C&P Notes? Increased rating?

[Patriot3g]

Does anybody understand this? Could it lead to an increased rating for PTSD? 

I tried to fix the copy paste mess up  

 

 

LOCAL TITLE: COMP AND PEN NOTE STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: SEP 06, 2018@15:30 ENTRY DATE: SEP 06, 2018@16:45:47 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED

Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire

Name of patient/Veteran: I

 

s 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: F43.12

2. Current Diagnoses -------------------

 

a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.12

Mental Disorder Diagnosis #2: MAJOR DEPRESSIVE DISORDER ICD Code: F33

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): NONE

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:

 

THE SYMPTOMS OF PTSD ARE OUTLINED ELSEWHERE IN THIS REPORT AND INCLUDE REEXPERIENCING, AVOIDANCE, HYPERAROUSAL, NEGATIVE COGNITIONS, HYPERVIGILANCE.

DEPRESSION IS CHARACTERIZED BY PERSISTENT DEPRESSED AND/OR IRRITABLE MOOD, ANHEDONIA, INTENSE GUILT AND JUDGEMENTS OF NEGATIVE SELF WORTH, DECREASED ENERGY, CHANGES IN APPETITE, SLEEP DISTURBANCE, PSYCHOMOTOR AGITATION OR SLOWING, AND SUICIDAL IDEATION.

THERE IS SIGNIFICANT OVERLAP IN SYMPTOMS WITH BOTH DISORDERS, SO ATTRIBUTION FOR SOME SYMPTOMS IS NOT POSSIBLE. DEPRESSION IS SECONDARY TO PTSD. DEPRESSION HAS BEEN EXACERBATED BY RECENT INCIDENTS RELATED TO PTSD (ARREST FOR ASSAULT RELATED OT PTSD EPISODE AND SUBSEQUENT SUSPENSION FORM HIS JOB).

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed Comments, if any: EXPOSED TO BLASTS IN IRAQ BUT NO SCREEN OR HOSPITALIZATION. HE HAD A BRIEF LOC AND SOME CONFUSION. HE HAD HEADACHES. SYMPTOMS CLEARED UP.

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 occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [X] Yes [ ] No [ ] Not Applicable (N/A) If yes, list which occupational and social impairment is attributable to each diagnosis: OCCUPATIONAL AND SOCIAL IMPAIRMETN IS DUE TO PTSD AS DEPRESSION IS SECONDARY TO PTSD.

 

c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ---------- Clinical Findings: ----------------- 1. Evidence Review ----------------- Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS

Evidence Comments: THE VETERAN'S LAST EXAM WAS FEBRUARY 2018 AND THE CURRENT EXAM GENERALLY FOCUSES ON TIME SINCE.

2. Recent History (since prior exam) ----------------------------------- a. Relevant social/marital/family history: MR. XXX LIVES ALONE IN AN APARTMENT IN QUEENSBURY. HE HAS A DOG.

HE HAS ARRESTED JULY 9TH FOR ATTACKING A FRIEND. HE DOES NOT REMEMBER THE INCIDENT. HE HAD A PANIC ATTACK. SINCE THEN HE STAYS AT HOME MOSTLY. HE VISITS HIS MOM DAILY AND COOKS HER DINNER. HE SEES HIS SIBLINGS OCCASIONALLY AS THEY DO NOT LIVE LOCALLY. HE HAS NOT HAD ROMANTIC ATTACHMENTS. HE CLEANS THE HOUSE. HE DOES HANG OUT WITH FRIENDS FROM WORK BUT MONEY IS TIGHT SO HE DOES NOT GO OUT. HE ATTENDED THE SARATOGA WAR HORSE PROGRAM FOR 3 DAYS (IN MARYLAND) WHICH HE ENJOYED. HE DOESN'T LIKE BEING AROUND CROWDS. HE ENJOYS FISHING, SWIMMING.

b. Relevant occupational and educational history: MR. XXX HAD BEEN WORKING AS A CORRECTIONS OFFICER AT A NYS CORRECTIONAL FACILITY FOR THE PAST 3 1/2 YEARS. HE ADMITTED THE WORK WAS DIFFICULT AND HE ENJOYED THE COMRADERY AMONG THE STAFF. HE WAS SUSPENDED WITHOUT PAY AFTER AN ARREST - HE HAD A PANIC ATTACK AND ATTACKED ONE OF HIS FRIENDS, THE NEIGHBORS CALLED THE POLICE AND HE WAS ARRESTED.

 

c. Relevant mental health history, to include prescribed medications and family mental health: THE VETERAN HAS HAD ONE VISIT WITH VA BH AND ONE VISIT WITH VA PSYCHIATRY SINCE LAST EXAM. HE HAD A HIGH RISK FLAG FOR SUICIDE RISK THAT WAS ENDED RECENTLY.

HE SEES A THERAPIST PRIVATELY, KRISTIN X IN X. HE TAKES WELLBUTRIN AND LEXAPRO AND BUSPAR. HE HAS BEEN PRESCRIBED XANAX BUT HASN'T TAKEN ANY YET. d. Relevant legal and behavioral history: ON JULY 9, 2018 HE HAD A PANIC ATTACK AND ATTACKED ONE OF HIS FRIENDS, THE NEIGHBORS CALLED THE POLICE AND HE WAS ARRESTED. HE DOES NOT RECALL THE INCIDENT. HE IS OPTIMISTIC FOR A GOOD OUTCOME LEGALLY AS HIS FRIEND IS WANTING HIM TO GET HELP VS. BEING PUNISHED.

e. Relevant substance abuse history: HE RARELY DRINKS ALCOHOL. HE HAS HAD >5 2X IN PAST YEAR. NO ILLICIT DRUG USE. HE CHEWS TOBACCO. 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 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 #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: Pre

 

sence 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 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 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] Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to

 

other factors such as head injury, alcohol, or drugs).

[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). [X] Markedly diminished interest or participation in significant activities.

[X] Feelings of detachment or estrangement from others.

[X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)

Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

[X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

[X] Reckless or self-destructive behavior.

[X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Criterion F: [X] 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] Suspiciousness [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Flattened affect [X] Impaired judgment [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] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Grossly inappropriate behavior

5. Behavioral observations ------------------------- THE VETERAN WAS ORIENTED TO THE NATURE OF EVALUATION, THE SEPARATION OF VHA AND VBA AND THAT THE AUTHOR WAS NOT PROVIDING TREATMENT AND THAT NO PATIENT PROVIDER RELATIONSHIP EXISTS. THE VETERAN WAS ORIENTED TO THE LIMITS OF CONFIDENTIALITY AND ASSENTED TO EVALUATION. HE WAS ALSO INFORMED OF THE NATURE OF THE REVIEW EXAM WHICH WOULD GENERALLY FOCUS ON TIME SINCE LAST EXAM.

MR. X PRESENTED ON TIME. HE WAS DRESSED CASUALLY AND APPROPRIATELY WITH ADEQUATE HYGIENE. HE WAS PLEASANT AND COOPERATIVE THROUGHOUT THE SESSION. HE WAS ALERT AND FULLY ORIENTED. MOOD WAS DEPRESSED/ANXIOUS; AFFECT WAS FLAT, CONSTRICTED WITH RESTRICTED RANGE. SPEECH WAS NORMAL IN TONE, RATE AND VOLUME. CONVERSATION WAS COHERENT.

THERE WERE SOME DEPRESSIVE SYMPTOMS INCLUDING: SAD/IRRITABLE MOODS, ANHEDONIA/LOSS OF INTEREST OR PLEASURE, SENSE OF GUILT, NEGATIVE SELF-WORTH, DECREASED ENERGY, DISTURBED SLEEP, PSYCHOMOTOR AGITATION.

HE DENIED CURRENT SUICIDAL IDEATION ALTHOUGH HAD EXPERIENCED THIS IN JULY AFTER BEING ARRESTED. HE DENIED HX OF PSYCHOSIS, MANIC OR HYPOMANIC EPISODES. HE HAS EXPERIENCED PANIC ATTACKS, OBSESSIONS, COMPULSIONS, FLASHBACKS, INTRUSIVE MEMORIES, EXAGGERATED STARTLE RESPONSE, HYPERVIGILANCE. 6. Other symptoms ---------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above?

 

[ ] Yes [X] No 7. Competency ------------ Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, (including any testing results) if any:

-------------------------------------------------- MR. X MEETS THE CRITERIA FOR CHRONIC PTSD. HE HAS HAD MULTIPLE INSTANCES OF PANIC AND DISASSOCIATION WHERE HE HAS ATTACKED OTHERS. THESE EPISODES ARE MORE LIKELY THAN NOT RELATED TO THE PTSD FORM MILITARY SERVICE. THESE EPISODES CAN BE DANGEROUS. HIS ABILITY TO EFFECTIVELY RETURN TO HIS CURRENT WORK ENVIRONMENT IS CERTAINLY QUESTIONABLE. HE LIKELY WILL HAVE SOME LIMITATIONS AND RESTRICTIONS WHERE HE CAN WORK. HE IS INT TREATMENT AND THERE IS SONE REASON THAT HE SYMPTOMS AND QUALITY OF LIFE CAN IMPROVE.

THE INSOMNIA AND ANXIETY ARE PART OF THE PTSD AND THESE SYMPTOMS DO NOT REQUIRE AN ADDITIONAL DIAGNOSIS.

 

/es/ Michael McCann, Ph. D. Licensed Psychologist/Neuropsychologist Signed: 09/06/2018 16:45

[bleggett29]

Looks like a 70% rating.

To get to the next rating level (100%) the examiner would need to check the box for "Total Occupational and Social Impairment", which was not done.

[GeekySquid]

On 9/9/2018 at 11:18 AM, Patriot3g said:

THESE EPISODES ARE MORE LIKELY THAN NOT RELATED TO THE PTSD FORM MILITARY SERVICE. THESE EPISODES CAN BE DANGEROUS. HIS ABILITY TO EFFECTIVELY RETURN TO HIS CURRENT WORK ENVIRONMENT IS CERTAINLY QUESTIONABLE

@Patriot3g

would consider looking into TDIU if you don't get bumped up to 100% Schedular for PTSD.

Be careful with TDIU, know what are the pro's and con's. If you are 100% schedular then you probably don't want TDIU. TDIU limits you to only being able to earn poverty level wages (except in very special circumstances) and unless you are P&T you will have to fill out income verification every year.

A single person at poverty wages can only earn about 12K a year.

A 100% schedular rating, not attached to SMC's for aid and attendance or housebound can earn as much as you want over and above your va compensation. If you are P&T you will likely never have another ptsd review again unless they decide you are committing fraud or something.

your site profile says you are currently rated at 70% PTSD. While no one can say for sure until your decision letter arrives there are some indicators you can look for.

Look at your past C&P results and compare them to this result. are these worse? are they closer to the 100% description for PTSD? did this examination use stronger words or new behaviors?
I

On 9/9/2018 at 11:18 AM, Patriot3g said:

THE VETERAN'S LAST EXAM WAS FEBRUARY 2018 AND THE CURRENT EXAM GENERALLY FOCUSES ON TIME SINCE.

so you have had two PTSD C&P exams in 2018? if so did the last one bump you up to 70%? or did it keep you at that level?

If it bumped you up, it would appear they are viewing your condition as getting worse or at least is not yet stable.

If you are not in counseling you may want to attend.

in general if you are 70% PTSD, the RO is supposed to evaluate for TDIU automatically but it does not often occur that way. If you plan on going back to your job or other work, you can ignore the document they will send you for "requesting" TDIU (assuming they evaluate you for TDIU without your asking). They  cannot force it on you.

Good luck and I would really look at counseling and finding out why you blacked out and cant remember attacking your friend. That is dangerous for anyone but in your field even more so.