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ArmyMajor

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About ArmyMajor

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  1. ArmyMajor

    C and P Exam PTSD/MST More Information

    Bertha, how do you go about obtaining a new C & P exam in a case such as this. The C & P examiner was a clinical psychologist and I will continue to work with my VSO. Thanks to you and others that have provided support in this case. This has been one the hardest things that I have ever had to do.
  2. ArmyMajor

    C and P Exam PTSD/MST More Information

    Vync, thank you for the information, there are markers that are contained in my record. I requested an immediate transfer from the unit and another marker is that I requested to retire, ilo of staying in the military. Of course, I had buddy statements to validate the change in my well-being and overall change in myself. I thank you in advance and your post has been extremely helpful. I hope that they look at the overwhelming evidence that has been provided through several therapy sessions and not just with short visit with the C & P examiner.
  3. ArmyMajor

    C and P Exam PTSD/MST More Information

    Broncovet, since the C & P, I have had two or three differing opinions that contradicts the C & P clinical psychologist evaluation (one psychiatrist/md, clinical pharmacist and another clinical psychologist that I saw within a week of the C & P.). I know that we all are hoping for the best. Her review was why so many people are hesitant in coming forward. Thank you for the feedback.
  4. ArmyMajor

    What qualifies for MST?

    Pockets, I too did my basic training at Fort Dix November 1984. Where first incident of harassment occurred. Makes one wonder.
  5. ArmyMajor

    C and P Exam PTSD/MST More Information

    I have been seen at VA mh since April 2018, which was a few days after the C & P....i had been seen by a private therapist and provided their notes as part of the filing of the claim. I also included.buddy statements. Will the rater consider the information that is after the C & P exam? The claim went back to gathering info in November (request for VA medical records).
  6. ArmyMajor

    C and P Exam PTSD/MST Update

    The C & P exam was performed prior to being seen at VA MH and I had only been seen by civilian therapist (provided those tx records): which indicated depression due to events that occurred during military service. I have been seen bi-weekly at VA MH since, April 2018, which was a week after the C& P. All have diagnosis of PTSD/MST or chronic depression. Are those findings considered by the rater? My latest update on Ebenefits is back to gathering phase (awaiting information from VA Medical facility. Thanks to everyone for their input. Yes, I submitted buddy letters and my own.
  7. I have included all of the information to include the opinions of three different VA psychologist/psychiatrist, clinical nurse practitioner and therapist opinions. The clinical nurse practitioner most recent diagnosis was chronic PTSD and depressive disorder by psychiatrist, medical doctor (April 2018) Therapist Notes (December 2018) PTSD SCREEN PC-PTSD-5+I9 PTSD Screening Score: 5 The score for this administration is 5, which indicates a POSITIVE screen for PTSD in the past month. PC-PTSD-5+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide. PHQ-2+I9 PHQ-2+I9 Depression Screening Score: 2 The score on this administration is 2, which indicates a negative screen on the Depression Scale over the past two weeks. PHQ-2+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide. AUDIT-C An alcohol screening test (AUDIT-C) was positive (score=9). Posted March 24, 2018 (edited) I was scheduled for an 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 VA Psychologist Notes (March 2018) 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 & P Examiners Notes (March 2018) 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
  8. I have a pending VA claim for PTSD/MST and I have included the original post that was related to conflicting information from the VA C & P examiner and notes from another VA psychologist that were made a few days later. The intake psychologist also diagnosed me in April 2018 with depressive disorder. I also included the most recent notes from my VA therapist that I have been seeing since March 2018. I am also followed by clinical nurse practitioner, which diagnosed with me as having chronic PTSD in December 2018. Any thoughts of a potential rating would be appreciated. Therapist Notes (December 2018) PTSD SCREEN PC-PTSD-5+I9 PTSD Screening Score: 5 The score for this administration is 5, which indicates a POSITIVE screen for PTSD in the past month. PC-PTSD-5+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide. PHQ-2+I9 PHQ-2+I9 Depression Screening Score: 2 The score on this administration is 2, which indicates a negative screen on the Depression Scale over the past two weeks. PHQ-2+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide. AUDIT-C An alcohol screening test (AUDIT-C) was positive (score=9). Posted March 24, 2018 (edited) I was scheduled for an 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 VA Psychologist Notes (March 2018) 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 & P Examiners Notes (March 2018) 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
  9. I currently have a pending claim for PTSD related to MST, any feedback would be appreciated. I have included information from the original post that includes in my opinion conflicting information from the C &P examiner versus that of the psychologist that saw me a few days later in March 2018. The first set of notes is from my most recent visit with my VA therapist. I have been seeing the therapist since April 2018 and have been diagnosed with PTSD. Therapist Notes (December 2018) PTSD SCREEN PC-PTSD-5+I9 PTSD Screening Score: 5 The score for this administration is 5, which indicates a POSITIVE screen for PTSD in the past month. PC-PTSD-5+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide. PHQ-2+I9 PHQ-2+I9 Depression Screening Score: 2 The score on this administration is 2, which indicates a negative screen on the Depression Scale over the past two weeks. PHQ-2+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide. AUDIT-C An alcohol screening test (AUDIT-C) was positive (score=9). Posted March 24, 2018 (edited) I was scheduled for an 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 VA Psychologist Notes (March 2018) 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 & P Examiners Notes (March 2018) 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
  10. Thank you for your feedback, I have had two apointments at VA within the last month one was the C and P and the examiner notes basically indicated no finding.  However, the other appointment with another VA psychologist who has referred me to a psychiatrist and therapist indicates PTSD/MST... I was curious how these varying opinions could impact the disability raiting, if applicable.  I did not other information to support the claim.

  11. Thank you for your feedback, I have had two separate appointments, one by the C and P examiner who indicated no findings basically and the other one by a VA psychologist who indicated PTSD/MST.  I included my statements as well as other evidence as part of the submission.  I was just curious how these potential differing opinions, could impact any disability ratings, if applicable.

  12. This post is in regards to a follow up 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. In addition, I am scheduled to meet with a psychiatrist and therapist at VA for counseling and prescription of meds. Any feedback would be great. 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.
  13. 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.

  14. I was scheduled for an 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 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).
  15. I w I was scheduled for an 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 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). +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ I received the C & P exam notes and I unsure of what it means, any help would be appreciated: 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.
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