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Ptsd Tbi?


IA11B
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Question

I have a few questions what does all this mean? And I saw he checked the box for my diagnosis of TBI but did he attribute all syptoms of TBI to PTSD? And did he diagnose me with PTSD also I know while I was active they diagnosed me I think. Thank you I am lost with this any help would be greatly appreciated.


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: F43.10

2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: F43.10

b. Medical diagnoses relevant to the understanding or management
of the
Mental Health Disorder (to include TBI): TBI in September,
2011

3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder
diagnosed?
[ ] Yes [X] No

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:
No behavioral, emotional, or cognitive symptoms are the
result of
TBI residuals.


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 occasional
decrease in work
efficiency and intermittent periods of inability to
perform
occupational tasks, although generally functioning
satisfactorily,
with normal routine behavior, self-care and conversation

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 [ ] No [X] 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?
[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 impairment level noted above is attributable to
PTSD.


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
[ ] Other:

b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No


2. History
----------
a. Relevant Social/Marital/Family history (pre-military,
military, and
post-military):
The veteran was born and raised in Missouri. While
growing up his
household included his biological parents and 3 younger
brothers.
Growth and development were regarded to be unremarkable.
He denied any
abuse or neglect during his childhood and described his
childhood as
"Good." He reported positive relationships and a good
social
adjustment while growing up. He denied any social
adjustment problems
upon entering the military.

He married in 2010 and the couple have a 9 month old
daughter. They
have been living with his mother-in-law in Grimes, Iowa
while they
search for a house to buy. He described his marriage as
stable and
supportive. He keeps in contact with some military
friends and has
made a couple friends at the Vets Center at Iowa State
University. He
and his wife go out socially about once a week for dinner.
He does not
belong to any clubs or organizations. He does not have
leisure time
activities as most of his time is spent on school.

The veteran reported being able to complete all ADLs and
IADLs on an
independent level


b. Relevant Occupational and Educational history (pre-military,
military, and
post-military):
The veteran graduated from high school in 2007, earning
average grades
and denying any learning disabilities or disciplinary
problems. He
worked for a while as a ranch hand in Wyoming and then
worked for a
plumbing company in Iowa. He completed freshman classes
at Des Moines
Area Community College, earning mostly Bs, and then
entered the Army,
serving from 4/5/10 to 7/15/14. He had an OEF deployment
in 2011 and
then again in 2013-2014. He is now attending Iowa State
University in
Ames, majoring in finance. He reported earning Bs and not
having
problems attending lectures in classrooms.



c. Relevant Mental Health history, to include prescribed
medications and
family mental health (pre-military, military, and post-
military):
Family Psychiatric History: None.

The veteran denied having any mental health services prior
to his
military service time.
He was diagnosed with Adjustment Disorder with Anxiety in
September,
2012 about
one year after his injury from a grenade in
Afghanistan,
attended appointments with a psychiatric Social Worker,
and was
prescribed trazodone for sleep. He was also being treated
in the TBI
clinic at the time. He is not currently prescribed any
psychoactive
medications.


d. Relevant Legal and Behavioral history (pre-military,
military, and
post-military):
None.

e. Relevant Substance abuse history (pre-military, military, and
post-military):
1. Caffeine: about 1 soda a day.
2. Tobacco: denied. Quit about 6 months ago.
3. ETOH: about 1 beer a month.
4. Street drugs: denied.


f. Other, if any:
None.

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: September, 2011 injured from shrapnel from a
grenade during
an ambush.

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

b. Stressor #2: Participated in several firefights, seeing
others severely
injured or killed during combat.

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

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] 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] 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
[X] Stressor #2

5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply
to the
Veteran's diagnoses:

[X] Anxiety
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or
recent
events

6. Behavioral Observations
--------------------------
1. General Appearance: Neatly groomed, appropriately dressed.
2. Psychomotor Activity/Mannerisms/Behaviors: appeared mildly
anxious.
3. Orientation: alert and fully oriented.


4. Speech: Spontaneous, coherent, goal directed.
5. Attitude Toward Examiner: Cooperative.
6. Affect: Appropriate.
7. Mood: "Ok, some good days, some bad days."
ANXIETY: Panic attacks about once a week, trouble relaxing,
some
irritability. Takes over an hour to calm self after intrusive
memories of
combat.
DEPRESSION: credibly denied thought of harm to self or others.
Denied
significant symptoms of depression. Sleep 4-5 hours a night,
sufficient
energy during the day. Wife says he screams and talks in his
sleep and is
restless. Nightmares about once a week. Sometimes cries when he
recalls
friends who were killed in action.
MANIC: No symptoms or episodes.
8. Obsessive/Ritualistic Behavior: None.
9. Attention: Spelling reversals and digits forwards/backwards
were within
normal limits. Described some problems with concentration and
needing to
utilizing list making more often.
10. Memory: able to recall 3/3 items after one minute delay.
Able to recall
remote and recent events during interview.
11. Thought Process and content: No hallucinations, delusions or
signs of
thought disorder.

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
--------------------------------------------------
The veteran is a 25 year old male seen for a psychological
evaluation on
11/3/14 in regard to his application for a service connected
disability
rating for a mental condition to include PTSD. Veteran
arrived on time for
the interview, reporting that he drove himself to the
facility. He was
informed of the purpose of the evaluation and provided verbal
consent to
participate. He was interviewed for approximately 60
minutes. He was
cooperative with the interview and responded to all
questions. There were
no indications of malingering or symptom exaggeration. The
Veteran was
informed of the Veterans Crisis Line number: 1-800-273-TALK
(8255).

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Yes, he gave a diagnosis of PTSD. He stated that you have a TBI as well. He also stated that the symptoms CAN BE SEPARATED. This is important. This allows you to get a separate rating for TBI and a separate rating for PTSD. Based on his opinion, he checked the box that corresponds to a 30% rating. The rater will review this C&P exam plus any other evidence in your file to decide what percentage to grant.

If you feel this is too low, you can always request an increase. The hard part of getting the service connection is done! Good job!

Have you also filed for TBI? If so, you should receive a separate C&P exam for that.

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Yes, I filed for TBI, vertigo, and migranes also. I have another c and p this week but it doesn't say what for I know I still have shoulders and back I need a c and p for which I assume is what this next appointment is for.

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