PTSD Medical Notes

USAF2K16

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#1
Hello,

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?

SECTION I:

----------

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

Questionnaire:


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

pains

(chronic)


3. Differentiation of symptoms

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

a. Does the Veteran have more than one mental disorder

diagnosed?

[ ] Yes [X] No



c. Does the Veteran have a diagnosed traumatic brain injury

(TBI)?

[ ] 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

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

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

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:



[ ] 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

post-military):

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

post-military):

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

peers/instructors.


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-

military):

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

sleep

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

encounter).

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

relationships,

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

outbursts.








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

military, and

post-military):

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

post-military):

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

considers

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

police

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

responsible

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

sexual

trauma?

[ ] 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

and

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

others


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)

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 with the traumatic

event(s).


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

blame

himself/herself or others.

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

horror, anger,

guilt, or shame).

[X] Markedly diminished interest or participation in

significant

activities.


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

no

provocation) typically expressed as verbal or physical

aggression

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

or

impairment in social, occupational, or other important

areas of

functioning.



Criterion H:

[X] The disturbance is not attributable to the

physiological effects of

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

medical

condition.



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

PTSD

diagnosis?:

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

affable

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.

XXXXXX

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

isn't

interested in doing his work, which reportedly affects his

productivity)

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

diagnostic



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

depression,

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

supervisors.

Although a clear conclusion could not be reached at the close

of the

current exam, further evaluation re" the presence of a

Personality

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.
 

tony292

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#3
I read it twice and did not see the occupational and social impairment statement. This will align with a VA rating.
 

tony292

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#5
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:

Keebs

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#6
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.
 

Keebs

Staff Member
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#7
Section 4.a of the above form should have one block and one lock 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
Mine has that as well. That is how I knew my rating before being notified.
 

PsychOfficer

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#8
[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.
 

chaplaincharlie

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#10
I say 0. Yes the social and occupational impairment is 10%, but there is no diagnosis. No diagnosis, no compensation.
 

USAF2K16

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#11
So...the doctor amended one of the questionnaire to yes PTSD was diagnosed. Long story short, I got my final rating 50% for PTSD.