Hey guys, so I went to the local ROI office here in Las Vegas and got copies of all of my C&P and my medical records. I want to post my C&P from my PTSD exam so you guys can look at it and tell me what you think the VA will give me based on what the Dr. has said.
Compensation and Pension Examination
Initial Evaluation for Post-Traumatic Stress Disorder (PTSD)
Date of Exam: October 28, 2010
PRESENT MEDICAL HISTORY – OVER THE PAST ONE YEAR.
Frequency, severity, duration of medical and psychiatric symptoms: The Veterans asthma is daily and mild, and she also complains of back pain which is daily and moderate. Knee pain is also daily and moderate. She also states that depression is daily and moderate to severe, with her anxiety being daily and severs. This woman rates herself at 9/10 anxiety-severity scale. Her score by self rating on a comparable scale for depression is 7/10. The self ratings are consistent with my clinical observations.
Length of remissions, to include capacity for adjustments during periods of remissions: None
PRE MILITARY HISTORY
Family structure and environment: The Veteran lived with her father, one brother, and two sisters. She is married and had two children prior to entering the service.
Quality of Peer Relationships: Good
Education: The Veteran graduated from High School
Employment History: She worked in sales and customer service prior to military service.
Legal Infractions: None
Delinquency or Behavior conduct disturbances: None
Substance Use: None
Significant Medical Problems/Treatment: None
Family Psychiatric History: None
Exposure to Traumatic Stressors: The Veterans’ mother was murdered in 1985.
SUMMARY ASSESSMENT: While this veteran was exposed to the trauma of her mother being murdered she actually functioned at a quite high level prior to entering the service. She graduated from H.S. and was able to maintain employment. She had no particular interpersonal or psychiatric problems, and she described the quality of her peer relationships as being “good”
MILITARY HISTORY:
BRANCH OF SERVICE: Army
Dates of Service: 2006-Present
Dates and location of war zone duty and number of months stationed in war zone: The Veteran was stationed in Iraq from December 2006-May 2007
Military Occupational Specialty: 88M Truck Driver
Highest rank obtained during service: PFC
Type of discharge from military: Honorable
Substance use: None
Combat wounds: Internal bleeding from an IED in February 2007
Specific stressor event considered particularly traumatic: The Veteran’s truck was hit with an IED, being shot at on a daily basis.
Overall level of traumatic exposure based on frequency and severity of incident: Moderate to severe
POST MILITARY PSYCHOSOCIAL ADJUSTMENT:
Marital and Family Relationships: The Veteran was married may 2007 and has three children.
Degree and quality of Social Relationships: Her relationship with her children is at a good status, but with her family members, co-workers, and friends are fair.
Activities and Leisure Pursuits: She states she has no time for any hobbies.
Substance Use: None
Significant Medical Disorders: None
Treatment History for Significant Medical Conditions: None
Summary: The Veteran obviously experienced deterioration in her level of functioning on a post service basis. Whereas previously her general interpersonal relationships were “good” no they are only fair. She is made very uncomfortable by certain “triggers” such as certain parts of the desert that remind her of Iraq. She complains that her husband says that she is now “different” and she acknowledges that her own children “get on my nerves” She told me that she has been trying to get help for 7 months from the VA but she feels that she is being discriminated against because “they did not want females in an infantry battalion” She has experienced disillusionment with the leadership of the Army and the country to be extent that she now feels that the Iraq war was “pointless” In contrast to her previously outgoing style of functioning, she now avoids traveling outside of the city and even her own children. As noted above she is now significantly anxious and depressed, both of which are typical symptoms of PTSD.
ASSESSMENT OF PTSD:
Identify primary stressors: The primary stressor in this case is clearly the veteran’s combat experiences, as detailed earlier in this report.
State if the veteran meets the DSM-IV stressor criterion: The veteran meets the DSM-IV stressor criteria for post traumatic stress.
Identify behavioral, cognitive, social, affective, or somatic changes the veteran attributes to stress exposure: The veteran has become very distrustful of the leadership of this country, which contributes to a significant feeling of insecurity. She is now anxious and depressed, and her sleep is disturbed. She is made extremely uncomfortable brought on by various triggers, such as parts of the desert around Las Vegas remind her of Iraq. She has interpersonal difficulties, now only getting along with others in a fair manner. She even has difficulty in tolerating her own children unfortunately. Her husband is complaining that she is now “different” obviously not regarding this as a positive change.
Describe specific PTSD symptoms present: Anxiety, depression, and negative reactions to stimuli that are reminiscent of Iraq. She has the predicted interpersonal problems, not only with others but within her own family and as detailed earlier in this report.
Specify onset/frequency/severity of symptoms: The onset was during combat, and the symptoms have been moderate to severe and continuous, without remission since her return from the war.
State is the current symptoms are linked to the identified stressor: The symptoms are definitely and are directly linked to the stress of combat, as shown by her negative reaction to scenes that remind her of her experiences in Iraq.
Diagnosis:
The veteran meets criteria for PTSD.
DIAGNOSTIC STATUS:
Axis I Disorders: Post traumatic stress disorder, associated with depression.
Axis II Disorders: None
Axis III Disorders: Asthma and orthopedic disorder as discussed above.
Axis IV Disorders: Moderate coping with anxiety, interpersonal and psychosocial/environmental stressors familiar difficulties, and financial pressures.
Axis V (Current GAF): 60
CAPACITY TO MANAGE FINANCIAL AFFAIRS: In my opinion the veteran is competent to manage her own VA benefit payments in her own best interest.
STRESSOR STATEMENT IN RELATION TO VETERANS FEAR TO HOSTILE MILITARY OR TERRORSIT ACTIVITY: The PTSD claimed by the veteran has been related specifically to her fear of hostile military and possible terrorist activity.
INTEGRATED SUMMARY AND CONCLUSIONS:
Changes in psychosocial functional status following trauma exposure: The veteran has clearly suffered a major deterioration in her ability to function both occupationally and interpersonally. She is now only able to relate to others in a “fair” manner, and she even has difficulty in toleration her own children. She is frequently uncomfortable by stimuli that remind her of combat experience and she is additionally frequently sleep deprived.
Changes in quality of life following trauma exposure: There has clearly been deterioration in this veteran’s quality of life.
Describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life: The deterioration in this veteran’s life and her presenting symptoms are clearly related to her combat experiences and that she functioned at a much higher level prior to entering the United States Army having had no significant psychiatric problems prior to her entrance into the service.
Extent to which disorders other than PTSD are independently responsible for impairment in psychosocial adjustment and quality of life: No other disorders appear relevant to me.
Describe pre trauma risk factors/characteristics that may have rendered the veteran vulnerable to developing PTSD subsequent to trauma exposure: While the murder of her mother might be regarded as a risk factor, the veteran actually appeared to deal with that quite well, being able to graduate from high school and maintain employment and secure induction into the United States Army. Therefore, I believe that she actually entered the Army with no preexisting risk factors for the development of my psychiatric disorder.
Prognosis for improvement of psychiatric condition and impairments in functional status: Good given her age and her desire to receive help, which she expressed to me on a number of occasions.
Capacity in managing benefit payments in veteran’s own best interest: No limitation
EFFECTS OF PTSD ON OCCUPATIONAL AND SOCIAL FUNCTIONING:
Statement: There is reduced reliability and productivity due to PTSD signs and symptoms.
Example: This veteran now suffers interpersonal difficulties and she is frequently uncomfortable around stimuli that remind her of Iraq she even has difficulty in tolerating her own children, and she has marital problems in the sense her husband regards her as now being “different” in a negative way.
I know it's a lot to read and I appreciate you taking the time out of your day to read this.
Question
Kim82
Hey guys, so I went to the local ROI office here in Las Vegas and got copies of all of my C&P and my medical records. I want to post my C&P from my PTSD exam so you guys can look at it and tell me what you think the VA will give me based on what the Dr. has said.
Compensation and Pension Examination
Initial Evaluation for Post-Traumatic Stress Disorder (PTSD)
Date of Exam: October 28, 2010
PRESENT MEDICAL HISTORY – OVER THE PAST ONE YEAR.
Frequency, severity, duration of medical and psychiatric symptoms: The Veterans asthma is daily and mild, and she also complains of back pain which is daily and moderate. Knee pain is also daily and moderate. She also states that depression is daily and moderate to severe, with her anxiety being daily and severs. This woman rates herself at 9/10 anxiety-severity scale. Her score by self rating on a comparable scale for depression is 7/10. The self ratings are consistent with my clinical observations.
Length of remissions, to include capacity for adjustments during periods of remissions: None
PRE MILITARY HISTORY
Family structure and environment: The Veteran lived with her father, one brother, and two sisters. She is married and had two children prior to entering the service.
Quality of Peer Relationships: Good
Education: The Veteran graduated from High School
Employment History: She worked in sales and customer service prior to military service.
Legal Infractions: None
Delinquency or Behavior conduct disturbances: None
Substance Use: None
Significant Medical Problems/Treatment: None
Family Psychiatric History: None
Exposure to Traumatic Stressors: The Veterans’ mother was murdered in 1985.
SUMMARY ASSESSMENT: While this veteran was exposed to the trauma of her mother being murdered she actually functioned at a quite high level prior to entering the service. She graduated from H.S. and was able to maintain employment. She had no particular interpersonal or psychiatric problems, and she described the quality of her peer relationships as being “good”
MILITARY HISTORY:
BRANCH OF SERVICE: Army
Dates of Service: 2006-Present
Dates and location of war zone duty and number of months stationed in war zone: The Veteran was stationed in Iraq from December 2006-May 2007
Military Occupational Specialty: 88M Truck Driver
Highest rank obtained during service: PFC
Type of discharge from military: Honorable
Substance use: None
Combat wounds: Internal bleeding from an IED in February 2007
Specific stressor event considered particularly traumatic: The Veteran’s truck was hit with an IED, being shot at on a daily basis.
Overall level of traumatic exposure based on frequency and severity of incident: Moderate to severe
POST MILITARY PSYCHOSOCIAL ADJUSTMENT:
Marital and Family Relationships: The Veteran was married may 2007 and has three children.
Degree and quality of Social Relationships: Her relationship with her children is at a good status, but with her family members, co-workers, and friends are fair.
Activities and Leisure Pursuits: She states she has no time for any hobbies.
Substance Use: None
Significant Medical Disorders: None
Treatment History for Significant Medical Conditions: None
Summary: The Veteran obviously experienced deterioration in her level of functioning on a post service basis. Whereas previously her general interpersonal relationships were “good” no they are only fair. She is made very uncomfortable by certain “triggers” such as certain parts of the desert that remind her of Iraq. She complains that her husband says that she is now “different” and she acknowledges that her own children “get on my nerves” She told me that she has been trying to get help for 7 months from the VA but she feels that she is being discriminated against because “they did not want females in an infantry battalion” She has experienced disillusionment with the leadership of the Army and the country to be extent that she now feels that the Iraq war was “pointless” In contrast to her previously outgoing style of functioning, she now avoids traveling outside of the city and even her own children. As noted above she is now significantly anxious and depressed, both of which are typical symptoms of PTSD.
ASSESSMENT OF PTSD:
Identify primary stressors: The primary stressor in this case is clearly the veteran’s combat experiences, as detailed earlier in this report.
State if the veteran meets the DSM-IV stressor criterion: The veteran meets the DSM-IV stressor criteria for post traumatic stress.
Identify behavioral, cognitive, social, affective, or somatic changes the veteran attributes to stress exposure: The veteran has become very distrustful of the leadership of this country, which contributes to a significant feeling of insecurity. She is now anxious and depressed, and her sleep is disturbed. She is made extremely uncomfortable brought on by various triggers, such as parts of the desert around Las Vegas remind her of Iraq. She has interpersonal difficulties, now only getting along with others in a fair manner. She even has difficulty in tolerating her own children unfortunately. Her husband is complaining that she is now “different” obviously not regarding this as a positive change.
Describe specific PTSD symptoms present: Anxiety, depression, and negative reactions to stimuli that are reminiscent of Iraq. She has the predicted interpersonal problems, not only with others but within her own family and as detailed earlier in this report.
Specify onset/frequency/severity of symptoms: The onset was during combat, and the symptoms have been moderate to severe and continuous, without remission since her return from the war.
State is the current symptoms are linked to the identified stressor: The symptoms are definitely and are directly linked to the stress of combat, as shown by her negative reaction to scenes that remind her of her experiences in Iraq.
Diagnosis:
The veteran meets criteria for PTSD.
DIAGNOSTIC STATUS:
Axis I Disorders: Post traumatic stress disorder, associated with depression.
Axis II Disorders: None
Axis III Disorders: Asthma and orthopedic disorder as discussed above.
Axis IV Disorders: Moderate coping with anxiety, interpersonal and psychosocial/environmental stressors familiar difficulties, and financial pressures.
Axis V (Current GAF): 60
CAPACITY TO MANAGE FINANCIAL AFFAIRS: In my opinion the veteran is competent to manage her own VA benefit payments in her own best interest.
STRESSOR STATEMENT IN RELATION TO VETERANS FEAR TO HOSTILE MILITARY OR TERRORSIT ACTIVITY: The PTSD claimed by the veteran has been related specifically to her fear of hostile military and possible terrorist activity.
INTEGRATED SUMMARY AND CONCLUSIONS:
Changes in psychosocial functional status following trauma exposure: The veteran has clearly suffered a major deterioration in her ability to function both occupationally and interpersonally. She is now only able to relate to others in a “fair” manner, and she even has difficulty in toleration her own children. She is frequently uncomfortable by stimuli that remind her of combat experience and she is additionally frequently sleep deprived.
Changes in quality of life following trauma exposure: There has clearly been deterioration in this veteran’s quality of life.
Describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life: The deterioration in this veteran’s life and her presenting symptoms are clearly related to her combat experiences and that she functioned at a much higher level prior to entering the United States Army having had no significant psychiatric problems prior to her entrance into the service.
Extent to which disorders other than PTSD are independently responsible for impairment in psychosocial adjustment and quality of life: No other disorders appear relevant to me.
Describe pre trauma risk factors/characteristics that may have rendered the veteran vulnerable to developing PTSD subsequent to trauma exposure: While the murder of her mother might be regarded as a risk factor, the veteran actually appeared to deal with that quite well, being able to graduate from high school and maintain employment and secure induction into the United States Army. Therefore, I believe that she actually entered the Army with no preexisting risk factors for the development of my psychiatric disorder.
Prognosis for improvement of psychiatric condition and impairments in functional status: Good given her age and her desire to receive help, which she expressed to me on a number of occasions.
Capacity in managing benefit payments in veteran’s own best interest: No limitation
EFFECTS OF PTSD ON OCCUPATIONAL AND SOCIAL FUNCTIONING:
Statement: There is reduced reliability and productivity due to PTSD signs and symptoms.
Example: This veteran now suffers interpersonal difficulties and she is frequently uncomfortable around stimuli that remind her of Iraq she even has difficulty in tolerating her own children, and she has marital problems in the sense her husband regards her as now being “different” in a negative way.
I know it's a lot to read and I appreciate you taking the time out of your day to read this.
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