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lucaswlandon

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Posts posted by lucaswlandon

    C And P Exam Opinions

    in Veterans Compensation & Pension Exams

    Posted

    SECTION I:
    ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
    based on today's evaluation?
    [X] Yes [ ] No
    ICD code: 309.81
    2. Current Diagnoses
    --------------------
    a. Diagnosis #1: PTSD
    ICD code: 309.81
    Indicate the Axis category:
    [X] Axis I [ ] Axis II
    Diagnosis #2: Major Depressive Disorder, recurrent, severe, without
    psychotic fearures
    ICD code: 296.33
    Indicate the Axis category:
    [X] Axis I [ ] Axis II
    Diagnosis #3: Alcohol Abuse
    ICD code: 305.00
    Indicate the Axis category:
    [X] Axis I [ ] Axis II
    b. Axis III - medical diagnoses (to include TBI): GERD
    c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
    Combat in Iraq
    d. Axis V - Current global assessment of functioning (GAF) score: 60
    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?
    [ ] Yes [X] No [ ] Not applicable (N/A)
    If no, provide reason that it is not possible to differentiate what
    portion of each symptom is attributable to each diagnosis:
    The symptoms of these disorders overlap and any attempt to
    separate
    then would be mere
    speculation.
    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 due to mild or transient symptoms
    which decrease work efficiency and ability to perform occupational
    tasks only during periods of significant stress, or; symptoms
    controlled by medication
    Page 17 of 33 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 [X] No [ ] No other mental disorder has been diagnosed
    If no, provide reason that it is not possible to differentiate what
    portion of the indicated level of occupational and social impairment
    is attributable to each diagnosis:
    The symptoms of these disorders overlap and any attempt to
    separate
    them would
    be mere speculation.
    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
    ------------------
    a. Records reviewed (check all that apply):
    [X] Claims folder (C-file):
    [ ] Yes
    [X] No
    If no, provide reason C-file was not reviewed:
    VBMS
    b. Was pertinent information from collateral sources reviewed?
    No response provided.
    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
    post-military):
    He was born and raised in Columbus, Ohio. He had two parents, one
    older
    brother and
    two younger sisters. He graduated from high school in 2000. He joined
    the National
    Guard in 2001. He deployed to Iraq on December 7, 2003 and served in
    Iraq from
    18 of 33 02/-08/04 until 02/02/05. He received the Combat Action Badge for
    direct involve-
    ment with the enemy on 04/19/04. He got an honorable discharge in
    2009.
    He got
    married on 11/20/2010 and has two daughters and one son. He sleeps i n
    a different
    room because he has to have the TV on to sleep. He stays in a small
    dark room
    with the TV on.
    b. Relevant Occupational and Educational history (pre-military, military,
    and
    post-military):
    He worked for did father in high school painting and wallpaper. He was
    a radio
    operator for a medical unit in the service. He worked for Grant
    Hospital for
    5 years as a dispacher, Med Flight for 3 months, for his father-in-law
    for a
    year sandblasting, and back at Grant Hospital and is has been accused
    of
    creating a hostile work environment.
    c. Relevant Mental Health history, to include prescribed medications and
    family mental health (pre-military, military, and post-military):
    He was treataed with Zoloft in 1998-1999 for a period of 6 months
    following the break-up
    with a girlfriend. He reported depression with insomnia in May 2004.
    In
    October, 2004, he
    reported suicidal thoughts. He reported a suicide attempt (Tylenol and
    Alcohol) in 2006
    following service and was hospitalized for 2-3 days at Mt. Carmel East
    in Columbus, Ohio.
    He went home for a day and was then hospitalized at Riverside
    Methodist
    Hospital in
    Columbus, Ohio, for 3 days. He has been seen at the Dayton VAMC for
    the
    last year in
    the PTSD program. He saw Dr. Moon who has him on Celexa-40mg daily,
    Vistaril-10mg tid
    as needed for anxiety and Ambien-10mg/qhs.
    d. Relevant Legal and Behavioral history (pre-military, military, and
    post-military):
    No legal issues
    Page 19 of 33
    e. Relevant Substance abuse history (pre-military, military, and
    post-military):
    He reported that he used to drink 6 beers at night in order to go to
    sleep. No DUI's. He now
    drinks socially and his last drink was 2 days ago (2 beers) at a
    Veteran's Day party.
    f. Sentinel Event(s) (other than stressors):
    No response provided.
    g. Other, if any:
    No response provided.
    3. Stressors
    ------------
    a. Stressor #1: On 04/19/2004, I was assigned to Charlie Company, 118 Area
    Support Medical BAttalion, and came into direct
    involvement with the
    emeny
    Does this stressor meet Criterion A (i.e., is it adequate to support
    the diagnosis of PTSD)?
    [X] Yes [ ] No
    Is the stressor related to the Veteran's fear of hostile military
    or
    terrorist activity?
    [X] Yes [ ] No
    b. Stressor #2: On 11/13/2004, I was assigned to the Company and we got
    mortared and Sgt. Catelina Dima was killed
    Does this stressor meet Criterion A (i.e., is it adequate to support
    the diagnosis of PTSD)?
    [X] Yes [ ] No
    Is the stressor related to the Veteran's fear of hostile military
    or
    terrorist activity?
    [X] Yes [ ] No
    4. PTSD Diagnostic Criteria
    ---------------------------
    a. Please check criteria used for establishing the current PTSD diagnosis.
    The diagnostic criteria for PTSD, referred to as Criteria A-F, are from
    the Diagnostic and Statistical Manual of Mental Disorders, 4th edition
    (DSM-IV).
    Criterion A: The Veteran has been exposed to a traumatic event where both
    of the following were present:
    Page 20 of 33 [X] The Veteran experienced, witnessed or was confronted with an event
    that involved actual or threatened death or serious injury, or a
    threat to the physical integrity of self or others.
    [X] The Veteran's response involved intense fear, helplessness or
    horror.
    Criterion B: The traumatic event is persistently reexperienced in 1 or
    more of the following ways:
    [X] Recurrent and distressing recollections of the event, including
    images, thoughts or perceptions
    [X] Recurrent distressing dreams of the event
    [X] Intense psychological distress at exposure to internal or external
    cues that symbolize or resemble an aspect of the traumatic event
    [X] Physiological reactivity on exposure to internal or external cues
    that symbolize or resemble an aspect of the traumatic event
    Criterion C: Persistent avoidance of stimuli associated with the trauma
    and numbing of general responsiveness (not present before
    the
    trauma), as indicated by 3 or more of the following:
    [X] Efforts to avoid thoughts, feelings or conversations associated
    with the trauma
    [X] Efforts to avoid activities, places or people that arouse
    recollections of the trauma
    [X] Markedly diminished interest or participation in significant
    activities
    [X] Feeling of detachment or estrangement from others
    [X] Restricted range of affect (e.g., unable to have loving feelings)
    Criterion D: Persistent symptoms of increased arousal, not present before
    the trauma, as indicated by 2 or more of the following:
    [X] Difficulty falling or staying asleep
    [X] Irritability or outbursts of anger
    [X] Difficulty concentrating
    [X] Hypervigilance
    [X] Exaggerated startle response
    Criterion E:
    [X] The duration of the symptoms described above in Criteria B, C and
    D
    is more than 1 month.
    Criterion F:
    [X] The PTSD symptoms described above cause clinically significant
    distress or impairment in social, occupational, or other important
    areas of functioning.
    b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:
    [X] Stressor #1
    [X] Stressor #2
    5. Symptoms
    Page 21 of 33 -----------
    For VA rating purposes, check all symptoms that apply to the Veterans
    diagnoses:
    [X] Depressed mood
    [X] Anxiety
    [X] Suspiciousness
    [X] Chronic sleep impairment
    [X] Mild memory loss, such as forgetting names, directions or recent
    events
    [X] Impairment of short- and long-term memory, for example, retention of
    only highly learned material, while forgetting to complete tasks
    [X] Flattened affect
    6. 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:
    Decreased appetite, energy level, interest in sex, concentration,
    he snaps at
    his wife and kids. He reported his depression as an 8-9 on a 0-10
    scale where
    0 is no depression and 10 is suicidal.
    7. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
    [X] Yes [ ] No
    8. Remarks, if any
    ------------------
    The Veteran meets DSM-IV-TR and DSM-5 criteria for PTSD related to his
    in-service experiences.
    His Major Depressive Disorder is related to his PTSD and depressive
    symptoms in service were
    early manifestations of the current disorder.

    C&p Exam (Ptsd/anxiety/insomnia/depression)

    in Veterans Compensation & Pension Exams

    Posted

    Thanks for the comments. i have very frequent "day dreams" where everything feels like im back there. that and an overdose and being placed in a metal ward for a few days... the history is sort of there. the meds help but dont come close to fixing anything, just helps them build up. been through one divorce and struggling through this marriage, though we re still together. same story as many on here im sure. it seems to be the constant minute by minute reminders and faces and events that relive in my head that have the VA concerned. iv been home since 2005

    C&p Exam (Ptsd/anxiety/insomnia/depression)

    in Veterans Compensation & Pension Exams

    Posted

    Hey all,

    I have an exam in 3 days for my mental health claim. I am very very nervious about reliving out loud what is running in my head every day. I only have had one GAF score so far and it was a 23. That is one of the lower GAF scores i saw so far when looking around. I had no idea what that was until recently. I was a communications spec (25c) for a medical unit in Iraq and saw a ton of pretty bad stuff to include holding a guy that got hit by a mortar that should have hit me. is there any heads up that anyone can give me? I'll make sure and update what happens in the exam as well.

    thanks in advance

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