Wednesday, March 26, 2014

Joe's Report of Medical Survey

Back in 2002 I was fortunate enough to receive Joe's Military records as well as his VA medical records. These records are very valuable in the sense that they shed a little light on part of who Joe was. Not only through the doctor's point of view, but there is also some family history background. To those who never knew their father that is everything.

This Report of Medical Survey is the first of five different medical records I have for him. I have transcribed most of the notes by the doctor, but I have left out some of the boring and gruesome medical details.

This 23 year old, married, Caucasian male, SR3 USN, was admitted to the sick list aboard the USS BORIE (DD-704) on 14 June 1962 with the diagnosis, Dermatitis, N,.E.C., Hands and Wrists, #7039 and was transferred the same date to the Dermatology Service of this hospital for further evaluation, treatment and disposition. The patient developed a rash above his left wrist approximately three months prior to admission.

Past medical history revealed that the patient had eczema from age two through six. Allergies included eggs, mustard and Penicillin.

Physical examination at the time of admission was limited to the skin of both wrists and the fourth left finger where there was a weeping lichenified eruptions consisting of several thickened erythematous, excoriated plaques and fine scaling. Indicated laboratory studies were all within normal limits.

While on the Dermatology Service the patent was treated with cool Burrow's compresses in addition to local steroids, Vioform and BHL paste. Under this regimen his response has been good, but apparently because of various situational difficulties resulting in severe anxiety and depression, his skin condition has gradually become worse. It has also been noted in the past that during periods of stress his skin would tend to erupt. The patient's skin condition plus the fact that he evidenced gross tremors tended to make his work as a barber quite difficult if not impossible. By 2 July 1962 the patient had become considerably more anxious and depressed, and by his own request sought psychiatric consultation. Concomitant to this his skin condition had become worse with much itching and self inflicted excoriations. On 12 July 1962 he was transferred to the Neuropsychiatric Service for further evaluation, treatment and disposition.

Mental status examination revealed a somewhat unkempt, overtly hostile, demanding and extremely anxious male. Affect was somewhat flat and unexpressive. Sustained mood was that of moderate depression. Judgment was poor with rather immature ideas and an inadequate social adjustment. Ideational content revealed some self derogatory thoughts and vague fears. The patient appeared to be quite neurotic with numerous pathologic defenses consisting for the most part of introjection, projection, irrationalization and somatization. He was well oriented in all three spheres and appeared to be of low average intelligence.

Background information obtained from the patient was considered to be reliable. He was born the youngest of three siblings to a lower middle class family in Massachusetts. Neuropathic traits of childhood included nail biting, stuttering and repetitive anxiety dreams. The patient indicated that he had a somewhat withdrawn childhood and that he was hospitalized "almost constantly" from age two to five years because of repetitive episodes of eczema. He apparently got along well with his parents, although he stated that his mother was quite compulsive, strict and domineering. The patient failed the second and third grades, was frequently truant, at one time being forced in a "boy's home" for same, was often involved in fights, was hostile toward all in authority and only completed the sixth grade because he "beat up" three teachers and spent a year in "reform school" for same. the patient stated that he entered the navy in order to "get off parole". Initially his service appeared to have been adequate, but within the last six months prior to this admission he has found it progressively more difficult to perform his duties. this difficulty revolves around a trying marital situation in which divorce action is now pending. Since the patient has been on the Neuropsychiatric Service his skin condition appears to have improved slightly, although he still remains quite only a minimal degree. He maintained a hostile, defiant, demanding attitude.

On 7 August 1962 Dg. #2 was revised to Dg. #3, Aggressive Reaction, #3213, moderate, manifested by defiance of authority, response to frustration with instability, temper tantrums and destructive behavior, a hostile attitude and somatization of aggressive feelings; predisposition, marked, life history of impulsive, defiant, delinquent behavior, poor school and social adjustments, neuropathic traits; external precipitating stress, minimal, routine duties of rate; impairment, marked for military service, minimal for civilian life.

It is the opinion of this Board of Medical Survey that this patient is unsuitable for further service. It is the recommendation of the Board that he be discharged from the U. S. Navy.

It is further the opinion of the Board that he has received maximum benefit of hospitalization, further treatment is not indicated at this time and will not restore this patient to a duty status. At the present time he is considered fully competent to be discharged into his own custody, does not constitute a menace to himself or others and is not likely to become a public charge.

There is no record at this command of any disciplinary action pending in this case. He has been informed of the Board's findings and recommended disposition and does not desire to submit a statement in rebuttal.

So it was this examination that led to the end of Joe's naval career.

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