C&P Examination.... is this the right rating?

[ozboi]

Hey guys, I'm a long time luker here.... finally decided to make an account....

 

A little background on me....

 

5 years Army Active duty (Supposed to be only 4.... but I got stop lost for 1 year and some change....)

2001-2006

3 deployments to Iraq.

 

I had my C&P late November for my PTSD.... I was rated at 50% SC. I was also rated 10% for Tinnutus.... giving me 55%... for a total of 60% SC rating.

I just wanted to seek some opinions from us folks if the 50% rating for PTSD is sufficient.... if not.... what I am looking for recommendations on what to do?....

 

I also have my first PCP appointment on March.....

 

Here is my PTSD C&P Results.... some info has been deleted (names and such)....

 

Date/Time:               xxxx Nov xxxx @ xxxx 
Note Title:              C&P EXAM
Location:                VA Southrn Nevada Hlthcare Sys
Signed By:              xxxx 
Co-signed By:           xxxx 
Date/Time Signed:        xxxx 
-------------------------------------------------------------------------

 LOCAL TITLE: C&P EXAM                                           
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE: NOV xxxx      ENTRY DATE: NOV xxxx 
      AUTHOR: xxxx    EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     

                  Initial Post Traumatic Stress Disorder (PTSD)
                        Disability Benefits Questionnaire
                         * Internal VA or DoD Use Only *

    Name of patient/Veteran:  xxxx 
    
                                   SECTION I:
                                   ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
    based on today's evaluation?
    [X] Yes   [ ] No
    
       ICD code:  F43.10
       
    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder
           ICD code: F43.10

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): Deferred to physician
         Comments, if any: Complaints of tinnitus, back pain and headaches with
         no current medical treatment
         

    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 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   [ ] 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
        [X] 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:
              Separation physical found in STRs in eFolder notes complaints of
              anxiety around unfamiliar people, a tendency to avoid crowds, and
              memory disturbance.  DD 214 shows Vetean recieved Iraq Campaign
              Medal.  Enlistment physical is negative for mental health
              complaints.  VA electronic records show no contact with VA mental
              health treating sources.
              
    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):
          xxxx 
          
          
    b. Relevant Occupational and Educational history (pre-military, military, 
and
       post-military):
          xxxx 
          
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
          Mr. xxxx did not report any history of mental health problems or
          treatment prior to military service.  He stated that he has never
          received mental health treatment of any kind.  He indicated that he
          filed a claim for a mental health condition because of frequent issues
          with poor sleep and irritability that have led to family strain.

          Mr. xxxx identified PTSD stressors related to military service.  He
          indicated that during his third deployment to Iraq he was frequently
          assigned to recovery missions that involved recovering disabled US
          military vehicles.  He indicated that these vehicles were often
          contaminated with blood and body matter.  He described a particular
          recovery mission during which the vehicle he was riding in and was hit
          by an IED at a busy intersection.  He stated that the explosion caused
          him to "black out" that he subsequently "woke up and down the gun 
Hatch
          crying, and I wanted to shoot people."  He indicated that no other
          servicemembers were injured during this incident.  He also stated that
          during deployments, especially his second deployment, he was 
repeatedly
          exposed to mortar shelling.

          Mr. xxxx  described ongoing PTSD symptoms related to the above
          stressors.  These symptoms were said to include intrusive memories 
that
          occur on a weekly basis or more frequently, and that are often
          triggered by tinnitus the reminds him of IED explosion described 
above.
          He stated that he will listen to music in an effort to reduce tinnitus
          and trauma memories. He estimated that he experiences nightmares of
          deployment about twice a month.  He did not report any clear
          dissociative flashbacks, but stated that he will sometimes be
          distracted by intrusive memories of deployment, causing him to "zone
          out".  He acknowledged avoidance of trauma reminders including Middle
          Eastern people, burning odors, cigarette smoke, busy intersections and
          news programs about war or terrorism.  He reported hypervigilant
          behaviors such as keeping weapons in his home, adding security 
features
          to his home, planning for emergencies, avoiding crowds, always
          remaining alert to his surroundings, preferring to sit with his back 
to
          the wall and near an exit, and always remaining alert to his
          surroundings.  He indicated that he continues to startle easily, and 
to
          respond defensively if startled.  He described onset of sleep as
          delayed by anxiety and indicated that mid-stage sleep is variably
          interrupted with delay returning to sleep.  He noted that his wife
          complains that he is active in his sleep.  He indicated that he 
awakens
          earlier than he wants to occasionally and denied sleeping excessively.
          He stated that he typically feels rested on awakening, and estimated
          that he sleeps 5-6 hours per night.  However, he complained of some
          daytime fatigue and unintentional sleep.  He reported irritability 
that
          he expresses either verbally or by isolating himself.  He noted that 
he
          will occasionally slam doors.  He denied violent or destructive
          thoughts or behaviors.  He indicated that concentration is poor in 
that
          he is easily distracted.  He stated that he has lost touch with family
          members and friends since being deployed.

          Mr. xxxx reported experiencing occasional, brief depressive episodes
          during which he feels sad and lonely.  He noted that he can feel free
          from emotional distress at times, for example during and after
          exercise.  He was vague regarding any experience of guilt or self
          blame.  He stated that he cries occasionally, without relief of
          distress.  He indicated that his appetite is good and he estimated 
that
          he has gained some 20 pounds in the last year because of reduced
          activity and occasionally eating for comfort.  He reported fair 
energy,
          and no manic or hypomanic symptoms were elicited.  He denied any
          history of suicidal ideation or suicide attempt.  He stated that he
          continues to enjoy time with his family, exercising, playing video
          games and watching movies.  Mr. xxxx  reported that he worries about
          his finances, situation and job and that worry can interfere with
          concentration.  Panic, obsessive-compulsive and psychotic symptoms 
were
          denied.
          
          
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          None reported
          
          
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          None reported
          
          
    f. Other, if any:
          NA
          
          
    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: Repeated exposure to blood and body matter while conducting
          recovery missions in Iraq
          
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [X] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [X] Yes  [ ] No
          
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [X] No
          
    b. Stressor #2: Being in a vehicle hit by an IED at a busy intersection in
          Iraq
          
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [X] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [X] Yes  [ ] No
          
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [X] No
          
    c. Stressor #3: Frequent exposure to mortar shelling in Iraq
    
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [X] Yes  [ ] No
         

          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [X] Yes  [ ] No
          
          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] Learning that the traumatic event(s) occurred to a close family
              member or close friend; cases of actual or threatened death must
              have been violent or accidental; or, experiencing repeated or
              extreme exposure to aversive details of the traumatic events(s)
              (e.g., first responders collecting human remains; police officers
              repeatedly exposed to details of child abuse); this does not apply
              to exposure through electronic media, television, movies, or
              pictures, unless this exposure is work related.

       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).
          [X] Recurrent distressing dreams in which the content and/or affect of
              the dream are related to 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).
          [X] Avoidance of or efforts to avoid external reminders (people,
              places, conversations, activities, objects, situations) that 
arouse
              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] Markedly diminished interest or participation in significant
              activities.
          [X] Feelings of detachment or estrangement from others.

       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] Hypervigilance.
          [X] Exaggerated startle response.
          [X] Problems with concentration.
          [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?:
          [X] Stressor #1
          [X] Stressor #2
          [X] Stressor #3

    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Anxiety
       [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

    6. Behavioral Observations
    --------------------------
    Mr. xxxx was casually dressed and groomed with an unremarkable appearance.
    Posture and eye contact were appropriate and facial expression was mobile.
    He was well oriented and remained cooperative throughout.  Mood was mildly
    anxious and affect was appropriate to topic.  Speech was fluent with rate,
    volume and intonation consistent with affect.  Thought processes were 
logical
    and goal-directed and cognition appeared intact based on verbal production.

    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
    --------------------------------------------------
       Portions of this document were completed using voice recognition 
software.
        While it has been proofread, some errors might remain.
       
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

 
 

What do you guys think?.... is 50% a fair rating? or did I get low balled.... also if I did get low balled.... what actions do I need to take?

 

Also I recently put in a claim for Sleep Apnea and IBS......

 Thanks a lot for reading and any input will be greatly appreciated!

 

 

 

[Slick]

agree with Allan1351

Did you file the OSA as secondary to PTSD?  Unless treatment or some reason for SA is in your book notoing to happen.  As secondary to PTSD and some er things better chance of approval

[ozboi]

To all that replied, THANK YOU!

I had forgotten about this post.

[ozboi]

On 6/10/2016 at 6:03 PM, Slick said:

agree with Allan1351

Did you file the OSA as secondary to PTSD?  Unless treatment or some reason for SA is in your book notoing to happen.  As secondary to PTSD and some er things better chance of approval

I did 2 tests, 1 at home sleep study, and 1 over night sleep study.

Negative for OSA.