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About mstsurvivor

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    E-2 Recruit

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  1. just spoke to by vso, i was rated at 70% for ptsd and combined with whatever claims they approved 80%. thanks for the two of you that replied! gave me some peace of mind yesterday i truly appreciate it.
  2. thank you so much, i will look into it. I'm just concerned because the doc wrote so much in the note but then didn't check off all the applicable boxes in the "for VA rating purposes" section.
  3. hi everyone, if anyone has any insight on the results of my C&P exam it would be greatly appreciated. i was sexually assaulted while AD AF, my claim was quick start filed 5 months ago, i had the exams over a month ago and things seemed to be going well, it went to pending decision approval two weeks ago and then all of a sudden dropped back to gathering of evidence and a pending appointment request. my AMVETS lady never answers me and when she does she says she will get back to me... and never does. my PTSD is at an all time high not knowing what all of this means. i also have a few other claims in for chronic pain and chronic gastritis (gastritis c&p stated that it was more likely psych related) 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: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: 309.81 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Chronic Pain 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 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? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] 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: [X] Military service treatment records [X] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [X] 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 [X] Other: VBMS, CPRS 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): The veteran was raised in ________by her biological parents. She described her childhood as "really good, compared to people I served with and hearing where they came from I was definitely blessed." She described her relationship with her parents as "normal" and indicated that they did not get along while she was an adolescent, but are now "best friends." She denied any experiences of abuse growing up. The veteran is currently living in ________ with her husband who is currently active duty in the military. She has no children and no other marriages. The veteran reports that they were married just 2 weeks prior to her sexual assault which occurred while they were stationed at separate bases. She indicated that although she is living with him now, they are estranged because of her ongoing symptoms since the assault. She plans to move in with her parents as soon as they have room for her to do so. She indicated that her husband says she's not the same person he married and that he doesn't know her anymore even though they've been together for 6 years. They have not been physically intimate since her assault. The veteran indicated that they plan to proceed with a divorce once she has addressed her medical and military issues. The veteran indicated that at present she is engaged in very few activities and spends the majority of her time at home. She indicated that she tries to take care of chores around the house or go grocery shopping, but she finds even those tasks to be challenging and her husband often has to remind her to do them. She indicated that she has few friends and that "I don't like people, I don't like talking to people, social settings." Prior to her sexual assault she describes herself as being a "social butterfly." Now, she spends a lot of time watching shows on Netflix. She typically would enjoy going to the gym, but has been unable to because of a back injury. b. Relevant Occupational and Educational history (pre-military, military, and post-military): The veteran's highest level of education is a high school diploma. She The veteran is currently unemployed both due to physical limitations (she has difficulty standing for long periods of time due to a back injury) as well as mental health issues (she is afraid of people). She has no income and her husband is currently supporting her financially. She was never deployed to an area where she received hazardous duty pay. Her Veteran received an honorable discharge due to "Hardship; Service Member Initiated Due to Dependency." The veteran reports that prior to her sexual assault she loved the work she did in the military and got along with her coworkers; she was "really happy and really proud." After the assault she reports that she was "emotionally checked out" at work and was reprimanded for insubordination by a superior officer. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran reported receiving sporadic mental health treatment through the Air Force following her sexual assault. Her medical records in VBMS reflect this. She was prescribed medication to assist with sleep and mood including melatonin, biotin, prozac, flexaril, and trazodone. She indicated that prior to this she was also seen for evaluation and treatment for ADD and was prescribed ritalin. The veteran indicated that since discharging she has run out of her medications and has not been on anything for several weeks. The veteran described symptoms including intrusive thoughts, flashbacks, nightmares, emotional and physical distress at trauma cues, avoidance of trauma related memories/feelings/conversations and situations, gaps in her memory of the event, emotional numbness, disconnection from others, negative change in beliefs about herself/others/world, persistent negative emotional state, anhedonia, irritability, difficulty sleeping, poor concentration, hypervigilance. She also reported having panic attacks daily (with increased heart rate, throat swelling, difficulty breathing, face flushed, feeling out of control, shakiness, uncontrollable tears) and feeling depressed. The veteran described feeling like she's on a "roller coaster." She indicated that she has nightmares of her assault nightly and finds herself triggered by other people who she now fears may be similarly harmful to her. Additional triggers include hearing the "Law-and-Order SVU" theme song and hearing about Bill Cosby in the news. She has not been back to base despite being able to get free healthcare there (because her husband is active duty), in order to avoid being triggered to remember what happened. She has a sense of "impending doom" and always feels that she needs to keep her guard up because something might happen. The perpetrator's family is involved in illegal activity and she worries that they might come after her, or that he will once he is released from prison. She has been sleeping in a separate bedroom from her husband and keeps the door to her room locked at night. On one occasion he heard her screaming and crying in the middle of the night and entered her room, and she punched him before she was fully aware of what was happening. She has difficulty sleeping at night because at the time of her assault she was sleeping next to someone she trusted, so now even sleep does not feel safe. She reported that when she was still working at ________, she would often miss work because her sleep medication would "knock me out for half the day." She indicated that she has been unable to relate to/open up to anyone and feels that she can't connect with others, even friends from childhood. She is embarrased about what happened and doesn't want others to know. She indicated that whereas she used to enjoy fashion and getting dressed-up, she now makes an effort to look unattractive; she does not shave her legs or wear make-up anymore. She goes days without showering and only does so when her husband directs her to. She reports that she often will not leave her house for days at a time. She spends a great deal of time watching Netflix and cooking in order to avoid memories of the event. She indicated that she has to force herself to eat, but that she often throws up what she's eaten. She has chronic gastritis and she indicated that the stress of the assault caused it to "flare-up." The veteran indicated that immediately after the assault she considered suicide, but got support from a friend and did not take any action. Since then she has had suicidal ideation, but no plan or intent. She reports that she last had thoughts of suicide at the end of January 2016. She continues to feel hopeless and has thoughts such as "I don't know what the point of all of this is," but has had no recent active suicidal ideation. She denied current or past self-injurious behavior. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The veteran denied any current or past legal problems with the exception of the case related to her military sexual assault. e. Relevant Substance abuse history (pre-military, military, and post-military): The veteran reported that she typically drinks one bottle of wine per month. She reported that for a week after the sexual assault she was binge drinking, roughly one bottle of wine daily every day of that week. She indicated that she stopped because she was having difficulty functioning at work and did not want to be sent for substance abuse treatment. She denied any history of drug use or experimentation. f. Other, if any: The veteran reported that 2 weeks following her marriage she was sexually assaulted by a friend. A court martial was pursued against her assailant, and the veteran, along with other victims testified against the perpetrator. The perpetrator was sentenced to time in prison, loss of rank, and dishonorable discharge. Please see documentation in VBMS for additional details. The veteran reported that the period between the report of her assault, and the completion of the court martial has been very difficult. She indicated that she feels her case was mishandled by the military for several reasons. First, she reports that she was encouraged to drop the charges initially which was "the biggest slap in the face." She also reports that at one point her supervisor addressed her in front of her peers about the incident. She indicated that once others became aware of what had happened she was ostracized. Male friends gave her the "cold-shoulder" because they worried she would "call rape" on them. She indicated that she was further harassed by another supervisor who interrogated her about what happened and then slapped her on her behind and called her "fake tits." The veteran reports that she continued to have negative experiences even after she was transferred to a different unit. She was told that she was insubordinate by a supervisor and people continued to ostracize her. 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: Sexual Assault 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 If no, explain: Related to military sexual trauma that occurred stateside Is the stressor related to personal assault, e.g. military sexual trauma? [X] Yes [ ] No If yes, please describe the markers that may substantiate the stressor. Sexual assault case was brought to trial in the military and the veteran's assailant was sentenced to time in prison, dishonorable discharge, and loss of rank. Veteran's symptoms began to emerge shortly after the assault and medical records show that she was seen for mental health treatment at that time and received medication. 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 #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) 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] Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). [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. [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] 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. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 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 [X] Chronic sleep impairment [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 [X] Suicidal ideation [X] Neglect of personal appearance and hygiene [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene 6. Behavioral Observations -------------------------- The veteran presented for the evaluation on time, appropriately dressed and groomed, and appearing her stated a ge. She wore an oversized sweatshirt. The veteran was alert throughout the evaluation, and was oriented to person, place, and time. Speech was normal in rhythm, rate, tone, and volume. Content was coherent and goal directed. Affect was full range and appropriate, and her mood appeared to be anxious and depressed. There was no evidence of hallucinations or delusions. Cognitive functioning was grossly intact. Insight and judgment were fair. The veteran denied current suicidal and homicidal ideation, plan, and intent. 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 -------------------------------------------------- The veteran currently meets DSM-V criteria for a diagnosis of PTSD stemming from her military sexual trauma. Her symptoms fall within the severe range and have had a significant impact on her functioning in all domains since the incident. Please see above for a full accounting of the veteran's symptoms and their impact, as well as a detailed account of the assault and its aftermath. With appropriate treatment, veteran's symptoms may improve over time. 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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