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! Dr.'s Notes From C&p: What Do You Think?

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Jroocan

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**I'm currently SC 50% PTSD, this was a C&P for an increase. Any thoughts? Suggestions? I don't know how to interpret this stuff. You all have the great brains in here.
Thanks for looking.
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been
diagnosed with PTSD?
[X] Yes[ ] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD, CHRONIC,
SEVERE
Mental Disorder Diagnosis #2: MAJOR DEPRESSIVE
DISORDER, RECURRENT,
MODERATE TO SEVERE
Mental Disorder Diagnosis #3: ALCOHOL USE DISORDER
IN EARLY REMISSION
b. Medical diagnoses relevant to the understanding
or management of the
Mental Health Disorder (to include TBI):
NEUROLOGICAL PROBLEMS, INCLUIDING
SEIZURES; BEING EVALUATED.
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:
DEPRESSION AND ALCOHOL PROBLEMS ARE OFTEN PART
OF PTSD'S SYMPTOM
COMPLEX &, IN THIS CASE, THEY SHOULD BE
CONSIDERED AS PART OF
VETERAN'S PTSD. THEY ARE MENTIONED ABOVE DUE
TO THEIR SEVERITY.
c. Does the Veteran have a diagnosed traumatic brain
injury (TBI)?
[X] Yes[ ] No[ ] Not shown in records reviewed
Comments, if any: MR SOROKA HAD A 2ND LEVEL TBI
EVALUATION DONE
11/16/12. EXAMINER CONCLUDED THERE WAS A
HISTORY OF TBI, BUT THAT
CURRENT CLINICAL SYMPTOMS WERE CONSISTERNT
WITH BEHAVIORAL HEATH
FACTORS SUCH AS PTSD & DEPRESSION,
d. Is it possible to differentiate what symptom(s)
is/are attributable to
each diagnosis?
[X] Yes[ ] No[ ] Not applicable (N/A)
If yes, list which symptoms are attributable to
each diagnosis:
SYMPTOMS ATTRIBUTABLE TO MENTALHEALTH DIAGNOSES
& NOT TBI
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: SEE ABOVE
COMMENTS
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?
[X] Yes[ ] No[ ] No diagnosis of TBI
If yes, list which portion of the indicated
level of occupational and
social impairment is attributable to each
diagnosis: NONE ARE
ATTRIBUTABLE TO 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?
[ ] Yes[X] No
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
[X] 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
[X] Other:
NO DOCUMENTS WERE AVAILABLE IN VBMS FOR THIS
VETERAN. HOWEVER, HIS
MEDICAL/TREATMENT RECORDS AT THE VARIOUS VAs
WERE AVAILABLE AND
REVIEWED IN VISTA WEB.
b. Was pertinent information from collateral sources
reviewed?
[X] Yes[ ] No
If yes, describe:
VETERAN'S FIANCEE WAS PRESENT & SHE BOTH
CORROBORATED HIS ACCOUNT & ADDED
PERTINENT INFORMATION
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
MR SOROKA'S LIFE SINCE HIS PRIOR C&P EXAM
(1/01/06) HAS BEEN PRIMARILY
DOMINATED BY INCARCERATIONS AND RESIDENTIAL
TREATMENT PROGRAMS (SEE
SECTIONS BELOW FOR DETAILS). IN '06-'07
VETERAN WAS INVOLVED WITH A
WOMAN WHO WAS ALSO A PROBLEM DRINKER. THEIR
RELATIONSHIP WAS
CHARACTERIZED BY FREQUENT FIGHTS & PHYSICAL
ACTING OUT. VETERAN
ARRESTED TWICE FOR DOMESTIC VIOLENCE. HE
ENTERED HIS PRESENT
SIGNIFICANT OTHER RELATIONSHIP (AMBER) IN '11;
THEY HAVE AN ALMOST 1 YO
DAUGHTER & NOW LIVE TOGETHER. SHE HAS HAD A
STEADYING & POSITIVE
AFFECT ON HIM--"BLESSED TO HAVE HER IN MY
LIFE...SHE'S SAVED ME ALOT OF
TIMES." HE'S BECOME DEPENDENT ON HER. SHE
ADMITS THAT THEY'VE HAD
"ROUGH PATCHES...HE HAS GOOD DAYS & BAD DAYS,
ESPECIALLY FEB TO MAY
(BEST FRIEND WAS KILLIED & MOTHER DIED WHILE HE
WAS IN PRISON)." MR
SOROKA WATCHES DAUGHTER WHILE AMBER IS AT WORK
(NURSE); WHEN BABY IS
UPSET, HE GETS UPSET, WHICH MAKES SITUATION MORE
TENSE; HE FREQUENTLY
ENDS UP YELLIN
G AT BABY. HE ALSO GETS UPSET AT
AMBER, VERBAL FIGHTS &
OCCASSIONALLY HAS PUSHED HER. HE SAYS HE'S
MAKING AN ATTEMPTS TO "TAKE
MY ANGER OUT ON THINGS NOT PEOPLE"; CONSEQUENTLY
THERE ARE A NUMBER OF
HOLES IN THE WALLS. SAYS HE ONLY HAS ONE
FRIEND; NO INTERESTS OR
OUTSIDE ACTIVITIES, STAYS HOME & PLAYS WITH
BABY; TRIES TO AVOID EVEN
FAMIY GET TOGETHERS; WATCHES TV, ON INTERNET
WITH FACEBOOK & E-MAILS.
b. Relevant Occupational and Educational history:
GOING TO ILLINOIS VALLEY COMMUNITY COLLEGE-
WORKING ON AN ASSOCIATES
DEGREE SINCE '06; DOES GOOD COUPLE CLASSS THEN
FAILS DUE TO POOR
CONCENTRATION, ABSENTEEISM DUE TO ANXIETY
ATTACKS & DEPRESSION.
INTERMITTED JOBS--WAITER IN QUAD CITIES,
GOODWILL BUT FIRED FOR
MISCONDUCT & ALTERCATIONS WITH COWORKERS.
PROBLEMS WITH
AUTHORITY--HATED SUPERVISORS. gOODWILL WAS
ACCOMDATING ORIGINALLY BUT
THEN WANTED HIM TO BE USUALY STAFF ACTIVITIES;
GOT IN TROUBLE OVER
ANXIETY WHEN TOLD TO WORK THE FLOOR. MORE UPSET
WHEN MOTHER DIED;
ACTED OUT AND EVEN AT HOME. MORE RECENTLY, A
BACKGROUND CHECK FOR
WALMART SHOWED HISTORY OF 7 FELONIES, SO HE
WASN'T HIRED.
c. Relevant Mental Health history, to include
prescribed medications and
family mental health:
PREVIOUS C&P PTSD EXAM (1/01/06) DIAGNOSED
PTSD,CHRONIC WITH
DEPRESSION, ALCOHOL DEPENDENCE IN EARLY
REMISSION, & GAF = 61. THE
EXAM WAS DONE WHILE VETEAN WAS IN THE
RESIDENTIAL SUBSTANCE ABUSE
TREATMENT PROGRAM (SATP) AT DANVILLE VA; WHILE
THERE HE WAS INVOLVED IN
THEIR PTSD TRACT ALSO. AFTER COMPLEATING THE
PROGRAM, HE RETURNED HOME
TO BLOOMINGTON, BUT RELAPSED & RETURNED TO THE
SATP THE SUMMER OF '07.
HE APPLIED TO THE RESIDENTIAL PTSD PROGRAM AT
THE TOPEKA VA, BUT WAS
INCARCERATED BEFORE ATTENDING. AFTER A
CORRECTIONAL BOOT CAMP PROGRAM
IN '10, VETERAN ENROLLED IN MENTAL HEALTH AT THE
CORAVILLE CBOC (PART
OF OMAHA VA'S NETWORK) AND THEN TRANSFERED TO
THE LA SALLE CBOC AFTER
MOVING TO PERU, IL. HIS INITIAL DIAGNOSES IN
8/21/12 WERE PTSD, MAJOR
DEPRESSIVE DISORDER, ALCOHOL DEPENDENCE, & GAF =
50. BESIDE SUPPORTIVE
THERAPY/MEDICATION MANAGEMENT, MR SOROKA BEGAN
PROLONGED EXPOSURE
THERAPY FOR HIS PTSD; THAT WAS SO SO UPSETTING
(CONFIRMED BY HIS
FIANCEE) THAT HE DISCONTINUED IN 2/07/13. HE
WAS ADMITTED TO HINES' 2S
PSYCHIATRIC UNIT 3/13 WITH DIAGNOSES OF PTSD,
ALCOHOL DEPENDENCE WITH
AGGRESSIVE BEHAVIOR, DEPRESSION, & GAF= 25;
DISCHARGED 4/13/13 WITH GAF
IMPROVED TO 58. HE CONTINUES WITH OUTPATIENT
TREATMENT AT LA SALLE
CBOC; HAS VERY GOOD RAPPORT WITH DR LIM; MOST
RECENT APP'T WAS 4/16/15;
PRESCRIBD TRAZODONE, KLONOPIN, GABAPENTIN, &
NALTRAXONE, WHICH HAS
REDUCED HIS CRAVING FOR ALCOHOL & RESULTED IN
HIS LONGEST PERIOD OF
SOBRIETY OUT SIDE A HOSPITAL OR PRISON.
d. Relevant Legal and Behavioral history:
ARRESTED NUMEROUS TIMES--AGGRAVATED BATTERY ON
POLICE '07 &'10. JAILED
10 TIMES FOR 2 DOMESTIC BATTERY & NUMEROUS BAR
FIGHTS; ALSO 3 DUIs.
ALL COURT CASES FINISHED; POROLE FINISHED.
e. Relevant Substance abuse history:
SAEE TREATMENT HISTORY ABOVE. USUALLY RELAPSES
SOON AFTER OUT OF
TREQTMENT. CURRENTLY HAS GONE A MONTH WITHOUT
DRINK (NALTRAXONE WORKING
PRETTY WELL). STILL SMOKING MARIJAUNA ONCE WEEK,
BUT NOT SINCE
FEBURARY. CLAIMS NO OTHER STREET DRUGS.
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
[X] Learning that the traumatic event(s)
occurred to a close
family member or close friend; cases
of actual or
threatened death must have been
violent or accidental; or,
experiencing repeated or extreme
exposure to aversive
details of the traumatic events(s)
(e.g., first responders
collecting human remains; police
officers repeatedly
exposed to details of child abuse);
this does not apply to
exposure through electronic media,
television, movies, or
pictures, unless this exposure is work
related.
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 acts 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 and exaggerated negative
beliefs or
expectations about oneself, others, or
the world (e.g., "I
am bad,: "No one can be trusted,: "The
world is completely
dangerous,: "My whole nervous system
is permanently
ruined").
[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] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Flattened affect
[X] Difficulty in understanding complex commands
[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] Obsessional rituals which interfere with
routine activities
[X] Impaired impulse control, such as unprovoked
irritability with periods
of violence
[X] Neglect of personal appearance and hygiene
5. Behavioral Observations:
---------------------------
TEARFUL THROUGHOUT EXAM INTERVIEW
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:
---------------------------------------------------
CONTINUE MR SOROKA'S SC PTSD. HIS FUNCTIONING
SINCE PRIOR EXAM HAD
DETEIORATED, BUT CURRENTLY SHOWS SOME IMPROVEMENT;
HOWEVER PRONOSIS IS
EXTREMELY GUARDED SINCE HIS HISTORY SINCE PRIOR
EXAM SHOW NO ABILITY TO
SUSTAIN IMPROVED FUNCTIONING OUTSIDE OF STRONGLY
STRUCTURED SETTINGS.
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  • HadIt.com Elder

Jaroocan

After reading your C&P exam it looks favorable to me for increase to maybe 70/80% however the Dr did not have your SMR's & Your C-file during the exam, but the things he said in this exam seem favorable for increase in my opinion.

That your PTSD has got worse since your last examination.

Now just wait and see what the their decision will be, hopefully you will get an increase.

others may chimme in GP what do you think? Berta, Gastone, broncovet

..........................Buck

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  • HadIt.com Elder

Anybody?

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The key answer the C/P examiner gave was in question #4 - Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood

That is equal to 70% for PTSD

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I could be wrong,I'm still learning,but I see 100% but not P&T,future exams scheduled.If this was for individual unemployability I see 100% P&T.You went from chronic to chronic/severe,your ptsd symptoms are worse.But your report doesn't say total occupational/social impairment,so maybe I'm wrong with the 100% P&T.Your examiners report is very similiar to mine and I was awarded 100% P&T. I definetly see an increase.Keep your head up bud,good luck.If your not granted 100%,i definetly see at least 70%,good luck.

Edited by Oiler1995
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