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Ptst C&p Exam --


philusmc
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Question

I have PTSD and diagnosed as bi-polar too. Personally, I think the bi-polar is not correct but, hey, I'm not a doctor. I missed my C&P exam in Houston TX in Oct 2011 (I moved back to Florida in August 2011 and did not get the notice). ANyway, I got notice in Dec 2011 that my claim for PTSD had been denied because I missed the exam. I went to my county VA office and the "&D&&" filed to wrong request -- he filed an appeal instead of requesting my case be reopened and requesting a new C&P date. Fast forward 3 years and here I am. I had my C&P exam this last Wednesday and personally don't know how it went. The doc was very straight laced with no personality (I think that's the way they're supposed to be). Hadn't slept well in about two-three days and only got about 1 hour on Tuesday night before the exam at 8:00am. I muddled through with the doc -- lasted about 45 min. and the took the mmpi2. The mmpi test results were "questionable validity with some validity scales elevated to the extent that profile interpretation is of limited utility". " Veteran endorsed many psychological symptons on a variety of clinical scales, often reporting moderate to severe levels of intensity. Overall this response pattern may indicate a sense of feeling overwhelmed, though exaggeration of psychological distress cannot be ruled out."

Here's the summary of my C&P exam and I'd appreciate any feedback. Semper Fi.

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: 309.28

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD

Mental Disorder Diagnosis #2: ALCOHOL USE DISORDER

Comments, if any:

moderate

Mental Disorder Diagnosis #3: MOOD DISORDER, NOS

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): SEE CPRS

3. Differentiation of symptoms

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

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

[X] Yes [ ] No

b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?

[ ] Yes [X] No [ ] Not applicable (N/A)

If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses:

SYMPTOMS OVERLAP

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 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 [X] No [ ] No other mental disorder has been diagnosed

If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment

is attributable to each diagnosis:

SYMPTOMS OVERLAP

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?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the Veteran's VA claims file:

ALL RELEVANT RECORDS REVIEWED

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

f. Other, if any:

MILITARY HISTORY

Service Discharge Type (Last): HONORABLE

Service Branch (Last): MARINE CORPS

1967- 69, 69-79

Service Discharge Type (NTL): HONORABLE

Service Branch (NTL): MARINE CORPS

Service Entry Date (NTL):

Did the veteran have combat experience: YES

Combat service location:

Vietnam 1968-69

Duties:

Were combat wounds sustained: no

Any mental health tx: NONE

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: SEE MILTARY HISTORY

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] 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] Inability to remember an important aspect of the traumatic

event(s)(typically due to dissociative amnesia and not to other factors

such as head injury, alcohol, or drugs).

[X] Persistent negative emotional state (e.g., fear, horror, anger,guilt, or shame).

[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] 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] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent events

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social relationships

6. Behavioral Observations

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

OTHER PSYCHIATRIC SYMPTOMS

Today the veteran reports "I'm very agitated, didn't sleep well. Nerves

raw"

Current stressors: health

The veteran described/endorsed the following symptoms associated with

depression:

Withdrawn, isolation, anhedonia, depressed mood, low energy, poor sleep,

poor

attention and concentration, forgetfulness, change in appetite, crying

spells, guilt, helpless, hopeless, and worthless.

Frequency of Symptoms: 4-5 days a week

Duration of Symptoms: hours

Onset of Symptoms: years

Severity of Symptoms: mild to moderate

The veteran described/endorsed the following symptoms associated with

anxiety: restlessness or feeling keyed up or on edge, easily fatigued,

difficulty concentrating or mind going blank, irritability, muscle tension,

sleep disturbance, excessive worrying, second guesses, what if?,

difficulties

with decisions

Frequency of Symptoms: frequently

Duration of Symptoms: minutes

Onset of Symptoms: years

Severity of Symptoms: mild to moderate

The veteran described/endorsed the following symptoms associated with Mania:

inflated self esteem, decreased need for sleep, pressured speech, FOI,

distractibility, increased goal-directed activities, reckless behaviors

Frequency of Symptoms: no recent manic episdoes, often has bouts of

depression

Duration of Symptoms: hours

Onset of Symptoms:years

Severity of Symptoms:mild to moderate

Denies psychosis

MENTAL STATUS EXAM:

Appearance: clean, neatly groomed, casually dressed

Orientation: AOX4

Mood: subdued, mildly agitated

Affect: constricted

Attitude: cooperative

Speech rate and tone: Unremarkable

Language: Good

Thought content and progression: Unimpaired

Tangentiality: none

Circumstantiality: none

Loose associations: none

Flight of ideas: none

Delusional: none

Difficulty in understanding complex commands: none

Gross impairment in thought processes or communication: none

Hallucinations: not present

Delusions: not present

Grossly inappropriate behavior: none

Memory:

Mild memory loss, such as forgetting names, directions or recent events

Attention and concentration: "its shot"

Fund of knowledge: Good

Intelligence: average

Insight and judgment: fair

Abstract Reasoning: wnl and a function of intelligence not reduced by mood

Obsessive-compulsive: used to be organized , now less so.

Sleep impairment: chronic difficulties with delayed onset, has sleep apnea ADLs: no impact from mental disorder

Suicidal ideation: in past

Homicidal ideation: none

Persistent danger of hurting self or others: none

Relationships: limited to partner (see social history for details)

Has difficulty with people, easily irritated in dealing with others.

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

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

MMPI2 RF- profile of questionable validity with some validity scales elevated to the extent that profile interpretation is of limited utility.

Veteran endorsed many psychological symptoms on a variety of clinical scales, often reporting moderate to severe levels of intensity.

Overall this response pattern may indicate a sense of feeling overwhelmed, though exaggeration of psychological distress cannot be ruled out.

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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