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Ptsd/mdd Exam


Guest Diver2
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Question

Guest D�i�v�e�r�2

Here are my results any ideas on a %?

LOCAL TITLE: C&P PTSD EXAM

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: NOV 24, 2014@09:30 ENTRY DATE: NOV 26, 2014@10:34:58

AUTHOR::

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:

MODERATELY SEVERE BY HISTORY.

Mental Disorder Diagnosis #2: MAJOR DEPRESSION

ICD code: 296.32

Comments, if any:

SECONDARY TO HISTORY OF LEFT KNEE PAIN, LEFT ANKLE PAIN, RIGHT

KNEE

PAIN, LUMBAR PAIN.

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

Mental Health Disorder (to include TBI):

No response provided.

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?

[ ] 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:

VETERAN'S PTSD AND MAJOR DEPRESSION ARE INTERACTIVE AND

INSEPARABLE.

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 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 [ ] 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?

[ ] 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?

[X] Yes [ ] No

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

Veteran's VA claims file:

The sources of

information used to establish this evaluation were a review of the

Veteran's records through VBMS. A review of the Veteran's VA

computer

medical records was also conducted, particularly treatment notes of

, MD, who saw the Veteran October 22, 2014, for symptoms

of PTSD and depression with depression associated with chronic pain; and

the treatment notes of, social worker who saw the Veteran on

October 14, 2014, for primary symptoms of PTSD and depression.

Information

was also obtained from the Veteran during the 1 hour and 30 minute

examination on November 24, 2014, at Seattle Veterans Hospital with

examiner, PhD, licensed clinical psychologist.

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?

[X] Yes [ ] No

If yes, describe:

The Veteran was

administered the Depression Survey, PHQ-9, scoring 14 out of 27

indicating

at least moderate symptoms of depression associated with chronic pain.

The Veteran's alcohol survey is negative. Drug survey is negative.

2. History

----------

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

post-military):

SEE REMARKS SECTION.

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

and

post-military):

SEE REMARKS SECTION.

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

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

SEE REMARKS SECTION.

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

post-military):

SEE REMARKS SECTION.

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

post-military):

SEE REMARKS SECTION.

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: U.S. ARMY FT. HOOD TEXAS 1994, COOK WAS BADLY BURNED IN HIS

PRESENCE. She was not burned badly and I told him of that.

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?

[ ] Yes [X] No

If no, explain:

COOK BURNING ACCIDENT.

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

trauma?

[ ] Yes [X] No

b. Stressor #2: FT. HOOD TEXAS HELICOPTER CRASH, PILOT HAD EYE TRAUMS, ARM

TRAUMA. We did not crash we fell a distance then the engines started again and the eye was a completely different patient. I also told him this.

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?

[ ] Yes [X] No

If no, explain:

HELICOPTER CRASH.

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 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.

[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] 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] Depressed mood

[X] Anxiety

[X] Chronic sleep impairment

[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

6. Behavioral Observations

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

No response provided

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

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

VETERAN'S NAME:

DATE OF BIRTH:

TYPE OF EXAM: PSYCHIATRIC EXAMINATION FOR COMPENSATION AND PENSION

I. IDENTIFICATION, INFORMATION, AND SOURCE:

is presently years of age having been born on

. The Veteran did serve honorably in the United States

Army

from September, 1992, to January 1995. Discharge rank was E4.

The

purpose of this examination is to evaluate the Veteran for symptoms of

depression and anxiety associated with chronic pain, lumbar pain,

bilateral knee pain, left knee instability, limited extension of

bilateral

knees, bilateral ankle disorder. The present examination took place on

November 24, 2014, at Seattle Veterans Hospital with examiner

PhD, licensed clinical psychologist. The sources of

information used to establish this evaluation were a review of the

Veteran's records through VBMS. A review of the Veteran's VA

computer

medical records was also conducted, particularly treatment notes of

, MD, who saw the Veteran October 22, 2014, for symptoms

of PTSD and depression with depression associated with chronic pain; and

the treatment notes of, social worker who saw the Veteran on

October 14, 2014, for primary symptoms of PTSD and depression.

Information

was also obtained from the Veteran during the 1 hour and 30 minute

actually it was only 10 minutes and he said to get me out quick.

examination on November 24, 2014, at Seattle Veterans Hospital with

examiner, PhD, licensed clinical psychologist.

II. MENTAL STATUS:

The Veteran did present promptly on time for his scheduled appointment.

The Veteran is dressed in casual attire and appears overall moderately

clean and moderately groomed. The Veteran is fundamentally oriented in

all spheres. The Veteran's responses to questions of content are

forthright and complete, and they do demonstrate an adequate fund of

knowledge. He also presents as an honest historian. The Veteran's

speech

pattern is overall of a regular rhythm, and volume of speech is normal.

The Veteran's expressed thoughts are overall direct and appropriate

to

topic. There is no indication of psychotic processes, no indication of

delusional disorder, and no indication of loosened associations or

organicity. The Veteran does have at least moderate to moderately severe

somatic concerns secondary to a long history of low back pain, left knee

pain, right knee pain, left ankle pain, right pain with pain on a scale

of

1-10 at a level 7-8 for which he has been placed on gabapentin daily and

OxyContin episodically. The Veteran's affect is not restricted.

Dominant

mood is at least moderately depressed. The Veteran denies any suicidal

and denies any homicidal ideation, plans, or intent. The Veteran does

have

concerns regarding future events secondary to a history of chronic back

pain, bilateral knee pain, bilateral ankle pain, and unemployment and

presently is pursuing vocational technical training. The Veteran was

administered the Depression Survey, PHQ-9, scoring 14 out of 27

indicating

at least moderate symptoms of depression associated with chronic pain.

The Veteran's alcohol survey is negative. Drug survey is negative.

III. HISTORY SINCE LAST RATING EXAMINATION WHEREIN 10% DISABILITY WAS

GRANTED FOR LIMITED LEFT KNEE FLEXION; 10% DISABILITY FOR LIMITED KNEE

EXTENSION; 10% DISABILITY FOR LIMITED FLEXION, RIGHT KNEE; 10% DISABILITY

FOR LIMITED KNEE CONDITION; 20% DISABILITY FOR LUMBAR PAIN, DISABILITY

FOR

LEFT ANKLE AND DISABILITY FOR RIGHT ANKLE:

The Veteran continues to reside in Renton, Washington, where he has lived

since 2008 with wife of 21 years. This marriage enjoys 13-year-old

daughter and 12-year-old son. The Veteran reports being employed at

June 2006, however, secondary to a history of

chronic

low back pain and bilateral knee and bilateral ankle pain, he is pursuing

vocational training secondary to inability to carry out present

responsibilities. The Veteran does report overall ability to attend to

his own daily needs including meals, hygiene, and medications. The

Veteran reports secondary to history of chronic back pain, bilateral knee

pain, and bilateral ankle pain, he has limited physical mobility. The

Veteran was seen by MD, October 22, 2014, for symptoms

of PTSD and depression and was placed on venlafaxine 225 mg. The Veteran

was seen by, social worker, October 14, 2014, for symptoms

of PTSD and depression.

IV. EVIDENCE OF TRAUMA AND PSYCHOLOGICAL IMPACT MEETING DSM-V AS WELL AS

A.M.I.E., C.P.E.P. GUIDELINES:

The Veteran was born in Seattle on. His father's name

was

**; he was a high school teacher. His mother's name was;

she

was a registered nurse. The Veteran is the youngest of 3 children. He

had an older sister and middle brother. The Veteran reports family life

as being stable and adequate. The Veteran graduated from high school in

1991. The Veteran denies any psychiatric or psychological disorders

prior

to entering the U.S. military.

The Veteran entered the United States Army at the age of 19 on September

16, 1992. The Veteran does report while serving active duty U.S. Army he

incurred a history of left knee pain, left ankle pain, right knee pain,

and right ankle pain, history of colonic lumbar pain for which he is

presently service-connected. The Veteran does report a history of pain on

a scale of 1-10 at a level 7-8 on a daily basis precludes the Veteran

from

engaging in more strenuous physical activities which he finds frustrating

and depressing. The Veteran does report taking gabapentin daily for pain

and OxyContin episodically. The Veteran does present with restricted

range of affective response and clearly lacks positive expectations for

future events. The Veteran does report sleep disturbance secondary to a

history of chronic pain. The Veteran reports pain disrupts sleep on a

nightly basis. The Veteran reports sleep of some 4-5 hours with 3-4

awakenings.

These symptoms are clinically important and do indicate the Veteran does

present with primary symptoms of posttraumatic stress by history; major

depressive disorder, 296.32, more probable than not secondary to a

history

of chronic left knee pain, right knee pain, left ankle pain, right ankle

pain, and lumbar pain with limited flexion and extension capability. The

overall impact of the Veteran's present psychological stress does

reduce

his reliability and productivity in social, occupational, and family

capabilities secondary to primary symptoms of PTSD and major depression

associated with chronic pain. The Veteran's symptoms are in need of

medications which he is in partial response to.

V. DIAGNOSES/IMPRESSION:

AXIS I:

1. Posttraumatic stress disorder (PTSD), 309.81, moderately severe by

history.

2. Major depressive disorder, 296.32, more probable than not secondary

to

history of chronic left knee pain, right knee pain, left ankle pain,

right

ankle pain, and lumbar pain with pain on a scale of 1-10 at a level

7-8.

AXIS II: No diagnosis.

AXIS III: Relevant medical conditions: History of left knee pain, left

ankle pain, right knee pain, right ankle pain, lumbar pain, and

tinnitus.

AXIS IV: Psychosocial and environmental factors:

1. Economic situation: Moderate stress, limited income.

2. Housing: Presently stable, adequate.

3. Primary support: Moderate marital discord associated with

Veteran's

symptoms of PTSD and major depression associated with chronic pain.

4. Alcohol and drug use: None indicated and none reported.

5. Legal difficulties: None reported.

6. Health issues: History of chronic back pain and history of left knee

pain, history of chronic right knee pain, history of bilateral ankle

pain.

AXIS V: Global assessment of functioning current level equal to 50.

Highest level in 6 months was 50.

IMPRESSION: Mr. is a veteran who does present today

with primary symptoms of PTSD by history along with a history of major

depression, 296.32, more probable than not secondary to Veteran's

history

of chronic lumbar pain, bilateral knee pain, bilateral ankle pain with

pain limiting the Veteran's ability to carry out work force

responsibilities. The Veteran's symptoms are in need of medication.

The

Veteran is competent to handle his own financial affairs, act responsibly

in his own financial best interest, and can be considered competent for

VA

purposes.

With the incorrect information what should I do about it?

thank you all

Diver

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Most C and P's have some incorrect info. I don't think they'll come after you for minor errors.

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Guest D�i�v�e�r�2

Thanks I don’t think I will be rated for PTSD sense it was non combat related but it still makes me nervous when he changed it to a helicopter crash and a severely burned patient. I have worked on so many people that it is hard to keep all of them strait in my head but those are etched in my brain and I see them daily.

diver

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If the VA does look into this claim for the PTSD and find the errors will they go after me for my MDD claim?

Diver

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I have submitted a letter through Ebenefits stating that the Dr stated the wrong facts about my stressors, I restated my correct stressors and I also stated that when I filed for PTSD to be considered long before my C&P I included a copy of my stressors that I had for my social worker with it. So they already had a copy of the stressors and I hope this will keep them from spending massive time looking for things that do not exist.

My question now is.

  1. Will this letter hurt or help me?
  2. Any guesses on what the rating may be with these corrections?

Thank you diver

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Has the VA asked you yet for inservice evidence of these stressors?

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no they have not asked for anything on this. I think that they will rait me on MDD but I would rather everything be correct.

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