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gmankd

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About gmankd

  • Rank
    E-2 Recruit

Previous Fields

  • Service Connected Disability
    50%
  • Branch of Service
    Army
  1. gmankd

    My Ptsd C&p Exam

    Thank you USMC_HVEQ, this has helped alot.
  2. gmankd

    My Ptsd C&p Exam

    Thank you for your response. I was not in the recovery process.
  3. Hello I was wondering if you guys can help me, and let me know what you think about my C&P exam. If you think that I will get a rating then what you think it might be. Thank you all. SECTION I: ---------- 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, chronic Comments, if any: The veteran also has depressive moods, but they are as likely as not related to his PTSD. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Migraine headaches; 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 If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: 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): Pre-Military - The veteran was born in the Dominican Republic, but his family came to the U.S. when he was approximately 3 years old. He grew up in Lynn, MA, in an intact family until age 13 when his parents divorced. After the divorce, the veteran stayed with his mother who did not re-marry. He has one sister and two half-sisters (on his father's side). There was no physical abuse during his childhood. He felt that both of his parents were caring to him. His father stayed in contact with him after he divorced the veteran's mother. The veteran also reports that he had many aunts in the area and thus he had a big extended family. He further notes that there were many children in his neighborhood with whom he could play. The family also stayed in touch with their relatives in the Dominican Republic. Military - The veteran was in the Army from 1999-2002. He then was in the Army Reserves and his unit was called up to serve in Iraq. He served in Iraq for 12 months in 2003-4. In Iraq, he worked as a petroleum supply specialist. He was first sent to Korea where he states that he got the difficult details. He was to change a tire but he was called to another detail. He had a friend who was then asked to change the tire. The tire exploded in his friend's face and he was killed. This man had a newborn child at home whom he had never seen. The veteran felt that this loss was heartbreaking. It was also a situation where he could have been the victim. In another incident in Iraq, he had gotten back from working security and he heard a big bang. He and a friend rushed to see what had happened. An Iraqi enemy group had rammed the barrier of an Italian military Police station with a truck. Then they drove a car throught the breach and blew up the Police station. The veteran found people who had beeen blown in half and many other body parts. Over 30 people died in the explosion. It was a horrifying event. The veteran also experienced alerts that signified possible danger. He feels that he adapted to these alerts. Post-Military - The veteran has never married, but he has a girlfriend whom he met after his military service and they have an 8 year old son. They live in Lynn in a rented apartment. When the veteran first got out of the military, he moved to Florida to attend Valencia Community College in computer technology. He met his girlfriend there. He reports that, after his war experience, he was somewhat withdrawn and did not like to go out. He feels that this affected his girlfriend and, although they had a child, they broke up for 4-5 years. They decided to give it another try about 2 years ago. During the separation, he maintained contact with his son. The veteran moved to MA in 2010 to be closer to his family. His girlfriend and his son then moved up here to be with him in 2012. For the past 2 and 1/2 years, he has worked in IT for Draeger Company which makes medical equipment. He states that he and his girlfriend have matured and are able to tolerate each other's differences better. He reports that he is still easily irritated, however, and he sometimes feels that he has trouble with the demands that an 8 year old son can make on him. He denies using any physical pu nishment with his son. The veteran states that his mother has encouraged him to seek mental health care. He feels that she has done this in a supportive way. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Pre-Military - The veteran graduated from high school and joined the Army. He reports that he was a B to C type student. He was never held back a grade. He had no known learning problems. He states that he played football in high school. In the summers, he worked in summer camps that were sponsored by the city and he also worked at a MacDonald's. Military - As noted above, in Iraq, the veteran worked as a petroleum supply specialist. He reports that he frequently inhaled fumes on his job. Post-Military - Immediately after his military service, the veteran did some contract IT work and one of his contracts was with Draeger Company. Draeger then decided to hire him into a full time position. He has been employed by Draeger for 2 and 1/2 years. He feels that they are satisfied with his performance. There are times when he gets irritated and needs to take a break and get outside. He states that his supervisors have been tolerant of these needs. The veteran is also taking college classes on-line. His objective is to get a bachelor's degree in IT. He feels that he is doing well in his courses. He is about 20 credits away from getting his bachelor's degree. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Pre-Military - The veteran did not need and was not referred for mental health care prior to entry into the Army. Military - The veetran was not referred to and did not seek mental health care while in the Army or the Army Reserves. Post-Military - When living in Florida after his Iraq War experience, the veteran felt very frustrated and sought care at the VA Clinic in Kissemmee, FL. He was seen there for a few sessions but he felt embarrassed to be seeking psychological care and he dropped out. In Massachusetts, he has sought treatment at the VA Clinic in Lynn. He sees Dr. Dennis O'Neil, a psychiatrist, about once every 2 months. Dr. O'Neil is treating him for PTSD and depression and he prescribes zoloft and trazadone. The veteran feels that the medication has helped with his mood and it seems to allow him to get out socially a bit more. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Pre-Military - The veteran did not have legal or disciplinary problems prior to entry into the Army. Military - The veteran did not have any disciplinary problems while in the Army or the Army Reserves. Post-Military - The vetran has not had any legal or disciplinary problems since leaving military service. e. Relevant Substance abuse history (pre-military, military, and post-military): Pre-Military - The veteran did not have a problem with alcohol or drugs prior to his military service. Military - The veteran drank on the weekends while in the Army. He became drunk on some occasions, but he denies that his drinking then created any problems for him in regard to carrying out his military duties. He did not abuse other drugs. Post-Military - The veteran reports that when he first got out of the military, the only way he could be happy was to drink alcohol. He drank every other day and he would drink to intoxication. He feels that he drank to improve his mood. Currently, the veteran has about 1-2 drinks on a weekend and that's about all. He does not abuse drugs. f. Other, if any: No response provided. 3. Stressors ------------ a. Stressor #1: While stationed in Korea, the veteran was to change a tire but he was called to another detail. He had a friend who was then asked to change the tire. The tire exploded in his friend's face and he was killed. This man had a newborn child at home whom he had never seen. The veteran felt that this loss was heartbreaking. It was also a situation where he could have been the victim. 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? [ ] Yes [X] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: In an incident in Iraq, the veetran had gotten back from working security and he heard a big bang. He and a friend rushed to see what had happened. An Iraqi enemy group had rammed the barrier of an Italian Military Police station with a truck. Then they drove a car through the breach and blew up the Police station. The veteran found people who had beeen blown in half and many other body parts. Over 30 people died in the explosion. It was a horrifying event. 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). 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). 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] 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 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] 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] Obsessional rituals which interfere with routine activities 6. Behavioral Observations -------------------------- No response provided 7. 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: The veetran has survivor guilt in regard to the event in Korea when his friend was killed attempting to change a tire that exploded. 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, if any ------------------ This veteran meets criteria for a DSM-5 diagnosis of PTSD with associated depressive feelings. His PTSD has clearly had an effect on his relationships with his significant other and with his son. At work, when suffering from PTSD-related frustration and irritability, he is able to take a time out and stabilize himself. he has also been able to take college courses on-line. His disability is as likely as not mild-moderate. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.
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