Hello,
This is my first post, but I have been lurking around since May. I got my CP results back this week and was wondering if anybody has any idea what rating I would receive. Any help would be appreciated
THANKS
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: 300.01
If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Panic Disorder without Agoraphobia
ICD code: 300.01
Mental Disorder Diagnosis #2: Unspecified Depressive Disorder
ICD code: 311
Mental Disorder Diagnosis #3: Alcohol Use Disorder, Moderate, in early
remission
ICD code: 303.90
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): None
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?
[X] Yes[ ] No[ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
Symptoms of Panic Disorder include frequent panic attacks, with
increased heart rate, difficulty breathing, restlessness, and sleep
disturbances, along with avoidance of situations which might
trigger
a panic attack. Symptoms of Unspecified Depressive Disorder
include
sad mood, low energy, feelings of helplessness and hopelessness,
and
anhedonia. Symptoms of Alcohol Use Disorder include a maladaptive
pattern of substance use, excessive use of alcohol, tolerance, and
interpersonal/occupational problems as a result of use.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes[X] No[ ] 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] Occupational and social impairment with occasional decrease in work
efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily,
with normal routine behavior, self-care and conversation
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:
Symptoms of Panic Disorder and Unspecified Depressive Disorder both
significantly contribute to the service member's level of
occupational and social impairment, to the extent that it is not
possible to tease out how each contributes independently of the
other. Symptoms of Alcohol Use Disorder are in early remission and
do not significantly impact functioning at the present time.
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. Medical record review:
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[ ] Yes[X] No
Was the Veteran's VA claims file (hard copy paper C-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
b. Was pertinent information from collateral sources reviewed?
[ ] Yes[X] No
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
The service member grew up in San Antonio, Texas. His parents divorced
when the service member was 4 years old. He was raised by his mother.
He has two younger brothers. He reported that childhood was
"different,
my mom moved around a lot". He lived with his father from age 15
through graduation from high school. No traumatic experiences were
reported, no physical abuse or sexual abuse was reported.
The service member is married. He and his wife have been married for 6
years. He stated tha things are going "great" in the relationship and
no significant problems or issues were reported at the present time.
The service member and his wife had been separated, but they reunited
recently. They have 2 children, ages 4 and 2. Socially, the service
member stated that he has few friends at his command, "I don't talk to
too many people". He has one friend from the ship with whom he talks
once every few months. He does keep in touch with his father, and he
talks to him twice a week. He has fairly regular contact with his
mother. He is closest to his wife. The service member spends his free
time at home, hanging out with his children. He used to be more
social,
but he started to have problems with anxiety in November 2013, which
have changed his activities, "I typically stay home".
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The service member stated that he did "okay" in school. He typically
got Bs and Cs. He graduated high school and went to community college
for one year. He started working in banking, he left school and
started
working full time. He worked in banking for 2 years, and then joined
the military at age 21.
The service member joined the Navy in October 2010. Rank is E5, MOS is
fire controlman. He is currently stationed in Dahlgram Virginia, where
he has been for a year and a few months. He has also been stationed in
Great Lakes and San Diego. No combat deployments.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-milit
ary):
No history of mental health treatment prior to the military was
reported.
The service member first began participating in mental health treatment
in August 2014. He has been in treatment regularly since then. He
participates in weekly individual therapy, and he has participated in
groups. He meets with his psychiatrist once a month. Current
medications are Prozac, Buspar, and Atarax. No psychiatric
hospitalizations, but the service member did go to a 21 day inpatient
alcohol treatment program at the Virginia Hospital Center in Arlington
Virginia in April 2015
According to the c-file, the service member has been diagnosed with
Panic Disorder, Depression, Adjustment Disorder with Depressed Mood,
and
Alcohol Dependence.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
None
e. Relevant Substance abuse history (pre-military, military, and
post-military):
The service member is not currently drinking. He has not drank since
April 2015 when he went to inpatient alcohol treatment. He had been
drinking 4-5 nights a week, and he was having 1-2 drinks at home, and
then up to 12 when out with friends. He self-referred to treatment
because, "I thought that it would help" with anxiety symptoms. No drug
use.
f. Other, if any:
None
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
Behavioral observations:
The service member endorsed problems with anxiety. He becomes anxious
while driving, he has panic attacks. He stated that, "I feel pretty
anxious most of the day". He feels anxious, "I feel like I'm going
crazy, something is really wrong with me" or "something horrible is
going to happen to me". He has panic attacks where he has shallow
breathing, his heart is racing, he starts to feel disconnected, he
becomes tingly on his hands and arms, he experiences chest pains, he
feels like he is having a heart attack. Panic attacks used to last
longer, but are currently lasting 5-10 minutes. He is currently
having
panic attacks 1-2 times per week, but they can be more frequent, 2-3
times a week. At one point, he was having panic attacks daily. He
avoids crowds, 4th of July, loud areas, situations where he thinks he
will become overwhelmed, certain work related tasks.
The service member endorsed anxiety about work. He worries that he
will mess up, that he will make a mistake, that he will forget to safe
lock a door. He worries about getting in trouble, letting his family
down, getting hurt, his health and various physical symptoms which are
hypochondrical in nature. He feels afrid that something terrible will
happen or that he will fail people around him. He is worrying 60% of
the time, he has a hard time controlling the worry. He feels tense,
restless; he experiences sleep disturbances.
The service member endorsed problems with sleep. He wakes up in a
panic. He is typically getting 4-6 hours of sleep a night. He denied
sleep onset problems, but he endorsed mid sleep awakening, and
difficulty returning to sleep after awakening.
The service member described his mood as typically anxious. He stated
that he does have times when he feels depressed and sad, "I'll just
say
screw it". This might occur once a month, and last for a few days.
He
rated his mood at a 4 on a 10 point scale (with 10 being high).
Appetite is variable, and his weight has fluctuated. Energy levels
are
low, "it's hard for me to get up, off the couch. He feels exhausted,
and drained. Mild anhedonia was reported, "I don't feel the same way
I
used to feel, I used to enjoy a lot of things". He endorsed feelings
of helplessness and hopelessness, "that I'll never get better, that
I'll feel this way for forever". He endorsed feelings of guilt
related
to helping out his wife at home, "I'll just go into my room, and cry"
and that he can't do his job in the Navy. No suicidal or homicidal
ideation was reported.
The service member screened positive for PTSD; however, he does not
report an event which meets Criterion A for a PTSD diagnosis.
4. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes[X] No
5. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
6. Remarks (including any testing results), if any:
---------------------------------------------------
Below is a summary of the service member's claimed conditions and diagnoses:
#1. Claimed condition: Panic Disorder
Diagnosis/Rationale: Panic Disorder without Agoraphobia - the
service
member meets full DSM-5 criteria for this diagnosis
#2. Claimed condition: Anxiety
Diagnosis/Rationale: No diagnosis - symptoms of anxiety can be
considered part of the panic disorder and do not warrant a separate diagosis
#3. Claimed condition: Adjustment Disorder with Depressed Mood
Diagnosis/Rationale: Unspecified Depressive Disorder - the
service
member meets full DSM-5 criteria for this diagnosis
#4. Claimed condition: n/a
Diagnosis/Rationale: Alcohol Use Disorder, Moderate, in early
remission - the service member meets full DSM-5 criteria for this diagnosis
****************************************************************************
COMPENSATION AND PENSION EXAMINATION REPORT (FREE TEXT)
=======================================================
Mental health - Separation Health Assessment
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Name of patient/Servicemember: Martinez, Stephen Jacob
SSN: ***********
Was a DD Form 2807-1, Report of Medical History, completed by the
Servicemember and available for review at the time of this examination?
[ ] Yes [X ] No [ ] N/A
Any changes to his/her health status since DD 2807-1 completed?
[ ] Yes [ ] No [X ] N/A
(Proposed) Date of separation from active service: No response provided.
1. Medical record review
-------------------------
Was the Veteran's VA claims file reviewed?
[X ] Yes [ ] No
2. Medical history (Review of Systems)
--------------------------------------
1. Psychiatric:
[ X] Yes [ ] No
#1. Claimed Condition: Panic Disorder
Onset: 2014
History: stable
Prognosis: good
#2. Claimed Condition: Anxiety
Onset: n/a
History:
Prognosis:
#3. Claimed Condition: Adjustment Disorder wtih Depressed Mood
Onset: 2014
History: stable
Prognosis: good
(Please follow format if more claims are being addressed)
PTSD SCREEN PC-PTSD
-------------------
In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that, in the past month, you:
1. Have had nightmares about it or thought about it when you did
not want to?
[X ] Yes [ ] No - related his wife leaving him
2. Tried hard not to think about it or went out of your way to
avoid situations that reminded you of it?
[X ] Yes [ ] No
3. Were constantly on guard, watchful, or easily startled?
[X ] Yes [ ] No
4. Felt numb or detached from others, activities, or your
surroundings?
[X ] Yes [ ] No
Depression screen: PHQ2
-----------------------
Over the past two weeks, how often have you been bothered by any
of the following problems?
Little interest or pleasure in doing things.
[ ] 0 = Not at all [ ] 1 = Several days [ ] 2 = More than half
the days [X ] 3 = Nearly every day
Feeling down, depressed, or hopeless.
[ ] 0 = Not at all [ ] 1 = Several days [X ] 2 = More than half
he
Days [ ] 3 = Nearly every day
Total Point Score: 5
Brief Suicide Risk Assessment
-----------------------------
- (Perform if score positive on Depression or PTSD screens)
Are you feeling hopeless about the present or future?
[X ] Yes [ ] No
Have you had thoughts about taking your life - if yes - when did
you have these thoughts and do you have a plan to take your
life?
[ ] Yes [X ] No
Have you ever had a suicide attempt?
[ ] Yes [X ] No
3. Physical Exam
-----------------
1. Psychiatric (Specify any personality deviation)
[ X] Normal [ ] Abnormal [ ] Not examined
5. Diagnosis:
-------------
#1. Claimed condition: Panic Disorder
Diagnosis/Rationale: Panic Disorder without Agoraphobia - the
service
member meets full DSM-5 criteria for this diagnosis
#2. Claimed condition: Anxiety
Diagnosis/Rationale: No diagnosis - symptoms of anxiety can be
considered
part of the panic disorder and do not warrant a separate diagosis
#3. Claimed condition: Adjustment Disorder with Depressed Mood
Diagnosis/Rationale: Unspecified Depressive Disorder - the service
member
meets full DSM-5 criteria for this diagnosis
#4. Claimed condition: n/a
Diagnosis/Rationale: Alcohol Use Disorder, Moderate, in early
remission
- the service member meets full DSM-5 criteria for this diagnosis
(for additional Claim/diagnosis, please follow above format)
6. Remarks, if any:
-------------------
All additional DBQs found to be necessary completed as appropriate at time
of signing this DBQ?
[X ] Yes [ ] No
-------------------------------------------------------------------------
This is my first post, but I have been lurking around since May. I got my CP results back this week and was wondering if anybody has any idea what rating I would receive. Any help would be appreciated
THANKSSECTION 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: 300.01
If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Panic Disorder without Agoraphobia
ICD code: 300.01
Mental Disorder Diagnosis #2: Unspecified Depressive Disorder
ICD code: 311
Mental Disorder Diagnosis #3: Alcohol Use Disorder, Moderate, in early
remission
ICD code: 303.90
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): None
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?
[X] Yes[ ] No[ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
Symptoms of Panic Disorder include frequent panic attacks, with
increased heart rate, difficulty breathing, restlessness, and sleep
disturbances, along with avoidance of situations which might
trigger
a panic attack. Symptoms of Unspecified Depressive Disorder
include
sad mood, low energy, feelings of helplessness and hopelessness,
and
anhedonia. Symptoms of Alcohol Use Disorder include a maladaptive
pattern of substance use, excessive use of alcohol, tolerance, and
interpersonal/occupational problems as a result of use.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes[X] No[ ] 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] Occupational and social impairment with occasional decrease in work
efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily,
with normal routine behavior, self-care and conversation
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:
Symptoms of Panic Disorder and Unspecified Depressive Disorder both
significantly contribute to the service member's level of
occupational and social impairment, to the extent that it is not
possible to tease out how each contributes independently of the
other. Symptoms of Alcohol Use Disorder are in early remission and
do not significantly impact functioning at the present time.
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. Medical record review:
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[ ] Yes[X] No
Was the Veteran's VA claims file (hard copy paper C-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
b. Was pertinent information from collateral sources reviewed?
[ ] Yes[X] No
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
The service member grew up in San Antonio, Texas. His parents divorced
when the service member was 4 years old. He was raised by his mother.
He has two younger brothers. He reported that childhood was
"different,
my mom moved around a lot". He lived with his father from age 15
through graduation from high school. No traumatic experiences were
reported, no physical abuse or sexual abuse was reported.
The service member is married. He and his wife have been married for 6
years. He stated tha things are going "great" in the relationship and
no significant problems or issues were reported at the present time.
The service member and his wife had been separated, but they reunited
recently. They have 2 children, ages 4 and 2. Socially, the service
member stated that he has few friends at his command, "I don't talk to
too many people". He has one friend from the ship with whom he talks
once every few months. He does keep in touch with his father, and he
talks to him twice a week. He has fairly regular contact with his
mother. He is closest to his wife. The service member spends his free
time at home, hanging out with his children. He used to be more
social,
but he started to have problems with anxiety in November 2013, which
have changed his activities, "I typically stay home".
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The service member stated that he did "okay" in school. He typically
got Bs and Cs. He graduated high school and went to community college
for one year. He started working in banking, he left school and
started
working full time. He worked in banking for 2 years, and then joined
the military at age 21.
The service member joined the Navy in October 2010. Rank is E5, MOS is
fire controlman. He is currently stationed in Dahlgram Virginia, where
he has been for a year and a few months. He has also been stationed in
Great Lakes and San Diego. No combat deployments.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-milit
ary):
No history of mental health treatment prior to the military was
reported.
The service member first began participating in mental health treatment
in August 2014. He has been in treatment regularly since then. He
participates in weekly individual therapy, and he has participated in
groups. He meets with his psychiatrist once a month. Current
medications are Prozac, Buspar, and Atarax. No psychiatric
hospitalizations, but the service member did go to a 21 day inpatient
alcohol treatment program at the Virginia Hospital Center in Arlington
Virginia in April 2015
According to the c-file, the service member has been diagnosed with
Panic Disorder, Depression, Adjustment Disorder with Depressed Mood,
and
Alcohol Dependence.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
None
e. Relevant Substance abuse history (pre-military, military, and
post-military):
The service member is not currently drinking. He has not drank since
April 2015 when he went to inpatient alcohol treatment. He had been
drinking 4-5 nights a week, and he was having 1-2 drinks at home, and
then up to 12 when out with friends. He self-referred to treatment
because, "I thought that it would help" with anxiety symptoms. No drug
use.
f. Other, if any:
None
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
Behavioral observations:
The service member endorsed problems with anxiety. He becomes anxious
while driving, he has panic attacks. He stated that, "I feel pretty
anxious most of the day". He feels anxious, "I feel like I'm going
crazy, something is really wrong with me" or "something horrible is
going to happen to me". He has panic attacks where he has shallow
breathing, his heart is racing, he starts to feel disconnected, he
becomes tingly on his hands and arms, he experiences chest pains, he
feels like he is having a heart attack. Panic attacks used to last
longer, but are currently lasting 5-10 minutes. He is currently
having
panic attacks 1-2 times per week, but they can be more frequent, 2-3
times a week. At one point, he was having panic attacks daily. He
avoids crowds, 4th of July, loud areas, situations where he thinks he
will become overwhelmed, certain work related tasks.
The service member endorsed anxiety about work. He worries that he
will mess up, that he will make a mistake, that he will forget to safe
lock a door. He worries about getting in trouble, letting his family
down, getting hurt, his health and various physical symptoms which are
hypochondrical in nature. He feels afrid that something terrible will
happen or that he will fail people around him. He is worrying 60% of
the time, he has a hard time controlling the worry. He feels tense,
restless; he experiences sleep disturbances.
The service member endorsed problems with sleep. He wakes up in a
panic. He is typically getting 4-6 hours of sleep a night. He denied
sleep onset problems, but he endorsed mid sleep awakening, and
difficulty returning to sleep after awakening.
The service member described his mood as typically anxious. He stated
that he does have times when he feels depressed and sad, "I'll just
say
screw it". This might occur once a month, and last for a few days.
He
rated his mood at a 4 on a 10 point scale (with 10 being high).
Appetite is variable, and his weight has fluctuated. Energy levels
are
low, "it's hard for me to get up, off the couch. He feels exhausted,
and drained. Mild anhedonia was reported, "I don't feel the same way
I
used to feel, I used to enjoy a lot of things". He endorsed feelings
of helplessness and hopelessness, "that I'll never get better, that
I'll feel this way for forever". He endorsed feelings of guilt
related
to helping out his wife at home, "I'll just go into my room, and cry"
and that he can't do his job in the Navy. No suicidal or homicidal
ideation was reported.
The service member screened positive for PTSD; however, he does not
report an event which meets Criterion A for a PTSD diagnosis.
4. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes[X] No
5. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
6. Remarks (including any testing results), if any:
---------------------------------------------------
Below is a summary of the service member's claimed conditions and diagnoses:
#1. Claimed condition: Panic Disorder
Diagnosis/Rationale: Panic Disorder without Agoraphobia - the
service
member meets full DSM-5 criteria for this diagnosis
#2. Claimed condition: Anxiety
Diagnosis/Rationale: No diagnosis - symptoms of anxiety can be
considered part of the panic disorder and do not warrant a separate diagosis
#3. Claimed condition: Adjustment Disorder with Depressed Mood
Diagnosis/Rationale: Unspecified Depressive Disorder - the
service
member meets full DSM-5 criteria for this diagnosis
#4. Claimed condition: n/a
Diagnosis/Rationale: Alcohol Use Disorder, Moderate, in early
remission - the service member meets full DSM-5 criteria for this diagnosis
****************************************************************************
COMPENSATION AND PENSION EXAMINATION REPORT (FREE TEXT)
=======================================================
Mental health - Separation Health Assessment
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Name of patient/Servicemember: Martinez, Stephen Jacob
SSN: ***********
Was a DD Form 2807-1, Report of Medical History, completed by the
Servicemember and available for review at the time of this examination?
[ ] Yes [X ] No [ ] N/A
Any changes to his/her health status since DD 2807-1 completed?
[ ] Yes [ ] No [X ] N/A
(Proposed) Date of separation from active service: No response provided.
1. Medical record review
-------------------------
Was the Veteran's VA claims file reviewed?
[X ] Yes [ ] No
2. Medical history (Review of Systems)
--------------------------------------
1. Psychiatric:
[ X] Yes [ ] No
#1. Claimed Condition: Panic Disorder
Onset: 2014
History: stable
Prognosis: good
#2. Claimed Condition: Anxiety
Onset: n/a
History:
Prognosis:
#3. Claimed Condition: Adjustment Disorder wtih Depressed Mood
Onset: 2014
History: stable
Prognosis: good
(Please follow format if more claims are being addressed)
PTSD SCREEN PC-PTSD
-------------------
In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that, in the past month, you:
1. Have had nightmares about it or thought about it when you did
not want to?
[X ] Yes [ ] No - related his wife leaving him
2. Tried hard not to think about it or went out of your way to
avoid situations that reminded you of it?
[X ] Yes [ ] No
3. Were constantly on guard, watchful, or easily startled?
[X ] Yes [ ] No
4. Felt numb or detached from others, activities, or your
surroundings?
[X ] Yes [ ] No
Depression screen: PHQ2
-----------------------
Over the past two weeks, how often have you been bothered by any
of the following problems?
Little interest or pleasure in doing things.
[ ] 0 = Not at all [ ] 1 = Several days [ ] 2 = More than half
the days [X ] 3 = Nearly every day
Feeling down, depressed, or hopeless.
[ ] 0 = Not at all [ ] 1 = Several days [X ] 2 = More than half
he
Days [ ] 3 = Nearly every day
Total Point Score: 5
Brief Suicide Risk Assessment
-----------------------------
- (Perform if score positive on Depression or PTSD screens)
Are you feeling hopeless about the present or future?
[X ] Yes [ ] No
Have you had thoughts about taking your life - if yes - when did
you have these thoughts and do you have a plan to take your
life?
[ ] Yes [X ] No
Have you ever had a suicide attempt?
[ ] Yes [X ] No
3. Physical Exam
-----------------
1. Psychiatric (Specify any personality deviation)
[ X] Normal [ ] Abnormal [ ] Not examined
5. Diagnosis:
-------------
#1. Claimed condition: Panic Disorder
Diagnosis/Rationale: Panic Disorder without Agoraphobia - the
service
member meets full DSM-5 criteria for this diagnosis
#2. Claimed condition: Anxiety
Diagnosis/Rationale: No diagnosis - symptoms of anxiety can be
considered
part of the panic disorder and do not warrant a separate diagosis
#3. Claimed condition: Adjustment Disorder with Depressed Mood
Diagnosis/Rationale: Unspecified Depressive Disorder - the service
member
meets full DSM-5 criteria for this diagnosis
#4. Claimed condition: n/a
Diagnosis/Rationale: Alcohol Use Disorder, Moderate, in early
remission
- the service member meets full DSM-5 criteria for this diagnosis
(for additional Claim/diagnosis, please follow above format)
6. Remarks, if any:
-------------------
All additional DBQs found to be necessary completed as appropriate at time
of signing this DBQ?
[X ] Yes [ ] No
-------------------------------------------------------------------------
