ptsd C&p Exam Here Are The Results From The Doc. Any Idea On Percentage

[the_stretcher]

C&P EXAM NOTE

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

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

a. Diagnosis #1: PTSD

Diagnosis #2: Depressive Disorder-NOS ICD code: 311

Indicate the Axis category: [X] Axis I [ ] Axis II

Diagnosis #3: No Diagnosis

ICD code: V71.09

Indicate the Axis category:

[X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): Chronic Low Back Pain, Paon

　

in Joint Involving Pelvic, Region, Thigh, and Lower Leg, Overweight

c. Axis IV - Psychosocial and Environmental Problems (describe, if any): Iraq War

d. Axis V - Current global assessment of functioning (GAF) score: 55

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:

The symptoms of these disorders overlap and any attempt to sseparate them would be mere

speculation

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

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:

The symptoms of these disorders overlap and any attempt to separate them would be mere

speculation

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 [ ] No [X] No diagnosis of TBI

　

SECTION II:

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Clinical Findings:

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

1. Evidence review

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

a. Records reviewed (check all that apply):

[X] Claims folder (C-file):

[ ] Yes

[X] No

If no, provide reason C-file was not reviewed: VVA

b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No

2. History

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a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):

He was born in Lima, Ohio. He had two parents, two brothers and two

sisters. His parents had problems with addictions and their parental rights were terminated when he was three

years olf and he was raised by his grandparents. He graduated fro high school in 2003.He joined the Army on June 12, 2003. He did BT at Ft. Benning and AIT at Ft. Gordon. He served in Iraq from November 2005 until November 2006. He got an honorable discharge on March 20, 2011. He got married on October 7, 2005. He has two daughters and one son.

b. Relevant Occupational and Educational history (pre-military, military, and post-military):

He worked at a fast food restaurant in high school. His MOS was

25U-Signal Support

Signal Specialist. He has worked at Wright-Patterson AFB as a

contractor for two years.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):

He saw Dr. Smith in the PTSD program at the DVAMC for about six months for therapy. He is

prescribed Prozac-20mg daily by his PCP. No psychiatric inpatient hospitalizations.

d. Relevant Legal and Behavioral history (pre-military, military, and post-military):

No legal issues

e. Relevant Substance abuse history (pre-military, military, and post-military):

No Substance Abuse issues

f. Sentinel Event(s) (other than stressors): No response provided.

g. Other, if any:

No response provided.

3. Stressors

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

a. Stressor #1: Mortar attacks in Ramidi, Iraq in February 2006

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

4. PTSD Diagnostic Criteria

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

a. Please check criteria used for establishing the current PTSD diagnosis.

　

The diagnostic criteria for PTSD, referred to as Criteria A-F, are from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

Criterion A: The Veteran has been exposed to a traumatic event where both of the following were present:

[X] The Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a

threat to the physical integrity of self or others.

[X] The Veteran's response involved intense fear, helplessness or horror.

Criterion B: The traumatic event is persistently reexperienced in 1 or more of the following ways:

[X] Recurrent and distressing recollections of the event, including images, thoughts or perceptions

[X] Recurrent distressing dreams of the event

[X] Acting or feeling as if the traumatic event were recurring; this includes a sense of reliving the experience, illusions,

hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated

　

Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before

trauma), as indicated by 3 or more of the following:

[X] Efforts to avoid thoughts, feelings or conversations associated with the trauma

[X] Efforts to avoid activities, places or people that arouse recollections of the trauma

[X] Markedly diminished interest or participation in significant activities

[X] Feeling of detachment or estrangement from others

Criterion D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or more of the following:

[X] Difficulty falling or staying asleep [X] Irritability or outbursts of anger [X] Difficulty concentrating

[X] Hypervigilance

[X] Exaggerated startle response\

Criterion E:

[X] The duration of the symptoms described above in Criteria B, C and

is more than 1 month. Criterion F:

[X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

b. Which stressor(s) contributed to the Veterans PTSD diagnosis?: [X] Stressor #1

5. Symptoms

-----------

For VA rating purposes, check all symptoms that apply to the Veterans

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Chronic sleep impairment

[X] Flattened affect

6. 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:

Anger issues-he ripped a door off its hinges at home last week

because it was not

opening, shoves his wife by the shoulders during arguments, yells

at his wife,

picks the locks to door to get to his wife, grabbed his daughter

(5) by the arm

and spanked her hard and threw her on the mattress in the living

room

7. Competency

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

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

8. Remarks, if any

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

The veteran meets DSM-IV-TR criteria for PTSD related to his claimed

stressor. His claimed

stressor is related to his fear of hostile military or terrorist

activity.

His Depressive

Disorder-NOS is related to his PTSD. His PTSD does not prevent him from

being able to

secure and maintain substantially gainful employment.

[Berta]

If you applied for TDIU, I think they should award it...TDIU is paid at the 100% rate.

I also think you should appeal the TBI, since it looks to me like that claim will be denied.

Even if the TBI claim rating, if awarded, does not involve more comp.....the SC for it could set the stage down the road for SMC if you develop severe ratable residuals from it.

Thank you for your service! Apply for SSDI benefits too.

I am going to add something I probably should not say here.

I had a 100% PTSD husband. He died. I got flashbacks from reading your post.But I commend your honesty with the doctor

"He saw Dr. Smith in the PTSD program at the DVAMC for about six months for therapy"

I suggest you continue that therapy , (I assume this was a 21 day PTSD program) and you should be being followed up by a VA shrink and you sure might find a lot of help at a vet center.too

It would help to even bring the wife and the child with you,if the vet center permits it.

My combat vet husband became very abusive to me,as he went from 30% to 100% PTSD, and alsoi had brain damage due to a 1151 stroke. but if he had hurt my child I would have had him arrested...and divorced him .

PTSD is not an excuse for abuse.

I do understand your anger....I understood my husband's anger....but we spouses are often a vet's only real support system and we are their only caretakers as they get older and more disabled ,and after they alienate everyone else in their life.

Maybe your meds are causing you more anger problems than you should have.

And it could be the TBI causing these outbursts......please forgive me if I have hurt you by stating what I said here.

I worked in a vet center and saw many spouses ( to include husbands of female vets) abused by their partner and many of the spouses ended up fed up and got out of the marriage.

If the mods here feel my comments are inappropriate they will delete my post.

It isn't your fault veteran ..... it is the aftermath of the horrific nature of war....

.but it isn't your wife's or child's fault either.

Edited October 7, 2013 by Berta

[the_stretcher]

Thank you for your response, The statements that happend with the wife can kid happened before i seen Dr. Smith and before i was taking medication. There is nothing in my record to show TBI. I am going for a PTSD rating. I did not apply for TDIU as i am currently working and have been ever since i got out of the army.

During my time with Dr. Smith i had the family come along and that is what helped me get everything in perspective. I still have anger outburst but with the therapy and medication i am able to do other stuff to combat the issues when it happens. I am very thankfull for the time i spent with Dr. Smith. I have had some minor issues at work but with my boss knowing what is going on and the ability for me to take medication that also helps me. Keeping a job is big for me because i have to support my wife and 3 kids. If i did not have that i am sure I would not be able to maintain a job. It hurt me to be honest with the doctor because when ever i look back to what i did i dont like it and i never want to be like that.

I put my claim in for PTSD because i have these issues and i beleive in the benefits that was faught for us current veterans.

If anyone could give any guidance on if i would gain any SC from my C&P please let me know as the VA denied my claim before i was able to go to the C&P and i want to make sure that i have a good fight for this claim.

Thanks

P.S Berta, I was not offended by your response.

[Berta]

Oh .......Thank you so much for clarifying all that.....!!!

Since you are working, the rating might be 30 to 50 but you can appeal any rating you get.

"I put my claim in for PTSD because i have these issues and i beleive in the benefits that was faught for us current veterans."

Yes we all want to see every vet get what they deserve due to their sacrifices for our country.

And Compensation is really NEVER enough to truly compensate any of you men and women.....

"If anyone could give any guidance on if i would gain any SC from my C&P please let me know as the VA denied my claim before i was able to go to the C&P and i want to make sure that i have a good fight for this claim."

I certainly feel this will gain you SC for PTSD.Others will chime in on a percent but one never knows what the VA will do.

How they rate PTSD is within the VA Schedule of Ratings here. It impinges a lot on a vet's working ability.

"Thanks

P.S Berta, I was not offended by your response."

Thank you again for that.........

"please let me know as the VA denied my claim before i was able to go to the C&P and i want to make sure that i have a good fight for this claim."

Huh? Did you miss a scheduled C & P and then they denied and they have not considered this new re scheduled C & P yet?

What did they deny on?That surprised me when you said that....when did the denial letter come?

Do you have a vet rep helping you?

It is VERY unusual, even as bad as the VA can be, to deny a claim prior to a C & P exam..........

how did you,in fact, get a C & P exam, did you question that right away with the VA?

Or maybe you re-opened the claim? because you didnt appeal a past denial?

You have the PTSD diagnosis from a VA MH provider.

You have the stressors conceded in this C & P, per the new C & regulations of 2010 in our PTSD forum.

I assume this a fairly recent C & P exam........

I cant wait to see what others think here.........if this is a re--open it looks to me they would owe you retro back to the older denial (but under 3.156 or CUE and that might not be addressed in the initial award.....)

You have,in my opinion,definitely the evidence for a rating. If you look over Diagnostic code 9411 in the Schedule of Ratings, you will have a better idea of what to expect. here it is from the VVA:

http://www.vva.org/ptsd_levels.html

[the_stretcher]

So for the denial, they denied me because i rescheduled the initial C&P exam because i was not informed of the appointment so i was forced to reschedule do to me not being able to make the appointment. The stamp date on my denial sheet shows a date from after when i rescheduled the appointment but before my appointment that got rescheduled. So to date it i had my original appointmen like 21st or 22nd august so i called them that very day to reschedule. The stamp date for my denial was august 25th. I had the second appointment on Sept 13th in which is the appointment that i was able to get to and that is how i got my C&P exam.

This is my first C&P for my first claim for PTSD.

I call the regional office of Ohio and they seen the huge mistake and the lady i talked to annotated in my file that my original claim would be reinstated due to a mishap from the VA. she said it would take 21 business days for it to show up on Ebenefits.com. Its been between 15-20 business days from which i called the regional office.

I have a feeling that i will be calling them again to make sure everything is straightened out. I do not have a vet rep helping me out, but right now i am in the middle of changing VFW posts, so if i can not do anything i will be getting help from them.

[Navy04]

the_stretcher,

Just keep your strength up and let us know what happens.

Berta,

You give such positive feedback. I was medically retired back in Feb this year, and I am 80% SC. I did not get good %s from the VA back in the spring because the Navy was already retiring me. I went thru the new IDES joint program where I received my VA %s before the Navy even retired me, so the VA low balled me. I went to my VSO that I use, who is very nice, but at times I think that he has too much faith in the VA and doesn't like to look at alternative methods of applying for benefits. I told him that I wanted to submit of my %s to be increased. He told me to do a FDC claim. The problem is I use 3 different VAs and he only listed 1 on the FDC that we submitted. My conditions that I put in for have gotten worse and well documented currently with VA Docs. If I submit evidence that will help me, Megh says that my FDC will go to a traditional claim and take years. Im afraid that I will wait 6 months for the FDC results just to be disappointed and then Feb will make it a year that I will be out, and I wonder if I should have submitted a NOD instead. Do you think that my chances of my PTSD, Crohn's Disease, Hearing and Knee are good to be increased since the VA lowballed me to begin with. Also I had to quit my job earlier this month cause I could not take it anymore due to my PTSD, Crohn's and Migraines. My friend told me to go this past week and apply for SSDI. Do you think since I am Medically Retired from the Navy, Have a good % thru the VA, and currently unemployed that they will approve my SSDI? Sorry, to bother you with so much info, I am just so worried for my Family. In a few months we will be wishing we had Top Ramen to put on the table. Just don't want to let my family down and lose precious time dealing with the VA.

[free_spirit_etc]

Navy04,

You might want to call some SSA attorneys, or Allsup They will screen you on the phone. If they (especially Allsup) are very interested in your claim - it means it looks pretty good for getting granted - which means it might be granted fairly quickly. If they aren't very interested, that doesn't mean it won't be granted, but it may mean that it could take awhile. Some attorneys don't take claimants until they have been denied. (They get a chunk of the back pay - and so they won't get much if you get approved fairly quickly) Others will take your claim from the start - and this can be good because they make sure everything is submitted correctly. Calling them doesn't mean you have to hire them. But it will give you some sense about what they think your chances are with a claim.