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C&p Exams All Done


ssgtob1

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Hi all,

I am new here and have a quick question about my C&P exams. I have many, and can copy and paste them all here if need be, but they all state: Does the Veteran's wrist condition impact his or her ability to work? [] Yes [x ] No

Does that mean that I wont be rated for any of these conditions?

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Not necessarily.

What matters is did the doc make a statement similar to, "the veterans wrist condition is at least as likely as not related to military service".

The second thing to look at is what boxes were checked off regarding the degree of disability. Then compare those to the rating schedule for your condition.

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Ok here goes:

1. Diagnosis

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

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

disorder(s)?

[X] Yes[ ] No

ICD code: 300.

If the Veteran currently has one or more mental disorders that conform to

DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Unspecified anxiety disorder

ICD code: 300.

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): none

2. Differentiation of symptoms

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

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes[X] No

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes[X] No[ ] Not shown in records reviewed

3. 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?

[ ] 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:

-----------

Clinical Findings:

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

1. Evidence review

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

a. Medical record review:

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

[X] Yes[ ] No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed?

[ ] Yes[X] No

If no, check all records reviewed:

[X] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[X] 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

3. Symptoms

-----------

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

Veteran's diagnoses:

[X] Anxiety

[X] Chronic sleep impairment

Behavioral observations:

The veteran was seen for 45 minutes. His VBMS file was reviewed prior

to the interview. The limits of confidentiality were explained to him

and he agreed to participate in the C&P evaluation. He was alert,

fully

oriented and cooperative. He was well groomed. Mood was good, affect

was euthymic. Speech and thought content were within normal limits.

Thought processes were logical and goal-directed. No evidence or

report

of delusions or hallucinations. Memory and attention appeared grossly

intact. Insight and judgment were fair. The veteran denied current

suicidal or homicidal ideation.

4. Other symptoms

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

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[X] Yes[ ] No

If yes, describe:

mild irritability

5. Competency

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

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

[X] Yes[ ] No

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

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

claimed condition: Anxiety

diagnosis: unspecified anxiety disorder

rationale: meets DSM-5 criteria

prognosis: good, symptoms are mild

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1. Medical history

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

Does the Veteran report recurrent tinnitus: Yes

Date and circumstances of onset of tinnitus: Veteran reports constant

bilateral tinnitus, left greater than right, described as a "ringing"

sound, onset in 2008 during deployment to Iraq.

2. Etiology of tinnitus

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

At least as likely as not (50% probability or greater) caused by or a result

of military noise exposure.

Rationale: Review of available service treatment records revealed the

notation "Subjective tinnitus" on a "Chronic Problems" list dated 5/21/13.

With service treatment records documentation showing diagnosis of tinnitus

during military service, it is this examiner's opinion that the veteran's

reported tinnitus is at least as likely as not related to his military

service.

3. Functional impact of tinnitus

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

Does the Veteran's tinnitus impact ordinary conditions of daily life,

including ability to work: No

4. Remarks, if any, pertaining to tinnitus:

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

CLAIMED CONDITION: TINNITUS

DIAGNOSIS: TINNITUS

RATIONALE: SERVICE TREATMENT RECORDS AND VETERAN'S REPORT AT THIS

C&P

EXAM

PROGNOSIS: GOOD

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran's

application.

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