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Low back pain secondary PTSD

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I have chronic back pain and I filed a ptsd claim and I was wondering if this looks like a approval for Low back pain and secondary ptsd?She mentioned The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition.

 

 

1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?  [X] Yes [ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Major Depressive Disorder ICD code: F33.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): n/a 3. 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 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 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 ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 2. MENTAL STATUS: Appearance: casually dressed, adequately groomed Activity: normal, no psychomotor agitation or retardation Attitude: polite, cooperative Speech: fluent, coherent Mood: depressed Affect: appropriate, mood congruent Perception: no hallucinations Thought flow: logical, goal directed Thought content: no delusions Thoughts of harm: no suicidal/homicidal ideation Level of consciousness: alert Oriented: to all spheres Attention: good Current Suicide Risk Factors: _X____ Does not have thoughts of suicide or self harm at this time _X____ Does not express feelings of hopelessness or helplessness at this time Current Suicide Assessment: _X____ Low: Patient judged NOT to be at significant risk for self-harm d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran has been arrested twice for domestic violence. He denied recent or pending charges. e. Relevant Substance abuse history (pre-military, military, and post-military): denied  f. Other, if any: n/a 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: As an MP, Veteran was among those who responded to a suicide. The EMT's were already there and had taken him down and had him on the stretcher. His job was to interview the family. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [ ] Yes [X] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] No criterion in this section met. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:  Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] No criterion in this section met. Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] No criterion in this section met. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] No criterion in this section met. Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: No response provided. 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent  [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 [X] Impaired impulse control, such as unprovoked irritability with periods of violence 6. Behavioral Observations -------------------------- depressed, low energy 7. 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: irritability, reduced concentration, low energy and fatigue, reduced interest in activities, tearfulness, feeilngs of worthlessness, limited coping and isolativeness; "I try to stay away from people if I can...Sometimes when I am really angry I bite my hand. I do that a lot." 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- The CAPS-5 for the assessment of ptsd was utilized in this evaluation. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. ****************************************************************************---------------------- Indicate method used to obtain medical information to complete this document: [X] Examination via approved video telehealth Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: 1. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION: Direct service connection Does the Veteran have a diagnosis of (a) PTSD, DEPRESSION, ANXIETY that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) MILITARY POLICE DUTIES during service? Rationale must be provided in the appropriate section. Additional remarks for the examiner: DD214 MOS MILITARY POLICE CAPRI ADJUSTMENT DISORDER ******************************************************************** 2. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.  Secondary Service Connection. Is the Veteran's PTSD, DEPRESSION, ANXIETY at least as likely as not (50 percent or greater probability) proximately due to or the result of low back pain? Rationale must be provided in the appropriate section. If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder. 3. If your examination determines that the Veteran does not have diagnosis of PTSD and you diagnose another mental disorder, please provide an opinion as to whether it is at least as likely as not that the Veteran's diagnosed mental disorder is a result of an in-service stressor related event. Additional remarks for the examiner: CAPRI ADJUSTMENT DISORDER b. Indicate type of exam for which opinion has been requested: DBQ PSYCH PTSD Initial TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: 1.& 3. There is no information to make a link or suggeat that the veteran's major depressive disorder was incurred in or caused by the MILITARY POLICE DUTIES during service or that it is a result of an in-service stressor related event. TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ]  a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: 2.Veteran describes his back pain as having played a role in his depression while in the military and now. Hence, there is some suggestion by the veteran's statement only that his depressive disorder is linked to or a partial result of his low back pain. ************************************************************************* 

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Yeah bad luck posting here. They had preparation for decision for next month on my claims. Now they requested a medical opinion from my my local va. Is that good or bad?Really pisses me off they keep on going back and fourth. 

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Hard to say if good or bad...what is the C & P exam for?

Is this the arthritis spine C & P -or , if you already had that, do you have the results of it?

 

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I called them and they said the physiologist needs a letter for the C@P exam I had with ptsd.You would think they would have to have a written statement when she submitted the results.  Think they want a letter to link ptsd secondary to low back pain.  Didn't like the results of the C@P exam of Lumbar Strain and Plantar fascittis. He did say it is as likely as not for my arthritis of the back to be service related. Dont think he did the Range of motion right. He said I had perfect range of motion. But I could barely bend down without pain. He seemed really shady and was practically saying that I was faking it. 

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I  dont see how they can link PTSD to the back pain.

The C & P doc might have had no experience at all in the field of your disabilities.

Have you googled his name to see what type of doctor he really is?

I hope others will chime in here....

This is a very odd C & P exam.

One thing to consider too is that many of the regulations take into account pain  as the Deluca factor.

Have you formally claimed depression as due to the pain?

If I were you I would claim higher ratings on any of your SCs, that fgall into a higher criteria by medical evidence than the ratings you have now...the arthritis Exam might boost the  lumbar rating....

The Exam states:

RESTATEMENT OF REQUESTED OPINION": a. Opinion from general remarks: 1. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: " but now they want a third exam done regarding PTSD?

This tells me the Examiner might not be a MH professional,at all ,  and/or might not be qualified at all to opine on lumbar and podiatric issues.

We need more input from other members here.

 

 

 

 

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  • HadIt.com Elder

You will need a VA MH PTSD DSM-5 Diagnose.

and you will need a MH qualified Dr to state your Back problem is secondary to PTSD, if you have PTSD You will need to prove a in service trauma event  combat or or other type trauma  that occurred during military.( medical records as evidence) or in service records as evidence) or combat ribbon /medal.

Just my opinion here  but

The only way a Dr can opien his her opinion is First they determine you have PTSD and you did something that was damaging to your Back...Accident or other type of injury caused by your PTSD which will be hard to prove on your part.

Ms berta Remember the Veterans widow that had a claim in when her Hubby was riding his Motor Cycle at a high rate of speed and popping wheelies and was killed but also had a diagnoses of PTSD  the veterans wife claimed he had a ''anxiety  attact at the time he was riding his Motor Cycle of the Accident and that his PTSD was the cause/contribute to his death.  had he not have a diagnose of PTSD then no that could not been the cause of his death...I never knew how that case turn out?

but same here with this veteran..PTSD Can be a secondary cause to another disability...if the Veteran injured himself and the cause was proven it was because of his PTSD.(Anxiety attact or episode of some type caused solely from/by his Diagnose of PTSD.

I could be all wrong here...this is just my opinion.

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Yes in the C@P exam I posted earlier she said I had PTSD. The VA asked her if the Low back pain could be related to PTSD. She said 50 percent or more likely. Its called secondary. Yes I was in the hospital for 3 days because of the pain in military. Yes it was a legit Mental Health Doctor. Right now Im waiting for her statement to be sent to the VA. 

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