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cablinginar

My C&p For 100% Ptsd

Question

I am now 70% PTSD, 40% Fibro, 30% IBS, 10% tinntius = 90% getting 100%IU .....SSDI for PTSD Symptoms only

I just had this C&P to bump my rating to 100% TDIU or P&T

These are my results form my C&P anyone have any comments that would help me understand this .....He seems to rate me at 50%.....then all of the rest seems to lean towards a P&T rating
LOCAL TITLE: C&P EXAM
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JAN 13, 2014@08:00 ENTRY DATE: JAN 14, 2014@11:46:23
AUTHOR: VAN PELT,DAVID M EXP COSIGNER:
URGENCY: STATUS: COMPLETED
CONFIDENTIAL Page 14 of 26 Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
Name of patient/Veteran:
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Post-Traumatic Stress Disorder (PTSD)
Mental Disorder Diagnosis #2: Psychological Factors Affecting Other
Medical Conditions
Mental Disorder Diagnosis #3: Major Depressive Disorder
Mental Disorder Diagnosis #4: Alcohol Use Disorder in remission (per
self-report)
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): fibromyalgia, irritable bowel
syndrome, sleep apnea, tinnitus, hypertension and potential chronic
fatigue syndrome (per self-report)
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: Mr.
Turnbow
has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the
requisite criteria for this diagnosis. He also meets the criteria
for
Major Depressive Disorder, Psychological Factors Affecting Other
Medical Conditions, and Alcohol Use Disorder, which is in remission
per his report. These problems coalesce to exacerbate his symptoms of
anxiety and depression. The symptoms are overlapping and
intermingled
and this makes it difficult to differentiate the symptoms to each
CONFIDENTIAL Page 15 of 26 diagnosis.
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 with reduced reliability and
productivity
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?
[ ] Yes[X] No[ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis: has symptoms of
Post-Traumatic Stress Disorder (PTSD) and meets the requisite
criteria
for this diagnosis. He also meets the criteria for Major Depressive
Disorder, Psychological Factors Affecting Other Medical Conditions,
and Alcohol Use Disorder, which is in remission per his report. These
problems coalesce to exacerbate his symptoms of anxiety and
depression. The symptoms are overlapping and intermingled and this
makes it difficult to differentiate the symptoms to each diagnosis.
The symptom picture presented comes together to cause substantial
impairment in his social and occupational functioning.
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:
-----------
Clinical Findings:
------------------
1. Evidence review
------------------
In order to provide an accurate medical opinion, the Veteran's claims
folder
must be reviewed.
a. Medical record review:
CONFIDENTIAL Page 16 of 26 -------------------------
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes[ ] No
Was the Veteran's VA claims file reviewed?
[X] Yes[ ] No
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes[ ] No
If yes, describe:
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
is currently married and has been for 5 years. He
described
the relationship with his wife as positive and said, "I have a
fairly
good relationship with her. She understands me." He has 2
daughters and
one son. He has no contact with his son or oldest daughter. His
youngest daughter lives at home with him and he described the
relationship with her is great. He also noted how he and his wife are
raising their 5-year-old granddaughter. He described the relationship
with his granddaughter as "good." has one adopted
brother
but has not had contact with him currently. Both of his parents are
living and he described having a positive relationship with them. He
noted seeing them one time a week and said the relationship is
"good
now but in the past and not so good."
b. Relevant Occupational and Educational history:
graduated high school in 1986 in Elgin, Illinois. He
CONFIDENTIAL Page 17 of 26 attended one semester of college but did not receive a degree. He is
currently unemployed. His last job was as a cable technician where he
worked for one year. He has not work since 2010 and his wife said,
"It
was before he got his disability." said he was fired
for
"taking my VA meds." His wife noted how he fell asleep at the
wheel and
also fell asleep one time in a meeting." When asked that his
current
limitations or restrictions to employment he said, "I
couldn't deal
with people and my physical disabilities. I have fibromyalgia and I
hurt all the time."
c. Relevant Mental
Health history, to include prescribed medications and
family mental health:
assessed his current health as "poor" and said
his current
medical conditions consist of fibromyalgia, irritable bowel syndrome,
sleep apnea, tinnitus, hypertension and he believes he has chronic
fatigue syndrome. All of his current medications are prescribed by the
VA and he noted taking medications as prescribed. He is experiencing a
side effect of dry mouth with his current medication regimen He denied
being hospitalized for physical reasons and last 5 years.
was hospitalized for psychiatric reasons in 2011 due to
suicidal ideation. He said the hospitalization was for one day and his
wife commented, "That was about the time my youngest son got
killed in
a car accident. He fell asleep behind the wheel." is
currently receiving mental health treatment at the Poplar Bluff VA
facility. He works with a social worker and psychiatrist and is in
group counseling. He has been receiving treatment for approximately 5
years. noted having suicidal ideations 2 or 3 times a
month
but denied any attempt at taking his life. He said, "I have a
daughter
who needs me." He noted having recurrent homicidal thoughts as
well and
said this involves "the person who raped my daughter and the
police who
screwed over my stepson. I have a list of 10 people who if I had 3
months to live I would do what I had to do." He denied any attempt
at
taking another's life.
d. Relevant Legal and Behavioral history:
currently possesses a valid driver's license but does
not
CONFIDENTIAL Page 18 of 26 operate a vehicle on a regular basis. He was cited with a DUI and was
under the influence of prescription medication. The offense occurred
in
2013 and he is currently on probation "until I pay a fine and
complete
the SATOP program." He is on 2 years supervised probation and when
this
coursework is completed he will be changed to unsupervised probation.
e. Relevant Substance abuse history:
denied smoking cigarettes currently. He currently uses
smokeless tobacco at a rate of one can a day and has been engaged in
this habit for 10 years. His current alcohol consumption is,
"hardly
any anymore; maybe a beer one time every 3 months." When drinking
his
heaviest he was consuming "a 30 pack and a fifth a day." He
drank at
this rate for 1.5 years and reduced his use approximately 3 years ago.
He experimented with marijuana "once or twice" but denied
regular use
of this substance. He denied use of crack, cocaine, amphetamines,
psychedelic substances, or heroin. He also denied history of
prescription drug abuse.
f. Other, if any:
When asked about his current psychological and mental health
difficulties, said, "its nightmares and flashbacks. I
have
these about 3 or 4 times a week. Sometimes I get stuck in my dreams.
It
I can't get out of the dream. He noted sleeping approximately 5
hours
during the night and is not refreshed upon waking. "I've also
heard
voices every once in a great while. I can't make them out it
Arabic
speaking. I have a lot of pain and that doesn't help the other
stuff. I
can do anything. The more physical I do the more I have to relax. I
stay at home all the time. The only place I go is to the VA or my
parents. I let her (wife) do all the shopping." He went on to
say,
"this is my forth marriage and this is better. I spout my 15
minutes
and then I'm all better. I'm not cool with the authority
figures. I'm
not cool with cops whatsoever." He noted having anger problems,
concentration problems and "short-term and loss. He denied
hypervigilance or an exaggerated startle response.
. I was recalled to the gulf war." He
was a
light vehicle mechanic and he attained a rank of E4. He denied having
he article 15's or other disciplinary action. He reported heavy
alcohol
consumption while in military but denied drug usage. When asked about
injuries he described how he broke his right ankle but does not
remember the date of the injury or which ankle it was. He was deployed
to Iraq from January 1991 until March 1991. He reported being exposed
to combat while in this region. reflects on his service in
the military "2-3 times a day."
indicated being exposed to actual or threatened death and
serious injury by directly experiencing a traumatic event or
witnessing, in person, a traumatic event that occurred with others.
This series of events, which are stated elsewhere in this report,
occurred while he was in the military service. There have been
recurrent, involuntary, and intrusive distressing recollections of the
trauma; recurrent distressing dreams in which the content or effect of
the dream is related to that trauma event; and dissociative reactions
and flashbacks in which there is a feeling that the traumatic event is
reoccurring. He indicated having an avoidance of or efforts to avoid
distressing memories, thoughts, or feelings about or closely
associated
with the trauma along an avoidance of or efforts to avoid external
reminders that arouse distressing memories, thoughts, or feelings
about
or closely associated with events. He has a persistent negative
emotional state; a markedly diminished interest or participation in
significant activities; feelings of detachment or estrangement from
others; and a persistent inability to experience positive emotions.
Additionally, he has irritable behavior and angry outbursts with
little
or no provocation; hypervigilance and an exaggerated startle response.
He also noted having problems with concentration and difficulty
falling
asleep, staying asleep and/or restless sleep.
was administered the PTSD Checklist-M (PCL-M), which is a
17-item inventory that assesses the degree which an individual has
experienced specific symptoms of PTSD in response to "stressful
military experiences" over the past month. The results of the
PCL-M
reveal a raw score of 74. This score is above the recommended cut
score
of 56 for Veterans assessed in a VA Mental Health Clinic and suggests
he does meet the requisite criteria for this Post-Traumatic Stress
Disorder (PTSD).
He indicated suffering from pain in one or more anatomical sites and
this is the predominant focus of the clinical presentation. His level
CONFIDENTIAL Page 20 of 26 of pain is of sufficient severity to warrant clinical attention. His
pain causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning. Both
psychological factors and a general medical condition are judged to
have important roles in the onset, severity, exacerbation, or
maintenance of the pain.
The symptoms indicated above do appear to be significantly impairing
his social or occupational functioning.
has lived in Northeast Arkansas for approximately 4 years.
His social support consists of his wife and daughter and mental health
workers. His activities of pleasure relaxation are limited to
"watching
TV, reading books and I'll go out and pet the dog." His
religious
affiliation is "none now." When queried about his strengths
he said, "I
am loyal, I am a good father, and that's all I know."
described his mood today as, "a low esteem mood; a mentally
draining
mood." He said his mood most days is "like this, not much

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You already have TDIU. If you want P&T you should just request it. Did you request an increase? You may get 100% scheduler. If you do then ask for SMC "S" which is housebound. IU and TDIU are the same thing. Does your spouse get ChampVA?

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With the statement that the Examiner states that you have only Occasional Impairment, you will probably continue at 70% which is great. Good luck and keep us posted

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Welcome.

Is there a typo in the year / dates quoted ?

"He was deployed
to Iraq from January 1991 until March 1991. He reported being exposed
to combat while in this region."

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I was IRR and recalled for the 1st Gulf War yes some people was in a combat zone then and I am an E-4 Spealist received two ranks while I was there corrected on a dd215

Edited by cablinginar

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