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C&p Exam For Ptsd

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mcnat1015

Question

Got the results of C&P today. Anyone care to guess about how it will turn out? Thank you very much

1. Diagnostic Summary

This section should be completed based on the current examination and clinical findings.

Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today’s evaluation?

Yes

2. Current Diagnoses

Diagnosis #1: PTSD

Diagnosis #2: Somatic Symptom Disorder, predominately pain

Diagnosis #3: Alcohol use disorder, in remission

Diagnosis #4: Cannabis Use Disorder, in remission

b. Axis III - medical diagnoses (to include TBI): Back Injury

3. Differentiation of symptoms

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

Yes

If yes, complete the following question:

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

No

If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to

each diagnosis:

Symptoms of the two disorders are enmeshed and overlap to a degree that to differentiate what portion of each symptom is attributable to each diagnosis is not possible. Alcohol and cannabis Use disorder are in remission. There is no clinical association between the diagnoses.

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

No

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

No

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)

Occupational and social impairment with reduced reliability and productivity

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?

No

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:

To assign portions of the occupational and social impairment to each diagnosis would be pure speculation

SECTION II:

Clinical Findings:

1. Evidence review

In order to provide an accurate medical opinion, the Veteran’s claims folder must be reviewed.

a. Records reviewed (check all that apply):

Claims folder (C-file):

Yes

b. Was pertinent information from collateral sources reviewed?

No

2. History

a. Relevant Social/Marital/Family history (pre-military, military, and post-military):

39 y/o white male. married to second wife for 9 years. Married and divorced on one previous occasion. Relationship with current wife is supportive. Has 4 children with whom he shares "no or distant" relationships. Two children live with ex-wife and he hasn't seen them in 3 years. He has two children with current wife. He has no friends with whom he associates and typically stays in the garage. He may do woodworking or other solitary things. Regarding family of origin: raised by mother, then grandmother, and then h is father, then his mother again. Divorced when he was 7. Relationship with parents while growing up was "fine" he has 1 younger brother and their relationship is "pretty close"

b. Relevant Occupational and Educational history (pre-military, military, and post-military):

Quit school in 9th grade but obtained GED in 1994. Participated in football, track, and basketball. He stated he was a good student but repeated 9th grade and quit in his 2nd year. He did not have special education assistance. Went to Job Corp where he got GED, worked as a forklift operator before he joined the military. He was in the Army from 1997 until 2007. He was deployed to Iraq on 2 occasions, once from 2003-2004 for 12 months and again from 05-06 for 12 months. At the time of this evaluation, the veteran is unemployed and "living off of in-laws." Veteran was in conflict with civilian supervisors and co-workers in many positions. He worked as a _________, _______, and __________.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military,

military, and post-military:

Veteran first sought attention from mental health professionals in 2003 for evaluation at fort hood. he has had counseling at the _____ VA clinic on and off since 2010. He first began taking medication for depression/anxiety around 2009. In the past, he has been prescribed medications including: Ambien, Guaifenesin, Citalopram and others. At the time of this evaluation he was prescribed Hydroxyzine, Prazosin, Sertaline, Atorvastatin. He was participating in individual therapy for 1 session. He admitted that he's been hospitalized for 4 days in _____ in ___ for Suicidal and homicidal ideation

d. Relevant Legal and Behavioral history (pre-military, military, and post-military):

2 DUIs and 1 DWI with the last DWI being in October 2014 and still pending

e. Relevant Substance abuse history (pre-military, military, and post-military):

Veteran has been sober since October 2014. He stated he abused alcohol to self-medicate due to nightmares, flashbacks, etc. "just not wanting to think about things. He admitted alcohol was a problem for him. Completed the SATP 30 day program then completed the PRRP inpatient program. Attends AA 1-2 times a week. Admitted he used illegal drugs last October, he abused drugs for approximately 4 years.

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: Omitted for privacy

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?

Yes

Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?

Yes

b. Stressor #2:Omitted for privacy

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?

Yes

Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?

Yes

c. Stressor #3: Omitted for privacy

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?

Yes

Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?

Yes

d. Stressor #4: Omitted for privacy

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?

Yes

Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?

Yes

4. PTSD Diagnostic Criteria

Criterion A: The Veteran has been exposed to a traumatic event where both of the following were present:

The Veteran experienced, witnessed or was confronted with an event that involved actual or

threatened death or serious injury, or a threat to the physical integrity of self or others.

The Veteran’s response involved intense fear, helplessness or horror.

Criterion B: The traumatic event is persistently reexperienced in 1 or more of the following ways:

- Recurrent and distressing recollections of the event, including images, thoughts or perceptions

- Recurrent distressing dreams of the event

- Acting or feeling as if the traumatic event were recurring; this includes a sense of reliving the

experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated

Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general

responsiveness (not present before the trauma), as indicated by one or both of the following:

Efforts to avoid thoughts, feelings or conversations associated with the trauma

Efforts to avoid activities, places or people that arouse recollections of the trauma

Criterion D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or

more of the following:

Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance

Exaggerated startle response

Criterion E:

The duration of the symptoms described above in Criteria B, C and D is more than 1 month.

Criterion F:

The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The disturbance is NOT attributable to the physiological effects of a substance

5. Symptoms

For VA rating purposes, check all symptoms that apply to the Veterans diagnoses:

Depressed mood

Anxiety

Suspiciousness

Panic attacks that occur weekly or less often

Panic attacks more than once a week

Near-continuous panic or depression affecting the ability to function independently, appropriately

and effectively

Chronic sleep impairment

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

Impairment of short- and long-term memory, for example, retention of only highly learned material,

while forgetting to complete tasks

Memory loss for names of close relatives, own occupation, or own name

Flattened affect

Circumstantial, circumlocutory or stereotyped speech

Speech intermittently illogical, obscure, or irrelevant

Difficulty in understanding complex commands

Impaired judgment

Impaired abstract thinking

Gross impairment in thought processes or communication

Disturbances of motivation and mood

Difficulty in establishing and maintaining effective work and social relationships

Difficulty in adapting to stressful circumstances, including work or a worklike setting

Inability to establish and maintain effective relationships

Suicidal ideation

Obsessional rituals which interfere with routine activities

Impaired impulse control, such as unprovoked irritability with periods of violence

Spatial disorientation

Persistent delusions or hallucinations

Grossly inappropriate behavior

Persistent danger of hurting self or others

Neglect of personal appearance and hygiene

Intermittent inability to perform activities of daily living, including maintenance of minimal personal

hygiene

Disorientation to time or place

6. Other symptoms

Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not

listed above

No

If yes, describe: ___________________________________________________

7. Competency

Is the Veteran capable of managing his or her financial affairs?

Yes

8. Remarks, if any ­­­­­­­­­­­­­­­­______________________________________________________________________

The veteran should be considered an increased but not current imminent risk of harm to himself. Denied he has any intent or plan to harm himself or anyone else at the time of this evaluation. Veteran stated he has the VA crisis number "all over"

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Hi there and welcome

Based on this answer:

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)

Occupational and social impairment with reduced reliability and productivity

That is a 50% S/C for PTSD

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Welcome aboard and sorry to hear of your issues. It looks like you will be granted, but hard to tell for sure, as the Occupational and Social impairment statement fits the 10-30% range, but the symptoms checked might yield up to 50% for PTSD. Good luck and keep us posted.

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The occupational and social impairment meets the 50% requirements but the symptoms - suicidal ideation, neglect of personal hygiene, and two others - meet the criteria for 70% and the grossly inappropriate behavior falls in the 100% category. So I was really wondering if they were more likely to rate 70% or 100%.

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