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ptsd Chronic Fatigue Syndrome C&p Progress Notes
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Question
mekon1971
Review of Medical Records
C-file review was requested by VARO but not available.
Medical Record review was requested by VARO but not available.
C-File Was: Requested by VARO but not available
Medical Records were: Requested by VARO but not available
Medical History:
Symptom(s):
Generalzed weakness, migratory joint pains, sleep disturbance, inability to concentrate, forgetfulness
Frequency of
Generalized weakness: Frequent
Migratory Joint Pains: Frequent
Sleep Disturbance: Frequent
Inability to concentrate: Frequent
Forgetfulness: Frequent
Physical Exam:
Vital Signs
Temperature: Normal
Pulse: 76 bpm
Respiratory Rate: 24
Blood Pressure: 160/100
Weight: 310 - pounds
Weight Change: Gain
is there evidence of pharyngitis? YES
Is there cervical lymphadenopathy? No
Is there axillary lymphadenopath? No
TESTS
Where the results of all tests included in the exam report? NO
Diagnosis:
Employment History
Usual Occupation: On SS since 2009 because of PTSD
Is the Veteran currently employed? No
Retired? No
Is the veteran unemployed but not retired? Yes
Duration of Current Unemployment: 2009
Reasons given for Unemployment: PTSD
Has the criterion of new onset of debilitating fatigue that is severe enough to reduce or impair average daily activity below 50 percent of the patient's preillness activity level for a period of 6 months been met? NO
Has the criterion that other clinical conditions that may produce similar symptoms have been excluded by thorough evaluation, based on history, physical examination, and appropriate laboratory tests been met? No
Have at least 6 of 10 Chronic Fatigue Syndrom diagnostic criteria been met? NO
Was a medical opinion requested? No
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