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!

[Berta]

32 contentions????????

Holy Cow.......I hope your main contention was the PTSD. They could award that and then defer the other stuff........

Are these all documented disabilities and/or secondaries or are many just symptoms?????

I have seen 20 or more claimed conditions at the BVA but 32.......no wonder they gave you a potential EP (end date) in 2015.

[mekon1971]

According to my claim, my contentions are:

Contentions: posttraumatic stress disorder (New), left shoulder injury (New), hearing loss right ear (New), tinnitis (New), hypertension (New), traumatic brain injury (New), lower back injury (New), chronic fatigue (New), skin disorders (New), gastrointestinal signs or symptoms (New), cardiovascular signs or symptoms (New), depression (New), anxiety (New), liver condition (New), diabetes (New), chronic ear infections (New), hearing loss, left ear (New), hypothyroidism (New), sleep apnea (New), sleep disturbances (also claimed as nightmares with frequent waking and insomnia) due to GW undiagnosed illness (New), eczema (also claimed as skin disorders of the feet, leg, right hand, upper back, abdomen, and groin area) due to GW undi (New), shortness of breath (New), heartburn/reflux/GERD, (also claimed as hiatal hernia, and vomiting) due to GW undiagnosed illness (New), neuropsychological condition due to GW undiagnosed illness (to include depression with anxiety, cognitive issues/difficu (New), neurological condition with symptoms of tingling in hands, feet, arms, and legs with skin insensitivity due to GW undiag (New), muscle and joint pain(10/28/11 & 10/31/11) (also claimed as chronic wide spread pain to include neck, back, arms, legs, (New), fasciculation, legs, arms, and abdomen (also claimed as restless legs/arms) (New), migraine headaches (New), blurred and reduced vision (New), abnormal sweating (New), sexual dysfunction / erectile dysfunction (New)

31 or 32? something like that and a couple others I'm waiting to file on. Yes, all gtg for service connection and/or aggravation (though a couple might be a fight and/or secondaries and a couple will be rolled together)

Edited August 21, 2013 by mekon1971

[harleyman]

Mekon1971-

I know you are on SSDI for PTSD and your other service related conditions. That being acknowledged, this PTSD exam appears from my viewpoint, a service grant at 50%. The examiner did not mark the issues regarding work and social inabilities at the higher level of impairment what issues are marked are in the 30% to 50% ranges..

[harleyman]

Also, it may be a while before you have decision on your claim. The RO or at least the RO where I work, current protocohl states, the RVSR is not allowed to defer any contentions (claimed conditions) in the rating. So the RO has to rate all issues on your claim one way or another, if your claim has a date of claim bewteen 7/1/11 and 12/31/2012. Claims opened after 12/31/12 might be able to have deferred issues, but they are really frowning on defers right now, it just prolongs the claim and makes their STATS look bad. -IMO

You are right, 32 issues is up there in number. However, it used to be that who ever worked the claim would be penalized greatly/ unfairly, if there was one error out of thirty 32 issues. So one wrong would be 100% wrong. But they have changed that and now if there is an error in the Rating decision, it would be pro-rated at 1/32 wrong and combined with the rest of the RVSRs stats. So it is not so detrimental to work a claim with lots and lots of contentions. However, it is still alot of work and a 32 issue claim could take from 1 to 3 days to rate, depending on the complexity of the issues.

While looking at the DBQ results you posted here on Hadit. Some of them had the opinions included and some did not. Usually, if an opinion is requested it means the VA is either needing a current diagnosis of a condition, or the VA needs the doctor to provide a nexus linking the condition (contention) to military service. I noticed some postings of you DBQs were the plain DBQ no questions for the examiner. Most of the time when no opinion is sought and the DBQ is requested, there is evidence in the file and records show you have had treatment since military service. There is evidence of is a current diagnosis therefore there is evidence of chronicity and no opinion is needed. But, on some of your exams you posted the exam states you were not diagnosed until many years after your discharge. I am questioning the VSR/RVSR rationale for ordering an exam in the first place on sme of these DBQs

.

Did you serve during the RVN era? Just trying to work out some of my own questions about your recent slew of exams posed here at Hadit. - Harleyman

[mekon1971]

Harley,

No, not a RVN era vet. Most of those exams were from a 2-day visit to the C&P clinic. And like you pointed out, most are clearly documented in SMR's but a few are related to G/W or are probably secondary to documented contentions. If there was an opinion, I put it on here, if there was not, I didn't. I only included checked portions of the DBQ's, if an area had nothing marked in it, I skipped over it to save on my typing.

P.S. Thank you for the time you are/have spent on my DBQ's - while I wait, it's nice to know what I need to try to get Nexus letters, buddy letters, etc. for.

Edited August 24, 2013 by mekon1971

[harleyman]

Did you have diabetis during your service? As the exam stated not diagnosed until 2009.