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Buck52

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    Helping other Veterans and watching my grand-monsters grow up! Vietnam Veteran old Dog

    To care for him who shall
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  1. Thank you for your input, but I had completed an early post in regards to a C and P exam, which I did not include in my latest post (new to the site). The post was in regards to a follow visit with a VA psychologist.  I will include the entire VA notes from the two separate visits at VA within two weeks of each other.I was scheduled for an appointment with a VA psychologist after my C and P exam and the below are her results, which seems to conflict the C and P examiner.  Any feedback would be great.

     

    I was scheduled for a followup appointment with a VA psychologist and the below are her results, which is seems to conflict the C and P examiner ...... any feedback is appreciated

     

    Second Visit with VA Psychologist Results:

    Military History

    Branch (years of service): MST: yes
     

    MEASUREMENT BASED CARE:
    PHQ-9: 19 (moderate)
    GAD-7: 16 (severe)
    PCL-5:
    AUDIT-C: 5 (above threshold)

     

    DIAGNOSTIC IMPRESSIONS:
    Anxiety Disorder, unsp
    MDD, recurrent, moderate

     

    Depression Monitoring (PHQ-9) 2017:
    Depression Screen:
    PHQ9 Screening
    PHQ-9
    A PHQ-9 screen was performed. The score was 19 which is suggestive
    of moderately severe depression.

     

    PTSD Screening:
    PTSD Screen:
    PTSD Screening
    PC PTSD
    A PTSD screening test (PC-PTSD) was positive (score=4).

     

    +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

     

    C and P Exam Notes from VA Clinical Psychologist

     

    SECTION I:
    ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
    based on today's evaluation?
    [ ] Yes [X] No
    If no diagnosis of PTSD, check all that apply:
    [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under
    DSM-5 criteria
    [X] Veteran has another Mental Disorder diagnosis. Continue to complete
    this Questionnaire and/or the Eating Disorder Questionnaire:
    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: UNSPECIFIED DEPRESSIVE DISORDER
    b. Medical diagnoses relevant to the understanding or management of the
    Mental Health Disorder (to include TBI): SEE MEDICAL CHART
    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 [ ] 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 due to mild or transient symptoms
    which decrease work efficiency and ability to perform occupational
    tasks only during periods of significant stress, or; symptoms
    controlled by medication

    TYPE OF MEDICAL OPINION REQUESTED: Military Sexual Trauma (MST)
    OPINION: Military Sexual Trauma (MST)
    This examination is being conducted to assist with determining whether the
    Veteran experienced an in-service personal assault stressor related to
    military sexual trauma (MST) that has resulted in a current PTSD diagnosis.
    Please review the claims file and state in your report that it was reviewed.
    In your review of the claims file, please pay special attention to signs,
    events, or circumstances that may represent markers for the MST stressor
    described by the Veteran. Your review is not limited to the evidence
    identified on this request form, or tabbed in the claims folder. If
    additional testing is required, please obtain it prior to rendering your
    opinion.
    Based upon your review of the evidence, please provide a medical opinion as
    to whether the MST stressor event described by the Veteran is at least as
    likely as not (50 percent or greater probability) supported by and consistent
    with the in-service marker evidence. Please provide a rationale for the
    opinion and list the marker evidence used to arrive at your decision.
    NO MARKERS IDENTIFIED. MEDICAL OPINION DOES NOT APPEAR WARRANTED.


    In addition:
    1. IF YOUR EXAMINATION DETERMINES THE VETERAN HAS A CURRENT DIAGNOSIS OF
    PTSD, please provide an opinion as to whether the current PTSD diagnosis is
    at least as likely as not (50 percent or greater probability) caused by or a
    result of the in-service MST-related marker(s), and provide a rationale.
    Please note that only PTSD can be service connected based on circumstantial
    marker evidence (38 CFR 3.304(f) (5)).
    VETERAN'S SYMPTOMS APPEAR TO BE BEST ACCOUNTED FOR BY A DIAGNOSIS OF
    UNSPECIFIED DEPRESSIVE DISORDER. MEDICAL OPINION DOES NOT APPEAR WARRANTED.

    2. IF YOUR EXAMINATION DETERMINES THAT, IN ADDITION TO PTSD, THE VETERAN HAS
    ADDITIONAL MENTAL DISORDERS, please state whether the additional mental
    disorders are at least as likely as not (50 percent or greater probability)
    secondary to the PTSD, and provide a rationale. For each mental disorder

    MEDICAL OPINION DOES NOT APPEAR WARRANTED.


    3. IF YOUR EXAMINATION DETERMINES THE VETERAN DOES NOT HAVE PTSD, BUT HAS A
    DIFFERENT MENTAL DISORDER(S), please review the service treatment records
    (STRs) and service personnel records for in-service direct evidence. Direct
    evidence is clear, undisputable proof of an event, injury, or disease. Such
    evidence includes, but is not limited to, mental health treatment, mental
    health symptoms, or a mental health diagnosis. If direct evidence exists in
    the STRs or service personnel records, please provide an opinion as to
    whether the mental disorder(s) diagnosed on examination is at least as likely
    as not (50 percent or greater probability) caused by or a result of the
    direct evidence noted in service. Please provide a rationale for the opinion
    and list the evidence used to arrive at your decision. (38 CFR 3.303).


    NO DIRECT EVIDENCE LOCATED. OPINION DOES NOT APPEAR WARRANTED.

    1. ArmyMajor

      ArmyMajor

      I had two separate appointments one as a C and P and another by VA psychologist and they seem to have differing opinions.... I was just curious how these opinions would impact the rating, if applicable.  I included buddy statements and other information as part of the evidence.  Thanks to all who have replied.

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