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C&p Exam Ptsd Inscrease Would Appeciate A Wag

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seventy5th

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hello all, just got a copy of my c&p for ptsd increase. i still have c&p's for my tbi and tdiu this friday. i am currently at 70% combined 50% ptsd 20% tbi and i believe 10% tinnitus. would like to know my chances for increase and TDIU

----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No

2. Current Diagnoses
--------------------
a. Diagnosis #1: PTSD
ICD code: 309.81
Indicate the Axis category:
[X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): TBI

c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
No response provided.

d. Axis V - Current global assessment of functioning (GAF) score: 45
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes[X] No

b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
No response provided.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[x] Yes

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 deficiencies in most areas, such as work, school, family relations, judgment,thinking and/or mood

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?
[X] Yes[ ] No No other mental disorder has been diagnosed

If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis:
Entirely due to PTSD


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?
[X] Yes[ ] No No diagnosis of TBI

If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis:

Entirely due to PTSD

SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence review
------------------
If any records (evidence) were reviewed, please list here:
CPRS of VA, C-file

2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
=14pxHe was divorced in 2007 after less than a year of marriage. She was of middle eastern decent, my best friend died in iraq and I did not want to
be with her anymore.

Broke up with girlfriend of 3 years. she complained that he would never go out and always staying home. it gradually led to arguments and the arguments gradually became intense and he finally ended relationship.

b. Relevant Occupational and Educational history:
=14px not employed
US Army was last job (discharged may 2009)

c. Relevant Mental Health history, to include prescribed medications and
family mental health:

He has been receiving psychiatric treatment in mental health VAMC Las Vegas.

" I dont like to be around people, i hate it. Hard to focus on things. I hear screams, voices jibberish. The only way they go off is if i put my head phones on.
sometimes they drive me to the wall. I hear those voices almost everyday. It is hard for me to remember things. Short term memory loss". I think of suicide all the time, tired of living like this, it would not go away.

" Me and my brother had a fight, I broke his nose and busted his lip".

While still in active duty in Georgia with 3rd ranger battalion he overdosed on pills prescribed by his army psychiatrist.

Current medications: Sertaline 150mg, Aripiprazole 10mg, prazosin 5mg, Trazodone 250mg, hydroxyziline 25mg

Veteran states Prazosin not helping with nightmares and abilify has not been helping him all the time controlling voices.

d. Relevant Legal and Behavioral history:
none

e. Relevant Substance abuse history:

Drinks alcohol usually on weekends sometimes marijuana no hard drugs.

f. Sentinel Event(s) (other than stressors):
No response provided.

g. Other, if any:
No response provided.

3. PTSD Diagnostic Criteria
---------------------------
Criterion A: The Veteran has been exposed to a traumatic event where both
of the following were present:

[X] The Veteran experienced, witnessed or was confronted with
an event that involved actual or threatened death or
serious injury, or a threat to the physical integrity of
self or others.
[X] The Veteran's response involved intense fear,
helplessness
or horror.

Criterion B: The traumatic event is persistently reexperienced in 1 or
more of the following ways:

[X] Recurrent and distressing recollections of the event,
including images, thoughts or perceptions
[X] Recurrent distressing dreams of the event
[X] Intense psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event
=1em[X] Intense psychological distress at exposure to internal or
=1emexternal cues that symbolize or resemble an aspect of the
=1emtraumatic event
=1em[x] physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C: Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
the
trauma), as indicated by 3 or more of the following:

[X] Efforts to avoid thoughts, feelings or conversations
associated with the trauma
[X] Efforts to avoid activities, places or people that arouse
recollections of the trauma
[X] Markedly diminished interest or participation in
significant activities
[X] Feeling of detachment or estrangement from others
[X] Restricted range of affect (e.g., unable to have loving feelings)
[x] Sense of a foreshortened future


Criterion D: Persistent symptoms of increased arousal, not present before
the trauma, as indicated by 2 or more of the following:

[X] Difficulty falling or staying asleep
[X] Irritability or outbursts of anger
[X] Difficulty concentrating
[X] Hypervigilance
[X] Exaggerated startle response


Criterion E:
[X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month.


Criterion F:
[X] The PTSD symptoms described above cause clinically
significant distress or impairment in social,
occupational, or other important areas of functioning.

4. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:

[X] Depressed mood
[X] Anxiety
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Flattened affect
[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] Suicidal ideation
[X] Persistent delusions or hallucinations
[X] Persistent danger in hurting self or others


5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
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, if any:
-------------------

No clinical evidence of impairment as a result of alcohol use and hence the diagnosis of alcohol abuse is not warranted.

I informed him that his visit with me today was for C&P examination and not for treatment an i am not going to be his treating psychiatrist

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I hope the award is for TDIU and think it will be.

That 20% TBI is probably too low too.

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I hope the award is for TDIU and think it will be.

That 20% TBI is probably too low too.

berta this was for a ptsd increase. i also applied for tbi increase and tdiu which i have c&p's for this friday. should this mental health eval been part of my tdiu c&p? or is that separate?

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