ptsd Ptsd C & P Results, Your Thoughts?

[chuck57thSig]

Here are the results of my C&P exam,

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* internal VA or DoD Use Only *

Name of patient/Veteran: (my name)

SECTION I:

1. Diagnostic Summary

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

based on today's evaluation? Yes

lCD code: 309. 81

2. Current Diagnoses

a. Mental Disorder Diagnosis #1: PTSD

ICD code: 309.81

Comments, if any:

Veteran received diagnosis of PTSD from PTSD specialist, Dr. Von Linden, on Mar 2014 during a PTSD evaluative consult appt.

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

Mental Health Disorder (to include TBI): polyarthalgia, chronic pain,

chronic migraines

c. Does the Veteran have a diagnosed traumatic brain injury (TBI) ? Not shown in records reviewed

3. Differentiation of symptoms

Does the veteran have more than one mental disorder diagnosed? No

Comments, if any:

Please refer to neurology for further assessment

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 onlyone)

[X] Occupational and social impairment with deficiencies in most areas,

such as work, school, family relations, judgment, thinking and/or mood

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?

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 ? No diagnosis of TBI

SECTION II:

Clinical Findings:

Evidence review

In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed.

Medical record review:

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? Yes

Was the veteran’s VA claims file (hard copy paper c-fire) reviewed? Yes

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

Veteran's VA claims file:

VHA medical record (CPRS) and VA e-folder were reviewed. There was no physical C-File for this case, per VBA instructions.

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

If yes, describe:

Veteran requested his spouse attend the C&P examination for assistance

with remembering remote details.

History

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

post-military) :

(much personal information omitted)

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

post-military) :

Veteran obtained a high school- diploma and originally enlisted in the

Navy and was transferred to the Army from 1981 to 1985 (13 Echo) and

then 1986 to 1992 (31 victor). Deployed to Desert storm campaign, in

Iraq. Discharged as an E-4. Veteran reported that he worked multiple job in several areas prior

to his current position, Reported that he uses FMLA leave approximately 1 day per

week for anxiety and chronic pain issues. Stated that dealing with

argumentative, angry customers becomes emotionally overwhelming such

that he becomes nauseated and vomits at least weekly.

Temple VAMC Record 9/8/94 revealed initial sleep difficulty approx 2-3

times per week.

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

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

Veteran reported no mental health issues prior to the military. Stated

that after his Iraq deployment, he experienced significant

post-traumatic stress and meets criteria for PTSD in all symptom

clusters, re-experiencing (intrusive thoughts/memories, anxious dreams,

physio-psychological distress), avoidance of external reminders

(isolates self, avoids external reminders and places), persistent

negative mood states (angered at times, highly anxious), and marked

physiological arousal (hypervigilance, sleep difficulty, concentration

issues). Reported that in recent years, as his children left the home,

his symptoms have worsened.

Worst period to date was Dec 2013, when his son left for the Air Force.

stated that he felt he needed to seek mental health treatment as he

began having morbid and suicidal thoughts for fear of his son’s safety

and well-being. Veteran enrolled in VA PTSD clinic in March 2014 and

has begun working with a PTSD specialist. Veteran reported that he attempted to seek MH services in 1995 at the Temple VA but had a negative experience (i.e., overheard a doctor

discounting veterans' symptoms) and did not return for his intake appt

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

No legal/behavioral issues reported.

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

post-military) :

Veteran reported smoking cannabis during his military service to manage his chronic migraine headaches.

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):

Stressor #1: (stressor info omitted)

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

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

trauma? No

b. Stressor #2: (stressor info omitted)

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

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

trauma? 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)

[X] Witnessing, in person, the traumatic event(s) as they occurred to others

Criterion B: Presence of (one or more) of the followi-ng 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) j-n 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) 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] Persistent and exaggerated negative bel-iefs 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] Hypervigilance.

[X] Problems with concentration.

[X] Sleep disturbance (e.9., 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 Veterans PTSD

diagnosis?:

[X] Stressor #1

[X] Stressor #2

5. Symptoms contributed to the that actively apply to the names, directions or recent

For VA rating purposes, check all symptoms

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

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

[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] Suicidal- ideation

[X] Intermittent inability to perform activities of daily living,

including maintenance of minimal personal hygiene

6. Behavioral Observations

Veteran attended session with spouse and service dog. Veteran carried his 13

medications in a bag. Became significantly anxious when discussing traumatic

events and pulled the wastebasket near him as he became nauseous. Examiner

assisted Veteran to engage in relaxation breathing to reduce physiological

symptoms of tension, nausea, and increased shallow breathing.

7. Other symptoms

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

Mental disorders) that are not listed above?

No

8. Competency

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

9. Remarks, (including any testing results) if any:

Veteran reported increased anxiety and depressed mood when his son left

for the Air Force on 3-Dec-2013. Stated that he experienced suicidal

thoughts and felt concern over the thoughts, sought immediate treatment at

VA MH Clinic.

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran’s

application.

/es/ , PHD

Veterans Justice Outreach Coordinator

Signed: 09/22/2014 08:09

/Es/

PhD

Cosigned: 09/22/2014 08 :23

LOCAL TITLE: PSYCHOLOGY NOTE

STANDARD TITLE: PSYCHOLOGY NOTE

DATE OF NOTE: AUG 27, 201,4@09:35 ENTRY DATE: AUG 2'7, 2014@09:35:06

AUTHOR: EXP COSIGNER:

URGENCY: STATUS: COMPLETED

C&P Examination for PTSD (Initial) completed 8/27/2014 and under review by Clinical Supervisor.

This note serves to close encounter. Please refer to C&P Examination note for

further information.

This case is supervised by the cosigning psychologist. I have discussed this

case with this supervisor and he agrees with this diagnosis and treatment plan

in this note or has indicated any additions,/corrections in the attached

addendum.

[Navy04]

Looks like 70% Bud, worse case 50%. Good Luck

[vet201060]

I would say you are looking at 70% based off what the C&P Dr selected. Below is the criteria for mental disorders. I wish you the best.

General Rating Formula for Mental Disorders:

Total occupational and social impairment, due to such symptoms as:

gross impairment in thought processes or communication;

persistent delusions or hallucinations; grossly inappropriate

behavior; persistent danger of hurting self or others; intermittent

inability to perform activities of daily living (including maintenance

of minimal personal hygiene); disorientation to time or place; memory

loss for names of close relatives, own occupation, or own name .................... 100

Occupational and social impairment, with deficiencies in most areas,

such as work, school, family relations, judgment, thinking, or mood,

due to such symptoms as: suicidal ideation; obsessional rituals

which interfere with routine activities; speech intermittently illogical,

obscure, or irrelevant; near-continuous panic or depression affecting

the ability to function independently, appropriately and effectively;

impaired impulse control (such as unprovoked irritability with periods

of violence); spatial disorientation; neglect of personal appearance and

hygiene; difficulty in adapting to stressful circumstances (including

work or a worklike setting); inability to establish and maintain

effective relationships ........................................................................................ 70

Occupational and social impairment with reduced reliability and

productivity due to such symptoms as: flattened affect; circumstantial,

circumlocutory, or stereotyped speech; panic attacks more than once

a week; difficulty in understanding complex commands; impairment

of short- and long-term memory (e.g., retention of only highly learned

material, forgetting to complete tasks); impaired judgment; impaired

abstract thinking; disturbances of motivation and mood; difficulty in

establishing and maintaining effective work and social relationships ............... 50

Occupational and social impairment with occasional decrease in work

efficiency and intermittent periods of inability to perform occupational

tasks (although generally functioning satisfactorily, with routine

behavior, self-care, and conversation normal), due to such symptoms

as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or

less often), chronic sleep impairment, mild memory loss (such as

forgetting names, directions, recent events) ...................................................... 30

**** 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 continuous medication .................................................................................. 10