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C&p Results

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Tela

Question

Sorry for the long post but I recently completed a C&P exam and would like some thoughts on it. Also, I haven't worked in almost 2 yrs. Should I apply for IU and SS? I also turned in 2 reports, 1 from my former supervisor and 1 from supervisor from my internship and they both said they didn't thing I was employable do to my disabilities. I don't post often but I do lurk and I value the knowledge wisdom here.

I am currently SC for RK@ 20% and LK@10%.

a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes [] No

[X] Axis I

Diagnosis #1:

Major Depressive Disorder, recurrent

Diagnosis #2:

Panic Disorder w/o agoraphobia

b. Axis III -Medical diagnoses (to include TBI): lCD code: n/a

Knee Issues, Migraine Headaches, Other Joint Issues

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

Severe; chronic pain, unable to sustain work, serious mental health issues

d. Axis V- Current Global assessment of functioning (GAF Score): 45

2. Differentiation of symptoms

a. Veteran have more than one mental disorder diagnosed? [X]Yes [] No

If yes, complete the following question:

a. Because her symptoms of depression and anxiety are co-mingled.

Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [] Yes [X] No [] Not applicable (N/A)

3. Occupational and social impairment

[X] Occupational and social impairment with reduced reliability and productivity

a. 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?

Because her symptoms are co-mingled.

SECTION II

Clinical Findings:

1. Evidence review

C-file reviewed.

FPC Examination 10/2011, Diagnosis: Adjustment Disorder w/ depressed mood and Generalized Anxiety Disorder NOS.

Temple VAMC C & P Exam for Knee Jan 2006 diagnosed Patellofemoral Syndrome.

Temple VAMC C & P Exam for Knee 9/2010, Diagnosis: Normal Knee.

KZ, MS, LPC Evaluation on July 2013, Diagnosis: Generalized Anxiety Disorder with opinion that root cause was knee injury.

Report on veteran's internship at Elmira's Lux-Sury Care from 6/2013 to 8/2013 (brought to examination by veteran) stating veteran "would not be employable anywhere due to issues that were evident while she attended classes. Mentioned lack of ability to stay focused on task and forgetfulness. Noted opinion that veteran would only be able to work from home and likely even then not be successful due to her mental state."

2. History

NOTE: Initial examinations require pre-military, military, and post-military history. If this is a review examination only indicate any relevant history since prior exam.

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

Veteran is a 29-year-old African American female who was born and raised in Waco, TX. Her parents never married and separated when she was 9 years old, "but they were both very active in my life." She said there were no issues of neglect or abuse growing up. She said her relationship with both parents was "pretty strong, it's still strong." She has 3 sisters and 1 brother; she said "we're fine" both growing up and currently. Veteran has not married and does not have a significant other. She has two children ages 7 and 4 who live with her in a townhouse. She said she and her children "are close." In school growing up veteran said she was in the Gifted and Talented Program until high school, then became an "average" student. In high school she played softball for the City but did not participate in extracurricular school activities.

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

After graduating from high school, she enlisted in the Army at age 17. She served 7 months and received an Honorable Discharge with the rank of E2. She was Med Boarded out due to her knees. She said she hurt her knee in Basic Training but does not know how she injured herself. She never had any Article 15s or other disciplinary issues. Her job in the military was Unit Supply. She was stationed in SC and VA. She left the Army in 2003 and has worked "off and on" for a temp service. She has not worked since Mar 2012. "Physically I just can't do the work; I'm in pain or the migraines are just too strong." She has never been fired from any job. She spends her time taking care of her children and is in college working toward an Associates in Network Administration.

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

Her first mental health treatment was shortly after she left the service at the Waco VA in 2004 or 2005 "off and on." She also saw a civilian counselor for a few months "before they cut my Medicaid off." She was put on several psychiatric medications at the VA clinic but "they didn't work." She is not currently taking any psychiatric medications. She said she has suicidal ideation (in the past

and currently, no attempts). She denied homicidal ideation and said she does not get violent. She said there is no mental health
historv in her family to her knowledge. (The underlined portion was left off).

Sentinel Event(s) (other than stressors

g. Other , if any:

Currently , her symptoms include sleep problems (takes on average up to 5 hours to fall asleep; she wakes up on average "no more than 3" times a night ; nightmares several times a week about death or demons). She is depressed (suicidal ideation, feeling hopeless , crying spells daily , anhedonia , self-isolation) and has anxiety (worrying , panic attacks with racing heart, can't breathe, feels "like I'm dying" multiQ!e times a week). She has anger issues "over little things."

3. Symptoms

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

[X] Depressed mood

[X] Anxiety

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

[X] Flattened affect

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social relationships

[X} Difficulty in adapting to stressful circumstances, including work or a work like setting

[X] Suicidal ideation

[X] Persistent danger of hurting self or others

4.Other symptoms

Does the Veteran have any other symptoms attributable to mental disorders that are not listed above?

[]Yes [X] No

5. Competency

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

[X]Yes []No

4.Medical opinion for secondary service connection

a. [X] The claimed condition is at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran's service connected condition.

c. Rationale:

Veteran received the injury in Basic Training and has become increasingly depressed and anxious because of the limitations in her activities caused by her knee problems. There is no evidence in either her statements or her records that she experienced panic attacks or depression prior to the injury.

Edited by Tela
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Tela - I commend you on your efforts to work AND better your education in spite of your disability. You have been given great advice in this thread. I wish you well and I'll keep you in my prayers as you go forward with your claims. Hang tough girl & continue to fight for yourself & your children.

LC

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I've been emailing my Voc Rehab counselor since the earlier part of December and just got a response yesterday. I'll be meeting with him soon to discuss my situation.

Thanks Loose Cannon for the encouragement and prayers! I've tried my hardest to work and go to school but its been a true struggle. I've tried both production and sedentary work but just couldn't cut it. So I decided I need to focus on treatment, not only for me but for my kids as well.

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