I recently got a copy of my medical records from the local va. As I suffer from ptsd, my memory is not very good. I had forgotten about visiting va shrinks in 05-20- 97 through 2001. I have six reports through this period. I HAD NEVER HEARD OF PTSD UNTIL 9-11 When my symtoms exploded and I went to the va for help.I know I wouldn't have lasted another week had I not gone. ( I know many of you can relate )
I was unoficially ad vised to file for ptsd. It took a year of treatment to learn what it was befor I filed a claim. I was awarded 30% without a c&p in 3 mos. my rep sent a nod , I then had a c&p exam. I remember the shrink telling me if I wouldn" tell him in detail what happened in nam, he would be limited in what he could do to help me. My stessor was well established. Had my wife not been sitting beside me perhaps I could have told him what he wanted to hear, but I doubt it. At any rate I did get my percentage raised to 50% due to his report. My rep appealed this for 70% a year and a half ago and thats where my case is now
I've done the imo thing with two shrinks who both give me a 45 on the gaf scale, also I have visited counslers at least once a month for the last year and a half and all their reports are all
under 50 on the gaf.
Now my question; My report in 5/20/97 states ( and this is only the last two paragraphs0
Mental status examination: The patient's mental status examination today is entirely normal. His affect, vegetative signs of depression, thinking process, motor behaior, and speech are all within nornal limints. His insight is poor to fair, and his judgement is fair to good.
DIAGNOSIS
Axis 1: Alcohol dependence by history, now in remission.
Major depression, recurrent, whith psycotic features.
Axis 11 No diagnosis.
AXIS 111 history of hiatal hernia.
history of false aortic aneurysum, from gun shot wound.
History of fractured back
History of surgery for coronary artery disease.
Axis 1V minimal
Axis V current gaf is 80
DISCUSSION: as stated above, I think this man has a unipolar recurring depression whit psycotic features, and he should stay on prozac. The alternative is to use low dose antipsycotic medication, but when one weighs the risk of the prozac versus a neuroleptic, I think the balance comes out in favor of prozac.
Treatment plan: The focus of treatment is to prevent the recurrence of depresion and particularly to prevent the recurrence of psycosis.It is also important for this man to abstain from all drugs and alcohal. He is a non smoker, so that is not an issue.
RECOMMENDATIONS:
1. CONTINUE PRAZAC 20MG ONE Q.A.M.
2. RETURN IN TWO MONTHS FOR RE-EVAUATION.
Dr ----- Psychiatrist
I seen other shrinks on my other appoints. they changed my diagnosis to ( depressive reaction, prolonged) Their statement was more closely related to.
1 My question is should I SEND THIS ONE REPORT and omit the others.
2 If I sent the report in question would the information in it help or hurt my case. I know Major depression would proably help, as it has been on every report I have gotten, However I am not sure about the other diagnosis's. The are new to me, and I DONT KNOW IF THEY ARE RELATED TO PTSD OR NOT.
Question
kkp
I recently got a copy of my medical records from the local va. As I suffer from ptsd, my memory is not very good. I had forgotten about visiting va shrinks in 05-20- 97 through 2001. I have six reports through this period. I HAD NEVER HEARD OF PTSD UNTIL 9-11 When my symtoms exploded and I went to the va for help.I know I wouldn't have lasted another week had I not gone. ( I know many of you can relate )
I was unoficially ad vised to file for ptsd. It took a year of treatment to learn what it was befor I filed a claim. I was awarded 30% without a c&p in 3 mos. my rep sent a nod , I then had a c&p exam. I remember the shrink telling me if I wouldn" tell him in detail what happened in nam, he would be limited in what he could do to help me. My stessor was well established. Had my wife not been sitting beside me perhaps I could have told him what he wanted to hear, but I doubt it. At any rate I did get my percentage raised to 50% due to his report. My rep appealed this for 70% a year and a half ago and thats where my case is now
I've done the imo thing with two shrinks who both give me a 45 on the gaf scale, also I have visited counslers at least once a month for the last year and a half and all their reports are all
under 50 on the gaf.
Now my question; My report in 5/20/97 states ( and this is only the last two paragraphs0
Mental status examination: The patient's mental status examination today is entirely normal. His affect, vegetative signs of depression, thinking process, motor behaior, and speech are all within nornal limints. His insight is poor to fair, and his judgement is fair to good.
DIAGNOSIS
Axis 1: Alcohol dependence by history, now in remission.
Major depression, recurrent, whith psycotic features.
Axis 11 No diagnosis.
AXIS 111 history of hiatal hernia.
history of false aortic aneurysum, from gun shot wound.
History of fractured back
History of surgery for coronary artery disease.
Axis 1V minimal
Axis V current gaf is 80
DISCUSSION: as stated above, I think this man has a unipolar recurring depression whit psycotic features, and he should stay on prozac. The alternative is to use low dose antipsycotic medication, but when one weighs the risk of the prozac versus a neuroleptic, I think the balance comes out in favor of prozac.
Treatment plan: The focus of treatment is to prevent the recurrence of depresion and particularly to prevent the recurrence of psycosis.It is also important for this man to abstain from all drugs and alcohal. He is a non smoker, so that is not an issue.
RECOMMENDATIONS:
1. CONTINUE PRAZAC 20MG ONE Q.A.M.
2. RETURN IN TWO MONTHS FOR RE-EVAUATION.
Dr ----- Psychiatrist
I seen other shrinks on my other appoints. they changed my diagnosis to ( depressive reaction, prolonged) Their statement was more closely related to.
1 My question is should I SEND THIS ONE REPORT and omit the others.
2 If I sent the report in question would the information in it help or hurt my case. I know Major depression would proably help, as it has been on every report I have gotten, However I am not sure about the other diagnosis's. The are new to me, and I DONT KNOW IF THEY ARE RELATED TO PTSD OR NOT.
lOOKING FORWARD TO ANY IN PUT ON THE MATTER
KKP
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