Just got the notes tonight, he didn't seem very friendly..I think this did not go well:
Is this DBQ being completed in conjunction with a VA 21-2507,
C&P Examination
Request?
[X] Yes [ ] No
SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed
with a mental
disorder(s)?
[X] Yes [ ] No
If the Veteran currently has one or more mental disorders
that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Unspecified Anxiety Disorder
with Panic
Attacks Specifier
ICD code: F41.9
b. Medical diagnoses relevant to the understanding or management
of the
Mental Health Disorder (to include TBI): Noncontributory
2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder
diagnosed?
[ ] Yes [X] No
c. Does the Veteran have a diagnosed traumatic brain injury
(TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
3. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of
occupational
and social impairment with regards to all mental diagnoses?
(Check only
one)
[X] Occupational and social impairment due to mild or
transient symptoms
which decrease work efficiency and ability to perform
occupational
tasks only during periods of significant stress, or;
symptoms
controlled by medication
b. For the indicated level of occupational and social
impairment, is it
possible to differentiate what portion of the occupational
and social
impairment indicated above is caused by each mental disorder?
[ ] Yes [ ] No [X] No other mental disorder has been
diagnosed
c. If a diagnosis of TBI exists, is it possible to differentiate
what portion
of the occupational and social impairment indicated above is
caused by the
TBI?
[ ] Yes [ ] No [X] No diagnosis of TBI
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
2. History
----------
a. Relevant Social/Marital/Family history (pre-military,
military, and
post-military):
The veteran was born and raised in Minnesota but moved
around a lot,
ending up in various places in MN. His father was not in
his life very
much. His mother worked for international Dairy Queen and
later as a
pharmacy technician. His parents divorced when he was about
6 and he
remained with his mother. He noted a couple of stepfathers
in his life
and they were generally okay. He has 2 sisters and 2
brothers. He
described a good childhood.
He has never been married. He has 1 child, 1, with his
girlfriend and
she has a child, 5. He and his girlfriend and children live
in
Janesville.
b. Relevant Occupational and Educational history (pre-military,
military, and
post-military):
The veteran graduated from high school in 2008. He attended
basic
training during the summer of his junior year; June and
July 2007,
finished school, then went back for AIT in September 2008
until December
2008. He was trained as an aviation operations specialist.
Following discharge from the Air National Guard he tried
school a few
times but dropped out. He said he has worked numerous jobs
but because
of anxiety and panic attacks isn't able to keep them. For
the last year
he has been working with the Geek squad which he said is
generally going
okay.
c. Relevant Mental Health history, to include prescribed
medications and
family mental health (pre-military, military, and post-
military):
The veteran noted that his father possibly had some mental
health issues
as well as being alcoholic.
The veteran said he has never been hospitalized
psychiatrically nor had
any counseling.
He said he started medications in 2011, on Paxil and Xanax
when
necessary. He is currently on Lexapro, Wellbutrin, and
hydroxyzine as
needed.
d. Relevant Legal and Behavioral history (pre-military,
military, and
post-military):
The veteran noted that he was charged with careless driving
in 2007 as
his blood alcohol was 0.07. He was also arrested in 2012
for driving
without insurance and missing a court date. In 2017 his ex-
girlfriend
went out of state with their child and they had a domestic
incident. He
is on probation for 2 years.
He denied any homicidal ideation. He said he had some
suicidal thoughts
on and off since he was 17. He is not currently suicidal.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
The veteran noted that he used marijuana at times
recreationally but not
for the past 3 years. He noted social drinking in the past
but said he
never drank heavily.
f. Other, if any:
The veteran served in the Air National Guard, completing
basic training
between June 2007 and August 2007 and AIT from September
2008 until
December 2008. He was trained as a aviation operations
specialist.
He left the Air National Guard in 2014. He said he broke
down in front
of his CO noting that he could no longer deal with the
service because
he felt that the weekend drills had become "mentally
torturing."
The veteran submitted in his statement:
During our training in 2007 there was a soldier threatening
to kill us
by hiding M16 rounds. That soldier was brought into the
Drill sergeants
office and a fight broke out. He was sent to a Mental
Hospital by MP's
for the entirety of our training most likely longer.
Between that
incident
and the numerous heat casualties I was witnessing on a near
daily basis
I began feeling like I was going to faint all the time
along with
difficulty breathing
and heart palpitations. I checked
myself into
Winder Medical Clinic on Ft. Benning and spoke to a female
doctor. She
said I may have vertigo and proceeded to transfer me to a
hospital
through an ambulance since I was having a sever panic
attack. I received
treatment at both facilities and ever since I have had
recurring issues
on a daily basis with Anxiety/PTSD. Standing in formation
would make
me feel like I'm going to faint or cause a panic attack
where I would be
forced to sit down no matter the consequence. There were
two deaths
of heat strokes possibly more during my stay at Ft.
Benning.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply
to the
Veteran's diagnoses:
[X] Anxiety
[X] Panic attacks that occur weekly or less often
[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
4. Behavioral observations
--------------------------
The veteran was casually dressed, appropriately groomed. Affect:
Congruent
and oddly engaging. Oriented X 4. Thought processes, generally
goal
directed. There were no perceptual disturbances.
The veteran noted that he is anxious "24/7" though I noted he
did not appear
anxious today. He said that is because he is on medications and
also does
meditation. He notes panic attacks occurring at least weekly. He
notes low
motivation at times to do things.
Voice and speech, within normal limits. Intelligence level
likely average.
There was no psychomotor agitation nor retardation observed.
Memory,
generally intact.
He goes to bed about 9 PM with some sleep continuity
disturbance, noting that
they have a 1-year-old. His appetite is poor though weight has
been stable.
Concentration is difficult at times. His mood is lethargic. His
energy level
is low.
He gets up about 6 AM. He works full time. He socializes on a
limited basis
noting he has difficulty with relationships and can't do a lot
of things
because of his anxiety. He said he stays home a lot.
He notes current stressors involve being on probation and
difficulty dealing
with people.
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental
disorders
that are not listed above?
[X] Yes [ ] No
If yes, describe:
There are likely personality disorder issues; deferred, and
not diagnosed
at this time.
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
---------------------------------------------------
STRs note the veteran was seen in July 2007 during basic
training reporting
chest pain. Records note he was told he had a small heart murmur
but it was
nothing serious. He was reportedly referred to his PCP.
There is also a reference during a periodic health assessment
about July 2007
indicating that he reacted to bee stings with "swell up, hives,
and anxiety."
There were no mental health issues noted in that report or
others.
Veteran seen at the Family Medical Center in 2011 noting anxiety
and panic
attacks in class.
Records from Lakeview in 2013-14 note diagnoses of generalized
anxiety
disorder and panic disorder.
The veteran has continued to be seen at Lakeview with diagnoses
of
generalized anxiety disorder and panic attacks. The intake exam
noted no
history of depression, mania, or psychosis. He reported no
suicidal thoughts
or suicidal intention. He reported no substance abuse. He noted
at that time
that he had been diagnosed with anxiety in the military at age
18.
In summary, the veteran meets ICD 10 diagnostic criteria for
Unspecified
Anxiety Disorder with Panic Attacks Specifier. This condition is
less likely
than not related to the veteran's report of anxiety in the
service noting
that there are no references to anxiety during his service time
other than
chest pains, possibly related to a small heart murmur. Records
suggest that
his primary anxiety issues began in 2011, much of it related to
work,
relationships, and psychosocial stressors.
the doctor notes that Records
suggest that
my primary anxiety issues began in 2011, much of it related to
work,
relationships, and psychosocial stressors.
However he never asked me how i was after basic training until that time like monthly drills and annual training. I was very disorganized and spacy, anxious, and reclusive. frequently missing drills, I told myself my mental health is more important than
them being mad at me for staying home. That was the case for everything including work and relationships, and still is to this day. I feel like i'm off to a terrible start to this claim.
Question
mnsoldier89
Just got the notes tonight, he didn't seem very friendly..I think this did not go well:
the doctor notes that Records
suggest that
my primary anxiety issues began in 2011, much of it related to
work,
relationships, and psychosocial stressors.
However he never asked me how i was after basic training until that time like monthly drills and annual training. I was very disorganized and spacy, anxious, and reclusive. frequently missing drills, I told myself my mental health is more important than
them being mad at me for staying home. That was the case for everything including work and relationships, and still is to this day. I feel like i'm off to a terrible start to this claim.
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