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: F43.10; F60.3
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: F43.10
Comments, if any:he veteran presents for an initial PTSD C&P assessment based
on
MST. She has a h/o premilitary trauma, and post military trauma.
SMRs show a diagnosis of PTSD following her military psych
admission. Her PTSD therefore predates her postmilitary trauma.
Despite documented awareness of her pre-military trauma, numerous
records and providers have documented her PTSD as being d/t her
MST. Although she continues to have some occasional reexperiencing
symptoms related to her premilitary trauma, the major and
intensity
of her reexperiencing symptoms is related to her MST, rather then
her other traumas (nonmilitary). MST remains the focus of her
treatment. There is no evidence that her post-military trauma
caused any permanent worsening of her PTSD beyond its normal
course.
Her PTSD is therefore felt to be primarily d/t her MST. There are
markers of a potential MST in her SMR and Personnell records.
Evidence indicates that she reported a MST the next day, had a
rape
kit performed at a private hospital 1 day later (results were no
DNA evidence but some evidence of physical trauma), and that an
OSI
investigation occured. Her sudden desire to get out of the service
(after wanting to make it a career) and ER psych visits within 2
weeks of her MST and psych hospitalization show a change in
behavior and psychiatric symptoms following her MST which is
consistent with MST and which previously was not present. Her
enlistment exam is negative for MH symptoms and treatment. A
routine psych screening performed on 7-14-08 showed no evidence of
psychiatric symptomatology prior to her MST. Additionally, she has
had difficulty with intimacy and occupational functioning
uncharacteristic of her pri-military functioning. There therefore
is sufficient evidence that the MST, as likely as not, occured and
resulted in a change in behavior and symptoms.
Records indicate that command had difficulty believing her account
of MST given the veteran's "changing events/timeline/and
details"
of the initial report and also making additional claim that she
was
assaulted and held at knifepoint in a vehicle outside her barracks
by one of her assailants that was proven to be false. Minor
changes
in her account are however not atypical of rape victims, as
indicated by the psych consultant who saw her on 12/15/08 in the
ER. Her false report can be adequately explained by her
frustration
with not being believed by her command, her desire to hold her
assailant accountable and with her desire to "get out of the
service" after the MST. Since being d/c'd from theaccount of the MST has been fairly consistent in minor details and
completely consistent in the major details.
Mental Disorder Diagnosis #2: Borderline Personality Disorder
ICD code: F60.3
Comments, if any:
There is clear evidence of a personality disorder as evidenced by
an active diagnosis of Borderline PD in both her outpt and inpt
psych records. Her personality disorder is not felt to be caused
by
the service or permanently aggravated by the service. Personality
disorders tend to be conditions which develop in adolescence or
early adulthood and tend to develop in response to severe or
prolonged trauma, as is the case with this veteran. She has a
pre-military history of extensive emotional and physical abuse by
various people and a h/o a sexual assault. She has a h/o self
cutting since age 16yo. Personality Disorders are often associated
with mood disorders and/or substance abuse which tend to stem from
long term behavior problems and psychosocial functioning
difficulties which stem from the personality disorder. It is more
likely than not that the presence of her preexisting personality
disorder is the primary cause of her relationship problems, self-
destructive behavior and difficulty adapting to the service and
pattern of misconduct which is documented in the SMRs and military
Personnell records and was the eventual cause of her
Administrative
separation after only 8-9 months. Although she did not endorse
mental health symptoms at the time of her enlistment exam, this
does not mean that she was not symptomatic in regard to her
personality disorder and (from premilitary trauma), especially in
light of her self admission (per her own statements in the
records)
of a pattern of lying and h/o self mutilation. Although it is as
likely as not that her Personality Disorder and PTSD mutually
affect each other, there is no clear evidence that her personality
disorder was permanently worsened by her PTSD/MST beyond it's
normal course.
Mental Disorder Diagnosis #3: Major Depression, moderate recurrent
ICD code: F32.1
Comments, if any:
Her depression is felt to be d/t a combination of her PTSD and
Personality Disorder. Both conditions are frequently associated
with depression. Since there is an overlap in symptoms and she has
significant psychosocial functioning difficulties related to each
condition, it would be speculative to try to determine which
condition is the cause of her depression (without resorting to
mere
speculation).
b. Medical diagnoses relevant to the understanding or management oftheeMental Health Disorder (to include TBI): noncontributory
ICD code: see medical notes
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?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no,
provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
There is such an overlap in symptoms that it would be speculative
to try to differentiate which symptoms and which psychosocial
functioning difficulties are due to any one condition with the
following exception:
Due to PTSD exclusively: Hypervigilance, mistrust, re-experiencing
symptoms, increased startle reaction, avoidance of crowds
Due to Borderline PD exclusively: deceitfulness/lying; pattern of
unstable interpersonal relationships self image and affects;
impulsivity; abandonment issues; pattern of parasuicidal
behavior/self harm; unstable self image; chronic feelings of
emptiness; victim mentality; transient stress related paranoia
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 deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood
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 [X] No [ ] No other mental disorder has been diagnosed
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:
There is such an overlap in symptoms that it would be speculative
to try to differentiate which psychosocial functioningdifficulties
specifically are due to any one condition. Each condition appears
to cause moderate to serious psychosocial functioning difficulty
(based on the severity of each condition).
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:
[X] Military service treatment records
[X] Military service personnel records
[X] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[X] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[X] 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:
statement of claim
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):
PREMILITARY HISTORY:
The veteran was born and raised in Ohio. She lived with her mother
after her parents divorced when she was very young. She has one
brother
and 7 1/2 brothers. They moved almost every year; she indicates that
it
was difficult to always have to make new friends. She indicates that
her father was barely involved in her life. She was repeatedly
emotionally abused by her mother and her mother's boyfriends. Her
brother's friend once tried unsuccessfully to rape her. Her mother
is
described as an alchoholic. Eventually her father took her brother to
live with him (when she was 13yo); she went to live with her
grandmother when she was 13yo. When her grandmother died, she returned
to her mother's home; she indicates that it was more stable after
she
married when the veteran was 11yo. She had stayed with her
grandmother
off and on in the summers previously. She graduated high school with
average grades with certification as a nursing assistant. She was
active in the drama club, track and cross country. She worked at a
local restaurant for 1.5 years before graduating and joining the
service. She wanted to make it a career.
Abuse or neglect: as per above
Discipline problems: none reported
Juvenile offenses: none
ETOH problems in adolescence: none
MILITARY HISTORY:
Branch: Air Force
Duration: 9 months (7/08-4/09)
Location/MOS/: noncombat; MOS: services helper
Discharge: General under Honorable-E1 (pattern of misconduct)
Active combat exposure: no
Military Sexual Trauma: Yes
Disciplinary Actions: 2 article XV for altering public records and
making a false statement or attack
General comments:
POSTMILITARY HISTORY: The veteran is single and has never married. She
moved in with her HS sweetheart after leaving the service. He was
emotionally abusive and physically abusive on one occasion. The
relationship resulted in 2 children (5yo and 1yo) but lasted only 6
years. For the last 8 months she has been in a new relationship with
her best friend's son (her age). She lives with her friend Emily,Emily's 2 children and her 2 children. She endorses almost
impulsively
marrying someone that she hardly knew after her MST. She indicates
that
both of her relationships were negative affected by her difficulty
with
intimacy which started after her MST. Her relationship currently is
also negatively affected by irritability, emotional detachment and
social withdrawal. She keeps to herself and does not interact with
neighbors or coworkers. She has 2-3 friends. She endorses mistrust of
most people. She has little contact with family.
Neglect of ADLs: none
Neglect of hygiene/appearance: none
Involvement in organizations: none
Activities/hobbies: horseback riding; service dog; kids; reading
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Educational history: The veteran graduated high school with average
grades. She had no difficulties with disciplinary problems. She
attended some classes at Stark State while in HS. When she graduated
from HS, she had her STNA certification. In 2011, she graduated from
Brown Macky College with a LPN. GPA 3.0. She failed anatomy and
physiology the first time.
Work history: She worked at a restaurant for 1.5 years in HS. Since
separating from the service, she has had problems keeping a job. She
was a full time student for 2 years. After graduating, she has
averaged
3-5 jobs per year, with most jobs (all LPN positions) lasting <3
months
until she was fired for calling off and going home early d/t
anxiety/PTSD symptoms. She has been at her current position as a LPN
charge nurse (supervising STNAs) for the last year. She is on
probation
and will be terminated if she calls off work one more time (she showed
this writer 3 reprimand letters). She has exhausted and gone beyond
their call off limitations, but supervisors have worked with her to
some degree because she is on FMLA and disclosed her PTSD to them. She
keeps to herself and does not interact with coworkers. She is well
liked by residents. She works the night shift on a psych ward and
feels
that she can related to the residents; she feels that she has last
longer at her current position becasue "things are quiet on the
night
shift". However she endorses panic attacks which causes her to go
home
early 3-4x/mo. She endorses difficulties with productivity,reliability
or effectiveness/efficiency d/t anxiety/panic and poor concentration.
She has been repeatedly reprimanded for charting errors. She denied
difficulty with accepting supervision and/or criticism. She endorses
difficulty with flexibility, concentration or impulsivity on the job.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
FAMILY History (mental health, substance abuse, suicide attempts):
ETOH: mother
autism: 1/2 brother
suicide: 1/2 brother
PTSD: brother
MENTAL HEALTH HISTORY:
Pre-military treatment: no treatment or symptoms except for one
incident of self cutting at age 16yo
Military treatment: SMR show that she presented for a routine psych
assessment 7/14/08 and was found to have no psychiatric symptoms or
diagnosis. After her MST, records show c/o many neurovegative symptoms
of depression, anxiety and PTSD symptoms. She was seen in the ER on
several occasions for psych complaints or vague GI symptoms. She was
psychatrically hospitalized at Lackland AFB for several days d/t a
suicidal gesture (cut on her leg) after her MST. She had some limited
outpt treatment including therapy and ambien for sleep problems until
she was separated. Records indicate that she was diagnosed with PTSD
and Adjustment Disorder with depression.
POST-MILITARY TREATMENT: The veteran sought treatment at various
civilian psych cewnters over the years, but had trouble trusting
providers. Her PCP (Dr. Volpe DO) has been treating her for MD and
PTSD since 2010 and continues to give her valium prn. Since 5/15, she
has transfer her MH treatment to the VA. She was evaluated by the MST
coordinator who confirmed a diagnosis of PTSD based on MST. She is now
seen weekly for therapy and q3mo for medication management. She has
found treatment to be helpful but remains quite symptomatic. She was
psychiatrically admitted in 6/15, where she was diagnosed with PTSD
and
Borderline PD. She continues to have active diagnoses of PTSD,
borderline PD and Major depression. She endorses chronic difficulty
with depression, anxiety and panic attacks 3-4x/day. She endorses
frequent irritability and anger outburst, but denies assault and
violence. She endorses occasional passive thoughts of death, but
denies
active SI/HI, intent and plan. She also endorses serious difficulty
with social withdrawal and emotional detachment. She has frequent
difficulty with hopelessness, helplessness, concentration, energy, and
impulsivity. She admits that she is impulsive with spending, reckless
driving, risk taking behaviors, self cutting and ETOH. She endorses
chronic nightmares and re-experiencing symptoms. She endorses
hypervigilance and trouble relaxing/high anxiety. She has problemsintimacy, mistrust, fear of abandonment and chronic feelings of
emptiness. She denies mania, OCD and psychotic symptoms.
Inpatient admissions: one in the military and one at the VA in 6/15
Substance abuse treatment: none
Suicide attempts: none, but intermittent suicidal gestures/thoughts
and chronic passive thoughts of death
Use of psychotropic meds: prozac, hydroxyzine and duloxetine (plus
valium prn from her PCP)
Side effects: GI upset
RELEVANT RECORDS:
#1. inpatient VA psych admission discharge summary 6/15:
Was gang raped by six active duty military members she
knew after being drugged in October 2008. Filed a report, obtained a
rape kit,
and was not believed by command. Was forced out of service under
general
conditions after 9 months of service, despite her desire to make the
AF
a
career
There's even more to report. But I couldn't get all of it on here. Some of her wording I don't understand. I was fine before the mst happened and she makes it very clear but im concerned they'll blame it on my childhood. And according to the rating thing she rated a 70 percent. Is that right? I know the reviewer is the decide but I know c and p exam can weigh in pretty heavy.
Question
Eliza
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: F43.10; F60.3
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: F43.10
Comments, if any:he veteran presents for an initial PTSD C&P assessment based
on
MST. She has a h/o premilitary trauma, and post military trauma.
SMRs show a diagnosis of PTSD following her military psych
admission. Her PTSD therefore predates her postmilitary trauma.
Despite documented awareness of her pre-military trauma, numerous
records and providers have documented her PTSD as being d/t her
MST. Although she continues to have some occasional reexperiencing
symptoms related to her premilitary trauma, the major and
intensity
of her reexperiencing symptoms is related to her MST, rather then
her other traumas (nonmilitary). MST remains the focus of her
treatment. There is no evidence that her post-military trauma
caused any permanent worsening of her PTSD beyond its normal
course.
Her PTSD is therefore felt to be primarily d/t her MST. There are
markers of a potential MST in her SMR and Personnell records.
Evidence indicates that she reported a MST the next day, had a
rape
kit performed at a private hospital 1 day later (results were no
DNA evidence but some evidence of physical trauma), and that an
OSI
investigation occured. Her sudden desire to get out of the service
(after wanting to make it a career) and ER psych visits within 2
weeks of her MST and psych hospitalization show a change in
behavior and psychiatric symptoms following her MST which is
consistent with MST and which previously was not present. Her
enlistment exam is negative for MH symptoms and treatment. A
routine psych screening performed on 7-14-08 showed no evidence of
psychiatric symptomatology prior to her MST. Additionally, she has
had difficulty with intimacy and occupational functioning
uncharacteristic of her pri-military functioning. There therefore
is sufficient evidence that the MST, as likely as not, occured and
resulted in a change in behavior and symptoms.
Records indicate that command had difficulty believing her account
of MST given the veteran's "changing events/timeline/and
details"
of the initial report and also making additional claim that she
was
assaulted and held at knifepoint in a vehicle outside her barracks
by one of her assailants that was proven to be false. Minor
changes
in her account are however not atypical of rape victims, as
indicated by the psych consultant who saw her on 12/15/08 in the
ER. Her false report can be adequately explained by her
frustration
with not being believed by her command, her desire to hold her
assailant accountable and with her desire to "get out of the
service" after the MST. Since being d/c'd from theaccount of the MST has been fairly consistent in minor details and
completely consistent in the major details.
Mental Disorder Diagnosis #2: Borderline Personality Disorder
ICD code: F60.3
Comments, if any:
There is clear evidence of a personality disorder as evidenced by
an active diagnosis of Borderline PD in both her outpt and inpt
psych records. Her personality disorder is not felt to be caused
by
the service or permanently aggravated by the service. Personality
disorders tend to be conditions which develop in adolescence or
early adulthood and tend to develop in response to severe or
prolonged trauma, as is the case with this veteran. She has a
pre-military history of extensive emotional and physical abuse by
various people and a h/o a sexual assault. She has a h/o self
cutting since age 16yo. Personality Disorders are often associated
with mood disorders and/or substance abuse which tend to stem from
long term behavior problems and psychosocial functioning
difficulties which stem from the personality disorder. It is more
likely than not that the presence of her preexisting personality
disorder is the primary cause of her relationship problems, self-
destructive behavior and difficulty adapting to the service and
pattern of misconduct which is documented in the SMRs and military
Personnell records and was the eventual cause of her
Administrative
separation after only 8-9 months. Although she did not endorse
mental health symptoms at the time of her enlistment exam, this
does not mean that she was not symptomatic in regard to her
personality disorder and (from premilitary trauma), especially in
light of her self admission (per her own statements in the
records)
of a pattern of lying and h/o self mutilation. Although it is as
likely as not that her Personality Disorder and PTSD mutually
affect each other, there is no clear evidence that her personality
disorder was permanently worsened by her PTSD/MST beyond it's
normal course.
Mental Disorder Diagnosis #3: Major Depression, moderate recurrent
ICD code: F32.1
Comments, if any:
Her depression is felt to be d/t a combination of her PTSD and
Personality Disorder. Both conditions are frequently associated
with depression. Since there is an overlap in symptoms and she has
significant psychosocial functioning difficulties related to each
condition, it would be speculative to try to determine which
condition is the cause of her depression (without resorting to
mere
speculation).
b. Medical diagnoses relevant to the understanding or management oftheeMental Health Disorder (to include TBI): noncontributory
ICD code: see medical notes
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?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no,
provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
There is such an overlap in symptoms that it would be speculative
to try to differentiate which symptoms and which psychosocial
functioning difficulties are due to any one condition with the
following exception:
Due to PTSD exclusively: Hypervigilance, mistrust, re-experiencing
symptoms, increased startle reaction, avoidance of crowds
Due to Borderline PD exclusively: deceitfulness/lying; pattern of
unstable interpersonal relationships self image and affects;
impulsivity; abandonment issues; pattern of parasuicidal
behavior/self harm; unstable self image; chronic feelings of
emptiness; victim mentality; transient stress related paranoia
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 deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood
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 [X] No [ ] No other mental disorder has been diagnosed
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:
There is such an overlap in symptoms that it would be speculative
to try to differentiate which psychosocial functioningdifficulties
specifically are due to any one condition. Each condition appears
to cause moderate to serious psychosocial functioning difficulty
(based on the severity of each condition).
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:
[X] Military service treatment records
[X] Military service personnel records
[X] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[X] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[X] 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:
statement of claim
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):
PREMILITARY HISTORY:
The veteran was born and raised in Ohio. She lived with her mother
after her parents divorced when she was very young. She has one
brother
and 7 1/2 brothers. They moved almost every year; she indicates that
it
was difficult to always have to make new friends. She indicates that
her father was barely involved in her life. She was repeatedly
emotionally abused by her mother and her mother's boyfriends. Her
brother's friend once tried unsuccessfully to rape her. Her mother
is
described as an alchoholic. Eventually her father took her brother to
live with him (when she was 13yo); she went to live with her
grandmother when she was 13yo. When her grandmother died, she returned
to her mother's home; she indicates that it was more stable after
she
married when the veteran was 11yo. She had stayed with her
grandmother
off and on in the summers previously. She graduated high school with
average grades with certification as a nursing assistant. She was
active in the drama club, track and cross country. She worked at a
local restaurant for 1.5 years before graduating and joining the
service. She wanted to make it a career.
Abuse or neglect: as per above
Discipline problems: none reported
Juvenile offenses: none
ETOH problems in adolescence: none
MILITARY HISTORY:
Branch: Air Force
Duration: 9 months (7/08-4/09)
Location/MOS/: noncombat; MOS: services helper
Discharge: General under Honorable-E1 (pattern of misconduct)
Active combat exposure: no
Military Sexual Trauma: Yes
Disciplinary Actions: 2 article XV for altering public records and
making a false statement or attack
General comments:
POSTMILITARY HISTORY: The veteran is single and has never married. She
moved in with her HS sweetheart after leaving the service. He was
emotionally abusive and physically abusive on one occasion. The
relationship resulted in 2 children (5yo and 1yo) but lasted only 6
years. For the last 8 months she has been in a new relationship with
her best friend's son (her age). She lives with her friend Emily,Emily's 2 children and her 2 children. She endorses almost
impulsively
marrying someone that she hardly knew after her MST. She indicates
that
both of her relationships were negative affected by her difficulty
with
intimacy which started after her MST. Her relationship currently is
also negatively affected by irritability, emotional detachment and
social withdrawal. She keeps to herself and does not interact with
neighbors or coworkers. She has 2-3 friends. She endorses mistrust of
most people. She has little contact with family.
Neglect of ADLs: none
Neglect of hygiene/appearance: none
Involvement in organizations: none
Activities/hobbies: horseback riding; service dog; kids; reading
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Educational history: The veteran graduated high school with average
grades. She had no difficulties with disciplinary problems. She
attended some classes at Stark State while in HS. When she graduated
from HS, she had her STNA certification. In 2011, she graduated from
Brown Macky College with a LPN. GPA 3.0. She failed anatomy and
physiology the first time.
Work history: She worked at a restaurant for 1.5 years in HS. Since
separating from the service, she has had problems keeping a job. She
was a full time student for 2 years. After graduating, she has
averaged
3-5 jobs per year, with most jobs (all LPN positions) lasting <3
months
until she was fired for calling off and going home early d/t
anxiety/PTSD symptoms. She has been at her current position as a LPN
charge nurse (supervising STNAs) for the last year. She is on
probation
and will be terminated if she calls off work one more time (she showed
this writer 3 reprimand letters). She has exhausted and gone beyond
their call off limitations, but supervisors have worked with her to
some degree because she is on FMLA and disclosed her PTSD to them. She
keeps to herself and does not interact with coworkers. She is well
liked by residents. She works the night shift on a psych ward and
feels
that she can related to the residents; she feels that she has last
longer at her current position becasue "things are quiet on the
night
shift". However she endorses panic attacks which causes her to go
home
early 3-4x/mo. She endorses difficulties with productivity,reliability
or effectiveness/efficiency d/t anxiety/panic and poor concentration.
She has been repeatedly reprimanded for charting errors. She denied
difficulty with accepting supervision and/or criticism. She endorses
difficulty with flexibility, concentration or impulsivity on the job.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
FAMILY History (mental health, substance abuse, suicide attempts):
ETOH: mother
autism: 1/2 brother
suicide: 1/2 brother
PTSD: brother
MENTAL HEALTH HISTORY:
Pre-military treatment: no treatment or symptoms except for one
incident of self cutting at age 16yo
Military treatment: SMR show that she presented for a routine psych
assessment 7/14/08 and was found to have no psychiatric symptoms or
diagnosis. After her MST, records show c/o many neurovegative symptoms
of depression, anxiety and PTSD symptoms. She was seen in the ER on
several occasions for psych complaints or vague GI symptoms. She was
psychatrically hospitalized at Lackland AFB for several days d/t a
suicidal gesture (cut on her leg) after her MST. She had some limited
outpt treatment including therapy and ambien for sleep problems until
she was separated. Records indicate that she was diagnosed with PTSD
and Adjustment Disorder with depression.
POST-MILITARY TREATMENT: The veteran sought treatment at various
civilian psych cewnters over the years, but had trouble trusting
providers. Her PCP (Dr. Volpe DO) has been treating her for MD and
PTSD since 2010 and continues to give her valium prn. Since 5/15, she
has transfer her MH treatment to the VA. She was evaluated by the MST
coordinator who confirmed a diagnosis of PTSD based on MST. She is now
seen weekly for therapy and q3mo for medication management. She has
found treatment to be helpful but remains quite symptomatic. She was
psychiatrically admitted in 6/15, where she was diagnosed with PTSD
and
Borderline PD. She continues to have active diagnoses of PTSD,
borderline PD and Major depression. She endorses chronic difficulty
with depression, anxiety and panic attacks 3-4x/day. She endorses
frequent irritability and anger outburst, but denies assault and
violence. She endorses occasional passive thoughts of death, but
denies
active SI/HI, intent and plan. She also endorses serious difficulty
with social withdrawal and emotional detachment. She has frequent
difficulty with hopelessness, helplessness, concentration, energy, and
impulsivity. She admits that she is impulsive with spending, reckless
driving, risk taking behaviors, self cutting and ETOH. She endorses
chronic nightmares and re-experiencing symptoms. She endorses
hypervigilance and trouble relaxing/high anxiety. She has problemsintimacy, mistrust, fear of abandonment and chronic feelings of
emptiness. She denies mania, OCD and psychotic symptoms.
Inpatient admissions: one in the military and one at the VA in 6/15
Substance abuse treatment: none
Suicide attempts: none, but intermittent suicidal gestures/thoughts
and chronic passive thoughts of death
Use of psychotropic meds: prozac, hydroxyzine and duloxetine (plus
valium prn from her PCP)
Side effects: GI upset
RELEVANT RECORDS:
#1. inpatient VA psych admission discharge summary 6/15:
Was gang raped by six active duty military members she
knew after being drugged in October 2008. Filed a report, obtained a
rape kit,
and was not believed by command. Was forced out of service under
general
conditions after 9 months of service, despite her desire to make the
AF
a
career
There's even more to report. But I couldn't get all of it on here. Some of her wording I don't understand. I was fine before the mst happened and she makes it very clear but im concerned they'll blame it on my childhood. And according to the rating thing she rated a 70 percent. Is that right? I know the reviewer is the decide but I know c and p exam can weigh in pretty heavy.
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Meddac
A rater has to input the exam findings which consist of several checked boxes. These occur in the latter pages of the exam DBQ. the question of whether or not it will be service connected has bee
Buck52
jmo yes I would say your rating is 70%, being you have good hygiene and can take care of your finances is why you were not rated 100% I see nothing in your childhood other than your parent
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