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C&P Anxiety notes. thoughts?
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Dabimmerman
Hey everyone, I just got my C&P notes back from my anxiety exam. I am not sure from what it says, but I think it looks to be favorable?
Any ideas of a possible rating %?
SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
disorder(s)?
[X] Yes [ ] No
ICD code: F32.9
If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Major Depressivve Disorder
ICD code: F32.9
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Lumbar strain ICD: S39.012
2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[] Yes [X] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[] Yes [ ] No [X ] Not applicable (N/A)
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
3. 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
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
He used to play sports, now he can't. He cant play legos with his kids
or board games. "I've lost a lot of my friends, I'm isolated more
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
He injured his back during military service during routine exerice during drill.
Currently employed full-time, but "I have no interest in my job" "My back always job, I have alot
of anxiety, and I'm not doing the right thing.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Sleep, I'm up all night, back pain persists. Gets 2-5 hours of sleep a night.
He still is depressed
No appetite, goes days without eating.
A major part of my life has changed..it sucks.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[] Suspiciousness
[] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Suicidal ideation
[X] Neglect of personal appearance and hygiene
4. Behavioral observations
--------------------------
See Remarks below.
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes [X] No
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
---------------------------------------------------
Clinical Examination:
He does appear to be in pain, depression.
He does describe major depression episodes. He has had suicidal ideation.
It is at least as likely as not the veterans Major Depressive Disorder w/ anxious distress is due to service connection.
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Dabimmerman
Thanks flores97! The exam only lasted about 20 minutes, he asked me a few questions and basically typed the entire time. I guess he got what he needed from our conversation. Some of these
GeekySquid
I have to ask about this statement. Do you currently have a 70% rating for some other condition?
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