF NOTE: JAN 27, 2016@16:53 ENTRY DATE: JAN 27, 2016@16:53:30 AUTHOR: MOORE,SHANNON M EXP COSIGNER: MILLER,JOHN A URGENCY: STATUS: COMPLETED PRIMARY CARE MENTAL HEALTH INTEGRATION (PCMHI) FOLLOW-UP NOTE This case is supervised by the co-signing psychologist. I have discussed this case with this Supervisor who agrees with this diagnosis and treatment plan in this note or indicated any additions/corrections in the attached addendum. DURATION OF ENCOUNTER: 30 minutes TYPE OF ENCOUNTER: Individual PURPOSE: Veteran was seen for scheduled follow-up for brief intervention with PCMHI psychologist related to: 1. Providing psychoeducation on common trauma and stressor reactions 2. Assisting with improving relaxation skills 3. Assisting with managing depression by decreasing maladaptive thoughts and behaviors. SESSION CONTENT: Reviewed and discussed common trauma and stressor reactions. Utilized guided imagery to assist Veteran with improving relaxation skills. Introduced positive affirmations to assist with decreasing negative cognitions. Assessed Veteran interest in referral to Behavioral Health for trauma and stressor interventions. Veteran endorsed interest in being referred. STAGE OF CHANGE: Preparation MENTAL STATUS EXAM: Veteran ambulated without assistance. Veteran was well-groomed and appropriately dressed for the weather. Veteran was alert and oriented to person, time, place, and situation. Veteran's mood was anxious; affect was tensed and eye contact was good. Veteran's speech was spontaneous, fluid, and goal-directed. There was no evidence of abnormal thought process. There were no sign of hallucinations or delusions. Veteran's insight and judgment appeared to be good. Memory was not formally assessed but appeared grossly intact. Veteran denied current suicidal or homicidal ideation, plan, or intent. SUICIDE RISK ASSESSMENT: Veteran reported NO suicidal or homicidal ideation, plans, or intentions DIAGNOSTIC IMPRESSION (DSM-5/ICD-10): Unspecified Trauma and Stressor Disorder Unspecified Depressive Disorder Financial Stressors Bereavement PLAN: 1. Facilitate linkage to MH provider. 2 Schedule follow-up appointment to assess functioning until linked with MH. 2. Veteran aware that he/she can come in as a walk-in to PCMHI psychologist should the need arise. ATTN MSA: Please schedule Veteran (if not already scheduled) in MCA PCMHI PSY 2 individual clinic on 02/10/2016 at 0900hrs for 30mins. /es/ SHANNON M MOORE SUPERVISED PSYCHOLOGY STAFF Signed: 01/28/2016 14:19 /es/ John A. Miller, PhD Health Behavior Coordinator Cosigned: 01/28/2016 16:43 Receipt Acknowledged By: 01/29/2016 12:40 /es/ SUZANNA M SALINAS Medical Support Assistant ------------------------------------------------------------------------- ========================================================================= Date/Time: 21 Jan 2016 @ 0910 Note Title: PC BEHAVIORAL HEALTH FOLLOW-UP Location: VA Texas Valley Coastal HCS Signed By: LABELLA,KERI A Co-signed By: LABELLA,KERI A Date/Time Signed: 21 Jan 2016 @ 1009 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH FOLLOW-UP STANDARD TITLE: MENTAL HEALTH INTERDISCIPLINARY NOTE DATE OF NOTE: JAN 21, 2016@09:10:17 ENTRY DATE: JAN 21, 2016@09:16:58 AUTHOR: LABELLA,KERI A EXP COSIGNER: URGENCY: STATUS: COMPLETED VA TEXAS VALLEY COASTAL BEND HCS - BEHAVIORAL HEALTH LAB FOLLOW UP REPORT CLINIC: MCOPC - Behavioral Health Lab ************************************************************ Last name: Sandoval First name: Edgar Julian Date of interview: 1/21/2016 9:10 AM Method of interview: Telephone Patient's age: 37 Patient's sex: Male ************************************************************ ACTION ITEMS / TREATMENT PLAN: Clinical intervention completed: Goal Setting/Problem-Solving, Care/Medication Management The patient will continue to be monitored. ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ####### RESULTS FOR INDIVIDUAL ASSESSMENTS ####### The remaining sections of the report contain the responses and/or summary information for each assessed domain. The individual responses are based on self-report and should be used in context with other available clinical information. ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ DEPRESSIVE SYMPTOMS (PHQ-9) 1. Little interest or pleasure: Several Days 2. Feeling down or hopeless: Several Days 3. Trouble sleeping: More than half the days 4. Tired, low energy: More than half the days 5. Poor appetite, over-eating: Several Days 6. Feelings of failure, guilt: Several Days 7. Trouble concentrating: Not at all 8. Motor retardation, agitation: More than half the days 9. Suicidal ideation: Not at all The PHQ-9 total score (measure of depressive symptoms) equals 10 1-4 = minimal symptoms 5-9= mild symptoms 10-14= moderate symptoms 15-19= moderately severe symptoms 20-27= severe depressive symptoms The patient stated that the depressive symptoms made it not at all difficult to do his work, take care of things at home, or get along with others. The current symptomatology represents a decrease of 6 from the initial PHQ score completed 268 days prior. PHQ Score Over Weeks: 27-| 26-| 25-| 24-| 23-| 22-| 21-| 20-| 19-| 18-| 17-| 16-|0 15-| 37 14-| 13-| 12-| 11-| 10-| 38 9-| 8-| 7-| 6-| 5-| 4-| 3-| 2-| 1-| 0-| ----------------------------- Visits (weeks since Baseline) 0 - 4/27/2015 37 - 1/11/2016 38 - 1/21/2016 ********************************************************** ANXIETY SYMPTOMS (GAD-7) Anxiety Scale (anxiety symptoms reported in the last two weeks): 1. Feeling nervous, anxious or on edge: Several days 2. Not being able to stop or control worrying: Nearly every day 3. Worrying too much about different things: Several days 4. Trouble relaxing: Several days 5. Feeling restless (hard to sit still): Several days 6. Becoming easily annoyed or irritable: Several days 7. Afraid as if something awful might happen: More than half the days The patient stated that the anxiety symptoms made it somewhat difficult to do his/her work, take care of things at home, or get along with others. The anxiety total score (general measure of anxiety) equals 10 0-4 =minimal symptoms 5-9=mild symptoms 10-14=moderate symptoms, 15-21=severe symptoms ************************************************************ MEDICATION TREATMENT, ADHERENCE, AND SIDE EFFECTS: The patient is prescribed a psychotropic medication. He reports taking the medication as prescribed. The patient does not report symptoms suggestive of adverse effects of medication. ************************************************************ The VA Texas Valley Coastal Bend HCS - Behavioral Health Lab is directed by Jennifer Wood, Ph.D.. If you have questions please call 956-291-9125. If you have questions regarding this patient's clinical management, please contact Keri LaBella at 956-618-7100 ext 67342. ========================================================================== Mr. Sandoval was called for a follow-up PHQ-9, GAD-7, and assessment. Veteran was called as a part of care management. PHQ-9 Score: 10 Previous PHQ-9 SCORE- 15 GAD-7 Score: 10 Previous GAD-7 score 20 PHQ-9 Score today consistent with moderate level of depression. GAD-7 score today consistent with moderate level of anxiety. In PC MHI care management since: 4/27/2015 PROBLEM: Current medical diagnoses, concerns: Veteran denied Medication Concerns: Veteran denied side effects to the medication Mental and Sleep Status Changes: Veteran denied Stressors, Strengths and Resources: not discussed with Veteran at this appointment Behavioral Activation/Pleasant Events Scheduling: Veteran is exercising and cleaning out his garage. Other Treatment(Psychotherapy/counselling, etc.): Veteran is wishing to engage in PTSD treatment in mental health. Suicidal Ideation: Veteran denied current active suicidal ideation/intent/plan. Patient Education: Veteran was educated about the importance of continuing to do pleasant things and actively engaging in treatment. RN instructed Veteran that in case of any further problems, questions or concerns, Veteran may call PC-MHI RN in this clinic during working hours. RN instructed Veteran that in case of psychiatric/emotional crisis or medical emergency, Veteran may call 911 and/or go to MMC, ERMC or McAllen Heart Hospital Emergency Room Dept. for evaluation/treatment. Veteran also has contact information for the Veterans Crisis Line 1-800-273-8255 and is aware to press 1 Impression: 1.Diagnosed: PTSD, dysthymic disorder Reports: resolving depression and anxiety 2.Patient identifies target symptom(s) as: PTSD PLAN: 1.Follow through with PC MHI program with phone calls for assessment as indicated: 2.Patient's stated action plan: Veteran will continue to exercise and clean his garage. 3. Alert MAS staff to schedule appointment for 2/12/2016 at 0900 Consults were reviewed and no needs were identified. Time Spent: 12 minutes ----------------------------------------------------------------------- Feb 12,2016 is the Clinically Indicated Date for RTC. ----------------------------------------------------------------------- /es/ KERI A LABELLA BS RN PCMHI Signed: 01/21/2016 10:09 Receipt Acknowledged By: 01/22/2016 10:31 /es/ SUZANNA M SALINAS Medical Support Assistant ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 1555 Note Title: SUICIDE SAFETY PLAN Location: VA Texas Valley Coastal HCS Signed By: MOORE,SHANNON M Co-signed By: MOORE,SHANNON M Date/Time Signed: 19 Jan 2016 @ 1612 ------------------------------------------------------------------------- LOCAL TITLE: SUICIDE SAFETY PLAN STANDARD TITLE: SUICIDE PREVENTION NOTE DATE OF NOTE: JAN 19, 2016@15:55 ENTRY DATE: JAN 19, 2016@15:55:38 AUTHOR: MOORE,SHANNON M EXP COSIGNER: MILLER,JOHN A URGENCY: STATUS: COMPLETED SANDOVAL,EDGAR JULIAN 457-65-1840 SAFETY PLAN STEP 1: WARNING SIGNS Pacing, feeling restless, acting "fidgety" Worrying a lot about everything Allowing bills to go unpaid Feeling irritable or angry most of the day/aggressively acting out Not communicating with friends and family Stressors: Anniversaries of trauma Financial problems Being very angry at something or someone STEP 2: INTERNAL COPING STRATEGIES- THINGS TO TAKE MY MIND OFF PROBLEMS Sing or listen to music Surf the Web Visit a friend Hear jokes/listen to/watch a comedy routine Organize or clean out a closet or "junk" drawer STEP 3: SOCIAL SETTINGS THAT PROVIDE DISTRACTION Be outdoors Go to the gym/health club Go to a garage sale Pray/attend church or synagogue Play with children, grandchildren, nieces, nephews STEP 4: PEOPLE WHOM I CAN ASK FOR HELP 1. Name Marisa Sandoval Phone number 956-802-8971 2. Name Jose Alvarado Phone number 956-777-0532 3. Name Teresa Sanez Phone number 956-739-8113 STEP 5: PROFESSIONAL AND AGENCIES I CAN CONTACT FOR HELP 1. Name Shannon Moore, PhD Phone number 956-618-7100, ext. 67336 --- DURING WORKING HOURS --- Valley Coastal Bend SPC Nicole Theriot (361) 806-5696 SPCM Phil Spears (956) 291-9132 SPC Dr. Rodolfo Quintana (956) 618-7100 x 67314 South Texas: SPC Larry Stokes (210) 617-5300 ext. 15824 or SPC Millicent Nwokolo-Udeaja (210) 617-5300 ext. 15132 --- AFTER WORKING HOURS --- Call 911 Veteran's Crisis Line - 1-800-273-8255 Press 1 VA Emergency Room Nearest local emergency room STEP 6: MAKING THE ENVIRONMENT SAFE I do not have access to firearms. Step 7. ATTN: HEALTHCARE PROVIDER. Please check on of the items below so as to identify the way in which the patient was provided with a written copy of the Safety Plan. The following was developed utilizing the VA Personal Safety Plan/Patient education pamphlet. The Veteran was provided with the above patient educational booklet. /es/ SHANNON M MOORE SUPERVISED PSYCHOLOGY STAFF Signed: 01/19/2016 16:12 /es/ John A. Miller, PhD Health Behavior Coordinator Cosigned: 01/19/2016 16:26 ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 1550 Note Title: SUICIDE RISK ASSESSMENT Location: VA Texas Valley Coastal HCS Signed By: MOORE,SHANNON M Co-signed By: MOORE,SHANNON M Date/Time Signed: 19 Jan 2016 @ 1555 ------------------------------------------------------------------------- LOCAL TITLE: SUICIDE RISK ASSESSMENT STANDARD TITLE: SUICIDE RISK ASSESSMENT NOTE DATE OF NOTE: JAN 19, 2016@15:50 ENTRY DATE: JAN 19, 2016@15:50:34 AUTHOR: MOORE,SHANNON M EXP COSIGNER: MILLER,JOHN A URGENCY: STATUS: COMPLETED IDEATION, PLAN and INTENT Ideation: No RISK FACTORS: Static (do not change, historical, or chronic): Previous history of suicide attempt Chronic unemployment Military trauma exposure Chronic mental illness: Unspecified Depressive Disorder, Unspecified Trauma and Stressor Related Disorder Recent losses: Veteran reported grieving death of mother in 4/2015. *Dynamic (immediate past or current; current exacerbation of a chronic issue; situational): Financial stress Job loss/inability to acquire a job PROTECTIVE FACTORS: Effective clinical care for mental, physical, and substance use disorders Easy access to a variety of clinical interventions and support for help seeking Positive therapeutic relationship Motivation for/optimism regarding treatment Restricted access to highly lethal means of suicide Sense of responsibility to family Children - underage and living in the home; pregnancy Reality testing ability OTHER RELEVANT FACTORS: Do you own or have access to a firearm? No. CLINICIAN'S OVERALL ANALYSIS OF RISK LEVEL: Short term, current risk: Low Long-term, chronic risk: Moderate RATIONALE for decisions/actions on the basis of risks vs benefits considered: Veteran denies current suicidal ideations, plan or intent. Veteran list family and children as protective factors. Veteran considers suicide an option. Veteran needs assistance with improving problem solving skills. IMMEDIATE SAFETY NEEDS: Suicide Safety Plan (see completed Safety Plan Note) MOST APPROPRIATE SETTING FOR TREATMENT: Outpatient SUICIDE RISK REDUCTION PLAN TO ADDRESS *DYNAMIC FACTORS: Provided Veteran Crisis Line number 1-800-273-8255, Press 1 Refer to: Individual Encourage continued compliance with treatment Safety Plan completed with Veteran this date. /es/ SHANNON M MOORE SUPERVISED PSYCHOLOGY STAFF Signed: 01/19/2016 15:55 /es/ John A. Miller, PhD Health Behavior Coordinator Cosigned: 01/19/2016 16:27 ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 1016 Note Title: PC BEHAVIORAL HEALTH INITIAL Location: VA Texas Valley Coastal HCS Signed By: MOORE,SHANNON M Co-signed By: MOORE,SHANNON M Date/Time Signed: 19 Jan 2016 @ 1547 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH INITIAL STANDARD TITLE: MENTAL HEALTH NOTE DATE OF NOTE: JAN 19, 2016@10:16 ENTRY DATE: JAN 19, 2016@10:16:46 AUTHOR: MOORE,SHANNON M EXP COSIGNER: MILLER,JOHN A URGENCY: STATUS: COMPLETED *** PC BEHAVIORAL HEALTH INITIAL Has ADDENDA *** PRIMARY CARE MENTAL HEALTH INTEGRATION (PCMHI) INITIAL This case is supervised by the co-signing psychologist. I have discussed this case with this Supervisor who agrees with this diagnosis and treatment plan in this note or indicated any additions/corrections in the attached addendum. NOTE: Veteran was informed about the limits of confidentiality and consented to this evaluation. Veteran was informed of role of PCMHI psychologist and that the purpose of the consultation was for brief assessment of presenting problem(s) and treatment planning. The information in this report was obtained through a review of medical records and a clinical interview with Veteran and, where possible, the administration of brief symptom checklists and questionnaires (see SCREENING section below). DURATION OF ENCOUNTER: 1 hour TYPE OF ENCOUNTER: Individual MILITARY SERVICE: Branch of Service: Army Dates of Service: 2000-2005 Occupational Specialty (job): Served in Combat: Yes DIAGNOSTIC IMPRESSIONS (DSM-5/ICD-10): Unspecified Trauma and Stressor Disorder Unspecified Depressive Disorder Financial Stressors Bereavement REASON FOR REFERRAL: Veteran referred by PCP, Maribel Barreiro, MD, for assistance with managing trauma and depression symptoms. Per PCP, Veteran had attempted suicide in 2003 and currently prescribed psychotropic medications to manage mood symptoms. SELF-IDENTIFIED CONCERNS/PROBLEMS: Veteran reported grieving the death of his mother and ongoing financial stressors related to being unemployed since 02/2015. HISTORY OF PRESENTING PROBLEM: Veteran reported combat deployment to Iraq, 2002-2003. Veteran disclosed attempting suicide by cutting wrist in 2003 due to "things I saw and things I did [while in Iraq]" . Veteran stated driving himself to hospital following suicide attempt and being hospitalized for 2-3wks. Veteran stated being followed by a military mental health provider weekly for approx. 7mos after suicide attempt. Veteran reported last suicidal ideations occurred 12/2015. Veteran stated having thoughts of using a gun. Veteran denied owning or having access to firearms. Veteran denied current suicidal ideations, plan or intent. Veteran reported ongoing trauma symptoms including: nightmares 3-4x/week, flashbacks, intense distress at exposure to internal or external cues that symbolize an aspect of trauma, persistent avoidance of stimuli associated with trauma (e.g. war themed movies, conversations about war, person that look or sound like Iraqians, etc.), irritability, exaggerated startle response, and hypervigilance. PSYCHIATRIC TREATMENT HISTORY: Veteran reported history of being followed by mental following suicide attempt in 2003. Currently, Veteran prescribed fluoxetine and Buspirone by PCP. HELPFUL PRESENT/PAST COPING MECHANISMS FOR IDENTIFYING PROBLEMS: family/social support, staying active FUNCTIONAL ASSESSMENT (Day-to-Day Functioning): Substance Use: Alcohol: No. Last use in 2012. Veteran reported paternal hx of alcohol abuse. Recreational Drugs: No. Tobacco: Yes (specify amount); cigarettes, 1pp4-5days Caffeine: Yes (specify amount); coffee 1c/day Veteran denied social, legal, or occupational problems as a result of past alcohol or other substance use. Sleep: Within normal limits - restorative Nightmares; frequency: 3-4x/wk Other (specify): sleeps, 7hrs/night, restorative Marital/Family Problems: Veteran reported grieving death of mother (04/2015). Work: Unemployed Financial Problems: Yes (explain): Veteran reported financial distress related to being unemployed. TRAUMA HISTORY: extremely frightening, horrifying, or upsetting military experiences ASSESSMENT RESULTS (instrument scores alone are not diagnostic and must be interpreted in the context of other clinical data): PHQ9: 10/27 PCL-5: 62/80 AUDIT: 0/40 Veteran's score(s) on the screening instruments suggest: Clinically significant levels of distress manifest in: Depressive symptoms and behavior, and Trauma-related symptoms and behavior. MENTAL STATUS EXAM: Veteran was alert and oriented x4. Veteran was dressed casually and well- groomed; mood was depressed; affect was anxious; and eye contact was good. Veteran's speech was spontaneous, fluid, and goal-directed. Thought processes were logical, linear and goal directed; thought content was WNL with no sign or reports of hallucinations, delusions, paranoia, or suicidal/homicidal ideation, plan or intent. Memory appeared grossly intact. Judgement and insight were good. SUICIDE RISK ASSESSMENT: Veteran report NO suicidal or homicidal ideation, plans, or intentions Low Risk: presence of risk is minimal Veteran provided with: Veteran Crisis Line contact information Appointment card and next step details Managing risks/seeking help information and literature Safety Plan TREATMENT OPTIONS, RECOMMENDATIONS, and INTERVENTIONS (all have been collaboratively discussed with and agreed to by the Veteran): 1. Behavioral Activation 2. Patient Education, Psycho-educational interventions, Handouts 3. Cognitive-Behavior interventions to alter: unhealthy thinking patterns, , trauma related behaviors, and depression. 4. Relaxation to aid with stress relief, chronic pain, and sleep: Slow, rhythmic, and focused breathing, Diaphragmatic (belly) Breathing, Visualization/Pleasant Imagery, and Progressive muscle relaxation (if not contraindicated by physician) TREATMENT PLAN: 1. Follow-up in 1 week to provide psychoeducation on common trauma and stressor reactions. 2. Assist with improving relaxation skills. 3. Assist with managing depression by decreasing maladaptive thoughts and behaviors. FOLLOW-UP: 1. RTC for follow-up. 2. Facilitate linkage to MH provider. Other Consultation(s): Consult placed to MH due to Veteran reporting interest in managing trauma symptoms. ATTN MSA: Please schedule Veteran (if not already scheduled) in individual clinic MCA PCMHI PSY 2 on Jan 26,2016@10:00 /es/ SHANNON M MOORE SUPERVISED PSYCHOLOGY STAFF Signed: 01/19/2016 15:47 /es/ John A. Miller, PhD Health Behavior Coordinator Cosigned: 01/19/2016 16:28 01/26/2016 ADDENDUM STATUS: COMPLETED ADDENDUM TO CHART: This provider contacted Veteran to reschedule today's, 01/26/2016 missed appointment. Veteran rescheduled appointment. MSA: Schedule appointment in MCA PCMHI PSY 2 on 01/27/2016 at 1000hrs for 30mins. /es/ SHANNON M MOORE SUPERVISED PSYCHOLOGY STAFF Signed: 01/26/2016 14:27 /es/ John A. Miller, PhD Health Behavior Coordinator Cosigned: 01/26/2016 14:46 Receipt Acknowledged By: 01/27/2016 16:03 /es/ SUZANNA M SALINAS Medical Support Assistant ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 0943 Note Title: MED RECONCILIATION Location: VA Texas Valley Coastal HCS Signed By: MENDEZ,ILEANA E Co-signed By: MENDEZ,ILEANA E Date/Time Signed: 19 Jan 2016 @ 0944 ------------------------------------------------------------------------- LOCAL TITLE: MED RECONCILIATION STANDARD TITLE: MEDICATION MGT NOTE DATE OF NOTE: JAN 19, 2016@09:43 ENTRY DATE: JAN 19, 2016@09:43:57 AUTHOR: MENDEZ,ILEANA E EXP COSIGNER: BARREIRO,MARIBEL B URGENCY: STATUS: COMPLETED EDGAR JULIAN SANDOVAL 2314 E 21ST STREET MISSION, TEXAS 78572 PATIENT PHONE - 956 802 8945 AGE: 37 SEX: MALE WEIGHT:200.9 lb [91.3 kg] (01/19/2016 08:43) SELECTED CLINICAL REMINDERS DUE: --STATUS-- --DUE DATE-- --LAST DONE-- V17 ALL Influenza Immunization DUE NOW DUE NOW unknown Pneumococcal PPSV23 (Pneumovax) DUE NOW DUE NOW unknown VACCINES OF RECORD IN VCB CPRS: Immunization Series Date Facility Reaction INFLUENZA 09/18/2008 MCALLEN OP* TDAP 07/30/2014 MCALLEN OP* Medicine Reconciliation Medication List: JAN 19, 2016 Allergies: TUNA =========================================================== No Active Remote Medications for this patient =========================================================== Active Medications ============================================================ 1) Buspirone Hcl 10Mg Tab Take one tablet by mouth three times a day as needed for Anxiety 2) Fluoxetine Hcl 20Mg Cap Take two capsules by mouth every day for mood 3) Lisinopril 20Mg Tab Take one-half tablet by mouth every day for blood pressure 4) Nicotine Polacrilex 2Mg Lozenge Dissolve 1 lozenge in cheek and gum until dissolved as Directed 5) Omeprazole 20Mg Ec Cap Take one capsule by mouth every day as needed take 30 to 60 Minutes before a meal. For reflux - short term Therapy - 90 days You have 5 active medications Your provider has NOT prescribed any new medications today. _______________________________________________________________________ Your provider has NOT discontinued any of your medications today. Consults or procedures that were ordered today: NO recent pending Consults found. Imaging studies,lab tests and previously scheduled appointments: NO recent pending Radiology found. No pending labs. CVF - Future Clinic Visits 01/19/2016 10:00 MCA PCMHI PSY 2 01/21/2016 08:30 MCA PCMHI TELEPH-X Today your provider was: ILEANA E MENDEZ Ileana Mendez, MD Resident PGY2 Medication education and counseling for new medications(if added today) was provided to the Veteran based on their individual needs. This included why the medication was prescribed, how they should take it and for how long, what to expect from it, and what happens if the medication is not taken as prescribed. By signing this note I certify that patient or caregiver or family member understood my instructions. MEDICATION RECONCILIATION PAPER COPY GIVEN TO PATIENT The patient/caregiver was instructed to always carry an updated Medication Reconciliation list to their next appointment whether with a VA or Non-VA provider and to discard any old lists. If after hours, weekends, holidays or long distance, call Telecare: 1-888-252-9970 VETERANS CRISIS LINE Phone: 1-800-273(TALK) 8255,push 1 to reach a VA mental health clinician. For medication refills call the automated medication refill line at 1-877-752-0650. ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 0940 Note Title: MENTAL HEALTH DIAGNOSTIC STUDY NOTE Location: VA Texas Valley Coastal HCS Signed By: MOORE,SHANNON M Co-signed By: MOORE,SHANNON M Date/Time Signed: 19 Jan 2016 @ 1536 ------------------------------------------------------------------------- LOCAL TITLE: MENTAL HEALTH DIAGNOSTIC STUDY NOTE STANDARD TITLE: MENTAL HEALTH DIAGNOSTIC STUDY NOTE DATE OF NOTE: JAN 19, 2016@09:40:59 ENTRY DATE: JAN 19, 2016@09:40:51 AUTHOR: MOORE,SHANNON M EXP COSIGNER: MILLER,JOHN A URGENCY: STATUS: COMPLETED URGENCY: STATUS: UNSIGNED Patient Health Questionnaire - 9 (PHQ-9) Date Given: 01/19/2016 Clinician: Moore,Shannon M Location: Mca Pcmhi Psy 2 Veteran: Sandoval, Edgar Julian SSN: xxx-xx-1840 DOB: Feb 10,1978 (37) Gender: Male PHQ-9 Depression Scale Score: 10 Guide for Interpreting PHQ-9 scores: 0-4: The score suggests the patient may not need depression treatment. 5-14: Physician uses clinical judgment about treatment based on patient's duration of symptoms and functional impairment. 15 or more: Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment. Questions and Answers Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things Several days 2. Feeling down, depressed, or hopeless Several days 3. Trouble falling or staying asleep, or sleeping too much More than half the days 4. Feeling tired or having little energy More than half the days 5. Poor appetite or overeating Several days 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down Several days 7. Trouble concentrating on things, such as reading the newspaper or watching television Not at all 8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual More than half the days 9. Thoughts that you would be better off dead or of hurting yourself in some way Not at all 10. If you checked off any problems, how DIFFICULT have these problems made it for you to do your work, take care of things at home or get along with other people? Somewhat difficult Information contained in this note is based on a self report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities. Copyright 2001 Pfizer Inc. All rights reserved. Reproduced with permission of Pfizer Inc. PRIME-MD is a trademark of Pfizer Inc __________________________________________________________________________ Alcohol Use Disorders Identification Test Date Given: 01/19/2016 Clinician: Moore,Shannon M Location: Mca Pcmhi Psy 2 Veteran: Sandoval, Edgar Julian SSN: xxx-xx-1840 DOB: Feb 10,1978 (37) Gender: Male AUDIT Score: 0 A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption. Questions and Answers 1. How often do you have a drink containing alcohol? Never 2. How many drinks containing alcohol do you have on a typical day when you are drinking? Not asked (due to responses to other questions) 3. How often do you have six or more drinks on one occasion? Not asked (due to responses to other questions) 4. How often during the last year have you found that you were not able to stop drinking once you had started? Not asked (due to responses to other questions) 5. How often during the last year have you failed to do what was normally expected from you because of drinking? Not asked (due to responses to other questions) 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Not asked (due to responses to other questions) 7. How often during the last year have you had a feeling of guilt or remorse after drinking? Not asked (due to responses to other questions) 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Not asked (due to responses to other questions) 9. Have you or someone else been injured as a result of your drinking? No 10. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested that you cut down? No Information contained in this note is based on a self report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities. /es/ SHANNON M MOORE SUPERVISED PSYCHOLOGY STAFF Signed: 01/19/2016 15:36 /es/ John A. Miller, PhD Health Behavior Coordinator Cosigned: 01/19/2016 16:29 ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 0900 Note Title: PC RESIDENT FOLLOW-UP PATIENT NOTE Location: VA Texas Valley Coastal HCS Signed By: MENDEZ,ILEANA E Co-signed By: MENDEZ,ILEANA E Date/Time Signed: 19 Jan 2016 @ 0943 ------------------------------------------------------------------------- LOCAL TITLE: PC RESIDENT FOLLOW-UP PATIENT NOTE STANDARD TITLE: PRIMARY CARE OUTPATIENT PROGRESS NOTE DATE OF NOTE: JAN 19, 2016@09:00 ENTRY DATE: JAN 19, 2016@09:00:26 AUTHOR: MENDEZ,ILEANA E EXP COSIGNER: BARREIRO,MARIBEL B URGENCY: STATUS: COMPLETED *** PC RESIDENT FOLLOW-UP PATIENT NOTE Has ADDENDA *** Reason for visit/chief complaint: Patient is a 37 year old WHITE MALE: 1: Pt had an anxiety attack in december and would like to f/u. Presently taking Buspirone which he believes is working well. Pt still taking fluoxetine and has an appointment with mental health to see if they are going to discontinue fluoxetine. Pt denies suicidal ideation at this time. Pt seems possitive and have plan. 2: Pt also smoking and would like patches or lozengers. 3: Blood pressure pt taking lisinopril and blood pressure is well control. Problem List was reviewed at today's appointment. Allergies: TUNA Active Medications ============================================================ 1) Buspirone Hcl 10Mg Tab Take one tablet by mouth three times a day as needed for Anxiety 2) Fluoxetine Hcl 20Mg Cap Take two capsules by mouth every day for mood 3) Lisinopril 20Mg Tab Take one-half tablet by mouth every day for blood pressure 4) Nicotine Polacrilex 2Mg Lozenge Dissolve 1 lozenge in cheek and gum until dissolved as Directed 5) Omeprazole 20Mg Ec Cap Take one capsule by mouth every day as needed take 30 to 60 Minutes before a meal. For reflux - short term Therapy - 90 days You have 5 active medications Reviewed home meds with patient/caregiver and NO discrepancies found. History: Review Of Systems: Pulm: Denies cough, excess sputum production, hemoptysis, SOB, or dysnea Cardiac: Denies chest pain, palpitations, or syncope GU: Denies any recent hematuria, stones, UTI's or voiding difficulties GI: Denies constipation, Diarrhea, Abdomianl pain, Dark Stools Neuro: No seizures, headaches, numbness, mental changes Psych: Denies homicidal or suicidal ideations Physical Exam: Vital Signs: Temperature: 98.2 F [36.8 C] (01/19/2016 08:43) Pulse: 78 (01/19/2016 08:43) Respiration: 20 (01/19/2016 08:43) BP: 117/71 (01/19/2016 08:43) Pain: 0 (01/19/2016 08:43) Height: 69 in [175.3 cm] (01/19/2016 08:43) Weight: 200.9 lb [91.3 kg] (01/19/2016 08:43) BMI: 29.7 GEN:Well nourished male in no acute distress. HEENT:PERRLA, EOM intact. Ear/Nose/Throat Clear. NECK: Supple neck with out bruits. CHEST: Clear to A& P without rales, rhonchi or wheezes CVS:Regular rate & rhythm, no murmur, No gallops, rubs. ABD: Soft, non-tender, BS in 4q, No bruits EXT: No C/C/E SKIN: No acute lesions BACK: No tenderness to vertebrae on palpation NEURO: oriented x 3. No focal defects noted. PSYCH: No delutions or hallucination Last diagnostic tests reviewed and discussed with patient. Assessment/Plan: 1. Anxiety and depression, pt feeling much better, for the time being we will continue on buspirone and fluoxetine. Pt is being seen by Dr. Moore this morning. 2. Smoking, pt to continue on lozengers and see how well he does in one month if he is not off cigaretts and feels he needs patches we will start him on them. 3. Hypertension/ continue on lisinopril, well controlled at this time. Continue all other meds Discussed DM/HTN/CHOL diet and exercise recomendations Nursing instructions: Diet, Seatbelts, exercise RTC in 6 months with PCP, do not overbook Pre-Clinic labs: Chem24, Lipid Profile, CBC, UA, I have discussed the patient with my Attending, Dr. Barreiro, who agrees with my assessment and plan. /es/ ILEANA E MENDEZ Ileana Mendez, MD Resident PGY2 Signed: 01/19/2016 09:43 /es/ MARIBEL B BARREIRO MD Cosigned: 01/19/2016 10:08 Receipt Acknowledged By: 01/19/2016 12:41 /es/ REBECCA BASALDUA 01/19/2016 ADDENDUM STATUS: COMPLETED seen discussed and agree with care. CLINICAL REMINDER ACTIVITY V17 P Eval + Depr/PTSD Screen: SUICIDE RISK SCREENING 1. Do you have current thoughts about suicide or self harm? No. 2. Do you have a prior history of past attempts? Yes Comment: 2004 3. Are you feeling hopeless and/or helpless? No. LOW RISK: Given the veteran's presentation at the time of this assessment, in my clinical judgement the veteran's current risk potential for suicidal behavior is low and patient is judged not to be at significant risk for self harm. Positive PTSD Screen PROVIDER ASSESSMENT AND PLAN The results of the PTSD Screen has been reviewed and the patient assessed including assessment of suicide risk. Based on the assessment, the following disposition plan will be implemented. Already receiving needed treatment. Contact information and instructions for accessing emergency services provided. Comment: patient taken to pch-mi, discussed saftey plan when he is having a good day /es/ MARIBEL B BARREIRO MD Signed: 01/19/2016 10:08 ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 0846 Note Title: PRIMARY CARE NURSE ANNUAL NOTE Location: VA Texas Valley Coastal HCS Signed By: ALANIZ,JANIS N Co-signed By: ALANIZ,JANIS N Date/Time Signed: 19 Jan 2016 @ 0854 ------------------------------------------------------------------------- LOCAL TITLE: PRIMARY CARE NURSE ANNUAL NOTE STANDARD TITLE: NURSING OUTPATIENT NOTE DATE OF NOTE: JAN 19, 2016@08:46 ENTRY DATE: JAN 19, 2016@08:46:22 AUTHOR: ALANIZ,JANIS N EXP COSIGNER: URGENCY: STATUS: COMPLETED Ebola Screening Have you traveled to an area where the Ebola Virus is prevalent in the past 21 days? No Have you had a known exposure to blood or body fluids of a patient with Ebola in the previous 21 days? No Problem/Chief Complaint: Problem: Pt alert and oriented x 3, came accompanied to MD visit by son. Pt noted with normal, steady gait. Pt denies pain at this time. Pt voices concern of having signs/symptoms of PTSD; flashbacks and nightmares. Intervention: Refer to PACT PCP. Evaluation: See PACT PCP plan of care. Current Vital Signs: Temp: 98.2 F [36.8 C] (01/19/2016 08:43) Pulse: 78 (01/19/2016 08:43) Resp: 20 (01/19/2016 08:43) B/P: 117/71 (01/19/2016 08:43) Pain: 0 (01/19/2016 08:43) 12/23/14 @ 0844 PULSE OXIMETRY: 98 Height:69 in [175.3 cm] (01/19/2016 08:43) Weight:200.9 lb [91.3 kg] (01/19/2016 08:43) BMI: 29.7 Morse Annual Screen Does the Veteran have a history of falling in the past 12 months? No Morse Fall Risk Scale The Morse Fall scale was performed and score was 0. This is indicative of low risk of falls. History of falling in past 3 months? No Secondary diagnosis: No Ambulatory aid: None/bedrest/nurse assist Intravenous therapy/Heparin lock: No Gait/Transferring: Normal/bed rest/immobile Mental Status: Oriented to own ability/knows own limitations Standard (Low Risk) 0 to 24 (No Interventions) PAIN INTERVIEW Pain Scale used: Numeric Rating Scale (NRS) 0-10 Patient denies pain. Most recent pain score: 0 (01/19/2016 08:43) Review of Past Immunizations entered in CPRS: JUL 30, 2014 TDAP SEP 18, 2008 INFLUENZA, UNSPECIFIED FORMULATION Patients language preference for health information is: English Learning Preferences/Learning Barriers Patient's preferred learning method: Kinestetic/Tactile/Hands On Barriers to learning identified: Hearing limitations: >>> Hearing-aid not available Visual limitations: >>> Wears glasses Current Physical Activities: Other: softball Nutrition: Current Diet: Regular No problem Current BMI is 29.7 Last height is 69 in [175.3 cm] (01/19/2016 08:43) Last weight is 200.9 lb [91.3 kg] (01/19/2016 08:43) MOVE! Reminder: --STATUS-- --DUE DATE-- --LAST DONE-- V17 ALL Weight Management-MOVE! DUE NOW DUE NOW unknown Does the patient meet any of the criteria for being considered incapacitated? No 1. In the last year, have you been hit, kicked, slapped, choked, punched, or touched inappropriately by someone? No 2. Are you afraid of your partner or someone else? No 3. Do you handle your own money? Yes Does the patient show any signs of: physical abuse, unexplained injuries, suspicious bruises, lacerations, fractures, or burns? No, the patient shows no signs of physical abuse,unexplained injuries,suspicious bruises,lacerations,fractures, or burns. Does the patient appear neglected? No Skin Integrity Screen Does the Veteran or caregiver report any current or a history of pressure ulcers? No Does the Veteran or caregiver report skin breakdown related to a medical device? No Does the Veteran require assistance to transfer or change positions? No Is the Veteran confined to a bed or a wheelchair user? No Skin Screen Results: Normal Index of ADL (KATZ) Bathing: either sponge bath, tub bath or shower. 3 points Receives no assistance (gets in and out of tub by self, if tub is usual means of bathing). Dressing: gets clothes from closets and drawers, including under-clothes,outer garments and using fasteners (including braces if worn). 3 points Gets clothes and dresses self without assistance. Toileting: going to the "toliet room" for bowel and urine elimination, cleaing self after elimination and arranging clothes. (may use cane,walker, or wheelchair, and manage bedpan or commode, emptying same next morning.) 3 points No assistance needed. Transfer: 3 points Moves in and out of bed, or chair, without assistance (may use support object like cane or walker). Continence: 3 points Controls urination and bowel movement completely by self. Feeding: 3 points Feeds self without assistance. Index of ADL (Katz) results: Katz Index of Independence in ADL: 18/18 A high index indicates independence, a low index means dependence on others to help with activities of daily living. Lawton-Brody Instrumental Activities of Daily Living Scale (IADL) A low score indicates dependence on others to help with daily activities. A high score indicates independent living. Range is 0 to 8. Ability to use telephone 1 point Operates telephone on own initative: looks up and dials numbers, etc. Shopping 1 point Takes care of all shopping needs independently. Food Preperation 1 point Plans, prepares and serves adequate meals independently. Housekeeping 1 point Maintains house alone or with occassional assistance (e.g. heavy work, domestic help). Laundry 1 point Does personal laundry completely. Mode of Transportation 1 point Travels independently on public transportation or drives own car. Responsibility for own medications 1 point Is responsible for taking medication in correct dosages at correct time. Ability to Handle Finances 1 point Manages financial matters indenpendently (budgets, writes checks, goes to bank). IADL point total is 8 /8 The KATZ and IADL were completed for this patient. Provider notified of the results. The following Clinical Nursing Reminders are due: --STATUS-- --DUE DATE-- --LAST DONE-- Advance Directive Screening DUE SOON 03/04/2016 03/04/2015 Nursing Annual Health History DUE SOON 03/04/2016 03/04/2015 V17 ALL Influenza Immunization DUE NOW DUE NOW unknown V17 ALL Tobacco Screen DUE SOON 03/04/2016 03/04/2015 V17 ALL Weight Management-MOVE! DUE NOW DUE NOW unknown V17 N Alcohol Screen DUE SOON 03/04/2016 03/04/2015 Nursing Clinical Reminders were reviewed today. Tips for Healthy Living At annual patient visit, the patient/caregiver was provided the "Tips for Healthy Living" and information on Methicillin-resistant Staphlococcous Aureus (MRSA) and Mult-drug Resistant Organisms (MDROs); hand hygeine; respiratory etiquette; exercise and nutrition; cancer screening; pain management; tobacco cessation; alcohol use; speak up information; and advance directive. TOPICS TAUGHT: Topics taught today Discussed with: Patient "In an Emergency" handout. Education provided: Contract Hospitals Level of Understanding: Good RN and Provider notified of change of status;condition,concerns. CLINICAL REMINDER ACTIVITY Advance Directive Screening: Veteran has been educated about advance directives and will contact the social worker when ready to complete a Advance Directive. Nursing Annual Health History: Patient had annual adult health history exam at this encounter. V17 ALL Influenza Immunization: Patient educated regarding need for vaccine and declines. Comment: personal reasons V17 ALL Tobacco Screen: Patient states they are a current tobacco user. Non-prescibing provider tobacco cessation couns eling. Advice to Quit 1. ADVISED patient to quit tobacco through total abstinence. 2. ASSISTED patient to quit using the following methods: a. Set a quit date, ideally with 2 weeks b. Get support from family, friends, and co-workers c. Review past quit attempts - what helped, what led to relapse d. Identify and plan ahead for challenges, particularly during the first two weeks, including nicotine withdrawal e. Identify reasons for quitting and benefits of quitting f. Remove tobacco products from home 3. Patient was given information on the 1-800-QUIT NOW (www.smokefree.gov)program. Offered patient a referral to Stop Smoking Clinic. Discussed available clinic class schedules with patient. Medication Discussion - Risks and benefits discussed with patient. Offered patient medication to assist with quitting. (Nicotine patches and/or bupropion) Patient desires medication. Will notify prescribing provider. Nicotine patches V17 ALL Weight Management-MOVE!: Most recent weight: 200.9 lb [91.3 kg] (01/19/2016 08:43) Most recent height: 69 in [175.3 cm] (01/19/2016 08:43) Calculated BMI: 29.7 BMI classification Patient does not have documented evidence of exclusion criteria. Health risks of overweight/obesity including heart disease, hypertension, diabetes, arthritis, sleep apnea and/or cancer were discussed. The patient was offered participation in the MOVE! Weight Management Program. Patient is not interested in MOVE! at this time. MOVE! handout "So You're Not Ready Yet" given to patient. V17 N Alcohol Screen: SCREEN FOR ALCOHOL (AUDIT-C) An alcohol screening test (AUDIT-C) was negative (score=0). 1. How often did you have a drink containing alcohol in the past year? Never 2. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? Response not required due to responses to other questions. 3. How often did you have six or more drinks on one occasion in the past year? Response not required due to responses to other questions. V17 N PTSD Screen: Patient's Service Separation Date: APR 16,2005 PC PTSD A PTSD screening test (PTSD 4Q) was positive (score=4). 1. Have had any nightmares about it or thought about it when you did not want to? Yes 2. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? Yes 3. Were constantly on guard, watchful, or easily startled? Yes 4. Felt numb or detached from others, activities, or your surroundings? Yes /es/ Janis N GOMEZ LVN Signed: 01/19/2016 08:54 Receipt Acknowledged By: 01/19/2016 10:07 /es/ MARIBEL B BARREIRO MD 01/20/2016 08:58 /es/ IRVETTE V MENDOZA Irvette V Mendoza, RN ------------------------------------------------------------------------- ========================================================================= Date/Time: 11 Jan 2016 @ 1423 Note Title: PC BEHAVIORAL HEALTH FOLLOW-UP Location: VA Texas Valley Coastal HCS Signed By: LABELLA,KERI A Co-signed By: LABELLA,KERI A Date/Time Signed: 11 Jan 2016 @ 1455 ------------------------------------------------------------------------- LOCAL TITLE: PC BEHAVIORAL HEALTH FOLLOW-UP STANDARD TITLE: MENTAL HEALTH INTERDISCIPLINARY NOTE DATE OF NOTE: JAN 11, 2016@14:23:32 ENTRY DATE: JAN 11, 2016@14:33:55 AUTHOR: LABELLA,KERI A EXP COSIGNER: URGENCY: STATUS: COMPLETED VA TEXAS VALLEY COASTAL BEND HCS - BEHAVIORAL HEALTH LAB FOLLOW UP REPORT CLINIC: MCOPC - Behavioral Health Lab ************************************************************ Last name: Sandoval First name: Edgar Julian Date of interview: 1/11/2016 2:23 PM Method of interview: Telephone Patient's age: 37 Patient's sex: Male ************************************************************ ACTION ITEMS / TREATMENT PLAN: Clinical intervention completed: Care/Medication Management, Goal Setting/Problem-Solving, Education The patient will continue to be monitored. ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ####### RESULTS FOR INDIVIDUAL ASSESSMENTS ####### The remaining sections of the report contain the responses and/or summary information for each assessed domain. The individual responses are based on self-report and should be used in context with other available clinical information. ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ DEPRESSIVE SYMPTOMS (PHQ-9) 1. Little interest or pleasure: Several Days 2. Feeling down or hopeless: Several Days 3. Trouble sleeping: More than half the days 4. Tired, low energy: Several Days 5. Poor appetite, over-eating: Nearly every day 6. Feelings of failure, guilt: More than half the days 7. Trouble concentrating: Nearly every day 8. Motor retardation, agitation: More than half the days 9. Suicidal ideation: Not at all The PHQ-9 total score (measure of depressive symptoms) equals 15 1-4 = minimal symptoms 5-9= mild symptoms 10-14= moderate symptoms 15-19= moderately severe symptoms 20-27= severe depressive symptoms The patient stated that the depressive symptoms made it somewhat difficult to do his work, take care of things at home, or get along with others. The current symptomatology represents a decrease of 1 from the initial PHQ score completed 259 days prior. PHQ Score Over Weeks: 27-| 26-| 25-| 24-| 23-| 22-| 21-| 20-| 19-| 18-| 17-| 16-|0 15-| 37 14-| 13-| 12-| 11-| 10-| 9-| 8-| 7-| 6-| 5-| 4-| 3-| 2-| 1-| 0-| ---------------------------- Visits (weeks since Baseline) 0 - 4/27/2015 37 - 1/11/2016 ********************************************************** ANXIETY SYMPTOMS (GAD-7) Anxiety Scale (anxiety symptoms reported in the last two weeks): 1. Feeling nervous, anxious or on edge: Nearly every day 2. Not being able to stop or control worrying: Nearly every day 3. Worrying too much about different things: Nearly every day 4. Trouble relaxing: Nearly every day 5. Feeling restless (hard to sit still): Nearly every day 6. Becoming easily annoyed or irritable: More than half the days 7. Afraid as if something awful might happen: Nearly every day The patient stated that the anxiety symptoms made it somewhat difficult to do his/her work, take care of things at home, or get along with others. The anxiety total score (general measure of anxiety) equals 20 0-4 =minimal symptoms 5-9=mild symptoms 10-14=moderate symptoms, 15-21=severe symptoms ************************************************************ MEDICATION TREATMENT, ADHERENCE, AND SIDE EFFECTS: The patient is prescribed a psychotropic medication. He reports taking the medication as prescribed. The patient does not report symptoms suggestive of adverse effects of medication. ************************************************************ The VA Texas Valley Coastal Bend HCS - Behavioral Health Lab is directed by Jennifer Wood, Ph.D.. If you have questions please call 956-291-9125. If you have questions regarding this patient's clinical management, please contact Keri LaBella at 956-618-7100 ext 67342. ============================================================================== Mr. Sandoval was called for a follow-up PHQ-9, GAD-7, PCL-C and assessment. Veteran was called as a part of care management. PHQ-9 Score: 15 Previous PHQ-9 SCORE- 7 GAD-7 Score: 20 Previous GAD-7 score 14 PHQ-9 Score today consistent with moderate severe level of depression. GAD-7 score today consistent with severe level of anxiety. In PC MHI care management since: 4/27/2015 PROBLEM: Current medical diagnoses, concerns: Veteran denied. Medication Concerns: veteran denied concerns about medication and denied side effects. Mental and Sleep Status Changes: Veteran states that he is sleeping 11-12 hours per day. Stressors, Strengths and Resources: Veteran is stressed about his financial situation. Veteran states that his car was repossessed. Veteran states that it hurts his pride to be feeling this way. Veteran states that he is feeling a little better with the anxiety medication. Veteran's source of motivation is his children. Veteran states that he has been yelling at his children and he does not want to do that. Behavioral Activation/Pleasant Events Scheduling: Veteran is unable to think about at this time. Other Treatment(Psychotherapy/counselling, etc.): Veteran is interested in therapy to talk about anger and anxiety. Suicidal Ideation: Veteran denied current active suicidal ideation/intent/plan. Patient Education: Veteran was educated about the medication buspirone including side effects and general indications. Veteran was also educated about being kind to himself in a time of need especially in willing to accept charity. RN instructed Veteran that in case of any further problems, questions or concerns, Veteran may call PC-MHI RN in this clinic during working hours. RN instructed Veteran that in case of psychiatric/emotional crisis or medical emergency, Veteran may call 911 and/or go to MMC, ERMC or McAllen Heart Hospital Emergency Room Dept. for evaluation/treatment. Veteran also has contact information for the Veterans Crisis Line 1-800-273-8255 and is aware to press 1 Impression: 1.Diagnosed: PTSD Reports: depression and anxiety 2.Patient identifies target symptom(s) as: anxiety PLAN: 1.Follow through with PC MHI program with phone calls for assessment as indicated: 2.Patient's stated action plan: Veteran stated he would be willing to engage in therapy. 3. Alert MAS staff to schedule appointment for 1/21/2016 at 0830 4. Will discuss case in weekly staff meeting Consults were reviewed and no needs were identified. Time Spent: 22 minutes ----------------------------------------------------------------------- Jan 21,2016 is the Clinically Indicated Date for RTC. ----------------------------------------------------------------------- /es/ KERI A LABELLA BS RN PCMHI Signed: 01/11/2016 14:55 Receipt Acknowledged By: 01/13/2016 15:16 /es/ SUZANNA M SALINAS Medical Support Assistant ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2016 @ 1536 Note Title: PRIMARY CARE SECURE MESSAGING Location: VA Texas Valley Coastal HCS Signed By: BARREIRO,MARIBEL B Co-signed By: BARREIRO,MARIBEL B Date/Time Signed: 05 Jan 2016 @ 1436 ------------------------------------------------------------------------- LOCAL TITLE: PRIMARY CARE SECURE MESSAGING STANDARD TITLE: PRIMARY CARE SECURE MESSAGING DATE OF NOTE: JAN 05, 2016@15:36:34 ENTRY DATE: JAN 05, 2016@14:36:35 AUTHOR: BARREIRO,MARIBEL B EXP COSIGNER: URGENCY: STATUS: COMPLETED ------Original Message------------------------ Sent: 12/29/2015 11:09 AM From: SANDOVAL, EDGAR To: **MOPC Dr Barreiro BLUE Team PC Subject: General Inquiry Morning Dr. Barrerio, I am a patient of yours, I recently went to Florida I drove to and from Florida. I started to have a anxiety attacks during my time at Florida. Then I was in Orlando and started to have flash backs when I was in Iraq, there were people from that part of the world wearing the stuff around there heads, talking there language I felt like I had to get out from where ever I was. I am just scared now that I have went through this an now am even more scared because I am afraid of hurting my family and friends. ------Original Message------------------------ Sent: 01/05/2016 03:36 PM From: BARREIRO, MARIBEL To: SANDOVAL, EDGAR Subject: General Inquiry Per our conversation, please pick up your anxiety medication in the window. You can always go to the behavioral hospital in Edinburg (we have a contract with them) if you feel worse. /es/ MARIBEL B BARREIRO MD Signed: 01/05/2016 14:36 ------------------------------------------------------------------------- --------------------- SELF REPORTED MEDICAL EVENTS ---------------------- Source: Self-Entered No information was available that matched your selection. ----------------------------- VA IMMUNIZATIONS -------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 Your VA Immunizations list may not be complete. If you have any questions about your information, visit the FAQs or contact your VA health care team. ========================================================================= This section shows your five most recent immunization records. Sorted By: Date Received(Descending) Immunization Date Received ------------------------------------------------------------------------- FLU,3 YRS (HISTORICAL) 18 Dec 2008 @ 1357 INFLUENZA, UNSPECIFIED FORMULATION 18 Dec 2008 @ 1357 FLU,3 YRS (HISTORICAL) 04 Dec 2006 @ 1511 INFLUENZA, UNSPECIFIED FORMULATION 04 Dec 2006 @ 1511 INFLUENZA, UNSPECIFIED FORMULATION 05 Dec 2005 @ 1049 ========================================================================= This section shows all of the immunizations listed in your VA health record, grouped by immunization. Sorted By: Immunization Name, then Date (Descending) ------------------------------------------------------------------------- Immunization: FLU,3 YRS (HISTORICAL) Date Received: 18 Dec 2008 @ 1357 Location: MC ALLEN OUTPATIENT CLINIC Reaction:* None Reported Comments: -- Immunization: FLU,3 YRS (HISTORICAL) Date Received: 04 Dec 2006 @ 1511 Location: MC ALLEN OUTPATIENT CLINIC Reaction:* None Reported Comments: -- Immunization: FLU,3 YRS (HISTORICAL) Date Received: 05 Dec 2005 @ 1049 Location: MC ALLEN OUTPATIENT CLINIC Reaction:* None Reported Comments: -- ------------------------------------------------------------------------- Immunization: INFLUENZA, UNSPECIFIED FORMULATION Date Received: 18 Dec 2008 @ 1357 Location: MC ALLEN OUTPATIENT CLINIC Reaction:* NONE Comments: -- Immunization: INFLUENZA, UNSPECIFIED FORMULATION Date Received: 18 Sep 2008 @ 1200 Location: MCALLEN OPC Reaction:* None Reported Comments: -- Immunization: INFLUENZA, UNSPECIFIED FORMULATION Date Received: 04 Dec 2006 @ 1511 Location: MC ALLEN OUTPATIENT CLINIC Reaction:* None Reported Comments: -- Immunization: INFLUENZA, UNSPECIFIED FORMULATION Date Received: 05 Dec 2005 @ 1049 Location: MC ALLEN OUTPATIENT CLINIC Reaction:* NONE Comments: -- ------------------------------------------------------------------------- Immunization: TDAP Date Received: 30 Jul 2014 @ 1030 Location: MCALLEN OPC Reaction:* None Reported Comments: -- ======================================================================== Reaction Key: * = Check information in your VA Allergies and Adverse Reactions as well as your Self Reported Allergies. This may let you know if you had a reaction to an immunization you received. -------------------- SELF REPORTED IMMUNIZATIONS ------------------------ Source: Self-Entered No information was available that matched your selection. ------------------------- VA LABORATORY RESULTS ------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 Sorted By: Date Specimen Collected (Descending) Lab Test(Alphabetical Order), then Time Specimen Collected VA Laboratory Results are available 3 calendar days after they have been verified. For some tests, results slightly outside the reference range are not unusual. In addition, not all results are clinically significant. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Lab Test: Microalbumin~PANEL Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Urine (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: CREATININE Result: 121.55 Units: mg/dL Reference Range: (60.00-200.00) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MICROALBUMIN Result: 22 Units: mg/L Reference Range: (><500) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MICROALBUMIN/CREAT RATIO Result: 18.1 Units: mg/G Reference Range: Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: TOTAL PROTEIN SCREEN Result: NEGATIVE Units: -- Reference Range: (NEG) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ========================================================================= Lab Test: Prostate Specific Ag Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Serum (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: PROSTATIC SPECIFIC ANTIGEN Result: 0.71 Units: ng/mL Reference Range: (0.00-4.00) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ========================================================================= Lab Test: Urinalysis Chemical w o micro Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Urine (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: APPEARANCE Result: Clear Units: -- Reference Range: (CLEAR) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: SPECIFIC GRAVITY Result: 1.010 Units: -- Reference Range: (<1.030) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE BILIRUBIN Result: Negative Units: -- Reference Range: (NEG.) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE BLOOD Result: Negative Units: -- Reference Range: (NEG.) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE COLOR Result: Yellow Units: -- Reference Range: (YELLOW) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE GLUCOSE Result: Negative Units: -- Reference Range: (NEG.) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE KETONES Result: Negative Units: -- Reference Range: (NEG.) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE LEUKOCYTE ESTERASE Result: Negative Units: -- Reference Range: (NEG) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE NITRITE Result: Negative Units: -- Reference Range: (NEG) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE PH Result: 6.0 Units: -- Reference Range: (5-8) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: URINE PROTEIN Result: Negative Units: -- Reference Range: (NEG.) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: UROBILINOGEN Result: Negative Units: EU/dL Reference Range: (0.2-1.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ========================================================================= Lab Test: Hemogram V Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Blood (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: BASOPHILE, ALTERNATE % Result: 0.9 Units: % Reference Range: (0.0-1.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: BASOPHILE, ALTERNATE ABS Result: 0.1 Units: 10.e3/uL Reference Range: (0.0-0.1) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: EOSINOPHIL, ALTERNATE % Result: 2.1 Units: % Reference Range: (0.0-6.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: EOSINOPHIL, ALTERNATE ABS Result: 0.1 Units: 10.e3/uL Reference Range: (0.0-0.4) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: HCT Result: 43.2 Units: % Reference Range: (41-53) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: HGB Result: 14.6 Units: g/dL Reference Range: (13.5-17.5) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: LYMPHOCYTE, ALTERNATE % Result: 21.9 Units: % Reference Range: (16.0-44.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: LYMPHOCYTE, ALTERNATE ABS Result: 1.3 Units: 10.e3/uL Reference Range: (0.9-3.1) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MCH Result: 30.4 Units: pg Reference Range: (26-34) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MCHC Result: 33.8 Units: gm/dL Reference Range: (32.0-36.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MCV Result: 89.9 Units: fl Reference Range: (78.0-98.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MONOCYTE, ALTENATE ABS Result: 0.4 Units: 10.e3/uL Reference Range: (0.2-0.8) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MONOCYTE, ALTERNATE % Result: 7.0 Units: % Reference Range: (3.0-12.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: MPV Result: 8.8 Units: fl Reference Range: (6.3-10.8) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: NEUTROPHIL, ALTERNATE % Result: 68.1 Units: % Reference Range: (44.0-75.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: NEUTROPHIL, ALTERNATE ABS Result: 4.0 Units: 10.e3/uL Reference Range: (1.8-6.5) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: PLTS Result: 174 Units: 10.e3/uL Reference Range: (150-400) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: RBC Result: 4.80 Units: 10.e6/uL Reference Range: (4.5-5.9) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: RDW Result: 13.3 Units: % Reference Range: (11.5-16.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: WBC Result: 5.9 Units: 10.e3/uL Reference Range: (4-10) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ------------------------------------------------------------------------- Comments: AUTOMATED DIFFERENTIAL ONLY. ========================================================================= Lab Test: Thyroid Stimulating Hormone Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Plasma (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: TSH Result: 1.21 Units: uIU/mL Reference Range: (0.27-4.20) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ========================================================================= Lab Test: Thyroxine Free (FT4) Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Plasma (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: FREE T4 Result: 1.13 Units: -- Reference Range: Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ========================================================================= Lab Test: Comprehensive Met Panel Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Plasma (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: ALBUMIN Result: 4.2 Units: g/dL Reference Range: (3.0-4.6) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: ALKALINE PHOSPHATASE Result: 62 Units: IU/L Reference Range: (42-113) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: ALT Result: 25 Units: IU/L Reference Range: (5-40) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: AST Result: 25 Units: IU/L Reference Range: (13-47) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: CALCIUM Result: 9.3 Units: mg/dL Reference Range: (8.6-10.3) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: CHLORIDE Result: 101 Units: mmol/L Reference Range: (97-112) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: CO2 Result: 29.3 Units: mmol/L Reference Range: (23-33) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: CREATININE Result: 0.86 Units: mg/dL Reference Range: (.7-1.2) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: GLUCOSE Result: 110 Units: mg/dL Reference Range: (75-110) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: POTASSIUM Result: 4.3 Units: mmol/L Reference Range: (3.5-5.0) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: PROTEIN,TOTAL Result: 7.7 Units: g/dL Reference Range: (6.1-8.2) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: SODIUM Result: 137.4 Units: mmol/L Reference Range: (133-145) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: TOTAL BILIRUBIN Result: 0.5 Units: mg/dL Reference Range: (0.3-1.1) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: UREA NITROGEN Result: 8 Units: mg/dL Reference Range: (6-23) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: eGFR Result: 99.5 Units: COMMENT Reference Range: (>60) Interpretation: Units= mL/min/1.73 m2 A eGFR OF 60 mL/min/1.73 m2 OR HIGHER IS IN THE NORMAL RANGE. Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ========================================================================= Lab Test: Lipid Panel Lab Type: Chemistry/Hematology Ordering Provider: BARREIRO, MARIBEL Ordering Location: MCALLEN OPC Specimen: Plasma (substance) Date/Time Collected: 18 Jul 2016 @ 0856 Collected Location: MCALLEN OPC ------------------------------------------------------------------------- Test Name: HDL Result: 44.2 Units: mg/dL Reference Range: (35.0-100.0) Interpretation: DESIRED LEVEL = >35 mg/dL. Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: LDL-CHOL CALCULATION Result: 119.6 Units: mg/dL Reference Range: (><100) Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: TOTAL CHOLESTEROL Result: 182 Units: mg/dL Reference Range: (0-200) Interpretation: DESIRED LEVEL = <200 mg/dl B0RDERLINE HIGH RISK = 200-240 mg/dL HIGH RISK = >240 mg/dL (NATIONAL CHOLESTEROL EDUCATION PROGRAM--1988) Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: TRIGLYCERIDE Result: 91 Units: mg/dL Reference Range: (0-200) Interpretation: TG>1200 mg/dL ARE REPORTED AS "LDLD NOT PERFORMED WHEN TRIG >1200". Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ---------------------- Test Name: VLDL CHOLESTEROL Result: 18.2 Units: mg/dL Reference Range: Interpretation: -- Performing Location: MCALLEN OPC 901 E. HACKBERRY AVE , MCALLEN, TX 78503-1272 Status: Final ========================================================================= ------------------------- VA PATHOLOGY REPORTS -------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 No information was available that matched your selection. However, if you recently had a VA pathology specimen collected, the reports may be available 14 calendar days after they have been completed. Some studies done at a non-VA facility may not be available or they may not necessarily include an interpretation. -------------------- SELF REPORTED LABS AND TESTS ----------------------- Source: Self-Entered No information was available that matched your selection. ------------------------ VA VITALS AND READINGS ------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 VA Vitals and Readings displays your vital signs and other health readings. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= This section shows your most recent record for each vital sign and health reading. Vital Sign or Health Reading Measurement Date/Time Collected ------------------------------------------------------------------------- Blood Pressure 131/82 mm[Hg] 25 Jul 2016 @ 1004 Pulse Rate 84 /min 25 Jul 2016 @ 1004 Respiration 18 /min 25 Jul 2016 @ 1004 Temperature 98.3 F 25 Jul 2016 @ 1004 Pain Level 3 25 Jul 2016 @ 1004 Height 69 in 25 Jul 2016 @ 1004 Weight 196.6 lb 25 Jul 2016 @ 1004 ========================================================================= This section shows all of the vital signs and health readings listed in your VA health record based on the dates you selected when you requested your VA Blue Button. They are grouped by the type of vital sign or health reading. Sorted By: Type of Vital Sign or Health Reading, then Date/Time (Descending) ----------------------------------------------------------- Vital Sign: Blood Pressure Measurement: 131/82 mm[Hg] Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 Vital Sign: Blood Pressure Measurement: 127/82 mm[Hg] Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 31 May 2016 @ 0830 Vital Sign: Blood Pressure Measurement: 131/77 mm[Hg] Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 26 May 2016 @ 0906 Vital Sign: Blood Pressure Measurement: 133/80 mm[Hg] Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 26 May 2016 @ 0905 Vital Sign: Blood Pressure Measurement: 117/71 mm[Hg] Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 19 Jan 2016 @ 0843 ----------------------------------------------------------- Vital Sign: Temperature Measurement: 98.3 F Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 Vital Sign: Temperature Measurement: 98.6 F Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 31 May 2016 @ 0830 Vital Sign: Temperature Measurement: 98.2 F Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 19 Jan 2016 @ 0843 ----------------------------------------------------------- Vital Sign: Height Measurement: 69 in Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 Vital Sign: Height Measurement: 68 in Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 31 May 2016 @ 0830 Vital Sign: Height Measurement: 68 in Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 26 May 2016 @ 0905 Vital Sign: Height Measurement: 69 in Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 19 Jan 2016 @ 0843 ----------------------------------------------------------- Vital Sign: Pain Level Measurement: 3 Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 Vital Sign: Pain Level Measurement: 7 Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 31 May 2016 @ 0830 Vital Sign: Pain Level Measurement: 0 Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 19 Jan 2016 @ 0843 ----------------------------------------------------------- Vital Sign: Pulse Oximetry Measurement: 98 % Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 ----------------------------------------------------------- Vital Sign: Pulse Rate Measurement: 84 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 Vital Sign: Pulse Rate Measurement: 84 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 31 May 2016 @ 0830 Vital Sign: Pulse Rate Measurement: 80 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 26 May 2016 @ 0906 Vital Sign: Pulse Rate Measurement: 73 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 26 May 2016 @ 0905 Vital Sign: Pulse Rate Measurement: 78 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 19 Jan 2016 @ 0843 ----------------------------------------------------------- Vital Sign: Respiration Measurement: 18 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 Vital Sign: Respiration Measurement: 16 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 31 May 2016 @ 0830 Vital Sign: Respiration Measurement: 18 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 26 May 2016 @ 0905 Vital Sign: Respiration Measurement: 20 /min Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 19 Jan 2016 @ 0843 ----------------------------------------------------------- Vital Sign: Weight Measurement: 196.6 lb Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 25 Jul 2016 @ 1004 Vital Sign: Weight Measurement: 199.2 lb Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 31 May 2016 @ 0830 Vital Sign: Weight Measurement: 201.5 lb Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 26 May 2016 @ 0905 Vital Sign: Weight Measurement: 200.9 lb Comments: -- Location: VA Texas Valley Coastal HCS Date/Time Collected: 19 Jan 2016 @ 0843 -------------------- SELF REPORTED VITALS AND READINGS ------------------ Source: Self-Entered No information was available that matched your selection. -------------------------- VA RADIOLOGY REPORTS ------------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 Sorted By: Date/Time Exam Performed (Descending) VA Radiology Reports are available 3 calendar days after they have been completed. Some studies done at a non-VA facility may not be available or they may not necessarily include an interpretation. If you have any questions about your information please visit the FAQs or contact the provider who ordered the study or your primary care provider. ========================================================================= Procedure/Test Name: KNEES, AP STANDING BILAT Date/Time Exam Performed: 31 May 2016 @ 0957 Ordering Location: VA Texas Valley Coastal HCS Requesting Provider: AFZAL,ZEESHAN Reasons for Study: RIGHT KNEE PAIN Clinical History: PAIN Performing Location: VA Texas Valley Coastal HCS 2106 TREASURE HILLS BLVD, HARLINGEN 78550 Radiologist: SOKOLOFF,RONALD M -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Exam: KNEE 3 VIEWS, KNEES, AP STANDING BILAT History: Right knee pain Comparison: None FINDINGS Osseous Structures: Unremarkable Joint Spaces: Unremarkable Soft Tissues: Unremarkable Other: N/A Impression: 1. Unremarkable exam. Signed by Ronald Sokoloff, MD on 5/31/2016 10:17 AM CDT Primary Diagnostic Code: ========================================================================= Procedure/Test Name: KNEE 3 VIEWS Date/Time Exam Performed: 31 May 2016 @ 0956 Ordering Location: VA Texas Valley Coastal HCS Requesting Provider: AFZAL,ZEESHAN Reasons for Study: Right knee pain Clinical History: Right knee pain Performing Location: VA Texas Valley Coastal HCS 2106 TREASURE HILLS BLVD, HARLINGEN 78550 Radiologist: SOKOLOFF,RONALD M -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Exam: KNEE 3 VIEWS, KNEES, AP STANDING BILAT History: Right knee pain Comparison: None FINDINGS Osseous Structures: Unremarkable Joint Spaces: Unremarkable Soft Tissues: Unremarkable Other: N/A Impression: 1. Unremarkable exam. Signed by Ronald Sokoloff, MD on 5/31/2016 10:17 AM CDT Primary Diagnostic Code: ========================================================================= ------------------ VA ELECTROCARDIOGRAM (EKG) REPORTS ------------------- Source: VA Last Updated: 03 Jan 2017 @ 1444 No information was available that matched your selection. ------------------ SELF REPORTED FAMILY HEALTH HISTORY ------------------ Source: Self-Entered Relationship: Self First Name: EDGAR Last Name: SANDOVAL Living or Deceased: Living Health Issues: ----------------------------- Other Health Issues: ----------------------------- Comments: ------------------ SELF REPORTED MILITARY HEALTH HISTORY ---------------- Source: Self-Entered No information was available that matched your selection. -------------------- SELF REPORTED ACTIVITY JOURNAL --------------------- Source: Self-Entered No information was available that matched your selection. ----------------------- SELF REPORTED FOOD JOURNAL ---------------------- Source: Self-Entered No information was available that matched your selection. -------------------- DoD Military Service Information ------------------- Source: DoD Last Updated: 03 Jan 2017 @ 1439 NOTES: 1) This report may not show your complete DoD Military Service Information. For more information go to the FAQ tab. Data prior to establishment of DEERS and full service reporting (c. 1980) may not appear. 2) It is normal for the begin/end dates in DoD records, adjusted by the Personnel Center after separation, to vary slightly from the DD-214. 3) No peacetime deployments will be displayed. For Gulf War I, only one period will be displayed even if you deployed more than once. No conflict prior to Gulf War I will be displayed. Kosovo, Bosnia, and Southern Watch data is incomplete and may not display. 4) For Guard/Reserve, periods of active duty may not display. No periods of Active duty service less than 30 days will display. -- Regular Active Service Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 04/17/2002 04/16/2005 Honorable PFC -- Reserve/Guard Association Periods Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 04/17/2005 05/11/2010 Honorable SP4 -- Reserve/Guard Activation Periods Service Begin Date End Date Activated Under (Title 10, 32, etc.) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Deployment Periods Service Begin Date End Date Conflict Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 02/08/2003 08/23/2003 OEF/OIF Kuwait -- DoD MOS/Occupation Codes -- Note: Both Service and DoD Generic codes may not be present in all records Service Begin Date Enl/Off Type Svc Occ Code DoD Occ Code - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 04/17/2002 Enlisted Primary 77F1O 821 Army 05/31/2002 Enlisted Duty 77F1O 821 Army 07/31/2002 Enlisted Duty 77F1 821 Army 10/31/2002 Enlisted Primary 77F1OH7 821 Army 12/31/2002 Enlisted Duty 77F1O 821 Army 10/31/2003 Enlisted Primary 92F1OH7 821 Army 10/31/2003 Enlisted Duty 92F1O 821 Army Reserve 04/17/2005 Enlisted Primary 92F1 H7 821 Army Reserve 04/17/2005 Enlisted Primary 92F1 H7 821 Army Reserve 10/14/2005 Enlisted Primary 92F0 H7 950 Army Reserve 10/14/2005 Enlisted Duty 92F1O 821 Army Reserve 11/30/2005 Enlisted Primary 92F1 Y2 821 Army Reserve 08/31/2006 Enlisted Duty 92F1OY2 821 Army Reserve 10/31/2006 Enlisted Duty 92F1OH7 821 Army Reserve 01/24/2007 Enlisted Primary 92F1 D3 821 Army Reserve 02/09/2007 Enlisted Primary 92F1 H7 821 Army Reserve 02/09/2007 Enlisted Duty 92A1O 551 Army Reserve 02/28/2007 Enlisted Primary 92F1 Y2 821 Army Reserve 11/02/2007 Enlisted Primary 92F1 H8 821 Army Reserve 05/27/2008 Enlisted Primary 92F1 F5 821 Army Reserve 05/27/2008 Enlisted Duty 92F1OF5 821 Army Reserve 05/31/2008 Enlisted Primary 92F1 Y2 821 Army Reserve 05/31/2008 Enlisted Duty 92F1OY2 821 Army Reserve 09/23/2008 Enlisted Duty 92F1 Y2 821 Army Reserve 10/24/2008 Enlisted Primary 92F1 2B 821 Army Reserve 10/24/2008 Enlisted Duty 92F1O2B 821 Army Reserve 10/31/2008 Enlisted Primary 92F1 Y2 821 Army Reserve 10/31/2008 Enlisted Duty 92F1OY2 821 Army Reserve 11/19/2008 Enlisted Duty 92A1O 551 Army Reserve 02/06/2009 Enlisted Duty 92A1 Y2 551 -- Military/Combat Pay Details Service Begin Date End Date Military Pay Type Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 02/01/2003 08/31/2003 02 Army 02/01/2003 08/31/2003 01 Kuwait -- Separation Pay Details Service Begin Date End Date Separation Pay Type - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Retirement Periods Service Begin Date End Date Retirement Type Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- DoD Retirement Pay Service Begin Date End Date Dsblty % Pay Stat Term Rsn Stop Pay Rsn - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Translations of Codes Used in this Section: Service Occupation Codes DoD Occupation Codes 551 Enlisted Supply Administration 821 Enlisted Missile Fuel and Petroleum 950 Enlisted Not Occupationally Qualified, General Military Pay Type Code 01 Combat Zone Tax Exclusion (CZTE) 02 Hostile Fire/Imminent Danger 03 Hazardous Duty incentive Separation Pay Type Code 01 Separation Pay 02 Readjustment Pay 03 Non-Disability Severance Pay 04 Disability Severance Pay 05 Discharge Gratuity 06 Death Gratuity 07 Special Separation Benefit 08 Voluntary Separation Incentive Pay 09 Voluntary Separation Pay (VSP) Retirement Type Code A Mandatory B Voluntary C Fleet Reserve D Temporary Disability Retirement List E Permanent Disability Retirement List F Title III G Special Act H Philippine Scouts Z Unknown Retired Pay Status Code 1 Receiving retired pay 2 Eligible, not receiving pay 3 Eligible, not receiving direct SBP remittance 4 Terminated 5 Suspended Retired Pay Termination Reason Code C Pay condition terminated S Pay terminated for the reason reported in the Stop Payment Reason Code W Not terminated Stop Payment Reason Code A Member died B Recalled to Active Duty C Removed from TDRL, returned to Active Duty D Removed from TDRL, returned to Civilian E Pay suspended, failure to report for TDRL physical F Civil Service retirement waiver G VA compensation waiver H Dual compensation, pay cap offset J Refused retired pay K Pay suspended, whereabouts unknown L Suspected death M Pay suspended, miscellaneous Z Not applicable -------------------- SELF REPORTED MY GOALS: CURRENT GOALS --------------- Source: Self-Entered Sorted By: Priority, then by Goal Start Date (Descending) Remember to share your self-entered information with your VA health care team. This section contains your My Goals: Current Goals information included in the date range selected when you requested your VA Blue Button. ========================================================================== ALL CURRENT GOALS - SUMMARY LIST (BY PRIORITY) -------------------------------------------------------------------------- None Entered ---------------- SELF REPORTED MY GOALS: COMPLETED GOALS -------------- Source: Self-Entered Sorted By: Date Goal Completed (Descending) Remember to share your self-entered information with your VA health care team. This section contains your My Goals: Completed Goals information included in the date range selected when you requested your VA Blue Button. ========================================================================== COMPLETED GOALS - SUMMARY LIST (BY DATE GOAL COMPLETED) -------------------------------------------------------------------------- None Entered ----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------