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wablackwell

Finally got my C&P rsults

Question

Hell0, I had a C&P Exam on 18 October, I finally got results. Would mind giving me your opinion on the exam.

Date/Time:               18 Oct 2016 @ 0900
Note Title:              C&P PTSD, INITIAL EVALUATION
Location:                EL PASO VA HEALTHCARE SYSTEM
Signed By:               HENDRY,KARA MATILE
Co-signed By:            HENDRY,KARA MATILE
Date/Time Signed:        01 Nov 2016 @ 0831
-------------------------------------------------------------------------

 LOCAL TITLE: C&P PTSD, INITIAL EVALUATION                       
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT         
DATE OF NOTE: OCT 18, 2016@09:00     ENTRY DATE: NOV 01, 2016@08:31:17      
      AUTHOR: Lastname,First name   EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     


                  Initial Post Traumatic Stress Disorder (PTSD)
                        Disability Benefits Questionnaire
                         * Internal VA or DoD Use Only *

    Name of patient/Veteran:  MY Name
    
                                   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  with 
delayed
       expression
           ICD code: F43.10

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): irritable bowel syndrome;
       enuresis; encopresis

    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] 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
    ------------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS
    [X] Other (please identify other evidence reviewed):
          JLV
          


    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
       post-military):
          The Veteran was born in San Antonio, Texas.  He has one brother and 
two
          sisters.  He was reared in Tulsa, Oklahoma and grauated from Owasso
          High School in 1988.  He reported that his father worked as a truck
          driver in the past and "was strict".  His father was later employed by
          the postal service.  He said that his mother worked for American
          Airlines in data management.

          Upon his high school graduation, Mr. Blackwell entered the Army on
          11/29/1988, per his DD 214.  His MOS was 14E30/Patriot FC Operator.
          He was discharged on 11/30/2008.    

          Mr Blackwell has been married for 25 years, and he and his wife have
          two children, a son and a daughter.  According to the Veteran, his
          22-year-old son "never had a job, but is trying to join the Air 
Force".
          The Vereran's 15-year-old daughter, was recently caught for smoking
          marijuana.  Mr. Blackwell noted, "I set new rules, and now she gets 
OTC
          drug tested.  She has been a 'straight A' student."

          His parents are till together, and they live in Oklahoma.  Mr.
          Blackwell reported that he had an aunt with mental health difficulties
          and that she is now deceased.
          
          
    b. Relevant Occupational and Educational history (pre-military, military, 
and
       post-military):
          Regarding his educational performance history, Mr. Blackwell noted, "I
          was a 'C' student.  That's why I joined the Army."  He enlisted on
          11/29/1988, and, as mentioned above, his MOS was 14E30/Patriot FC
          Operator.

          His deployments are as follows:  

          Saudi Arabia in 1993 - Per available records, Mr. Blackwell reported
          having been deployed to this area five times.    

          Turkey in 1999

          Kuwait from 01/2003 to 06/2003

          He received multiple Army service awards, including Army Commendation
          Medals and Army Achievement Medals (among others).  On April 29, 2003,
          he received a recommendation for an award designating his service that
          "helped to maintain the battery's high readiness".

          Regarding disciplinary actions, the Veteran reported having obtained
          "maybe four to seven counseling statements", but no Article 15s.   He
          was discharged from Army active duty on November 30, 2008. 

          Following his discharge, he "tried college from 2009 to 2012, but I
          would make either 'Ws' (withdrawals) or 'Fs' (failures).  I couln't
          concentrate, and I would skip class, because I had too much anxiety."
          He worked for White Sands Missile Range as a civilian security guard
          with normal duties, until 2014, when he was placed on light duty,
          during which time "they were evaluating me for a year at a clinic on
          base."

          Subsequent to this evaluation process, per his evaluating mental 
health
          provider, on April 29, 2016, it was "determined he is not fit for 
duty.
          Mr. Blackwell has a long history of significant behavioral health
          issues which have not responded to treatment.  In addition to
          counseling he has been prescribed numerous psychotropic medications
          including Prazosin, Abilify, Paxil, Ambien, Effexor, Trazodone and
          Zoloft.  Most recently, last year, he was in an intensive 8-week VA
          inpatient treatment program for Veterans suffering from Post-Traumatic
          Stress Disorder.  While he showed some treatment gains from the
          experience, in my opinion, he remains unfit for duty."

          Since this time, the Veteran reported that he performs household
          duties, such as "making dinner, vacuuming things around the house, and
          going to weekly appointments".
          
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
          Mr. Blackwell reported, "During the military, I had feelings like
          sadness, depression, and anxiety, but I held it in.  It was the
          military.  You don't say anything.  I was too embarrassed to tell
          people.  When I had five years left (active duty), I did say something
          in the questionnaires, but nobody did anything."

          He continued, "I can't sleep.  I have nightmares of being attacked in
          the perimeter...scuds coming in...convoy getting attacked. I have seen
          people die in my dreams.  I have seen people get shot and died.  I 
wake
          up kicking and punching about three times a week.  I have a CPAP
          machine and Prazosin.  That's supposed to get rid of the
 nightmares."

          The Veteran's available records were not significant for much mental
          health treatment during his active duty.  Per 08/06/2013 note, Mr.
          Blackwell was involved in "a couple of sessions while active duty in
          2002...he did not find them helpful."  At that time, there was no
          history of psychiatric hospitalizations or psychotropic medications.

          Mr. Blackwell did not report any mental health-related difficulties
          following his discharge from the Army until several years subsequent 
to
          his 11/30/2008 discharge.  For example, on a 01/21/2010 OEF/OIF note,
          the provider reported a negative PTSD screen for Mr. Blackwell (PTSD 
4Q
          score of 0).  06/22/2010 PTSD and depression screens were negative.
          There were also no reports of PTSD symptoms, such as nightmares. The
          next month (07/21/2010), he continued to deny mental health symptoms,
          though he also reported difficulties with sleep.  In 2011, a note
          reported that "all was going well".   As mentioned, the Veteran was in
          the process of attending school, which initiated in 2009 and continued
          for a couple of years, until the Veteran began to have problem with
          concentration and anxiety and was skipping school.  During today's
          evaluation, he remembered having had fear related to being in class
          groups at the time. 

          The Veteran reportedly did not seek mental health treatment during his
          time on active duty, "due to employment that keeps close watch on
          employee medical and mental health due to job responsibilities" (per
          ELP MH Intake note dated 08/06/2013).  

          According to available electronic records, on 11/24/2014, there was a
          "concern that mental status was deteriorating", and it was determined
          that Mr. Blackwell to be unfit for duty.   The next month, he was
          hospitalized at University Behavioral Health on 12/12/2014 and placed
          on new psychotropic medication.  He was discharged on 12/24/2014 with
          (relevant) diagnoses of post-traumatic stress disorder, severe major
          depressive disorder, suicidal ideation, irritable bowel syndrome, and
          pain.  

          In 2015, an ELP MH provider recommended that the Veteran attend
          inpatient PTSD services.  In 09/2015, Mr. Blackwell was admitted to 
the
          Temple Texas VAMC and received PRRC (Psychosocial Rehabilitation
          Recovery) treatment until his discharge in November (2015).  Such
          mental health stabilization treatment services included treatment via
          music therapy, among others.   

          Records were found in support of a PTSD diagnosis earlier this year,
          when on 04/13/2016, a C&P evaluator reported the Veteran had
          "continuing symptoms of PTSD".   On 09/21/2016, he was admitted to a
          third psychiatric inpatient facility (UBH/El Paso Behavioral Health)
          after he presented at the El Paso VA for services and was found to be
          "shaking" in the lobby.  He was discharged in October (2016) after a
          21-day treatment program. 

          The Veteran has had ongoing suicide risk factors during the past
          several years, which have continued to be treated with ongoing mental
          health services and inpatient psychiatric stabilization.  Risk
          assessment on 10/17/2016 reported ongoing risk, but that the Veteran
          was "stable under current circumstances".  He has been involved in
          intensive weekly individual therapy with a mental health social worker
          and is being treated via medication management, as well,  to ensure 
his
          safety and mental health stabilization.
          
          
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          Mr. Blackwell denied history of legal or behavioral difficulties, 
aside
          from some counseling statements received, while on active duty.
          Available electronic chart records are consistent with this.
          
          
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          Mr. Blackwell reported some alcohol use history, whereby "I probably
          drink once a month...three or four drinks."    He denied drug or
          tobacco use history.

          Available electronic recorcs do not dispute this.
          
          
    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: "We were in Iraq around 03/21/2003....I lost people I saw
          every day.  They got trapped in the convoy.  They took a wrong turn 
and
          went through an area they shouldn't have, and they got fired upon.  
The
          first sergeant died."
          
          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: "We mistakenly shot an American plane down.  Two British and
          one American died....I have a lot of guilt about it."
          
          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: "We got small arms fire in perimeter of April 2003.  It was
          scary...I thought I was going to die that night."
          
          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
          
    d. Additional stressors: If additional stressors, describe (list using the
       above sequential format):
          Stressor #4:  "There were a lot of scud alerts...constant scud
          launches.  It was a scary time, because we didn't know what was going
          to happen.  I thought about my family and last wishes.  It happened
          continuously for three weeks every day.  It was a strain on the body
          and the brain."

          Does the stressor meet Criterion A?
          Yes

          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?

          Yes
          
          
    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 Criterion 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 Criterion 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 violence, 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 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).

       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).

       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] 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] Hypervigilance.
                   [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:
                         Stresso #4
                         

    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] Flattened affect
       [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

    6. Behavioral Observations
    --------------------------
    Mr. Blackwell reported to this examination in a timely manner.  Prior to
    beginning the examination, he was advised of the nature and purpose of the
    examination and the limits of confidentiality as applies to any contact with
    a mental health professional, but specifically the forensic disability
    examination.  He verbalized understanding these limitations and the fact 
that
    this particular meeting was for the purposes of the disability examination
    and not for treatment purposes. 

    He was neatly attired and appropriately groomed.  He appeared his stated 
age.
    He was oriented X3 and appeared to demonstrate grossly intact memory for
    distant and recent events.  On this date, his mood was appropriate.  His eye
    contact was appropriate.  Speech was normal.  There were no indications of
    confusion, disorientation or psychotic thinking during this interview. 

    Mr. Blackwell is estimated to be at moderate-to-high risk for suicidal
    behavior at this time.  He does have significant chronic (historical) risk
    factors noted through records review, (history of inpatient psychiatric
    admissions and history of suicide behaviors.)  He has had 3 psychiatric
    inpatient admissions (12/2014-2 weeks at UBH/El Paso Behavioral Health;
    09/20-11/12/2015 Temple Texas VA; and most recently, 09/21-10/12/2016 at
    UBH/El Paso Behavioral Health.

    His risk is higher than that of an individual without a stressor disorder 
and
    without a history of psychiatric inpatient admissions.  This level of
    severity is evidenced by the flag placed on his records subsequent to recent
    suicidal behavior.  However, there was no imminent risk during this
    evaluation, and the Veteran receives ongoing weekly counseling sessions with
    a mental health provider.  Therefore, he appears stable, at this point.

    His protective factors include connections with the VA Healthcare System,
    ongoing mental health treatment, and his family.  On this date, while he
    reported some passive suicidal ideation, he denied plan or intent. The
    Veteran underscored this by remarking, "I think about my kids and my wife...
    that stops me.  I feel hopeless sometimes, but then I think what that would
    do to my kids."

    He was advised of the resources available to veterans and active duty
    military service members, in case of a mental health crisis, such as using
    the Veteran's Crisis Line, reporting to the local Emergency Room for a
    psychiatric evaluation for inpatient care, or calling 9-1-1 in situation in
    which there is imminent danger of suicidal or homicide or if he feels he
    cannot function due to a severe escalation in symptoms.  He was provided a
    wallet card with suicide risk factors and warning signs on one side and the
    umber of the Veteran's Crisis Line on the other, and he agreed to call the

    number in case of a mental health crisis.  He reported having called this
    number about 6 weeks ago, and that he was provided helpful information when
    he called.

    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
    --------------------------------------------------
       When asked to describe his current problems and impairments, Mr. 
Blackwell
       described symptoms that are characteristic of a stressor disorder such as
       sleep related difficulties ("I can't sleep"), intrusive symptoms ("I have
       nightmares,"), marked alterations in reactivity ("I am hypervigilant"),
       persistent negative emotional state ("I have a lot of guilt").

       The MMPI-2 was administered to obtain additional information regarding 
the
       Veteran's current functioning, Results are below:

                      L   F   K   HS  D   HY  PD  MF  PA  PT  SC  MA  SI  
         Raw Score:   3  12  11   23  39  31  23  22  18  36  37  16  55
         K Corr.                   6           4          11  11   2
         T Score:    48  73  41   88  91  74  59  42  79  94  87  45  84
         ? Cannot Say (Raw): 0            F-K (Raw): 1
         Percent True: 47       Percent False: 53       Profile Elev.: 77.1
         Welsh Code (new): 72*180"63'-4/95:   F'-/LK:   unable to show ties

       The MMPI-2 "validity" scales revealed a willingness to acknowledge 
serious
       problems and symptoms, although without evidence of exaggeration or
       magnification that might suggest negative dissimulation or malingering.
       Hence, the current result were believed to be an accurate representation
       of current adjustment.

       The MMPI-2 clinical profile included multiple elevations denoting the
       presence of serious psychological and emotional disturbance.  Patients
       with this pattern would be vulnerable to even modest levels of increased
       stress that could trigger periods of more pronounced breakdown in the
       clarity of thinking and processing.  In association with unusual,
       ruminative, and disturbed thinking likely to incorporate somatic
       preoccupations and paranoid fears, persons rendering this configuration
       appear prone to high levels of anxiety and internal agitation accompanied
       by restlessness and irritability.

       The MMPI-2 pattern also underscored the presence of distress, 
unhappiness,
       and propensities for social avoidance and introversion, The somatic fears
       and preoccupations evidenced by these patients might incorporate multiple
       body systems, and often include perceived neurologic dysfunction such as
       irregular perceptions, altered states of consciousness, impaired
       processing, and defective memory.

       Mr. Blackwell endorsed several MMPI-2 critical items during today's
       evaluation. For example, he answered "TRUE" to items reading: "At times I
       have a strong urge to do something harmful or shocking," "The future 
seems
       hopeless to me," and "I have recently considered killing myself."
       During careful post-test debriefing and exploration, he stated, "My
       children keep me from doing it...I do coping skills, listen to music and
       cook.  I find ways to null and void the (suicidal) thoughts...it has not
       gone that far."

       On this date, he denied current intent to harm himself or another person,
       and he promised to seek further professional mental health treatment if
       ever having such thoughts or impulses.  He was provided with the national
       crisis hotline number (800-273-TALK).

       It is this Examiner's opinion that that Veteran is currently experiencing
       Post-traumatic Stress Disorder with delayed expression.  This diagnosis 
is
       evidenced by his treatment records, testing, and personal interview.
       PTSD, while generally occurring with several months of an incurred
       stressor, may take years to emerge.  Such situations, while not common,
       are possible.  As the Veteran noted, he did not seek mental health
       services during Army active duty, although, per his report, he had been
       experiencing mental health-related difficulties such as depression and
       anxiety.  He also has been diagnosed with medical issues, such as 
enuresis
       and encopresis, which likely increase the expression of his PTSD 
symptoms.

       As mentioned above, he is currently receiving ongoing weekly mental 
health
       counseling.  He also receives psychotropic treatment for his current
       symptoms of PTSD (such as anxiety and depression), which appear to have
       stabilized his functioning, at least for the time being.


       Notably, findings and impressions derived from a PTSD C&P Examination
       could not be used to comment on the physical aspects of functioning in 
the
       employment realm.  However, results and impressions gleaned from a PTSD
       Examination would be useful in assessing crucial mental, emotional,
       cognitive, and/or social aspects of functioning which relate to the
       capacity to perform substantial gainful employment.  Thus, in accordance
       with the results from today's evaluation, this Veteran was believed to
       possess the following work-related abilities, limitations or impairments:

       "Marked Limitation" in the work setting in the following categories:

       --The ability to perform activities within a schedule, maintain regular
       attendance, and be punctual within customary tolerances. 
       --The ability to work in coordination with or proximity to others without
       being distracted by them. 
       --The ability to complete a normal workday and work-week without
       interruptions from psychologically based symptoms and to perform at a
       consistent pace without an unreasonable number and length of rest periods. 

       --The ability to accept instructions and respond appropriately to
       criticism from supervisors. 
       --The ability to get along with coworkers or peers without distracting
       them or exhibiting behavioral extremes. 
       --The ability to set realistic work-related goals or make plans
       independently of others. 
       --The ability to respond to changes in the work setting. 

       "Moderate Limitation" in the work setting in the following categories:

       --The ability to maintain attention and concentration for extended
       periods. 
       --The ability to sustain an ordinary routine without special supervision.
       --The ability to interact appropriately with the general public 
       --The ability to understand and remember detailed instructions. 
       --The ability to carry out detailed instructions. 
       --The ability to remember location and work-like procedures. 
       --The ability to understand and remember very short and simple
       instructions. 

       "Mild Limitation" in the work setting in the following categories:
       --The ability to maintain socially appropriate behavior and to adhere to
       basic standards of neatness and cleanliness. 
       --The ability to make simple work-related decisions. 


       "No Limitation" in the work setting in the following categories:
       --The ability to be aware of normal hazards and take appropriate
       precaution
       --The ability to travel to unfamiliar places or use public 
transportation.
       --The ability to ask simple questions or request assistance. 


       
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.


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


                                 Medical Opinion
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  My Name
    
    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS
    [X] Other (please identify other evidence reviewed):
          JLV
          


    MEDICAL OPINION SUMMARY
    -----------------------
    RESTATEMENT OF REQUESTED OPINION: 

    a. Opinion from general remarks: Is it as least as likely as not (greater
    than 50 percent probability) that the Veteran's PTSD is a result of an
    in-service stressor related event (fear of enemy/hostile activity, Iraq)?


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

    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: It is this Examiner's opinion that that Veteran is currently
    experiencing Post-traumatic Stress Disorder with delayed expression.  This
    diagnosis is evidenced by his treatment records, testing, and personal
    interview.  PTSD, while generally occurring with several months of an
    incurred stressor, may take years to emerge.  Such situations, while not
    common, are possible.  As the Veteran noted, he did not seek mental health
    services during Army active duty, although, per his report, he had been
    experiencing mental health-related difficulties such as depression and
    anxiety.  He also has been diagnosed with medical issues, such as enuresis
    and encopresis, which likely increase the expression of his PTSD symptoms.

    As mentioned above, he is currently receiving weekly mental health 
counseling
    and also receives psychotropic treatment of his current symptoms of PTSD
    (such as anxiety and depression), which appear to have stabilized his
    functioning, at least for the time being.

    TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL
    EVIDENCE ] 

    I have reviewed the conflicting medical evidence and am providing the
    following opinion: There is no conflicting medical evidence.


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

 
/es/ Ohyscholist name
Clinical Psychologist
Signed: 11/01/2016 08:31

 

Thankyou, Bill

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just a guess I would say 50% to probably 70% S.C. PTSD Rating

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Thanks Buck for your opinion, I know how slow this process can be. Hopefully, I will get a decision in the near future, Thanks

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Your Welcome

My PTSD C&P was simular to yours  I got 70% 

Here are the Disabilitys rating on s

 

  

General Rating Formula for Mental Disorders

    Rating
Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100
Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 70
Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50
Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 30
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 continuous medication. 10
A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.  

 

 

 

 

 

 

Edited by Buck52
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If they rate you according to the chart, your suicide ideation will net you the 70% rating. 

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I agree with Andyman. 70%

Now just in my opinion only

if you had went to this C&P  with  bad hygiene and unkempt appearance   =  like not shaved in a month, dirty messy hair ,not clean, smelled of B.O.  just bad hygiene all around  you would have got the 100%.

I promise.  I've seen Veterans do this on purpose.

 

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