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Now Waiting Game For Me?


bojack

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This veteran's C&P exam was recently completed by MSLA, under the
national DEM contract. Please refer to the C&P exam, which has been emailed in a PDF
format to the initiating Regional Office.
I just finished all my C&P exams 2 weeks ago.
More TBI follow up....
CC/HPI: h/o TBI. In 2005 fell 2 stories when stairway collapsed, loc unknown
duration. Was awoken and helped up by colleague. Was evaluated in field and then
sent back out. In 2007 fell 2+ stories from ladder of guard tower more than 2
stories, loc (unknown duration) and woke up on ground. Was evaluated in field
then sent back out.
**reports extreme light and glare sensitivity indoors and outdoors. Reports the
new sunglasses he got do not help him enough. LEE 4/11/14 VA LB.
**reports much difficulty with near work, especially reading. Reports letters
float on page, int diplopia, blur, headache and at times nausea when attempting
to read for long periods of time
INCOMING OCULAR HISTORY: photophobia
FAMILY OCULAR HISTORY:
(-) Glaucoma
(-) Blindness
(-) Age Related Macular Degeneration
OCULAR MEDICATIONS: none
INCOMING SYSTEMIC/PSYCHOLOGICAL HISTORY:
Computerized Problem List is the source for the following:
1. Laceration NEC (ICD-9-CM E928.9) 10/05/11 HECHANOVA,DEM
2. Headache 02/06/14 LEE,SE-YOUNG
3. Tinnitus 02/06/14 LEE,SE-YOUNG
4. Neck pain 02/06/14 LEE,SE-YOUNG
5. Chronic low back pain 02/06/14 LEE,SE-YOUNG
6. Foot pain 02/06/14 LEE,SE-YOUNG
7. Knee pain 02/06/14 LEE,SE-YOUNG
8. Insomnia 02/06/14 LEE,SE-YOUNG
9. Chronic rhinitis 02/06/14 LEE,SE-YOUNG
10. Traumatic brain injury with brief loss of 03/05/14 HAGER,GILBERT
P
consciousness
11. Other Signs and Symptoms Involving Cognition 03/05/14 HAGER,GILBERT
P
12. Posttraumatic stress disorder (SNOMED CT 05/29/14 HAGER,GILBERT
P
47505003)
13. Pain in joint involving shoulder region 05/29/14 HAGER,GILBERT
P
14. MDD, Recurrent, Moderate 07/17/14 WANGEN,KERRY
E
SYSTEMIC MEDICATIONS:
Active Outpatient Medications (including Supplies):
CONFIDENTIAL Page 25 of 205 Active Outpatient Medications Status
=========================================================================
1) CETIRIZINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
DAILY FOR ALLERGY
2) FLUNISOLIDE 0.025% 200D NASAL INH SPRAY INHALE 2 ACTIVE
SPRAYS IN EACH NOSTRIL TWICE A DAY FOR NASAL
ALLERGY
3) MIRTAZAPINE 15MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE
BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT
CONSULTING YOUR PROVIDER.
4) PAROXETINE HCL 40MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE
BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT
CONSULTING YOUR PROVIDER. ** NOTE DOSE INCREASE **
.
5) PRAZOSIN HCL 2MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE
BEDTIME FOR 7 DAYS, THEN TAKE TWO CAPSULES AT
BEDTIME FOR 7 DAYS, THEN TAKE THREE CAPSULES AT
BEDTIME ** MUST CONTACT/SEE VA PROVIDER FOR REFILL
**
6) TOPIRAMATE 25MG TAB TAKE ONE TABLET BY MOUTH TWICE A ACTIVE
DAY FOR 4 WEEKS, THEN TAKE TWO TABLETS TWICE A DAY
AVOID DEHYDRATION
7) TRAZODONE HCL 100MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE
BEDTIME
ALLERGIES:
Patient has answered NKA
INCIDENT HISTORY:
Presumed/confirmed traumatic brain injury/acquired brain injury due to: series
of head traumas
When did the incident occur (OEF, OIF, OND, other): 2007
Type of TBI injury (blast, penetrating, intraocular, etc): blunt force and blast
induced
Any ocular or periocular injury to the eyes: N
History of treatment for traumatic brain injury (VA facility, Dept. of
Defense or elsewhere): evaluated in field but sent out shortly after
PRIOR VISUAL HISTORY:
1. When was your last eye examination? 4/11/14, VA LB (no DFE yet)
2. Do you wear glasses or contacts? N
3. How old is your most recent eyeglasses or contact lens prescription?
4. Any history of lazy eye/amblyopia, eye turn, patching, or vision therapy? N
5. Any history of face turn or head tilt? N
6. Any history of eye surgery/injury? N
7. Did you use personal protective eye wear in the service? Y
CONFIDENTIAL Page 26 of 205URGENT VISUAL CONDITIONS (if sudden):
(-) Flashes
(+) Floaters
(+) Missing part of visual field/restricted field of vision: sometimes
(+) Bumping into objects/walls while moving: sometimes
(-) Covering/closing one eye
(-) Decreased night vision
(-) Curtain/shade over vision
(-) Inability to completely close eyes
(-) Double vision
(-) Wandering eye
(+) Pain in or around the eyes- associated with light
(-) Pain with movement of eyes
VISUAL SYMPTOMS (PRE/POST ABI)
1. Blurred vision at distance (with glasses if rx'ed): N
2. Blurred vision at near (with glasses if rx'ed): Y
3. Pulling or tugging of eyes: Y
4. Face or head turn: N
5. Covering/closing an eye: N
6. Photosensitivity
When indoors: Y
When outdoors: Y
Glare from indoor OR outdoor surfaces: Y
Light adapted: N
7. Decreased night vision: Y
8. Do you have dry eye symptoms: N
9. Headache or browache associated with vision: Y
10. Bothered by movement in spatial world: Y
11. Bothered by noises in environment: Y
12. Dizziness or balance problems Y, postural changes
When riding in moving vehicle:
Walking down a hall or aisle in store:
Concentration at near:
Walking in crowd:
Approaching busy intersections:
13. Do you seem to neglect/not notice objects, people, doorways to one side
or the other when walking or moving in wheelchair? Is it to the right or left?
Comment further. N
14. Do you notice postural shifts when standing and/or walking? Y
READING SYMPTOMS (WITH GLASSES):
1. Fatigue while reading: Y
2. Strain while reading: Y
3. Skip or lose place while reading:
4. Have difficulty finding next line:
5. Note doubling of words: Y
6. Words float off page: Y
7. Transient blur while reading: Y
8. Unable to sustain near work/reading: Y
9. Blur in distance after reading: N
CONFIDENTIAL Page 27 of 20510. Difficulty shifting focus from near to far/far to near: N
11. Browache/headache associated with reading: Y
12. Poor reading comprehension: N
13. Easily distracted/decreased attention span: Y
14. Poor concentration: Y
-----------------------------------------------------------------------------
LENSOMETRY:
CURRENT SPECTACLES
OD: pl sph
OS: pl sph
COMMENTS: sunglasses, amber tint?, from last exam (says they do not help enough
to block out the sun)
VISUAL ACUITY (cc/primary gaze): Snellen
OD: 20/20
OS: 20/20
OU: 20/20
NVA (cc) OU: 20/20
ENTRANCE TESTING
Cover test: ortho at D, 4 XP at near
EOMs: Full range of motion (-)pain/diplopia
Confrontation VF: (peripheral, simultaneous)
Fixation: un/steady
OD: Full to finger counting
OS: Full to finger counting
PUPILS: ERRL, (-) APD
_____________________________________________________________________
REFRACTIVE DATA
Subjective Refraction:
OD: pl sph
OS: pl sph
Binocular balance:
OD: pl sph
OS: pl sph
TRIAL FRAME/FINAL RX:
OD: pl sph 20/20
OS: pl sph 20/20
BINOCULAR VA: 20/20
____________________________________________
_________________________
OCULOMOTOR, VESTIBULAR, ACCOMODATIVE, VERGENCE ASSESSMENT
CONFIDENTIAL Page 28 of 205Step Vergences
Distance Base In: x/4/1
Distance Base Out: x/4/1
Near Base In: x/6/2
Near Base Out: x/4/1
**patient very sensitive to testing and tiring towards end of exam
Accommodation Testing
Method Used:
(X)Push Up
( )Pull Away
( )Minus Lens
( )Fused Cross Cyl (FCC)
OD: 25 cm (4D)
OS: 25 cm (4D)
Near point of convergence (break/recovery): 13cm/20 cm
Facility Testing
Method Used:
+/-1.00 Flippers
OU: difficulty clearing minus, 5 cpm (very slow)
RECOMMENDED GLASSES: leader wrap sunglasses (dark tinted) and near reading
glasses with 0.5 BI prism OD and OS, grey tint 1 and AR coat
_____________________________________________________________________________
GENERAL HEALTH ASSESSMENT
SLIT LAMP FINDINGS:
Lids & Lashes: clear OU
Conjunctiva: white & quiet OU
Cornea: clear OU
Angles: open OU
Ant Chamber: deep & quiet OU
Iris findings: flat, avascular OU
Lens: clear OU (undilated)
INTRAOCULAR PRESSURE (mmHg)
( )GAT (x)Tonopen @ 9:40am
OD: 11
OS: 11
OPHTHALMOSCOPY FINDINGS
(X)UNDILATED
( )DILATED WITH 1% T AND 2.5% PE OU-PT ED ON SIDE EFFECTS
C/D Ratios:
OD: 0.20
OS: 0.20
Optic Nerve Head Evaluation:
PARK, JU EUN CONFIDENTIAL Page 29 of 205 OD: (-) pallor with distinct margins, pink & healthy rim tissue
OS: (-) pallor with distinct margins, pink & healthy rim tissue
***patient defers dilation today due to light sensitivity. Will bring someone to
drive him at next appointment for DFE.
Assessment:
1. H/o traumatic brain injury
- photophobia and glare sensitivity
- convergence insufficiency and accommodative insufficiency
2. Essential emmetropia OU
Plan:
Order separate sunglasses and near work glasses. Near work glasses to have
0.5 base in prism in each eye, with grey tint 1 and anti-reflective coat.
Sunglasses to be leader with wrap and dark tint.
***Return in 1 month for dilation and check on progress with glasses
Final Rx:
OD: pl sph
OS: pl sph
See consult for glasses information
_____________________________________________________________________
Assessment and plan reviewed and approved by Staff Attending
Disclaimer: Because the acuities and fields in this evaluation were taken
using special techniques and lighting NOT contained in the VA Physician Guide
Disability Evaluation Examination, they cannot be used for rating purposes.
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Also, my case mangers and PTSD doctor is trying to get me a PTSD service dog since I got 85/85 on my PCLM test.

BRIEF ASSESSMENT: CV waiting for C&P exam. Writer requested this
CONFIDENTIAL Page 77 of 205opportunity to
follow up with CV. He reports things are going better. His place of employment
has made changes and he is unable to advance due to his s/s PTSD. However, they
are currently working with the CV to sustain employment. CV states Dr. Wangen in
PTSD Clinic has been so helpful and understanding. CV is feeling more
safe/secure and non threaten in his therapy. He states Dr. Wangen mention the
possibility of a service dog. However, CV declined stating he does not want to
take away from a blind veteran. Writer educated CV on the difference between a
PTSD service dog and a dog for the blind. Writer also recommend that CV have a
conversation regarding reconsidering utilizing a PTSD service dog.
CASE MANAGEMENT INTERVENTIONS:
1. Writer provided a safe and clean environment
2. Writer listen to CV needs/concerns
3. Writer provided education, support, and encouragement
PLANS/RECOMMENDATIONS:
1/ Medical/Mental Health Plans: continue following recommendation from PCP, MH,
TBI, PTSD
2/Transitional/Vocational Plans: continue following recommendation from employer
such as continue therapy.
EDUCATION:
1. Educated CV on PTSD service dogs: they allow for the CV to feel safe and
protected within their environment. Recovering from PTSD is an on going process.
Evidence-based treatments for PTSD help CVs do things they have been avoiding
because of their PTSD, such as standing close to a stranger or going into a
building without scanning it for danger first. Evidence-based treatments can
also help CVs feel better emotionally and physically. Dogs can help CVs deal
with some parts of living with PTSD, but they are not a substitute for effective
PTSD treatment.
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More PTSD results

Military MOS:
0311 Rifleman, light infantry, heavy machine gunner, turret
gunner, attached to a helicopter company
Rank/Rate During Deployment: E4 corporal
Responsible/Accountable for How Many:
35 "I was a barracks NCO, even downrange"
Service Connected Disability: NSC:
Financial: GMT COPAY REQUIRED
Employment: EMPLOYED PART TIME
Occupation: COUNTY EMPLOYEE
Religion/Spiritual Connection: CHRISTIAN (NON-SPECIFIC)
Race/Ethnicity/Cultural Background: ASIAN
Primary Care Provider: LEE,SE-YOUNG
PTSD Score(s): Date Instrument Raw Trans Scale
07/17/2014 09:00 PCLC 85 Total
02/06/2014 14:00 PC PTSD 2 Total
PCP: LEE,SE-YOUNG
Next Appt. w/: JUL 17,2014@09:00 LB MH: PTSD JONAS
SEP 11,2014@15:00 LB PULM: SLEEP FOLLOW UP
OCT 1,2014@15:00 LB NEURO: CABLE
Mental Health Missed Appts.: MH Appointments Missed Last 10 Days
No Missed Appointments Found
Problem List: Computerized Problem List is the source for the following:
1. Laceration NEC (ICD-9-CM E928.9) 10/05/11 HECHANOVA,DEM
2. Headache 02/06/14 LEE,SE-YOUNG
3. Tinnitus 02/06/14 LEE,SE-YOUNG

4. Neck pain 02/06/14 LEE,SE-YOUNG
5. Chronic low back pain 02/06/14 LEE,SE-YOUNG
6. Foot pain 02/06/14 LEE,SE-YOUNG
7. Knee pain 02/06/14 LEE,SE-YOUNG
8. Insomnia 02/06/14 LEE,SE-YOUNG
9. Chronic rhinitis 02/06/14 LEE,SE-YOUNG
10. Traumatic brain injury with brief loss of 03/05/14 HAGER,GILBERT P
consciousness
11. Other Signs and Symptoms Involving Cognition 03/05/14 HAGER,GILBERT P
12. Posttraumatic stress disorder (SNOMED CT 05/29/14 HAGER,GILBERT P
47505003)
13. Pain in joint involving shoulder region 05/29/14 HAGER,GILBERT P
Medications: Active Outpatient Medications (including Supplies):
CETIRIZINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH DAILY FOR ACTIVE
ALLERGY
FLUNISOLIDE 0.025% 200D NASAL INH SPRAY INHALE 2 SPRAYS IN ACTIVE
EACH NOSTRIL TWICE A DAY FOR NASAL ALLERGY
MIRTAZAPINE 15MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE (S)
BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT
CONSULTING YOUR PROVIDER.
PAROXETINE HCL 40MG TAB TAKE ONE TABLET BY MOUTH AT PENDING
BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT
CONSULTING YOUR PROVIDER.
PRAZOSIN HCL 2MG CAP TAKE ONE CAPSULE BY MOUTH AT BEDTIME ACTIVE (S)
FOR 7 DAYS, THEN TAKE TWO CAPSULES AT BEDTIME FOR 7
DAYS, THEN TAKE THREE CAPSULES AT BEDTIME ** MUST
CONTACT/SEE VA PROVIDER FOR REFILL **
TRAZODONE HCL 100MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE
BEDTIME
Language/Language Preference: English
Referred by: MH Dr. Glass
Identifiers and Chief Complaints:
1. "Headache really really bad migraine, sometimes I have to lay down in a
pitch
dark in my room my windows are just blacked out, I wear sunglasses when
I walk around indoors."
2."My headache gets bad, it affects my job, I'm a deputy for the
sherrif's
department."
3. I don't get sleep I'm always up on guard, I'm very detached, an
inmate
committed suicide in front of me, it doesn't bother me at all."
4. "my chest hurts alot, I wake up in the middle of the night time and I
puke
sometimes."
CONFIDENTIAL Page 106 of 2055. "I think I don't get enough some kind of oxygen flow, and I
puke."
6. "I lost 40 lbs, sometimes I gain 45 pounds sometimes I don't eat and
lose 45
pounds."
7. " I get depressed alot, I used to be outgoing used to have a good
relationship with females my family."
8. "I just don't care about alot of things, ever since I got out of
deplyoment."
9. 'I get angry easily, I can't sleep without my gun,"
10. "I worried that I want to have a family, but scared because I have to
sleep
with a gun."
11. "I think I found a girl, but worried about my conditions, maybe if she
finds
out down the road, maybe that's why I'm depressed too."
12. "I think alot about things, I have running thoughts."
Deployments: 3
Total length in Combat Zone: 20months
Physical Injuries (combat related):
***fall >his height, gunshot wounds and concussion injury
"I took a 1 bullet to the chest, 1 bullet to the right leg went through my
pant
and grazed my right leg. got ambusshed fell d9own the stairs. I fell down fromn
2 story high the stairs collapsed on my I smashed my head on the humvee
windshield. Someone threw a flare with a barbeque propane tank through the
window and hit me on the head. I fell down the cliff while I was in philippines,
the rope snapped, I hit my head and my back in a bunch of rocks."
History of concussion, number, and if loss of consciousness occurred:
"2 or 3 times, I think"
Legal Status (any current charges, probation, parole?) No
SPECIFY}
none, **vet on work probabation***
Developmental History:
Education:
"2 Associate degrees, Accounting and Human Behavior, just want
to get it to get a job"
Social History: Describe family relationships, romantic relationships, friends?
CONFIDENTIAL Page 107 of 205 pre-military:
"it was good I went to baseball games, pool parties,
concerts regular stuff dances. Family we had good times, friendly
outgoing meet new people, it was good."
non-combat military:
"marine corps life was tough but it was still
good, everybody life is tough but my
family was supportive, no I didn't really drink."
post-military:
"My family is supportive still but I don't really talk
about anything with my family, (girlfriend) she asks me stuff but I just
don't give her the answer, I just go around it I don't really
answer too
much. i don't have any friends now. Coworkers) they're just my
coworkers, I don't really call them after work. I only call 2 of
them
because they are vets, and their son's in army too, other than vets
I
don't talk to anyone else, because they talk shit about me."
Work History:
pre-military:
"highschool, I worked at a golf course and I helped my family
business, they used to own a little shoe store"
post-military:
"Sheriff's deputy, went to school used my GI Bill, I'm a
correctiona
l officer, I want to go to field but psych will not let me pass."

Nutrition Screening:
The patient notes an unintentional weight gain.
Amount: 44 lbs "Because of the medicine they gave me I'm not
able
to eat."
Most recent measurements:
Measurement DT WEIGHT
LB(KG)[bMI]
06/25/2014 08:20 149(67.59)[23]
05/28/2014 08:27 152(68.95)[24]
02/06/2014 13:52 171.9(77.97)[27]
Edited by bojack
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I might lose my job maybe, I am scared VA might low ball me even with all these evidence to back it up.... I just hope my claim gets setted fast because San Diego RO did tell me she is going to try to end my claim by this year.

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This patient was seen last week and I had asked him to return to evaluate meds -
he says he doesnt want to see me since I am threatening to him - he seems to
remember the evaluation very different from my memories and I am surprised by
his description to OEF-OIF case manager the next day - he is indeed paranoid -
he has apparantly been reassigned to a different psychiatrist who cannot see him
today - he wants to report that the
temazepam 30 mg qhs
had no effect what so ever and he was very wide awake a couple of hours later
and he has decided that he needs to be on medications - I suggested that his new
doctor may have different ideas about insomnia but he asked if he could pick up
something else in the way of medication while he awaited the new doctor. I gave
Temazepam 100 mg qhs
I told him that it was an antidepressant that was very sedating and it had the
anticholinergic side effects of having a dry mouth the next morning but it is
always good to increase fluids when you wake up - all he had to say was that I
was too intimidating - I wished him well but I do have concerns about his need
to have a gun with him and his seeing things in the shadows and he is easily up
set. He seems to hear things that were not there too!
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