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marinevet1

Some Info On C&p Exam Results & If I Can File For P&t

Question

Hi

Here is my C&P for PTSD...I 'm also was awarded SSDI and I'm 61

How or do i qualify for PTSD & P&T or how do I get P&T

Here my review back for the PTSD, and what my rating next

What's my next step in the process????

LOCAL TITLE: COMPENSATION & PENSION EXAMINATION REPORT

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: NOV 02, 2010@13:43 ENTRY DATE: NOV 02, 2010@13:44:43

AUTHOR: XXXXXXXXXXX EXP COSIGNER:

URGENCY: STATUS: COMPLETED

C-FILE WAS:

Reviewed

MEDICAL RECORDS WERE:

Reviewed

OTHER MATERIAL REVIEWED:

Psychometric Tests and Questionnaires, DD-214, Other Records/Documents

WAS THERE OUTPATIENT TREATMENT FOR A MENTAL DISORDER? Yes

DATE(S) OF OUTPATIENT TREATMENT: Began outpatient treatment in 2009 after

and began medications and psychotherapy; began VA treatment at West LA and

Sepulveda in 12/2009.

CONDITION(S) AND LOCATION OF TREATMENT:

Bipolar disorder; Post-Traumatic Stress Disorder; Chronic

SUMMARY OF CURRENT TREATMENT FOR A MENTAL DISORDER:

Veteran is part of the psychosocial group treatment module at the POST, at VA

West Los Angeles Medical Center and also is managed by

Dr. Warren-psychiatrist from POST. He attends groups twice weekly, Medic PTSD and is

compliant with medication by his report, notes from his psychiatric record

also indicate his compliance with treatment.

CURRENT TREATMENT(S): Anti-manic

MEDICATION SIDE EFFECT(S): Drowsiness, Fatigue, weight gain

GROUP THERAPY: Yes 2

INDIVIDUAL PSYCHOTHERAPY: Yes

EFFECTIVENESS OF THERAPY: fair

----------------

Veteran was staioned in Da Nang, Vietnam attatched to 1st Marine Div., 1st Recon

Battalion, Charlie company 2nd platoon, team 1; MOS was 0311 and 8651-primarily

Recon: carrying medical supplies, save lives at all expense, exposed to serious injury,

called medi vacs and give morphine; saw and killed VC; save soldier lives;

DATE(S) OF SERVICE: 4/1969-09/70

BRANCH OF SERVICE: Marine Corps

HIGHEST RANK OBTAINED: E3

TYPE OF DISCHARGE: Honorable

RANK AT DISCHARGE: E3

MILITARY OCCUPATIONAL SPECIALTY: MOS: and 0311; Rifleman; 8651 Reconnaissance,

went on patrols and fire-fights, called in artillery strikes; cobra and naval gunships in Da Nang;

DECORATIONS AND MEDALS AWARDED: Combat Action Ribbon; Bronze Star

Presidential Unit of Citattion; National Defense Service Medal; Vietnam

Campaign Medal; Good Conduct Medal

DISCIPLINARY INFRACTIONS AND ADJUSTMENT PROBLEMS: None.

DID THE VETERAN HAVE COMBAT EXPERIENCE: Yes

WERE COMBAT WOUNDS SUSTAINED: No

LOCATION AND DATE OF COMBAT EXPERIENCE: Da Nang 11/17/69 to 07/30/70;

INSIGHT: Patient understands that he/she has a problem.

DOES THE PATIENT HAVE SLEEP IMPAIRMENT? Yes

COMMENTS AND DESCRIPTION OF EXTENT SLEEP IMPAIRMENT INTERFERES WITH DAILY

ACTIVITY:

Veteran sleeps irregularly, has frequent dreams, flashbacks which causes

interrupted sleep; early insomnia, has problem falling asleep, takes 1-2 hours

to fall asleep; sleep is not restful, is fatigued, feels as if he's been fighting in his sleep;

TYPE OF HALLUCINATIONS:

None

DOES THE PATIENT HAVE INAPPROPRIATE BEHAVIOR? Yes

INTERPRETS PROVERBS APPROPRIATELY? Yes

DOES THE PATIENT HAVE OBSESSIVE/RITUALISTIC BEHAVIOR? No

DOES THE PATIENT HAVE PANIC ATTACKS? Yes

-------------

STRESSOR EVENT(S) THE VET FOUND PARTICULARLY TRAUMATIC:

Combat experience

DESCRIPTION OF STRESSOR: Combat experience

DATE AND LOCATION: 11/1969 to 07/1970 Da Nang Vietnam.

TRAUMA OCCURRED: During Military Service

INTENSE FEAR: Yes

FEELING OF HELPLESSNESS: Yes

FEELING OF HORROR: Yes

OTHER REACTION: Yes

DESCRIBE OTHER: Dissociation

ADDITIONAL COMMENTS: Veteran served as a medic in Vietnam combat zones,

with multiple exposures to seriously wounded, dying soldiers that he

attempted to save. Witnessed horrific trauma involving severed limbs, gun

shots wounds and multiple injuries.

TRAUMA EXPOSURE TESTING

-----------------------

TESTING FOR TRAUMA EXPOSURE VETERAN HAS UNDERGONE:

Combat Exposure Scale, Trauma Questionnaire

RESULTS OF IDENTIFIED TRAUMA EXPOSURE TESTING:

Veteran experienced intensely traumatic combat episodes as a medic in Vietnam

as evidenced by his documented receipt of the Combat Action Ribbon which

corroroborates his DD-214 citation as well as his report of extreme combat

trauma while serving as medic in Vietnam between 1969-1970;

OVERALL LEVEL OF TRAUMATIC STRESS EXPOSURE: High

PTSD SYMPTOMS

-------------

PERSISTENT RE-EXPERIENCING THE TRAUMATIC EVENT BY:

Multi times per month

PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED WITH THE TRAUMA

AND NUMBING OF GENERAL

RESPONSIVENESS:

Efforts to avoid thoughts, feelings, or conversations associated with the

trauma, Efforts to avoid activities, places, or people that arouse recollections

of the trauma, Inability to recall an important aspect of the trauma, Markedly

diminished interest or participation in significant activities, Feeling of

detachment or estrangement from others, Restricted range of affect

Sense of a foreshortened future

PERSISTENT SYMPTOMS OF INCREASED AROUSAL:

Difficulty falling or staying asleep, Irritability or outbursts of anger,

Hypervigilance, Exaggerated startle response, reliving experiences.

THE DISTURBANCE CAUSES CLINICALLY SIGNIFICANT DISTRESS OR

IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR OTHER IMPORTANT

AREAS OF FUNCTIONING: Yes

DESCRIPTION OF THE ONSET OF SYMPTOMS: Chronic

FREQUENCY, SEVERITY AND DURATION OF PTSD SYMPTOMS FOUND:

Veteran experiences severe symptoms of PTSD that occur weekly and that have

lasted for 40 years. Upon examination, Veteran reports that he is bothered at

least several days each week by intrusive, avoidant and hyperarousal symptoms of

post-traumatic stress.

QUALITY OF PEER RELATIONSHIPS AND SOCIAL ADJUSTMENT:

Pre-military, Veteran claims he was outgoing, had many friends, rode

motorcycles; reports having a great social life and that he had lots of friends.

When he came back from Vietnam, he was living in Westminister, near Little

Saigon, believes he started to have ptsd (shell shock) symptoms and then his

former, highschool friends also began moving away, resulting in a serious change

in his social interaction. Veteran reports that he began isolating at that time

which has persisted to the present; Veteran states that he currently has no real

friends, finds it difficult to manage his anger and emotional responses when in

crowds or large groups; prefers to be alone because he feels safer; does nothing

for recreation; watches television primarily, avoids reading newspapers or other

sources of written information. Unable to work due to the DDD.

DESCRIPTION OF DEGREE AND QUALITY OF SOCIAL RELATIONSHIPS AND WORK:

Can't work has DDD, SSDI from SSA, has very few friends, doesn't socialize;

spend most of his time in the Haven Senior Program at West LA VA.

DESCRIPTION OF ACTIVITIES AND LEISURE PURSUITS:

Watched TV; plays with computer;

HISTORY OF SUICIDE ATTEMPTS? Yes

COMMENTS AND ADDITIONAL INFORMATION:

Took aspirin in attempted suicide because he was having flashbacks of

vietnam. Disclosed to family doctor; re-experiencing related to what else he

could he have done to help injured and dying on the battlefield.

HISTORY OF VIOLENCE/ASSAULTIVENESS? No

SUMMARY STATEMENT OF CURRENT PSYCHOSOCIAL FUNCTIONAL STATUS:

Veteran is not very social, isolates and prefers to stay alone, avoids crowds,

ISSUES ASSOCIATED WITH ALCOHOL USE:

No use

ISSUES ASSOCIATED WITH OTHER SUBSTANCE USE:

No use

PSYCH EXAM

COMMENTS AND DESCRIPTION OF EXTENT SLEEP IMPAIRMENT INTERFERES WITH DAILY

ACTIVITY:

Veteran sleeps irregularly, has frequent dreams, flashbacks which causes

interrupted sleep; early insomnia, has problem falling asleep, takes 1-2 hours

to fall asleep;

sleep is not restful, is fatigued, feels as if he's been fighting in DATES, CURRENT TREATMENT,

AND OTHER SIGNIFICANT DETAILS OF NON-PSYCHIATRIC ISSUES:

1996- L shoulder surgery; 1969 Malaria in Vietnam; High blood pressure treatment

in 2005. Severe Degenerative Disk diagnosed in 1983 at Kaiser related to Military medical records

his sleep; Satellite TV Technician for Direct TV as Supervisior.

IS THE VETERAN CURRENTLY EMPLOYED? No

IS VETERAN RETIRED? Yes

IS VETERAN DISABLE? Yes

DATE OF RETIREMENT: 12/30/2006

Primary Care Physician

Mr. XXXX is on time for his appointment

and takes his medications as prescribed.

The following conditions should be connected to his Military Service

Agent Orange Exposure

Post Traumatic Stress Disorder, combined w/ Bipolar Disorder

Hypertension

Traumatic arthritis, pain in right shoulder and neck

Tinnitus

Malaria

Erectile Dysfunction, has elevation of the HGB A1C, w/early Diabetes,

as a by product of taking medications for HTN and possible Agnnt Orange Exposure

INTERVIEW-BASED DIAGNOSTIC INSTRUMENTS FOR PTSD:

PTSD Symptom Scale

QUANTITATIVE PSYCHOMETRIC ASSESSMENT OF PTSD SYMPTOM SEVERITY:

PTSD Checklist for Combat and Non-Combat Trauma, Trauma Symptom Inventory

PSYCHOMETRIC ASSESSMENT SCORES:

Veteran was administered The PTSD Checklist (PCL), which is a 17- item

questionnaire also designed to assess symptoms associated with combat related

PTSD. On this administration of the PCL scale, he obtained a score of 68,

which exceeds the score of 50 that is consistent with a diagnosis of PTSD in

military populations. Of note, he reported within the past month being very bothered by

disturbing memories, thoughts and images of his combat experiences, feeling

cut off from other people, avoiding activities or situations because they remind

him of stressful military experiences, being super-alert, watchful and on-guard,

feeling irritable and having angry outbursts, feeling jumpy and being easily startled,

insomnia and feeling emotionally numb. Additionally, he was also administered

the Trauma Symptom Inventory, a 100-item questionnaire designed to appraise

symptoms of posttraumatic stress disorder, clinical depression, affect regulation and

dysfunctional behavior. He produced a valid, interpretable profile, with

no exaggeration of unusual symptoms. There were clinically significant

elevations on the Tension Reduction Behaviors (T = 93), Intrusive Experiences (T = 98) and

Defensive Avoidance (T = 83) and Dissociation (T = 86) scales.

He also meets criteria for PTSd based on PTSD Symptom Scale (Foa) as evidenced by

at least one re-experiencing symptom (nightmares), three avoidance symptoms

(avoiding, thoughts, feelings, detachment from others) and two hyperarousal

symptoms (insomnia and pronounced irritability).

DOES THE VETERAN MEET THE DSM-IV CRITERIA FOR A DIAGNOSIS OF PTSD? Yes

AXIS I: 309.81 PTSD-Chronic, 296.00 Bipolar NOS Moderate to Severe

IF ANY ADDITIONAL MENTAL DISORDERS HAVE BEEN DIAGNOSED, EXPLANATION OF HOW THE

SYMPTOMS ARE RELATED TO OR ARE PART OF EACH MENTAL DISORDER:

The symptoms of PTSD and Bipolar depression do overlap to a large extent

particularly as it relates to unrelenting presence of persistent, bothersome,

intrusive symptoms of re-experienced thoughts, images and feelings associated

with the trauma and hypervigilance manifesting as insomnia and startle

response, It appears in this case

that the veteran is experiencing both chronic anxiety and a significant,

complex mood disorder, hence both diagnoses are indicated.

SYMPTOMS ARE RELATED TO OR ARE PART OF EACH MENTAL DISORDER:

The symptoms of PTSD and Bipolar depression do overlap to a large extent

particularly as it relates to unrelenting presence of persistent, bothersome,

intrusive symptoms of re-experienced thoughts, images and feelings associated

with the trauma and hypervigilance manifesting as insomnia and startle

response, It appears in this case that the veteran is experiencing both chronic

anxiety and a significant, complex mood disorder, hence both diagnoses are indicated.

AXIS II: 799.99

AXIS III: Degenerative Disk; Malaria, No longer can work

AXIS IV: Heavy Extreme Combat Exposure

AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING

SCORE: 45 TIME FRAME: Current functioning

WAS A MEDICAL OPINION REQUESTED? No

/es/ XXXXXXXXXX, Ph.D.

CLINICAL PSYCHOLOGIST

Signed: 11/16/2010 09:30

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2 answers to this question

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Have you formally applied for TDIU yet?

Is the SSDI solely for these potential SC conditions?

You are certainly looking at a SC rating but it could be too low-

On the other hand the VA could rate you as TDIU and even also P & T - too soon to tell.

Is VA aware of the SSDI records yet?

They only send out the TDIU form when they rate SC at 70%- here it is as I feel you should send it in to them.

Qyestion 18 check Yes and then under Remarks tell them what the SSDI you get if for..

Under # 25 "Remarks" you can refer them to additional page, put your name address and C file number on it and tell them any side affects of any meds you take that hinder employment, if VA Voc REehab ever turned you down due to any SC condition, and anything else you feel they should consider as to your unemployability due to these potentially service connectable disabilities.

This is the only problem area I see here:

"Post Traumatic Stress Disorder, combined w/ Bipolar Disorder"

I wish it had said PTSD with secondary bi polar disorder.

I don't see any evidence here of bi polar symptoms at all but I am not a doctor.

Could the Bi polar diagnosis be an old one , prior to when the medical community recognized what PTSD was?

But I am sure this claim will go well for you.

This all his conforms to both the old and the new criteria for PTSD.

Do you have a vet rep?

TDIU 21-8940.pdf

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Have you formally applied for TDIU yet?

Is the SSDI solely for these potential SC conditions?

You are certainly looking at a SC rating but it could be too low-

On the other hand the VA could rate you as TDIU and even also P & T - too soon to tell.

Is VA aware of the SSDI records yet?

They only send out the TDIU form when they rate SC at 70%- here it is as I feel you should send it in to them.

Qyestion 18 check Yes and then under Remarks tell them what the SSDI you get if for..

Under # 25 "Remarks" you can refer them to additional page, put your name address and C file number on it and tell them any side affects of any meds you take that hinder employment, if VA Voc REehab ever turned you down due to any SC condition, and anything else you feel they should consider as to your unemployability due to these potentially service connectable disabilities.

This is the only problem area I see here:

"Post Traumatic Stress Disorder, combined w/ Bipolar Disorder"

I wish it had said PTSD with secondary bi polar disorder.

I don't see any evidence here of bi polar symptoms at all but I am not a doctor.

Could the Bi polar diagnosis be an old one , prior to when the medical community recognized what PTSD was?

But I am sure this claim will go well for you.

This all his conforms to both the old and the new criteria for PTSD.

Do you have a vet rep?

Thank You Berta !

ALl the report not here it was 17 pages I just put what i thought the

site would needed. The SSDI & DDD from SSA was for the SSDI

awarded March this year.

If I can get the 70% well maybe....

Yes hand carried and date stamped SSDI award letter to RO myself

Yes I submitted for TDIU and did as you spoke above

checked #18 yes, so yes explained as you said.

The PTSD came first after seeing and being diagnaos for PTSD

later like 3 month later VA Psy told me the BIpolar disorder

was due to the PTSD. No family records of anybody in family

having it anywhere. VA doctor said help supports my PTSD

and that 25% of people with PTSD have a bipolar disorder

along with it.

This C&P was just the reports, I also had a Malaria and Hearing

and TInnitus C&P also now wait for the ratings in 2 or 3 month I

hope. Much thanks for the info. i need all the help I can get.

Yes went to the DAV

Bless You

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