ptsd PTSD C&P Exam Result

[M1A2Tanker]

Hello Veterans,

I'd like to thank everyone here for your service.  This is my first posting I've ever done here.  I've followed here closely and want to thank everyone for their discussions.  I finished my C&P exam and was wanting to see what everyone thought my outcome may be.  It's been a long road as I'm sure it's been for most.  This site has been such a help to so many veterans.

Id really appreciate your thoughts.

Thank you.


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: Post Traumatic Stress Disorder
           ICD code: F43.10

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): Chronic back pain from military
       injury
         ICD code: See medical books

    3. 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
       
    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?
       [ ] 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
        [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
    
        
    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
       post-military):
          Pre-Military:  

          Military:
          

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

          Military:  
           
          
          
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          Pre-Military:  None

          Military:  None

          Post-Military:  None
          
          
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          Pre-Military:  None

          Military:  Drank alcohol, but no problems with alcohol.

          Post-Military:  Doesn't drink alcohol at all; no illicit drug use.
          
          
    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

          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:
          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
          
    c. Stressor #3: Please See Section II.2. (3), Mental Health, Military 
Section
          for additional stressors.
          
          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
          
    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
          [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, 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 negative emotional state (e.g., fear, horror, anger,
              guilt, or shame).
          [X] Markedly diminished interest or participation in significant
              activities.

       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] Hypervigilance.
          [X] Exaggerated startle response.
          [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
          [X] Stressor #3
          [X] Other, please indicate stressor number (i.e., Stressor #4, #5,
              etc.) as indicated above:

    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Depressed mood
       [X] Anxiety
       [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] 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] Suicidal ideation
       [X] Neglect of personal appearance and hygiene

    6. Behavioral Observations
    --------------------------
    The Veteran was on time for the scheduled appointment, and he was 
cooperative
    and very pleasant throughout the interview. His grooming and hygiene were
    good, and he was dressed in casual attire, which was appropriate for the
    setting.  The veteran's mood appeared to be mildly dysthymnic.  His affect
    was mood congruent.  His psychomotor activity level was within normal 
limits.
    His receptive and expressive language were within normal limits.  His 
thought
    processes appeared to be logical and goal directed.  His reality testing was
    good.  He denied having delusions or hallucinations.  His intellectual
    functioning appeared to be within the above-average range. His insight 
seemed
    to be good. His judgment seemed to be good. He denied having suicidal or
    homicidal ideations, and there were no safety concerns present at the time 
of
    this interview.

    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
    --------------------------------------------------
       The Veteran DOES meet DSM-5 diagnostic criteria for Post Traumatic Stress
       Disorder.  It is more likely than not (greater than 75%) his PTSD is due
       to his military service (please see the Military section of Section 
II.2.3
       for a list of traumatic experiences the Veteran had while in Kuwait).  Veteran, as stated earlier, he had numeroud stressors that qualify as
       trauma according to DSM-5 and which indeed are realted to his PTSD
       diagnosis.
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

[allan1351]

Hey Tanker

I would go with 30 to 50%....probably 50%.......Good luck and have a great day....Allan

[Gastone]

Was this from a PTSD FDC? If so, you should get a definitive rating soon.

When I compared my 2010 C&P PTSD DBQ to the 38 CFR 4, I was certain I met the 30 with a possibility of a 50, was awarded a 70.

Looks like you'll end up 80 to 90SC. Nice little Retro (how long has claim been in) for Christmas or New Year.

Semper Fi

Semper Fi

[M1A2Tanker]

Thank you both for your thoughts.  Claim was started in March 2015, and FDC completed in Sep.  Hoping to hear back soon.  Is there a place I can look when it's finalized before their mail goes out?

Thanks again.  Merry Christmas.

[Buck52]

What about the part when ask does the veteran have any more disability's that contribute to PTSD?

if the veteran has depressive symptoms that should be related as another diagnoses to PTSD

  For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
   
       [X] Depressed mood
       [X] Anxiety
       [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] 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] Suicidal ideation
       [X] Neglect of personal appearance and hygiene

 

I would guess that being he has good Hygiene   then  70% rating is what I'd expect. as what the examiner mention in this report.

 

jmo

 

........Buck

 

[Navy04]

Glad to see you made it thru the exam bud. It looks like you will be granted 50-70% minimum. Good luck and keep us posted, God Bless