Can You Guys Tell Me What You Think

[Aruis1971]

so i got my C&P exam back and wanted to know what you guys think. I went into the hospital a few weeks ago because i got in a bad way because of a job. the therapist there told me that they didn't think i needed to work and i realize that doesn't mean crap but he did put it into my files.so could you guys give it a look and tell me what you all think. How long is the v.a. taking when it goes into a preparation for decision status.this is for an increase on ptsd and iu. im currently at 70% for ptsd

SECTION I:

---------

1. Diagnostic Summary

--------------------Does

the Veteran now have or has he/she ever been diagnosed with PTSD?

[X] Yes[ ] No

ICD Code: 309.81

2. Current Diagnoses

-------------------a.

Mental Disorder Diagnosis #1: PTSD

ICD Code: 309.81

Mental Disorder Diagnosis #2: unspecified depressive d/o

ICD Code: 311.00

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): no acute conditions identifed

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:

shared sx presentation

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes[X] No[ ] 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 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[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: shared sx presentation.

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[X] No[ ] 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:

as detailed in VBMS

review of VA med record

review of previous C & P evaluations.

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?

[X] Yes[ ] No

If yes, describe:

as detailed in record

wife present for evaluation and offers collateral

2. Recent History (since prior exam)

-----------------------------------a.

Relevant Social/Marital/Family history:

wife accompanies Vet to interview...."we just had our 4 yr

anniversary"

limited activity base.

increasing isolation.

b. Relevant Occupational and Educational history:

"lost job in April last yr" ...."I got laid

off...."

"they're still there....I'm not...." "they

said I was being

confrontational to the new boss".

c. Relevant Mental Health history, to include prescribed medications and

family mental health:

recent hospitalization ACY , 5 days....."I should have stayed

longer......" but Vet notes concern about Vehicle that was left at

COPC

where he had been seen prior to ACY admission.

before hospitalizaion med compliance had been a problem

wife notes "that was part of the reason for hospitalization...get

back...regulated....".

d. Relevant Legal and Behavioral history:

none

e. Relevant Substance abuse history:

none

f. Other, if any:

No response provided.

3. PTSD Diagnostic Criteria

--------------------------Please

check criteria used for establishing the current PTSD diagnosis. The

diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual

of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to

combat, personal trauma, other life threatening situations (non-combat

related stressors.) 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 #6 - "Other

symptoms".

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] Dissociative reactions (e.g., flashbacks) in which the

individual feels or ac

ts as if the traumatic event(s) were

recurring. (Such reactions may occur on a continuum,

with

the most extreme expression being a complete loss of

awareness of present surroundings).

[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, 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] The duration of the symptoms described above in Criteria

B, C, and D are more than 1 month.

Criterion G:

[X] The PTSD symptoms described above cause 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.

4. Symptoms

----------For

VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Near-continuous panic or depression affecting the ability to function

independently, appropriately and effectively

[X] Chronic sleep impairment

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

events

[X] Impairment of short- and long-term memory, for example, retention of

only highly learned material, while forgetting to complete tasks

[X] Flattened affect

[X] Impaired judgment

[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

[X] Impaired impulse control, such as unprovoked irritability with

periods

of violence

5. Behavioral Observations:

--------------------------alert

with prompting. oriented and cooperative. Affect restricted. slow

gait.

6. Other symptoms

----------------Does

the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

[ ] Yes[X] No

7. Competency

------------Is

the Veteran capable of managing his or her financial affairs?

[X] Yes[ ] No

8. Remarks, (including any testing results) if any:

--------------------------------------------------regarding

IU

findings indicate that PTSD related sx acuity includes poor frustration

tolorance and ease to react with anger in response to minimal stressors,

increased isolation, concentration difficutlty. Adjustment to

medications

may be confounding. Drive, motivation, and and ability to complete tasks

are very likely impaired. Findings indicate sx severity is at times quite

severe and due the sxs noted Vet would not be able to secure or maintain

viable gainful employment in any setting, physical or sedentary.

Edited March 28, 2015 by Aruis1971 (see edit history)

[Pete53]

It appears from this C&P that you should be rated for service connection. Good Luck. Reminder if you can't work file for Social Security.

[Navy04]

Sorry to hear of your troubles bud. Your Exam report looks a lot like my recent PTSD Review, I too am currently 70%. The Occupational and Social statement fits the 70% Range, but your symptoms checked off fit the 100%, as mine do too. It is really just hard to say whether it will go up or remain. I believe in my Experience that you could definitely get IU. How long have you had the 70% rating for PTSD. I will tell you that I spent 3 months in a Civilian Mental Hospital while Active, yet the VA only granted me a 30% PTSD Rating originally, so the VA does not always go by what other Docs say, but what instead the Rater decides to use as evidence. My current FDC has been in Prep for Decision since Feb 20th. Good luck and God Bless!!!

[13Bcannoncocker]

every region/case is different. I just recently was awarded tdiu p&t with an already established 70% for ptsd. i'm in seattle. mine tdiu was approved days after ebenefits went into prep for decision. try calling your vso. check your va letters on ebenefits, in most cases they will be updated before it says complete. try not to let it tear you up.. you will know soon. and sounds like you will stay at 70% and have a very good chance for tdiu. To get 100% ptsd is very hard, basically you'd have to be institutionalized.

Edited March 29, 2015 by 13Bcannoncocker (see edit history)

[chiefjr]

It took me 4-5 Months to get my increase. but watch your paper work read it carefully and take it to the American Legon or DAV to see if you are unemplouable. Again look to see if it says IU 100%. But don't take my advice alone seek A.L. or DAV.