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OEFMP

Seaman
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About OEFMP

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  • Birthday February 10

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  1. OEFMP

    Blown Away!

    I'm wondering what my rating maybe if at all... I had my C&P for PTSD and I'm hoping I didn't get to screwed, it only lasted 35 mins. Please help me out with a "ballpark %" ... thanks in advance. 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 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: F43.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): See below. Comments, if any: CPRS indicates 30% service-connection for: IMPAIRED HEARING (0%-SC) PARALYSIS OF MEDIAN NERVE (10%-SC) TINNITUS (10%-SC) LUMBOSACRAL OR CERVICAL STRAIN (10%-SC) PARALYSIS OF SCIATIC NERVE (10%-SC) LIMITED FLEXION OF FOREARM (0%-SC) Computerized records indicate: Knee pain Tobacco Dependence Overweight Tinnitus, Subjective Elevated Liver Function Tests Lumbar Radiculopathy Degen Disc Dis, Lumbar Hearing loss Low Back Pain 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 with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation 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 [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Mr. XXXXX was born in Corpus Christi, TX and raised in TX and NV. His parents never divorced. Mr. XXXXX has no siblings and has an excellent relationship with his parents. Mr. XXXXX's first marriage lasted from 2003-2005 and his second from 2007-2010. He remarried in 2010 and described his current relationship as "rocky." Mr. XXXXX has four children and described the relationship with his children as also "rocky." He currently lives with his parents in XXXXX, NV. Income sources include the GI Bill and current service-connection. Mr. XXXXX enjoys target practice every couple of months. He rarely socializes. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran completed a GED in 2003. Veteran noted that he was diagnosed with Attention Deficient Disorder as a child. Mr. XXXXX joined with the National Guard in 2004 and is currently enlisted. MOS include infantry (11B), combat engineer (21B) and military police (21B). Mr. XXXXX reported exposure to combat fire (small arms, mortars, rockets, RPGs) in Afghanistan from 2011-2012. His current rank is E-5. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Interim Mental Health History: Mr. XXXXX and his wife currently participate in marital counseling at the XXXXX Vet Center. Mr. XXXXX also participates in individual therapy with Dr. Krogh and group therapy targeted at PTSD symptoms. Mr. XXXXX is also followed by Dr. Pai for psychiatric medication management. CPRS lists active medications as: AMITRIPTYLINE TAB 50MG PRAZOSIN CAP,ORAL 1MG HydrOXYzine PAMOATE CAP,ORAL 25MG GABAPENTIN CAP,ORAL 300MG METHOCARBAMOL TAB 500MG LAMOTRIGINE TAB,ORAL 25MG DICLOFENAC TAB,EC 75MG MORPHINE TAB,SA 15MG ----------------------------------------------------------------------- -------------------- PTSD Symptoms: Intrusive Thoughts - Mr. XXXXX reported intrusive thoughts regarding stressor #1 on a weekly basis. Sleep/Nightmares - Mr. XXXXX reported nightmares that occur on a weekly basis. Dissociative reactions - Denied. Psychological/Physiological Reactions - Anxiety, heart palpitations And perspiration. Avoidance - Veteran tends to avoid thoughts and conversations Regarding combat experience. Difficulty Remembering - Denied. Distorted expectations/beliefs/blame - Chronic self-blame and suspiciousness. Persistent negative emotion - Chronic anger. Loss of Interest - Rarely participates in hobby activities. Distant/Emotionally Numb - Rarely socializes. Irritability - Irritability on a daily basis. Self-destructive/reckless - Denied. Hypervigilance/Startle - Mr. XXXXX often scans for environmental threats and is easily startle by sudden noises. Difficulty Concentrating - He has difficulty concentrating on mundane tasks. ----------------------------------------------------------------------- -------------------- d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran reported legal problems for failure to comply with a court order. e. Relevant Substance abuse history (pre-military, military, and post-military): Alcohol: Pre military: Rarely. During Military: Weekend binge drinking. Post Military: Three beers/week. 3. Stressors ------------ a. Stressor #1: Exposure to combat fire. 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] 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 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] 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. 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 provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [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] Suspiciousness [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- Mr. XXXXX arrived on time for his appointment. Grooming and hygiene Were adequate. He was alert and cooperative throughout the examination. Expressive speech was fluent; thought processes were logical. Veteran described his mood as "frustrated and eager to get out of here"; affect was congruent with his mood state. He denied any suicidal/homicidal ideation, plan, or intent. There were no indications of delusions, hallucinations or other signs of frank psychosis. Insight and judgment were intact. 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 ------------------ Veteran completed the PCL-5, a self-report measure of PTSD and obtained a 56. On the BDI-II, a self-report measure of depression, Veteran obtained a 34, suggesting severe depression. The BAI is a self-report measure of anxiety; his score of 20 indicates moderate anxiety. Veteran currently meets DSM 5 criteria for PTSD and currently Participates in relevant mental health treatment at the XXXXX VAMC. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. Income sources include the GI Bill and current service-connection. Patient enjoys target practice every couple of months. He rarely socializes. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran completed a GED in 2003. Veteran noted that he was diagnosed with Attention Deficient Disorder as a child. Patient joined with the National Guard in 2004 and is currently enlisted. MOS include infantry (11B), combat engineer (21B) and military police (21B). Patient reported exposure to combat fire (small arms, mortars, rockets, RPGs) in Afghanistan from 2011-2012. His current rank is E-5. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Interim Mental Health History: Patient and his wife currently participate in marital counseling at the XXXXX Vet Center. Patient also participates in individual therapy with Dr. XXX and group therapy targeted at PTSD symptoms. Patient is also followed by Dr. XXX for psychiatric medication management. CPRS lists active medications as: AMITRIPTYLINE TAB 50MG PRAZOSIN CAP,ORAL 1MG HydrOXYzine PAMOATE CAP,ORAL 25MG GABAPENTIN CAP,ORAL 300MG METHOCARBAMOL TAB 500MG LAMOTRIGINE TAB,ORAL 25MG DICLOFENAC TAB,EC 75MG MORPHINE TAB,SA 15MG ----------------------------------------------------------------------- -------------------- PTSD Symptoms: Intrusive Thoughts - Patient reported intrusive thoughts regarding stressor #1 on a weekly basis. Sleep/Nightmares - Patient reported nightmares that occur on a weekly basis. Dissociative reactions - Denied. Psychological/Physiological Reactions - Anxiety, heart palpitations And perspiration. Avoidance - Veteran tends to avoid thoughts and conversations Regarding combat experience. Difficulty Remembering - Denied. Distorted expectations/beliefs/blame - Chronic self-blame and suspiciousness. Persistent negative emotion - Chronic anger. Loss of Interest - Rarely participates in hobby activities. Distant/Emotionally Numb - Rarely socializes. Irritability - Irritability on a daily basis. Self-destructive/reckless - Denied. Hypervigilance/Startle - Patient often scans for environmental threats and is easily startle by sudden noises. Difficulty Concentrating - He has difficulty concentrating on mundane tasks. ----------------------------------------------------------------------- -------------------- d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran reported legal problems for failure to comply with a court order. a. Stressor #1: Exposure to combat fire. 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
  2. Hey guys I'm going to piggy back alittle off this forum. But I was wondering if anyone could maybe give me a ballpark figure from my PTSD C&P exam? Thanks in advance. 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 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: F43.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): See below. Comments, if any: CPRS indicates 30% service-connection for: IMPAIRED HEARING (0%-SC) PARALYSIS OF MEDIAN NERVE (10%-SC) TINNITUS (10%-SC) LUMBOSACRAL OR CERVICAL STRAIN (10%-SC) PARALYSIS OF SCIATIC NERVE (10%-SC) LIMITED FLEXION OF FOREARM (0%-SC) Computerized records indicate: Knee pain Tobacco Dependence Overweight Tinnitus, Subjective Elevated Liver Function Tests Lumbar Radiculopathy Degen Disc Dis, Lumbar Hearing loss Low Back Pain 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 with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation 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 [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Mr. XXXXX was born in Corpus Christi, TX and raised in TX and NV. His parents never divorced. Mr. XXXXX has no siblings and has an excellent relationship with his parents. Mr. XXXXX's first marriage lasted from 2003-2005 and his second from 2007-2010. He remarried in 2010 and described his current relationship as "rocky." Mr. XXXXX has four children and described the relationship with his children as also "rocky." He currently lives with his parents in XXXXX, NV. Income sources include the GI Bill and current service-connection. Mr. XXXXX enjoys target practice every couple of months. He rarely socializes. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran completed a GED in 2003. Veteran noted that he was diagnosed with Attention Deficient Disorder as a child. Mr. XXXXX joined with the National Guard in 2004 and is currently enlisted. MOS include infantry (11B), combat engineer (21B) and military police (21B). Mr. XXXXX reported exposure to combat fire (small arms, mortars, rockets, RPGs) in Afghanistan from 2011-2012. His current rank is E-5. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Interim Mental Health History: Mr. XXXXX and his wife currently participate in marital counseling at the XXXXX Vet Center. Mr. XXXXX also participates in individual therapy with Dr. Krogh and group therapy targeted at PTSD symptoms. Mr. XXXXX is also followed by Dr. Pai for psychiatric medication management. CPRS lists active medications as: AMITRIPTYLINE TAB 50MG PRAZOSIN CAP,ORAL 1MG HydrOXYzine PAMOATE CAP,ORAL 25MG GABAPENTIN CAP,ORAL 300MG METHOCARBAMOL TAB 500MG LAMOTRIGINE TAB,ORAL 25MG DICLOFENAC TAB,EC 75MG MORPHINE TAB,SA 15MG ----------------------------------------------------------------------- -------------------- PTSD Symptoms: Intrusive Thoughts - Mr. XXXXX reported intrusive thoughts regarding stressor #1 on a weekly basis. Sleep/Nightmares - Mr. XXXXX reported nightmares that occur on a weekly basis. Dissociative reactions - Denied. Psychological/Physiological Reactions - Anxiety, heart palpitations And perspiration. Avoidance - Veteran tends to avoid thoughts and conversations Regarding combat experience. Difficulty Remembering - Denied. Distorted expectations/beliefs/blame - Chronic self-blame and suspiciousness. Persistent negative emotion - Chronic anger. Loss of Interest - Rarely participates in hobby activities. Distant/Emotionally Numb - Rarely socializes. Irritability - Irritability on a daily basis. Self-destructive/reckless - Denied. Hypervigilance/Startle - Mr. XXXXX often scans for environmental threats and is easily startle by sudden noises. Difficulty Concentrating - He has difficulty concentrating on mundane tasks. ----------------------------------------------------------------------- -------------------- d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran reported legal problems for failure to comply with a court order. e. Relevant Substance abuse history (pre-military, military, and post-military): Alcohol: Pre military: Rarely. During Military: Weekend binge drinking. Post Military: Three beers/week. 3. Stressors ------------ a. Stressor #1: Exposure to combat fire. 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] 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 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] 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. 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 provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [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] Suspiciousness [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- Mr. XXXXX arrived on time for his appointment. Grooming and hygiene Were adequate. He was alert and cooperative throughout the examination. Expressive speech was fluent; thought processes were logical. Veteran described his mood as "frustrated and eager to get out of here"; affect was congruent with his mood state. He denied any suicidal/homicidal ideation, plan, or intent. There were no indications of delusions, hallucinations or other signs of frank psychosis. Insight and judgment were intact. 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 ------------------ Veteran completed the PCL-5, a self-report measure of PTSD and obtained a 56. On the BDI-II, a self-report measure of depression, Veteran obtained a 34, suggesting severe depression. The BAI is a self-report measure of anxiety; his score of 20 indicates moderate anxiety. Veteran currently meets DSM 5 criteria for PTSD and currently Participates in relevant mental health treatment at the XXXXX VAMC. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. Income sources include the GI Bill and current service-connection. Patient enjoys target practice every couple of months. He rarely socializes. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran completed a GED in 2003. Veteran noted that he was diagnosed with Attention Deficient Disorder as a child. Patient joined with the National Guard in 2004 and is currently enlisted. MOS include infantry (11B), combat engineer (21B) and military police (21B). Patient reported exposure to combat fire (small arms, mortars, rockets, RPGs) in Afghanistan from 2011-2012. His current rank is E-5. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Interim Mental Health History: Patient and his wife currently participate in marital counseling at the XXXXX Vet Center. Patient also participates in individual therapy with Dr. XXX and group therapy targeted at PTSD symptoms. Patient is also followed by Dr. XXX for psychiatric medication management. CPRS lists active medications as: AMITRIPTYLINE TAB 50MG PRAZOSIN CAP,ORAL 1MG HydrOXYzine PAMOATE CAP,ORAL 25MG GABAPENTIN CAP,ORAL 300MG METHOCARBAMOL TAB 500MG LAMOTRIGINE TAB,ORAL 25MG DICLOFENAC TAB,EC 75MG MORPHINE TAB,SA 15MG ----------------------------------------------------------------------- -------------------- PTSD Symptoms: Intrusive Thoughts - Patient reported intrusive thoughts regarding stressor #1 on a weekly basis. Sleep/Nightmares - Patient reported nightmares that occur on a weekly basis. Dissociative reactions - Denied. Psychological/Physiological Reactions - Anxiety, heart palpitations And perspiration. Avoidance - Veteran tends to avoid thoughts and conversations Regarding combat experience. Difficulty Remembering - Denied. Distorted expectations/beliefs/blame - Chronic self-blame and suspiciousness. Persistent negative emotion - Chronic anger. Loss of Interest - Rarely participates in hobby activities. Distant/Emotionally Numb - Rarely socializes. Irritability - Irritability on a daily basis. Self-destructive/reckless - Denied. Hypervigilance/Startle - Patient often scans for environmental threats and is easily startle by sudden noises. Difficulty Concentrating - He has difficulty concentrating on mundane tasks. ----------------------------------------------------------------------- -------------------- d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran reported legal problems for failure to comply with a court order. a. Stressor #1: Exposure to combat fire. 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
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