Opinion On C&p Exam

[Memphis10Vet]

SECTION I:

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1. Diagnostic Summary

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Does the Veteran now have or has he/she ever been diagnosed with

PTSD?

[X] Yes[ ] No

ICD Code:

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD

ICD Code: 309.81

Comments, if any: 30% service connected for PTSD.

b. Medical diagnoses relevant to the understanding or management

of the

Mental Health Disorder (to include TBI):

No response provided.

3. Differentiation of symptoms

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

a. Does the Veteran have more than one mental disorder

diagnosed?

[ ] Yes[X] No

b. Is it possible to differentiate what symptom(s) is/are

attributable to

each diagnosis?

No response provided.

c. Does the Veteran have a diagnosed traumatic brain injury

(TBI)?

[ ] Yes[X] No[ ] 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 deficiencies in

most areas,

such as work, school, family relations, judgment,

thinking and/or mood

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[ ] No[X] No other mental disorder has been diagnosed

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

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

In order to provide an accurate medical opinion, the Veteran's

claims folder

must be reviewed.

a. Medical record review:

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

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?

[ ] Yes[X] No

Was the Veteran's VA claims file reviewed?

[X] Yes[ ] No

If yes, list any records that were reviewed but were not

included in the

Veteran's VA claims file:

previous C & P

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[X] No

If yes, describe:

2. Recent History (since prior exam)

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

a. Relevant Social/Marital/Family history:

Veteran is engaged to the mother of his children, but

there has been

recent conflict. They are living together with their 2

children 4y and

10m. Veteran's wife works and children go to Day Care.

Veteran had a

physical confrontation with one of his brothers 2-3 weeks

ago. Shots

were fired but no one was hurt.

b. Relevant Occupational and Educational history:

Veteran is unemployed. He was fired from USPS for "no call

no show." He

reports conflict with co-workers and supervisor. He was

shot--didn't

bring proper documentation. Supervisor claimed he was not

following

orders. Veteran states he couldn't comprehend them--

thought he was

following orders. Veteran worked for 1 day for his uncle.

He got into

an arguement with a customer, and then in an argument with

his uncle.

Uncle then stated he could not work for him. He has been

unemployed

since January 2014.

c. Relevant Mental Health history, to include prescribed

medications and

family mental health:

Veteran was seeing Donna Denato, Ph.D. She referred him

to a

psychiatrist for medication. The provider was on

vacation, and he

never made contact. Veteran wants outpatient treatment

now. He is

willing to come to the VA for outpatient treatment.

d. Relevant Legal and Behavioral history:

Veteran was arrested for possession of marijuana and

commission of a

felony with a firearm. He was stopped by the police for a

license

plate issue. His car was searched and marijuana was found

in his

trunk. He had a hand gun and a permit. Veteran is going

back to

court--has been offerred probation.

e. Relevant Substance abuse history:

Veteran is smoking 2 blunts of marijuana 1-2 times per

day. His last

use was 10:30pm last night. He started using THC after

active duty in

the military--11/2011. He drinks alcohol 3-4 times per

month-- 2 shots

of Whiskey. His last drink was 6/23/2014.

f. Other, if any:

Veteran states he was already paranoid when got shot

1/16/2014. He was

looking for a friend in South Memphis. Some men

approached him and

started shooting. He was treated at the Med for a gunshot

wound to the

torso. Now, he keeps his gun handy at all times. Veteran

has to be in

court tomorrow as he is being sued by a truck driver for

breaking his

jaw. This truck driver hit his car and did not stop.

Veteran chased

him, forcing him to stop. The truck driver denied ever

hitting his

car. The arguement then got physical. As witnesses saw

the truck hit

his car, the truck driver cannot press charges.

3. PTSD Diagnostic Criteria

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

Please check criteria used for establishing the current PTSD

diagnosis. The

diagnostic criter

ia for PTSD, are from the Diagnostic and

Statistical Manual

of Mental Disorders, 5th edition (DSM-5). The stressful event

can be due to

combat, personal trauma, other life threatening situations (non-

combat

related stressors.) Do NOT mark symptoms below that are clearly

not

attributable to the criteria A stressor/PTSD. Instead,

overlapping symptoms

clearly attributable to other things should be noted under #5 -

"Other

symptoms".

Criterion A: Exposure to actual or threatened a) death, b)

serious injury,

c) sexual violation, in on or more of the

following ways:

[X] Directly experiencing the tramuatic event(s)

Criterion B: Presence of (one or more) of the following

intrusion symptoms

associated with the traumatic event(s), beginning

after the

traumatic event(s) occurred:

[X] Recurrent, involuntary, and intrusive

distressing memories

of the traumatic event(s).

[X] Recurrent distressing dreams in which the

content and/or

affect of the dream are related to the

traumatic event(s).

[X] Intense or prolonged psychological distress at

exposure to

internal or external cues that symbolize or

resemble an

aspect of the traumatic event(s).

[X] Marked physiological reactions to internal or

external

cues that symbolize or resemble an aspect of

the traumatic

event(s).

Criterion C: Persistent avoidance of stimuli associated with

the traumatic

event(s), beginning after the traumatic events(s)

occurred,

as evidenced by one or both of the following:

[X] Avoidance of or efforts to avoid distressing

memories,

thoughts, or feelings about or closely

associated with the

traumatic event(s).

[X] Avoidance of or efforts to avoid external

reminders

(people, places, conversations, activities,

objects,

situations) that arouse distressing memories,

thoughts, or

feelings about or closely associated with the

traumatic

event(s).

Criterion D: Negative alterations in cognitions and mood

associated with

the traumatic event(s), beginning or worsening

after the

traumatic event(s) occurred, as evidenced by two

(or more) of

the following:

[X] Persistent and exaggerated negative beliefs or

expectations about oneself, others, or the

world (e.g., "I

am bad,: "No one can be trusted,: "The world is

completely

dangerous,: "My whole nervous system is

permanently

ruined").

[X] Persistent negative emotional state (e.g.,

fear, horror,

anger, guilt, or shame).

[X] Markedly diminished interest or participation

in

significant activities.

[X] Feelings of detachment or estrangement from

others.

Criterion E: Marked alterations in arousal and reactivity

associated with

the traumatic event(s), beginning or worsening

after the

traumatic event(s) occurred, as evidenced by two

(or more) of

the following:

[X] Irritable behavior and angry outbursts (with

little or no

provocation) typically expressed as verbal or

physical

aggression toward people or objects.

[X] Reckless or self-destructive behavior.

[X] Hypervigilance.

[X] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or

staying

asleep or restless sleep).

Criterion F:

[X] The duration of the symptoms described above

in Criteria

B, C, and D are more than 1 month.

Criterion G:

[X] The PTSD symptoms described above cause

clinically

significant distress or impairment in social,

occupational, or other important areas of

functioning.

Criterion H:

[X] The disturbance is not attributable to the

physiological

effects of a substance (e.g., medication,

alcohol) or

another medical condition.

4. Symptoms

-----------

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

Veterans

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Near-continuous panic or depression affecting the ability

to function

independently, appropriately and effectively

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or

recent

events

[X] Impaired judgment

[X] Disturbances of motivation and mood

[X] Difficulty in adapting to stressful circumstances,

including work or a

worklike setting

[X] Intermittent inability to perform activities of daily

living,

including maintenance of minimal personal hygiene

5. Behavioral Observations:

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

Veteran was alert, oriented, with no hygiene issues on this

date. He

denied hallucinations, and does not appear to have delusions.

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:

Veteran has times when he "shuts down" for 4-5 days at

a time. He

does not bathe, brush his teeth, doesn't come out of

his bed or

his room. He doesn't eat and loses weight at these

times. He

states he doesn't want to deal with anybody, cuts off

his phone and

doesn't watch TV. His children are in day care as he

cannot be

responsible for them at these times.

7. Competency

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

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

[X] Yes[ ] No

8. Remarks, (including any testing results) if any:

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

Veteran denies suicidal or homicidal ideations at this time.

He has

fleeting suicidal thoughts on rare occasions with no intent

or plan.

Veteran does not appear to be able to work at this time due

to

psychological distress. The diagnosis used was per DSM-V.

The veteran

confirmed identity by stating his full name and full Social

Security

number, when asked, before the exam began. The limits of

confidentiality

were explained to the veteran, and the veteran indicated

understanding of

those limits when asked, before the exam began. The veteran

gave the

examiner permission of conduct the exam.

[Veldrina]

Based on this exam i would guess about 50%....however I don't see the examiner relating your stressors to service or even discussing service, which is a concern because it is otherwise a denial.

[Memphis10Vet]

I'm already at a 30% rating as of now but my stressor is service ralated due to a incident in Iraq don't know why it's not in the second exam. Why wouldn't they put me at 100% with the inability to work? N thanks for the reply

[Veldrina]

It's becuz of the symptomology, that's what bumps u up. Passive suicidal ideation, irritability with unproboked periods of violence, obsessive rituals (which can be anything like repeatedly checking locks on everything & not going to sleep till u do, or cant leave house until u make sure everything is secure, etc) can bump u up to 70 as well. Neglect of hygiene, hallucinations, weird speech etc can get u bumped up to 100% sometimes. I'm not advocating this, mind u, just saying. I DO see that suicidal ideation was mentioned however u stated it's rare & u denied it on exam, hence why it wasn;t checkmarked. Same thing with "shutting down" & not taking care of hygiene...it's not constant, therefore why it's not checkmarked.

If you have other conditions that are service connected that also contribute to your inability to work & they equal a combined 70% you can still qualify for unemployability.

[LarryYoung3]

Valdrina

I was recently denied higher rating for ptsd . I have all the symtoms for 70-100% . I am at 50% now. Had c&p exam which doctor said 100% total social and occupational impairment. received soc that said that i am taking meds again and kept me at 50%. Then I checked e-benefits and it showed admin.review for new claim of depression. I thought depression was included as part of ptsd.three months in admin. review at prep. of decision. Appeal since 2011 of original disagreement of 2006.Can you shed light on admin review. thanks

[carlie]

Valdrina

I was recently denied higher rating for ptsd . I have all the symtoms for 70-100% . I am at 50% now. Had c&p exam which doctor said 100% total social and occupational impairment. received soc that said that i am taking meds again and kept me at 50%. Then I checked e-benefits and it showed admin.review for new claim of depression. I thought depression was included as part of ptsd.three months in admin. review at prep. of decision. Appeal since 2011 of original disagreement of 2006.Can you shed light on admin review. thanks

Welcome.

Please start a new topic with your questions.

Thanks

[Memphis10Vet]

I was giving 70% with iu bump me to a100%