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C&p For Ptsd Initial

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Chemdawg

Question

I recently had to attend a total of three appointments for an initial PTSD claim. I was wondering if this is normal as I had to see two different doctors at the VAMC and also had to see an additional doctor at an offsite location that was scheduled through VES. So far, I have the following exam results from the VAMC, anybody know what this can lead to so far without knowing what the Non-VA Psychologist says?

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: F

2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD (MILD)
ICD code: F
Comments, if any:
IT IS AT LEAST AS LIKLEY AS NOT THAT THE VETERAN'S PTSD HAS BEEN
CAUSED BY HIS FEAR OF HOSTILE MILITARY ACTIIVITES IN AFGHANISTAN.

b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): TINNITUS,
ICD code: F

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 [X] No [ ] Not shown in records reviewed

Comments, if any:
HEADACHES

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 due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication

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 [ ] 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 [ ] No


2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
***********

b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
THE VETERAN HAD COMPLETED EIGHT GRADE PRIOR TO HIS MILITARY SERVICE.
HE
SERVE DIN THE U.S. ARMY FROM 2007 TO 2014. HE COMPLETED HIS GED PRIOR
TO HIS MILITARY SERVICE. HE HAS BEEN A FULL-TIME COLLEGE STUDENT
STUDYING BUSINESS. HE ALSO HAS BEEN WORKING PART-TIME IN SECURITY.

c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
WAS TREATED DURING HIS FIRST TOUR IN AFGHANISTAN. THE VETERAN WAS
EXPERIENICNG MARITAL PROBLEMS AND ALSO IT WAS HIS FIRST EXPERIENCE
WITH
AFGHANISTAN. HE TOOK CELEXA FOR THREE MONTHS.

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

e. Relevant Substance abuse history (pre-military, military, and
post-military):
NONE

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: "WE GOT ATTACKED ONE DIED AND FIFTEEN OR SIXTEEN WERE WOUNDED.

I HAD TO CLEAR THE BUILDING,
AND ASSESS THE WOUNDED.."

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: "WE HAD CONSTANT MORTAR AND ROCKET ATTACKS. WE ALWAYS HAD TO
BE ON EDGE."

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 criteri
a 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).

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 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 negative emotional state (e.g., fear, horror, anger,
guilt, or shame).
[X] Markedly diminished interest or participation in significant
activities.

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] Hypervigilance.
[X] Exaggerated startle response.

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] Panic attacks more than once a week

6. Behavioral Observations
--------------------------
THE VETERAN WAS AAO X 3. HE WAS APPROPRIATELY DRESSED AND GROOMED. HE SPOKE
RAPIDLY AND HIS MOOD WAS ANXIOUS. HIS THOUGHT PROCESS WAS LOGICAL AND GOAL
ORIENTED. HIS MEMORY AND CONCENTRATION WERE INTACT. HIS JUDGEMENT WAS GOOD.
THERE WERE NO INDICTAIONS OF HALLUCINATIONS OR DELUSIONS. THE VETERAN DENIED
EXPERIENCING ANY SUICCIDAL/HOMICIDAL THOUGHTS OR PLANS.

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
--------------------------------------------------
No remarks provided.

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This should definitely get you a SC rating for PTSD but will be probably at 30% ( others might disagree) but you can check that out with the PTSD ratings in the VA Schedule of Ratings here in a different link under Diagnostic Code 9411....

It is not unusual to have a fairly good job ( but yours is Part time) and also be pursuing a college degree but PTSD can raise it's head years after the fact ,by getting worse, and you can always file for a higher rating if you feel this is causing you more problems in the future, with work or with your education..

I hope others chime in because I feel 30% is really too low for anyone with PTSD but the word "mild" in the C & P and other factors there make me think 30%

Edited by Berta
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gee

I forgot to add::

"SERVE DIN THE U.S. ARMY FROM 2007 TO 2014."

If you filed this claim within one year after your discharge date, the retro should go back to the day after your discharge.

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This should definitely get you a SC rating for PTSD but will be probably at 30% ( others might disagree) but you can check that out with the PTSD ratings in the VA Schedule of Ratings here in a different link under Diagnostic Code 9411....

It is not unusual to have a fairly good job ( but yours is Part time) and also be pursuing a college degree but PTSD can raise it's head years after the fact ,by getting worse, and you can always file for a higher rating if you feel this is causing you more problems in the future, with work or with your education..

I hope others chime in because I feel 30% is really too low for anyone with PTSD but the word "mild" in the C & P and other factors there make me think 30%

I believe the "Mild" portion is incorrect and I don't believe the exam with the VA was as thorough as the exam I had with a psyc through VES. The VA examiner didn't note anything about my constant anger episodes and lack of socialization as well as keeping myself away from people in general.

I was looking over the results and the rating schedule and one of the symptoms is "Panic attacks more than once a week" which falls into the 50% bracket. I guess I will have to wait and see....

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gee

I forgot to add::

"SERVE DIN THE U.S. ARMY FROM 2007 TO 2014."

If you filed this claim within one year after your discharge date, the retro should go back to the day after your discharge.

I did file within one year

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Occupational and social impairment due to mild or transient symptoms

which decrease work efficiency and ability to perform occupational

tasks only during periods of significant stress, or; symptoms controlled

by continuous medication .................................................................................. 10

Looks like 10% S/C for PTSD for you

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