diabetes Ptsd C&p Progress Notes

[mekon1971]

1. Diagnostic Summary

Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today's evaluation? YES

2. Current Diagnoses

a. Diagnosis #1: PTSD

Axis I

Diagnosis #2: Alcohol Dependence in remission

Axis I

b. Axis III - medical diagnoses (to include TBI):

Chronic pain, diabetes, hyperlipidemia, hypothyroidism, GERD, HTN, sleep apnea

c. Axis IV - Psychosocial and Environmental Problems (describe, if any):

Unemployment, recent death of dog

d. Axis V - Current global assessment of functioning (GAF) score:

50

3. Differentiation of symptoms

a. Does the Veteran have more than one mental disorder diagnosed? YES

b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? YES

If yes, list which symptoms are attributable to each diagnosis:

The Veteran no longer drinks alcohol.

4. Occupational and Social Impairment

a. <X> Occupational and social impairment with reduced reliability and productivity

SECTION II: CLINICAL FINDINGS:

1. Evidence Review

a. <X> Claims Folder (C-file)

<X> YES

<X> Other, please describe:

Interview, CPRS and Vistaweb review

b. Was pertinent information from collateral sources reviewed? NO

2. History

a. Relevant Social/Marital/Family history (pre-military, military, and post-military):

The Veteran reported a generally normal childhood and socialization although he had few friends growing up. He was married once for 6 years and had one daughter, but divorced after his wife cheated. He was married a second time for 4 years, but divorced after his wife cheated. He has been married for the past 3 years which is doing well. He spends his days shopping, cooking, watching TV, doing yardwork, going to church, and sometimes fishing.

b. Relevant Occupational and Educational history (pre-military, military, and post-military):

The Veteran completed the 12th grade. He completed 1.5 years of college with a 3.5 GPA in construction management, but left school when he was unemployed and unable to afford it. The Veteran worked in construction management at 2 different positions for 7 years total, leaving them for better positions, but at his 3rd position which he held for 4-5 years he was laid off as part of a downsizing maneuver. The Veteran did well and was being groomed for a VP position, but did have an argument with a client which he believes may have impacted the decision to let him go. He has been unable to find work and began collecting SSDI for PTSD in 2009.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):

The Veteran first began psychiatric care in 2005 and psychotherapy last year. He currently attends group therapy and medications include prazosin and sertraline. He did participate in marital counseling during his second marriage. Family mental health history is positive for suicide and addiction.

d. Relevant Legal and Behavioral history (pre-military, military, and post-military):

One suspension in school for fighting. One Article 15 in 1996 for having a foreign national in his barracks.

e. Relevant Substance abuse history (pre-military, military, and post military):

The Veteran does not smoke. He did smoke marijuana regularly from 2000-05. The Veteran began drinking heavily following Desert Storm until 2009 and would drink 24 beers or more until passing out.

3. Stressors

a. Stressor #1: On 2/25/91 the Veteran was on guard duty at Khobar, Saudi Arabia when a SCUD landed and killed 28 soldiers and injured 250 others. The Veteran was later required to remove his protective mask to assess the possibility of chemical agents.

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? YES

Is the stressor related to the Veteran's fear of hostile military or terrorist activity? YES

4. PTSD Diagnostic Criteria

a.

Criterion A:

<X> The Veteran experienced, witnessed, or was confronted with an event that involved actual or threateded death or serious injury, or a threat to the physical integrity of self or others.

<X> The Veteran's response involved intense fear, helplessness or horror.

Criterion B:

<X> Recurrent and distressing recollections of the event, including images, thoughts, or perceptions

<X> Recurrent distressing dreams of the event

Criterion C:

<X> Efforts to avoid thoughts, feelings or conversations associated with the trauma

<X> Efforts to avoid activities, places or people that arouse recollections of the trauma

<X> Markedly diminished interest or participation in significant activities

<X> Feeling of detachment or estrangement from others

<X> Restricted range of affect (e.g., unable to have loving feelings)

Criterion D:

<X> Difficulty falling or staying asleep

<X> Irritability or outbursts of anger

<X> Difficulty concentrating

<X> Hypervigilance

Criterion E:

<X> The duration fo the symptoms described above in Criteria B, C, and D is more than 1 month

Criterion F:

<X> The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:

<X> Stressor #1

5. Symptoms

<X> Anxiety

<X> Chronic sleep impairment

<X> Difficulty in establishing and maintaining effective work and social relationships

<X> Difficulty in adapting to stressful circumstances, including work or a worklike setting

6. Other symptoms: NO

7. Competency

Is Veteran capable of managing his or her financial affairs? YES

8. Remarks, if any

The Veteran reported symptoms consistent with a diagnosis of PTSD. He reported a stressor wich would meet diagnostic Criterion A for PTSD and is consistent with the kinds of duties expected of a service member at that time and in those circumstances. There are no pre- or post-military traumas which would account for his symptoms and his entrance physicals on 5/31/88 and 7/7/88 do not show any indications of prior psychiatric history or treatment. It is at least as likely as not that the Veteran has PTSD that was caused by or resulted from military service. The Veteran reported only mild anergia and amotivation as current symptoms of depression. He did report prior depressive episodes beginning after service in Desert Storm, but these are more likely than not manifestations of PTSD rather than a separate medical entity.

After the interview, the psychologist shook my had, thanked me for my service, and said "enjoy your retirement"

Thoughts? Thanks in Advance!

[Philip Rogers]

Probably 70% and possibly TDIU. With the SSDI you should get TDIU, period. jmo

pr

[Berta]

Absolutely.! TDIU.

If the SSDI award preceded the date of the claim,it is possible there would be an additional year retro to the filing date.

I dont have the reg in front of me.... will look for it and post it here....

I just hope VA is award of the SSDI award and has obtained those records.

"The Veteran was later required to remove his protective mask to assess the possibility of chemical agents."

Say what?

Sounds like a GPM (guinea pig maneuver) Geez

Maybe I misunderstood that.

[Berta]

This is what I meant by the EED retro.and additional year due to SSDI.

This depends on the criteria here in M21-1MR:

M21-1, Part VI January21, 2004
Change 109


"Unemployability. Authorization will tell the veteran the form can be used to apply for a 100 percent evaluation based on individual unemployability. If evidence is submitted establishing individual unemployability due to service-connected disabilities, prepare a disability rating granting the individual unemployability.

The effective date will be the earliest date the evidence shows individual unemployability if a claim is received within 1 year from such date. Otherwise, the effective date will be the date of claim, provided that the evidence shows entitlement as of that date and the date is not prior to August 1, 1975. See 38 CFR §3.400(o). If evidence is submitted establishing individual unemployability, but because of the reduced evaluations the percentage requirements of 38 CFR §4.16 are not met, refer the claims folder to Central Office (211B) for consideration under 38 CFR §3.321((1). "

from:http://64.233.167.104/custom?q=cache:MZXWz1SWPHkJ:www.warms.vba.va.gov/admin21/m21_1/part6/chg109.doc+M21-1+earliest+effective+date&hl=en&ct=clnk&cd=2&gl=us&ie=UTF-8&client=pub-2090988506854078

It works in practice (if the VARO does the claim right)

My husband

his SSA date solely for PTSD was Nov 1,1991.

He applied for TDIU after his major 1151 CVA in Aug 1992.

His TDIU app was received by VA within one year of the SSA PTSD award date:

"the effective date will be the earliest date the evidence shows individual unemployability if a claim is received within 1 year from such date. Otherwise, the effective date will be the date of claim, provided that the evidence shows entitlement as of that date and the date is not prior to August 1, 1975. See 38 CFR §3.400(o). "

Both his 1151 claim and his TDIU claim were pending at his death and I continued those claims.Three years after he after died the VA awarded an accrued 100% P & T rating for PTSD as of the Nov 1,1991 date, posthumously because they cannot award TDIU to a deceased veteran.

(at least I don't think they can..I could be wrong and .I hope others chime in here on that. He did met the 100% PTSD criteria in the VA Schedule of Ratings.)

I would think if Voc Rehab, during the first year prior to a veteran filing for TDIU, declared the veteran unable to continue in or even begin to participate in Voc Rehab,solely due to their SC, that would also be a reason for VA to determine the EED as possibly due to the Voc Rehab documentation date, regardless of whether they were on SSA for any SC or not

Any thoughts on that?

Edited August 17, 2013 by Berta

[mekon1971]

If the SSDI award preceded the date of the claim,it is possible there would be an additional year retro to the filing date.

I just hope VA is award of the SSDI award and has obtained those records.

"The Veteran was later required to remove his protective mask to assess the possibility of chemical agents."

Say what?

Sounds like a GPM (guinea pig maneuver) Geez

Maybe I misunderstood that.

You didn't misunderstand....

I filed for SSDI the same time I filed the VA Claim, SSI back-dated the SSDI 2 years but only paid 1 year retro from date of filing (they gave me a year SSDI backpay even though I was approved for SSDI in 3 months)

This is my part of my initial claim and is nearing the 2-year mark, just got the progress notes from the C&P which was over a year ago (7/25/12) - still no award from VA though - been a long wait.

[Berta]

Are you hooked into ebenefits?

Sometimes the info there is hard to interpret I think....but often it has at least some sort of status...per the vets here who use it.

I wish I could use ebenefits. VA told me widow claimants cant use it because "DOD doesn't know who we are. "

Sure they do.

Boy the VA is so often full of S--T ,ooops I mean spin.

[mekon1971]

I am using e-benefits, on there it was in Waco, TX but was moved to Lincoln, NE. On the WACO part it has "Gathering of Evidence" and on Lincoln, it has "Preparation for Decision", I was scheduled for an eye exam last Friday, so still doing C&P's. Original Claim date is 10/14/2011. The WACO one says anticipated completion date of 10/24/2014 to 06/09/2015 (It used to be in 2013), and the Lincoln one says "At this time, your Regional Office is unable to provide an estimated completion date for this type of claim" and "Regulatory or Procedural Review" for Claim Type.

I have 32 contentions, so it is a complicated claim and probably gets pushed to the bottom of the stack on a regular basis.