Hello everyone I was wondering if I can get some advice on my comp & pen results for PTSD which was on October 27th 2016. LOCAL TITLE: C&P MENTAL DISORDERS STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT DATE OF NOTE: OCT 27, 2016@13:00 ENTRY DATE: OCT 27, 2016@13:18:43 Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes [ ] No ICD code: F43.1 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: PTSD ICD code: F43.1 Mental Disorder Diagnosis #2: Major Depressive Disorder, Severe ICD code: F33.4 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 2. 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: Significant overlap c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 3. 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] Total occupational and social impairment 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: Signficant overlap 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 ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): Veteran brought in Statement in Support of PTSD and a handwritten letter as well. This was given to Ricardo Sealy for scanning. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Veteran stated that he continues to live with his wife, but in separate bedrooms. "It's been rough the past two months, I haven't been speaking to anyone. I haven't been at work for two weeks, since that incident. It's been hell - the anxiety, don't want to be around people. I had time driving here, my dad was supposed to drive me here last week. But I had to take myself here, since he went on vacation. I don't talk to anyone -not at all. Since the incidnet, at work, I haven't been able to go back. I feel that people are out to get me." b. Relevant Occupational and Educational history (pre-military, military, and post-military): "I've been struggling at work for the past three months. It was something that triggered my episode. I was Dunkin Donuts, and a guy threatened this young lady. She kept apologizing, he was going to stab her. I had a confrontation with him, I didn't care if I lived or died. She grabbed my hand, but when I turned around she was gone. I've had that happen a couple of times [witnessing someone being threatened]. There was a veteran shouting at the secretary, and I lost it. I went home early that day. I was going home early from work about 4 times per week. The incident at work was when a veteran got mad at me and threatened my life. I thought I was going to lose it, come after him. They've been calling me to come back to work, but I can't talk to them, I can't go back there." c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): "I haven't been to work since then [the incident two weeks ago]. They have been trying not contact me, but I don't talk to anyone. I last saw psychologist in Newington last week. I'm struggling, I take the bus, I have anxiety. I eat once in a while - lost 25 pounds. I haven't taken a bath in a few days. In the same clothes for the past three days. In the last weeks, I only sleep for two hours per night. I wake up tired, wiht nightmares about my friend. Flashbacks - that's why I'm not driving. I had one at a stop sign. People blowing horns, then there was a cop on my window. I haven't driven since the last day I went to work. I had to drive myself here. Suicidal - I think about it every day, my brother had my firearms for now. I feel safe to go home today. agreed to call crisis line. Declined immediate support, did not want to be walked to the psych ER. Mood - anxious, depressed most of the time. I feel like I have no Energy to do anything." The PTSD reported developed after veteran and his close friend witness a fight at a bar near Andrews AFB in May 1985. They intervened to help the ladies, and his friend was shot and killed. Veteran was holding his friend in his arms, as he died immediately. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Nothing in the past year, in terms of legal issues. Veteran's last arrest in 2001 for assaulting two police officers. e. Relevant Substance abuse history (pre-military, military, and post-military): No relapses with alcohol or drug use. "I've been close. I almost acted on it last week." When asked why he didn't, he said that his dog licked my face. Now, his service dog doesn't leave his side. f. Other, if any: No response provided. 3. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [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 work like setting [X] Inability to establish and maintain effective relationships [X] Suicidal ideation [X] Neglect of personal appearance and hygiene [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene 4. Behavioral observations -------------------------- Mental Status and Behavioral Observations: -ORIENTATION: Alert and oriented x3. -PRESENTATION: Appropriately dressed in casual attire and well-groomed. -RAPPORT: Cooperative and open with his concerns. -MOOD/AFFECT: Mood appeared dysthymic; affect congruent with mood or excessively flat. -THOUGHTS: Linear and goal-directed. -SPEECH: Flatt and sparse in terms of rate, rhythm, and volume. -INSIGHT AND JUDGMENT: Fair insight and judgment. 5. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [ ] Yes [X] No 6. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 7. Remarks (including any testing results), if any: --------------------------------------------------- Veteran meets criteria for PTSD as well as MDD, based on report sympotms and chart review. He experienced an incident at work about 2 weeks ago, and since that time he has been impaired in his emotional functioning, communication, eabilities, and ADLs.