My VSO and I put in a request for TDIU. I also wonder why E-Benfits shows IU and increase for 100% PTSD when we did not file for 100% PTSD increase? Is this automatic? I am currenty at 80% total, 70% is for PTSD-Combat. My last C&P for PTSD was less than a year ago. 08/12/2015. The doctor that did the new onebelow called it a "REVIEW"??? I was working during the 1st one and I am not now, I resigned in December 2015. Please let me know what you think and please answer my above questions. THANK YOU!!
Service Connected Disabilities:
ASTHMA,BRONCHIAL (30%-SC)
INGUINAL HERNIA (0%-SC)
KNEE CONDITION (10%-SC)
POST-TRAUMATIC STRESS DISORDER-COMBAT (70%-SC)
IMPAIRED HEARING (0%-SC)
TINNITUS (10%-SC)
Review Post Traumatic Stress Disorder (PTSD)Disability Benefits QuestionnaireName of patient/Veteran:
SECTION I:----------1. Diagnostic Summary---------------------Does the Veteran now have or has he/she ever been diagnosed with PTSD?[X] Yes[ ] NoICD
Code: F43.102.
Current Diagnoses--------------------a. Mental Disorder Diagnosis #1: Post traumatic Stress DisorderICD Code: F43.10Comments, if any: Previously diagnosed by Dr. David Coron on 8/12/2015.Currently Service Connected 70% for PTSD. Total service connection isreported to be 80%Mental Disorder Diagnosis
#2: Opiod Dependence in RemissionICD Code: 304.01Comments, if any: Reports that he has been clean for last 6 years.b.
Medical diagnoses relevant to the understanding or management of theMental Health Disorder (to include TBI): Please refer to Medical Recordsand CPRS for all medical problems and concerns.
Veteran is currently 30%service connected for asthma; 10% for knee, 10 % for tinnitus , 0% ofinguinal hernia and 0% for hearing impairment.
3. Differentiation of symptoms------------------------------a. Does the Veteran have more than one mental disorder diagnosed?[X] Yes[ ] Nob. Is it possible to differentiate what symptom(s) is/are attributable toeach diagnosis?[ ] Yes[X] No[ ] Not applicable
(N/A)If no, provide reason that it is not possible to differentiate whatportion of each symptom is attributable to each diagnosis and discusswhether there is any clinical association between these diagnoses:Comorbid relationship between diagnosis such that separation ofsymptoms can not be reliably performed without engaging inspeculation.
It is likely that all symptoms are related to PTSD.c.
Does the Veteran have a diagnosed traumatic brain injury (TBI)?[ ] Yes[X] No[ ] Not shown in records reviewed4.
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 onlyone)
[X] Occupational and social impairment with deficiencies in most areas,such as work, school, family relations, judgment, thinking and/ormoodb. For the indicated level of occupational and social impairment, is itpossible to differentiate what portion of the occupational and socialimpairment 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 whatportion of the indicated level of occupational and social impairmentis attributable to each diagnosis: Comorbid relationship betweendiagnosis such that separation of symptoms can not be reliablyperformed without engaging in speculation. It is likely that allsymptoms are related to PTSD.c.
If a diagnosis of TBI exists, is it possible to differentiate whatportionof the occupational and social impairment indicated above is caused bytheTBI?[ ] 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?[X] Yes[ ] NoIf yes,
list any records that were reviewed but were not included in theVeteran's VA claims file:Elecronic Medical Record was also reviewed today.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 treatmentrecords)[ ] Civilian medical records[ ] Interviews with collateral witnesses (family and others who haveknown the Veteran before and after military service)[ ] No records were reviewed[ ] Other:b. Was pertinent information from collateral sources reviewed?[X] Yes[ ] NoIf yes, describe:Electronic Medical Record was also reviewed today.2.
Recent History (since prior exam)------------------------------------a. Relevant Social/Marital/Family history:This is a 52 year old male Veteran who has been married 2 times. Hisfirst marriage was from 1988 to 1993 and he has 2 adult daughters,ages31 and 28 from this marriage. He was married a second time in 2011 and his wife, , is a medical secretary. He has no children from this marriage. He does report today that he has another daughter from aprevious high school relationship in 1986. He has some contact withher, but does not see her regularly. Veteran was born and raised in. Veteran reports that his parents were divorced when he was approximately 10 years of age. His parents have both passed away from heart attacks and he reports having one younger brother and one younger sister. He does not have contact with them on a regular basis. He attended xxxxxxxx school and graduated in1985.b.
Relevant Occupational and Educational history:Upon graduation from high school this Veteran worked for approximately1 year in construction. He then entered the military (Army) on August19, 1986 and was discharged on August 19, 1995. He completed basictraining at Fort Knox, Kentucky and was then stationed at FortBelvoir,Virginia for the next 3 years. His MOS was 52-Charlie, utilitiesequipment repair. After Fort Belvoir, he spent approximately 3 yearsat Fort Bragg. He was then deployed to Desert Storm for approximately9 months, followed by 1 year in Korea. He returned to Fort Riley,Kansas for 2/3 years before discharge. While at Fort Riley he alsoattended xxxxxxxxxxx xxxxx in Kansas and obtained an associateddegree in liberal arts. Regarding his deployment to Desert Storm hestates that he was responsible for driving parts back and forth,maintenance on vehicles and generators and filling sandbags. Upondischarge in 1995 and began workinginheating and air-conditioning. He worked for xxxx forapproximately 9 years until 2004, xxxxxxx for 8/9 years until2013,xxxxx for less than a year and finally xxxxxxy for lessthana year. He resigned from xxxxxx in December of 2015. Asked forthereason he resigned, he stated that "I couldn't take thestress andanxiety of the job. They were willing to let me work from home, butthat didn't work either". He continued to say that he began"havingdifficulty rememberingthe names of clients and what needed to bedone". Since that time he has not worked. He reports that he wasreceiving NYS Insurance, but that ended 3 months ago. His TotalService Connection is currently 80%, 70% of which is for PTSD. Hestates he receives approximately 1800.00 monthly from this serviceconnection.c. Relevant Mental Health history, to include prescribed medications andfamily mental health:Veteran states that he had no medical or psychological issues as achild/teenager. While in the military he had knee surgery, a herniarepair and dental surgery. He reports that while he was at FortRiley,he received drug and alcohol counseling and was then sent to Miramarfor a 30 day inpatient stay. He reports that he began drinkingheavilyafter his deployment to Desert Storm. Continued drinking heavily inKorea and his first wife eventually divorced him. After his dischargefrom the military he reports that he attended SA treatment at thexxxxxx VA in 2000 for 28 days. At that point he states that hestopped drinking alcohol. However, he then became addicted toVicadin,which he reports that he stopped in 2011. He began taking Suboxonewhich was originally given to him by an outside provider, but which henow receives from Dr. xxxxx here at the xxxxx Suboxone clinic. His psychiatrist here at the xxxx is Dr. xxxxx, who is prescribing Quetapine, Duloxetine and Prazosin. He also reports that he sees xxxxxxx currently at the Veteran's Outreach Center on a weekly basis for individual counseling since 2015. Symptoms reported today include increased anxiety and depression. He reports feeling that his self-worth and esteem have decreased since losing his job and he keeps obsessing about the fact that he was earning 85,000 a year and now"can't hack it". He continues to report nightmares,fighting and screaming in his sleep, often wakes up wet and soaking as a result of this dreams, hyper vigilance and high startle. He also reports that hestill cannot wear a seat belt, which he attributes to a fire he wasinvolved in in Saudi Arabia and is triggered by the smells of gasoline and burning fires. He also reports panic attacks and isolating behaviors.
d. Relevant Legal and Behavioral history:DWI in 2000. No other significant legal history.e.
Relevant Substance abuse history:States that he has been clean from alcohol use since 2000. Clean fromOpioid Use (vicadin) since 2011. Does admit that he currently smokes tobacco.f. Other, if any:No response provided.3.
PTSD Diagnostic Criteria---------------------------Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manualof Mental Disorders, 5th edition (DSM-5).
The stressful event can be due tocombat, personal trauma, other life threatening situations (non-combatrelated stressors.) Do NOT mark symptoms below that are clearly notattributable to the Criteria A stressor/PTSD. Instead, overlapping symptomsclearly attributable to other things should be noted under #6 - "Othersymptoms". Criterion A: Exposure to actual or threatened a) death, b) seriousinjury,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 theyoccurred to others Criterion B: Presence of (one or more) of the following intrusionsymptomsassociated with the traumatic event(s), beginning after thetraumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressingmemoriesof the traumatic event(s). [X] Recurrent distressing dreams in which the content and/oraffect of the dream are related to the traumaticevent(s). [X] Intense or prolonged psychological distress at exposuretointernal or external cues that symbolize or resemble anaspect of the traumatic event(s). [X] Marked physiological reactions to internal or externalcues that symbolize or resemble an aspect of thetraumaticevent(s).Criterion C: Persistent avoidance of stimuli associated with thetraumaticevent(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 withthetraumatic event(s). [X] Avoidance of or efforts to avoid external reminders(people, places, conversations, activities, objects,situations) that arouse distressing memories, thoughts,orfeelings about or closely associated with the traumaticevent(s).Criterion D: Negative alterations in cognitions and mood associated withthe traumatic event(s), beginning or worsening after thetraumatic event(s) occurred, as evidenced by two (or more)ofthe following: [X] Persistent negative emotional state (e.g., fear, horror,anger, guilt, or shame). [X] Markedly diminished interest or participation insignificant activities. [X] Persistent inability to experience positive emotions(e.g., inability to experience happiness, satisfaction,orloving feelings.)Criterion E: Marked alterations in arousal and reactivity associated withthe traumatic event(s), beginning or worsening after thetraumatic event(s) occurred, as evidenced by two (or more)ofthe following: [X] Irritable behavior and angry outbursts (with little or noprovocation) typically expressed as verbal or physicalaggression 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 stayingasleep or restless sleep). Criterion F:[X] The duration of the symptoms described above in CriteriaB, C, and D are more than 1 month. Criterion G:[X] The PTSD symptoms described above cause clinicallysignificant distress or impairment in social,occupational, or other important areas of functioning. Criterion H:[X] The disturbance is not attributable to the physiologicaleffects of a substance (e.g., medication, alcohol) oranother medical condition.4. Symptoms-----------For VA rating purposes, check all symptoms that actively apply to theVeteran'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 recentevents [X] Difficulty in establishing and maintaining effective work and socialrelationships [X] Difficulty in adapting to stressful circumstances, including work oraworklike setting [X] Inability to establish and maintain effective relationships5.
Behavioral Observations:---------------------------Cooperative and genuine throughout interview. No evidence of hallucinations or delusions. No evidence of suicidal or homicidalideation or intent.6. Other symptoms-----------------Does the Veteran have any other symptoms attributable to PTSD (and othermental disorders) that are not listed above?[ ] Yes[X]
No7. Competency-------------Is the Veteran capable of managing his or her financial affairs?[X] Yes[ ]
No8. Remarks, (including any testing results) if any:---------------------------------------------------Based on today's evaluation this Veteran continues to meet thecriteriafor a diagnosis of PTSD. He is currently service connected 70% for PTSDbased on his last Compensation and Pension Evaluation performed by Dr.xxxxxx on 8/12/2015. Veteran reports that he resigned from his job in December of 2015 because " I couldn;take the stress and anxietyof thejob. They were willing to let me work at home, but that didn't workeither". He was receiving NYS Insurance up until 3 weeks ago andthat hasnow ended. Based on the veteran's report today, it does not appear that his PTSD symptoms have necessarily worsened (he is currently service connected 70% or PTSD. It appears that he was experiencing stress related specifically to his job. Since he has resigned, he has increased stress and anxiety and is emotional today, stating that he is feeling like a failure to his family because he lost a job where he was earning 85,000 because "I couldnt hack it anymore". This examiner encourage this Veteran to conitnue his weekly counseling At the Veteran's Oureach Centerwith Les xxx and to also consider vocational rehabilitation, It is hoped that one his self image and self worth begins to increase and he is able to secure another vocational opportunity, that his overall stress and anxietywill lessen. It may be that he will have to begin slowly with part time opportunities until his overall self image and self worth is restored.
Question
Markay2k
My VSO and I put in a request for TDIU. I also wonder why E-Benfits shows IU and increase for 100% PTSD when we did not file for 100% PTSD increase? Is this automatic? I am currenty at 80% total, 70% is for PTSD-Combat. My last C&P for PTSD was less than a year ago. 08/12/2015. The doctor that did the new onebelow called it a "REVIEW"??? I was working during the 1st one and I am not now, I resigned in December 2015.
Please let me know what you think and please answer my above questions. THANK YOU!!
Service Connected Disabilities:
ASTHMA,BRONCHIAL (30%-SC)
INGUINAL HERNIA (0%-SC)
KNEE CONDITION (10%-SC)
POST-TRAUMATIC STRESS DISORDER-COMBAT (70%-SC)
IMPAIRED HEARING (0%-SC)
TINNITUS (10%-SC)
Review Post Traumatic Stress Disorder (PTSD)Disability Benefits QuestionnaireName of patient/Veteran:
SECTION I:----------1. Diagnostic Summary---------------------Does the Veteran now have or has he/she ever been diagnosed with PTSD?[X] Yes[ ] NoICD
Code: F43.102.
Current Diagnoses--------------------a. Mental Disorder Diagnosis #1: Post traumatic Stress DisorderICD Code: F43.10Comments, if any: Previously diagnosed by Dr. David Coron on 8/12/2015.Currently Service Connected 70% for PTSD. Total service connection isreported to be 80%Mental Disorder Diagnosis
#2: Opiod Dependence in RemissionICD Code: 304.01Comments, if any: Reports that he has been clean for last 6 years.b.
Medical diagnoses relevant to the understanding or management of theMental Health Disorder (to include TBI): Please refer to Medical Recordsand CPRS for all medical problems and concerns.
Veteran is currently 30%service connected for asthma; 10% for knee, 10 % for tinnitus , 0% ofinguinal hernia and 0% for hearing impairment.
3. Differentiation of symptoms------------------------------a. Does the Veteran have more than one mental disorder diagnosed?[X] Yes[ ] Nob. Is it possible to differentiate what symptom(s) is/are attributable toeach diagnosis?[ ] Yes[X] No[ ] Not applicable
(N/A)If no, provide reason that it is not possible to differentiate whatportion of each symptom is attributable to each diagnosis and discusswhether there is any clinical association between these diagnoses:Comorbid relationship between diagnosis such that separation ofsymptoms can not be reliably performed without engaging inspeculation.
It is likely that all symptoms are related to PTSD.c.
Does the Veteran have a diagnosed traumatic brain injury (TBI)?[ ] Yes[X] No[ ] Not shown in records reviewed4.
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 onlyone)
[X] Occupational and social impairment with deficiencies in most areas,such as work, school, family relations, judgment, thinking and/ormoodb. For the indicated level of occupational and social impairment, is itpossible to differentiate what portion of the occupational and socialimpairment 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 whatportion of the indicated level of occupational and social impairmentis attributable to each diagnosis: Comorbid relationship betweendiagnosis such that separation of symptoms can not be reliablyperformed without engaging in speculation. It is likely that allsymptoms are related to PTSD.c.
If a diagnosis of TBI exists, is it possible to differentiate what portionof the occupational and social impairment indicated above is caused bytheTBI?[ ] 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?[X] Yes[ ] NoIf yes,
list any records that were reviewed but were not included in theVeteran's VA claims file:Elecronic Medical Record was also reviewed today.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 treatmentrecords)[ ] Civilian medical records[ ] Interviews with collateral witnesses (family and others who haveknown the Veteran before and after military service)[ ] No records were reviewed[ ] Other:b. Was pertinent information from collateral sources reviewed?[X] Yes[ ] NoIf yes, describe:Electronic Medical Record was also reviewed today.2.
Recent History (since prior exam)------------------------------------a. Relevant Social/Marital/Family history:This is a 52 year old male Veteran who has been married 2 times. Hisfirst marriage was from 1988 to 1993 and he has 2 adult daughters,ages31 and 28 from this marriage. He was married a second time in 2011 and his wife, , is a medical secretary. He has no children from this marriage. He does report today that he has another daughter from aprevious high school relationship in 1986. He has some contact withher, but does not see her regularly. Veteran was born and raised in. Veteran reports that his parents were divorced when he was approximately 10 years of age. His parents have both passed away from heart attacks and he reports having one younger brother and one younger sister. He does not have contact with them on a regular basis. He attended xxxxxxxx school and graduated in1985.b.
Relevant Occupational and Educational history:Upon graduation from high school this Veteran worked for approximately1 year in construction. He then entered the military (Army) on August19, 1986 and was discharged on August 19, 1995. He completed basictraining at Fort Knox, Kentucky and was then stationed at FortBelvoir,Virginia for the next 3 years. His MOS was 52-Charlie, utilitiesequipment repair. After Fort Belvoir, he spent approximately 3 yearsat Fort Bragg. He was then deployed to Desert Storm for approximately9 months, followed by 1 year in Korea. He returned to Fort Riley,Kansas for 2/3 years before discharge. While at Fort Riley he alsoattended xxxxxxxxxxx xxxxx in Kansas and obtained an associateddegree in liberal arts. Regarding his deployment to Desert Storm hestates that he was responsible for driving parts back and forth,maintenance on vehicles and generators and filling sandbags. Upondischarge in 1995 and began workinginheating and air-conditioning. He worked for xxxx forapproximately 9 years until 2004, xxxxxxx for 8/9 years until2013,xxxxx for less than a year and finally xxxxxxy for lessthana year. He resigned from xxxxxx in December of 2015. Asked forthereason he resigned, he stated that "I couldn't take thestress andanxiety of the job. They were willing to let me work from home, butthat didn't work either". He continued to say that he began"havingdifficulty rememberingthe names of clients and what needed to bedone". Since that time he has not worked. He reports that he wasreceiving NYS Insurance, but that ended 3 months ago. His TotalService Connection is currently 80%, 70% of which is for PTSD. Hestates he receives approximately 1800.00 monthly from this serviceconnection.c. Relevant Mental Health history, to include prescribed medications andfamily mental health:Veteran states that he had no medical or psychological issues as achild/teenager. While in the military he had knee surgery, a herniarepair and dental surgery. He reports that while he was at FortRiley,he received drug and alcohol counseling and was then sent to Miramarfor a 30 day inpatient stay. He reports that he began drinkingheavilyafter his deployment to Desert Storm. Continued drinking heavily inKorea and his first wife eventually divorced him. After his dischargefrom the military he reports that he attended SA treatment at thexxxxxx VA in 2000 for 28 days. At that point he states that hestopped drinking alcohol. However, he then became addicted toVicadin,which he reports that he stopped in 2011. He began taking Suboxonewhich was originally given to him by an outside provider, but which henow receives from Dr. xxxxx here at the xxxxx Suboxone clinic. His psychiatrist here at the xxxx is Dr. xxxxx, who is prescribing Quetapine, Duloxetine and Prazosin. He also reports that he sees xxxxxxx
currently at the Veteran's Outreach Center on a weekly basis for individual counseling since 2015. Symptoms reported today include increased anxiety and depression. He reports feeling that his self-worth and esteem have decreased since losing his job and he keeps obsessing about the fact that he was earning 85,000 a year and now"can't hack it". He continues to report nightmares,fighting and screaming in his sleep, often wakes up wet and soaking as a result of this dreams, hyper vigilance and high startle. He also reports that hestill cannot wear a seat belt, which he attributes to a fire he wasinvolved in in Saudi Arabia and is triggered by the smells of gasoline and burning fires. He also reports panic attacks and isolating behaviors.
d. Relevant Legal and Behavioral history:DWI in 2000. No other significant legal history.e.
Relevant Substance abuse history:States that he has been clean from alcohol use since 2000. Clean fromOpioid Use (vicadin) since 2011. Does admit that he currently smokes tobacco.f. Other, if any:No response provided.3.
PTSD Diagnostic Criteria---------------------------Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manualof Mental Disorders, 5th edition (DSM-5).
The stressful event can be due tocombat, personal trauma, other life threatening situations (non-combatrelated stressors.) Do NOT mark symptoms below that are clearly notattributable to the Criteria A stressor/PTSD. Instead, overlapping symptomsclearly attributable to other things should be noted under #6 - "Othersymptoms".
Criterion A: Exposure to actual or threatened a) death, b) seriousinjury,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 theyoccurred to others
Criterion B: Presence of (one or more) of the following intrusionsymptomsassociated with the traumatic event(s), beginning after thetraumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressingmemoriesof the traumatic event(s).
[X] Recurrent distressing dreams in which the content and/oraffect of the dream are related to the traumaticevent(s).
[X] Intense or prolonged psychological distress at exposuretointernal or external cues that symbolize or resemble anaspect of the traumatic event(s).
[X] Marked physiological reactions to internal or externalcues that symbolize or resemble an aspect of thetraumaticevent(s).Criterion C: Persistent avoidance of stimuli associated with thetraumaticevent(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 withthetraumatic event(s).
[X] Avoidance of or efforts to avoid external reminders(people, places, conversations, activities, objects,situations) that arouse distressing memories, thoughts,orfeelings about or closely associated with the traumaticevent(s).Criterion D: Negative alterations in cognitions and mood associated withthe traumatic event(s), beginning or worsening after thetraumatic event(s) occurred, as evidenced by two (or more)ofthe following:
[X] Persistent negative emotional state (e.g., fear, horror,anger, guilt, or shame).
[X] Markedly diminished interest or participation insignificant activities.
[X] Persistent inability to experience positive emotions(e.g., inability to experience happiness, satisfaction,orloving feelings.)Criterion E: Marked alterations in arousal and reactivity associated withthe traumatic event(s), beginning or worsening after thetraumatic event(s) occurred, as evidenced by two (or more)ofthe following:
[X] Irritable behavior and angry outbursts (with little or noprovocation) typically expressed as verbal or physicalaggression 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 stayingasleep or restless sleep).
Criterion F:[X] The duration of the symptoms described above in CriteriaB, C, and D are more than 1 month.
Criterion G:[X] The PTSD symptoms described above cause clinicallysignificant distress or impairment in social,occupational, or other important areas of functioning.
Criterion H:[X] The disturbance is not attributable to the physiologicaleffects of a substance (e.g., medication, alcohol) oranother medical condition.4. Symptoms-----------For VA rating purposes, check all symptoms that actively apply to theVeteran'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 recentevents
[X] Difficulty in establishing and maintaining effective work and socialrelationships
[X] Difficulty in adapting to stressful circumstances, including work oraworklike setting
[X] Inability to establish and maintain effective relationships5.
Behavioral Observations:---------------------------Cooperative and genuine throughout interview. No evidence of
hallucinations or delusions. No evidence of suicidal or homicidalideation or intent.6. Other symptoms-----------------Does the Veteran have any other symptoms attributable to PTSD (and othermental disorders) that are not listed above?[ ] Yes[X]
No7. Competency-------------Is the Veteran capable of managing his or her financial affairs?[X] Yes[ ]
No8. Remarks, (including any testing results) if any:---------------------------------------------------Based on today's evaluation this Veteran continues to meet thecriteriafor a diagnosis of PTSD. He is currently service connected 70% for PTSDbased on his last Compensation and Pension Evaluation performed by Dr.xxxxxx on 8/12/2015. Veteran reports that he resigned from his job in December of 2015 because " I couldn;take the stress and anxietyof thejob. They were willing to let me work at home, but that didn't workeither". He was receiving NYS Insurance up until 3 weeks ago andthat hasnow ended. Based on the veteran's report today, it does not appear that his PTSD symptoms have necessarily worsened (he is currently service connected 70% or PTSD. It appears that he was experiencing stress related specifically to his job. Since he has resigned, he has increased stress and anxiety and is emotional today, stating that he is feeling like a failure to his family because he lost a job where he was earning 85,000 because "I couldnt hack it anymore". This examiner encourage this Veteran to conitnue his weekly counseling At the Veteran's Oureach Centerwith Les xxx and to also consider vocational rehabilitation, It is hoped that one his self image and self worth begins to increase and he is able to secure another vocational opportunity, that his overall stress and anxietywill lessen. It may be that he will have to begin slowly with part time opportunities until his overall self image and self worth is restored.
So what do you think???
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