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Ptsd C&p Exam Results


Shadow2b

Question

Good Evening Everyone
I have gotten a lot of good info from this forum and was just looking for an opinion of what my rating might be based on my C&P exam from last week. My guess is 30% for sure, but is there any chance of 50?, There are glaring errors in this exam (i didn't fire on the vehicle with women and children in it, the Iraqis did, i just witnessed the event and aftermath, I didn't recieve a CAB, i had a CIB), and a bunch of other details that he didn't transfer correctly from my files. Since i had submitted a stressor statement ato the VA allready, it seems he just reviewed those and only asked me the questions on the DBQ.He clearly didn't review any of my treatment records from the VA. I don't want to bitch to the VA anymore about this being incorrect, since this has take a few years just to get this far, but these errors are mildly irritating. I also have been diagnosed by the VA with depression and anxiety, but from what I understand these are included in this correct? Any help or opinions would be much appreciated. I know it hinges off of the occupational and social impairment, but I wasn't sure if they take all the other factors (treatment, medication, the fact I was turned down from a law enforcement job because I had PTSD in my medical record) Any help or opinion would be greatly appreciated. I am also applying for Achilles tendonitis and knee sprain, but I don't think I will be getting anything for those.



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
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: 309.81
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): none
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
occupational
and social impairment with regards to all mental diagnoses? (Check only
one)
[X] Occupational and social impairment with occasional decrease in work
efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily,
with normal routine behavior, self-care and conversation
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:
[ ] 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
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Veteran grew up in the . His father was a welder and his
mother was a grocery clerk. Veteran has two sisters, one younger and one
older. His parents divorced when veteran was 14. Veteran's father
physically and mentally abused veteran, and an uncle sexually abused
him. It appears the abuse was reserved for the veteran.Veteran was
removed from the home and put him in group and foster homes from ages
12-18. He did not get any treatment for this.
In high school veteran's GPA was 3.5. He played soccer for a year.
He had buddies and a part-time job. He had 2-3 girlfriends in his junior
and senior years. He went to community college from 2005-2008.
After his 1997 graduation, veteran went right into the military. His
current marriage has lasted 12 years, with a 5-year relationship
before. They have 2 children. The family lives in a house veteran and
wife are buying. Their income is from veteran's job and his drill
check (reserves) every month.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Veteran has been in the National Guard and the Army, 1997-2001 and
2007-present. He was deployed in Iraqnd Afghanistan,
with 15 months total in the mid-East. His highest grade was SGT, and
this was his rank when honorably discharged. Infantryman was his job.
He was awarded the Combat Action Badge (for Afghanistan). He had one
Article 15 rank for failing a drug test. "This is what I regret
the most." He was busted from E-4 to E-1, but he was repromoted.
Veteran has been working since his discharge. His wife doesnt work "Our
income
barely covers our expenses."
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Veteran was treated for insomnia in Iraq, with medication. In 2009 his
sleep was getting worse, and he went to the VA for help. He was
given buproprion. He had a few appointments but stopped going.
He tried to keep things together but in October 2010 "my wife and
I almost split up over my anger issues." Veteran was working in the
SanDiego area, so he went for help to the Naval Medical Center. He went to
marriage couseling without his wife because she could not drive. He
thinks this helped "a little bit." He then stopped this
because he was deployed to Afghanistan, but he went to the Combat Stress Clinic
there.
When he came back home, his wife "spotted right away that I was
not right, and I decided to go back to the VA.
Veteran in now in individual therapy and is getting medication
management. He takes sertraline and propanolol, which he finds
helpful.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
none
e. Relevant Substance abuse history (pre-military, military, and
post-military):
none
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: Veteran has the Combat Action Badge, and combat exposure is
conceded. On one occasion veteran was a machine gunner when a small
car approached them. Veteran fired some warning shots to get the car to
stop, which it eventually did. Veteran could see that there were women
and children in the car. The Iraqi Police approached the car. Veteran
heard screaming and crying. Veteran was able to see one woman dead and
one of the children shot.
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
b. Stressor #2: During one of 80 IDF attacks when he was in Afghanistan
veteran and a SGT heard and felt a large explosion right in front of
them. They ran to get equipment and when they got to the pint of
explosion they saw 3 injured service members and 3 severely injured
soldiers. One soldier was missing some butt cheek and lower leg.
Another female was struck in the face and stomach, screaming for help,
and another had many shrapnel wounds. Veteran did what he could to
help.
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).
[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.
[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] 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
[X] Stressor #2
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Suicidal ideation
6. Behavioral Observations
--------------------------
Veteran's suicidal ideation is passive.
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

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Thanks US Vet, I appreciate it. I will say that the examiner did a terrible job on the report. There are a lot of mistakes, and he left a lot of info from my treatment records out. I will definitely post my results when I get them.

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