Aruis1971

so i got my C&P exam back and wanted to know what you guys think. I went into the hospital a few weeks ago because i got in a bad way because of a job. the therapist there told me that they didn't think i needed to work and i realize that doesn't mean crap but he did put it into my files.so could you guys give it a look and tell me what you all think. How long is the v.a. taking when it goes into a preparation for decision status.this is for an increase on ptsd and iu. im currently at 70% for ptsd SECTION I: --------- 1. Diagnostic Summary --------------------Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: 309.81 2. Current Diagnoses -------------------a. Mental Disorder Diagnosis #1: PTSD ICD Code: 309.81 Mental Disorder Diagnosis #2: unspecified depressive d/o ICD Code: 311.00 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): no acute conditions identifed 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 and discuss whether there is any clinical association between these diagnoses: shared sx presentation 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 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? [ ] 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: shared sx presentation. 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[X] No[ ] 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? [X] Yes[ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: as detailed in VBMS review of VA med record review of previous C & P evaluations. 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? [X] Yes[ ] No If yes, describe: as detailed in record wife present for evaluation and offers collateral 2. Recent History (since prior exam) -----------------------------------a. Relevant Social/Marital/Family history: wife accompanies Vet to interview...."we just had our 4 yr anniversary" limited activity base. increasing isolation. b. Relevant Occupational and Educational history: "lost job in April last yr" ...."I got laid off...." "they're still there....I'm not...." "they said I was being confrontational to the new boss". c. Relevant Mental Health history, to include prescribed medications and family mental health: recent hospitalization ACY , 5 days....."I should have stayed longer......" but Vet notes concern about Vehicle that was left at COPC where he had been seen prior to ACY admission. before hospitalizaion med compliance had been a problem wife notes "that was part of the reason for hospitalization...get back...regulated....". d. Relevant Legal and Behavioral history: none e. Relevant Substance abuse history: none f. Other, if any: No response provided. 3. PTSD Diagnostic Criteria --------------------------Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) 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 #6 - "Other symptoms". 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] Witnessing, in person, the traumatic event(s) as they occurred to others 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). [X] Dissociative reactions (e.g., flashbacks) in which the individual feels or ac ts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of 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] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) 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] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause 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. 4. 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] Mild memory loss, such as forgetting names, directions or recent events [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Flattened affect [X] Impaired judgment [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 worklike setting [X] Suicidal ideation [X] Impaired impulse control, such as unprovoked irritability with periods of violence 5. Behavioral Observations: --------------------------alert with prompting. oriented and cooperative. Affect restricted. slow gait. 6. Other symptoms ----------------Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------regarding IU findings indicate that PTSD related sx acuity includes poor frustration tolorance and ease to react with anger in response to minimal stressors, increased isolation, concentration difficutlty. Adjustment to medications may be confounding. Drive, motivation, and and ability to complete tasks are very likely impaired. Findings indicate sx severity is at times quite severe and due the sxs noted Vet would not be able to secure or maintain viable gainful employment in any setting, physical or sedentary.