Chemdawg

So basically other listed symptoms have no effect on the rating?

I did file within one year

I recently had to attend a total of three appointments for an initial PTSD claim. I was wondering if this is normal as I had to see two different doctors at the VAMC and also had to see an additional doctor at an offsite location that was scheduled through VES. So far, I have the following exam results from the VAMC, anybody know what this can lead to so far without knowing what the Non-VA Psychologist says? SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: F 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD (MILD) ICD code: F Comments, if any: IT IS AT LEAST AS LIKLEY AS NOT THAT THE VETERAN'S PTSD HAS BEEN CAUSED BY HIS FEAR OF HOSTILE MILITARY ACTIIVITES IN AFGHANISTAN. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): TINNITUS, ICD code: F 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed Comments, if any: HEADACHES 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 (hard copy paper C-file) reviewed? [ ] 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 [ ] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): *********** b. Relevant Occupational and Educational history (pre-military, military, and post-military): THE VETERAN HAD COMPLETED EIGHT GRADE PRIOR TO HIS MILITARY SERVICE. HE SERVE DIN THE U.S. ARMY FROM 2007 TO 2014. HE COMPLETED HIS GED PRIOR TO HIS MILITARY SERVICE. HE HAS BEEN A FULL-TIME COLLEGE STUDENT STUDYING BUSINESS. HE ALSO HAS BEEN WORKING PART-TIME IN SECURITY. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): WAS TREATED DURING HIS FIRST TOUR IN AFGHANISTAN. THE VETERAN WAS EXPERIENICNG MARITAL PROBLEMS AND ALSO IT WAS HIS FIRST EXPERIENCE WITH AFGHANISTAN. HE TOOK CELEXA FOR THREE MONTHS. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): NONE e. Relevant Substance abuse history (pre-military, military, and post-military): NONE f. Other, if any: No response provided. 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: "WE GOT ATTACKED ONE DIED AND FIFTEEN OR SIXTEEN WERE WOUNDED. I HAD TO CLEAR THE BUILDING, AND ASSESS THE WOUNDED.." 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: "WE HAD CONSTANT MORTAR AND ROCKET ATTACKS. WE ALWAYS HAD TO BE ON EDGE." 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 criteri a 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 #7 - 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 (DSM-5). 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) [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). 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 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. 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. 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. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Panic attacks more than once a week 6. Behavioral Observations -------------------------- THE VETERAN WAS AAO X 3. HE WAS APPROPRIATELY DRESSED AND GROOMED. HE SPOKE RAPIDLY AND HIS MOOD WAS ANXIOUS. HIS THOUGHT PROCESS WAS LOGICAL AND GOAL ORIENTED. HIS MEMORY AND CONCENTRATION WERE INTACT. HIS JUDGEMENT WAS GOOD. THERE WERE NO INDICTAIONS OF HALLUCINATIONS OR DELUSIONS. THE VETERAN DENIED EXPERIENCING ANY SUICCIDAL/HOMICIDAL THOUGHTS OR PLANS. 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, (including any testing results) if any -------------------------------------------------- No remarks provided.