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C&p Notes From 4/22/10


Ok everyone, I went to the VA today and got my papers from my recent exam. This will be alot of typing, so bear with me my mispellings. I'm going to Pass through some of the past stuff and just get to what he saw in my exam.

Frequency, severity and duration of Non-PTSD Psychiatric Medical Symptoms: Generally, his mood has been down and depressed, he is not sure why he is down other than some troubles at work. Has had issues dealing with people in the place. Feels nervous much of the time, as well.

Legal History? No

Educational Accomplishments? No

Description of Marital and Family Relationships: Trouble getting along with his wife. "I get on her nerves, I guess" Tends to yell at her when she is driving. Gets along fairly with siblings and Parents are deceased.

Description of degree and quality of social Relationships: Most of his friends are being deployed; i.e, 2-3 friends. No civilian friends

Description of activities and leisure pursuits: No active hobbies or interets, "I basiclally take care of my kid" Used to be interested in fishing and hunting...but "fishing agitates me" and don't like shooting stuff anymore.

History of Suicide Attempts? Yes. *Going to leave this one out due to personal reasons* B)

History of Violence/Assaultiveness? Yes "I tend to throw stuff" Does not hit people or throw things at people.

Issues associated with alcohol use: When he drinks, he drinks more than he plans to, may drink up to 18 beers. Last did at a wedding in Oct, 09

No substance abuse

Psych Exam

General Appearance:

Casually dressed, Other

Description of any other appearance characteristics, Har was mussed from his hat; not shaved; smelled of smoke and mild BO

Psychomotor Activity: Restless, Other

Description of any other psychomotor activitiy: Foot was bouncing; sweaty hands

Speech: Hesitant, clear, coherent

Attitude toward examiner: Cooperative, Other

Description of any other attitude: Seemed tense, comes accross as immature

Affect: Full

Mood: Anxious, hopeless, depressed, dysphoric, Other

Description of any other mood: Comes across as negative and complaining.

Attention: Attention Disturbance (Easily Distracted) Attention Disturbance (Short Attention Span)

Able to do Serial 7's? No (Counting backwards by 7 from 100)

Able to spell a word forward and backward? Yes

Comments: Rates his concentration as poor, has affected his ability to drive, as drives past where he is supposed to be going. Has trouble keeping on a single task at work.


Intact to person: Yes

Intatct to time: Yes

Intact to place : Yes

Delusions: None

Judgement: Understands outcome of behavior

Intelligence: Avg.

Insight: Patient understands that he/she has a problem

Does the patient have sleep Imparment? Yes

Says he has not slept very good over past month; has nightmares "just about every night" Takes a long time to get to sleep. I get alot of thoughts in my head, such as work the next day.

Average 3-5 hours of sleep per night, never feels rested. During the day it stresses me out

Innapropriate behavior? Yes

Has trouble controlling his comments when he is dealing with people, his (illegible) tells him he is too harsh

Interprets Proverbs Appropriately? No

Explanation: Very concrete

Obsessive/ritualistic behavior? No

Panic Attacks? Yes

Frequency severity, duration and effects on functioning: Claims he has panic attacks "a lot" one reason he takes hydroxyzine; may increase when someone at work will point guns at him. Sometimes at home..he might wake up with his heart racing

Homicidal Thoughts: No

Suicidal Thoughts: Yes, 5-6 times per week

Extent of impulse control: Fair

Examples of effects on motivation/mood

When his mother was passing away, he went out and bought a suv. Usually does not use money impulsively. Make go for drives on a whim. (This examiner is judging me on my grammar, intelligence, yet he cannot type out a logical sentince... Just found this funny)

Ability to Maintain minimum personal hygene? No

Comments, Showers once every 4-5 days

Wife complains about his hygine "All the time" i.e. about his clothes, teeth

I there problem with activities of daily living? Yes

Household chores: Moderate

Toileting: none

Grooming: Moderate

Shopping: Moderate

Bathing: Moderate



Description of other problem with activities of daily living: Tends to avoid driving, has road rage and inattentiveness.

Comemnts or elaboration of any items int he MSE or for items not covered or other comments:

Self esteem is "Pretty Low" gets feeling that people do not care about him or want to talk to him

Appetite is good enough to eat once per day.

Weight is down by 5-10 pounds over past two months, with intentional effort



Recent:Mildly impared

Immediate: Mildly Impared

Persistent Re-experiencing the traumatic event by:

Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions, Recurrent distressing dreams of the event. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, physiological reach on exposure to tinernal or external cues that symbolize or resemble an aspect of the traumatic event.

Persistent avoidance of stumuli associated with the trauma and tumbing of GE Responsiveness:

Efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that arounse recollection of the trauma. Markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted of affect. E.G. Unable to have loging feelings

Persistent symptoms of increased arousal: Difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypevigilance, exaggerated startle respons

Description of fthe onset Symptoms: Chronic

Frequency, Severity and duration of ptsd symptoms Found: Almost every day he has intrusive memories, Stuff I could have done different, including one about a tanker fire. Has trigered memories from explosions or "Bangs"

Tries not to think about what happened; side tracks himself by watching TV not like talking about what happened. Avoids being in loud places or crowded places. Feels disconnected with most people.

Length of remissions, etc: None noted.

Then it continues about asking if I know amounts of benefits, bills etc. All were "YES" except Personally handling money and paying bills

He handed over the responsibilities because he was getting frustraded, when he does he sets up automatic payments.

Is a social work assessment necessary to render an opinion? No

Employment History...

Currently employed? Yes


Part time

Less than 1 year

Time lost from work durning last 12 month period: Has missed work, calls in when he does not sleep or "just not wanting to (cut off)

before that, security guard (very part time) for about a year, until he was fired for "disobeyeing some order" he had had problems getting along with his coworkers.

Problems related to occupational functioning: Decreased concentration, increased abesnteeism, poor social interaction

Does the veteran meet the dsm-IV Stressor Criterion? Yes

Description of the primary stressors related to PTSD: Combat

Does the veteran meet the dsm-IV criteria for a diagnosis of PTSD? Yes

Axis I : PTSD; Major deperessive disorder, recurrent, mild to moderate

Axis II: Deferred

Axis III See medical records

Axic IV : WOrk stress

Axis V: GAF

Score: 50Time Frame: Current funcitioning

Changes in functional status and quality of life since last exam: Performance in employment, routine responsibilities of self-care, family role functioning, Social/interpersonal relationships, Recreation/leisure pursuits

Comments concerning Functional status and quality of life: Trouble functioning at work usually du e to high anxiety and interpersonnal issues

Displays marginal hygene, has trouble getting on things

Has very little involvement with other people; socially isolated. No acting on recreational pursuits. Ongoing strain with his wife, due to irritability

Description of linkage between PTSD symptoms and aforementioned changes in imparement in fuctional state, and quality of life: Trouble functioning at work, usually due to high anxiety and interpersonal...

Has very little involvement with other people. socially Isolated. no active... same as above

State prognosis for improvement of psychiatric condition and imparements in functional status

Prognosis appears fair

PTSD REVIEW: Effects of PTSD on Occupational and Social Functioning

Is there total occupational an d social imparement due to ptsd signs and symptoms? NO

If there is not total occupational and social imparement, do ptsd signs and symptoms result in deficiencies in the following areas (Judgement, Thinking, RElations, Work, Mood, or School? Yes

Judgement? Yes

Examples including those already reported: Displays road rage when driving or riding in a vheicle; says things he regrets when he gets frustraded with people at work or at home

Thinking? Yes

Examples: Easily side tracked when he is doing things; tends to get preoccupied, has poor mentla staminda due to anxiety and low moods

Family Relations? Yes

Examples: Strained relationship with his wife, due to his irritability.

Work? Yes

Examples: Problems coping with stress at work; gets irritable with customers and coworkers.

Mood? Yes

Examples: Persistently depressed and anxious, very hypervigilant in public place. Startles easily with noise and commotion, to point he feels overwhelmed.

School? N/A

Was a medial opinion requested? NO

So this was my exam. i don't know what the Axis things were. If any of you have any opinions on my exam let me know. I'm currently at 50% PTSD, this was my appeal interview, so I'm hoping to get up to 70. Let me know what you all thing. My hands are tired now, so I'm going to rest them...lol

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This is ONLY my opinion but from everything you've posted

I see PTSD staying at 50 percent.



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I am not seeing the definitive reason or results here to grant a higher %, but I hope you will receive favorable results, JMHO. B)

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Hi Everyone. Well after a long and painful journey trying to get an increase from 50% for PTSD, I finally got good news today from my VSO. He informed me I will be recieving an increase to 70% backdated from March of this year. He also stated that I should file for IU tomorrow. This took a while to get through, but all I can say about it is don't let the VA drag you down and wear you out. Stay on top of your information, and keep driving forward. There were a couple of times where I got to the point that I just wanted to give up on it, but if you keep working at it good things CAN happen. Thank you all for all of the help and input on the matter, I don't know if any of this had been possible without the help of this website. It's great that there are sites like this for advice, because before I started browsing here, I was clueless. Thank you all again and God Bless!

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That is Great News!

I only wish that you had filed for TDIU when you filed for an increase in your PTSD.

Your service officer should be kicked in the ass, and, that's all I gotta say 'bout that!

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If I remember correctly, he said I had to wait until I was at least 70% in my total disability to file for TDIU. I know I mentioned it to him. Oh well, I'm not going to get upset about that, this is a good day!

Also, I wanted to know, now at 80% disability, should I be doing anything more besides applying for TDIU? Should I be doing anything on the Social Security side, or is that only for 100%'ers? Does Social Security affect my VA disability rating or payments? This is all very blank area for me, I know noting about the Social Security side of it. Thank you again for your replies!

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