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Recent Ptsd C&p


Milehighvet

Question

So first off I wanted to say hello to everyone, and without all the help i've had from lurking this site the last few months, I would have given up a while ago.

Anyways, I recently had a comp exam for a ptsd claim that I filed in March of 2014. I got my results today on MyHealtheVet, and have no idea what to make of it. Mainly i'm concerned because it says that my claim file wasn't reviewed, and I'm worry that may cause it to be inadequate. I'm also concerned because I've only recently started treatment at my VA clinic (the day I went in was actually the day two of my brothers were killed in afghanistan), and I'm worried that since I don't have a long record of treatment since getting out, that the VA may try and deny me. If anyone could make heads or tails of this, it'd be much appreciated I've been stressing this for months now and now that i'm so close to being done I'm ready to pull out my hair. If it helps, I am an infantryman with a CIB. Apologize in advance for the wall of text, tried to delete out irrelevant (and personal) info.

SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[X] Yes [ ] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: 309.81
Comments, if any:
Is at least as likely as not caused by or the result of fear of
hostile military or terrorist activity.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): See claims file.
3. 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 [ ] No [X] Not shown in records reviewed
4. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of
veterans 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:
-----------
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:
-------------------------
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 yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
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
[X] 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)
Veteran 1 [ ] No records were reviewed
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
f. Other, if any:
No response provided.
3. Stressors
------------
Describe one or more specific stressor event(s) the Veteran considers
traumatic (may be pre-military, military, or post-military):
a. Stressor #1: Combat deployment to Afghanistan 2011-12
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
Is the stressor related to personal assault, e.g. military sexual
trauma?
[ ] Yes [X] No
4. PTSD Diagnostic Criteria
---------------------------
Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria
for PTSD, referred to as Criteria A-H, are from the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Criterion A: Exposure to actual or threatened a) death, b) serious
injury,
c) sexual violation, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)
[X] Witnessing, in person, the traumatic event(s) as they occurred to
others
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).
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, distorted cognitions about the cause or consequences
of
the traumatic event(s) that lead to the individual to blame
himself/herself or others.
[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.
[X] Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings.)
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] 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] Duration of the disturbance (Criteria B, C, D, and E) is more than
1 month.
Criterion G:
[X] The disturbance causes 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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's 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
worklike setting
[X] Suicidal ideation
6. Behavioral Observations
--------------------------
No response provided
7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
This veteran served a combat deployment of approximately
11 months in Afghanistan from 2011 to 2012. During that time, he
was in frequent fire fights and witnessed numerous deaths including
the deaths of friends of his. He also witnessed the deaths of
Afghanis including an Afghan policeman with whom they worked and
become friends who was killed as they were clearing a building. Vet has had anniversary reactions to the deaths of 2 friends that
occurred on August 14, 2011. After his unit went back to Germany in
May 2012, veteran had chronic sleep impairment and did seek
treatment. He made 1 suicide attempt August of 2012 when he almost
hung himself, though he interrupted the act before he completed it.
He was diagnosed at some time in Landstuhl RMC with adjustment
disorder. He was seen at the Denver VAMC August 14, 2014,
anniversary of the deaths of his friends and has been diagnosed with
PTSD. I do concur with that diagnosis. Please refer to the DBQ for
complete list of current symptoms.
All diagnoses considered in the course of this exam condition are
based upon criteria in DSM-5.
The veteran is able to maintain activities of daily living including
personal hygiene. He has not experienced significant trauma since
discharge. There have not been remissions during the past year.
Symptoms are continuous. He does not have problems with drug and
alcohol abuse. There is not inappropriate behavior. He is in
treatment but has just initiated it and it is too early to determine
how he will respond. He has been prescribed Fluoxetine. Thought
processes and communication are not impaired. Social functioning is
impaired as described. Employment is impacted due to psychological
issues as described. The veteran has had significant difficulty
interacting with the public and was terminated from a position
earlier this year. He is currently enrolled in school but is having
difficulty completing his assignments. The veteran describes post
military stressors from tension in his primary romantic relationship
as a result of his symptoms and estrangement from his family. Other
than diagnoses listed no other mental conditions were found. The
veteran is competent to handle VA funds.
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Looking at the rating chart you should be rated 70% for PTSD. That is how the C&P examiner felt about it anyway. I put the one they checked on yours below. That doesnt mean that is what it will be but it should be that. JMHO
[X] Occupational and social impairment with deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood

General Rating Formula for Mental Disorders

Rating Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100%
Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 70%
Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50%
Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 30%
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 continuous medication. 10%
A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 0%

Edited by vet201060
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