b. Axis III - medical diagnoses (to include TBI): Back Injury
3. Differentiation of symptoms
a. Does the Veteran have more than one Mental disorder diagnosed?
Yes
If yes, complete the following question:
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
No
If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to
each diagnosis:
Symptoms of the two disorders are enmeshed and overlap to a degree that to differentiate what portion of each symptom is attributable to each diagnosis is not possible. Alcohol and cannabis Use disorder are in remission. There is no clinical association between the diagnoses.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
No
d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
No
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)
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?
No
If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational
and social impairment is attributable to each diagnosis:
To assign portions of the occupational and social impairment to each diagnosis would be pure speculation
SECTION II:
Clinical Findings:
1. Evidence review
In order to provide an accurate medical opinion, the Veteran’s claims folder must be reviewed.
a. Records reviewed (check all that apply):
Claims folder (C-file):
Yes
b. Was pertinent information from collateral sources reviewed?
No
2. History
a. Relevant Social/Marital/Family history (pre-military, military, and post-military):
39 y/o white male. married to second wife for 9 years. Married and divorced on one previous occasion. Relationship with current wife is supportive. Has 4 children with whom he shares "no or distant" relationships. Two children live with ex-wife and he hasn't seen them in 3 years. He has two children with current wife. He has no friends with whom he associates and typically stays in the garage. He may do woodworking or other solitary things. Regarding family of origin: raised by mother, then grandmother, and then h is father, then his mother again. Divorced when he was 7. Relationship with parents while growing up was "fine" he has 1 younger brother and their relationship is "pretty close"
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
Quit school in 9th grade but obtained GED in 1994. Participated in football, track, and basketball. He stated he was a good student but repeated 9th grade and quit in his 2nd year. He did not have special education assistance. Went to Job Corp where he got GED, worked as a forklift operator before he joined the military. He was in the Army from 1997 until 2007. He was deployed to Iraq on 2 occasions, once from 2003-2004 for 12 months and again from 05-06 for 12 months. At the time of this evaluation, the veteran is unemployed and "living off of in-laws." Veteran was in conflict with civilian supervisors and co-workers in many positions. He worked as a _________, _______, and __________.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military,
military, and post-military:
Veteran first sought attention from mental health professionals in 2003 for evaluation at fort hood. he has had counseling at the _____ VA clinic on and off since 2010. He first began taking medication for depression/anxiety around 2009. In the past, he has been prescribed medications including: Ambien, Guaifenesin, Citalopram and others. At the time of this evaluation he was prescribed Hydroxyzine, Prazosin, Sertaline, Atorvastatin. He was participating in individual therapy for 1 session. He admitted that he's been hospitalized for 4 days in _____ in ___ for Suicidal and homicidal ideation
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
2 DUIs and 1 DWI with the last DWI being in October 2014 and still pending
e. Relevant Substance abuse history (pre-military, military, and post-military):
Veteran has been sober since October 2014. He stated he abused alcohol to self-medicate due to nightmares, flashbacks, etc. "just not wanting to think about things. He admitted alcohol was a problem for him. Completed the SATP 30 day program then completed the PRRP inpatient program. Attends AA 1-2 times a week. Admitted he used illegal drugs last October, he abused drugs for approximately 4 years.
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: Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
b. Stressor #2:Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
c. Stressor #3: Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
d. Stressor #4: Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
4. PTSD Diagnostic Criteria
Criterion A: The Veteran has been exposed to a traumatic event where both of the following were present:
The Veteran experienced, witnessed or was confronted with an event that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others.
The Veteran’s response involved intense fear, helplessness or horror.
Criterion B: The traumatic event is persistently reexperienced in 1 or more of the following ways:
- Recurrent and distressing recollections of the event, including images, thoughts or perceptions
- Recurrent distressing dreams of the event
- Acting or feeling as if the traumatic event were recurring; this includes a sense of reliving the
experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated
Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by one or both of the following:
Efforts to avoid thoughts, feelings or conversations associated with the trauma
Efforts to avoid activities, places or people that arouse recollections of the trauma
Criterion D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or
more of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Criterion E:
The duration of the symptoms described above in Criteria B, C and D is more than 1 month.
Criterion F:
The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is NOT attributable to the physiological effects of a substance
5. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans diagnoses:
Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Panic attacks more than once a week
Near-continuous panic or depression affecting the ability to function independently, appropriately
and effectively
Chronic sleep impairment
Mild memory loss, such as forgetting names, directions or recent events
Impairment of short- and long-term memory, for example, retention of only highly learned material,
while forgetting to complete tasks
Memory loss for names of close relatives, own occupation, or own name
Flattened affect
Circumstantial, circumlocutory or stereotyped speech
Speech intermittently illogical, obscure, or irrelevant
Difficulty in understanding complex commands
Impaired judgment
Impaired abstract thinking
Gross impairment in thought processes or communication
Disturbances of motivation and mood
Difficulty in establishing and maintaining effective work and social relationships
Difficulty in adapting to stressful circumstances, including work or a worklike setting
Inability to establish and maintain effective relationships
Suicidal ideation
Obsessional rituals which interfere with routine activities
Impaired impulse control, such as unprovoked irritability with periods of violence
Spatial disorientation
Persistent delusions or hallucinations
Grossly inappropriate behavior
Persistent danger of hurting self or others
Neglect of personal appearance and hygiene
Intermittent inability to perform activities of daily living, including maintenance of minimal personal
hygiene
Disorientation to time or place
6. Other symptoms
Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not
listed above
No
If yes, describe: ___________________________________________________
7. Competency
Is the Veteran capable of managing his or her financial affairs?
Yes
8. Remarks, if any______________________________________________________________________
The veteran should be considered an increased but not current imminent risk of harm to himself. Denied he has any intent or plan to harm himself or anyone else at the time of this evaluation. Veteran stated he has the VA crisis number "all over"
Question
mcnat1015
Got the results of C&P today. Anyone care to guess about how it will turn out? Thank you very much
1. Diagnostic Summary
This section should be completed based on the current examination and clinical findings.
Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today’s evaluation?
Yes
2. Current Diagnoses
Diagnosis #1: PTSD
Diagnosis #2: Somatic Symptom Disorder, predominately pain
Diagnosis #3: Alcohol use disorder, in remission
Diagnosis #4: Cannabis Use Disorder, in remission
b. Axis III - medical diagnoses (to include TBI): Back Injury
3. Differentiation of symptoms
a. Does the Veteran have more than one Mental disorder diagnosed?
Yes
If yes, complete the following question:
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
No
If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to
each diagnosis:
Symptoms of the two disorders are enmeshed and overlap to a degree that to differentiate what portion of each symptom is attributable to each diagnosis is not possible. Alcohol and cannabis Use disorder are in remission. There is no clinical association between the diagnoses.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
No
d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
No
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)
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?
No
If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational
and social impairment is attributable to each diagnosis:
To assign portions of the occupational and social impairment to each diagnosis would be pure speculation
SECTION II:
Clinical Findings:
1. Evidence review
In order to provide an accurate medical opinion, the Veteran’s claims folder must be reviewed.
a. Records reviewed (check all that apply):
Claims folder (C-file):
Yes
b. Was pertinent information from collateral sources reviewed?
No
2. History
a. Relevant Social/Marital/Family history (pre-military, military, and post-military):
39 y/o white male. married to second wife for 9 years. Married and divorced on one previous occasion. Relationship with current wife is supportive. Has 4 children with whom he shares "no or distant" relationships. Two children live with ex-wife and he hasn't seen them in 3 years. He has two children with current wife. He has no friends with whom he associates and typically stays in the garage. He may do woodworking or other solitary things. Regarding family of origin: raised by mother, then grandmother, and then h is father, then his mother again. Divorced when he was 7. Relationship with parents while growing up was "fine" he has 1 younger brother and their relationship is "pretty close"
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
Quit school in 9th grade but obtained GED in 1994. Participated in football, track, and basketball. He stated he was a good student but repeated 9th grade and quit in his 2nd year. He did not have special education assistance. Went to Job Corp where he got GED, worked as a forklift operator before he joined the military. He was in the Army from 1997 until 2007. He was deployed to Iraq on 2 occasions, once from 2003-2004 for 12 months and again from 05-06 for 12 months. At the time of this evaluation, the veteran is unemployed and "living off of in-laws." Veteran was in conflict with civilian supervisors and co-workers in many positions. He worked as a _________, _______, and __________.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military,
military, and post-military:
Veteran first sought attention from mental health professionals in 2003 for evaluation at fort hood. he has had counseling at the _____ VA clinic on and off since 2010. He first began taking medication for depression/anxiety around 2009. In the past, he has been prescribed medications including: Ambien, Guaifenesin, Citalopram and others. At the time of this evaluation he was prescribed Hydroxyzine, Prazosin, Sertaline, Atorvastatin. He was participating in individual therapy for 1 session. He admitted that he's been hospitalized for 4 days in _____ in ___ for Suicidal and homicidal ideation
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
2 DUIs and 1 DWI with the last DWI being in October 2014 and still pending
e. Relevant Substance abuse history (pre-military, military, and post-military):
Veteran has been sober since October 2014. He stated he abused alcohol to self-medicate due to nightmares, flashbacks, etc. "just not wanting to think about things. He admitted alcohol was a problem for him. Completed the SATP 30 day program then completed the PRRP inpatient program. Attends AA 1-2 times a week. Admitted he used illegal drugs last October, he abused drugs for approximately 4 years.
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: Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
b. Stressor #2:Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
c. Stressor #3: Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
d. Stressor #4: Omitted for privacy
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
4. PTSD Diagnostic Criteria
Criterion A: The Veteran has been exposed to a traumatic event where both of the following were present:
The Veteran experienced, witnessed or was confronted with an event that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others.
The Veteran’s response involved intense fear, helplessness or horror.
Criterion B: The traumatic event is persistently reexperienced in 1 or more of the following ways:
- Recurrent and distressing recollections of the event, including images, thoughts or perceptions
- Recurrent distressing dreams of the event
- Acting or feeling as if the traumatic event were recurring; this includes a sense of reliving the
experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated
Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by one or both of the following:
Efforts to avoid thoughts, feelings or conversations associated with the trauma
Efforts to avoid activities, places or people that arouse recollections of the trauma
Criterion D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or
more of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Criterion E:
The duration of the symptoms described above in Criteria B, C and D is more than 1 month.
Criterion F:
The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is NOT attributable to the physiological effects of a substance
5. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans diagnoses:
Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Panic attacks more than once a week
Near-continuous panic or depression affecting the ability to function independently, appropriately
and effectively
Chronic sleep impairment
Mild memory loss, such as forgetting names, directions or recent events
Impairment of short- and long-term memory, for example, retention of only highly learned material,
while forgetting to complete tasks
Memory loss for names of close relatives, own occupation, or own name
Flattened affect
Circumstantial, circumlocutory or stereotyped speech
Speech intermittently illogical, obscure, or irrelevant
Difficulty in understanding complex commands
Impaired judgment
Impaired abstract thinking
Gross impairment in thought processes or communication
Disturbances of motivation and mood
Difficulty in establishing and maintaining effective work and social relationships
Difficulty in adapting to stressful circumstances, including work or a worklike setting
Inability to establish and maintain effective relationships
Suicidal ideation
Obsessional rituals which interfere with routine activities
Impaired impulse control, such as unprovoked irritability with periods of violence
Spatial disorientation
Persistent delusions or hallucinations
Grossly inappropriate behavior
Persistent danger of hurting self or others
Neglect of personal appearance and hygiene
Intermittent inability to perform activities of daily living, including maintenance of minimal personal
hygiene
Disorientation to time or place
6. Other symptoms
Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not
listed above
No
If yes, describe: ___________________________________________________
7. Competency
Is the Veteran capable of managing his or her financial affairs?
Yes
8. Remarks, if any ______________________________________________________________________
The veteran should be considered an increased but not current imminent risk of harm to himself. Denied he has any intent or plan to harm himself or anyone else at the time of this evaluation. Veteran stated he has the VA crisis number "all over"
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mcnat1015
Official rating is 100%
mcnat1015
The status on ebenefits changed from preparation for notification to pending decision approval. This is ridiculous and nerve wracking
Andyman73
Gonna drive you crazy, that ebennies thing!
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