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hypertension Ptsd C&p Exam ..can I Go For P&t
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marinevet1
Hi
Here is my C&P for PTSD...I 'm also was awarded SSDI and I'm 61
How or do i qualify for PTSD & P&T or how do I get P&T
Here my review back for the PTSD, and what my rating next
What's my next step in the process????
LOCAL TITLE: COMPENSATION & PENSION EXAMINATION REPORT
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: NOV 02, 2010@13:43 ENTRY DATE: NOV 02, 2010@13:44:43
AUTHOR: XXXXXXXXXXX EXP COSIGNER:
URGENCY: STATUS: COMPLETED
C-FILE WAS:
Reviewed
MEDICAL RECORDS WERE:
Reviewed
OTHER MATERIAL REVIEWED:
Psychometric Tests and Questionnaires, DD-214, Other Records/Documents
WAS THERE OUTPATIENT TREATMENT FOR A MENTAL DISORDER? Yes
DATE(S) OF OUTPATIENT TREATMENT: Began outpatient treatment in 2009 after
and began medications and psychotherapy; began VA treatment at West LA and
Sepulveda in 12/2009.
CONDITION(S) AND LOCATION OF TREATMENT:
Bipolar disorder; Post-Traumatic Stress Disorder; Chronic
SUMMARY OF CURRENT TREATMENT FOR A MENTAL DISORDER:
Veteran is part of the psychosocial group treatment module at the POST, at VA
West Los Angeles Medical Center and also is managed by
Dr. Warren-psychiatrist from POST. He attends groups twice weekly, Medic PTSD and is
compliant with medication by his report, notes from his psychiatric record
also indicate his compliance with treatment.
CURRENT TREATMENT(S): Anti-manic
MEDICATION SIDE EFFECT(S): Drowsiness, Fatigue, weight gain
GROUP THERAPY: Yes 2
INDIVIDUAL PSYCHOTHERAPY: Yes
EFFECTIVENESS OF THERAPY: fair
----------------
Veteran was staioned in Da Nang, Vietnam attatched to 1st Marine Div., 1st Recon
Battalion, Charlie company 2nd platoon, team 1; MOS was 0311 and 8651-primarily
Recon: carrying medical supplies, save lives at all expense, exposed to serious injury,
called medi vacs and give morphine; saw and killed VC; save soldier lives;
DATE(S) OF SERVICE: 4/1969-09/70
BRANCH OF SERVICE: Marine Corps
HIGHEST RANK OBTAINED: E3
TYPE OF DISCHARGE: Honorable
RANK AT DISCHARGE: E3
MILITARY OCCUPATIONAL SPECIALTY: MOS: and 0311; Rifleman; 8651 Reconnaissance,
went on patrols and fire-fights, called in artillery strikes; cobra and naval gunships in Da Nang;
DECORATIONS AND MEDALS AWARDED: Combat Action Ribbon; Bronze Star
Presidential Unit of Citattion; National Defense Service Medal; Vietnam
Campaign Medal; Good Conduct Medal
DISCIPLINARY INFRACTIONS AND ADJUSTMENT PROBLEMS: None.
DID THE VETERAN HAVE COMBAT EXPERIENCE: Yes
WERE COMBAT WOUNDS SUSTAINED: No
LOCATION AND DATE OF COMBAT EXPERIENCE: Da Nang 11/17/69 to 07/30/70;
INSIGHT: Patient understands that he/she has a problem.
DOES THE PATIENT HAVE SLEEP IMPAIRMENT? Yes
COMMENTS AND DESCRIPTION OF EXTENT SLEEP IMPAIRMENT INTERFERES WITH DAILY
ACTIVITY:
Veteran sleeps irregularly, has frequent dreams, flashbacks which causes
interrupted sleep; early insomnia, has problem falling asleep, takes 1-2 hours
to fall asleep; sleep is not restful, is fatigued, feels as if he's been fighting in his sleep;
TYPE OF HALLUCINATIONS:
None
DOES THE PATIENT HAVE INAPPROPRIATE BEHAVIOR? Yes
INTERPRETS PROVERBS APPROPRIATELY? Yes
DOES THE PATIENT HAVE OBSESSIVE/RITUALISTIC BEHAVIOR? No
DOES THE PATIENT HAVE PANIC ATTACKS? Yes
-------------
STRESSOR EVENT(S) THE VET FOUND PARTICULARLY TRAUMATIC:
Combat experience
DESCRIPTION OF STRESSOR: Combat experience
DATE AND LOCATION: 11/1969 to 07/1970 Da Nang Vietnam.
TRAUMA OCCURRED: During Military Service
INTENSE FEAR: Yes
FEELING OF HELPLESSNESS: Yes
FEELING OF HORROR: Yes
OTHER REACTION: Yes
DESCRIBE OTHER: Dissociation
ADDITIONAL COMMENTS: Veteran served as a medic in Vietnam combat zones,
with multiple exposures to seriously wounded, dying soldiers that he
attempted to save. Witnessed horrific trauma involving severed limbs, gun
shots wounds and multiple injuries.
TRAUMA EXPOSURE TESTING
-----------------------
TESTING FOR TRAUMA EXPOSURE VETERAN HAS UNDERGONE:
Combat Exposure Scale, Trauma Questionnaire
RESULTS OF IDENTIFIED TRAUMA EXPOSURE TESTING:
Veteran experienced intensely traumatic combat episodes as a medic in Vietnam
as evidenced by his documented receipt of the Combat Action Ribbon which
corroroborates his DD-214 citation as well as his report of extreme combat
trauma while serving as medic in Vietnam between 1969-1970;
OVERALL LEVEL OF TRAUMATIC STRESS EXPOSURE: High
PTSD SYMPTOMS
-------------
PERSISTENT RE-EXPERIENCING THE TRAUMATIC EVENT BY:
Multi times per month
PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED WITH THE TRAUMA
AND NUMBING OF GENERAL
RESPONSIVENESS:
Efforts to avoid thoughts, feelings, or conversations associated with the
trauma, Efforts to avoid activities, places, or people that arouse recollections
of the trauma, Inability to recall an important aspect of the trauma, Markedly
diminished interest or participation in significant activities, Feeling of
detachment or estrangement from others, Restricted range of affect
Sense of a foreshortened future
PERSISTENT SYMPTOMS OF INCREASED AROUSAL:
Difficulty falling or staying asleep, Irritability or outbursts of anger,
Hypervigilance, Exaggerated startle response, reliving experiences.
THE DISTURBANCE CAUSES CLINICALLY SIGNIFICANT DISTRESS OR
IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR OTHER IMPORTANT
AREAS OF FUNCTIONING: Yes
DESCRIPTION OF THE ONSET OF SYMPTOMS: Chronic
FREQUENCY, SEVERITY AND DURATION OF PTSD SYMPTOMS FOUND:
Veteran experiences severe symptoms of PTSD that occur weekly and that have
lasted for 40 years. Upon examination, Veteran reports that he is bothered at
least several days each week by intrusive, avoidant and hyperarousal symptoms of
post-traumatic stress.
QUALITY OF PEER RELATIONSHIPS AND SOCIAL ADJUSTMENT:
Pre-military, Veteran claims he was outgoing, had many friends, rode
motorcycles; reports having a great social life and that he had lots of friends.
When he came back from Vietnam, he was living in Westminister, near Little
Saigon, believes he started to have ptsd (shell shock) symptoms and then his
former, highschool friends also began moving away, resulting in a serious change
in his social interaction. Veteran reports that he began isolating at that time
which has persisted to the present; Veteran states that he currently has no real
friends, finds it difficult to manage his anger and emotional responses when in
crowds or large groups; prefers to be alone because he feels safer; does nothing
for recreation; watches television primarily, avoids reading newspapers or other
sources of written information. Unable to work due to the DDD.
DESCRIPTION OF DEGREE AND QUALITY OF SOCIAL RELATIONSHIPS AND WORK:
Can't work has DDD, SSDI from SSA, has very few friends, doesn't socialize;
spend most of his time in the Haven Senior Program at West LA VA.
DESCRIPTION OF ACTIVITIES AND LEISURE PURSUITS:
Watched TV; plays with computer;
HISTORY OF SUICIDE ATTEMPTS? Yes
COMMENTS AND ADDITIONAL INFORMATION:
Took aspirin in attempted suicide because he was having flashbacks of
vietnam. Disclosed to family doctor; re-experiencing related to what else he
could he have done to help injured and dying on the battlefield.
HISTORY OF VIOLENCE/ASSAULTIVENESS? No
SUMMARY STATEMENT OF CURRENT PSYCHOSOCIAL FUNCTIONAL STATUS:
Veteran is not very social, isolates and prefers to stay alone, avoids crowds,
ISSUES ASSOCIATED WITH ALCOHOL USE:
No use
ISSUES ASSOCIATED WITH OTHER SUBSTANCE USE:
No use
PSYCH EXAM
COMMENTS AND DESCRIPTION OF EXTENT SLEEP IMPAIRMENT INTERFERES WITH DAILY
ACTIVITY:
Veteran sleeps irregularly, has frequent dreams, flashbacks which causes
interrupted sleep; early insomnia, has problem falling asleep, takes 1-2 hours
to fall asleep;
sleep is not restful, is fatigued, feels as if he's been fighting in DATES, CURRENT TREATMENT,
AND OTHER SIGNIFICANT DETAILS OF NON-PSYCHIATRIC ISSUES:
1996- L shoulder surgery; 1969 Malaria in Vietnam; High blood pressure treatment
in 2005. Severe Degenerative Disk diagnosed in 1983 at Kaiser related to Military medical records
his sleep; Satellite TV Technician for Direct TV as Supervisior.
IS THE VETERAN CURRENTLY EMPLOYED? No
IS VETERAN RETIRED? Yes
IS VETERAN DISABLE? Yes
DATE OF RETIREMENT: 12/30/2006
Primary Care Physician
Mr. XXXX is on time for his appointment
and takes his medications as prescribed.
The following conditions should be connected to his Military Service
Agent Orange Exposure
Post Traumatic Stress Disorder, combined w/ Bipolar Disorder
Hypertension
Traumatic arthritis, pain in right shoulder and neck
Tinnitus
Malaria
Erectile Dysfunction, has elevation of the HGB A1C, w/early Diabetes,
as a by product of taking medications for HTN and possible Agnnt Orange Exposure
INTERVIEW-BASED DIAGNOSTIC INSTRUMENTS FOR PTSD:
PTSD Symptom Scale
QUANTITATIVE PSYCHOMETRIC ASSESSMENT OF PTSD SYMPTOM SEVERITY:
PTSD Checklist for Combat and Non-Combat Trauma, Trauma Symptom Inventory
PSYCHOMETRIC ASSESSMENT SCORES:
Veteran was administered The PTSD Checklist (PCL), which is a 17- item
questionnaire also designed to assess symptoms associated with combat related
PTSD. On this administration of the PCL scale, he obtained a score of 68,
which exceeds the score of 50 that is consistent with a diagnosis of PTSD in
military populations. Of note, he reported within the past month being very bothered by
disturbing memories, thoughts and images of his combat experiences, feeling
cut off from other people, avoiding activities or situations because they remind
him of stressful military experiences, being super-alert, watchful and on-guard,
feeling irritable and having angry outbursts, feeling jumpy and being easily startled,
insomnia and feeling emotionally numb. Additionally, he was also administered
the Trauma Symptom Inventory, a 100-item questionnaire designed to appraise
symptoms of posttraumatic stress disorder, clinical depression, affect regulation and
dysfunctional behavior. He produced a valid, interpretable profile, with
no exaggeration of unusual symptoms. There were clinically significant
elevations on the Tension Reduction Behaviors (T = 93), Intrusive Experiences (T = 98) and
Defensive Avoidance (T = 83) and Dissociation (T = 86) scales.
He also meets criteria for PTSd based on PTSD Symptom Scale (Foa) as evidenced by
at least one re-experiencing symptom (nightmares), three avoidance symptoms
(avoiding, thoughts, feelings, detachment from others) and two hyperarousal
symptoms (insomnia and pronounced irritability).
DOES THE VETERAN MEET THE DSM-IV CRITERIA FOR A DIAGNOSIS OF PTSD? Yes
AXIS I: 309.81 PTSD-Chronic, 296.00 Bipolar NOS Moderate to Severe
IF ANY ADDITIONAL MENTAL DISORDERS HAVE BEEN DIAGNOSED, EXPLANATION OF HOW THE
SYMPTOMS ARE RELATED TO OR ARE PART OF EACH MENTAL DISORDER:
The symptoms of PTSD and Bipolar depression do overlap to a large extent
particularly as it relates to unrelenting presence of persistent, bothersome,
intrusive symptoms of re-experienced thoughts, images and feelings associated
with the trauma and hypervigilance manifesting as insomnia and startle
response, It appears in this case
that the veteran is experiencing both chronic anxiety and a significant,
complex mood disorder, hence both diagnoses are indicated.
SYMPTOMS ARE RELATED TO OR ARE PART OF EACH MENTAL DISORDER:
The symptoms of PTSD and Bipolar depression do overlap to a large extent
particularly as it relates to unrelenting presence of persistent, bothersome,
intrusive symptoms of re-experienced thoughts, images and feelings associated
with the trauma and hypervigilance manifesting as insomnia and startle
response, It appears in this case that the veteran is experiencing both chronic
anxiety and a significant, complex mood disorder, hence both diagnoses are indicated.
AXIS II: 799.99
AXIS III: Degenerative Disk; Malaria, No longer can work
AXIS IV: Heavy Extreme Combat Exposure
AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING
SCORE: 45 TIME FRAME: Current functioning
WAS A MEDICAL OPINION REQUESTED? No
/es/ XXXXXXXXXX, Ph.D.
CLINICAL PSYCHOLOGIST
Signed: 11/16/2010 09:30
Thank You
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