diver Posted November 30, 2014 Share Posted November 30, 2014 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 and any guesses of a raiting? Diver Link to comment Share on other sites More sharing options...
0 bojack Posted November 30, 2014 Share Posted November 30, 2014 Hard to tell because it's all up to rating officer.... maybe 30%?? Link to comment Share on other sites More sharing options...
0 Mikemmlj Posted November 30, 2014 Share Posted November 30, 2014 30-50%? Link to comment Share on other sites More sharing options...
0 bojack Posted December 1, 2014 Share Posted December 1, 2014 I took two bullets in iraq and multiple tbi unconscious injuries and they only gave me 70% ptsd. Also, I take more than 7 medication as wellI took two bullets in iraq and multiple tbi unconscious injuries and they only gave me 70% ptsd. Also, I take more than 7 medication as well Link to comment Share on other sites More sharing options...
0 Guest D�i�v�e�r�2 Posted December 2, 2014 Share Posted December 2, 2014 bojack I have the utmost respect for what you have done for all of use and for the wounds that you have sustained in the performance of those duties. Thank you for being willing to give me your opinion on my claim. I was only a stateside field medic and know that with all that I have seen and gone through it does not compare to what you have seen and done. THANK YOU FOR YOUR SERVICE AND SACRIFICE. Diver Link to comment Share on other sites More sharing options...
0 Guest D�i�v�e�r�2 Posted December 2, 2014 Share Posted December 2, 2014 I was looking at the criteria for rating and I noticed that the only place that “Occupational and social impairment with reduced reliability and productivity” shows up is on the 50% & 70% ratings so knowing the VA 10% but I can always hope. Thanks Diver Link to comment Share on other sites More sharing options...
0 diver Posted December 2, 2014 Author Share Posted December 2, 2014 What are the chances that they will take the report and assign a percentage based on what the C&P examiner marked? If they do that then I should receive 50%.I am very curious on what others here think about my results. diver Link to comment Share on other sites More sharing options...
Question
diver
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 and any guesses of a raiting?
Diver
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