elijahdoe Posted December 1, 2014 Share Posted December 1, 2014 Here are my C&P Results. Any idea how this looks and if it will be approved: 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, with panic attacks ICD code: 309.81 Comments, if any: Panic attacks occur once every 3 weeks in which he experiences, sweaty palms, increased heart rate, dizzy, feels like dying, tingling on fingers. PTSD- history of nightmares related to good friend killing 2 old ladies, and that his friend could have killed him. Vet has daily intrusive thoughts about the murders, avoids crowds, irritable in crowds, concentration problems, hypervigilance, insomnia in which he gets 3-4 hours sleep most nights. 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 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 [ ] 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? [ ] Yes [X] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [X] Yes [ ] 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): Vet was raised by bio parents with sister in Ohio; he denied abuse, and is close to his parents and sister. He reports close relationship with his wife of 8 years, and his adopted daughter, age 12. HE states he really has no close friends other than through his wife's friends. He states he avoids crowds, is irritable daily at work, and towards family, especially towards his wife. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Vet served in the airforce from 2001-4, and served in Kyrgyzstan in 2002. He has wored since then as a computer security worker, and has been with his current company for 3 years. He admits he has to work from home frequently due to anxiety symptoms. HE reports 20 days he has stayed home this year, and reports difficulty talking on the phone with customers. He finished high school and has taken some college courses. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Vet sees Dr. Nagaraj and Dr. Vasquez for treatment of ptsd and panic attacks, and takes Zoloft for PTSD and Valium as needed for panic. 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: Vet was shocked to find out that one of his best friends on base at Travis AFB, committed murder of two women, and vet realized he could have been a target of his friend's murderous rage. HE also reports feeling guilty he didn't do anything to stop his friend's murders. 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? [ ] Yes [X] No If no, explain: see above Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: Vet reports he feared for his life while serving in Kyrgystan due to fear of terrorist attacks and mortor attacks 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] 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 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] 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 [X] Stressor #2 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Disturbances of motivation and mood 6. Behavioral Observations -------------------------- Vet appears as a cooperative, casually dressed, well groomed, 31 year old Caucasian male who was oriented times 4. There was no evidence of hallucinations, delusions, or of significant cognitive impairment. He displayed tangential speech and needed frequent redirection. He complains of suffering from a chronically anxious mood, and he displayed a wide range of affect.He denies suffering from suicidal or homicidal ideation. 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 -------------------------------------------------- VEt appears at least as likely as not to meet the DSM-5 criteria for PTSD with secondary panic attacks caused by both the fear of hostile military activity in Kyrgystan and his good friend's murders of 2 elderly women near Travis Airbase. Vet suffers from mild to moderate social and emotional impairment and mild overall occupational impairment due to his PTSD and panic symptoms previously noted. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. Link to comment Share on other sites More sharing options...
0 Content Curator/HadIt.com Elder Vync Posted December 3, 2014 Content Curator/HadIt.com Elder Share Posted December 3, 2014 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 It could be 50% per §4.130 Schedule of ratings—Mental disorders because that statement matches "Occupational and social impairment with reduced reliability and productivity". MH disorder ratings get to be a bit difficult to predict because they read like Chinese stereo instructions. Hang in there! Good luck! Link to comment Share on other sites More sharing options...
0 snake doctor Posted December 4, 2014 Share Posted December 4, 2014 Hello, How did you post your c&p results? I'm catching heck trying to figure it out! I need to post my results from the examination as well. Any help would be greatly appreciated. Link to comment Share on other sites More sharing options...
0 elijahdoe Posted December 11, 2014 Author Share Posted December 11, 2014 The C&P results have a .pdf version and a .txt version. I downloaded the Txt version, copied and pasted it. Link to comment Share on other sites More sharing options...
0 elijahdoe Posted December 24, 2014 Author Share Posted December 24, 2014 Thank you all for the info. I just got my rating back and it is 50%. Summary of benefit information Include? Information Value Include the information in this row You have one or more service-connected disabilities: YesInclude the information in this row Your combined service-connected evaluation is: 50% Include the information in this row and the one below it Your current monthly award amount is: $917.13 The effective date of the last change to your current award was: December 01, 2014 Do you know if I should get my retro pay? Thank you all very much for the information. The great thing about being a veteran is that even though all of us are strangers and don't know each other, we all are brothers who look out for each other. Thanks again Link to comment Share on other sites More sharing options...
0 Mikemmlj Posted December 24, 2014 Share Posted December 24, 2014 Congrats. Effective date of December 01? Will that affect retro? Link to comment Share on other sites More sharing options...
0 Navy04 Posted December 24, 2014 Share Posted December 24, 2014 Congrats, and yes if this is your first claim, then your retro will be paid back to the initial filing date. God Bless and hope you have a Christmas!!! Link to comment Share on other sites More sharing options...
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elijahdoe
Here are my C&P Results. Any idea how this looks and if it will be approved:
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