thatguy157

Not exactly sure what you were trying to say there

Currently 30% PTSD SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: 309.81 Comments, if any: Previously service connected Mental Disorder Diagnosis #2: Alcohol use disorder ICD Code: 303.90 Comments, if any: Previously diagnosed as alcohol dependence. Diagnosis updated for DSM-5. Secondary to PTSD b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No relevant diagnoses 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? [X] Yes[ ] No[ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: PTSD Intrusive memories, nightmares, distress in response to triggers, flashbacks Avoidance of thoughts and discussions related to the trauma, avoidance of reminders Decreased participation in activities, disconnection from other people, lack of positive emotions Irritability, hypervigilance, insomnia, anxiety attacks Alcohol use disorder: Currently, 2-3 days a week, up to a bottle of wine, sometimes beer and liquor as well 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 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[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: Due to overlap and the interaction effects between symptoms, it is not possible to apportion the source of occupational/social impairment. 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 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria 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 #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic 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] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [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 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] 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 actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Flattened affect [X] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting 5. Behavioral Observations: --------------------------- The veteran arrives on time to his appointment. His grooming and hygiene are fair and he dresses casually in a black hoodie and jeans. He has several days of facial hair. He carries a large can of Red Bull with him. He is very polite but seems to be emotionally disengaged. Eye contact is appropriate. Mood appears to be apathetic and depressed and affect is constricted. He does not exhibit any psychomotor abnormalities. Speech is soft and rapid and sometimes his words run together. Process of thought is organized and linear with no suggestions of thought disorder. He does not describe any delusional thinking, hallucinations, or other psychotic symptoms. Level of insight and judgment appear to be fair. He is a reasonable historian for past events. The veteran endorses passive suicidal ideation at baseline. He has had 2 previous suicidal threats, most recently in December 2013. Risk factors for suicide include the veteran's male gender, Caucasian race, history of attempts, severity of PTSD, and social isolation. He is considered a moderate to high risk for suicide and should be monitored. PHQ-9 depression screen is a 22 and reflects severe depression. Performance on cognitive screening is within the normal range (26/30 on the MoCA). The veteran misses 4/5 words on delayed recall. His performance is otherwise intact. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- SUMMARY: The veteran continues to exhibit intrusion, hyperarousal, avoidance, negative cognition and mood symptoms consistent with PTSD. He describes a history of problems with alcohol use, nightmares, severe insomnia, hypervigilance, anger, irritability with physical aggression, and emotional numbing. The veteran initiated treatment through the VA, but has been told that he needs to complete substance abuse treatment before he can connect with general mental health services. Other than the diagnoses listed, no other mental conditions were apparent. The veteran is able to maintain activities of daily living including personal hygiene. There has been inappropriate behavior in terms of aggression in bars that has resulted in fights. He also inadvertently hit his wife when she woke him up from a dream. There has not been any significant trauma since Afghanistan. Thought processes and communication are not impaired. Social functioning is impacted by irritability resulting in conflict in his marriage, general dislike of people, emotional withdrawal, and depressed mood. Employment is primarily impacted by irritability and poor response to authority. He also describes memory and concentration problems, anhedonia, and low frustration tolerance. He is not currently in treatment. Symptoms are continuous and could benefit from continuous medication. There have been no remissions in the past year. He was sober for 4-1/2 years, but then relapsed and is now drinking moderately per his report. Prognosis for improvement is estimated to be guarded based on the severity of symptoms and chronicity.

SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: 309.81 Comments, if any: Previously service connected Mental Disorder Diagnosis #2: Alcohol use disorder ICD Code: 303.90 Comments, if any: Previously diagnosed as alcohol dependence. Diagnosis updated for DSM-5. Secondary to PTSD b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No relevant diagnoses 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? [X] Yes[ ] No[ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: PTSD Intrusive memories, nightmares, distress in response to triggers, flashbacks Avoidance of thoughts and discussions related to the trauma, avoidance of reminders Decreased participation in activities, disconnection from other people, lack of positive emotions Irritability, hypervigilance, insomnia, anxiety attacks Alcohol use disorder: Currently, 2-3 days a week, up to a bottle of wine, sometimes beer and liquor as well 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 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[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: Due to overlap and the interaction effects between symptoms, it is not possible to apportion the source of occupational/social impairment. 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 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria 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 #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic 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] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [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 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] 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 actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Flattened affect [X] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting 5. Behavioral Observations: --------------------------- The veteran arrives on time to his appointment. His grooming and hygiene are fair and he dresses casually in a black hoodie and jeans. He has several days of facial hair. He carries a large can of Red Bull with him. He is very polite but seems to be emotionally disengaged. Eye contact is appropriate. Mood appears to be apathetic and depressed and affect is constricted. He does not exhibit any psychomotor abnormalities. Speech is soft and rapid and sometimes his words run together. Process of thought is organized and linear with no suggestions of thought disorder. He does not describe any delusional thinking, hallucinations, or other psychotic symptoms. Level of insight and judgment appear to be fair. He is a reasonable historian for past events. The veteran endorses passive suicidal ideation at baseline. He has had 2 previous suicidal threats, most recently in December 2013. Risk factors for suicide include the veteran's male gender, Caucasian race, history of attempts, severity of PTSD, and social isolation. He is considered a moderate to high risk for suicide and should be monitored. PHQ-9 depression screen is a 22 and reflects severe depression. Performance on cognitive screening is within the normal range (26/30 on the MoCA). The veteran misses 4/5 words on delayed recall. His performance is otherwise intact. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- SUMMARY: The veteran continues to exhibit intrusion, hyperarousal, avoidance, negative cognition and mood symptoms consistent with PTSD. He describes a history of problems with alcohol use, nightmares, severe insomnia, hypervigilance, anger, irritability with physical aggression, and emotional numbing. The veteran initiated treatment through the VA, but has been told that he needs to complete substance abuse treatment before he can connect with general mental health services. Other than the diagnoses listed, no other mental conditions were apparent. The veteran is able to maintain activities of daily living including personal hygiene. There has been inappropriate behavior in terms of aggression in bars that has resulted in fights. He also inadvertently hit his wife when she woke him up from a dream. There has not been any significant trauma since Afghanistan. Thought processes and communication are not impaired. Social functioning is impacted by irritability resulting in conflict in his marriage, general dislike of people, emotional withdrawal, and depressed mood. Employment is primarily impacted by irritability and poor response to authority. He also describes memory and concentration problems, anhedonia, and low frustration tolerance. He is not currently in treatment. Symptoms are continuous and could benefit from continuous medication. There have been no remissions in the past year. He was sober for 4-1/2 years, but then relapsed and is now drinking moderately per his report. Prognosis for improvement is estimated to be guarded based on the severity of symptoms and chronicity.