PTSD Eam results, possible rating?

[dgraham82]

wondering if anyone can help decipher a possible rating out of this info.

 

 

 

 

                                  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 was reviewed. Records available in CPRS were reviewed.  The
              veteran provided history and clinical information.
             
    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):
          The veteran was born in Los Gatos, CA and grew up Sunnyvale and
          Patterson, CA. He was reared in an intact family.  The veteran had 2
          younger biological siblings.  He reports he went through the 13th
grade
          (joined service after 9/11), graduating HS with 2.0 academic marks.
          Attended 3 weeks college before service.   The veteran notes he had
          friends. He denies behavioral problems/ arrests. He endorses alcohol
          use/abuse - "drank 3 out of 4 weekends" a month ("6 beers over 2
          hours"); denies drug use. The veteran denies a history of emotional,
          physical, and sexual abuse.
          
          The veteran has been married 1 time for 5 years (2003 - 2008) and has
3
          children.  He states he is not close to his ex-wife. Ex-wife has
          primary physical custody of his 2 younger children, and vet has
          physical custody of the older child. The veteran attributes failure of
          the marriage to his drinking and his irritability.  He lives with his
          oldest daughter and has phone contact 3 x a week with his younger
          daughters.  The veteran states he is close to his children.  He
          describes limitedly close relationships with his siblings/extended
          family - vet lives with his parents; brother and sister are less than
1
          mile away, but he sees them only 2-3 x a year primarily on birthdays.
          
          The veteran has resided with his parents since his divorce, except for
          the year he lived in Dubai.

          He comments he has no friends.
            
         
         
    b. Relevant Occupational and Educational history (pre-military, military,
and
       post-military):
     
5 years Active Duty + Air Guard from 2008-2012  and was given a
Honorable
          discharge.  The veteran was exposed to combat - mortared daily + there
          were shots at the jets outside the gate.   Denies a history of MST.
          
          Education:  The veteran notes he did go back to school after service,
          attaining an AA degree in Culinary Arts  with passing academic marks,
          except for one class he failed due to taking care of his grandmother.
          He did not obtain any degrees in-service.
          
          Occupation: The veteran is currently employed on a part-time basis as
          part of the work study program (receptionist) at the VSO, last working
          4 days ago.  He describes his work performance as "good", his
          attendance record as "good" with 3-4 missed days from work in the last
          1 month due to medical appts, and his ability to get along with his
          supervisors as "fine" and  his coworkers as "fine" - "all veterans".
He
          admits to being fired from 1 previous job - reportedly due to
          attendance - missing 1 day a week - "did not like being there" -
          "everyone there pissed me off".  The veteran mentions he has held ~ 4
          jobs since service.  He is not on State Disability or Social Security
          Disability.
          
          The veteran does report some PTSD issues of anger and irritability and
          difficulty getting along with supervisors and coworkers - previous job
          was "not organized" and staff always late causing him to work harder.
          
          Activities: Watches TV, computer, nightly walks with daughter.
         
         
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
          The veteran reports a history of family mental health problems -  M'
          grandfather died of cirrhosis after WWII due to drinking, cousin died
          from heroin, father became depressed after vet went to Iraq.
          
          The veteran denies pre-military mental health problems, but did "get
          angry at parents for rules".  To reiterate,  he does not have a
history
          of childhood trauma.  He denies developmental problems or learning
          disabilities.
          
          The veteran states he was not treated in-service for mental health or
          substance abuse issues.
          
          He reports his first mental health treatment was ~JUN 11, 2015 at the
          Modesto Clinic for PTSD, depression, and alcohol.  The veteran denies
          previous psychiatric hospitalizations.  The veteran denies previous
          substance abuse programs other than mandatory classes for his
squadron.
          The veteran has been in previous outpatient mental health treatment.
          The veteran is currently in outpatient treatment with BOYOVICH,JENNA
          and PEDDU,VANDANA DEVI (Modesto VA OP MHC and Livermore VA OP MHC).

          Previous diagnoses have included: See above. The veteran is taking
          psychotropic medications currently:
          "1)   PRAZOSIN HCL 1MG CAP TAKE ONE CAPSULE BY MOUTH AT      PENDING
                 BEDTIME
          2)   SERTRALINE HCL 50MG TAB TAKE ONE TABLET BY MOUTH       PENDING
                 EVERY EVENING".

          He does not report a history of previous psychotropic medication.
          
          The veteran reports he has not made any previous suicide attempts or
          acts of self mutilation.  The veteran does have a history of fights.
          Last fight - 2009 - in the Air Guard.  Denies domestic violence 
      
          
          Current MSE is negative for expressed psychotic symptoms or acute
          suicidal or homicidal ideation. Reports some road rage
   

          Last CRRS Mental Health Progress Note: AUG 21, 2015.
          
          
          
          
         
         
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          Denies history of  pre-military behavioral or legal problems.
          Denies history of  military behavioral or legal problems - letter of
          reprimand - ex-wife bounced a check at the PX.
          Endorses history of  post-military behavioral or legal problems- $3000
          in tickets - speeding and reckless driving + driving without a
license.
          Denies history of being on parole or probation.
          Denies current legal problems.
          
         
         
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          Minimizes history of  pre-military substance abuse.
          Endorses history of military substance abuse - when returned from
Iraq.
          Endorses history of  post-military substance abuse. 
          Any previous substance abuse-related legal charges: Denies.
          Last drink: 06/2015
          Last drug use: Freshman year of HS - "tried  MJ"
         
         
    f. Other, if any:
          Iraq
         
         
    3. Stressors
    ------------
    
          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)
          [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] Inability to remember an important aspect of the traumatic
event(s)
              (typically due to dissociative amnesia and not to other factors
              such as head injury, alcohol, or drugs).
          [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.

       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] Reckless or self-destructive behavior.
          [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] Impaired judgment
       [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] Inability to establish and maintain effective relationships

    6. Behavioral Observations
    --------------------------
    Causally attired tattooed male wearing an Operation Iraqi Freedom hat.

    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:
              "Impulsive with driving and money"
              Motivation - has to be forced to
              get out of the house most of the time. Checks locks at night, does
              not like to have blinds open.  Gets anxious if not 15 minutes
early
              for appts.
             
             
    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 does meet the DSM-5 criteria for PTSD. His claimed stressor
       is, at least as likely as not, related to the veteran's fear of hostile
       military or terrorist activity during his tour of duty in Iraq.

      
      
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

[SeattleShay]

Looks a lot like mine and I got 50%...

[USMC_VET]

i was going to say 50% is most likely.  you do have some ones that fall within 70%, but how the VA rates, is based on taking all your symptoms

They then match them up with what % it falls under, whoever has more wins, unless its something severe like suicidal attempts, homicidal thoughts or actions, then that will bump you up even if the others fall mostly into 50%.

I would say 50%.

 

Im glad you are in therapy, keep at it brother.

[bluevet]

I agree, I would guess a 50% rating. Are you already service connected? If so, What is your current rating; is this a claim for increase?

Edited September 5, 2015 by bluevet

[dgraham82]

I'm currently 30% for MDD, I opened a new claim, for TBI, Tinnitus, Migraines and PTSD. So far it looks like all of them have been connected to my service. I am just waiting on the rating decision now.

[bluevet]

I'm currently 30% for MDD, I opened a new claim, for TBI, Tinnitus, Migraines and PTSD. So far it looks like all of them have been connected to my service. I am just waiting on the rating decision now.

OK, I was just trying to understand why this examiner did not review your c-file, but I suppose if the VA is not requesting an opinion on service connection and are only seeking a picture of your current condition/symptomology, then it may not be of consequence, although, in rating your claim the rater should be looking at the total picture of your disabilities and not just the most recent exam.

[dgraham82]

Finally got my rating back. 80 percent total. 70 percent PTSD, mdd and tbi, 30 percent post traumatic headaches and 10 percent tinnitus