Ok so I have listed my VA Problem list first so you can see that the PTSD C&P notes left out the other mental health problems. My question is what should I do about it? Also stressor #2 is nothing I said or added. I did have more than one stressor and they are not mentioned. There are a total of 3 stressors. Below this list of VA PROBLEMS is the results from my PTSD C&P results. PLEASE ADVISE.
Thank You.
VA Problem List
Source: VA
Last Updated: Sorted By: Date/Time Entered (Descending) then alphabetically by Problem
Your VA Problem List contains active health problems your VA providers are helping you to manage.
This information is available 3 calendar days after it has been entered. It may not contain active
problems managed by non-VA health care providers. If you have any questions about your information,
visit the FAQs or contact your VA health care team.
Problem: Anxiety Disorder (ICD-9-CM 300.00)
Provider:
DIVISION
Status: ACTIVE
Comments: per DSM-5, unspecified anxiety disorder
Problem: Depressive Disorder NOS (ICD-9-CM
311.)
Provider:
Location:
Status: ACTIVE
Comments: per DSM-5, unspecified depressive disorder
Problem: Nightmares (SCT 419145002)
Provider
Status: ACTIVE
Comments: --
Note
*******************************************
********************************************
LOCAL TITLE: COMP AND PEN NOTE
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE:
AUTHOR EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed? No
If no, check all records reviewed:
[X] Other:
CPRS and VBMS
MEDICAL OPINION SUMMARY
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: does veteran suffer from Post Traumatic
Stress Disorder, and if so, does it appear to be service connected
b. Indicate type of exam for which opinion has been requested: DBQ Initial
PTSD and DBQ Medical Opinion
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: based upon clinical interview; review of records; application
of DSM V criteria; clinical experience and expertise
Question
Markay2k
Ok so I have listed my VA Problem list first so you can see that the PTSD C&P notes left out the other mental health problems. My question is what should I do about it? Also stressor #2 is nothing I said or added. I did have more than one stressor and they are not mentioned. There are a total of 3 stressors. Below this list of VA PROBLEMS is the results from my PTSD C&P results. PLEASE ADVISE.
Thank You.
Source: VA
Last Updated: Sorted By: Date/Time Entered (Descending) then alphabetically by Problem
Your VA Problem List contains active health problems your VA providers are helping you to manage.
This information is available 3 calendar days after it has been entered. It may not contain active
problems managed by non-VA health care providers. If you have any questions about your information,
visit the FAQs or contact your VA health care team.
Problem: Anxiety Disorder (ICD-9-CM 300.00)
Provider:
DIVISION
Status: ACTIVE
Comments: per DSM-5, unspecified anxiety disorder
Problem: Depressive Disorder NOS (ICD-9-CM
311.)
Provider:
Location:
Status: ACTIVE
Comments: per DSM-5, unspecified depressive disorder
Problem: Nightmares (SCT 419145002)
Provider
Status: ACTIVE
Comments: --
*******************************************
********************************************
LOCAL TITLE: COMP AND PEN NOTE
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE:
AUTHOR EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed? No
If no, check all records reviewed:
[X] Other:
CPRS and VBMS
MEDICAL OPINION SUMMARY
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: does veteran suffer from Post Traumatic
Stress Disorder, and if so, does it appear to be service connected
b. Indicate type of exam for which opinion has been requested: DBQ Initial
PTSD and DBQ Medical Opinion
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: based upon clinical interview; review of records; application
of DSM V criteria; clinical experience and expertise
************************************************************************
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:
previously diagnosed with disorders comprising the symptoms of
PTSD
Mental Disorder Diagnosis #2: Opioid Dependence (in remission)
ICD code: 304.01
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): see medical chart
ICD code: see medical chart
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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
all symptoms seem to be related to his PTSD
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [X] No [ ] 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 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 [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
[ ] 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
[X] Other:
VBMS and CPRS
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):
see reports dated 10/23/00 and 4/11/15 for details
no significant changes since 4/11/15; does not describe father's
death
as a major trauma due to veteran's age at the time and lack of
full
awareness of impact
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
see reports dated 10/23/00 and 4/11/15 for details as well as
Stetments
in Support of Claim contained in VBMS to saccounts of military traumas
and experiences
good student at Watertown High School; attended college Barton
Community College and Monroe Commun
ity College-Associates Degrees or
certificates from both schools.
following military, has worked in HVAC and is currently a Territory
Manager for a local company.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
has been seen by Dr. Barry and receives escitalopram and prazosin;
medication recently started and veteran does not know if they are
effective.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
arrested for DWI in 2000 prior to treatment; served six months in
Livingston County Correctional Facility
e. Relevant Substance abuse history (pre-military, military, and
post-military):
see reports dated 10/23/00 and 4/11/15 for details
was seen in residential ETOH treatment at Canandaigua in 2000 for 28
days; has been sober since; no use of illicit drugs, although he was
addicted to opiates which were prescribed to him. Is now on suboxone
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: military experiecnes as set forth above in previous reports
and Statement in Support of Claim
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
Is the stressor related to personal assault, e.g. military sexual
trauma?
[ ] Yes [X] No
b. Stressor #2: deaht of father from heart related illness
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:
civilian/familial situation
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 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
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] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[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] Inability to establish and maintain effective relationships
6. Behavioral Observations
--------------------------
demure; quiet; reserved
7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[X] Yes [ ] No
If yes, describe:
cannot recite serial sevens or recite months of year correctly;
consistently recalls seven digits forward; can spell selected word
forward and backward; recalls two of three items after five
minutes; recalls four of the last five presidents, though nor in
correct order.
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
it is much more likely than not that veteran's military experiences
are
the critical stressors that underlie his PTSD and therefore his PTSD
would
seem much more likely than not to be service connected
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
Thanks Everyone.
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