Went for a second c&p exam last week and I'm afraid it doesn't look good for me. Currently I'm 50% for PTSD and 10% for tinnitus. My first exam was back in '08 when I originally filed so I guess this exam was just a follow up. I'm an OIF 1 veteran if that makes a difference. Below are my exam notes.
Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
SECTION I:
1. Diagnostic Summary
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No
ICD Code: 309.81
2. Current Diagnoses
a. Mental Disorder Diagnosis #1: PTSD
ICD Code: 309.81
Comments, if any: Based on DSM-5. VBMS and CPRS records reviewed.
Based on today's review examination, the veteran continues to meet DSM
diagnsotic criteria for PTSD. The veteran has reported a worsening of
PTSD symptoms since his 2008 Initial examination, with additional
stressors (highlighted in other sections of this examinaiton report).
Veteran is currently prescribed psychotropic medications by his former
VA-primary care provider, Dr. Shissler, who has since retired-veteran
receives medications by mail. Veteran is not currently seen by VA
mental health providers.
Mental Disorder Diagnosis #2: Alcohol Intoxication
ICD Code: 303.00
Comments, if any: Based on DSM-5. VBMS and CPRS records reviewed.
Based on today's examination, the veteran currently meets DSM-5
diagnostic criteria for Alcohol Intoxication. The veteran's current
substance-related and addictive disorders diagnosis is based on
veteran's report of consuming 5-16oz bottles of beer less than 24hrs
prior to this examination. In addition, veteran reported history of
alcohol addiction and treatment through the VA-Baton Rouge South SATP
with Dr. Reidwald.
Veteran's current Alcohol Intoxication/Alcohol Dependence diagnosis is
at least as likely as not (50/50chance) due to, or result of his PTSD
diagnosis.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Dyslipidemia, deviated nasal
septum, chronic maxillary sinusis, tinnitus, bilateral sensori hearing
loss, hypertension,
Comments, if any: Medical diagnoses taken from CPRS records.
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?
[X] Yes[ ] No[ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis:
Alcohol Intoxication-
Recent ingestion of alcohol
-Clinically significant/problematic behavioral/psychological changes
associated with recent consumption of alcohol
-One or more of the following sx onset with consumptions of/shortly
after consumptions of alcohol: slurred speech, incoordination,
unsteady gait, nystagmus, impaired attention/memory, stupor/coma
-Sx are not attributable to another medical condition nor explained by
another mental disorder
PTSD
-recurrent and intrusive memories and thoughts of the event
-recurrent and disturbing dreams of the event
-psychological reactivity
-efforts to avoid conversations, thoughts, feelings, related to
trauma
-loss of interest or participation in activities
-feelings of detachment or estrangement from others
-emotional numbing
-difficulty falling asleep/staying asleep
-irritability/anger
-difficulty concentrating
-hypervigilence
-exaggerated startle response
-suicidal ideation
-memory problems
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
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: Due to overlap of affective and
behavioral symptoms.
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
In order to provide an accurate medical opinion, the Veteran's claims folder
must be reviewed.
a. Medical record review:
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes[ ] No
Was the Veteran's VA claims file reviewed?
[X] Yes[ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
CPRS records reviewed.
Attention was givent to the Veteran's Initial PTSD examination report,
with Dr. Kodur, 8/18/08. Based on his Initial PTSD examination, the
veteran met criteria for PTSD, and obtained a GAF score of 49, which
suggested serious impairment in the veteran's social and occupational
functioning at the time.
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes[X] No
If yes, describe:
2. Recent History (since prior exam)
a. Relevant Social/Marital/Family history:
Veteran reported since his 2008 Initial examination, hw ans his Wife
have had two children (ages 5, 2) and their 8yr old dog has died
(December 2013). Veteran reported his Wife now works full-time, having
weekend and night shift as a Nurse, and veteran provides most of the
care and parenting for their children. Veteran reported he enjoys this
responsibility, however at times this is stressful.
Veteran reported his marriage is currently strained, due to his return
to excessive drinking. Veteran reported he has attempted to "quit"
several times, and has been successful for short periods of time.
Veteran reported when drinking alcohol, he at times becomes argumentive
with his Wife, and angry. Veteran reported at times, including within
the past 24hrs prior to this appointment, he consumes 5-16oz containers
of beer in one sitting, and this irritates his Wife. Veteran reported
this is typically how arguments begin. Veteran reported his Wife has
stopped communicating with him and gives him the silent treatment when
he drinks now. Veteran reported this usually leads to him becoming
angrier. Veteran reported last night, his Wife refused to talk to him.
Veteran reported they have sought marital counseling in the past, and
the counselor challenged him to not drink for 30 days, which he did.
Veteran reported he does not feel his drinking is excessive or
problematic, although he has been labeled a "functional alcoholic."
Veteran expressed concerns for losing his family due to his excessive
drinking at this time. Veteran reported alcohol helps him to cope with
sx of PTSD including nightmares and unwanted thoughts, and stated these
are issues his Wife does not understand.
Veteran reported feeling supported by his family/parents, and they too
have encouraged him to seek treatment for his excessive drinking, and
to resume marital counseling.
b. Relevant Occupational and Educational history:
Veteran reported he continues to work as and Industrial Contractor
along with his father and brother. Vetran reported doing this work
since 2007, and denied having problems on the job. Vetran reported when
he is stressed on the job, or experiences panic attacks, his family
members are "understanding" and they allow him time to relax in his
office. Veteran described having a panic attack some years ago on the
job, in which his father drove him to the emergency room. Veteran
reported feeling as though he were having a heart attack, and later
after tests, he was told he suffered a panic attack.
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
Veteran reported he is not currently receiving mental health services.
Veteran reported he is prescribed psychotropic medication, Citalopram,
which was origianlly prescribed by his former VA primary care provider,
Dr. Shissler. Veteran denied being referred to mental health, and
stated his medications continue to come to him via mail. Veteran
reported he feels the medication helps him to not feel depressed,
however, the medication does not prevent panic attacks, nor does it
help him to sleep. Veteran reported he was previously seen at the
VA-Baton Rouge South clinic in the SATP program by Dr. Reinwald in
2012. Veteran reported he completed the program, although he did not
feel he had problems with alcohol at that time. Veteran denied history
of inpatient hospitalization since his last examination.
Veteran endorsed current sx to include increased tearfulness,
sad/depressed mood, chronic sleep impairment, restlessness, increased
nervousness, difficulty managing stress, increased memory problems,
distractibility, increased panic attacks, difficulty in crowds and
amongst people unknown to him, racing heart/pounding heartbeat, and
increased use of alcohol and nicotine. Vetran denied thoughts of
harming himself or others, however, reported at times he has become
verbally aggressive when stressed or after drinking. Veteran reported
increased nightmares, and described a mixture of real events along with
events that had not occured in his nightmares. Veteran reported current
fear of "being sent back to Iraq," at times.
CPRS records indicate veteran was last seen at the VA Baton Rouge South
Clinic in the SATP program in February 2012. Records indicate veteran
was last seen in psychiatry by Ms. Joseph in March 2012 for medication
management. Veteran has a diagnostic history to include Alcohol
Dependence, PTSD, and Panic Disorder, NOS.
d. Relevant Legal and Behavioral history:
Veteran denied
e. Relevant Substance abuse history:
Veteran reported he was previously seen at the VA-Baton Rouge South
clinic in the SATP program by Dr. Reinwald in 2012. Veteran reported he
completed the program, although he did not feel he had problems with
alcohol at that time. Veteran reported his marriage is currently
strained, due to his return to excessive drinking. Veteran reported he
has attempted to "quit" several times, and has been successful for
short periods of time. Veteran reported when drinking alcohol, he at
times becomes argumentive with his Wife, and angry. Veteran reported at
times, including within the past 24hrs prior to this appointment, he
consumes 5-16oz containers of beer in one sitting, and this irritates
his Wife. Veteran reported this is typically how arguments begin.
Veteran reported his Wife has stopped communicating with him and gives
him the silent treatment when he drinks now. Veteran reported this
usually leads to him becoming angrier. Veteran reported last night, his
Wife refused to talk to him. Veteran reported they have sought marital
counseling in the past, and the counselor challenged him to not drink
for 30 days, which he did. Veteran reported he does not feel his
drinking is excessive or problematic, although he has been labeled a
"functional alcoholic." Veteran expressed concerns for losing his
family due to his excessive drinking at this time.
Veteran has history of Alcohol Dependence diagnosis. Veteran was last
seen in the SATP program 2/6/12.
f. Other, if any:
No response provided.
3. PTSD Diagnostic Criteria
Please check criteria used for establishing the current PTSD diagnosis. The
diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
combat, personal trauma, other life threatening situations (non-combat
related stressors.) Do NOT mark symptoms below that are clearly not
attributable to the criteria A stressor/PTSD. Instead, overlapping symptoms
clearly attributable to other things should be noted under #5 - "Other
symptoms".
Criterion A: Exposure to actual or threatened a) death, b) serious injury,
c) sexual violation, in on or more of the following ways:
[X] Directly experiencing the tramuatic event(s)
Criterion B: Presence of (one or more) of the following intrusion
symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing memories
of the traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s).
[X] Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
[X] Marked physiological reactions to internal or external
cues that symbolize or resemble an aspect of the traumatic
event(s).
Criterion C: Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic events(s) occurred,
as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts, or
feelings about or closely associated with the traumatic
event(s).
Criterion D: Negative alterations in cognitions and mood associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following:
[X] Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to
other factors such as head injury, alcohol, or drugs).
[X] Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead to the
individual to blame himself/herself or others.
[X] Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Markedly diminished interest or participation in
significant activities.
[X] Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction, or
loving feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
[X] Reckless or self-destructive behavior.
[X] Hypervigilance.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
Criterion F:
[X] The duration of the symptoms described above in Criteria
B, C, and D are more than 1 month.
Criterion G:
[X] The PTSD symptoms described above cause clinically
significant distress or impairment in social,
occupational, or other important areas of functioning.
Criterion H:
[X] The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or
another medical condition.
4. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Impaired judgment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or a
worklike setting
[X] Impaired impulse control, such as unprovoked irritability with periods
of violence
5. Behavioral Observations:
MSE:
Veteran presented as a neatly and casually dressed 33yr old male with good
hygiene and flat affect. Veteran stared at the Examiner, and noted to sit
on the edge of the seat in the examination room. Veteran reported
consuming 5-16-oz beers last night, and stated this led to problems and
silent treatment at home. Vetran then became tearful, and reported fear of
losing his family, due to difficulties related to alcohol dependence.
Veteran reported consuming alcohol at this time on a daily basis. Veteran
reported being able to participate in today's examination, however, and
denied problems with comprehension of questions/interview at this time.
Veteran denied thoughts of harming himself or others at this time.
6. Other symptoms
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes[X] N
7. Competency
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
8. Remarks, (including any testing results) if any:
Based on DSM-5. VBMS and CPRS records reviewed.
Based on today's review examination, the veteran continues to meet DSM
diagnostic criteria for PTSD. The veteran has reported a worsening of PTSD
symptoms since his 2008 Initial examination, with additional stressors
(highlighted in other sections of this examination report).
Based on today's examination, the veteran also currently meets DSM-5
diagnostic criteria for Alcohol Intoxication. The veteran's current
substance-related and addictive disorders diagnosis is based on veteran's
report of consuming 5-16oz bottles of beer less than 24hrs prior to this
examination. In addition, veteran reported history of alcohol addiction
and treatment through the VA-Baton Rouge South SATP with Dr. Reidwald.
Veteran's current Alcohol Intoxication/Alcohol Dependence diagnosis is at
least as likely as not (50/50chance) due to, or result of his PTSD
diagnosis.
Veteran is currently prescribed psychotropic medications by his former
VA-primary care provider, Dr. Shissler, who has since retired-veteran
receives medications by mail. Veteran was seen by NP Ms. Joseph, for
medication management (3/2012), however no other appointments with MH
since that time. Veteran is not currently seen by VA mental health
providers.
Sorry if that makes peoples head hurt. It just seems like the examiner wrote more about my drinking problem than a review of my symptoms.
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
This is what worries me, in my initial exam it was stated as severe, not mild.
Im really worried about my rating being dropped, can someone help me decipher all this?
If you need more info. from me about anything just let me know.
Question
arty1
Went for a second c&p exam last week and I'm afraid it doesn't look good for me. Currently I'm 50% for PTSD and 10% for tinnitus. My first exam was back in '08 when I originally filed so I guess this exam was just a follow up. I'm an OIF 1 veteran if that makes a difference. Below are my exam notes.
Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
SECTION I:
1. Diagnostic Summary
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No
ICD Code: 309.81
2. Current Diagnoses
a. Mental Disorder Diagnosis #1: PTSD
ICD Code: 309.81
Comments, if any: Based on DSM-5. VBMS and CPRS records reviewed.
Based on today's review examination, the veteran continues to meet DSM
diagnsotic criteria for PTSD. The veteran has reported a worsening of
PTSD symptoms since his 2008 Initial examination, with additional
stressors (highlighted in other sections of this examinaiton report).
Veteran is currently prescribed psychotropic medications by his former
VA-primary care provider, Dr. Shissler, who has since retired-veteran
receives medications by mail. Veteran is not currently seen by VA
mental health providers.
Mental Disorder Diagnosis #2: Alcohol Intoxication
ICD Code: 303.00
Comments, if any: Based on DSM-5. VBMS and CPRS records reviewed.
Based on today's examination, the veteran currently meets DSM-5
diagnostic criteria for Alcohol Intoxication. The veteran's current
substance-related and addictive disorders diagnosis is based on
veteran's report of consuming 5-16oz bottles of beer less than 24hrs
prior to this examination. In addition, veteran reported history of
alcohol addiction and treatment through the VA-Baton Rouge South SATP
with Dr. Reidwald.
Veteran's current Alcohol Intoxication/Alcohol Dependence diagnosis is
at least as likely as not (50/50chance) due to, or result of his PTSD
diagnosis.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Dyslipidemia, deviated nasal
septum, chronic maxillary sinusis, tinnitus, bilateral sensori hearing
loss, hypertension,
Comments, if any: Medical diagnoses taken from CPRS records.
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?
[X] Yes[ ] No[ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis:
Alcohol Intoxication-
Recent ingestion of alcohol
-Clinically significant/problematic behavioral/psychological changes
associated with recent consumption of alcohol
-One or more of the following sx onset with consumptions of/shortly
after consumptions of alcohol: slurred speech, incoordination,
unsteady gait, nystagmus, impaired attention/memory, stupor/coma
-Sx are not attributable to another medical condition nor explained by
another mental disorder
PTSD
-recurrent and intrusive memories and thoughts of the event
-recurrent and disturbing dreams of the event
-psychological reactivity
-efforts to avoid conversations, thoughts, feelings, related to
trauma
-loss of interest or participation in activities
-feelings of detachment or estrangement from others
-emotional numbing
-difficulty falling asleep/staying asleep
-irritability/anger
-difficulty concentrating
-hypervigilence
-exaggerated startle response
-suicidal ideation
-memory problems
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
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: Due to overlap of affective and
behavioral symptoms.
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
In order to provide an accurate medical opinion, the Veteran's claims folder
must be reviewed.
a. Medical record review:
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes[ ] No
Was the Veteran's VA claims file reviewed?
[X] Yes[ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
CPRS records reviewed.
Attention was givent to the Veteran's Initial PTSD examination report,
with Dr. Kodur, 8/18/08. Based on his Initial PTSD examination, the
veteran met criteria for PTSD, and obtained a GAF score of 49, which
suggested serious impairment in the veteran's social and occupational
functioning at the time.
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes[X] No
If yes, describe:
2. Recent History (since prior exam)
a. Relevant Social/Marital/Family history:
Veteran reported since his 2008 Initial examination, hw ans his Wife
have had two children (ages 5, 2) and their 8yr old dog has died
(December 2013). Veteran reported his Wife now works full-time, having
weekend and night shift as a Nurse, and veteran provides most of the
care and parenting for their children. Veteran reported he enjoys this
responsibility, however at times this is stressful.
Veteran reported his marriage is currently strained, due to his return
to excessive drinking. Veteran reported he has attempted to "quit"
several times, and has been successful for short periods of time.
Veteran reported when drinking alcohol, he at times becomes argumentive
with his Wife, and angry. Veteran reported at times, including within
the past 24hrs prior to this appointment, he consumes 5-16oz containers
of beer in one sitting, and this irritates his Wife. Veteran reported
this is typically how arguments begin. Veteran reported his Wife has
stopped communicating with him and gives him the silent treatment when
he drinks now. Veteran reported this usually leads to him becoming
angrier. Veteran reported last night, his Wife refused to talk to him.
Veteran reported they have sought marital counseling in the past, and
the counselor challenged him to not drink for 30 days, which he did.
Veteran reported he does not feel his drinking is excessive or
problematic, although he has been labeled a "functional alcoholic."
Veteran expressed concerns for losing his family due to his excessive
drinking at this time. Veteran reported alcohol helps him to cope with
sx of PTSD including nightmares and unwanted thoughts, and stated these
are issues his Wife does not understand.
Veteran reported feeling supported by his family/parents, and they too
have encouraged him to seek treatment for his excessive drinking, and
to resume marital counseling.
b. Relevant Occupational and Educational history:
Veteran reported he continues to work as and Industrial Contractor
along with his father and brother. Vetran reported doing this work
since 2007, and denied having problems on the job. Vetran reported when
he is stressed on the job, or experiences panic attacks, his family
members are "understanding" and they allow him time to relax in his
office. Veteran described having a panic attack some years ago on the
job, in which his father drove him to the emergency room. Veteran
reported feeling as though he were having a heart attack, and later
after tests, he was told he suffered a panic attack.
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
Veteran reported he is not currently receiving mental health services.
Veteran reported he is prescribed psychotropic medication, Citalopram,
which was origianlly prescribed by his former VA primary care provider,
Dr. Shissler. Veteran denied being referred to mental health, and
stated his medications continue to come to him via mail. Veteran
reported he feels the medication helps him to not feel depressed,
however, the medication does not prevent panic attacks, nor does it
help him to sleep. Veteran reported he was previously seen at the
VA-Baton Rouge South clinic in the SATP program by Dr. Reinwald in
2012. Veteran reported he completed the program, although he did not
feel he had problems with alcohol at that time. Veteran denied history
of inpatient hospitalization since his last examination.
Veteran endorsed current sx to include increased tearfulness,
sad/depressed mood, chronic sleep impairment, restlessness, increased
nervousness, difficulty managing stress, increased memory problems,
distractibility, increased panic attacks, difficulty in crowds and
amongst people unknown to him, racing heart/pounding heartbeat, and
increased use of alcohol and nicotine. Vetran denied thoughts of
harming himself or others, however, reported at times he has become
verbally aggressive when stressed or after drinking. Veteran reported
increased nightmares, and described a mixture of real events along with
events that had not occured in his nightmares. Veteran reported current
fear of "being sent back to Iraq," at times.
CPRS records indicate veteran was last seen at the VA Baton Rouge South
Clinic in the SATP program in February 2012. Records indicate veteran
was last seen in psychiatry by Ms. Joseph in March 2012 for medication
management. Veteran has a diagnostic history to include Alcohol
Dependence, PTSD, and Panic Disorder, NOS.
d. Relevant Legal and Behavioral history:
Veteran denied
e. Relevant Substance abuse history:
Veteran reported he was previously seen at the VA-Baton Rouge South
clinic in the SATP program by Dr. Reinwald in 2012. Veteran reported he
completed the program, although he did not feel he had problems with
alcohol at that time. Veteran reported his marriage is currently
strained, due to his return to excessive drinking. Veteran reported he
has attempted to "quit" several times, and has been successful for
short periods of time. Veteran reported when drinking alcohol, he at
times becomes argumentive with his Wife, and angry. Veteran reported at
times, including within the past 24hrs prior to this appointment, he
consumes 5-16oz containers of beer in one sitting, and this irritates
his Wife. Veteran reported this is typically how arguments begin.
Veteran reported his Wife has stopped communicating with him and gives
him the silent treatment when he drinks now. Veteran reported this
usually leads to him becoming angrier. Veteran reported last night, his
Wife refused to talk to him. Veteran reported they have sought marital
counseling in the past, and the counselor challenged him to not drink
for 30 days, which he did. Veteran reported he does not feel his
drinking is excessive or problematic, although he has been labeled a
"functional alcoholic." Veteran expressed concerns for losing his
family due to his excessive drinking at this time.
Veteran has history of Alcohol Dependence diagnosis. Veteran was last
seen in the SATP program 2/6/12.
f. Other, if any:
No response provided.
3. PTSD Diagnostic Criteria
Please check criteria used for establishing the current PTSD diagnosis. The
diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
combat, personal trauma, other life threatening situations (non-combat
related stressors.) Do NOT mark symptoms below that are clearly not
attributable to the criteria A stressor/PTSD. Instead, overlapping symptoms
clearly attributable to other things should be noted under #5 - "Other
symptoms".
Criterion A: Exposure to actual or threatened a) death, b) serious injury,
c) sexual violation, in on or more of the following ways:
[X] Directly experiencing the tramuatic event(s)
Criterion B: Presence of (one or more) of the following intrusion
symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing memories
of the traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s).
[X] Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
[X] Marked physiological reactions to internal or external
cues that symbolize or resemble an aspect of the traumatic
event(s).
Criterion C: Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic events(s) occurred,
as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts, or
feelings about or closely associated with the traumatic
event(s).
Criterion D: Negative alterations in cognitions and mood associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following:
[X] Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to
other factors such as head injury, alcohol, or drugs).
[X] Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead to the
individual to blame himself/herself or others.
[X] Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Markedly diminished interest or participation in
significant activities.
[X] Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction, or
loving feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
[X] Reckless or self-destructive behavior.
[X] Hypervigilance.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
Criterion F:
[X] The duration of the symptoms described above in Criteria
B, C, and D are more than 1 month.
Criterion G:
[X] The PTSD symptoms described above cause clinically
significant distress or impairment in social,
occupational, or other important areas of functioning.
Criterion H:
[X] The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or
another medical condition.
4. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Impaired judgment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or a
worklike setting
[X] Impaired impulse control, such as unprovoked irritability with periods
of violence
5. Behavioral Observations:
MSE:
Veteran presented as a neatly and casually dressed 33yr old male with good
hygiene and flat affect. Veteran stared at the Examiner, and noted to sit
on the edge of the seat in the examination room. Veteran reported
consuming 5-16-oz beers last night, and stated this led to problems and
silent treatment at home. Vetran then became tearful, and reported fear of
losing his family, due to difficulties related to alcohol dependence.
Veteran reported consuming alcohol at this time on a daily basis. Veteran
reported being able to participate in today's examination, however, and
denied problems with comprehension of questions/interview at this time.
Veteran denied thoughts of harming himself or others at this time.
6. Other symptoms
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes[X] N
7. Competency
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
8. Remarks, (including any testing results) if any:
Based on DSM-5. VBMS and CPRS records reviewed.
Based on today's review examination, the veteran continues to meet DSM
diagnostic criteria for PTSD. The veteran has reported a worsening of PTSD
symptoms since his 2008 Initial examination, with additional stressors
(highlighted in other sections of this examination report).
Based on today's examination, the veteran also currently meets DSM-5
diagnostic criteria for Alcohol Intoxication. The veteran's current
substance-related and addictive disorders diagnosis is based on veteran's
report of consuming 5-16oz bottles of beer less than 24hrs prior to this
examination. In addition, veteran reported history of alcohol addiction
and treatment through the VA-Baton Rouge South SATP with Dr. Reidwald.
Veteran's current Alcohol Intoxication/Alcohol Dependence diagnosis is at
least as likely as not (50/50chance) due to, or result of his PTSD
diagnosis.
Veteran is currently prescribed psychotropic medications by his former
VA-primary care provider, Dr. Shissler, who has since retired-veteran
receives medications by mail. Veteran was seen by NP Ms. Joseph, for
medication management (3/2012), however no other appointments with MH
since that time. Veteran is not currently seen by VA mental health
providers.
Sorry if that makes peoples head hurt. It just seems like the examiner wrote more about my drinking problem than a review of my symptoms.
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
This is what worries me, in my initial exam it was stated as severe, not mild.
Im really worried about my rating being dropped, can someone help me decipher all this?
If you need more info. from me about anything just let me know.
thanks
Link to comment
Share on other sites
Top Posters For This Question
10
3
2
1
Popular Days
Mar 23
6
Mar 24
5
Mar 22
4
Apr 23
3
Top Posters For This Question
arty1 10 posts
Navy04 3 posts
63SIERRA 2 posts
USMC_HVEQ 1 post
Popular Days
Mar 23 2014
6 posts
Mar 24 2014
5 posts
Mar 22 2014
4 posts
Apr 23 2014
3 posts
Popular Posts
arty1
Update I just spoke with my VSO after seeing a rating was made on ebenefits yesterday and she said my rating is staying the same!!! I had an unfavorable C&P exam and was worried about a reduc
21 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