ptsd C And P Exam Opinions

[lucaswlandon]

SECTION I:

----------

1. Diagnostic Summary

---------------------

Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

--------------------

a. Diagnosis #1: PTSD

ICD code: 309.81

Indicate the Axis category:

[X] Axis I [ ] Axis II

Diagnosis #2: Major Depressive Disorder, recurrent, severe, without

psychotic fearures

ICD code: 296.33

Indicate the Axis category:

[X] Axis I [ ] Axis II

Diagnosis #3: Alcohol Abuse

ICD code: 305.00

Indicate the Axis category:

[X] Axis I [ ] Axis II

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

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

Combat in Iraq

d. Axis V - Current global assessment of functioning (GAF) score: 60

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:

The symptoms of these disorders overlap and any attempt to

separate

then would be mere

speculation.

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 due to mild or transient symptoms

which decrease work efficiency and ability to perform occupational

tasks only during periods of significant stress, or; symptoms

controlled by medication

Page 17 of 33 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:

The symptoms of these disorders overlap and any attempt to

separate

them would

be mere speculation.

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

------------------

a. Records reviewed (check all that apply):

[X] Claims folder (C-file):

[ ] Yes

[X] No

If no, provide reason C-file was not reviewed:

VBMS

b. Was pertinent information from collateral sources reviewed?

No response provided.

2. History

----------

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

post-military):

He was born and raised in Columbus, Ohio. He had two parents, one

older

brother and

two younger sisters. He graduated from high school in 2000. He joined

the National

Guard in 2001. He deployed to Iraq on December 7, 2003 and served in

Iraq from

18 of 33 02/-08/04 until 02/02/05. He received the Combat Action Badge for

direct involve-

ment with the enemy on 04/19/04. He got an honorable discharge in

2009.

He got

married on 11/20/2010 and has two daughters and one son. He sleeps i n

a different

room because he has to have the TV on to sleep. He stays in a small

dark room

with the TV on.

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

and

post-military):

He worked for did father in high school painting and wallpaper. He was

a radio

operator for a medical unit in the service. He worked for Grant

Hospital for

5 years as a dispacher, Med Flight for 3 months, for his father-in-law

for a

year sandblasting, and back at Grant Hospital and is has been accused

of

creating a hostile work environment.

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

He was treataed with Zoloft in 1998-1999 for a period of 6 months

following the break-up

with a girlfriend. He reported depression with insomnia in May 2004.

In

October, 2004, he

reported suicidal thoughts. He reported a suicide attempt (Tylenol and

Alcohol) in 2006

following service and was hospitalized for 2-3 days at Mt. Carmel East

in Columbus, Ohio.

He went home for a day and was then hospitalized at Riverside

Methodist

Hospital in

Columbus, Ohio, for 3 days. He has been seen at the Dayton VAMC for

the

last year in

the PTSD program. He saw Dr. Moon who has him on Celexa-40mg daily,

Vistaril-10mg tid

as needed for anxiety and Ambien-10mg/qhs.

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

post-military):

No legal issues

Page 19 of 33

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

post-military):

He reported that he used to drink 6 beers at night in order to go to

sleep. No DUI's. He now

drinks socially and his last drink was 2 days ago (2 beers) at a

Veteran's Day party.

f. Sentinel Event(s) (other than stressors):

No response provided.

g. Other, if any:

No response provided.

3. Stressors

------------

a. Stressor #1: On 04/19/2004, I was assigned to Charlie Company, 118 Area

Support Medical BAttalion, and came into direct

involvement with the

emeny

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

b. Stressor #2: On 11/13/2004, I was assigned to the Company and we got

mortared and Sgt. Catelina Dima was killed

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

4. PTSD Diagnostic Criteria

---------------------------

a. Please check criteria used for establishing the current PTSD diagnosis.

The diagnostic criteria for PTSD, referred to as Criteria A-F, are from

the Diagnostic and Statistical Manual of Mental Disorders, 4th edition

(DSM-IV).

Criterion A: The Veteran has been exposed to a traumatic event where both

of the following were present:

Page 20 of 33 [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

[X] Physiological reactivity on 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

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

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

[X] Exaggerated startle response

Criterion E:

[X] The duration of 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

[X] Stressor #2

5. Symptoms

Page 21 of 33 -----------

For VA rating purposes, check all symptoms that apply to the Veterans

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent

events

[X] Impairment of short- and long-term memory, for example, retention of

only highly learned material, while forgetting to complete tasks

[X] Flattened affect

6. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

[X] Yes [ ] No

If yes, describe:

Decreased appetite, energy level, interest in sex, concentration,

he snaps at

his wife and kids. He reported his depression as an 8-9 on a 0-10

scale where

0 is no depression and 10 is suicidal.

7. Competency

-------------

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

[X] Yes [ ] No

8. Remarks, if any

------------------

The Veteran meets DSM-IV-TR and DSM-5 criteria for PTSD related to his

in-service experiences.

His Major Depressive Disorder is related to his PTSD and depressive

symptoms in service were

early manifestations of the current disorder.

[Berta]

With the CAB , OEF service, and this VA diagnosis of PTSD you should certainly expect a SC award,in my opinion.

The Veteran meets DSM-IV-TR and DSM-5 criteria for PTSD related to his

" His Major Depressive Disorder is related to his PTSD and depressive

symptoms in service were

early manifestations of the current disorder."

How soon after your discharge did you file this claim?

Reason I ask might not apply to you here......... but it pays to mention from time to time.......

Awards on claims filed within one year after discharge, use the day after the discharge as the EED (earliest effective date) for the retro.

[lucaswlandon]

what is SC award? no i was discharged in 2007 with 2 years of irr. so 2009 completely out. thanks for the reply

[stillhere]

SC= service connection

Stillhere

[john999]

It sounds like a 30% rating to me since doctor describes your ptsd as mild. Once you get the SC for PTSD you can hire IME/IMO doctor to show your ptsd is not based on mild symptoms.

[lucaswlandon]

i just found out that i have a 50% rating in the pending desicion approval stage.

[Navy04]

Great news bud