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Please Provide And Opinion On This C & P Exam

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Jaydog

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I just received a copy of my C & P exam. It only took 20 days. I will post an edited copy of it and any feedback would be great also I noticed an error about the dates. I will Highlight the error. Now how would I go about getting that fixed ?

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LOCAL TITLE: C&P PTSD
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
DATE OF NOTE: JUL 08, 2015@10:00 ENTRY DATE: JUL 29, 2015@18:07:05
AUTHOR: XXXXXXXXXx EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
Name of patient/Veteran:xxxxxxx
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
CONFIDENTIAL Page 5 of 54
[ ] Yes [X] No
If no diagnosis of PTSD, check all that apply:
[X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria
[X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire:
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Major Depressive Disorder, Recurrent, Moderate ICD code: 292.32
Comments, if any:
Although Veteran has been treated for Bipolar II disorder, his
long hours of work are more conceputalized as avoidance rather than
hyperproductivity during those hours at work. Veteran does express
chronic irritability toward self and others. He denied other
hypomanic behaviors that met criteria for Bipolar II disorder at
the present time.
Mental Disorder Diagnosis #2: Other Specified Anxiety Disorder
ICD code: 300.09
Comments, if any:
Subthreshold for features of Social Anxiety Disorder and Other
Stressor Related Disorder. Please see "remarks" section below for further detail.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): N/A
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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these diagnoses:
Pervasive feelings of shame, negative view of self, passive
suicidal ideation without intent, anhedonia, isolation, anergia,
absent libido are more accounted for by Major Depressive Disorder.
Avoidance of social contact and relationships were reportedly
related to negative views of self, and negative self-appraisal.
Anxiety symptoms were reportedly largely related to interpersonal
relationships.
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 due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms controlled by medication
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
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
------------------
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?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
If no, check all records reviewed:
[X] Military service treatment records
[X] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[X] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatmentrecords)
[X] 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?
[ ] Yes [X] No
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and post-military):
was born and raised in northern California, although
relocated frequently as his father served in the U.S. Coast Guard. He
is the 3rd of 2 brothers and 2 sisters and grew up in an intact family.
Veteran denied social or behavioral problems during development, was
social and made friends, and denied any history of childhood physical,
sexual, or emotional abuse or any exposure to violence in the home. He
enlisted in the military at age 18, serving from 1994-1996 when he was
discharged due to failed alcohol rehabilitation; discharge status was
honorable. Mr. xxxx reported continued problems related to alcohol
use and worked sporadic jobs after discharge. In 2005, he married his 1st
wife and had two children who are now 11 and 10 years old. He and
ex-wife divorced in 2006, and he last had any contact with his
children approximately 1.5 years ago. He married again in 2011 and has 1 child
age 3 y/o. He and his wife moved to xxxxxxx approximately 2 years
ago for a job transfer for him to manage a dealership in xxxxx. He
reported challenges with his wife, as he stated being emotionally shut
down with her, about which he feels very guilty. He denied any intimate
partner violence in his current marriage.
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
xxxxxx completed high school and attended some college. While in the
military, he worked as a mechanic and after discharge, worked in
various jobs. Most recently he has been working as a sales manager at a
car dealership in xxxxxxx, and stated that he works approximately 13
hours per day, 6 days a week, "to avoid going home." He reported
feeling that his work provides a place for him to focus on tasks,
though he acknowledged that it is not service of productivity as much
as it serves his avoidance.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
xxxxxxx denied any mental health treatment prior to the military,
although VA progress notes indicate that he reported onset of
depressive symptoms at age 13 (see notes MH-Medication Management by
, MD on 5/1/08 and MH Biopsychosocial signed by J Leif
on 6/26/08). During the military, after his DUI and
continued alcohol use, he reported to be referred to an Alcohol and
Drug Program "for a few weeks" that included some group and individual
sessions, though he reported not receiving much benefit. After the
military, xxxxxxxx was hospitalized once in 2005 for suicide attempt
by drug overdose and multiple times in 2006 for suicidal ideation in
the context of alcohol use. He was treated in the community at xxxxx
xxxxxxxxxxxx CDDP and outpatient treatment. VA medical records
indicate sporadic and minimal engagement, first presenting to VANCHCS in 1999 (2
visits), 2003 (1 visit); he engaged in medication management visits
2008-2013 for the treatment of depression by xxxxxxxx at VANCHCS.
He relocated to xxxxxxx in 2013 and started being treated by
xxxxxxxxxxxxxxx, NP on 10/16/2013 for bipolar II disorder. His current
psychiatric medication regimen includes quetiapine 50 mg, gabapentin
100 mg, sertraline 100 mg, and buspar 5 mg. On 8/6/2014, he disclosed
to xxxxxxx and his treatment was adjusted to
include PTSD 2/2 MST. This disclosure precipitated his submitted
statement for service connection for PTSD due to MST dated 8/21/2014,
after 1st denial of claim for depression/anxiety on 8/23/2013 and his
notice of disagreement on 9/10/2013. He attended a screening and 1
group appointment for men with MST support, but has not received
psychotherapy for mental health problems since the mid-1990s
when he was being treated for alcohol abuse and attending AA. He
reported to continue to be abstinent from alcohol
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
Prior to the military, Veteran went to juvenile hall for being drunk in
public. During the military, Veteran denied any demotions or Article15s.
Veteran was arrested in 1995 for domestic violence against his wife ( The date is wrong it was 2004 ) He denied current problems with behavioral violence or legal issues.
e. Relevant Substance abuse history (pre-military, military, and post-military):
Mr. xxxx reported use of alcohol 1x when 15 y/o and was arrested for
being drunk in public. He denied drinking again until he was in the
service and began drinking heaviily while in the service. He reported
having one "wet reckless" detainment as he was driving wet but under
the BAC limit, and received 1 DUI in 1996. He reported drinking heavily
"off and on" from 1996 - 2008. He reported attending AA and has a
sponsor; last drink was reportedly July 15, 2008. He reported being in
contact with his sponsor by phone. He denied current use of nicotine,
marijuana, cocaine, opiates, hallucinogens or other illicit substances.
f. Other, if any:
No response provided.
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: Edited
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
[ ] Yes [X] No
Is the stressor related to the Veteran's fear of hostile military or terrorist activity?
[ ] Yes [X] No
Is the stressor related to personal assault, e.g. military sexual trauma?
[X] Yes [ ] No
If yes, please describe the markers that may substantiate the stressor.
It is at least as likely as not that the stressor occurred.
Veteran attributes increase in quantity and frequency of drinking
and disturbed self-image after this incident, although that is
unclear, as he reportedly had been drinking even prior to this
incident. Veteran stated in his statement of disagreement with
denial of claim for depression/anxiety on 9/10/2013: "I will not
say it was one single event that happened during my time in
service. It was a series of experiences that happened during my
service... I still have a very hard time when ever I hear
helicopters and smell diesel fuel exhaust." When queried in
the exam interview about the "series of experiences" that
he found to be distressing, he reported that antagonistic harassment by
superiors related to alcohol rehabilitation contributed to his
distress. The intrusive reminders of diesel exhaust and
helicopters are not consistent with the MST and the experience
of antagonism by his superiors do not meet criterion A for PTSD.
Clinical symptoms appear to be more consistent with major
depressive disorder with strong anxiety features contributing to
avoidance. Please see "Remarks" below for further results from
the examination.
4. PTSD Diagnostic Criteria
---------------------------
No response provided
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Suicidal ideation
6. Behavioral Observations
--------------------------
Appearance and Behavior: A&Ox4, appeared stated age, casually
dressed/groomed, avoidant eye contact, clammy palms consistent with
presentation of anxiety, cooperative with interview, polite, did not require redirection.
Motor Activity:
No PMA/PMR, no abnormal movements
Speech: regular rate and rhythm, normal prosody and tone
Mood: Anxious, dysphoric
Affect: congruent with content, restricted range of affect
Thought Process: linear, goal oriented
Thought Content: the patient reported passive suicidal/homicidal ideation,
but denies intent. No evidence of psychosis, mania, or other formal thought disorder.
Perception: No evidence of auditory/visual hallucinations.
Insight/Judgment: limited/limited; intact/intact
7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
xxxxxxxxx was examined via clinical interview and the gold-standard
Clinician-Administered PTSD Scale (CAPS-5), and self-report measures via
Minnesota Multiphasic Personality Inventory (2nd edition; MMPI-II),
Millon Clinical Multiaxial Inventory (3rd edition; MCMI-III), Beck Depression
Inventory (2nd edition; BDI-II), Alcohol Use Disorders Identification
Test (AUDIT), and Life Events Checklist (LEC). In addition to this examiner,
with the patient's verbal consent, another licensed psychologist
observed the
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It looks to me that it will not be granted SC due to Docs statement. You may have to get and IMO to submit as evidence, but if somehow you are granted it would be in the 30-50% range. Good luck

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  • HadIt.com Elder

Probably the Severe Depressive Disorders, Specific Anxiety Disorder, should warrant a 10% to30% rating.

PTSD Denied.

but this is just my opinion, you could be rated at a higher rating.

don't give up, if your denied , copy & paste the reasons & basis for the decision (cover all personal infor name and SS Number Address)

You can Appeal the decision if you disagree with it.

jmo

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

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I agree, go and get an IMO/IME. It costs money up front.

Sign a sworn declaration along with a copy of the police report stating that the arrest was in 2004 and not 1995.

Was there anything else in this Exam that you disagree with, was there something you said that was not indicated or the opposite was indicated? If so make sure the IMO/IME report/dbq reflects this.

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How would this be rated, any input appreciated

4. PTSD Diagnostic Criteria

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

Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria

for PTSD, referred to as Criteria A-H, are from the Diagnostic and

Statistical Manual of Mental Disorders, 5th edition (DSM-5).

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] 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 distressing dreams in which the content and/or affect of

the dream are related to 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.

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] Reckless or self-destructive behavior.

[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] Duration of the disturbance (Criteria B, C, D, and E) is more than

1 month.

Criterion G:

[X] The disturbance causes 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.

Criterion I: Which stressor(s) contributed to the Veteran's PTSD

diagnosis?:

[X] Stressor #1

5. Symptoms

-----------

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

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[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] 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] Impaired impulse control, such as unprovoked irritability with

periods of violence

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