Hey Brothers and Sisters...Sorry I haven't been around for a quite a while. Things have gotten a little rough on the homefront. That being said, I just did another C&P eval last Tuesday, and I'm not sure how to determine what the results may be...I'm currently 50%, but put in for an increase based on the first time I applied....I thought it was MUCH worse than that. Any thoughts? I appreciate you all, and thank you.
LOCAL TITLE: C&P PTSD, REVIEW STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: APR 14, 2015@10:00 ENTRY DATE: APR 14, 2015@11:19:52 AUTHOR: SKADELAND,DEAN R EXP COSIGNER: URGENCY: STATUS: COMPLETED *** C&P PTSD, REVIEW Has ADDENDA *** Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: Michael xxxxxx SECTION I: ---------- 1. Diagnostic Summary ---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: 309.81 2.
Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: 309.81
Mental Disorder Diagnosis #2: Depression xxxxx, MICHAEL xxxx CONFIDENTIAL
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------
a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes[ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
[X] Yes[ ] No[ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: The majority of his symptoms relate to his PTSD diagnosis. The depression appears primarily related to the impairment in social and personal functioning in his daily life that PTSD has caused.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ]
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? [X] Yes[ ] No[ ]
No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The majority of his impairment is realted to PTSD.
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: xxxx, MICHAEL ANDREW CONFIDENTIAL 3 ------------------
1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No
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 [X] 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: b. Was pertinent information from collateral sources reviewed? [ ] Yes[X]
No 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Since the veterans initial eval Jan 2014, he stated that he continues to be very distant from others. Other than his two daughters, he does not really have contact with his family. In addition, about 3 months ago his girlfriend of about 3 years left. He stated she said, she "can't take it anymore dealing with me".
b. Relevant Occupational and Educational history: The veteran stated he lost his job in March 2014 due to difficulty dealing with others and stress related to his PTSD symptoms. He had difficulty sleeping, high stress, and was not able to perform his job in sales dealing with people. In addition, he is presently in Voc Rehab studying Information xxxxx, MICHAEL ANDREW CONFIDENTIAL Technology. He does have a real interest in his coursework but it is very difficult dealing with school and also his PTSD symptoms. He also has had to deal coping with panic attacks that occur while in class. This makes learning and following the lecture very difficult.
c. Relevant Mental Health history, to include prescribed medications and family mental health: The veteran is followed by the Leavenworth VA MH program. He did see a psychologist for a few session for PTSD but stated he had so much anticipatory anxiety before and immediately after his appts that it was "too difficulty to go" until he anxiety is able to be reduced. The veteran stated he has been having increased high levels of anxiety involving panic attacks along with depression. He reported being hospitalized twice around March 2014 for suicidal thoughts. Both hospitalizations were at the University of Kansas. After the 2nd hospitalization he was referred to a substance abuse recovery center but left as he would have missed school. He did start going to AA for about a dozen times and then came to know he cannot drink while depressed. Especially stressful for him are the almost daily panic attacks, which often result in concentration and memory problems. He was especially bothered that he forgot his daughter birthday (by a week) earlier this month. When directly questioned, he stated that he does continue to have thoughts of self-harm but "I would never do it or harm myself because of my two daughters...they are so important to me...". He also noted that in the past, the two incidents of becoming suicidal occurred when had been drinking heavily. He stated he knows he can no longer ever drink when he is depressed. He is currently followed by psychiatrist Dr. Pattison at the Leavenworth, VA who has been adjusting his medication to improve his mood. He did state that the Xanax does help for sleep. He reported that Dr. Pattison and he are developing a plan to get his anxiety under control somewhat better so that he can again initiate psychotherapy with Dr. Paolo Psychologist at Leavenworth. He likes his Leavenworth MH providers, but did stated he was closer to the KCVA in miles. As a courtesy, before the veteran left, he was provided the national suicide prevention hotline number and thet KCVA phone number. He was also informed he can walk in to this VA during the day and be seen in MHC without an appt or after hours walk in and be seen in the emergency department. He was also provided contact information about the KCVA PCT PSTD program at the Honor Annex.
d. Relevant Legal and Behavioral history: The veteran denied any legal problems.xxxxx, MICHAEL ANDREW CONFIDENTIAL
e. Relevant Substance abuse history: The veteran stated that though in the past he had drank very heavily this was due primarily do being depressed. He stated he no longer drinks when he is depressed as he knows it is a bad combination. The veteran does not believe he has an alcohol problem. He had never gotten a DUI and never had any job or school related problems due to alcohol. f. Other, if any: No response provided. 3. PTSD Diagnostic Criteria ---------------------------
Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)
[X] Witnessing, in person, the traumatic event(s) as they occurred to others 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:
[X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
[X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic xxxx, MICHAEL ANDREW CONFIDENTIAL event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
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] Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
[X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined").
[X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
[X] Markedly diminished interest or participation in significant activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)
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] Irritable behavior and angry outbursts (with little or no xxxx, MICHAEL ANDREW CONFIDENTIAL provocation) typically expressed as verbal or physical aggression toward people or objects.
[X] Exaggerated startle response.
[X] Problems with concentration
. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
[X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G:
[X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
[X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:
[X] Depressed mood [X] Anxiety [X] Suspiciousness
[X] Panic atacks more than once a week
[X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent events
[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
5. Behavioral Observations: --------------------------- The veteran was consistently pleasant and cooperative. He did display indications of heightened stress and anxiousness. On a couple occasions he did tear up when describing his symptoms and stresses in his life; xxxx, MICHAEL ANDREW CONFIDENTIAL especially those involving relationships.
6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above?
[ ] Yes[X]
No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ]
No 8. Remarks, (including any testing results) if any:-
Objective Data: PCL5 Score= 74 Above cutoff suggestive of PTSD
Mississippi Score= 152 Above cutoff suggestive of PTSD