Diagnoses left out on C&P Please Provide And Opinion On This C & P Exam

[Markay2k]

Ok so I have listed my VA Problem list first so you can see that the PTSD C&P notes left out the other mental health problems.   My question is what should I do about it? Also stressor #2 is nothing I said or added.  I did have more than one stressor and they are not mentioned.  There are a total of 3 stressors.    Below this list of VA PROBLEMS is the results from my PTSD C&P results.  PLEASE ADVISE.

Thank You.

 

VA Problem List

Source: VA

Last Updated: Sorted By: Date/Time Entered (Descending) then alphabetically by Problem

Your VA Problem List contains active health problems your VA providers are helping you to manage.

This information is available 3 calendar days after it has been entered. It may not contain active

problems managed by non-VA health care providers. If you have any questions about your information,

visit the FAQs or contact your VA health care team.

Problem: Anxiety Disorder (ICD-9-CM 300.00)

Provider:

DIVISION

Status: ACTIVE

Comments: per DSM-5, unspecified anxiety disorder

Problem: Depressive Disorder NOS (ICD-9-CM

311.)

Provider:

Location:

Status: ACTIVE

Comments: per DSM-5, unspecified depressive disorder

Problem: Nightmares (SCT 419145002)

Provider

Status: ACTIVE

Comments: --

 

Note

*******************************************

********************************************

LOCAL TITLE: COMP AND PEN NOTE

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: 

AUTHOR EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran:

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to

prepare the DBQ and such an examination will likely provide no

additional

relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

 

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

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

Was the Veteran's VA claims file reviewed? No

If no, check all records reviewed:

[X] Other:

CPRS and VBMS

 

MEDICAL OPINION SUMMARY

RESTATEMENT OF REQUESTED OPINION:

 

a. Opinion from general remarks: does veteran suffer from Post Traumatic

Stress Disorder, and if so, does it appear to be service connected

b. Indicate type of exam for which opinion has been requested: DBQ Initial

PTSD and DBQ Medical Opinion

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

a. The condition claimed was at least as likely as not (50% or greater

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: based upon clinical interview; review of records; application

of DSM V criteria; clinical experience and expertise

************************************************************************

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

Name of patient/Veteran:

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD

ICD code: 309.81

Comments, if any:

previously diagnosed with disorders comprising the symptoms of

PTSD

Mental Disorder Diagnosis #2: Opioid Dependence (in remission)

ICD code: 304.01

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

Mental Health Disorder (to include TBI): see medical chart

ICD code: see medical chart

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:

all symptoms seem to be related to his PTSD

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 [ ] 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

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

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:

[ ] 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

[ ] 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:

VBMS and CPRS

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):

see reports dated 10/23/00 and 4/11/15 for details

no significant changes since 4/11/15; does not describe father's

death

as a major trauma due to veteran's age at the time and lack of

full

awareness of impact

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

and

post-military):

see reports dated 10/23/00 and 4/11/15 for details as well as

Stetments

in Support of Claim contained in VBMS to saccounts of military traumas

and experiences

good student at Watertown High School; attended college Barton

Community College and Monroe Commun

ity College-Associates Degrees or

certificates from both schools.

following military, has worked in HVAC and is currently a Territory

Manager for a local company.

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

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

has been seen by Dr. Barry and receives escitalopram and prazosin;

medication recently started and veteran does not know if they are

effective.

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

post-military):

arrested for DWI in 2000 prior to treatment; served six months in

Livingston County Correctional Facility

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

post-military):

see reports dated 10/23/00 and 4/11/15 for details

was seen in residential ETOH treatment at Canandaigua in 2000 for 28

days; has been sober since; no use of illicit drugs, although he was

addicted to opiates which were prescribed to him. Is now on suboxone

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: military experiecnes as set forth above in previous reports

and Statement in Support of Claim

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] 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?

[ ] Yes [X] No

b. Stressor #2: deaht of father from heart related illness

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

Is the stressor related to the Veteran's fear of hostile military

or

terrorist activity?

[ ] Yes [X] No

If no, explain:

civilian/familial situation

Is the stressor related to personal assault, e.g. military sexual

trauma?

[ ] Yes [X] No

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] Witnessing, in person, the traumatic event(s) as they occurred to

others

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] 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 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] 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] Panic attacks that occur weekly or less often

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent

events

[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] Inability to establish and maintain effective relationships

6. Behavioral Observations

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

demure; quiet; reserved

7. Other symptoms

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

Does the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

 [X] Yes [ ] No

If yes, describe:

cannot recite serial sevens or recite months of year correctly;

consistently recalls seven digits forward; can spell selected word

forward and backward; recalls two of three items after five

minutes; recalls four of the last five presidents, though nor in

correct order.

8. Competency

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

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

[X] Yes [ ] No

9. Remarks, (including any testing results) if any

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

it is much more likely than not that veteran's military experiences

are

the critical stressors that underlie his PTSD and therefore his PTSD

would

seem much more likely than not to be service connected

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran's

application.

 

Thanks Everyone. 

 

 

[Berta]

This is an odd C & P to me, because the main stressor is not clearly defined 

. "Stressor #1: military experiecnes as set forth above in previous reports

 

and Statement in Support of Claim"

Do you have proof of those stressors--- at least proof of one of them?

The  examiner did give the 'more than likely statement' but has VA asked for any proof yet?

 

 

[Navy04]

I don't know exactly what you are asking, as it appears to be a well documented symptoms exam. Looks like you will get 30-50% granted for PTSD and SC. Good luck and keep us posted.

[Markay2k]

Berta, yes I have proof and did submit it to my MH doctors.   One MH doctor did a full write up in my medical records.  I also submitted letters from my X and current wife as well as my own for all 3 stressors.  

 

Navy04,  The question I was asking is the C&P exam left out the top section on my VA problems list, the other conditions.  Will the person who rates for SC see this as it is to on the C&P?

Thank You.

[bluevet]

 

Navy04, the C&P examiner states that he reviewed your CPRS and VBMS files. CPRS is your electronic VA medical records and VBMS is your paperless claims file. This means that the doctor had access to your VA problems list.  The good news is that he has pretty much guaranteed you service connection. He lowballed you on his opinion of your level of impairment, but the symptoms list suggests a much higher rating.  There's a good chance that you'll get a pretty good rating with this DBQ  and you always have a DRO review to fall back on if you're not happy. If it were me, I would not do anything to call this DBQ into question. It has issues with insufficient rationals, but if the VA doesn't notice them, I would get my service connection and initial rating, then deal with getting increased if necessary. Hope this helps. 

Edited August 19, 2015 by bluevet

[Markay2k]

Bluevet,  What do you mean by this sentence? “He lowballed you on his opinion of your level of impairment, but the symptoms list suggests a much higher rating."

 

 

[pwrslm]

lowball is where they downplay the severity of the condition and give you a rating that does not reflect the level of disability in accordance with the code