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

[Jroocan]

**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.

[Buck52]

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

[Buck52]

Anybody?

[Navy4life]

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

[Oiler1995]

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 May 12, 2015 by Oiler1995

[Pete53]

I see 100% TDIU if you are not able to work. Good luck

[Jroocan]

Do I have to file a claim for TDIU? Or is that applied with the rating?

Edited May 11, 2015 by Jroocan