ptsd Low back pain secondary PTSD

[dsd84dsd]

 

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. ************************************************************************* 

[dsd84dsd]

When the examiner sends back the letter to the Va will it show up in myhealthvet?

[dsd84dsd]

I did read on myhealthevet that one of the doctors put there are physiological effects in the notes on back pain when I was in the military. 

[Berta]

I agree with you Buck, because a PTSD diagnosis is dependent on an inservice stressor, as you said.

But this is new info:

"I did read on myhealthevet that one of the doctors put there are physiological effects in the notes on back pain when I was in the military. "

Is the back pain due to the SC kidney (urination) condition., or as Buck asked, to an inservice event or accident?

Yes Buck, that widow came back ,much sooner than I expected, to tell us she got her DIC.

[dsd84dsd]

I did list one of my stressers being in a Korean hospital for a few days with kidney problems and  back problems.

[Berta]

I think she did...she said she was awarded but DIC did not have a formal award letter yet...and I gave her a VA link to the Office of Survivors-VA.

There were 31 pages to her claim but I was baffled as to how she did get the DIC, and like many widows we get here, we ask importrant questions that never get answered.

 

[Berta]

DSD84DSD

"I did list one of my stressers being in a Korean hospital for a few days with kidney problems and  back problems."

That sure sounds like it might be  an inservice stressor.

I didnt know you gave the VA any info on stressors....that info is new too and that changes my opinion....now I believe  it is quite possible they are considering SC for PTSD.