DATE OF NOTE: OCT 27, 2014@08:00 ENTRY DATE: OCT 27, 2014@13:11:21
URGENCY: STATUS: COMPLETED
Medical Opinion
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[X] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because the existing medical evidence provided sufficient information on which
to prepare the DBQ and such an examination will likely provide no
additional relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[ ] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed? Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
VBMS/CPRS reviewed
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Please review and opine if this diagnosis
is related to his claimed stressors from military service. (please see list of
stressors in your exam. If his diagnosis is related to any of these
stressors, please if possible indicate which ones.
MEDICAL OPINION: is veterans diagnosis of unspecified depressive disorder
with anxious distress as least as likely as not related to any of his
claimed stressors from military service. Please provide rationale.
b. Indicate type of exam for which opinion has been requested: PTSD
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
b. The condition claimed was less likely than not (less than 50%
probability) incurred in or caused by the claimed in-service injury, event
or illness.
c. Rationale: The veteran's reported stressors occurred in 1999. His
reported symptoms are not consistent with a post-traumatic disorder, including PTSD,
depression or anxiety. Rather, his symptoms are a mild non-specific
depression. As noted in my evaluation, it appears that the veteran has tied
his symptoms to in-service events, but has done so mistakenly. He reported
irritability with anger, poor sleep, loss of interest and anxiety in crowds,
on airplanes and during fireworks. There is no evidence of mental health
treatment until 2012, 13 years after his reported stressors. His report of
symptoms has been rather vague and not consistent with a post-traumatic
disorder. Thus, there is insufficient evidence to link his current mild
depression to reported stressors that occurred in 1999.
I understand it's been years with no treatment but if you don't know anything is wrong how can you get help. I was diagnosed by a civilian doctor and have been going to treatment at the vet center and the VA is giving med meds.
Question
smoothc100
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: OCT 27, 2014@08:00 ENTRY DATE: OCT 27, 2014@13:11:21
URGENCY: STATUS: COMPLETED
Medical Opinion
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[X] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because the existing medical evidence provided sufficient information on which
to prepare the DBQ and such an examination will likely provide no
additional relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[ ] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed? Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
VBMS/CPRS reviewed
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Please review and opine if this diagnosis
is related to his claimed stressors from military service. (please see list of
stressors in your exam. If his diagnosis is related to any of these
stressors, please if possible indicate which ones.
MEDICAL OPINION: is veterans diagnosis of unspecified depressive disorder
with anxious distress as least as likely as not related to any of his
claimed stressors from military service. Please provide rationale.
b. Indicate type of exam for which opinion has been requested: PTSD
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
b. The condition claimed was less likely than not (less than 50%
probability) incurred in or caused by the claimed in-service injury, event
or illness.
c. Rationale: The veteran's reported stressors occurred in 1999. His
reported symptoms are not consistent with a post-traumatic disorder, including PTSD,
depression or anxiety. Rather, his symptoms are a mild non-specific
depression. As noted in my evaluation, it appears that the veteran has tied
his symptoms to in-service events, but has done so mistakenly. He reported
irritability with anger, poor sleep, loss of interest and anxiety in crowds,
on airplanes and during fireworks. There is no evidence of mental health
treatment until 2012, 13 years after his reported stressors. His report of
symptoms has been rather vague and not consistent with a post-traumatic
disorder. Thus, there is insufficient evidence to link his current mild
depression to reported stressors that occurred in 1999.
I understand it's been years with no treatment but if you don't know anything is wrong how can you get help. I was diagnosed by a civilian doctor and have been going to treatment at the vet center and the VA is giving med meds.
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