Possible Positive At C&p

[brokensoldier244th]

So, im hoping that when the mental examiner for a mental C&P asks me near the end if I have already filed for SSDI or not, that is a positive?

[Notorious Kelly]

I don't try to evaluate C&Ps cuz it's such a dart throw but I wish you the best with this soldier!

[Navy4life]

I know, but my reasoning for iu was mental not physical. That's why I'm not as worried about it.

I understand but your C/P's you listed is really focusing on your "physical" attributes and the inability to drive in a car for long periods of a time, sit, etc...That is physical - I understand you wren't worried about the UI for them but thought I would provide my opinion since you were asking...

I hope the outcome is a good one my fellow solider!

[brokensoldier244th]

Very true. Good point. Thanks!

CAS

[brokensoldier244th]

Prep for decision. The RO has my physical and mental results already.

And a long weekend.

And with my In laws all weekend, too.

[brokensoldier244th]

Looking over what MyHealth has, I guess I have a Beck score of 41, whatever that means in the whole thing. My actual C/P notes are not there yet, though.

[brokensoldier244th]

C&P mental notes

Beck score 41, Notes from C&P below

Source: VA

Last Updated: 25 May 2015 @ 2301

Sorted By: Date/Time (Descending)

VA Notes from January 1, 2013 forward are available 3 calendar days after

they have been completed and signed by all required members of your VA

health care team. If you have any questions about your information please

visit the FAQs or contact your VA health care team.

=========================================================================

Date/Time: 20 May 2015 @ 1054

Date/Time Signed: 20 May 2015 @ 1054

-------------------------------------------------------------------------

LOCAL TITLE: MENTAL HEALTH DIAGNOSTIC STUDY NOTE

STANDARD TITLE: MENTAL HEALTH DIAGNOSTIC STUDY NOTE

DATE OF NOTE: MAY 20, 2015@10:54:12 ENTRY DATE: MAY 20, 2015@10:54:12

.

Beck Depression Inventory--Second Edition

Date Given: 05/20/2015

Location: L/C&p Local Ro Psy-Review-X

Veteran: S

DOB: Nov (38)

Gender: Male

BDI2 Score: 41 indicates severe depression. The overall range is 0 to 63

with severe depression above 29.

Questions and answers

1. I am sad all the time (2 points)

2. I do not expect things to work out for me (2 points)

3. I feel I am a total failure as a person (3 points)

4. I get very little pleasure from the things I used to enjoy (2 points)

5. I feel quite guilty most of the time (2 points)

6. I don't feel I am being punished (0 point)

7. I am disappointed in myself (2 points)

8. I blame myself for everything bad that happens (3 points)

9. I don't have any thoughts of killing myself (0 point)

10. I cry more than I used to (1 point)

11. I am no more restless or wound up than usual (0 point)

12. It's hard to get interested in anything (3 points)

13. I have much greater difficulty in making decisions than I used to (2

points)

14. I feel more worthless as compared to other people (2 points)

15. I don't have enough energy to do very much (2 points)

16. I sleep a lot more than usual (2 points)

17. I am irritable all the time (3 points)

18. My appetite is much greater than usual (2 points)

19. I find I can't concentrate on anything (3 points)

20. I am too tired or fatigued to do most of the things I used to do (3 points)

21. I am much less interested in sex now (2 points)

Second Edition (BDI-II). Copyright © 1996 Aaron T. Beck. Reproduced,

adapted and translated with permission of Publisher NCS Pearson, Inc. All

rights reserved.

Information contained in this note is based on a self-report assessment

and is not sufficient to use alone for diagnostic purposes. Assessment results

should be verified for accuracy and used in conjunction with other diagnostic

activities and procedures.

-------------------------------------------------------------------------

=========================================================================

Date/Time: 20 May 2015 @ 1000

Note Title: C&P MENTAL DISORDERS

Location: VA CENTRAL PLAINS HEALTH NETWORK - OMAHA DIVISION

Date/Time Signed: 21 May 2015 @ 1837

-------------------------------------------------------------------------

LOCAL TITLE: C&P MENTAL DISORDERS

STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT

DATE OF NOTE: MAY 20, 2015@10:00 ENTRY DATE: MAY 21, 2015@18:37:07

AUTHOR: AMES H EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Mental Disorders

(other than PTSD and Eating Disorders)

Disability Benefits Questionnaire

Name of patient/Veteran:

SECTION I:

----------

1. Diagnosis

------------

a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes[ ] No

ICD code: 296.23

If the Veteran currently has one or more mental disorders that conform to

DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Major Depressive Disorder, Severe without

psychosis

ICD code: 296.23

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

Mental Health Disorder (to include TBI): None

2. Differentiation of symptoms

------------------------------

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

[ ] Yes[X] No

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

[ ] Yes[ ] No[X] Not shown in records reviewed

3. 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] Total occupational and social impairment

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[ ] No[X] No other mental disorder has been diagnosed

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[ ] No[X] No diagnosis of TBI

SECTION II:

-----------

Clinical Findings:

------------------

1. Evidence review

------------------

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:

The VBMS fiel whihc is the electronic claims file is reviewed.

b. Was pertinent information from collateral sources reviewed?

[X] Yes[ ] No

If yes, describe:

Statement from Veteran's Wife - Buddy Statement.

2. History

----------

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

post-military):

The veteran is married to Kolette to whom he has been married for 16

years. They have four children: Trevelian (15); Briallen (12);

Rowen (11); and Haevyn (6). The veteran has special time with Haevyn

in

the evening. His oldest child is now going to movies wiht her friends.

His wife is a theatre manager and "we dont see each other a whole

lot.... I am on FMLA leave until they terminate me."

The veteran stated that he has been at home for the past 3 months on

FMLA. he has had a hard time getting motivated to do dishes, cleaning

in house, etc. The veteran stated that his wife and he have a white

board, for his to do list and to schedule his time.

The veteran will wear his clothes many days in a row. He may cook

simple meals such as boiling noods or cooking pizza rolls, or frozen

pizzas. His shopping lists are random and non directed.

The veteran stated that he has one friend who has "bipolary type

issues", but other than that he does not have any one with whom he

associates with.

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

and

post-military):

For the past few years the veteran has worked for a health care

solutions provider such as RFID and WiFi Tagging (Arrow Scout Product).

The veteran has been doing basic door locks and wires, and now had to

step away from the work. Teh veteran stated that he is getting spacy

and

"things that I should know... command line stuff... and basic

communication is not consistent with good professional business... the

days I am on I am on but days I am off it's off... they cant isolate me

from others... I have a long list of absences such as 38 times last

year....". The veteran is on FMLA. The veteran has applied at other

businesses in town "but because of reference and performance issues...

requirements I come here weekly... the places say that while we would

like to hire you you have these issues...". The veteran stated that he

has been in trouble for markedly irritability and outbursts of anger

with others at work. Many times trainees ask for others to teach them,

although he is an expert on certain systems.

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

family mental health (pre-military, military, and post-military):

The veteran is seeing Dr. Fl about one time per week. However, in

the past three weeks veteran missed an appointment as he was not

feeling

well, Dr. Fl had to reschedule due to life circumstances, and

then

they are coordinating now for the next appointment.

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

post-military):

None.

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

post-military):

None reported.

f. Other, if any:

I have reviewed the record by Stanley M of Stanely Healthcare.

Customer compaints are noted for sarcastic outburts, lapses in

concentration on a daily basis, he is an emoitonal roler coaster at

work

and lacks the subtle socal skills. He is an extrem liability with the

client base of hopsitals and elder care facilities.

3. Symptoms

-----------

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

Veteran's diagnoses:

[X] Depressed mood

[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] Di

fficulty in adapting to stressful circumstances, including work or a

worklike setting

[X] Inability to establish and maintain effective relationships

[X] Neglect of personal appearance and hygiene

[X] Intermittent inability to perform activities of daily living,

including maintenance of minimal personal hygiene

Behavioral observations:

N/A

4. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[ ] Yes[X] No

5. Competency

-------------

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

[X] Yes[ ] No

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

---------------------------------------------------

DBQ PSYCH Mental disorders:

Please review the Veteran's electronic folder in VBMS and state that it was

reviewed in your report.

The Veteran is service connected for major depressive disorder (claimed as

depression and chronic pain) which is currently evaluated at 70%. Please

evaluate for the current level of severity of the Veteran's service

connected disability. If the diagnosis rendered is different from the

disability for which the Veteran is service connected, please indicate

whether the Veteran's current diagnosis is a progression of the service

connected disability or the original diagnosis was in error.

***Please comment on the effect of the Veteran's service connected

disabilities on his or her ability to function in an occupational

environment and describe any identified functional limitations. Please

refrain from opining on if the veteran is unemployable or employable;

instead focus and reflect on the functional impairments and how these

impairments impacts occupational and employment activities.

.............................................................................

.............................................................................

............................

SUMMARY: The VBMS file is reviewed.

The veteran is seen today for current serverity of service related Major

Depressive Disorder. the veteran's MDD is severe. He is involved with

psychiatric intervention with two medications as well as intervetion with

Dr.

F to address the psychotherapeutic aspects of his mental disorder. I

have reviewed the veteran's statment from his employer as well as his wife's

letter. The veteran's MDD would lead to Total Social and Occupational

functioning impairment. The veteran's functional restrictions are:

Functional Restrictions due to service related MDD:

Shopping: Moderate

Hygiene: Severe

Cooking: Moderate

Driving: Moderate

Cleaning: Severe

Toileting: None

Dressing: None

Edited May 26, 2015 by brokensoldier244th