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Ptsd Exam Results 20140818


ctbenja1015

Question

Newbie looking for general Idea of compensation: I was thinking 30%, but not sure how the secondary illness' affect it.

VA Notes

Source: VA

Last Updated: 22 Aug 2014 @ 0346

Sorted By: Date/Time (Descending)

VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed

and signed by all required members of your VA health care team. If you have any questions about your

information please visit the FAQs or contact your VA health care team.

Date/Time: 18 Aug 2014 @ 1200

Note Title: C&P MENTAL HEALTH 16257

Location: PALO ALTO HEALTH CARE SYSTEM - PALO ALTO DIVSION

Signed By:

Co-signed By:

Date/Time Signed: 19 Aug 2014 @ 1639

Note

LOCAL TITLE: C&P MENTAL HEALTH 16257

STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT

DATE OF NOTE: AUG 18, 2014@12:00 ENTRY DATE: AUG 19, 2014@16:39:32

AUTHOR:

EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

Name of patient/Veteran

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD

ICD code: 309.81

Comments, if any:

The veteran's depression and anxiety are considered to be, at least as likely as not, secondary to his PTSD. Mental Disorder Diagnosis #2: Unspecified Depressive Disorder

ICD code: 311

Comments, if any:

Ongoing anxiety for ~ 5 years - anxiety started during

pre-mobilization- served in Iraq -2009-2010. Depression began in

2010.

Mental Disorder Diagnosis #3: Alcohol Use Disorder

ICD code: 303.90

Comments, if any:

Sober for 3 years. At peak drank a 6 pack + 8-10 shots several

times a week. His alcohol abuse was, at least as likely as not,

exacerbated by his PTSD. He states he normally only drank a few

drinks with friends before service.

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): See below

ICD code: See below

Comments, if any: "----------------------------- PLL - All

Problems

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

13 Problems

ST PROBLEM LAST MOD

PROVIDER

A Generalized Anxiety Disorder (ICD/DSM 300.02)

A Depressive Disorder NEC (ICD-9-CM 311.)

SA Alcohol abuse, in remission (ICD-9-CM 305.03

A Unspecified Sleep Disturbance (ICD-9-CM 780.50)

A Posttraumatic Stress Disorder (ICD/DSM 309.81)

A Other and unspecified hyperlipidemia (ICD-9-CM 04/18/2014272.4)

A Erectile dysfunction associated with type 2 diabetes mellitus (SCT 428007007) (ICD-9-CM250.80/607.84)

A Esophageal Reflux (ICD-9-CM 530.81)

A Cervicalgia (ICD-9-CM 723.1) 04/18/2014

A Lumbago (ICD-9-CM 724.2) 04/18/2014

A Tobacco Use Disorder (ICD-9-CM 305.1) 04/18/2014

A Plantar fascial fibromatosis (ICD-9-CM 728.71) 04/18/2014

A Unspecified Sleep Apnea (ICD-9-CM 780.57) 04/18/2014

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 and discuss

whether there is any clinical association between these diagnoses:

Overlapping symptoms and interaction of symptoms prevent

attribution of symptoms to one specific diagnosis. That stated, it

is, at least as likely as not, his depression is secondary to his

PTSD, and his alcohol use was exacerbated by his PTSD.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records reviewed

Comments, if any:

Denies hx of LOC or coma

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 [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:

Overlapping symptoms and interaction of symptoms prevent

attribution of symptoms to one specific diagnosis. That stated, it

is, at least as likely as not, his depression is secondary to his

PTSD, and his alcohol use was exacerbated by his PTSD.

The veteran is currently employed on a full-time basis as a

maintenance mechanic for the range at Fort Hunter-Liggett.

He is not currently in school.

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 (hard copy paper C-file) reviewed?

[ ] Yes [X] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

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

[X] Other:

VBMS (electronic C-file) was reviewed. Records available in CPRS

were reviewed. The veteran and his wife provided history and

clinical information.

b. Was pertinent information from collateral sources reviewed?

[X] Yes [ ] No

If yes, describe:

The veteran was interviewed with his wife.

2. History

----------

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

post-military):

The veteran was born in Penn and grew up in Penn, Albuquerque NM, then

Georgia. He was reared in somewhat chaotic circumstances - parents

divorced when vet was 4 yo - grew up with his stepfather; financial

constraints - 7 children; father was an alcoholic. The veteran had 6

biological siblings + 1 stepbrother. He reports he went through the

12th grade, graduating HS with C academic marks. No college before

service.

The veteran states he had friends. He denies behavioral problems/

arrests. He endorses alcohol abuse occasionally and later drug abuse -

MJ, methamphetamine (30 - 31 yo- episodic). The veteran denies a

history of emotional, physical, and sexual abuse.

The veteran has been married 3 times, to his third wife for ~ 2

years, and has 3 biological + 3 stepchildren - "all grown and out

of

the house". He states he is close to his 3rd wife. The veteran

remarks he occasionally talked with his first wife in rearing the

children. Could not be friends with his second wife. First wife became

a drug addict and left him for a 19 yo. Second wife wanted a divorce

due to his being gone so long, and she had to undergo surgery without

him. The veteran has contact with his children and describes himself

as close to them. He describes close relationships with his siblings

when they are together.

Currently he rents a house on Post where he resides with his wife and

dogs.

The veteran notes that he has friends.

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

and

post-military):

Military History: Enlisted into the Army Reserves at 37 years old. Had

planned to go into service after HS but was in a MVA and ended up

working at a papermill. He was trained as a truck driver, serving in

Iraq as a truck driver between 2009-2010. The veteran did drink

during

service - to excess when he came back. He has served for ~ 8 years to

date from 2006 to Present - currently ETS is an instructor for truck

drivers. He was given an Honorable discharge from Active Duty. The

veteran was exposed to combat. Denies a history of MST.

Education: The veteran notes he did go back for job specific

education

after service attaining no degrees with good academic marks. He did

not obtain any degrees in-service to date.

Occupation: The veteran is currently employed on a full-time basis for

the Department of the Army as a maintenance mechanic for the ranges,

last working Friday. He describes his work performance as fair, his

attendance record as excellent with no missed time from work in the

last 1 year due to mental health problems other than appointments, and

his ability to get along with his supervisors as well and his

coworkers

as "95% of the time well". The veteran is still in service as

a TPU

soldier - actively drilling and doing his Reserve status. He admits to

being fired from Wal-Mart Distribution Center in 2012 due to workplace

violence - "threw a shop rag" after being employed there for 5 years.

He mentions he has held ~ 2 jobs since service. The veteran is not on

State Disability or Social Security Disability. He transferred from

another Army job due to inability to get along with his superiors.

Activities: "Watch TV".

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

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

The veteran reports a history of family mental health problems

including father was an alcoholic.

The veteran denies pre-military mental health problems. To reiterate,

he does have a history of +/-childhood trauma to which he does not

endorse clinical symptoms -Stepbrother was killed in a MVA - "not

that

close - lived States apart". Stepbrother was killed in a MVA in NJ

-

vet was in Georgia at the time. He denies developmental problems or

learning disabilities.

The veteran states he was treated in-service for mental health or

substance abuse issues - after 2nd wife said she wanted a divorce, vet

went into a depression - OP MHC x 3 months in-service and has been

"treated ever since".

He reports his first mental health treatment was in-service in 2010 at

the Combat Stress Center in Speicher, Tikrit for depression.

Pre-Deployment Health Assessment dated 08/08/2009 (page 15) does

indicate the veteran had sought care or counseling in the year prior

to

deployment. The veteran endorses 1 previous psychiatric

hospitalizations 11/2010 - Iowa City VAH for anxiety, depression, and

PTSD like symptoms. He endorses 1 previous substance abuse program -

Rock Island, Illinois at the VA - Intensive OP Treatment - for

alcohol.

The veteran has been in previous outpatient mental health or

substance abuse treatment. The veteran is currently in outpatient

treatment with the Monterey CBOC

(WITTLIN,BYRON J: CHAPMAN-GOREY,STACI). Previous diagnoses have

included: See above. The veteran is taking psychotropic medication

currently: Paxil, Welbutrin. He does report a history of previous

psychotropic medications. STR's of 7/10/2014 indicate a history

of

"PTSD, Anxiety and depression" and treatment with Welbutrin

and Paxil.

The veteran reports he has not made any previous suicide attempts or

acts of self mutilation. He comments he "did have a self destructive

nature when got back - drinking and driving". The veteran denies a

history of physical violence. Last fight: "Why left otherjob" -

04/2014 - verbal altercation with a supervisor. Last physical fight -

HS. Denies domestic violence - "swings" in his sleep, per

wife. Denies history of anger management classes.

Current MSE is negative for expressed psychotic symptoms or acute

suicidal or homicidal ideation. Last CRRS Mental Health Progress Note: JUL 28, 2014.

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

Endorses history of pre-military behavioral or legal problems- DUI -

in 2000 on Superbowl Sunday.

Denies history of military behavioral or legal problems.

Endorses history of post-military behavioral or legal problems -

04/2011 - DUI and reckless driving.

Denies history of being on parole or probation.

Denies current legal problems.

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

Endorses history of pre-military substance abuse.

Endorses history of military substance abuse - did not drink on Active

Duty.

Endorses history of post-military substance abuse.

Any previous substance abuse-related legal charges: Yes.

Last drink: 04/30/2011.

Last drug use: 2003- Methamphetamines.

f. Other, if any:

No response provided.

3. Stressors

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

Describe one or more specific stressor event(s) the Veteran considers

traumatic (may be pre-military, military, or post-military):

a. Stressor #1: Shot at, rockets on the base , mortared, 4 convoys hit by

IED's- only once was his company's truck involved - minor

damage

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

Is the stressor related to personal assault, e.g. military sexual trauma?

[ ] Yes [X] No

4. PTSD Diagnostic Criteria

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

Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria

for PTSD, referred to as Criteria A-H, are from the Diagnostic and

Statistical Manual of Mental Disorders, 5th edition (DSM-5).

Criterion A: Exposure to actual or threatened a) death, b) serious

injury,

c) sexual violation, in one or more of the following ways:

[X] Directly experiencing the traumatic 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] Dissociative reactions (e.g., flashbacks) in which the individual

feels or acts as if the traumatic event(s) were recurring. (Such

reactions may occur on a continuum, with the most extreme

expression being a complete loss of awareness of present

surroundings).

[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) thatarouse

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] Persistent and exaggerated negative beliefs or expectations about

oneself, others, or the world (e.g., "I am bad,: "No one can be

trusted,: "The world is completely dangerous,: "My whole nervous

system is permanently ruined").

[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] Feelings of detachment or estrangement from others.

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] Hypervigilance.

[X] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or staying asleep or

restless sleep).

Criterion F:

[X] Duration of the disturbance (Criteria B, C, D, and E) is more than

1 month.

Criterion G:

[X] The disturbance causes 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.

Criterion I: Which stressor(s) contributed to the Veteran's PTSD

diagnosis?:

[X] Stressor #1

5. Symptoms

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Go to 38 CFR part 4 and check out the subsection showing the requirements for the disability ratings for "mental disorders."

Compare the comments and responses in your C & P exam against the requirements in 38 CFR part 4 and you will be able to get an idea as to the rating you deserve. If you do not receive the rating you believe you deserve based on the comparison then you should appeal. Hopefully you will get the correct rating.

Good luck to you.

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Just my opinion but I believe you will get the service connection.

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