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Ptsd C&p Results - Advice ?


elijahdoe
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Question

Here are my C&P Results: Do you know what my outcome may be? Any advice would be appreciated. Thank you

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
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.
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I would think 10 to 30 %....but that is just a guess..

You can always appeal any rating that you feel is too low.

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My status just switched to PREPARATION FOR NOTIFICATION. Does anyone know how long this part takes and what happens next? Thanks

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