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C & P exam results for TDIU Claim


smith22

Question

All,

I competed my C & P exam for TDIU claim for PTSD and Lumbar DDD.  I am uploading the notes from my C & P exam for PTSD.   The examiner stated I do not know why you are here because your last C & P was in March.  If anyone has experience with interpreting the notes I would appreciate your help.   I did delete her extensive notes about what I said about my family and events....    My previous C & P exam was 70% for PTSD and total rating of 90%     40 lumbar ddd and radiculopathy,  10% for each knee, 10% for tinnitus.  

Also I was just diagnosed with Moderate to severe Sleep apnea.... but I have not filed for disability.   I would have to get a nexus letter from doc stating secondary to PTSD.  If I am denied TDIU I will start that process.... 

I would like any advice on the results below and also what should I do with sleep apnea claim...  I also have High BP...  not sure if I should submit Sleep apnea claim and try to go for SC 100%

Thanks in advance for your "time and your help"

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 had a diagnosis of PTSD?

[X] Yes [ ] No

2. Current Diagnoses

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

If the Veteran currently has one or more mental disorders that conform to

DSM-5 criteria, provide all diagnoses:

a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder

ICD Code: F43.10

Mental Disorder Diagnosis #2: Major Depressive Disorder

ICD Code: F33.9

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

mental

health disorder(s):

Physical health problems that he described as affecting his day-to-day

functioning or requiring the use of daily medication or medical devices

include back pain and sleep apnea. Just got a CPAP yesterday. Please see his

medical records for additional information about his physical health

conditions.

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: These conditions can

co-occur, and there is some overlap in their symptoms and associated

features, which precludes attribution of certain specific difficulties to

JOHN DOECONFIDENTIAL Page 22 of 68

one

condition or another without resorting to speculation. Consequently, these

conditions cannot be fully differentiated from each other.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [X] No [ ] Not shown in records reviewed

Comments: Not applicable.

d. Is it possible to differentiate what symptom(s) is/are attributable to

each diagnosis?

[ ] Yes [ ] No [X] Not applicable (N/A)

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 deficiencies in most areas, such

as work, school, family relations, judgment, thinking, and/or mood

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 [ ] Not applicable (N/A)

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: As these conditions cannot be fully differentiated from

each other, their associated functional impairments cannot be differentiated

without resorting to speculation.

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 and Virtual VA)

[X] CPRS

[X] Other (please identify other evidence reviewed): VistaWeb or JLV

JOHN DOECONFIDENTIAL Page 23 of 68

2. History

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

Relevant Family and Social History:

 

Relevant Mental Health History:

EVALUATION AND TREATMENT HISTORY

EMOTIONAL AND BEHAVIORAL PROBLEMS:

SUICIDAL OR SELF-INJURIOUS IDEATION OR BEHAVIOR:

Other Relevant History:

None reported.

3. 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)

JOHN DOECONFIDENTIAL Page 26 of 68

sexual violence, in one or more of the following ways:

[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] 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 the individual to blame himself/herself or

others.

[X] Persistent negative emotional state (e.g., fear, horror, anger, guilt,

or

shame).

JOHN DOECONFIDENTIAL Page 27 of 68

[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] Hypervigilance.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or staying asleep or

restless

sleep).

Criterion F:

[X] Duration of the symptoms described above in Criteria B, C, D, and E is

more than 1 month.

Criterion G:

[X] The 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] Suspiciousness

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

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

[X] Impairment of short- and long-term memory, for example, retention of

only

highly learned material, while forgetting to complete tasks

[X] Flattened affect

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

CONFIDENTIAL Page 28 of 68

[X] Difficulty in adapting to stressful circumstances, including work or a

worklike setting

5. Behavioral Observations

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

The Veteran arrived on time for the appointment. His appearance was

unremarkable, and his grooming and hygiene were appropriate. He was alert

and

oriented to person, place, time, and situation. The nature and purpose of

the

evaluation, the examiner's role in the disability claims adjudication

process, and the limits of confidentiality were discussed with him. He

verbalized understanding and consented to participate.

He engaged well with the examiner, and his responses to inquiries were

appropriate in content and level of detail. While no formal evaluation of

his

mental status was conducted, his cognitive functioning appeared to be

adequately intact for the purpose of the present interview. His thoughts

were

logical, coherent, and goal-directed. His speech was clear and intelligible,

and of normal rate, volume, and prosody. There was no evidence of

significant

expressive or receptive language impairments. There was no overt evidence of

perceptual disturbances, delusional beliefs, or perseverative thoughts. His

attention, concentration, and motor activity were unremarkable. His mood and

affect were appropriate in nature, range, and intensity to the situation and

to the topic of conversation. He was tearful throughout much of the

interview. He denied current suicidal or homicidal ideation, intent, or

plan.

He appeared to be a reliable historian and credible informant, and there

were

no overt indications of malingering or of symptom overreporting or

underreporting.

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:

[X] Irritable or angry mood

[X] Loss of interest or pleasure in activities

[X] Appetite disturbance

[X] Weight disturbance

[X] Fatigue or loss of energy

[X] Difficulty thinking, concentrating, or making decisions

[X] Feelings of worthlessness or guilt

CONFIDENTIAL Page 29 of 68

[X] Emotional numbing and detachment

7. Competency

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

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

[X] Yes [ ] No

If no, explain: Not applicable.

8. Remarks, (including any testing results) if any:

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

JOHN DOE: is a 45-year-old male who was in

the Army, and who had a deployment to Iraq in xxxxxxx. He has a

service connection for PTSD, with a current rating of 70%. This examination

was focused on his functioning since the previous examination on 3/15/2017,

although information regarding prior history was reviewed and obtained where

relevant to the issues in question. Please see the report of the previous

examination for relevant prior history. The present examination was based on

a face-to-face interview with the Veteran and review of records as indicated

above. Except where otherwise indicated, historical information presented

above is taken from the interview.

Results of the examination indicate that the Veteran's difficulties are

consistent with current diagnostic criteria for PTSD. They also indicate

that

he experiences symptoms supporting a diagnosis of Major Depressive Disorder

(MDD) at this time. These are considered to be separate, comorbid conditions

which share some symptoms and a common etiology. Due to the overlap in

symptoms and associated features of these disorders, it can at times be

difficult to determine--and clinicians may reasonably differ

regarding--whether the clinical picture might be better accounted for by a

single diagnosis or by multiple diagnoses.

Results of the examination indicate that as a result of his mental health

conditions, he is experiencing significant impairments in a number of

domains, including occupational functioning. As he is no longer working, his

occupational functioning is inferred from his past work history, from his

current social functioning, and from the nature and severity of his current

symptomatology. He has not held paid employment since February 2016, when he

lost his job due to irritability and angry outbursts. He indicated a

previous

history of work-related difficulties due to anxiety and panic. Taken

together

with fatigue, problems with attention and concentration, forgetfulness,

intrusive thoughts, hypervigilance, discomfort in interpersonal

interactions,

and a propensity for social withdrawal and avoidance as a means of coping

with stress, these difficulties would significantly limit his ability to

secure and maintain gainful employment. He would likely experience

challenges

in adjusting successfully to a work environment due to difficulty

establishing and maintaining effective work relationships, as well as to

reduced reliability, productivity, efficiency, accuracy, and timeliness in

JOHN DOECONFIDENTIAL Page 30 of 68

attending work and fulfilling job responsibilities.

 

 

 

 

***This DBQ was completed solely for the purpose of a disability evaluation,

and does not represent the results of a comprehensive clinical or forensic

evaluation of this Veteran. It represents the information and impressions

which could be gathered and reported within the constraints of the time

allotted for interview, review of records, and documentation, and within the

constraints of this mandated format. DBQs are completed in highly

specialized

ways that conform to the requirements of the disability claims adjudication

and appeals processes. Some items may be left blank or diagnoses may be

omitted where the symptoms or disorders might actually be present but, for

example, cannot be attributed to a specific cause or etiology, cannot be

attributed to the specific condition for which the C&P examination was

requested, or cannot be linked to the Veteran's military service on the

basis

of evidence that conforms to the required standards. The conclusions and

opinions documented on this form were based upon the information available

to

the examiner at the time the evaluation was completed, and may differ from

those of professionals who have evaluated the Veteran in a clinical setting

and/or from the findings of any previous C&P examinations. New or

additional

information might result in changes to the examiner's interpretations,

conclusions, or opinions as documented on this form.***

NOTE: VA may request additional medical information, including additional

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

application.

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I filed in June for IU.  I was rated 70% for PTSD and 90% overall. Instead of approving me for IU they rated me at 100%  Permanent and Total for PTSD.  I had only been rated at 70% PTSD for 3 months.  I lost my job on those 3 months because of meds that I am taking and the fatigue it was causing me (I drove a public bus) plus I have anger issues.  I also have sleep apnea but not service connected.  When that happened,  I applied for IU.  I never expected it to go to 100% P&T.  Now I'm waiting on SSDI who wants me to go for one of their exams next month. 

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3 hours ago, Trapperx6 said:

I filed in June for IU.  I was rated 70% for PTSD and 90% overall. Instead of approving me for IU they rated me at 100%  Permanent and Total for PTSD.  I had only been rated at 70% PTSD for 3 months.  I lost my job on those 3 months because of meds that I am taking and the fatigue it was causing me (I drove a public bus) plus I have anger issues.  I also have sleep apnea but not service connected.  When that happened,  I applied for IU.  I never expected it to go to 100% P&T.  Now I'm waiting on SSDI who wants me to go for one of their exams next month. 

Trapperx6,

I appreciate posting your experience.  Thanks....   I have also been scheduled an exam with SSDI for PTSD.   I called the SSA office and told them I had just been diagnosed with Moderate to severe sleep apanea.  She said make sure to fax test results in as well as my new C & P exam. 

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