Hi everyone so I'm new to this I had my Comp & Pen exam for PTSD on October 27 2016. I check Ebenefits on the status of my claim which still in gathering evidence phase and I also got my Comp & Pen exam from Ebenefits also. I'm 50% for depression, 30% for Ankle, 30% for scars and 10% for left foot arthritis. Here's my comp & Pen can any help me with the results. I got diagnosis at the VA for both Depression and PTSD and I'm also do individual treatment the VA for PTSD I'm doing Cognitive Processing Therapy right going on my 9th session.
C&P MENTAL DISORDERS
This writer met with veteran for C&P exam. He reported significant increase
In MDD and PTSD symptoms, and expresesd daily passive suidical ideation. He
contracted with this writer for safety, and stated that he gave his firearms to
his brother. However, he continues to experience ongoing ideation and remains at
high risk.
Mental Disorders
(other than PTSD and Eating Disorders)
Disability Benefits Questionnaire
Name of patient/Veteran: Alex Googe
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
disorder(s)?
[X] Yes [ ] No
ICD code: F43.1
If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: PTSD
ICD code: F43.1
Mental Disorder Diagnosis #2: Major Depressive Disorder, Severe
ICD code: F33.4
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
Significant overlap
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
3. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of
occupational
and social impairment with regards to all mental diagnoses? (Check only
one)
[X] Total occupational and social impairment
b. For the indicated level of occupational and social impairment, is it
possible to differentiate what portion of the occupational and social
impairment indicated above is caused by each mental disorder?
[ ] Yes [X] No [ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis:
Signficant overlap.
c. If a diagnosis of TBI exists, is it possible to differentiate what
portion
of the occupational and social impairment indicated above is caused by
the
TBI?
[ ] Yes [ ] No [X] No diagnosis of TBI
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
[X] Other (please identify other evidence reviewed):
Veteran brought in Statement in Support of PTSD and a handwritten
letter as well.
This was given to Ricardo Sealy for scanning.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Veteran stated that he continues to live with his wife, but in separate
bedrooms. "It's been rough the past two months, I haven't
been speaking to anyone.
I haven't been at work for two weeks, since that incident.
It's been hell - the anxiety, don't want to be around poeple. I had time
Driving here, my dad was supposed to drive me here last week. But I had to take
myself here, since he went on vacation.
I don't talk to anyone -not at all. Since the incidnet, at work, I
haven't been able to go back. I feel that people are out to get me."
b. Relevant Occupational and Educational history (pre-military, military,
and post-military):
"I've been struggling at work for the past three months. It
Was something that triggered my episode. I was Dunkin Donuts, and a guy
threatened this young lady. She kept apologizing, he was going to stab
her. I had a confrontation with him, I didn't care if I lived or
died. She grabbed my hand, but when I turned around she was gone.
I've had that happen a couple of times [witnessing someone being
threatened].
There was a veteran shouting at the secretary, and I lost
it. I went home early that day. I was going home early from work about
4 times per week. The incident at work was when a veteran got mad at me and threatened my
life. I thought I was going to lose it, come after him. They've
been calling me to come back to work, but I can't talk to them, I
can't go back there."
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
"I haven't been to work since then [the incident two weeks
ago]. They have been trying not contact me, but I don't talk to anyone. I last
saw psychologist in Newington last week. I'm struggling, I take the
bus, I have anxiety.
I eat once in a while - lost 25 pounds. I haven't taken a bath in a
Few days. In the same clothes for the past three days. In the last weeks, I
only sleep for two hours per night. I wake up tired, wiht nightmares
about my friend. Flashbacks - that's why I'm not driving. I had one at a stop
sign. People blowing horns, then there was a cop on my window. I haven't
driven since the last day I went to work. I had to drive myself here.
Suicidal - I think about it every day, my brother had my firearms for
now.I feel safe to go home otday. agreed to call crisis line. Declined
immediat support, did not want to be walked to the psych ER.
Mood - anxious, depressed most of the time. I feel like I have no
Energy to do anything."
The PTSD reported developed after veteran and his close friend
Witnessed a fight at a bar near Andrews AFB in May 1985. They intervened to help
the ladies, and his friend was shot and killed. Veteran was holding his
friend in his arms, as he died immediately.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or
a
work like setting
[X] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[X] Neglect of personal appearance and hygiene
[X] Intermittent inability to perform activities of daily living,
including maintenance of minimal personal hygiene
4. Behavioral observations
--------------------------
Mental Status and Behavioral Observations:
-ORIENTATION: Alert and oriented x3.
-PRESENTATION: Appropriately dressed in casual attire and well-groomed.
-RAPPORT: Cooperative and open with his concerns.
-MOOD/AFFECT: Mood appeared dysthymic; affect congruent with mood or
excessively flat.
-THOUGHTS: Linear and goal-directed.
-SPEECH: Flatt and sparse in terms of rate, rhythm, and volume.
-INSIGHT AND JUDGMENT: Fair insight and judgment.
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes [X] No
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.
OPINION REQUESTED: Secondary Service Connection.
Is the Veteran's PTSD at least as likely as not (50 percent or greater
probability) proximately due to or the result of Major depression?
Rationale must be provided in the appropriate section.
If more than one mental disorder is diagnosed please comment on their
relationship to one another and, if possible, please state which symptoms
are attributed to each disorder.
If your examination determines that the Veteran does not have diagnosis of
PTSD and you diagnose another mental disorder, please provide an opinion as
to whether it is at least as likely as not that the Veteran's diagnosed
mental disorder is a result of an in-service stressor related event.
West Haven VA exam dated 10/27/2016, diagnosed PTSD and noted that PTSD has
a significant overlap of symptoms with service connected Major Depression.
Question for Clarification:
Is the diagnosis of PTSD a progression of the Veteran's service connected
Major Depression condition?
RESPONSE:
The veteran's PTSD is at least as likely as not(50 percent or greater)
proximately due to his major depressive symptoms.Based on the most recent
examination, it appears that he had presenting as primarily depressive, but his PTSD symptoms of hypervigilance, recklessness, and signficant social deficits have been activated to a highly dressing level in the past few months. This has affected him in all areas of his life, especially at home and his ability to interact with others in a work setting.
Both PTSD and Major Depressive Disorder are valid diagnoses, and the increase in PTSD symptoms should be treated as the progression of a the former disability. In this writer's opinion, this should be viewed as a secondary service connection.
Question
Alex Googe
Hi everyone so I'm new to this I had my Comp & Pen exam for PTSD on October 27 2016. I check Ebenefits on the status of my claim which still in gathering evidence phase and I also got my Comp & Pen exam from Ebenefits also. I'm 50% for depression, 30% for Ankle, 30% for scars and 10% for left foot arthritis. Here's my comp & Pen can any help me with the results. I got diagnosis at the VA for both Depression and PTSD and I'm also do individual treatment the VA for PTSD I'm doing Cognitive Processing Therapy right going on my 9th session.
C&P MENTAL DISORDERS
This writer met with veteran for C&P exam. He reported significant increase
In MDD and PTSD symptoms, and expresesd daily passive suidical ideation. He
contracted with this writer for safety, and stated that he gave his firearms to
his brother. However, he continues to experience ongoing ideation and remains at
high risk.
Mental Disorders
(other than PTSD and Eating Disorders)
Disability Benefits Questionnaire
Name of patient/Veteran: Alex Googe
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
disorder(s)?
[X] Yes [ ] No
ICD code: F43.1
If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: PTSD
ICD code: F43.1
Mental Disorder Diagnosis #2: Major Depressive Disorder, Severe
ICD code: F33.4
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
Significant overlap
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
3. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of
occupational
and social impairment with regards to all mental diagnoses? (Check only
one)
[X] Total occupational and social impairment
b. For the indicated level of occupational and social impairment, is it
possible to differentiate what portion of the occupational and social
impairment indicated above is caused by each mental disorder?
[ ] Yes [X] No [ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis:
Signficant overlap.
c. If a diagnosis of TBI exists, is it possible to differentiate what
portion
of the occupational and social impairment indicated above is caused by
the
TBI?
[ ] Yes [ ] No [X] No diagnosis of TBI
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
[X] Other (please identify other evidence reviewed):
Veteran brought in Statement in Support of PTSD and a handwritten
letter as well.
This was given to Ricardo Sealy for scanning.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Veteran stated that he continues to live with his wife, but in separate
bedrooms. "It's been rough the past two months, I haven't
been speaking to anyone.
I haven't been at work for two weeks, since that incident.
It's been hell - the anxiety, don't want to be around poeple. I had time
Driving here, my dad was supposed to drive me here last week. But I had to take
myself here, since he went on vacation.
I don't talk to anyone -not at all. Since the incidnet, at work, I
haven't been able to go back. I feel that people are out to get me."
b. Relevant Occupational and Educational history (pre-military, military,
and post-military):
"I've been struggling at work for the past three months. It
Was something that triggered my episode. I was Dunkin Donuts, and a guy
threatened this young lady. She kept apologizing, he was going to stab
her. I had a confrontation with him, I didn't care if I lived or
died. She grabbed my hand, but when I turned around she was gone.
I've had that happen a couple of times [witnessing someone being
threatened].
There was a veteran shouting at the secretary, and I lost
it. I went home early that day. I was going home early from work about
4 times per week. The incident at work was when a veteran got mad at me and threatened my
life. I thought I was going to lose it, come after him. They've
been calling me to come back to work, but I can't talk to them, I
can't go back there."
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
"I haven't been to work since then [the incident two weeks
ago]. They have been trying not contact me, but I don't talk to anyone. I last
saw psychologist in Newington last week. I'm struggling, I take the
bus, I have anxiety.
I eat once in a while - lost 25 pounds. I haven't taken a bath in a
Few days. In the same clothes for the past three days. In the last weeks, I
only sleep for two hours per night. I wake up tired, wiht nightmares
about my friend. Flashbacks - that's why I'm not driving. I had one at a stop
sign. People blowing horns, then there was a cop on my window. I haven't
driven since the last day I went to work. I had to drive myself here.
Suicidal - I think about it every day, my brother had my firearms for
now.I feel safe to go home otday. agreed to call crisis line. Declined
immediat support, did not want to be walked to the psych ER.
Mood - anxious, depressed most of the time. I feel like I have no
Energy to do anything."
The PTSD reported developed after veteran and his close friend
Witnessed a fight at a bar near Andrews AFB in May 1985. They intervened to help
the ladies, and his friend was shot and killed. Veteran was holding his
friend in his arms, as he died immediately.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or
a
work like setting
[X] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[X] Neglect of personal appearance and hygiene
[X] Intermittent inability to perform activities of daily living,
including maintenance of minimal personal hygiene
4. Behavioral observations
--------------------------
Mental Status and Behavioral Observations:
-ORIENTATION: Alert and oriented x3.
-PRESENTATION: Appropriately dressed in casual attire and well-groomed.
-RAPPORT: Cooperative and open with his concerns.
-MOOD/AFFECT: Mood appeared dysthymic; affect congruent with mood or
excessively flat.
-THOUGHTS: Linear and goal-directed.
-SPEECH: Flatt and sparse in terms of rate, rhythm, and volume.
-INSIGHT AND JUDGMENT: Fair insight and judgment.
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes [X] No
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
---------------------------------------------------
Veteran meets criteria for PTSD as well as MDD, based on report sympotms and
chart review. He experienced an incident at work about 2 weeks ago, and
since
that time he has been impaired in his emotional functioning, communication,
abilities, and ADLs.
LOCAL TITLE: C&P PTSD, INITIAL EVALUATION
STANDARD TITLE: PSYCHIATRY C & P EXAMINATION CONSULT
DATE OF NOTE: DEC 22, 2016@08:31:12 ENTRY DATE: DEC 22, 2016@08:31:12
AUTHOR: ROGINSKY,BINA EXP COSIGNER:
URGENCY: STATUS: COMPLETED
COMPENSATION AND PENSION EXAMINATION REPORT (FREE TEXT)
=======================================================
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.
OPINION REQUESTED: Secondary Service Connection.
Is the Veteran's PTSD at least as likely as not (50 percent or greater
probability) proximately due to or the result of Major depression?
Rationale must be provided in the appropriate section.
If more than one mental disorder is diagnosed please comment on their
relationship to one another and, if possible, please state which symptoms
are attributed to each disorder.
If your examination determines that the Veteran does not have diagnosis of
PTSD and you diagnose another mental disorder, please provide an opinion as
to whether it is at least as likely as not that the Veteran's diagnosed
mental disorder is a result of an in-service stressor related event.
West Haven VA exam dated 10/27/2016, diagnosed PTSD and noted that PTSD has
a significant overlap of symptoms with service connected Major Depression.
Question for Clarification:
Is the diagnosis of PTSD a progression of the Veteran's service connected
Major Depression condition?
RESPONSE:
The veteran's PTSD is at least as likely as not(50 percent or greater)
proximately due to his major depressive symptoms. Based on the most recent
examination, it appears that he had presenting as primarily depressive, but his PTSD symptoms of hypervigilance, recklessness, and signficant social deficits have been activated to a highly dressing level in the past few months. This has affected him in all areas of his life, especially at home and his ability to interact with others in a work setting.
Both PTSD and Major Depressive Disorder are valid diagnoses, and the increase in PTSD symptoms should be treated as the progression of a the former disability. In this writer's opinion, this should be viewed as a secondary service connection.
Edited by Alex Googeadded medical opionion
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