ptsd Nervous about C&P Exam Notes

[H0ckeyPhreak]

Hey HadIt! Long time lurker, first time poster. I got my PTSD C&P notes yesterday off of myHealtheVet and from what everyone had said on others before on here, it sounds like 50%; however, I thought I'd ask you all about your interpretation. The other question I had was, is it normal for the examiner *NOT* to review your C-File? Thanks in advance for your help!

 

 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: F43.10

 2. Current Diagnoses
-------------------a.
Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder
ICD code: F43.10

Mental Disorder Diagnosis #2: Major Depressive Disorder, Recurrent,
Moderate
ICD code: F33.1

 b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
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:

 PTSD symptoms are outlined elsewhere. Symptoms of depression
include sadness, diminished interest and pleasure, decreased

energy
and motivation, frequent crying, sense of failure, and morbid
thinking.

 c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] 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 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?
[X] Yes [ ] No [ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and

 social impairment is attributable to each diagnosis:
Social and occupational impairment are attributed to symptoms of
PTSD.

 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?
No response provided.

 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

 [X] Military service personnel records
[ ] Military enlistment examination
[X] Military separation examination
[ ] Military post-deployment questionnaire
[X] 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
[ ] Other:

 b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
 
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: rocket and mortar attack (Iraq, 2004)
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?

 [X] Yes [ ] No
Is the stressor related to personal assault, e.g. military sexual
trauma?
[ ] Yes [X] No

b. Stressor #2: witnessing assault and killing of servicemember by another
servicemember ( Qatar, 2007)
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:
Veteran reported witnessing one military servicemember assault
with a knife and kill another military servicemember while in
military R&R compound in Qatar (2007). This traumatic event

was
not related to hostile military or terrorist activity but was
directly related to active duty military service.

 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] 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] 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
[X] Stressor #2
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 more than once a week
[X] Chronic sleep impairment
[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
[X] Obsessional rituals which interfere with routine activities
6. Behavioral Observations
-------------------------Veteran
arrived on time and looked clean, neat, and appropriately dressed.
He was alert and fully oriented. Veteran maintained adequate eye contact
during exam. His mood was anxious and depressed. His affect was congruent.
Veteran was observed to be tearful and visibly anxious when recounting

traumatic events during the exam. His speech was clear and coherent. His
thoughts were linear with evidence of hypervigilance bordering on paranoia

at
times. Veteran also reported a history of auditory hallucinations (hearing
voices in his house) but none on this date. Veteran denied past or current

 suicidal or homicidal ideation, plan, or intent.

 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:
Veteran also suffers from sensitivity to light and noise that he
attributed to hearing problems. Although he may have a medical
condition (evaluation for such deferred to audiology and/or MD),
this sensitivity may also be related to low frustration tolerance
and general irritability/anger consistent with PTSD. In addition,
Veteran reported other distressing perceptual problems including
psychotic like symptoms (paranoia, hearing voices in his house,
etc) for which he is currently being treated with anti-psychotic
medication. He denied visual or command hallucinations.

 8. Competency
------------Is
the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No

[bluevet]

This looks like a 70% rating to me. You may get 50% from whomever rates you, but an appeal would probably net 70% based on the symptoms checked.

If you are already service connected, or if you have a diagnosis of PTSD and the VA has already found evidence of a stressor on your DD-214 or in your 201 file, then the VA will not necessarily seek an opinion on service connection from the C&P examiner. In such a case, the VA is only seeking a picture of your current level of disability caused by your claimed condition. 

C&P examiners provide 2 distinct services to the VA.

1. An M.E. (Medical Examination)

2. An M.O. (Medical Opinion)

The VA can request one or both of these from a C&P examiner. If the VA is not seeking an M.O. regarding service connection from the examiner, then a review of your c-file would not be necessary.

Was this exam done at the VA or was it a contracted doctor ? Are you already service connected?

Edited September 8, 2015 by bluevet

[H0ckeyPhreak]

This looks like a 70% rating to me. You may get 50% from whomever rates you, but an appeal would probably net 70% based on the symptoms checked.

If you are already service connected, or if you have a diagnosis of PTSD and the VA has already found evidence of a stressor on your DD-214 or in your 201 file, then the VA will not necessarily seek an opinion on service connection from the C&P examiner. In such a case, the VA is only seeking a picture of your current level of disability caused by your claimed condition. 

C&P examiners provide 2 distinct services to the VA.

1. An M.E. (Medical Examination)

2. An M.O. (Medical Opinion)

The VA can request one or both of these from a C&P examiner. If the VA is not seeking an M.O. regarding service connection from the examiner, then a review of your c-file would not be necessary.

Was this exam done at the VA or was it a contracted doctor ? Are you already service connected?

Thanks bluevet for the breakdown. The C&P was done at the VA and no, I'm not already service connected. This is my first experience with the VA.

[bluevet]

Thanks bluevet for the breakdown. The C&P was done at the VA and no, I'm not already service connected. This is my first experience with the VA.

 Where the doctor indicated he had not reviewed your claims file, it is asking specifically about a hard paper copy of the file. Since he indicates that he did review your "Military service personnel records, Military separation examination, and your Department of Defense Form 214 Separation Documents, I assume that he had access to your electronic claims file. Everything here looks OK to me. Again, if you receive anything less than 70%, I would appeal. 

Edited September 8, 2015 by bluevet

[Gastone]

Back in 11, after reviewing my PTSD DBQ, I thought I was a 30 Firm with a possible 50 lite, awarded 70% firm, so what do I know. You'll know soon enough.

I had a CAD, SA & PH C & P today and the VA Dr was really having a difficult time. In my 05/15 FDC I advised the Rating Dept that all my supporting medical evidence was with the Det VAMC and wanted to go the "Quick Decision" route. The C&P was held at the Det VAMC. The staff Dr said he couldn't access my VAMC medical records and hadn't reviewed my C-file.

We spent about 15 min of me dictating my conditions and DX dates and Dr's names. I asked if he wanted me to Fax or Email any certain documents. He said as soon as I walk out the door, he hits the button and the C&P DBQ, incomplete as it was, is sent to the Detroit RO Rating Dept. I think my FDC is about to turn into a Reg Axx Claim.

 

Semper Fi

[Matthew Hill]

I agree with bluevet about the rating: it should be 70%.  But first you need to make sure that they grant service connection.  Once you get that then you need to appeal if you do not get 70%.  Also, if you are not working, or working and making less than $12,000/yr, then you need to consider applying for IU.  The doctor indicated some severe symptoms that would interfere with your ability to work

[SemperAye]

Agreed should be 70%