ptsd Ptsd C&p Exam Results

[devildoghawg]

Could anyone help me determine a possible rating? I removed some information from the report for my own privacy. Thanks in advance.

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 due to Military Service

ICD code: 309.81

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?

[ ] Yes [X] No

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?

[ ] 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

[X] 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):

Married four years to third wife; as with previous two marriages,

reports impairments given his poor anger and impulse control with

verbal outbursts. However unlike the previous two marriages, reports

his wife is understanding and supportive given her military family.

Reports decreased interests overall and limited to bow hunting (no

longer enjoys guns given exaggerated startle response) and being

outdoors in nature given its seclusion. Avoidance of people given

heightened anxiety, hypervigilance, detachment, and poor anger

control.

Purposefully lives in secluded wooded area near a lake.

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

and

post-military):

Bachelor's degree, which he reports took him a long time to complete

given impaired concentration and performance given his poor sleep and

also because he could not handle being in the classroom given his

anxiety and hypervigilance (thus, had to finish online). For last two

years (which represents longest job he has had since military

service)

Reports his current bosses (two fellow veterans) are supportive and

understanding of his issues and will let him work from home frequently

or are understanding when he is late to work due to poor sleep. Prior

six to seven jobs for brief tenures given fighting at work or being

late or missing work due to poor sleep.

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

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

The Veteran denies symptoms prior to service. Denies treatment in

service or post service.

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

post-military):

N/A

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

post-military):

The Veteran reports that he drinks maybe one beer weekly. Reports

high

consumption just out of service to help him sleep. Denies illicit

drug

use.

f. Other, if any:

DD 214 indicates receipt of Combat Action Ribbon

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: I removed this for my own privacy

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)

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).

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] 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] 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

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] 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] Impaired impulse control, such as unprovoked irritability with

periods

of violence

6. Behavioral Observations

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

The Veteran presents neatly dressed with excellent grooming and hygiene.

Cooperative, yet detached with flattened affect. However, he did become

quite emotionally distressed with discussing his stressor and ensuing guilt.

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's PTSD is at least as likely as not incurred in or caused by

his combat experience given lack of symptoms pre service and development

of symptoms post service.

[Mikemmlj]

30-50% sounds like the range they chose.

[Philip Rogers]

I'm thinking more in the 10% or 30% range. jmo

pr

[Navy04]

I agree with Phillip bud, looks like SC will be granted in the 10-30% range. Good luck and keep us posted.

[devildoghawg]

I moved into the Prep for Decision phase yesterday. Also the notes for TBI, both shoulders and both knees, and IBS are in the system and mostly look favorable. After looking at the PTSD rating axis, I think the large majority of my symptoms fall into the 50% range with even a few in the 70% range. Thank you all for your input. Semper Fi.

[devildoghawg]

My claim was finalized today. Came back at 90% combined. 70% PTSD, 10% bi-lateral knee, 10% right shoulder, 30% IBS

[silverdollar22]

Wow!!! Good for you man. Congrats!!