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Rating For Ptsd C & P


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#1 MOMO68

 
MOMO68

    E-2 Recruit

  • Seaman
  • Pip
  • 2 posts
  • Service Connected Disability: none
  • Branch of Service: usa
 

Posted 07 October 2013 - 01:05 PM

----------

1. Diagnostic Summary

---------------------

Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

--------------------

a. Diagnosis #1: PTSD due to MST and combat

ICD code: 309.81

Indicate the Axis category:

[X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): Deferred to medical

records

c. Axis IV - Psychosocial and Environmental Problems (describe, if any):

No response provided.

d. Axis V - Current global assessment of functioning (GAF) score: 65

3. Differentiation of symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

4. Occupational and social impairment

-------------------------------------

a. Which of the following best summarizes the Veteran's level of

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

 [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

------------------

a. Records reviewed (check all that apply):

[X] Claims folder (C-file):

[X] Yes

[ ] No

b. Was pertinent information from collateral sources reviewed?

[ ] Yes [X] No

 

3. Stressors

------------

a. Stressor #1: In total darkness in the bunker Gulf war.

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

b. Stressor #2: MST (Patient later stated this should be #1)

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

c. Stressor #3: We were close to where that skud missle hit.

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

4. PTSD Diagnostic Criteria

---------------------------

a. Please check criteria used for establishing the current PTSD diagnosis.

The diagnostic criteria for PTSD, referred to as Criteria A-F, are from

the Diagnostic and Statistical Manual of Mental Disorders, 4th edition

(DSM-IV).

Criterion A: The Veteran has been exposed to a traumatic event where both

of the following were present:

[X] The Veteran experienced, witnessed or was confronted with an event

that involved actual or threatened death or serious injury, or a

threat to the physical integrity of self or others.

[X] The Veteran's response involved intense fear, helplessness or

horror.

Criterion B: The traumatic event is persistently reexperienced in 1 or

more of the following ways:

[X] Recurrent and distressing recollections of the event, including

images, thoughts or perceptions

[X] Recurrent distressing dreams of the event

Criterion C: Persistent avoidance of stimuli associated with the trauma

and numbing of general responsiveness (not present before

the

trauma), as indicated by 3 or more of the following:

[X] Efforts to avoid activities, places or people that arouse

recollections of the trauma

[X] Feeling of detachment or estrangement from others

[X] Restricted range of affect (e.g., unable to have loving feelings)

Criterion D: Persistent symptoms of increased arousal, not present before

the trauma, as indicated by 2 or more of the following:

[X] Difficulty falling or staying asleep

[X] Irritability or outbursts of anger

[X] Hypervigilance

Criterion E:

[X] The duration of the symptoms described above in Criteria B, C and

D

is more than 1 month.

Criterion F:

[X] The PTSD symptoms described above cause clinically significant

distress or impairment in social, occupational, or other important

areas of functioning.

b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:

[X] Stressor #1

[X] Stressor #2

[X] Stressor #3

5. Symptoms

-----------

For VA rating purposes,

check all symptoms that apply to the Veterans

 

 [X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

[X] Flattened affect

[X] Suicidal ideation

6. 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:

Panic attacks are twice weekly.

Lack of trust issues.

7. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

8. Remarks, if any

------------------

Currently taking 150 mg Zoloft

 

Medical Opinion 1

Disability Benefits Questionnaire

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?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

C-file was reviewed.

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

[ ] Other:

1. Definitions

--------------

Not applicable

2. Restatement of requested opinion

-----------------------------------

a. Insert requested opinion from general remarks:

Is the Veteran's post traumatic stress disorder at least as likely as

 

not

(50 percent or greater probability) incurred in or caused by active

duty where she served in Southwest Asia?

b. Indicate type of exam for which opinion has been requested (e.g. Skin

Diseases):

PTSD

3. Medical opinion for direct service connection

------------------------------------------------

a. [X] The claimed condition was at least as likely as not (50 percent or

greater probability) incurred in or caused by the claimed in-service

injury, event, or illness. Provide rationale in section c.

b. [ ] The claimed condition was less likely than not (less than 50 percent

probability) incurred in or caused by the claimed in-service injury,

event, or illness. Provide rationale in section c.

c. Rationale: Patient experienced both MST as well as combat related

trauma.

Personal physical assault, and long term fear for loss of

life and lives of others has been associated with the

development of emotional pathologies meeting DSM-IV

diagnostic

criteria.

4. Medical opinion for secondary service connection

---------------------------------------------------

Not applicable

5. Medical opinion for aggravation of a condition that existed prior to

service

-------------------------------------------------------------------------------

Not applicable

6. Medical opinion for aggravation of a nonservice connected condition by a

service connected condition

---------------------------------------------------------------------------

Not applicable

7. Opinion regarding conflicting medical evidence

-------------------------------------------------



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#2 Philip Rogers

 
Philip Rogers

    HadIt.com Elder

  • HadIt.com Elder
  • PipPipPipPipPipPipPipPipPip
  • 3877 posts
  • Service Connected Disability: 100
  • Branch of Service: US Army Airborne
 

Posted 08 October 2013 - 04:55 AM

0% - 50%.  jmo

 

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