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Can You Guys Tell Me What You Think


Aruis1971

Question

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 by Aruis1971 (see edit history)
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  • HadIt.com Elder

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.

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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!!!

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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 by 13Bcannoncocker (see edit history)
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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.

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