diabetes C&P Exam results from Myhealthevet, opinons?

[Inarticulate&Distorted]

 LOCAL TITLE: C&P MENTAL DISORDERS
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: SEP 08, 2015@09:00 ENTRY DATE: SEP 08, 2015@10:06:32
 AUTHOR: redacted for privacy COSIGNER:
 URGENCY: STATUS: COMPLETED
 Mental Disorders
 (other than PTSD and Eating Disorders)
 Disability Benefits Questionnaire
 Name of patient/Veteran: REDACTED BY VETERAN
 SECTION I:
 ----------
 1. Diagnosis
 ------------
 a. Does the Veteran now have or has he/she ever been diagnosed with a mental
 disorder(s)?
 [X] Yes[ ] No
 ICD code: 300.4
 If the Veteran currently has one or more mental disorders that conform to
 DSM-5 criteria, provide all diagnoses:
 Mental Disorder Diagnosis #1: Persistent Depressive Disorder
 ICD code: 300.4
 Comments, if any: Vet states he suffers from chronic dsyphoric mood, low motivation,
 insomnia, hypersomnia, low energy levels, low self-esteem,
concentration problems.
 b. Medical diagnoses relevant to the understanding or management of the
 Mental Health Disorder (to include TBI): Diabetes Melitis
2. Differentiation of symptoms
 ------------------------------
 a. Does the Veteran have more than one mental disorder diagnosed?
 [ ] Yes[X] No
 c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
 [ ] Yes[ ] No[X] Not shown in records reviewed
 3. Occupational and social impairment
 -------------------------------------
 a. Which of the following best summarizes the Veteran's level of
occupational and social impairment with regards to all mental diagnoses? (Check only
 one)
 [X] Occupational and social impairment with deficiencies in most areas,
 such as work, school, family relations, judgment, thinking and/or
mood
 b. For the indicated level of occupational and social impairment, is it
 possible to differentiate what portion of the occupational and social
 impairment indicated above is caused by each mental disorder?
 [ ] Yes[ ] No[X] No other mental disorder has been diagnosed
 c. If a diagnosis of TBI exists, is it possible to differentiate what
portion of the occupational and social impairment indicated above is caused by
the TBI?
 [ ] Yes[ ] No[X] No diagnosis of TBI
 SECTION II:
 -----------
 Clinical Findings:
 ------------------
 1. Evidence review
 ------------------
 a. Medical record review:
 Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
 [X] Yes[ ] No
 Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
 [ ] Yes[X] No
 If no, check all records reviewed:
 [X] Military service treatment records
 [X] Military service personnel records
 [ ] Military enlistment examination
 [ ] Military separation examination
 [ ] Military post-deployment questionnaire
 [ ] Department of Defense Form 214 Separation Documents
 [X] Veterans Health Administration medical records (VA treatment
records)
 [ ] Civilian medical records
 [ ] Interviews with collateral witnesses (family and others who have
 known the Veteran before and after military service)
 [ ] No records were reviewed
 [ ] Other:
 b. Was pertinent information from collateral sources reviewed?
 [ ] Yes[X] No
 2. History
 ----------
 a. Relevant Social/Marital/Family history (pre-military, military, and
 post-military):
 Vet states he runs away from conflict, and has moved out of state 10
 times since his discharge from the army in 2000. VEt lives with his
 father and grandmother in Washington. Vet states he cannot live alone
 due to fear, and depression. He said he tried living with a girlfriend
 once, for 2 months. He states that relationship ended due to arguing.
 Vet has never married and has no children. HE reports he has not had a
 girlfriend since 2008 because he is controlling and has difficulty
 trusting others. VEt states he has no close friends, other than video
 game friends he has on-line. Vet was raised by his father, sister, who is deceased, and 2
half-sister and half brother. He states he is distant from his mother, and
siblings. He state he cuts out people that cause him stress in his life. Vet
 reports he didn't live with his mom growing up due to her drug
abuse.
 b. Relevant Occupational and Educational history (pre-military, military,
and post-military):
 Vet worked most recently in April, 2015, in a factory making industrial
 windows. HE reports he worked there a few months. Vet states he walked
 off the job because he said, "people were screaming at me." He
was most stably employed at a gas station for a year from 2011-12. He said that
 job ended when he had an argument with his brother, whom he was living
 with at the time, and had to move out of state. HE notes he has moved 4
 times out of state in the past 4 years.
 Vet reports he served in the army for a few months in 2000, but was
 discharged early due to his low motivation, and depression symptoms.
Vet adds he got into fights with members of his platoon. Vet reports he has
 had 26 jobs since his discharge in 2000.
 c. Relevant Mental Health history, to include prescribed medications and
 family mental health (pre-military, military, and post-military):
 Vet reports he had 2 counselors, once for 4 sessions and once for 3
 sessions, and received Adderall and Ritalin tried 8 years ago.
 Vet was diagnosed in service with Adjustment Disorder with depressed
 mood by Dr. Chin on 5 October, 2000.
 d. Relevant Legal and Behavioral history (pre-military, military, and
 post-military):
 jail for assault, of neighbor in 2011, at same time criminal mischief,
 and possession of marijuana in 2002.
 e. Relevant Substance abuse history (pre-military, military, and
 post-military):
 heroin abuse, age 22, marijuana on and off until 2011, alcohol abuse
 from 2009-2014, after sister died of brain aneurism.
 f. Other, if any:
 No response provided.
 3. Symptoms
 -----------
 For VA rating purposes, check all symptoms that actively apply to the
 Veteran's diagnoses:
 [X] Depressed mood
 [X] Anxiety
 [X] Suspiciousness
 [X] Chronic sleep impairment
 [X] Impaired judgment
 [X] Disturbances of motivation and mood
 [X] Difficulty in establishing and maintaining effective work and social
 relationships
 [X] Difficulty in adapting to stressful circumstances, including work or
a worklike setting
 [X] Inability to establish and maintain effective relationships
 [X] Suicidal ideation
 Behavioral observations:
 Vet appears as a cooperative, casually dressed, well groomed, long bearded, Caucasian male who was oriented X 4. He was able to accurately list 3 words after a 3 minute delay. He accurately performed serial sevens, and listed the 5 most recent presidents of the U.S.A. without difficulty. He admits to having episodic suicidal ideation without a specific plan. He denies suffering from homicidal or psychotic ideation. Vet complains of suffering from a chronically dysphoric and anxious mood, and he displayed a wide range of affect.
4. Other symptoms
 -----------------
Does the Veteran have any other symptoms attributable to mental disorders
 that are not listed above?
 [ ] Yes[X] No
 5. Competency
 -------------
 Is the Veteran capable of managing his or her financial affairs?
 [X] Yes[ ] No
 6. Remarks (including any testing results), if any:
 ---------------------------------------------------
 Vet appears at least as likely as not to meet the DSM-5 criteria with Persistent Depressive Disorder (Dysthymia). It appears at least as likely as not that the vet's current symptoms of depression are related to vet's depression and low motivation noted in service medical records dated 18 October, 2000, in which vet was described with "constant depression...failure to adapt to military life...low motivation."
 In summary, vet does not have a diagnosis of adjustment disorder with depressed mood that is at least as likely as not caused by diagnosis in service. Instead, vet's current diagnosis of persistent depressive disorder appears to be a continuation of his prior diagnosis of Adjustment Disorder with Depressed mood which was noted in mental status evaluation by Dr. Chin on 5 October, 2000. Vet suffers from severe social, emotional, and occupational impairment as a result of his depressive disorder.
/es/ redacted for privacy PhD
LICENSED CLINICAL PSYCHOLOGIST
Signed: 09/08/2015 10:06

Edited September 14, 2015 by Inarticulate&Distorted
privacy for the Dr

[Inarticulate&Distorted]

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