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USMC123

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  1. I received the notes from my C & P exam. Need your thoughts on what you think I will receive. I often have trouble with my PTSD and would like to get it fixed. I don't need the money, I would rather prefer to just be back to normal. However what can they rate me at based on the exam? 1. Diagnostic Summary ---------------------Does the Veteran have a diagnosis of PTSD that conforms to DMS-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 2. Current Diagnoses --------------------a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder ICD code: 309.81 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Please See Medical Records 3. Differentiation of symptoms ------------------------------a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No 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 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 ------------------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 reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: CPRS; CAPRI 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 [ ] 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. History ----------a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The Veteran is age 2*. He has been in a common-law marriage for 2.5-3 years. He has a daughter age 1. The Veteran was raised by both parents. He has an older sister age 31 and a twin sister. He denied any childhood abuse. He described his childhood as great. b. Relevant Occupational and Educational history (pre-military, military, and post-military): He graduated high school in 2004, and was a B-C student. He was on the basketball team during his freshman and sophomore years. He denied any disciplinary issues in school. He joined the Marine Corps Reserves in 2005. From 2005 until 2008 he worked at the *CA. He then worked for the * Arizona *Department for two months until he transitioned into active duty status. The Veteran was on active duty from 2008 until 2009. He then was in the reserves until 2011. His highest rank was E-4 and he worked in artillery and rocket artillery. He denied any disciplinary issues in the military. He received an Honorable discharge. He has been employed since 201* at the * Department. He investigates internal affairs. This is a fulltime job. He has never been fired from a job. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The Veteran denied any mental health treatment prior to or during the military. He has received mental health services at the El Paso VA over the past year. His most recent appointment was in 09/13. He has never been prescribed psychotropic medication. He denied any psychiatric hospitalizations and he denied any suicide attempts. He denied any family history of psychiatric treatment. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The Veteran denied any arrests or other legal difficulties. e. Relevant Substance abuse history (pre-military, military, and post-military): From 2009 until 2012 he drank excessively, which included binge drinking on the weekends, and having five drinks a night during the week. He significantly reduced his drinking on his own in 2012. He has about five drinks a week or every other week. f. Other, if any: No response provided. 3. Stressors ------------a. Stressor #1: "It was March or April 2009 and we were on Delaram post in Afghanistan. We were eating and we heard a loud bang and then another one. It was close to nighttime. A suicide bomber killed himself and killed a Marine in doing so. We saw it after it happened. I was terrified about dying there." 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: :" This was on Delaram post in May 2009 in Afghanistan. There was a warrant officer, a big stout guy. He was leaving to go home soon. He went out on a convoy and got blown up by an IED that he was disarming." 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: : "This was the first mortar attack. It was in February or March 2009 in Afghanistan. I had just finished my shift. I put on my kevolar. Everybody started running. It was fear of the unknown. Anyone could die at any time. " 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 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 criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DMS-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violatrion, in one or more of the following ways: [X] Directly experiencing the tramuatic event(s) [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 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 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). Criterion C: 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] 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] 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] Feelings of detachment or estrangement from others. 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] Hypervigilance. [X] Exaggerated startle response. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). 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. 5. Symptoms -----------For VA rating purposes, check all symptoms that apply to the Veterans diagnoses: [X] Depressed mood [X] Anxiety [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment 6. Behavioral Observations --------------------------MENTAL STATUS EXAM: Grooming and Hygiene-[X ] Good, [ ] Fair, [ ] Poor, [ ] Other: Eye Contact-[X ] Good, [ ] Fair, [ ] Poor, [ ] Other: Orientation- Alert, Oriented to [X ] Person, [X ] Place, [X ] Date, [X ] Situation. Behavior- [X ] Attentive and cooperative, [ ] Guarded, [ ] Angry, [] Demanding Speech- [X ] regular rate and rhythm [ ] Soft, [ ] Loud [ ] Hostile Mood- [ ] anxious [X ] dysphoric [ ] agitated [ ] labile [ ] expansive [ ] happy [ ] depressed [ ] fearful [ ] other Affect- [X ] congruent and appropriate [ ] incongruent. Thought process- [ X ] coherent, logical, goal oriented. [X ] Other: Thought Content- [X ] denies suicidal ideation [X ] Denies hallucinations Insight- [X ] Good, [ ] Fair, [ ] Poor, [ ] Impaired Judgment-[X ] Good, [ ] Fair, [ ] Poor, [ ] Impaired 7. Other symptoms -----------------Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency -------------Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, if any ------------------PSYCHOLOGICAL TESTING: MMPI-2 RESULTS: L F K HS D HY PD MF PA PT SC MA SI Raw Score: 6 24 8 26 40 32 26 26 14 33 46 22 47 K Corr. 4 3 8 8 2 T Score: 61 110 35 90 93 76 64 50 64 81 98 59 75 ? Cannot Say (Raw): 0 F-K (Raw): 16 The Veteran produced an invalid MMPI-2 profile; therefore the testing results cannot be interpreted. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review ---------------a. Was the Veteran's VA claims file reviewed? Yes If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: CPRS; CAPRI MEDICAL OPINION SUMMARY -----------------------RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER. Contention: Veteran with service in Afghanistan 2008/2009 claiming numerous issues of joint and muscle pain, respiratory issues, neurological, skin, gastrointestinal, and mental issues. VA Treatment records provide contintuity of treatment. Opinion Requested: Direct service connection Are the Veteran's claimed conditions (See list) at least as likely as not (50 percent or greater probability) incurred in or caused by service in Afghanistan or exposure to environmental hazards that occurred 2008/2009. Rationale must be provided in the appropriate section below. Your review is not limited to the evidence identified on this request form, or tabbed in the claims folder. If an examination or additional testing is required, obtain them prior to rendering your opinion. b. Indicate type of exam for which opinion has been requested: DBQ Initial PTSD TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The Veteran's PTSD is at least as likely as not (50 percent or greater probability) caused by military service. The Veteran had no history of mental health treatment prior to the military. In addition, he did not report any traumatic experiences prior to the military.
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