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Memphis10Vet

Seaman
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About Memphis10Vet

  • Rank
    E-3 Seaman

Previous Fields

  • Service Connected Disability
    40%
  • Branch of Service
    Army
  1. Memphis10Vet

    Opinion On C&p Exam

    I was giving 70% with iu bump me to a100%
  2. Memphis10Vet

    Opinion On C&p Exam

    Thanks... Would they consider me a 100% with my inability to work?
  3. Memphis10Vet

    Opinion On C&p Exam

    I'm already at a 30% rating as of now but my stressor is service ralated due to a incident in Iraq don't know why it's not in the second exam. Why wouldn't they put me at 100% with the inability to work? N thanks for the reply
  4. SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: 309.81 Comments, if any: 30% service connected for PTSD. 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? [ ] Yes[X] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? No response provided. 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? [ ] 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? [ ] Yes[X] 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: previous C & P 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 If yes, describe: 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Veteran is engaged to the mother of his children, but there has been recent conflict. They are living together with their 2 children 4y and 10m. Veteran's wife works and children go to Day Care. Veteran had a physical confrontation with one of his brothers 2-3 weeks ago. Shots were fired but no one was hurt. b. Relevant Occupational and Educational history: Veteran is unemployed. He was fired from USPS for "no call no show." He reports conflict with co-workers and supervisor. He was shot--didn't bring proper documentation. Supervisor claimed he was not following orders. Veteran states he couldn't comprehend them-- thought he was following orders. Veteran worked for 1 day for his uncle. He got into an arguement with a customer, and then in an argument with his uncle. Uncle then stated he could not work for him. He has been unemployed since January 2014. c. Relevant Mental Health history, to include prescribed medications and family mental health: Veteran was seeing Donna Denato, Ph.D. She referred him to a psychiatrist for medication. The provider was on vacation, and he never made contact. Veteran wants outpatient treatment now. He is willing to come to the VA for outpatient treatment. d. Relevant Legal and Behavioral history: Veteran was arrested for possession of marijuana and commission of a felony with a firearm. He was stopped by the police for a license plate issue. His car was searched and marijuana was found in his trunk. He had a hand gun and a permit. Veteran is going back to court--has been offerred probation. e. Relevant Substance abuse history: Veteran is smoking 2 blunts of marijuana 1-2 times per day. His last use was 10:30pm last night. He started using THC after active duty in the military--11/2011. He drinks alcohol 3-4 times per month-- 2 shots of Whiskey. His last drink was 6/23/2014. f. Other, if any: Veteran states he was already paranoid when got shot 1/16/2014. He was looking for a friend in South Memphis. Some men approached him and started shooting. He was treated at the Med for a gunshot wound to the torso. Now, he keeps his gun handy at all times. Veteran has to be in court tomorrow as he is being sued by a truck driver for breaking his jaw. This truck driver hit his car and did not stop. Veteran chased him, forcing him to stop. The truck driver denied ever hitting his car. The arguement then got physical. As witnesses saw the truck hit his car, the truck driver cannot press charges. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criter ia 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 #5 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in on or more of the following ways: [X] Directly experiencing the tramuatic event(s) 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 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] Reckless or self-destructive behavior. [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] 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. Criterion H: [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 apply to the Veterans diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [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] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene 5. Behavioral Observations: --------------------------- Veteran was alert, oriented, with no hygiene issues on this date. He denied hallucinations, and does not appear to have delusions. 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: Veteran has times when he "shuts down" for 4-5 days at a time. He does not bathe, brush his teeth, doesn't come out of his bed or his room. He doesn't eat and loses weight at these times. He states he doesn't want to deal with anybody, cuts off his phone and doesn't watch TV. His children are in day care as he cannot be responsible for them at these times. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- Veteran denies suicidal or homicidal ideations at this time. He has fleeting suicidal thoughts on rare occasions with no intent or plan. Veteran does not appear to be able to work at this time due to psychological distress. The diagnosis used was per DSM-V. The veteran confirmed identity by stating his full name and full Social Security number, when asked, before the exam began. The limits of confidentiality were explained to the veteran, and the veteran indicated understanding of those limits when asked, before the exam began. The veteran gave the examiner permission of conduct the exam.
  5. SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: 309.81 Comments, if any: 30% service connected for PTSD. 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? [ ] Yes[X] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? No response provided. 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? [ ] 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? [ ] Yes[X] 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: previous C & P 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 If yes, describe: 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Veteran is engaged to the mother of his children, but there has been recent conflict. They are living together with their 2 children 4y and 10m. Veteran's wife works and children go to Day Care. Veteran had a physical confrontation with one of his brothers 2-3 weeks ago. Shots were fired but no one was hurt. b. Relevant Occupational and Educational history: Veteran is unemployed. He was fired from USPS for "no call no show." He reports conflict with co-workers and supervisor. He was shot--didn't bring proper documentation. Supervisor claimed he was not following orders. Veteran states he couldn't comprehend them-- thought he was following orders. Veteran worked for 1 day for his uncle. He got into an arguement with a customer, and then in an argument with his uncle. Uncle then stated he could not work for him. He has been unemployed since January 2014. c. Relevant Mental Health history, to include prescribed medications and family mental health: Veteran was seeing Donna Denato, Ph.D. She referred him to a psychiatrist for medication. The provider was on vacation, and he never made contact. Veteran wants outpatient treatment now. He is willing to come to the VA for outpatient treatment. d. Relevant Legal and Behavioral history: Veteran was arrested for possession of marijuana and commission of a felony with a firearm. He was stopped by the police for a license plate issue. His car was searched and marijuana was found in his trunk. He had a hand gun and a permit. Veteran is going back to court--has been offerred probation. e. Relevant Substance abuse history: Veteran is smoking 2 blunts of marijuana 1-2 times per day. His last use was 10:30pm last night. He started using THC after active duty in the military--11/2011. He drinks alcohol 3-4 times per month-- 2 shots of Whiskey. His last drink was 6/23/2014. f. Other, if any: Veteran states he was already paranoid when got shot 1/16/2014. He was looking for a friend in South Memphis. Some men approached him and started shooting. He was treated at the Med for a gunshot wound to the torso. Now, he keeps his gun handy at all times. Veteran has to be in court tomorrow as he is being sued by a truck driver for breaking his jaw. This truck driver hit his car and did not stop. Veteran chased him, forcing him to stop. The truck driver denied ever hitting his car. The arguement then got physical. As witnesses saw the truck hit his car, the truck driver cannot press charges. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criter ia 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 #5 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in on or more of the following ways: [X] Directly experiencing the tramuatic event(s) 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 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] Reckless or self-destructive behavior. [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] 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. Criterion H: [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 apply to the Veterans diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [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] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene 5. Behavioral Observations: --------------------------- Veteran was alert, oriented, with no hygiene issues on this date. He denied hallucinations, and does not appear to have delusions. 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: Veteran has times when he "shuts down" for 4-5 days at a time. He does not bathe, brush his teeth, doesn't come out of his bed or his room. He doesn't eat and loses weight at these times. He states he doesn't want to deal with anybody, cuts off his phone and doesn't watch TV. His children are in day care as he cannot be responsible for them at these times. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- Veteran denies suicidal or homicidal ideations at this time. He has fleeting suicidal thoughts on rare occasions with no intent or plan. Veteran does not appear to be able to work at this time due to psychological distress. The diagnosis used was per DSM-V. The veteran confirmed identity by stating his full name and full Social Security number, when asked, before the exam began. The limits of confidentiality were explained to the veteran, and the veteran indicated understanding of those limits when asked, before the exam began. The veteran gave the examiner permission of conduct the exam.
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