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TresSam

PTSD C&P Results dbq not accurate though

Question

I recently did a new C&P for PTSD when I filed for I.U. He neglected to mark a lot of my symptoms. I am currently rated at 50% PTSD, was wondering if you think this keeps me a the same or warrants an increase. He did forget to mark my suicidal ideations and a few other symptoms though so I am worried I won't be rated correctly.

 

 Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes  [ ] No
    

                                   SECTION I:
                                   ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran now have or has he/she ever been diagnosed with PTSD?
    [X] Yes  [ ] No
       ICD Code: F43.10

    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: PTSD
         ICD Code: F43.10

       Mental Disorder Diagnosis #2: Panic Disorder
         ICD Code: F41.0

       Mental Disorder Diagnosis #3: Major Depressive Disorder, Recurrent
         ICD Code: F33.1

       Mental Disorder Diagnosis #4: No Axis II disorder

    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?
       [ ] Yes  [X] No  [ ] Not applicable (N/A)
       
           If no, provide reason that it is not possible to differentiate what
           portion of each symptom is attributable to each diagnosis and discuss
           whether there is any clinical association between these diagnoses: 
The
           PTSD is currently the more severe and responsible for the veteran's
           current level of impairment; the clinical depression and the Panic
           Disorder are certainly significant, however.  The depression and 
Panic
           Disorder are seen as more likely than not caused by the chronic PTSD
           symptoms.  It is difficult to ferret out the contribution of the 
three
           disorders due to the overlap of symptoms and variability of degree; 
at
           times any of the three disorders may be the more severe, but the PTSD
           is responsible for the current level of impairment.
           
    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  [X] No  [ ] No other mental disorder has been diagnosed
       
           If no, provide reason that it is not possible to differentiate what
           portion of the indicated level of occupational and social impairment
           is attributable to each diagnosis: The PTSD is currently the more
           severe and responsible for the veteran's current level of impairment;
           the clinical depression and the Panic Disorder are certainly
           significant, however.  The depression and Panic Disorder are seen as
           more likely than not caused by the chronic PTSD symptoms.  It is
           difficult to ferret out the contribution of the three disorders due 
to
           the overlap of symptoms and variability of degree; at times any of 
the
           three disorders may be the more severe, but the PTSD is responsible
           for the current level of impairment.
           
    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


    2. Recent History (since prior exam)
    ------------------------------------
    a. Relevant Social/Marital/Family history:
          Veteran received his previous PTSD C&P on Mar 2016.  At that time he
          was living in an aparments.  He still lives in
       but has moved to a different aprtment.  He lives with a
          roommate.  He is not in a relationship.  The veteran is not employed.
          His typical day consists of going to school, "I have classes five days
          a week but "I only go two days a week because of panic attacks.  When
          I'm home I sometimes lay in bed and cry or think about everything."  
He
          noted he does not sleep much at all.  He 
          said he only gets out for school; is roommate will cook and get most 
of
          the 
          groceries. 
          
          
    b. Relevant Occupational and Educational history:
          The veteran has  not worked since he was discharged from the Air Force
          in 
          2016.  He has applied for jobs and tried to do a work study
          but quit 
          because of panic attacks; at times he will scream and hit his back
          pack. 
           He started there in August and is
          taking 12 
          units.  He is schedule to attend classes five days a week but rarely
          makes all 
          five days.  "I'm close to failing a couple of classes for attendance. 
          
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health:
          The veteran is current being followed by a staff psychologist every 
two
          weeks; 
          he has being seeing her since August.  He is also followed by a staff 
          psychiatrist who prescribes: prazosin and  Celexa.  He has taken other 

          medications.  He said they  help only a little bit. 
          
          
    d. Relevant Legal and Behavioral history:
          Denied by the veteran.  He did say he got into an altercation about 
two
          weeks 
          ago at the gym when he through a dumbbell at the floor; he was kicked
          out. 
          
          
    e. Relevant Substance abuse history:
          The veteran has not drank alcohol for over one years; he denied ever
          abusing it. 
          He does not use illegal substances. 
          
          
    f. Other, if any:
       No response provided.
       
    3. PTSD Diagnostic Criteria
    ---------------------------

    Please check criteria used for establishing the current PTSD diagnosis. The
    diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
    of Mental Disorders, 5th edition (DSM-5).  The stressful event can be due to
    combat, personal trauma, other life threatening situations (non-combat
    related stressors).  Do NOT mark symptom
s below that are clearly not
    attributable to the Criterion A stressor/PTSD.  Instead, overlapping 
symptoms
    clearly attributable to other things should be noted under #6 - "Other
    symptoms".
    
       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)

       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).

       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, distorted cognitions about the cause or
                       consequences of the traumatic event(s) that lead the
                       individual to blame himself/herself or others.
                   [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] Problems with concentration.
                   [X] Sleep disturbance (e.g., difficulty falling or staying
                       asleep or restless sleep).

       Criterion F:
                   [X] The duration of the symptoms described above in Criteria
                       B, C, and D are more than 1 month.

       Criterion G:
                   [X] The PTSD symptoms described above cause 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.

    4. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Depressed mood
       [X] Anxiety
       [X] Panic attacks more than once a week
       [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] Neglect of personal appearance and hygiene

    5. Behavioral observations
    --------------------------
       No unusual behaviors observed.
       
    6. 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:
              The veteran reports having suicidal thoughts 3-4 times a week but
              doesn't dwell on them.  He said he would never attempt suicided
              because of his kids.
              
    7. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
    [X] Yes  [ ] No
    
    8. Remarks, (including any testing results) if any:
    ---------------------------------------------------
    No remarks provided.

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You can do a PTSD Review any time that you like. You cannot do a PTSD initial with a private provider, but you can do a PTSD review with a private provider. Just submit a claim for a PTSD increase.

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There are a few ways to correct this.  Start by amending your records, as follows:

https://www.law.cornell.edu/cfr/text/38/1.579

Next, another VA doc may or may not be willing to document your additional symptoms. 

 

If that fails, you can get an IMO/IME.  

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On 11/12/2016 at 4:55 PM, TresSam said:

I recently did a new C&P for PTSD when I filed for I.U. He neglected to mark a lot of my symptoms. I am currently rated at 50% PTSD, was wondering if you think this keeps me a the same or warrants an increase. He did forget to mark my suicidal ideations and a few other symptoms though so I am worried I won't be rated correctly.

 


 Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes  [ ] No
    

                                   SECTION I:
                                   ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran now have or has he/she ever been diagnosed with PTSD?
    [X] Yes  [ ] No
       ICD Code: F43.10

    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: PTSD
         ICD Code: F43.10

       Mental Disorder Diagnosis #2: Panic Disorder
         ICD Code: F41.0

       Mental Disorder Diagnosis #3: Major Depressive Disorder, Recurrent
         ICD Code: F33.1

       Mental Disorder Diagnosis #4: No Axis II disorder

    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?
       [ ] Yes  [X] No  [ ] Not applicable (N/A)
       
           If no, provide reason that it is not possible to differentiate what
           portion of each symptom is attributable to each diagnosis and discuss
           whether there is any clinical association between these diagnoses: 
The
           PTSD is currently the more severe and responsible for the veteran's
           current level of impairment; the clinical depression and the Panic
           Disorder are certainly significant, however.  The depression and 
Panic
           Disorder are seen as more likely than not caused by the chronic PTSD
           symptoms.  It is difficult to ferret out the contribution of the 
three
           disorders due to the overlap of symptoms and variability of degree; 
at
           times any of the three disorders may be the more severe, but the PTSD
           is responsible for the current level of impairment.
           
    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  [X] No  [ ] No other mental disorder has been diagnosed
       
           If no, provide reason that it is not possible to differentiate what
           portion of the indicated level of occupational and social impairment
           is attributable to each diagnosis: The PTSD is currently the more
           severe and responsible for the veteran's current level of impairment;
           the clinical depression and the Panic Disorder are certainly
           significant, however.  The depression and Panic Disorder are seen as
           more likely than not caused by the chronic PTSD symptoms.  It is
           difficult to ferret out the contribution of the three disorders due 
to
           the overlap of symptoms and variability of degree; at times any of 
the
           three disorders may be the more severe, but the PTSD is responsible
           for the current level of impairment.
           
    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


    2. Recent History (since prior exam)
    ------------------------------------
    a. Relevant Social/Marital/Family history:
          Veteran received his previous PTSD C&P on Mar 2016.  At that time he
          was living in an aparments.  He still lives in
       but has moved to a different aprtment.  He lives with a
          roommate.  He is not in a relationship.  The veteran is not employed.
          His typical day consists of going to school, "I have classes five days
          a week but "I only go two days a week because of panic attacks.  When
          I'm home I sometimes lay in bed and cry or think about everything."  
He
          noted he does not sleep much at all.  He 
          said he only gets out for school; is roommate will cook and get most 
of
          the 
          groceries. 
          
          
    b. Relevant Occupational and Educational history:
          The veteran has  not worked since he was discharged from the Air Force
          in 
          2016.  He has applied for jobs and tried to do a work study
          but quit 
          because of panic attacks; at times he will scream and hit his back
          pack. 
           He started there in August and is
          taking 12 
          units.  He is schedule to attend classes five days a week but rarely
          makes all 
          five days.  "I'm close to failing a couple of classes for attendance. 
          
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health:
          The veteran is current being followed by a staff psychologist every 
two
          weeks; 
          he has being seeing her since August.  He is also followed by a staff 
          psychiatrist who prescribes: prazosin and  Celexa.  He has taken other 

          medications.  He said they  help only a little bit. 
          
          
    d. Relevant Legal and Behavioral history:
          Denied by the veteran.  He did say he got into an altercation about 
two
          weeks 
          ago at the gym when he through a dumbbell at the floor; he was kicked
          out. 
          
          
    e. Relevant Substance abuse history:
          The veteran has not drank alcohol for over one years; he denied ever
          abusing it. 
          He does not use illegal substances. 
          
          
    f. Other, if any:
       No response provided.
       
    3. PTSD Diagnostic Criteria
    ---------------------------

    Please check criteria used for establishing the current PTSD diagnosis. The
    diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
    of Mental Disorders, 5th edition (DSM-5).  The stressful event can be due to
    combat, personal trauma, other life threatening situations (non-combat
    related stressors).  Do NOT mark symptom
s below that are clearly not
    attributable to the Criterion A stressor/PTSD.  Instead, overlapping 
symptoms
    clearly attributable to other things should be noted under #6 - "Other
    symptoms".
    
       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)

       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).

       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, distorted cognitions about the cause or
                       consequences of the traumatic event(s) that lead the
                       individual to blame himself/herself or others.
                   [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] Problems with concentration.
                   [X] Sleep disturbance (e.g., difficulty falling or staying
                       asleep or restless sleep).

       Criterion F:
                   [X] The duration of the symptoms described above in Criteria
                       B, C, and D are more than 1 month.

       Criterion G:
                   [X] The PTSD symptoms described above cause 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.

    4. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Depressed mood
       [X] Anxiety
       [X] Panic attacks more than once a week
       [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] Neglect of personal appearance and hygiene

    5. Behavioral observations
    --------------------------
       No unusual behaviors observed.
       
    6. 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:
              The veteran reports having suicidal thoughts 3-4 times a week but
              doesn't dwell on them.  He said he would never attempt suicided
              because of his kids.
              
    7. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
    [X] Yes  [ ] No
    
    8. Remarks, (including any testing results) if any:
    ---------------------------------------------------
    No remarks provided.

Can you go back and review the notes and see towards the end if there's  a nexus of opinion?

I don't see a nexus of opinion stating the minimum threshold of "at least as likely as not" (equal to or greater than 50% probability) that your PTSD has worsened.

In addition, a rationale was not provided by the examiner.

Your claim will probably get kicked back to "gathering of evidence" and the ratings scheduler will request further information from the c&p examiner which could delay the process 2 weeks or more.

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      Fast forward to 2015 I report for a VA requested future exam for the four SC joints.  I made the complaint of joint pain in 11 joints to include the joints stated above from the 2009 C&P.  These were recorded in the results as pain.  In addition to the documentation in the 2015 exam, they VA acknowledged the additional joint pain and suggested I contact them if I wished to claim these.  I stupidly did not see this until recently. 
      Would I be able to get these joints connected and EED back dated to 2009 or 2015 based on an inferred issue and that no decision was made on the other joints?
      Again the VA is the one that requested the additional joints to be evaluated in 2009 and not me.  Then they were never addressed.  I am interested in this because I have been finding information on claims being considered open if the VA never renders a decision.  While they rarely miss a veteran claim they often miss inferred issues.  This seems like a pretty obvious inferred miss to me.  The VA specifically requested the additional joints. Might be a stretch but this would be significant retro.
       

    • By jdelta
      Like the title says, i go to have an exam for fibro, gerd, and eczyma. Now the last one is a toss up, and the gerd maybe too i don't know. A doctor outside the VA diagnosed me with fibro a few years back. He was an idiot though so i don't know if it was documented(probably, but i also have 30 percent for p.s.t.d. so i'm probably being paranoid). Then again this doctor told me it was my weight blah blah blah. I told him multiple times that a few years prior i was going to the gym alot and the pain has become worse as i age amking it harder to be as active. I try to eat good(chicken and rice, oatmeal) most of the times but we are human. So back to the exam, i have only had one for the p.t.s.d. I was in Iraq day one of the war(March 2003). I was around burn pits and was exposed to the aftermaths of exploded tanks and buildings(hell some we even enter to make sure nobody was hiding or any wmd. I'm registered for the burn pits. I just don't know what to expect, will it be questions, will it be a physical? It's an outside contractor, so i'm hoping less va bias. I'm also too the point of drowning in debt. It's trigger my p.t.s.d. to the point my wife can't even sleep due to my nightmares and waking up with night terrors. I have become much angrier and lashing out. Not physically though, but i don't know what state i'll be in if i get another denial(btw with what i mentioned, i have a bva for freaking tinnitus even though i have stated where i have been. I was also a cavalry scout in the army so i was trained for combat. I have lay statements from a battle buddy, mom, wife, ex and a friend. I just need to know what to expect or what else i need to do to have a shot at an approval? I'm also filed for apnea, va diagnosed me and i have a cpap. Never had a chance to have any of this documented in service due to being told to man up. 
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