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Braincloud

Seaman
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Posts posted by Braincloud

  1. This is my initial claim, so will requesting my c-file actually help. I am also using e-benefits for my completion date and info, but spoke with someone on the benefits who stated that my claim was complete. My mental DBQ is below.

     

    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
     Comments, if any:
     This condition is more likely than not (greater than 50%
     probability) related to military service.
     Rationale: Traumatic stressors resulting in PTSD occured while
     active duty and i the line of duty.
     Mental Disorder Diagnosis #2: Major Depressive Disorder, severe
     ICD code: 296.32
     Comments, if any:
     This condition is more likely than not (greater than 50%
     probability) related to military service.
     Rationale: Veteran was seen for Psychiatric counseling with
     depressed mood while active duty.
     
     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?
     [X] Yes [ ] No
     
     b. Is it possible to differentiate what symptom(s) is/are attributable to
     each diagnosis?
     [ ] Yes [X] No [ ] Not applicable (N/A)
     
     If no, provide reason that it is not possible to differentiate what
     portion of each symptom is attributable to each diagnosis and discuss
     whether there is any clinical association between these diagnoses:
     Due to the overlapping and intricately interwoven symptoms of PTSD
     and Major Depressive Disorder it is not possible, without 
    resorting
     to mere speculation, to differentiate what portion of each symptom
     is attributable to each diagnosis. The two diagnoses have a

    strong
     clinical association and likely exacerbate each other.
     
     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 the overlapping and intricately interwoven symptoms of PTSD
     and Major Depressive Disorder, severe, it is not possible without
     resorting to mere speculation to differentiate what portion of the
     indicated level of occupational and social impairment is
     attributable to each diagnosis.
     
     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
     ------------------
     Evidence reviewed (check all that apply):
     
     [X] VA e-folder (VBMS or Virtual VA)
     [X] CPRS
     2. History
     ----------
     

    not connect well with others, experienced "mood changes". 
    Veteran
     lost a mentor, Lt Col Joseph A. Hoelscher who died April 26, 2006 at
     Eglin AFB. The mentor was doing a physical fitness test and became
     unresponsive, Veteran was a first responder and was unable to save
     him. Wonders now what the mentor's family thinks. Also went to 
    2-3
     month course twice in Maryland, University of Maryland in trauma ER 
    and
     ambulance training in Baltimore. He had a lot of DNR calls and
     "watched them die". He also had multiple calls on trauma
     resessitations, including children. Had been married and got 
    divorced.

    b. Relevant Occupational and Educational history (pre-military, military, 
    and
     post-military):
     Stayed with parents when out of military, could not work with people,
     became reculsive. Worked five months at a job that brother got for 
    him
     as an assistant pressmen. Missed a lot of days and then just quit,
     could not deal with being around people. Wife suggested they come 
    back
     to Alaska, he got a job working in a warehouse, pulling lines, but 
    quit
     after two weeks due to depression. 
     
     
     c. R
    elevant Mental Health history, to include prescribed medications and

    family mental health (pre-military, military, and post-military):
     Wanted to seek help at Eglin but being a medic he feared others could
     see his records. In England saw a social worker for therapy and Dr.
     Talon. REF Upwood in England for a year. Hospitalized in Providence
     Hospital in 2015 for a week due to suicidal ideation, started on 
    Prozac
     and rimron,switched to Effexor 225mg and rimron 15mg and klonipine for
     panic attacks, which he took 3-4 times a month. With rimron he was
     able to get some sleep. Continues to have night sweats and 
    nightmares,
     which have to do with not being able to save people. He did attend
     group therapy and saw SW for therapy. Currently has tremendous
     difficulty with motivation. He recognizes that he has avoided therapy
     due to fear. Now that wife is working there are days Veteran does not
     get out of bed at all, wife directs him to take showers, change
     clothes. He does talk with Mom and brother on the phone, feels he
     needs a lot of time alone, goes on walks, smokes a cigarette. No
     social life here, no friends, just spouse. Continues to not be
     comfortable around people. 
     
     
     d. Relevant Legal and Behavioral history (pre-military, military, and
     post-military):
     In veteran's court for domestic violence. Finished Vet Court and 
    eight
     months of treatment for PTSD and domestic violence, took 8 months
     instead of 6 months because had difficulty getting out of bed,
     depressive symptoms. 
     
     
     e. Relevant Substance abuse history (pre-military, military, and
     post-military):
     Use to drink some and that seemed to have a relationship to the
     domestic violence, which did involve alcohol, now very seldom uses
     alcohol. Continues to smoke. 
     
     
     f. Other, if any:
     Admitted to Providence Psychiatric Unit 10/13/2015 - 10/19/2015 with
     diagnosis of Major Depressive Disorder, severe; PTSD, and Social
     Anxiety Disorder.
     Medications: bupropion 300 mg 24 hr tablet
     Commonly known as: WELLBUTRIN XL
     Take 1 tablet by mouth Daily.
     Cholecalciferol 2000 UNITS Tabs
     Commonly known as: VITAMIN D-3
     Take 2 tablets by mouth Daily.
     mirtazapine 30 mg disintegrating tablet
     Commonly known as: REMERON SOLTAB
     Take 1 tablet by mouth nightly for 30 days.

    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: First responder at the death of his mentor, Lt Col Joseph A.
     Hoelscher who died April 26, 2006 at Eglin AFB. The mentor was doing 
    a
     physical fittness test and became unresponsive, Veteran was a first
     responder and was unable to save him. Felt he received no debriefing
     or support.
     
     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: Also went to 2-3 month course twice in Maryland, University
     of Maryland in trauma ER and ambulance training in Baltimore. He had 
    a
     lot of DNR calls and "watched them die". He also had multiple 
    calls on
     trauma resessitations, including children who died.
     
     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:
     Working in Baltimore ER for training in ER medicine, 4-6 months
     total, while active duty, C-STARS class.

    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 Criterion 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 Criterion 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 violence, in one or more of the following ways:
     
     [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 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] 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, distorted cognitions about the cause or
     consequences of the traumatic event(s) that lead the
     individual to blame himself/herself or others.
     [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] 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
     [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 that occur weekly or less often
     [X] Chronic sleep impairment
     [X] Mild memory loss, such as forgetting names, directions or recent
     events
     [X] Flattened affect
     [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] Neglect of personal appearance and hygiene
     [X] Intermittent inability to perform activities of daily living,
     including maintenance of minimal personal hygiene

     

     

     

     

     

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