H0ckeyPhreak

Thanks bluevet for the breakdown. The C&P was done at the VA and no, I'm not already service connected. This is my first experience with the VA.

Hey HadIt! Long time lurker, first time poster. I got my PTSD C&P notes yesterday off of myHealtheVet and from what everyone had said on others before on here, it sounds like 50%; however, I thought I'd ask you all about your interpretation. The other question I had was, is it normal for the examiner *NOT* to review your C-File? Thanks in advance for your help! SECTION I: --------- 1. Diagnostic Summary --------------------Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: F43.10 2. Current Diagnoses -------------------a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder ICD code: F43.10 Mental Disorder Diagnosis #2: Major Depressive Disorder, Recurrent, Moderate ICD code: F33.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 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? [X] Yes [ ] No [ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: PTSD symptoms are outlined elsewhere. Symptoms of depression include sadness, diminished interest and pleasure, decreased energy and motivation, frequent crying, sense of failure, and morbid thinking. 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? [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: Social and occupational impairment are attributed to symptoms of 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? No response provided. 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? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [X] Military service personnel records [ ] Military enlistment examination [X] Military separation examination [ ] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] 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 [X] No 3. Stressors -----------Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: rocket and mortar attack (Iraq, 2004) Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: witnessing assault and killing of servicemember by another servicemember ( Qatar, 2007) Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: Veteran reported witnessing one military servicemember assault with a knife and kill another military servicemember while in military R&R compound in Qatar (2007). This traumatic event was not related to hostile military or terrorist activity but was directly related to active duty military service. Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). 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 acts 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 and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [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] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes 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. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2 5. Symptoms ----------For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once a week [X] Chronic sleep impairment [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] Inability to establish and maintain effective relationships [X] Obsessional rituals which interfere with routine activities 6. Behavioral Observations -------------------------Veteran arrived on time and looked clean, neat, and appropriately dressed. He was alert and fully oriented. Veteran maintained adequate eye contact during exam. His mood was anxious and depressed. His affect was congruent. Veteran was observed to be tearful and visibly anxious when recounting traumatic events during the exam. His speech was clear and coherent. His thoughts were linear with evidence of hypervigilance bordering on paranoia at times. Veteran also reported a history of auditory hallucinations (hearing voices in his house) but none on this date. Veteran denied past or current suicidal or homicidal ideation, plan, or intent. 7. Other symptoms ----------------Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: Veteran also suffers from sensitivity to light and noise that he attributed to hearing problems. Although he may have a medical condition (evaluation for such deferred to audiology and/or MD), this sensitivity may also be related to low frustration tolerance and general irritability/anger consistent with PTSD. In addition, Veteran reported other distressing perceptual problems including psychotic like symptoms (paranoia, hearing voices in his house, etc) for which he is currently being treated with anti-psychotic medication. He denied visual or command hallucinations. 8. Competency ------------Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No