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C & P Exam Results Opinion


MEDIC04

Question

----------
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

Mental Disorder Diagnosis #2: Alcohol Use Disorder mild
ICD code: 305.00

b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Brain Injury wihtout open
intracranial wound and with concussion
Comments, if any: See evaluation of 08/29/2014 in CPRS

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 and
discuss whether there is any clinical association between these
diagnoses:
Pt's ETOH use disorder causes him to drink excess ETOH about 3
times a week or so.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[X] Yes [ ] No [ ] Not shown in records reviewed

d. 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:
Per TBI eval - memory issues and headaches attributed to the TBI
with insomnia which could be due to PTSD as well.

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 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?
[X] Yes [ ] No [ ] No other mental disorder has been diagnosed

If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
The PTSD causes the majority of his social and occupational
problems and the TBI contributes by mainly causing his memory
issues which impact his work.

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?
[X] Yes [ ] No [ ] No diagnosis of TBI

If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
The PTSD causes the majority of his social and occupational
problems and the TBI contributes by mainly causing his memory
issues which impact his work.

MILITARY STRESSORS: served for 8 years in the Army and was deployed to
Iraq from 2008-
2009 and worked as combat medic. He experienced many traumatic events
while there. One incident is described where an Iraqi with both arms and legs
blown off which he treated etc and the pt later died. There were many
such incidents dealing with the severly injured and dying. He has had
many combat experiences and was in convoys and exposed to ied blasts

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: Combat experience in Iraq

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)
[X] Witnessing, in person, the traumatic event(s) as they occurred to
others
[X] Learning that the traumatic event(s) occurred to a close family
member or close friend; cases of actual or threatened death must
have been violent or accidental; or, experiencing repeated or
extreme exposure to aversive details of the traumatic events(s)
(e.g., first responders collecting human remains; police officers
repeatedly exposed to details of child abuse); this does not apply
to exposure through electronic media, television, movies, or
pictures, unless this exposure is work related.

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) 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 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 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.
[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] 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
-----------
For VA rating purposes, check all symptoms that actively apply to the
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] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Flattened affect
[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] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[X] Impaired impulse control, such as unprovoked irritability with
periods
of violence

6. Behavioral Observations
--------------------------
Neat, clean, anxious at first and tense, pleasent and coorperative and
answered questions willingly. Good eye contact. Denies any current SI/HI
thoughts, plans or intentions but states that he is afraid he could hurt
people when he is very angry.

7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No

8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No

9. Remarks, (including any testing results) if any
--------------------------------------------------
See rationale.

NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.

****************************************************************************

Medical Opinion
Disability Benefits Questionnaire


Indicate method used to obtain medical information to complete this
document:

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed? No

If no, check all records reviewed:

[X] Civilian medical records
[X] Other:
VBMS

MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: REQUESTED OPINION:
1. Is the Veteran's PTSD at least as likely as not (50 percent or greater
probability) proximately due to or the result of DUTY. If, in your opinion,

it is not due to the veteran's s/c disability, but was as likely as not
aggravated by the service connected disability, please so state.

b. Indicate type of exam for which opinion has been requested: PTSD Initial
Evaluation

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]

a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.

c. Rationale: This pt meets DSM V criteria for PTSD. His history indicates
that the PTSD clearly started while in Iraq after he was exposed to many
severly traumatic incidents. His entire personality and life changed after
that. He does currently work and it appears that the pt is able to maintain
this job as his boss is also a Vet and helps the pt alot but the pt still
has
trouble at work especially with memory related issues and dealing with co
workers. The tp has a supportive GF but has no contact with anyone else in
the family or past friends etc. This pt does have moderate to severe PTSD
and
was encouraged to follow up on all treatment recommendations.

*************************************************************************

etc.

Any guess on a ball park of what % I should get? I know the VA awards differently it seems from person to person, im just curious on opinions. Thanks a ton.

Edited by MEDIC04
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