MOMO68 Posted October 7, 2013 Share Posted October 7, 2013 ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 2. Current Diagnoses -------------------- a. Diagnosis #1: PTSD due to MST and combat ICD code: 309.81 Indicate the Axis category: [X] Axis I [ ] Axis II b. Axis III - medical diagnoses (to include TBI): Deferred to medical records c. Axis IV - Psychosocial and Environmental Problems (describe, if any): No response provided. d. Axis V - Current global assessment of functioning (GAF) score: 65 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No 4. 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 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 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. Records reviewed (check all that apply): [X] Claims folder (C-file): [X] Yes [ ] No b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 3. Stressors ------------ a. Stressor #1: In total darkness in the bunker Gulf war. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No b. Stressor #2: MST (Patient later stated this should be #1) Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No c. Stressor #3: We were close to where that skud missle hit. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No 4. PTSD Diagnostic Criteria --------------------------- a. Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, referred to as Criteria A-F, are from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Criterion A: The Veteran has been exposed to a traumatic event where both of the following were present: [X] The Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. [X] The Veteran's response involved intense fear, helplessness or horror. Criterion B: The traumatic event is persistently reexperienced in 1 or more of the following ways: [X] Recurrent and distressing recollections of the event, including images, thoughts or perceptions [X] Recurrent distressing dreams of the event Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following: [X] Efforts to avoid activities, places or people that arouse recollections of the trauma [X] Feeling of detachment or estrangement from others [X] Restricted range of affect (e.g., unable to have loving feelings) Criterion D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or more of the following: [X] Difficulty falling or staying asleep [X] Irritability or outbursts of anger [X] Hypervigilance Criterion E: [X] The duration of the symptoms described above in Criteria B, C and D is more than 1 month. Criterion F: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. b. Which stressor(s) contributed to the Veterans PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2 [X] Stressor #3 5. Symptoms ----------- For VA rating purposes, check all symptoms that apply to the Veterans [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Flattened affect [X] Suicidal ideation 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: Panic attacks are twice weekly. Lack of trust issues. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, if any ------------------ Currently taking 150 mg Zoloft Medical Opinion 1 Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: C-file was reviewed. If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] 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: 1. Definitions -------------- Not applicable 2. Restatement of requested opinion ----------------------------------- a. Insert requested opinion from general remarks: Is the Veteran's post traumatic stress disorder at least as likely as not (50 percent or greater probability) incurred in or caused by active duty where she served in Southwest Asia? b. Indicate type of exam for which opinion has been requested (e.g. Skin Diseases): PTSD 3. Medical opinion for direct service connection ------------------------------------------------ a. [X] The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rationale in section c. b. [ ] The claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rationale in section c. c. Rationale: Patient experienced both MST as well as combat related trauma. Personal physical assault, and long term fear for loss of life and lives of others has been associated with the development of emotional pathologies meeting DSM-IV diagnostic criteria. 4. Medical opinion for secondary service connection --------------------------------------------------- Not applicable 5. Medical opinion for aggravation of a condition that existed prior to service ------------------------------------------------------------------------------- Not applicable 6. Medical opinion for aggravation of a nonservice connected condition by a service connected condition --------------------------------------------------------------------------- Not applicable 7. Opinion regarding conflicting medical evidence ------------------------------------------------- Link to comment Share on other sites More sharing options...
HadIt.com Elder Philip Rogers Posted October 8, 2013 HadIt.com Elder Share Posted October 8, 2013 0% - 50%. jmo pr Link to comment Share on other sites More sharing options...
Question
MOMO68
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Diagnosis #1: PTSD due to MST and combat
ICD code: 309.81
Indicate the Axis category:
[X] Axis I [ ] Axis II
b. Axis III - medical diagnoses (to include TBI): Deferred to medical
records
c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
No response provided.
d. Axis V - Current global assessment of functioning (GAF) score: 65
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
4. 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 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
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. Records reviewed (check all that apply):
[X] Claims folder (C-file):
[X] Yes
[ ] No
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
3. Stressors
------------
a. Stressor #1: In total darkness in the bunker Gulf war.
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[X] Yes [ ] No
Is the stressor related to the Veteran's fear of hostile military
or
terrorist activity?
[X] Yes [ ] No
b. Stressor #2: MST (Patient later stated this should be #1)
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[X] Yes [ ] No
Is the stressor related to the Veteran's fear of hostile military
or
terrorist activity?
[X] Yes [ ] No
c. Stressor #3: We were close to where that skud missle hit.
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[X] Yes [ ] No
Is the stressor related to the Veteran's fear of hostile military
or
terrorist activity?
[X] Yes [ ] No
4. PTSD Diagnostic Criteria
---------------------------
a. Please check criteria used for establishing the current PTSD diagnosis.
The diagnostic criteria for PTSD, referred to as Criteria A-F, are from
the Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV).
Criterion A: The Veteran has been exposed to a traumatic event where both
of the following were present:
[X] The Veteran experienced, witnessed or was confronted with an event
that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others.
[X] The Veteran's response involved intense fear, helplessness or
horror.
Criterion B: The traumatic event is persistently reexperienced in 1 or
more of the following ways:
[X] Recurrent and distressing recollections of the event, including
images, thoughts or perceptions
[X] Recurrent distressing dreams of the event
Criterion C: Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
the
trauma), as indicated by 3 or more of the following:
[X] Efforts to avoid activities, places or people that arouse
recollections of the trauma
[X] Feeling of detachment or estrangement from others
[X] Restricted range of affect (e.g., unable to have loving feelings)
Criterion D: Persistent symptoms of increased arousal, not present before
the trauma, as indicated by 2 or more of the following:
[X] Difficulty falling or staying asleep
[X] Irritability or outbursts of anger
[X] Hypervigilance
Criterion E:
[X] The duration of the symptoms described above in Criteria B, C and
D
is more than 1 month.
Criterion F:
[X] The PTSD symptoms described above cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.
b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:
[X] Stressor #1
[X] Stressor #2
[X] Stressor #3
5. Symptoms
-----------
For VA rating purposes,
check all symptoms that apply to the Veterans
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Flattened affect
[X] Suicidal ideation
6. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[X] Yes [ ] No
If yes, describe:
Panic attacks are twice weekly.
Lack of trust issues.
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
8. Remarks, if any
------------------
Currently taking 150 mg Zoloft
Medical Opinion 1
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
C-file was reviewed.
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] 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:
1. Definitions
--------------
Not applicable
2. Restatement of requested opinion
-----------------------------------
a. Insert requested opinion from general remarks:
Is the Veteran's post traumatic stress disorder at least as likely as
not
(50 percent or greater probability) incurred in or caused by active
duty where she served in Southwest Asia?
b. Indicate type of exam for which opinion has been requested (e.g. Skin
Diseases):
PTSD
3. Medical opinion for direct service connection
------------------------------------------------
a. [X] The claimed condition was at least as likely as not (50 percent or
greater probability) incurred in or caused by the claimed in-service
injury, event, or illness. Provide rationale in section c.
b. [ ] The claimed condition was less likely than not (less than 50 percent
probability) incurred in or caused by the claimed in-service injury,
event, or illness. Provide rationale in section c.
c. Rationale: Patient experienced both MST as well as combat related
trauma.
Personal physical assault, and long term fear for loss of
life and lives of others has been associated with the
development of emotional pathologies meeting DSM-IV
diagnostic
criteria.
4. Medical opinion for secondary service connection
---------------------------------------------------
Not applicable
5. Medical opinion for aggravation of a condition that existed prior to
service
-------------------------------------------------------------------------------
Not applicable
6. Medical opinion for aggravation of a nonservice connected condition by a
service connected condition
---------------------------------------------------------------------------
Not applicable
7. Opinion regarding conflicting medical evidence
-------------------------------------------------
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