ptsd Chronic Fatigue Syndrome C&p Progress Notes

[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