If a moderator would move to this to the right location if this isnt it please.
I am going to try and copy and paste maybe some relevant information
-----------------------------------------------------general med---------------------------------------------------------
List of Symptomatic Symptoms:
Anus and Rectum; Abdomen and Viscera; Genitourinary; Upper extremities; Lower extremities; Spine; Identifying body marks, scars, tattoos; Skin/Lymphatic; Psychiatric;
List of Abnormal Findings:
Examination of the skin is abnormal; findings show plantar wart left foot 0% exposed <1% entire body, folliculitis posterior scalp 4% exposed 2% entire body There are findings of identifying body marks, scars or tattoos; findings show scar both hips and multiple tattoos Rectal examination is abnormal; findings show hemorrhoids, normal prostate There is a complaint of tinnitus.
Diagnosis Summary:
The claimed condition is SCARS, S/P BILATERAL HIP SURGERY. The diagnosis is SCARS, LEFT HIP X3 ; RIGHT HIP X2 S/P BILATERAL HIP SURGERY and the rationale is the history and exam findings. --- --The claimed condition is INGROWN HAIRS, SCALP AND NECK. The diagnosis is folliculitis scalp and the rationale is the history and exam findings. ----- The claimed condition is PLANTAR WART, LEFT FOOT. The diagnosis is PLANTAR WART, LEFT FOOT and the rationale is the history and exam finding. - ---- The claimed condition is ULCERATIVE COLITIS and there is no diagnosis because there is no pathology to render a diagnosis. ----- The claimed condition is RIGHT WRIST CONDITION, WITH LOSS OF MOTION. The diagnosis is WRIST SPRAIN and the rationale is the history and exam finding of less movement with pain and tenderness. ----- The claimed condition is LEFT HIP ARTHRITIS (MEB REFERRED CONDITION) LEFT HIP STATUS POST ARTHROSCOPY, LABRAL REPAIR, CAM AND PINCER OSTEOPLASTY AND CAPSULAR REPAIR (21OCT2014) WITH POST SURGICAL PAIN AND ARTHRITIS (MEB REFERRED CONDITION) The diagnosis is LEFT HIP STATUS POST ARTHROSCOPY, LABRAL REPAIR, CAM AND PINCER OSTEOPLASTY AND CAPSULAR REPAIR (21OCT2014) WITH POST SURGICAL PAIN AND ARTHRITIS and the rationale is the history and exam finding of less movement with pain and tenderness. ----- The claimed condition is RIGHT HIP ARTHRITIS (MEB REFERRED CONDITION) RIGHT HIP STATUS POST ARTHROSCOPY, CAM AND PINCER OSTEOPLASTY, CHONDROPLASTY ACETABULUM, LABRAL REPAIR AND PARTIAL CAPSULAR REPAIR (09SEP2014) WITH POST SURGICAL PAIN (MEB REFERRED CONDITION) The diagnosis is RIGHT HIP STATUS POST ARTHROSCOPY, CAM AND PINCER OSTEOPLASTY, CHONDROPLASTY ACETABULUM, LABRAL REPAIR AND PARTIAL CAPSULAR REPAIR (09SEP2014) WITH POST SURGICAL PAIN and the rationale is the history and exam finding of less movement with pain and tenderness. The claimed condition is RIGHT FEMUR CYST and there is no diagnosis because there is no pathology to render a diagnosis. ----- The claimed condition is LUMBAR DEGENERATIVE DISC DISEASE L5-S1 WITH MULTIPLE SPRAINS The diagnosis is LUMBAR STRAIN with DEGENERATIVE DISC DISEASE L5-S1 and the rationale is the history and exam finding of less movement with pain. ----- The claimed condition is ERECTILE DYSFUNCTION. The diagnosis is ERECTILE DYSFUNCTION and the rationale is the history and medication profile. ----- The claimed condition is EXTERNAL/INTERNAL HEMORRHOIDS, STATUS POST SURGERY; ANAL FISSURES, WITH LEAKAGE. The diagnosis is EXTERNAL/INTERNAL HEMORRHOIDS, STATUS POST HEMMORRHOIDECTOMY; ANAL FISSURES IN REMISSION and the rationale are the history and exam findings.
for range of motion it said this:
"the initial range of motion on the current exam is such that as to make an estimate of any additional degree of ROM loss during pain on use or a flare-up as nothing more than conjecture "
--------------------------------------mental health-------------------------------------------------------------------------
a.Mental Disorder Diagnosis #1: Post Traumatic Stress Disorder, Chronic
Comments, if any: The claimants overall symptoms can be best understood as relating to the traumatic
experiences he had during combat on deployments and his continuous symptoms such as anxiety, dissociative states, difficulty getting along and reacting to others, insomnia and low mood are generally attributed to triggers related to traumatic experiences.
Mental Disorder Diagnosis #2: Major Depressive Disorder, Moderate, Recurrent
Comments, if any: As a result of inadequate treatment thus far, and exposure to multiple stressors and negtive experiences have contributed to the claimant having recurrent bouts of depressive symptoms that have interferred with his general functiong.
3. Differentiation of symptoms
a. Does the Veteran have more than one Mental disorder diagnosed? Yes
If yes, complete the following question (3b):
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? Yes
a. Which of the following best summarizes the Veteran’s level of occupational and social impairment with regards to all mental diagnoses?
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication
list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: 100% of the impairment is due to the PTSD diagnosis
i meet all criteria for A-H for PTSD diagnosis
5. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans diagnoses:
Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Chronic sleep impairmen
Disturbances of motivation and mood
Difficulty in adapting to stressful circumstances, including work or a worklike setting
Spatial disorientation
Based upon the examination, the claimant needs to seek follow up treatment. The claimant requires referral to a formal PTSD treatment program that address coping skills along with exposure and response prevention approaches. This information was conveyed to the claimant during the examination. The claimant does not appear to pose any threat of danger or injury to self or others.
--------------------------------------------------------------------------------v---------------------------------------------------------------------
what do you all think? from reading other cases I belive I will get 30% Army and I know at least 50% VA but just wondering what you all think since the NARSUM is so backloged right now at trippler its going to be a long time before i sign that guy
I am going to try and copy and paste maybe some relevant information
-----------------------------------------------------general med---------------------------------------------------------
List of Symptomatic Symptoms:
Anus and Rectum; Abdomen and Viscera; Genitourinary; Upper extremities; Lower extremities; Spine; Identifying body marks, scars, tattoos; Skin/Lymphatic; Psychiatric;
List of Abnormal Findings:
Examination of the skin is abnormal; findings show plantar wart left foot 0% exposed <1% entire body, folliculitis posterior scalp 4% exposed 2% entire body There are findings of identifying body marks, scars or tattoos; findings show scar both hips and multiple tattoos Rectal examination is abnormal; findings show hemorrhoids, normal prostate There is a complaint of tinnitus.
Diagnosis Summary:
The claimed condition is SCARS, S/P BILATERAL HIP SURGERY. The diagnosis is SCARS, LEFT HIP X3 ; RIGHT HIP X2 S/P BILATERAL HIP SURGERY and the rationale is the history and exam findings. --- --The claimed condition is INGROWN HAIRS, SCALP AND NECK. The diagnosis is folliculitis scalp and the rationale is the history and exam findings. ----- The claimed condition is PLANTAR WART, LEFT FOOT. The diagnosis is PLANTAR WART, LEFT FOOT and the rationale is the history and exam finding. - ---- The claimed condition is ULCERATIVE COLITIS and there is no diagnosis because there is no pathology to render a diagnosis. ----- The claimed condition is RIGHT WRIST CONDITION, WITH LOSS OF MOTION. The diagnosis is WRIST SPRAIN and the rationale is the history and exam finding of less movement with pain and tenderness. ----- The claimed condition is LEFT HIP ARTHRITIS (MEB REFERRED CONDITION) LEFT HIP STATUS POST ARTHROSCOPY, LABRAL REPAIR, CAM AND PINCER OSTEOPLASTY AND CAPSULAR REPAIR (21OCT2014) WITH POST SURGICAL PAIN AND ARTHRITIS (MEB REFERRED CONDITION) The diagnosis is LEFT HIP STATUS POST ARTHROSCOPY, LABRAL REPAIR, CAM AND PINCER OSTEOPLASTY AND CAPSULAR REPAIR (21OCT2014) WITH POST SURGICAL PAIN AND ARTHRITIS and the rationale is the history and exam finding of less movement with pain and tenderness. ----- The claimed condition is RIGHT HIP ARTHRITIS (MEB REFERRED CONDITION) RIGHT HIP STATUS POST ARTHROSCOPY, CAM AND PINCER OSTEOPLASTY, CHONDROPLASTY ACETABULUM, LABRAL REPAIR AND PARTIAL CAPSULAR REPAIR (09SEP2014) WITH POST SURGICAL PAIN (MEB REFERRED CONDITION) The diagnosis is RIGHT HIP STATUS POST ARTHROSCOPY, CAM AND PINCER OSTEOPLASTY, CHONDROPLASTY ACETABULUM, LABRAL REPAIR AND PARTIAL CAPSULAR REPAIR (09SEP2014) WITH POST SURGICAL PAIN and the rationale is the history and exam finding of less movement with pain and tenderness. The claimed condition is RIGHT FEMUR CYST and there is no diagnosis because there is no pathology to render a diagnosis. ----- The claimed condition is LUMBAR DEGENERATIVE DISC DISEASE L5-S1 WITH MULTIPLE SPRAINS The diagnosis is LUMBAR STRAIN with DEGENERATIVE DISC DISEASE L5-S1 and the rationale is the history and exam finding of less movement with pain. ----- The claimed condition is ERECTILE DYSFUNCTION. The diagnosis is ERECTILE DYSFUNCTION and the rationale is the history and medication profile. ----- The claimed condition is EXTERNAL/INTERNAL HEMORRHOIDS, STATUS POST SURGERY; ANAL FISSURES, WITH LEAKAGE. The diagnosis is EXTERNAL/INTERNAL HEMORRHOIDS, STATUS POST HEMMORRHOIDECTOMY; ANAL FISSURES IN REMISSION and the rationale are the history and exam findings.
for range of motion it said this:
"the initial range of motion on the current exam is such that as to make an estimate of any additional degree of ROM loss during pain on use or a flare-up as nothing more than conjecture "
--------------------------------------mental health-------------------------------------------------------------------------
a.Mental Disorder Diagnosis #1: Post Traumatic Stress Disorder, Chronic
Comments, if any: The claimants overall symptoms can be best understood as relating to the traumatic
experiences he had during combat on deployments and his continuous symptoms such as anxiety, dissociative states, difficulty getting along and reacting to others, insomnia and low mood are generally attributed to triggers related to traumatic experiences.
Mental Disorder Diagnosis #2: Major Depressive Disorder, Moderate, Recurrent
Comments, if any: As a result of inadequate treatment thus far, and exposure to multiple stressors and negtive experiences have contributed to the claimant having recurrent bouts of depressive symptoms that have interferred with his general functiong.
3. Differentiation of symptoms
a. Does the Veteran have more than one Mental disorder diagnosed? Yes
If yes, complete the following question (3b):
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? Yes
a. Which of the following best summarizes the Veteran’s level of occupational and social impairment with regards to all mental diagnoses?
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication
list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: 100% of the impairment is due to the PTSD diagnosis
i meet all criteria for A-H for PTSD diagnosis
5. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans diagnoses:
Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Chronic sleep impairmen
Disturbances of motivation and mood
Difficulty in adapting to stressful circumstances, including work or a worklike setting
Spatial disorientation
Based upon the examination, the claimant needs to seek follow up treatment. The claimant requires referral to a formal PTSD treatment program that address coping skills along with exposure and response prevention approaches. This information was conveyed to the claimant during the examination. The claimant does not appear to pose any threat of danger or injury to self or others.
--------------------------------------------------------------------------------v---------------------------------------------------------------------
what do you all think? from reading other cases I belive I will get 30% Army and I know at least 50% VA but just wondering what you all think since the NARSUM is so backloged right now at trippler its going to be a long time before i sign that guy
