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Dr's Notes Wrong,now What?


coastie72
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Question

I have finally gotten into Myhealthvet and read some of the notes that has been made about me. Some by the Psych and others by the Vet Hotline.

There are many errors and what was said twisted. I am going to try and copy and past some of the most glaring.

Any advice or help is appreciated;

Within the last month have you had thoughts of harming or killing yourself? Yes, patient admits to having thoughts of harming him/herself. What type of thoughts have you been having? Suicidal Ideation (thoughts of killing oneself/engaging in suicide-related behavior) When did the thoughts start, how often do they occur, and have these changed over time (i.e.in intensity or frequency)? Describe: Started 10 years ago. Plan since 10 years ago. No intent. Somewhat increased intensity of SI recently. Do you have a plan for how you would harm or kill yourself? Yes, patient has a plan for harming or killing self.

No intent?, if I didn't have intent I would not be there!

Are you feeling hopeless? No

I am feeling very hopeless and getting worse. Liars

Do you have the means available? Comment: Not right now

"Means" yes I do, guts, not today! Liars

Pt reports that he notes that his mood worsens as his tinnitus worsens. The pt reports that his tinnitus bothers him "all day and night." He states that he feels this contributes significantly to his depressed mood

The tinnitus is "constant"..."it has gotten worse over the years". It is not like it changes throughout the day! Twisting words....My mood is almost constant as well!!!!!

The pt notes that he has had intermittent SI over the past 10 years. The pt states that he has had the same plan to end his life for the past 10 years. The pt states that his wife had a "mental break down" 10 years ago and her psychiatrist informed him that "he was her rock" and he states that ever since then he feels like he could never harm himself because he would be abandoning his wife.

My wife had a mental breakdown in 1989. 25 YEARS AGO, not 10 years ago. I stated that she is what gives me the strength to not kill myself, but my strength is getting weaker!!!! And I read this crap it is not helping. Liars!!!!!

MSE: APPEARANCE: well dressed in appropriate attire ATTITUDE: cooperative; pleasant MOTOR BEHAVIOR: no signs of psychomotor agitation or retardation SPEECH: regular in rate, rhythm, tone, volume, spontaneity and production ATTENTION: adequate by spelling 'world' forwards and backwards and by serial 7s ORIENTATION: x4 MOOD: "depressed" AFFECT: congruent PERCEPTUAL DISTURBENCES: denies THOUGHT PROCESS/THOUGHT D/O: logical and goal directed DELUSIONS, OBSESSIONS, COMPUJSIONS: denies MEMORY: intact per eval but not formally tested INSIGHT: good JUDGMENT: good.

DSM-5 MDD Rule Out PTSD

How do you rule out something that you will not allow me to tell you about?

. Given patient's chronic suicidality, the patient will likely benefit from individual therapy as well as group therapy that can be tailored around his work schedule if at all possible. Diagnostically, the patient certainly meets criteria for recurrent major depression, however, this writer will future meetings with pt to tease out further symptoms of PTSD, given that at this time he does not have a clear criterion A trauma. No evidence of bipolarity in mood or evidence of psychosis.

A PTSD screening test (PTSD 4Q) was positive (score=4).

??????

From Hotline Notes

Call Synopsis: Suicidal ideation without suicidal intent. Veteran struggles with suicidal thoughts more intensely lately and reports he is concerned. He does not talk to many people about how he is feeling but states he knows emotions are getting worse/ SI is worse. Depression has increased, nightmares often, agitation, and frequent moments of suicidal ideation. He is aware of how he may suicide but unwilling to disclose means. He accepts a consult for counseling supports. Responder discussed safety planning. Veteran has been able to turn to some supports (friends, family) and says he has spoken with his non-VA primary physician (this dr. prescribes his medication for depression). He states he will consider chatting or calling the crisis line again. provided veteran with SPC contact, Vet Center #, Vet 2 Vet contact. No flags in CAPRI

Suicide risk factors present: Chronic pain, chronic medical problems, and financial struggles.

I do have level 3 pain, but who don't at 64, I have a bum knee that aches constantly. I do have medical problems, but they are of no immediate concern. I NEVER SAID A WORD ABOUT FINANCIAL STRUGGLES......I earn a good living and both my wife and I have Beacon scores of 800+. Damn Liars

ATTENTION: adequate by spelling 'world' forwards and backwards and by serial 7s ORIENTATION: x4

I have not spelled anything forward or backwards and have no idea what the rest of that line means. I know I have overlooked other "errors"

Advice and or opinions please.

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Was the claim for depression secondary to the tinnitus or was this filed as a PTSD claim?

I think you mentioned you had an IMO from a private doc associating the depression to the SC tinnitus....Does VA have that IMO?

"How do you rule out something that you will not allow me to tell you about?"

A PTSD claim depends on a stressor inservice

The doc did state:

"Diagnostically, the patient certainly meets criteria for recurrent major depression, however, this writer will future meetings with pt to tease out further symptoms of PTSD, given that at this time he does not have a clear criterion A trauma"

I think that is what the doc means here....if there has been a stressor inservice, he could determine PTSD in the future...but whatever the MH issue is, they only pay for one anyhow......

Did the IMO doc fully adhere to the IMO forum here?

If VA does not grant the depression as secondary to the tinnitus , do you have anything in your SMRs indicating inservice depression and.or an inservice event that would cause it ?

Edited by Berta
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Hello Berta,

There is a claim filed for Depression secondary to Tinnitus. The nexus from my personal Dr. was submitted with the claim. I don't know if my MH Dr. has that or not?

There is a PTSD claim filed as well. I have recurrent dreams, nightmares, visions out of no where about "three" separate incidents I was involved in where death and body recovery was done.

One of them I have proof of in several newspaper articles about the incident in 1971. It is the most vivid and the one that effects me most. I was on a USCG boat with a crew of 8 and knew one of the individuals that died in that incident.

It was a civilian boat that exploded, burned and sank.

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I did not know the hotline kept notes on us.

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That is sure where this line came from;

Call Synopsis: Suicidal ideation without suicidal intent. Veteran struggles with suicidal thoughts more intensely lately and reports he is concerned. He does not talk to many people about how he is feeling but states he knows emotions are getting worse/ SI is worse. Depression has increased, nightmares often, agitation, and frequent moments of suicidal ideation. He is aware of how he may suicide but unwilling to disclose means. He accepts a consult for counseling supports. Responder discussed safety planning. Veteran has been able to turn to some supports (friends, family) and says he has spoken with his non-VA primary physician (this dr. prescribes his medication for depression). He states he will consider chatting or calling the crisis line again. provided veteran with SPC contact, Vet Center #, Vet 2 Vet contact. No flags in CAPRI

Suicide risk factors present: Chronic pain, chronic medical problems, and financial struggles

Surprisingly within hours of posting this today, guess who called? YES, The Hotline.......coincidence?

Maybe we should be wary of what we post, or is it just that part of me that has little trust for anyone?

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That is sure where this line came from;

Call Synopsis: Suicidal ideation without suicidal intent. Veteran struggles with suicidal thoughts more intensely lately and reports he is concerned. He does not talk to many people about how he is feeling but states he knows emotions are getting worse/ SI is worse. Depression has increased, nightmares often, agitation, and frequent moments of suicidal ideation. He is aware of how he may suicide but unwilling to disclose means. He accepts a consult for counseling supports. Responder discussed safety planning. Veteran has been able to turn to some supports (friends, family) and says he has spoken with his non-VA primary physician (this dr. prescribes his medication for depression). He states he will consider chatting or calling the crisis line again. provided veteran with SPC contact, Vet Center #, Vet 2 Vet contact. No flags in CAPRI

Suicide risk factors present: Chronic pain, chronic medical problems, and financial struggles

Surprisingly within hours of posting this today, guess who called? YES, The Hotline.......coincidence?

Maybe we should be wary of what we post, or is it just that part of me that has little trust for anyone?

coastie,

I'm sure the call was just coincidental - there is no way fro them to tie you to posting here.

Try not to let what the records say bother you much for now, remember your just getting

started. Perhaps the depression secondary to the SC'd tinnitus is the best, (least resistant)

route to go if you have medical evidence from the MH peeps in support of it.

VA only provides one evaluation for MH purposes even tho some are co-morbid.

I always suggest the path of least resistance for claim issues.

jmho

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coastie,

I'm sure the call was just coincidental - there is no way fro them to tie you to posting here.

Try not to let what the records say bother you much for now, remember your just getting

started. Perhaps the depression secondary to the SC'd tinnitus is the best, (least resistant)

route to go if you have medical evidence from the MH peeps in support of it.

VA only provides one evaluation for MH purposes even tho some are co-morbid.

I always suggest the path of least resistance for claim issues.

jmho

Perhaps the depression secondary to the SC'd tinnitus is the best, (least resistant)

route to go if you have medical evidence from the MH peeps in support of it.

Thanks Carlie,

I am just a layman for certain and a rookie one at that. This all seems surreal in a way to me. It almost seems like I am on trial and so my instincts say to tell it like it is.

I have been holding this all trapped inside of me for over 40 years, I see the same faces, feel the same shock be it in a dream or a day dream because it happens then too.

I have learned hear on these forums that you need evidence of Stressors for MDD/PTSD. I have 43 year old Yellowed newspaper clippings from an incident that my service records

prove I was there for. Long before my tinnitus got to the point it is at I was having panic attacks nearly daily, back some 40 years ago. I still have them now, though better controlled by

mind over matter. Then the nightmares started and they have never stopped. For many years I was ashamed to tell even my wife about them. Then there is this devil constantly screaming in my head. It's pretty much now or never for me.

I am right with my Lord and Savior Jesus Christ so if tonight is the night, I'm ready. I know what the Bible says about suicide, but I am quickly losing my grip on that! I feel God will forgive.

I need help, I'm trying after all these years I am trying. I might have waited too long. The stress of all of this is really taking it's toll on me farther. I think maybe I should have never went to the VA.

If I am on trial I want ALL my evidence on the table!

Sorry Carlie,

You are a very loving and caring lady that I wish I had met many years ago, at least a few. sorry for the rant.

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