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Ptsd C&p Back In March Possible Raing

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maine2000

Question

Here are some of the things in the report.What do you guys think of this report?

03/19/2011 INITIAL EVALUATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD)

Priority of Exam: ORIGINAL SC

Examination results:

EXAMINATION TYPE: Stress disorder.

PRIORITY OF EXAMINATION: Original.

The C-file was reviewed in its entirety.

HISTORY OF PRESENT ILLNESS: The Veteran, who carries a diagnosis of

posttraumatic stress disorder, experienced an incident in which there was an

explosion aboard the ship he was working, and he watched another sailor burn to

death. The Veteran was evaluated previously

on 11/23/10. Dr.diagnosed the patient with posttraumatic stress

disorder and gave him a global assessment of functioning of 54. She verified

that his symptoms were related to this explosion aboard ship. The Veteran

continues to complain of intrusive recollections of the traumatic event . He

reports having nightmares every night. He is taking medication that helps him

sleep and without medication, he is unable to sleep. He has flashbacks during

the daytime with olfactory hallucinations of flesh burning. He reports feeling

anxious and depressed when reminded of this soldier's death. The Veteran

avoids thinking about or being reminded of this event. The Veteran states that

he continues to feel very emotionally apart from others. He is very irritable

and has become physically violent as recently as in the last week. He has

difficulty concentrating and problems with his short-term memory. He startles

very easily and is extremely watchful in crowds. He states he has thoughts

frequently of suicide. He is medicated with citalopram and trazodone.

He is treated at the VA. He denies a history of family psychiatric problems.

He denies abuse of alcohol or drugs.He did have a history of using alcohol to excess

but no longer drinks at all.

SOCIAL HISTORY: The Veteran lives at various homes between different family

members. He was born in SC and raised by both of his parents. He

graduated from high school. He works part-time for a company that does

computer work for dental offices. He is able to perform all activities of

daily living.

MEDICAL HISTORY: The Veteran has hypertension, right shoulder pain, leg pain,

and back pain.

MENTAL STATUS EXAMINATION: The Veteran is an adequately groomed male,

appearing his stated age. He is somewhat guarded during the interview and

appears anxious. He maintains intermittent eye contact with the examiner. He

exhibits some psychomotor restlessness. His speech is rapid at times .

He describes his mood as very down. His affect is blunted. His thoughts are

generally organized with some circumstantiality. He has chronic suicidal

thoughts but no intent at this time. He has olfactory hallucinations when

experiencing flashbacks. His concentration is impaired. His short - term memory

is impaired. His intelligence is average. His insight and judgment are

somewhat impaired.

DIAGNOS I S: Axis I: Posttraumatic stress disorder, chronic. Axis II: No

diagnosis. Axis III: See medical history portion of report. Axis IV:

Family, social, occupational, economic problems. Axis V: The Veteran's

current global assessment of functioning is 55.

The Veteran is able to manage VA benefits.

OPI NIONS: It is the opinion of the evaluator that the Veteran's posttraumatic

stress disorder is secondary to an incident that occurred while he was on

a ctive duty but is not related to his fear of hostile military or terrorist

activity.

11/23/2010 INITIAL EVALUATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD)

Priority of Exam: ORIGINAL SC

11/24/2010 The first C&P

Examination results:

MEDICAL HISTORY AND HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old,

married one time but separated, African-American male who presents for an

evaluation to establish service connection for posttraumatic stress disorder.

When questioned about what brought him to evaluation, he says he has mental

health problems. The claims file was available at the time of the evaluation

and was reviewed by this clinician. It provided evidence of his claim for

PTSD. There was a statement in support of his claim. There were notes from

the VA Clinic. It was noted that the Veteran has been diagnosed

with PTSD. There was a rule out of bipolar and a substance-induced mood

disorder. There was PTSD and a rule out of alcohol abuse from DR.

There was a statement in support of the Veteran's claim talking about the

incident on the ship with an explosion and his anxiety and PTSD is a result of

that and it was noted that he has been diagnosed also with depression and

prescribed citalopram. There was a treatment plan from the DR and

treatment notes. The Veteran denied a family history of mental illness and

denied a history of trauma prior to service in the military. For additional

information about his current symptoms, please refer to the discussion section

o f the report. Medically, the Veteran reported that he has hypertension, pain

in his right shoulder, his legs, his feet, and chest pain from his shoulder.

PAST PSYCHIATRIC HISTORY: The Veteran reported that he has seen in

the past for counseling and now he has a new medication provider that he sees

SOCIAL AND OCCUPATI ONAL HISTORY: The Veteran suggested that he lives in SC

. He noted that he completed high school. He described military service

in the Navy from August 1989 to July 1993 where he was a Navy Aviation

Boatswain ' s Mate . He reported that he was in the Middle East during Desert

Storm . He reported a traumatic incident that happened in August 1991 . He said

that they were out to sea and a sailor was blown up on the ship from liquid

oxygen bottle and he saw his body. He said that when he heard the explosion he

worried that the ship was going to sink and he feared for his life. In terms

of his work history, he said he works. He has been there for a year. He denied he has missed

any time from work because of PTSD other than for appointments. He denied

problems with irritability. He says he can have some trouble with

concentration on the job that can slow him down and cause him t o make mistakes.

He denied a history of legal involvement. When questioned about his use of

addictive substances , he denied using drugs. When questioned about his relationships with others,

he reported that he has been married 1 time but he has been separated for 5

years and he has an 8-month-old daughter. He says he lives between his parents

house and his girlfriend 's house but more with his girlfriend. The

relationship with his girlfriend is fair. He says he can be irritable and

withdrawing sometimes. He says the relationship is good with his daughter. He

described a fair relationship with his parents because of his withdrawal and

irritability . He says he has 2 close friends and they talk. He talks to one

of them every 4 months because he lives out of state and the other he sees

about once every 2 weeks. He says he watches sports on TV and he spends time

on the computer . He has fished about twice in the past year. He does some

cooking and cleaning and spends time with his daughter.

MENTAL STATUS EXAMINATION: The Veteran was alert, oriented and attentive ana

appeared his stated age. His mood appeared to be dysphoric and his affect was

constricted. His speech was of regular rate and rhythm. There was no evidence

of psychomotor agitation or retardation. The Veteran's eye contact was fair.

He was cooperative and pleasant with the examiner . His thought process was

logical and coherent . His thought content was devoid of current auditory or

visual hallucinations. No evidence of delusional content was noted. He denied

current thoughts of hurting himself or hurting others. Denied a history of

suicide attempts and said the last time he was physically aggressive with

somebody was last week. He did say that he sometimes has passive suicidal

ideat i on in the face of a lot of stress but he is able to push the ideation

aside. His intelligence is estimated to be in the average range

and the Veteran had fair insight into his current condition.

DIAGNOSTIC IMPRESSION: Axis I: Posttraumatic stress disorder. Axis II:

Deferred. Axis III: Per the Veteran's report hypertension and pain in his

right shoulder, his legs, feet and chest pain from his shoulder. Axis IV:

Relationship problems and some difficulties with employment. Axis V: A GAF

score currently of 54.

DISCUSSION: This Veteran is exhibiting moderate to at times moderate to

considerable symptoms associated with PTSD. His PTSD appears to be related to

the above- mentioned stressor in which he feared for his life but it does not

appear to be related to fear of hostile military activity. Specifically, he

reported intrusive thoughts of his trauma twice a month and nightmares 1 time

every 2 weeks. He described psychological and physiological reactivity to some

loud noises or seeing fire or fire on TV. He says he does not like to talk or

think about his trauma and avoids crowds. His affect was constricted. He

described emotional detachment from others and less interest in activities. He

says he sleeps about 4 hours and has trouble concentrating. He reported an

exaggerated startle reaction to loud noises or unexpected approaches in a

hypervigilant style. He reported depressive symptoms in the past but he says

the depression lasted no more than a couple of days except when he was using

alcohol heavily. He says he has had his symptoms since 1992. He feels his

symptoms have gotten worse. He denied periods of remission and denied problems

with activities of daily living such as feeding, bathing or toileting himself.

In terms of his social adaptability and interactions with others, this appears

to be moderately to moderately to considerably impaired. In terms of his

ability to maintain employment and perform job duties in a reliable/efficient

manner, this appears to be moderately impaired. Overall, I would estimate his

level of disability to be in the moderate to moderate to considerable range and

I would say the Veteran is capable of handling his own funds.

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  • HadIt.com Elder

I would say that you probably should be Service Connected for PTSD and my guess would be a 30% rating.

Veterans deserve real choice for their health care.

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maine2000,

Welcome to Hadit .com

I read the full report.

To me it looks good, to grant SC for PTSD at an evaluation level of 30 - 50 percent.

Carlie passed away in November 2015 she is missed.

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  • HadIt.com Elder

If you filed your claim in Columbia SC VARO more 30% than 50% they tend to low ball claims here for some reason probably no more than just because they can I have as little to do with them as possible anymore the last time I went there was in Feb 2009 for my BVA hearing but between Dec 2003 and June 2007 they made my life a living hell with denials and low ball awards good luck

100% SC P&T PTSD 100% CAD 10% Hypertension and A&A = SMC L, SSD
a disabled American veteran certified lol
"A journey of a thousand miles must begin with a single step."

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