PTSD Medical Notes

Discussion in 'PTSD and Mental Health Conditions' started by USAF2K16, Sep 21, 2016.

  1. USAF2K16

    USAF2K16 Registered Member

    Sep 21, 2016
    Trophy Points:

    I was able to obtain notes from my C&P exam for PTSD. It is a tad confusing. From your personal experience, can anyone "guestimate" what is being said here and what type of rating this may lead to?



    1. Diagnostic Summary


    Does the Veteran have a diagnosis of PTSD that conforms to DSM-5

    criteria based on today's evaluation?

    [ ] Yes [X] No

    If no diagnosis of PTSD, check all that apply:

    [X] Veteran's symptoms do not meet the diagnostic criteria

    for PTSD under

    DSM-5 criteria

    [X] Veteran has another Mental Disorder diagnosis. Continue

    to complete

    this Questionnaire and/or the Eating Disorder


    2. Current Diagnoses


    a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder

    ICD code: 309.81

    Comments, if any:

    Cluster B traits (Narcisstic)

    b. Medical diagnoses relevant to the understanding or management

    of the

    Mental Health Disorder (to include TBI): Back/shoulder/ankle



    3. Differentiation of symptoms


    a. Does the Veteran have more than one mental disorder


    [ ] Yes [X] No

    c. Does the Veteran have a diagnosed traumatic brain injury


    [ ] Yes [X] No [ ] 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


    [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


    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



    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)


    [ ] 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:

    Reviewed files in VBMS.

    b. Was pertinent information from collateral sources reviewed?

    [X] Yes [ ] No

    If yes, describe:

    -Reviewed the vet's statement in support of claim detailing

    his traumatic

    exposure event dated 03/25/16.

    -Reviewed a letter from the Police Department confirming the

    vet's presence during the claimed stressor (dated 03/27/09).

    2. History


    a. Relevant Social/Marital/Family history (pre-military,

    military, and


    Mr. XXXXXX was born and raised in Rochester, NY by his

    mother. He stated that his father was not involved in his rearing. He

    described his relationship with his mother as being "strained" due

    to her history of using illicit drugs and other behaviors commonly

    associated with chronic abuse. He reported that, due to her behavior and

    limitations, he had been living on his own since the age of 15. He

    expressed that he did not have a relationship with his mother for apprx 15-

    20 years and that now she is trying to rebuild their relationship. He

    denied having much of a relationship with his father. He stated that the

    extent of his relationship with his father is limited to requests

    for financial favors. He has 1 full sister, 4 half sisters via his

    mother and 18 known siblings via his father. He described his

    relationship with his siblings via his mother as variable. He stated that he

    speaks to his oldest and second to youngest sister on a regular basis.

    He expressed that his relationship is very close with his second to

    youngest sister("that's my baby"). He reported that he speaks with his

    youngest 2 brothers via his father "off and on." He described his

    overall childhood as being "rough" in association with his

    mother's behavior, physical and sexual abuse by his stepfather, as well as a

    lack of his father being present in his life.

    Mr. XXXXXX reported that he has friends primarily in NY.

    He denied talking to people as much as he used to. He added that as

    he ages, he is "starting to learn myself" and as a result, he has been

    a bit more distant. He further clarified that due to his

    irritability, he avoids going around people so that he doesn't get upset with

    them. He stated that he maintains contact with his friends via phone and

    social media. He communicated that he does not see his friends often. In

    his leisure time, the vet stated that he enjoys helping people repair

    their credit or otherwise helping people in other domains.

    Mr. XXXXXX denied a history of ever being married. He

    denied being in a romantic relationship. He added that

    "I am very difficult to get along with...primarily because I have trust and abandonment

    issues." He has 7 children via 4 different mothers. He expressed having

    longstanding concerns about "subjecting" his children to the same

    upbringing he had, which did not consist of having a mother and a father in

    the home. He described his relationship with his oldest son as being

    "strained" and "good" with the remainder of his children. He stated that

    2 of his sons live relatively locally (in the state of GA). His children

    range in age from 3-19 y/o.

    Mr. XXXXXX reported that he lives by himself. He denied

    having any pets.

    b. Relevant Occupational and Educational history (pre-military,

    military, and


    Mr. XXXXXX's highest level of education is 2 Master's

    degrees (MBA in Finance and an MA in Accounting). He stated that his

    Accounting degree was from XXXXXXX in 2013 and his Finance degree was from

    XXXXXXXXXX University in 2008. He described his

    performance in school as "easier as I got older." He added that he does

    not "even know how he got through high school." He denied a history of

    ever being diagnosed with a learning disability. He denied a history

    of experiencing any on-going behavioral issues with his


    Mr. XXXXXX served in the Army Reserves from 1996-2004 as a

    supply, then civil affairs tech. He then served in the Air Force

    Reserves from 2006-present as a finance technician. He denied a history

    of disciplinary infractions while in service. He reported a

    history of deployment to only stateside locations. His highest rank

    in service is E-7.

    While in the reserves, the vet's civilian employment is

    with the XXXXXXXXXXXXXXXXXXX (since 02/2016) as an accountant.

    From 2008-2014, he worked as a contractor for XXXXXXXXXXX

    (senior functional analyst) followed by XXXXXXXXXXXX (senior

    staff consultant). Prior to 2008, the vet reported that he

    worked for XXXXXXXXXXXXas a technical support coordinator. He described

    his performance across jobs as being "fine." He added that his

    time actually working on the job has been patchy due to the

    reserves frequently sending him on long-term TDYs.

    c. Relevant Mental Health history, to include prescribed

    medications and

    family mental health (pre-military, military, and post-


    Mr. XXXXXX reported a history of MH treatment in 2009

    after he

    witnessed a young man get killed by the police. He stated

    that he saw

    someone in MH a few times, but eventually told them he was

    "OK" out of

    fear of damaging his career as well as "embarrassment."

    STRs are

    positive for MH encounters subsequent to the vet's

    reported trauma. It

    appears that he was initially seen on 02/16/09 apprx 2

    weeks after he

    had been exposed to the trauma and was experiencing both


    disturbances and ruminative thoughts about the incident.

    Although he

    was diagnosed with Insomnia, his encounter noted

    "suggestive of an

    Acute Stress Disorder at this time." Another diagnosis

    listed in the

    vet's STRs is Observation for Suspected Mental Condition,

    which was

    rendered around the same time as his Insomnia diagnosis.

    He has a

    history of being prescribed with Zoloft (depression/panic

    attacks) and

    Ambien (sleep). He denied a history of psychiatric

    hospitalizations or

    ER visits for MH reasons.

    Mr. XXXXXX reported that he participated in MH treatment

    in 02/2015 at

    Bolling AFB with respect to his sleep issues. He stated

    that he last

    saw a MH professional via his company's EAP for 3 sessions

    in 03/2016.

    He was last seen for MH treatment on 08/15/16 (psychiatry


    Per the encounter, the vet's chief complaint was anxiety

    and his only

    listed diagnosis was "panic attacks by history." He

    described his

    current symptoms as involving sleeping difficulties (with

    both going to

    sleep and staying asleep), challenging interpersonal


    increased irritation/aggravation, avoidance of situations

    that are

    likely to anger him, avoidance of thinking about his

    traumatic exposure

    (via "staying busy"), detachment from others/dislike of

    being around

    people including his children and crying spells/emotional


    d. Relevant Legal and Behavioral history (pre-military,

    military, and


    The vet reported a history of getting arrested 2x (falsely

    accused of

    selling stolen property and criminal mischief). He denied

    having a

    record because each of the charges were dropped. He

    reported that he is

    currently involved in a lawsuit against a company that

    attempted to say

    he abandoned his civilian job as opposed to leaving for

    military duty,

    as was reportedly the case.

    e. Relevant Substance abuse history (pre-military, military, and


    Unremarkable. The vet reported a family history of

    substance abuse

    involving his mother (poly-drug abuse), father (crack-

    cocaine) and

    sister (alcohol and drugs).

    f. Other, if any:

    No response provided.

    3. Stressors


    Describe one or more specific stressor event(s) the Veteran


    traumatic (may be pre-military, military, or post-military):

    a. Stressor #1: The vet reported that he was involved in an

    incident where a

    young man was killed in front of him while he was on TDY

    to Robins AFB.

    He stated that he attempted to assist the man after he was

    shot, but

    then the police reportedly trained their guns on his chest

    and he was

    ordered to get down on the ground. He added that it took

    the ambulance

    over 30 minutes to arrive and that he was lying on the

    ground next to

    the man as he died. He stated that whenever he hears about


    shootings, he gets re-traumatized. He stated that he feels


    for not being able to save the young man or get through to

    him about

    going home.

    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?

    [ ] Yes [X] No

    If no, explain:

    The vet reported that he was given a USAF

    Commendation Medal for

    Act of Courage given his involvement in the situation

    and that he

    hates it because he was not in fact helping the

    police, but

    trying to help the young man with the gun via

    diffusing the

    situation. He stated that he is fearful of how he

    could have been

    shot by the young man or the police. He added that he

    can still

    remember hearing each of the gun shots and the sounds

    of the

    young man getting hit with the bullets and listening

    to him

    trying to breath on the ground just before dying.

    Is the stressor related to personal assault, e.g. military



    [ ] 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


    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


    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).

    Criterion C: Persistent avoidance of stimuli associated with

    the traumatic

    event(s), beginning after the traumatic events(s)


    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


    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] Persistent, distorted cognitions about the cause or

    consequences of

    the traumatic event(s) that lead to the individual to


    himself/herself or others.

    [X] Persistent negative emotional state (e.g., fear,

    horror, anger,

    guilt, or shame).

    [X] Markedly diminished interest or participation in



    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


    provocation) typically expressed as verbal or physical


    toward people or objects.

    [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


    impairment in social, occupational, or other important

    areas of


    Criterion H:

    [X] The disturbance is not attributable to the

    physiological effects of

    a substance (e.g., medication, alcohol) or another



    Criterion I: Which stressor(s) contributed to the Veteran's



    No response provided.

    5. Symptoms


    For VA rating purposes, check all symptoms that actively apply

    to the

    Veteran's diagnoses:

    [X] Anxiety

    [X] Chronic sleep impairment

    [X] Memory loss for names of close relatives, own occupation,

    or own name

    [X] Disturbances of motivation and mood

    6. Behavioral Observations


    Mr. XXXXXX presented as a 37 year-old African-American man of

    average height

    and build. He was casually dressed and neatly groomed, he

    appeared his stated

    age. He arrived to his appointment 20 minutes late. He readily

    greeted this

    examiner and accompanied her to her office. No gait

    abnormalities were

    observed. He was alert and oriented in all spheres and clearly

    understood the

    undersigned's role and the purpose of the current examination.

    The vet cooperated well with the current exam. He maintained an


    demeanor and readily engaged in dialogue. He responded to all

    questions asked

    of him, and his speech was normal in rate, volume, and

    intensity. His

    thinking, as evidenced in his speech, seemed logical and

    organized. His mood

    appeared euthymic and he exhibited a broad range of affect. Mr.


    expressed clear future orientation and denied having thoughts of

    wanting to

    harm himself or others. He stated that he has had "dark

    moments" and that he

    is able to feel better when he thinks about "tomorrow."

    Sleep: 3-4 hrs a night, reported that he frequently thinks about

    an incident

    involving a man being shot and killed by police in front of him.

    Interest Level: "Low"

    Guilt: Increased about situation with the young man

    Energy: I don't have a lot of energy and my body aches all the

    time, I've put

    on 25 lbs because I don't exercise like I used to

    Concentration: It's hard to concentrate on 1 particular thing,

    stated that he

    looks forward to TDYs because it get's him away from work (he


    interested in doing his work, which reportedly affects his


    Appetite: "It fluctuates"

    Psychomotor Agitation/Retardation: No

    7. Other symptoms


    Does the Veteran have any other symptoms attributable to PTSD

    (and other

    mental disorders) that are not listed above?

    [ ] Yes [X] No

    8. Competency


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

    [X] Yes [ ] No

    9. Remarks, (including any testing results) if any


    On the basis of the current examination, including the


    interview and review of records, Mr. XXXXXX has been

    diagnosed with PTSD.

    He reported symptoms that were consistent with each criterion

    listed for

    diagnosis. He also expressed experiencing both anxiety and


    which are both symptoms of PTSD. As such, additional

    diagnoses are not

    warranted at this time. The vet did not communicate his

    experience of

    "panic attacks" and so a panic attack diagnosis or specifier

    was not

    added. His potential history of panic attacks warrants

    further evaluation.

    Of note, the vet appeared to evidence symptoms/social history

    that seemed

    somewhat consistent with a disordered personality. He

    expressed having

    challenging relationship with friends, family, co-workers and


    Although a clear conclusion could not be reached at the close

    of the

    current exam, further evaluation re" the presence of a


    Disorder (with Narcissistic features) is also warranted

    (though, given the

    nature of personality disorders, military service would not

    have played a

    causal role in its development).

    Mr. XXXXXX's STR's were positive for sleep disturbances, both

    anxiety and

    depressive symptoms, as well as documented responses to

    trauma exposure.

    In consideration of the available information, it is the

    opinion of the

    undersigned that the vet's current diagnosis of PTSD is at

    least likely as

    not related to, or was incurred during, his military service.

    NOTE: VA may request additional medical information, including

    additional examinations if necessary to complete VA's review of the

    Veteran's application.
  2. USAF2K16

    USAF2K16 Registered Member

    Sep 21, 2016
    Trophy Points:
    203 reviews....not "1" comment :(
  3. tony292

    tony292 PEB Forum Veteran

    Oct 16, 2010
    Trophy Points:
    I read it twice and did not see the occupational and social impairment statement. This will align with a VA rating.
  4. tony292

    tony292 PEB Forum Veteran

    Oct 16, 2010
    Trophy Points:
  5. tony292

    tony292 PEB Forum Veteran

    Oct 16, 2010
    Trophy Points:
    Section 4.a of the above form should have one block and one block only checked which will align with this:

    General Rating Formula for Mental Disorders:

    Total occupational and social impairment, due to such symptoms as:

    gross impairment in thought processes or communication;

    persistent delusions or hallucinations; grossly inappropriate

    behavior; persistent danger of hurting self or others; intermittent

    inability to perform activities of daily living (including maintenance

    of minimal personal hygiene); disorientation to time or place; memory

    loss for names of close relatives, own occupation, or own name 100

    Occupational and social impairment, with deficiencies in most areas,

    such as work, school, family relations, judgment, thinking, or mood,

    due to such symptoms as: suicidal ideation; obsessional rituals

    which interfere with routine activities; speech intermittently illogical,

    obscure, or irrelevant; near-continuous panic or depression affecting

    the ability to function independently, appropriately and effectively;

    impaired impulse control (such as unprovoked irritability with periods

    of violence); spatial disorientation; neglect of personal appearance and

    hygiene; difficulty in adapting to stressful circumstances (including

    work or a worklike setting); inability to establish and maintain

    effective relationships 70

    Occupational and social impairment with reduced reliability and

    productivity due to such symptoms as: flattened affect; circumstantial,

    circumlocutory, or stereotyped speech; panic attacks more than once

    a week; difficulty in understanding complex commands; impairment

    of short- and long-term memory (e.g., retention of only highly learned

    material, forgetting to complete tasks); impaired judgment; impaired

    abstract thinking; disturbances of motivation and mood; difficulty in

    establishing and maintaining effective work and social relationships 50

    Occupational and social impairment with occasional decrease in work

    efficiency and intermittent periods of inability to perform occupational

    tasks (although generally functioning satisfactorily, with routine

    behavior, self-care, and conversation normal), due to such symptoms

    as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or

    less often), chronic sleep impairment, mild memory loss (such as

    forgetting names, directions, recent events) 30

    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 continuous medication 10

    A mental condition has been formally diagnosed, but symptoms are not

    severe enough either to interfere with occupational and social

    functioning or to require continuous medication0
    Last edited: Oct 5, 2016
    Keebs likes this.
  6. Keebs

    Keebs Staff Member PEB Forum Veteran

    Jul 16, 2016
    Trophy Points:
    So here is what I am reading (I am not a doctor nor a lawyer):

    The very beginning says that you do not have PTSD based on the DSM-V (diagnostics and statistical manual version 5). (The DSM is the "bible" of the mental health world. It helps MH providers diagnose patients.) It then states that you have narcissistic behaviors. It goes on to discuss the event that is referred to as the "stressor" and over a personal and professional history. You have been able to complete two advanced degrees and have a pretty stable and outstanding working history. (I have PTSD and have had over 30 jobs in 10 years). It goes on to say how it has affected you but that you can maintain relationships to some extent and that you do have things you enjoy to do. You also have sleep issues, anger issues, and a few others. It ends by saying you do have PTSD based on the VA's requirements and that it is most likely service connected. It also states that you have a narcissistic personality and that needs to be evaluated as well.
  7. Keebs

    Keebs Staff Member PEB Forum Veteran

    Jul 16, 2016
    Trophy Points:
    Mine has that as well. That is how I knew my rating before being notified.
    tony292 likes this.
  8. PsychOfficer

    PsychOfficer PEB Forum Veteran Registered Member

    Sep 25, 2012
    Trophy Points:
    [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

    Above was in the report - 10%

    it is confusing - it states both that you were diagnosed and that you weren't diagnosed.
  9. USAF2K16

    USAF2K16 Registered Member

    Sep 21, 2016
    Trophy Points:
    My claim got deferred, it is back in the "gathering evidence" phase...
  10. chaplaincharlie

    chaplaincharlie PEB Forum Veteran Registered Member

    May 20, 2010
    Trophy Points:
    I say 0. Yes the social and occupational impairment is 10%, but there is no diagnosis. No diagnosis, no compensation.
  11. USAF2K16

    USAF2K16 Registered Member

    Sep 21, 2016
    Trophy Points:
    So...the doctor amended one of the questionnaire to yes PTSD was diagnosed. Long story short, I got my final rating 50% for PTSD.
  12. tony292

    tony292 PEB Forum Veteran

    Oct 16, 2010
    Trophy Points:
    Was your final result PDRL or TDRL?

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