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

[the_stretcher]

C&P EXAM NOTE

SECTION I:

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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:

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1. Evidence review

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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.

[Navy04]

Free,

Thanks for the kind words. I called 3 or 4 different lawyers, one of the being Binder and Binder and all accepted my case. All lawyers said yeah "Im a shoe in" but I just don't believe anything anymore. My twin is disabled due to Crohn's, he was never in the Military. I went with his lawyer, local, and they were very friendly to me. As you know that will take time too, and I just hope that the FDC I have in comes back good, and I don't have to do a NOD and sit around for two years waiting for the results. God bless all of you, as I always say. I don't have a lot of faith in people these days.

[Berta]

“I wonder if I should have submitted a NOD instead. “

A good ideas if you are still within on year from the VA decision date. But... see below*

“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 “

Yes if you have documented medical evidence that puts them into a higher perceentage rating per the VA Schedule of Ratings here at hadit.

“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.”

Did any doctor or your employer themselves suggest that you quit?

****If you are awarded SSDI solely for the SC conditions you have now, that will be excellent evidence for TDIU.

Has your VSO suggested filing for TDIU? (Total Disability due to Individual Unemployabity) which is paid at the 100% rate.

I am unfamiliar with the FDC process, but I assume you still have appeal rights and can file a NOD????

Hope others chime in here on this question I have:

I think the FDC process eliminates the right to request a DRO Review and if denied the claim is appealed with an I-9 to the BVA. I might be wrong...please correct me someone....

Hell I would never want a DRO to handle my stuff again anyhow. But that is because I never had a DRO who could read.

Is it really a bad thing for the BVA to get the claim without a DRO review? To me that would be faster anyhow,assuming the DRO would just deny again anyhow in some cases.

And is that the point of the FDC scenario? No DRO?

[Navy04]

Berta,

Yes my employer suggested I resign as I was a Agent with the state Tracking Violent Sex Offenders. My current Psych Docs, PCM, and Crohns Dr said that they would sign paperwork saying that I can not work due to bad health. My VSO told me to put in the FDC to see if 1 of my 4 30%s will get increased to atleast 40% and then we will put in for TDIU. Even though I just found out that I could have put TDIU anyways due to my unemployment being related to my current SC disabilities. I just hope that the FDC comes back fast and if it is good fine, if not then I will submit a NOD for my ratings and I know that will be good, just don't want to wait 2 years, you know. Kind of a slow reaction either way. I hope that the SSD goes well. They always say "You are guaranteed" as I have found out the hard way the last 10 years in the Military, there is nothing guaranteed. Thanks again Berta, boy you really do have a good heart.

[deestee]

The biggie is what they check for occupational impairment i just had a c and p and she checked off all the 70 percent criteria. I work...but i work only because the job is ideal for my ptsd i barely make minimum wage and work totally alone i have zero interaction with people