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CptDT

C&P feedback

Question

Had C&P. Results posted on healthevet. 

I don't think i communicated some issues very well, especially "suicidal" thoughts, nor do I recall even discussing the workplace.

I should also stop downplaying the alcohol use.

Opinions?

 

 

LOCAL TITLE: COMPENSATION ASSESSMENT COPY

STANDARD TITLE: C & P EXAMINATION NOTE

 

----------

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: PTSD

ICD code: F43.10

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?

[ ] Yes [X] No

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

[ ] Yes [X] No [ ] 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 occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation

 

b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder?

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

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

2. History

----------

a. Relevant social/marital/family history (pre-military, military, and post-military):

The veteran grew up in xx. His parents stayed together during childhood. He has one brother and one sister. He reported that childhood was "normal"; he denied traumatic experiences

During childhood.

 

The veteran is divorced. He is currently living with his partner of 10 years. He stated that he and his partner are getting along fine but "it's more of a roommate type situation". He denied arguments, but he reported emotional distance, "I just sort of live there". No children.

 

Socially, the veteran reported that he has "no social contact outside of folks at work". He is friendly with people at work, but he does not see them outside of work. He talks to his mother once every few months, "when she calls". He talks to siblings twice a year.

 

He is not close with anyone. He spends his free time at home, "I will lie on the couch, sleep, do laundry". He has few activities or interests.

 

b. Relevant occupational and educational history (pre-military, military, and post-military):

The veteran stated that he performed average in school, "Bs, Cs, it wasn't exciting". He graduated high school and moved to xxx, started working. He joined the military at 23.

 

The veteran served in the Marine Corps from ...   xxx…

 

The veteran is currently working at xxx. He has held this job for the past three years. He is working full time; he denied any significant problems or issues at work.

Prior to this, the veteran worked at xxx, but he stated that his employment was intermittent. He would work for a few years, quit and then go back.

 

c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military):

No history of mental health treatment prior to the period of military service was reported.

 

The veteran first sought mental health treatment in 2005; he was participating in medication management and psychotherapy during the period of military service. He was hospitalized twice in 2007 for approximately 5 days for suicidal ideation. He was diagnosed with ADHD and Depression while in the military.

 

Post military, the veteran participated in mental health treatment at xxx Medical Center and the xxx VA Medical Center. He is currently participating in mental health treatment at the

xxx VA Medical Center. He last met with his psychiatrist in January 2018 when he was diagnosed with PTSD. Current medications are xxx. No sleep medications.

 

The veteran denied any psychiatric hospitalizations post military.

 

d. Relevant legal and behavioral history (pre-military, military, and post-military):

None

 

e. Relevant substance abuse history (pre-military, military, and post-military):

The veteran reported that he might drink alcohol twice a week, where he will have between 4 to 8 drinks in a sitting when he goes out to a bar.

 

No drug use, no marijuana use was reported. He denied a history of substance abuse treatment.

 

f. Other, if any:

None

 

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: The veteran stated while xxx…

 

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?

[ ] Yes [X] No

 

If no, explain:

The above traumatic event was a military sexual trauma which did not involve hostile military or terrorist activity Is the stressor related to personal assault, e.g. military sexual trauma?

[X] Yes [ ] No

If yes, please describe the markers that may substantiate the stressor.

None

 

b. Stressor #2: After the hospitalization, xxx…

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?

 

[ ] Yes [X] No

If no, explain:

The above traumatic event was a military sexual trauma which did not involve hostile military or terrorist activity

Is the stressor related to personal assault, e.g. military sexual trauma?

[X] Yes [ ] No

If yes, please describe the markers that may substantiate the stressor.

 

After the trauma with xxx…

 

The veteran reported that post military, he told the battalion xo what happened;  xxx… registered as a sex offender, and xxx.

 

4. PTSD Diagnostic Criteria

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

Note: 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)

 

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).

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).

 

[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] Hypervigilance.

 

[X] Problems with concentration.

 

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

 

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] Flattened affect

[X] Disturbances of motivation and mood

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

[X] Inability to establish and maintain effective relationships

 

6. Behavioral Observations

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

The veteran had two hospitalizations for suicidal ideation and a suicide attempt.

 

The veteran does not like to talk about the traumatic events, "who I am I going to talk about it with, what would be the point? I have no one".

 

He avoids therapy, he avoids memories related to the trauma. He avoids people at work who "creep me out". He avoids certain types of television shows, "I don't watch CSI, nothing deep". He no longer goes to church.

 

The veteran is socially isolated. He secludes himself. He used to be more social, but he started to isolate himself after the perpetrator got out of prison and was living relatively nearby; the service member is emotionally numb, he has a hard time experiencing love and joy, "I don't think love exists". He also endorses anhedonia and trauma related guilt.

 

The veteran stated that he thinks about the traumatic events, "it's the weird, feeling like I was stalked at work, I picture myself reading the emails". He will have the memories "every couple of days... I've thought about it for 10 years". He endorses distress related to the memories.

 

The veteran has dreams of telling his friends about the trauma, which is happening a few times a week. He denied waking up from the dreams, but he will remember them the next day. No flashbacks. The veteran denied panic attacks.

The veteran endorses mild sleep disturbances. He is typically getting 6-7 hours of sleep a night, "it is greatly improved". He goes to bed around 8:30 or 9pm; he denied sleep onset problems, but he will wake up during the night and be awake for an hour or so until he can fall back asleep. He started to sleep better after he came off the ADHD medication.

 

The veteran is hypevigilant, he put cameras up outside his home; he doesn't feel safe, "there's a weird paranoia". He denied having weapons at home. He doesn't like to go out. He denied a significant startle response. He denied significant problems with anger or irritability.

The veteran described his mood as flat. He rated his mood at a 3 on a 10 point scale (with 10 being high). Appetite is good, energy levels are low, "I don't have any energy".

He is exercising but "I'll go to the gym on Saturday morning at 4am".

 

He denied significant feelings of helplessness or hopelessness. He denied any immediate suicidal ideation, plan or intent. He admitted to feelings of "it would be better if I weren't here, wishing it had been more successful in the past". He denied having a plan for suicide.

 

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

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

The veteran meets full DSM-5 criteria for a PTSD diagnosis. Symptoms are directly related to the veteran's traumatic experiences, as noted above. The veteran reports intrusive memories and nightmares of the military sexual trauma, avoidance of trauma related stimuli, trauma related changes in mood and cognition and hyperarousal, which were caused by the above traumatic experiences/military sexual trauma.

 

Symptoms of depression and an anxiety condition can be considered part of the post traumatic stress syndrome and do not warrant a separate diagnosis.

 

 

 

Edited by CptDT
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I see this as a mostly favorable exam.  You have a current diagnosis (PTSD), a "stressor", but I would have liked to see a more difinitive nexus.  You might need an IMO to provide a clear nexus.  Your diagnosis in the military may help with this.  

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1 minute ago, broncovet said:

I see this as a mostly favorable exam.  You have a current diagnosis (PTSD), a "stressor", but I would have liked to see a more difinitive nexus.  You might need an IMO to provide a clear nexus.  Your diagnosis in the military may help with this.  

I'm betting on the court martial records for that.

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On 12/6/2018 at 9:29 AM, broncovet said:

I see this as a mostly favorable exam.  You have a current diagnosis (PTSD), a "stressor", but I would have liked to see a more difinitive nexus.  You might need an IMO to provide a clear nexus.  Your diagnosis in the military may help with this.  

Any guess at what rater might say? 

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It looks like maybe a 30% evaluation.

This is the criteria for rating mental disorders up to 50%.

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 shortand
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 .............. 0

Might I suggest that you work more on opening up with your psychiatrist about your issues, this will help with treatment and show a desire to work on your issues.  Documentation of your case is your friend when it comes to ratings in most cases.  It will also help you in other ways.  And could you start attending church again?  It will help.  Sorry if I am intrusive, just wanting to help.

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In my opinion  he was hospitalized for  2 Suicide attempts, I would think along with what all the examiner check this would be consider as chronic PTSD for a 70% rating  also possibly 100%

My exam was basically the same  I got 70% because I comb my hair/clean and was dressed casual  with the exception mine was combat trauma   this Veteran has MST some of the symptoms won't be the same.

Edited by Buck52

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