[My C&p For 100% Ptsd]

Received my 100% P&T now working on getting a schedule S

[My C&p For 100% Ptsd]

I was IRR and recalled for the 1st Gulf War yes some people was in a combat zone then and I am an E-4 Spealist received two ranks while I was there corrected on a dd215

[My C&p For 100% Ptsd]

No I just have IU this was C&P for 100% PTSD

[My C&p For 100% Ptsd]

I am now 70% PTSD, 40% Fibro, 30% IBS, 10% tinntius = 90% getting 100%IU .....SSDI for PTSD Symptoms only

I just had this C&P to bump my rating to 100% TDIU or P&T

These are my results form my C&P anyone have any comments that would help me understand this .....He seems to rate me at 50%.....then all of the rest seems to lean towards a P&T rating

LOCAL TITLE: C&P EXAM

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: JAN 13, 2014@08:00 ENTRY DATE: JAN 14, 2014@11:46:23

AUTHOR: VAN PELT,DAVID M EXP COSIGNER:

URGENCY: STATUS: COMPLETED

CONFIDENTIAL Page 14 of 26 Review Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

Name of patient/Veteran:

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran now have or has he/she ever been diagnosed with PTSD?

[X] Yes[ ] No

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: Post-Traumatic Stress Disorder (PTSD)

Mental Disorder Diagnosis #2: Psychological Factors Affecting Other

Medical Conditions

Mental Disorder Diagnosis #3: Major Depressive Disorder

Mental Disorder Diagnosis #4: Alcohol Use Disorder in remission (per

self-report)

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): fibromyalgia, irritable bowel

syndrome, sleep apnea, tinnitus, hypertension and potential chronic

fatigue syndrome (per self-report)

3. 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: Mr.

Turnbow

has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the

requisite criteria for this diagnosis. He also meets the criteria

for

Major Depressive Disorder, Psychological Factors Affecting Other

Medical Conditions, and Alcohol Use Disorder, which is in remission

per his report. These problems coalesce to exacerbate his symptoms of

anxiety and depression. The symptoms are overlapping and

intermingled

and this makes it difficult to differentiate the symptoms to each

CONFIDENTIAL Page 15 of 26 diagnosis.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes[ ] No[X] 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 reduced reliability and

productivity

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: has symptoms of

Post-Traumatic Stress Disorder (PTSD) and meets the requisite

criteria

for this diagnosis. He also meets the criteria for Major Depressive

Disorder, Psychological Factors Affecting Other Medical Conditions,

and Alcohol Use Disorder, which is in remission per his report. These

problems coalesce to exacerbate his symptoms of anxiety and

depression. The symptoms are overlapping and intermingled and this

makes it difficult to differentiate the symptoms to each diagnosis.

The symptom picture presented comes together to cause substantial

impairment in his social and occupational functioning.

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:

CONFIDENTIAL Page 16 of 26 -------------------------

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?

[X] Yes[ ] No

Was the Veteran's VA claims file reviewed?

[X] Yes[ ] No

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

[ ] Other:

b. Was pertinent information from collateral sources reviewed?

[ ] Yes[ ] No

If yes, describe:

2. Recent History (since prior exam)

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

a. Relevant Social/Marital/Family history:

is currently married and has been for 5 years. He

described

the relationship with his wife as positive and said, "I have a

fairly

good relationship with her. She understands me." He has 2

daughters and

one son. He has no contact with his son or oldest daughter. His

youngest daughter lives at home with him and he described the

relationship with her is great. He also noted how he and his wife are

raising their 5-year-old granddaughter. He described the relationship

with his granddaughter as "good." has one adopted

brother

but has not had contact with him currently. Both of his parents are

living and he described having a positive relationship with them. He

noted seeing them one time a week and said the relationship is

"good

now but in the past and not so good."

b. Relevant Occupational and Educational history:

graduated high school in 1986 in Elgin, Illinois. He

CONFIDENTIAL Page 17 of 26 attended one semester of college but did not receive a degree. He is

currently unemployed. His last job was as a cable technician where he

worked for one year. He has not work since 2010 and his wife said,

"It

was before he got his disability." said he was fired

for

"taking my VA meds." His wife noted how he fell asleep at the

wheel and

also fell asleep one time in a meeting." When asked that his

current

limitations or restrictions to employment he said, "I

couldn't deal

with people and my physical disabilities. I have fibromyalgia and I

hurt all the time."

c. Relevant Mental

Health history, to include prescribed medications and

family mental health:

assessed his current health as "poor" and said

his current

medical conditions consist of fibromyalgia, irritable bowel syndrome,

sleep apnea, tinnitus, hypertension and he believes he has chronic

fatigue syndrome. All of his current medications are prescribed by the

VA and he noted taking medications as prescribed. He is experiencing a

side effect of dry mouth with his current medication regimen He denied

being hospitalized for physical reasons and last 5 years.

was hospitalized for psychiatric reasons in 2011 due to

suicidal ideation. He said the hospitalization was for one day and his

wife commented, "That was about the time my youngest son got

killed in

a car accident. He fell asleep behind the wheel." is

currently receiving mental health treatment at the Poplar Bluff VA

facility. He works with a social worker and psychiatrist and is in

group counseling. He has been receiving treatment for approximately 5

years. noted having suicidal ideations 2 or 3 times a

month

but denied any attempt at taking his life. He said, "I have a

daughter

who needs me." He noted having recurrent homicidal thoughts as

well and

said this involves "the person who raped my daughter and the

police who

screwed over my stepson. I have a list of 10 people who if I had 3

months to live I would do what I had to do." He denied any attempt

at

taking another's life.

d. Relevant Legal and Behavioral history:

currently possesses a valid driver's license but does

not

CONFIDENTIAL Page 18 of 26 operate a vehicle on a regular basis. He was cited with a DUI and was

under the influence of prescription medication. The offense occurred

in

2013 and he is currently on probation "until I pay a fine and

complete

the SATOP program." He is on 2 years supervised probation and when

this

coursework is completed he will be changed to unsupervised probation.

e. Relevant Substance abuse history:

denied smoking cigarettes currently. He currently uses

smokeless tobacco at a rate of one can a day and has been engaged in

this habit for 10 years. His current alcohol consumption is,

"hardly

any anymore; maybe a beer one time every 3 months." When drinking

his

heaviest he was consuming "a 30 pack and a fifth a day." He

drank at

this rate for 1.5 years and reduced his use approximately 3 years ago.

He experimented with marijuana "once or twice" but denied

regular use

of this substance. He denied use of crack, cocaine, amphetamines,

psychedelic substances, or heroin. He also denied history of

prescription drug abuse.

f. Other, if any:

When asked about his current psychological and mental health

difficulties, said, "its nightmares and flashbacks. I

have

these about 3 or 4 times a week. Sometimes I get stuck in my dreams.

It

I can't get out of the dream. He noted sleeping approximately 5

hours

during the night and is not refreshed upon waking. "I've also

heard

voices every once in a great while. I can't make them out it

Arabic

speaking. I have a lot of pain and that doesn't help the other

stuff. I

can do anything. The more physical I do the more I have to relax. I

stay at home all the time. The only place I go is to the VA or my

parents. I let her (wife) do all the shopping." He went on to

say,

"this is my forth marriage and this is better. I spout my 15

minutes

and then I'm all better. I'm not cool with the authority

figures. I'm

not cool with cops whatsoever." He noted having anger problems,

concentration problems and "short-term and loss. He denied

hypervigilance or an exaggerated startle response.

. I was recalled to the gulf war." He

was a

light vehicle mechanic and he attained a rank of E4. He denied having

he article 15's or other disciplinary action. He reported heavy

alcohol

consumption while in military but denied drug usage. When asked about

injuries he described how he broke his right ankle but does not

remember the date of the injury or which ankle it was. He was deployed

to Iraq from January 1991 until March 1991. He reported being exposed

to combat while in this region. reflects on his service in

the military "2-3 times a day."

indicated being exposed to actual or threatened death and

serious injury by directly experiencing a traumatic event or

witnessing, in person, a traumatic event that occurred with others.

This series of events, which are stated elsewhere in this report,

occurred while he was in the military service. There have been

recurrent, involuntary, and intrusive distressing recollections of the

trauma; recurrent distressing dreams in which the content or effect of

the dream is related to that trauma event; and dissociative reactions

and flashbacks in which there is a feeling that the traumatic event is

reoccurring. He indicated having an avoidance of or efforts to avoid

distressing memories, thoughts, or feelings about or closely

associated

with the trauma along an avoidance of or efforts to avoid external

reminders that arouse distressing memories, thoughts, or feelings

about

or closely associated with events. He has a persistent negative

emotional state; a markedly diminished interest or participation in

significant activities; feelings of detachment or estrangement from

others; and a persistent inability to experience positive emotions.

Additionally, he has irritable behavior and angry outbursts with

little

or no provocation; hypervigilance and an exaggerated startle response.

He also noted having problems with concentration and difficulty

falling

asleep, staying asleep and/or restless sleep.

was administered the PTSD Checklist-M (PCL-M), which is a

17-item inventory that assesses the degree which an individual has

experienced specific symptoms of PTSD in response to "stressful

military experiences" over the past month. The results of the

PCL-M

reveal a raw score of 74. This score is above the recommended cut

score

of 56 for Veterans assessed in a VA Mental Health Clinic and suggests

he does meet the requisite criteria for this Post-Traumatic Stress

Disorder (PTSD).

He indicated suffering from pain in one or more anatomical sites and

this is the predominant focus of the clinical presentation. His level

CONFIDENTIAL Page 20 of 26 of pain is of sufficient severity to warrant clinical attention. His

pain causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning. Both

psychological factors and a general medical condition are judged to

have important roles in the onset, severity, exacerbation, or

maintenance of the pain.

The symptoms indicated above do appear to be significantly impairing

his social or occupational functioning.

has lived in Northeast Arkansas for approximately 4 years.

His social support consists of his wife and daughter and mental health

workers. His activities of pleasure relaxation are limited to

"watching

TV, reading books and I'll go out and pet the dog." His

religious

affiliation is "none now." When queried about his strengths

he said, "I

am loyal, I am a good father, and that's all I know."

described his mood today as, "a low esteem mood; a mentally

draining

mood." He said his mood most days is "like this, not much