Ask Your VA Claims Questions | Read Current Posts
Read VA Disability Claims Articles
Search | View All Forums | Donate | Blogs | New Users | Rules
- 0
ptsd C&p Results For Ptsd What Kind Of Rating Just Guessing
Rate this question
-
Similar Content
-
- 0 comments
- 957 views
-
- 0 replies
- 336 views
-
- 3 answers
- 320 views
-
- 0 comments
- 1,090 views
-
- 0 replies
- 359 views
-
Question
maine2000
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No
2. Current Diagnoses
--------------------
a. Diagnosis #1: PTSD
ICD code: 309.81
Indicate the Axis category:
[X] Axis I [ ] Axis II
b. Axis III - medical diagnoses (to include TBI): Chronic pain, plantar
faciitis
c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
No response provided.
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[X] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
No response provided.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
No response provided.
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 reduced reliability and
productivity
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
------------------
If any records (evidence) were reviewed, please list here:
CPRS and claims file available and reviewed in its entirety
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
Veteran currently lives with girlfriend. Reports that their
relationships are strained. He has been married and has one daughter
who lives in rock hill.
b. Relevant Occupational and Educational history:
Veteran reports that he has been out of work since July 2013 because
of
problems with his knee and back. He had been on this job since 2009.
He reports that he felt that he was being taken advantage of, because
they would send him to far away jobs. He reports that he was having
problems with communication with others/ He also reports having been
written up for poor performance and difficulty with concentration.
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
Veteran continues to get treatment for PTSD; he is prescribed
hydroxyzine, trazodsone, and venlafaxine. he reports that he feels the
medications do not help. He has been getting treatment since 2007
d. Relevant Legal and Behavioral history:
none
e. Relevant Substance abuse history:
none
f. Sentinel Event(s) (other than stressors):
No response provided.
g. Other, if any:
No response provided.
3. PTSD Diagnostic Criteria
---------------------------
Criterion A: The Veteran has been exposed to a traumatic event where both
of the following were present:
[X] The Veteran experienced, witnessed or was confronted with
an event that involved actual or threatened 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: The traumatic event is persistently reexperienced in 1 or
more of the following ways:
[X] Recurrent and distressing recollections of the event,
including images, thoughts or perceptions
[X] Recurrent distressing dreams of the event
[X] Intense psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event
Criterion C: Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
the
trauma), as indicated by 3 or more of the following:
[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
Criterion D: Persistent symptoms of increased arousal, not present before
the trauma, as indicated by 2 or more of the following:
[X] Difficulty falling or staying asleep
[X] Irritability or outbursts of anger
[X] Difficulty concentrating
[X] Hypervigilance
Criterion E: No response provided.
Criterion F:
[X] The PTSD symptoms described above cause clinically
significant distress or impairment in social,
occupational, or other important areas of functioning.
4. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[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] Suicidal ideation
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes[X] No
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
7. Remarks, if any:
-------------------
veteran continues to meet the criteria for PTSD re
lated to previously
described stressors. He is getting treatment although he reports no
signficant relief from his symptoms.
Link to comment
Share on other sites
Top Posters For This Question
8
4
1
1
Popular Days
Oct 3
5
Oct 6
3
Oct 4
2
Oct 5
2
Top Posters For This Question
maine2000 8 posts
harleyman 4 posts
carlie 1 post
Philip Rogers 1 post
Popular Days
Oct 3 2013
5 posts
Oct 6 2013
3 posts
Oct 4 2013
2 posts
Oct 5 2013
2 posts
15 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now