Axis 1: Post-traumatic stress disorder. alcohol dependence, in remission.
Axis 2: None.
Axis 3: Per medical records.
Axis 4: None.
Axis 5: Current global assessment of functioning of 75.
Capacity to manage financial affairs: this man can manage his financial affairs in his own best interest.
Other opinion: In my opinion, this man has post traumatic stress disorder as a direct result of his time in Iraq.
Effects on Occupational and Functioning: In my opinion this man's occupational functioning is no affected. His social functioning is affected slightly.
It looks like the Phyciatriast c&p reported to the normal MD c&p and the most notable items the MD c&p states is:
1. there is no physical evidence of a undiagnosable disease or verifiable undiagnosable conditions. Therefore, there is no evidence for a specific Gulf War syndrome.
2. There is evedence for PTSD or at least a significant nighttime physiological distress and this must be evaluated by psychiatry.
3. He has morning headaches consistent with sleep apnea or night anxiety and hypertension.
4. There is no significant tooth decay noted.
5. It appears as likely than not that he has gastroesophageal reflux, but he has not been tested for this and has not had a trial of medications.
6. He has normal right ear examination.
7. He has allergic type or mildly reactive mucosa in the mouth consistant with allergies/ reflux.
8. there is a history of non-cardiac chest pain but nothing consistant. an impression would be this is more likely to be gastroesophageal reflux.
9. there is a finding of rib tenderness, third rib on the right, but this is a normal variant and is not associated with his chest pain.
10. there is no lateralization of the neurologic signs or findings, right side versus the left, and no difference in sensation.
11. he does not meet the criteria for ibs, he has very mild hardening of stools one day a week, and some soft stools eith vague abdominal pain that goes away with the bowel movement.
12. no rash is observed on the legs or wlsewhere.
13. fourth toe on the left foot will be evaluated under a different claim and was not examined.
14. Mild obstructive sleep apnea as confirmed by sleep study, sleep disturbance appears affected.
Question
Chris111
Hi my Diagnosis from the PTSD C&P state:
Axis 1: Post-traumatic stress disorder. alcohol dependence, in remission.
Axis 2: None.
Axis 3: Per medical records.
Axis 4: None.
Axis 5: Current global assessment of functioning of 75.
Capacity to manage financial affairs: this man can manage his financial affairs in his own best interest.
Other opinion: In my opinion, this man has post traumatic stress disorder as a direct result of his time in Iraq.
Effects on Occupational and Functioning: In my opinion this man's occupational functioning is no affected. His social functioning is affected slightly.
It looks like the Phyciatriast c&p reported to the normal MD c&p and the most notable items the MD c&p states is:
1. there is no physical evidence of a undiagnosable disease or verifiable undiagnosable conditions. Therefore, there is no evidence for a specific Gulf War syndrome.
2. There is evedence for PTSD or at least a significant nighttime physiological distress and this must be evaluated by psychiatry.
3. He has morning headaches consistent with sleep apnea or night anxiety and hypertension.
4. There is no significant tooth decay noted.
5. It appears as likely than not that he has gastroesophageal reflux, but he has not been tested for this and has not had a trial of medications.
6. He has normal right ear examination.
7. He has allergic type or mildly reactive mucosa in the mouth consistant with allergies/ reflux.
8. there is a history of non-cardiac chest pain but nothing consistant. an impression would be this is more likely to be gastroesophageal reflux.
9. there is a finding of rib tenderness, third rib on the right, but this is a normal variant and is not associated with his chest pain.
10. there is no lateralization of the neurologic signs or findings, right side versus the left, and no difference in sensation.
11. he does not meet the criteria for ibs, he has very mild hardening of stools one day a week, and some soft stools eith vague abdominal pain that goes away with the bowel movement.
12. no rash is observed on the legs or wlsewhere.
13. fourth toe on the left foot will be evaluated under a different claim and was not examined.
14. Mild obstructive sleep apnea as confirmed by sleep study, sleep disturbance appears affected.
advice please on what to expect?
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