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Bluebonnie

C and p exam(need input)

Question

Posted (edited)

First, I don't understand my results of c and p exam. Can someone help me out with this. After having my c and p exam 12/31/2018 my status changed quickly to prep for decision on 01/03/2019, then the next day on 1/04/2019 it changed to pending decision approval. Does this mean that it will be denied because it's moving so quickly. Why is it changing so fast? I have a copy of my report. Also estimated completion date is 1/12/2019-01/18/2019. Seems all to quickly to me which makes it scary.    

 

1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[ ] Yes [X] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Other Specified Trauma- and Stressor-Related
Disorder
ICD code: F43.8
Comments, if any:
Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD.
While the veteran did experience a Criterion A trauma event
(physical assault by significant other), her other significant
stressor in the service does NOT meet Criterion A (sexual
harassment), though the latter appears to have had a more long-term
impact on her functioning. She does NOT endorse, exhibit, and there
is no record of her experiencing core symptoms (arousal) that are
essential to a PTSD diagnosis based on the Criterion A stressor
(her arousal is far more closely related to her reported sexual
harassment). However, the veteran DOES meet DSM 5 diagnostic
criteria for Other Specified Trauma- and Stressor-Related Disorder.
It is AT LEAST AS LIKELY AS NOT that the Other Specified Traumaand Stressor-Related Disorder is the result of an in-service
stressor related event.
Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia
ICD code: F41.0
Comments, if any:
Veteran also meets full DSM 5 diagnostic criteria for Panic
Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that
the veteran's Panic Disorder is SECONDARY TO her Other Specified
Trauma- and Stressor-Related Disorder.
Mental Disorder Diagnosis #3: Unspecified Depressive Disorder
ICD code: F32.9 

Comments, if any:
Veteran also meets full DSM 5 diagnostic criteria for Unspecified
Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the
veteran's Unspecified Depressive Disorder is SECONDARY TO her Other
Specified Trauma- and Stressor-Related 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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
PTSD Symptoms: 
* Sleep disturbance due to nightmares 
* Recurring/intrusive thoughts about his/her trauma(s). 
* Arousal symptoms, including hypervigilance, exaggerated startle
response; irritability/angry outbursts; difficulty remembering
specifics related to the trauma event(s); 
* Avoidance symptoms of avoiding reminders of the trauma(s);
having strong reactions when aspects of the trauma(s) are
encountered/experienced.
* Negative alterations in cognitions and mood associated with the
traumatic event(s)
Symptoms associated with veteran's depressive disorder include:
* depressed mood most of the day, nearly every day
* markedly diminished interest in or pleasure in all, or almost
all, activities most of the day, nearly every day
* significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in
appetite nearly every day
* insomnia or hypersomnia nearly every day
* psychomotor agitation or retardation nearly every day
(observable to others)
* fatigue or loss of energy nearly every day
* feelings of worthlessness or excessive or inappropriate guilt
nearly every day
* diminished ability to think or concentrate, or indecisiveness,
nearly every day
* recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation or suicidality
OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not
limited to:
sleep problems (related to onset and maintenance);
fatigue;
concentration difficulties; difficulties experiencing
positive
emotions; feeling isolated or disconnected from others;
loss of
interest in previously enjoyable activities; having
strong negative
beliefs about oneself, the world, others. As well as
feelings of
worthlessness or excessive or inappropriate guilt nearly
every day.
Symptoms associated with veteran's panic disorder include:
* palpitations, pounding heart, or accelerated heart rate
* excessive perspiration/sweating
* trembling or shaking
* sensation of shortness of breath or smothering
* feelings of choking
* chest pain or discomfort
* nausea or abdominal distress
* feeling dizzy, unsteady, light-headed, or faint  chills or heat sensations
* derealization (feelings of unreality) or depersonalization
(being detached from one-self)
* fear of losing control or "going crazy"
* fear of dying
* persistent fear or worry about additional panic attacks or their
consequences
* significant maladaptive change in behavior related to the
attacks
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 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?
[ ] Yes [X] No [ ] Not Applicable (N/A)
If no, provide reason:
It is not feasible to parse out the veteran's level of
occupational/social impairment (a global assessment of impairment)
into diagnostic categories as the conditions have a significant,
bidirectional impact on one another with significant overlap in
symptoms.
NOTE: The overall functional impairment of this veteran is best
conceptualized via the chosen statement above in Section 1, Item 4a
("occupational and social impairment...") and NOT the symptoms
checklist at the conclusion of this report (see section 2, Item 3 -
"Symptoms") as symptom endorsement alone do not capture the
frequency or severity of their presence.

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
[X] Other (please identify other evidence reviewed):
Veteran's electronic C-File (through VBMS) and CPRS medical records
were reviewed. Particular attention was directed to 
previous C&P examination 

dated: n/a
prior mental health notes: CPRS 

VBMS documents including, but not limited to: buddy/lay statement

DD-214; STRs (negative for psych, depression, anxiety)
VA Form 21-0781 
VA Form 21-526EZ
No collateral information was available in C-file and no collaterals
joined veteran to C&P evaluation. 
Evidence Comments:
DBQ PSYCH PTSD Initial:

Please review the Veteran's electronic folder in VBMS and state that it was 
reviewed in your report. MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION: Direct service connection
Does the Veteran have a diagnosis of (a) post traumatic Stressor disorder 
that is at least as likely as not (50 percent or greater probability) 
incurred in or caused by (the) personal trauma during service?
Rationale must be provided in the appropriate section.
If more than one mental disorder is diagnosed please comment on their 
relationship to one another and, if possible, please state which symptoms 
are attributed to each disorder.
If your examination determines that the Veteran does not have diagnosis of 
PTSD and you diagnose another mental disorder, please provide an opinion as 
to whether it is at least as likely as not that the Veteran's diagnosed 
mental disorder is a result of an in-service stressor related event.

Additional remarks for the examiner:
Tab B (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 
Tab C (Stressor Statement in VBMS) Stessor Statement VAF 21-0781

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: sexual harrasment (mainly verbal with some physical
posturing)
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[ ] Yes [X] No
Is the stressor related to the Veteran's fear of hostile military or
terrorist activity?
[ ] Yes [X] No
If no, explain:
sexual harrassment
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.
MST event

b. Stressor #2: physical assault while pregnant by significant other (which
prompted her military discharge)
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:
personal assault
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.
see above
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] No criterion in this section met.
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] 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 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.
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] 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 #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] Panic attacks more than once a week
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Difficulty in adapting to stressful circumstances, including work or a
worklike setting
[X] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[X] Neglect of personal appearance and hygiene
[X] Intermittent inability to perform activities of daily living,
including maintenance of minimal personal hygiene.

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
--------------------------------------------------
As part of this C&P evaluation, veteran was administered the PTSD
Checklist - DSM 5 (PCL-5) & Beck Depression Inventory - Second Edition
(BDI-II). 
The PTSD Checklist - DSM 5 is a 20-item self-report instrument for
measuring the severity of criteria for posttraumatic stress disorder. Ms.(......)
PCL score of 68 is above the recommended score that is typically
indicative of PTSD symptomatology (31-33 based on Bovin et al., 2015,
Psych Assessment; maximum score of 80). No previous administration(s) of
this instrument were located in the veteran's records. The PCL is
considered a screening measure and does NOT include validity scales. As
such, it is susceptible to positive and negative impression management.
The Beck Depression Inventory - Second Edition (BDI-II) is a 21-item
self-report instrument for measuring the severity of depression in adults
and adolescents aged 13 years and older. Ms. (........) BDI-II score of 46 is
indicative of severe depressive symptoms being endorsed at the present
time. No previous administration(s) of this instrument were located in the
veteran's records. The BDI-2 is considered a screening measure and does
NOT include validity scales. As such, it is susceptible to positive and negative impressions.

Timeline

C and p exam done Monday 12/31/2018 

Results ready/claim status change to prep for decision on        Thursday 01/03/2019

Friday 01/04/2019 pending decision approval

Edited by Bluebonnie
Added something

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If you want us to interpret the results of your c and p exam, you will need to post it, redacting your name, address, etc.  

The speed of your claim is not related to whether its a denial or not, except that it may take longer to figure out your retro, and its possible they are doing that now.  

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1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[ ] Yes [X] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Other Specified Trauma- and Stressor-Related
Disorder
ICD code: F43.8
Comments, if any:
Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD.
While the veteran did experience a Criterion A trauma event
(physical assault by significant other), her other significant
stressor in the service does NOT meet Criterion A (sexual
harassment), though the latter appears to have had a more long-term
impact on her functioning. She does NOT endorse, exhibit, and there
is no record of her experiencing core symptoms (arousal) that are
essential to a PTSD diagnosis based on the Criterion A stressor
(her arousal is far more closely related to her reported sexual
harassment). However, the veteran DOES meet DSM 5 diagnostic
criteria for Other Specified Trauma- and Stressor-Related Disorder.
It is AT LEAST AS LIKELY AS NOT that the Other Specified Traumaand Stressor-Related Disorder is the result of an in-service
stressor related event.
Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia
ICD code: F41.0
Comments, if any:
Veteran also meets full DSM 5 diagnostic criteria for Panic
Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that
the veteran's Panic Disorder is SECONDARY TO her Other Specified
Trauma- and Stressor-Related Disorder.
Mental Disorder Diagnosis #3: Unspecified Depressive Disorder
ICD code: F32.9 

Comments, if any:
Veteran also meets full DSM 5 diagnostic criteria for Unspecified
Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the
veteran's Unspecified Depressive Disorder is SECONDARY TO her Other
Specified Trauma- and Stressor-Related 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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
PTSD Symptoms: 
* Sleep disturbance due to nightmares 
* Recurring/intrusive thoughts about his/her trauma(s). 
* Arousal symptoms, including hypervigilance, exaggerated startle
response; irritability/angry outbursts; difficulty remembering
specifics related to the trauma event(s); 
* Avoidance symptoms of avoiding reminders of the trauma(s);
having strong reactions when aspects of the trauma(s) are
encountered/experienced.
* Negative alterations in cognitions and mood associated with the
traumatic event(s)
Symptoms associated with veteran's depressive disorder include:
* depressed mood most of the day, nearly every day
* markedly diminished interest in or pleasure in all, or almost
all, activities most of the day, nearly every day
* significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in
appetite nearly every day
* insomnia or hypersomnia nearly every day
* psychomotor agitation or retardation nearly every day
(observable to others)
* fatigue or loss of energy nearly every day
* feelings of worthlessness or excessive or inappropriate guilt
nearly every day
* diminished ability to think or concentrate, or indecisiveness,
nearly every day
* recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation or suicidality
OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not
limited to:
sleep problems (related to onset and maintenance);
fatigue;
concentration difficulties; difficulties experiencing
positive
emotions; feeling isolated or disconnected from others;
loss of
interest in previously enjoyable activities; having
strong negative
beliefs about oneself, the world, others. As well as
feelings of
worthlessness or excessive or inappropriate guilt nearly
every day.
Symptoms associated with veteran's panic disorder include:
* palpitations, pounding heart, or accelerated heart rate
* excessive perspiration/sweating
* trembling or shaking
* sensation of shortness of breath or smothering
* feelings of choking
* chest pain or discomfort
* nausea or abdominal distress
* feeling dizzy, unsteady, light-headed, or faint  chills or heat sensations
* derealization (feelings of unreality) or depersonalization
(being detached from one-self)
* fear of losing control or "going crazy"
* fear of dying
* persistent fear or worry about additional panic attacks or their
consequences
* significant maladaptive change in behavior related to the
attacks
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 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?
[ ] Yes [X] No [ ] Not Applicable (N/A)
If no, provide reason:
It is not feasible to parse out the veteran's level of
occupational/social impairment (a global assessment of impairment)
into diagnostic categories as the conditions have a significant,
bidirectional impact on one another with significant overlap in
symptoms.
NOTE: The overall functional impairment of this veteran is best
conceptualized via the chosen statement above in Section 1, Item 4a
("occupational and social impairment...") and NOT the symptoms
checklist at the conclusion of this report (see section 2, Item 3 -
"Symptoms") as symptom endorsement alone do not capture the
frequency or severity of their presence.

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
[X] Other (please identify other evidence reviewed):
Veteran's electronic C-File (through VBMS) and CPRS medical records
were reviewed. Particular attention was directed to 
previous C&P examination dated: n/a
prior mental health notes: CPRS
VBMS documents including, but not limited to: buddy/lay statement 

DD-214; STRs (negative for psych, depression, anxiety)
VA Form 21-0781
VA Form 21-526EZ
No collateral information was available in C-file and no collaterals
joined veteran to C&P evaluation. 
Evidence Comments:
DBQ PSYCH PTSD Initial:
Please review the Veteran's electronic folder in VBMS and state that it was 
reviewed in your report.  

MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION: Direct service connection
Does the Veteran have a diagnosis of (a) post traumatic Stressor disorder 
that is at least as likely as not (50 percent or greater probability) 
incurred in or caused by (the) personal trauma during service?
Rationale must be provided in the appropriate section.
If more than one mental disorder is diagnosed please comment on their 
relationship to one another and, if possible, please state which symptoms 
are attributed to each disorder.
If your examination determines that the Veteran does not have diagnosis of 
PTSD and you diagnose another mental disorder, please provide an opinion as 
to whether it is at least as likely as not that the Veteran's diagnosed 
mental disorder is a result of an in-service stressor related event.
Additional remarks for the examiner:
Tab B (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 
Tab C (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 

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: sexual harassment (mainly verbal with some physical
posturing)
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[ ] Yes [X] No
Is the stressor related to the Veteran's fear of hostile military or
terrorist activity?
[ ] Yes [X] No
If no, explain:
sexual harassment
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.
MST event 

b. Stressor #2: physical assault while pregnant by significant other (which
prompted her military discharge)
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:
personal assault
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.
see above
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] No criterion in this section met.
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] 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 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.
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] 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 #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] Panic attacks more than once a week
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Difficulty in adapting to stressful circumstances, including work or a
work like setting
[X] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[X] Neglect of personal appearance and hygiene
[X] Intermittent inability to perform activities of daily living,
including maintenance of minimal personal hygiene

6. Behavioral Oberservations( I'm skipping it)

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
--------------------------------------------------
As part of this C&P evaluation, veteran was administered the PTSD
Checklist - DSM 5 (PCL-5) & Beck Depression Inventory - Second Edition
(BDI-II). 
The PTSD Checklist - DSM 5 is a 20-item self-report instrument for
measuring the severity of criteria for posttraumatic stress disorder. (My name)PCL score of 68 is above the recommended score that is typically
indicative of PTSD symptomatology (31-33 based on Bovin et al., 2015,
Psych Assessment; maximum score of 80). No previous administration(s) of
this instrument were located in the veteran's records. The PCL is
considered a screening measure and does NOT include validity scales. As
such, it is susceptible to positive and negative impression management.
The Beck Depression Inventory - Second Edition (BDI-II) is a 21-item
self-report instrument for measuring the severity of depression in adults
and adolescents aged 13 years and older. (Name)  BDI-II score of 46 is
indicative of severe depressive symptoms being endorsed at the present
time. No previous administration(s) of this instrument were located in the
veteran's records. The BDI-2 is considered a screening measure and does
NOT include validity scales. As such, it is susceptible to positive and negative impressions.

 

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Posted (edited)
14 hours ago, Bluebonnie said:

First, I don't understand my results of c and p exam. Can someone help me out with this. After having my c and p exam 12/31/2018 my status changed quickly to prep for decision on 01/03/2019, then the next day on 1/04/2019 it changed to pending decision approval. Does this mean that it will be denied because it's moving so quickly. Why is it changing so fast? I have a copy of my report. Also estimated completion date is 1/12/2019-01/18/2019. Seems all to quickly to me which makes it scary.    

 

1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[ ] Yes [X] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Other Specified Trauma- and Stressor-Related
Disorder

ICD code: F43.8
Comments, if any:
Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD.
While the veteran did experience a Criterion A trauma event
(physical assault by significant other), her other significant
stressor in the service does NOT meet Criterion A (sexual
harassment), though the latter appears to have had a more long-term
impact on her functioning. She does NOT endorse, exhibit, and there
is no record of her experiencing core symptoms (arousal) that are
essential to a PTSD diagnosis based on the Criterion A stressor
(her arousal is far more closely related to her reported sexual
harassment). However, the veteran DOES meet DSM 5 diagnostic
criteria for Other Specified Trauma- and Stressor-Related Disorder.
It is AT LEAST AS LIKELY AS NOT that the Other Specified Traumaand Stressor-Related Disorder is the result of an in-service
stressor related event.
Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia
ICD code: F41.0
Comments, if any:
Veteran also meets full DSM 5 diagnostic criteria for Panic
Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that
the veteran's Panic Disorder is SECONDARY TO her Other Specified
Trauma- and Stressor-Related Disorder.
Mental Disorder Diagnosis #3: Unspecified Depressive Disorder
ICD code: F32.9 

Comments, if any:
Veteran also meets full DSM 5 diagnostic criteria for Unspecified
Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the
veteran's Unspecified Depressive Disorder is SECONDARY TO her Other
Specified Trauma- and Stressor-Related 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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
PTSD Symptoms: 
* Sleep disturbance due to nightmares 
* Recurring/intrusive thoughts about his/her trauma(s). 
* Arousal symptoms, including hypervigilance, exaggerated startle
response; irritability/angry outbursts; difficulty remembering
specifics related to the trauma event(s); 
* Avoidance symptoms of avoiding reminders of the trauma(s);
having strong reactions when aspects of the trauma(s) are
encountered/experienced.
* Negative alterations in cognitions and mood associated with the
traumatic event(s)
Symptoms associated with veteran's depressive disorder include:
* depressed mood most of the day, nearly every day
* markedly diminished interest in or pleasure in all, or almost
all, activities most of the day, nearly every day
* significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in
appetite nearly every day
* insomnia or hypersomnia nearly every day
* psychomotor agitation or retardation nearly every day
(observable to others)
* fatigue or loss of energy nearly every day
* feelings of worthlessness or excessive or inappropriate guilt
nearly every day
* diminished ability to think or concentrate, or indecisiveness,
nearly every day
* recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation or suicidality
OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not
limited to:
sleep problems (related to onset and maintenance);
fatigue;
concentration difficulties; difficulties experiencing
positive
emotions; feeling isolated or disconnected from others;
loss of
interest in previously enjoyable activities; having
strong negative
beliefs about oneself, the world, others. As well as
feelings of
worthlessness or excessive or inappropriate guilt nearly
every day.
Symptoms associated with veteran's panic disorder include:
* palpitations, pounding heart, or accelerated heart rate
* excessive perspiration/sweating
* trembling or shaking
* sensation of shortness of breath or smothering
* feelings of choking
* chest pain or discomfort
* nausea or abdominal distress
* feeling dizzy, unsteady, light-headed, or faint  chills or heat sensations
* derealization (feelings of unreality) or depersonalization
(being detached from one-self)
* fear of losing control or "going crazy"
* fear of dying
* persistent fear or worry about additional panic attacks or their
consequences
* significant maladaptive change in behavior related to the
attacks
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 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?
[ ] Yes [X] No [ ] Not Applicable (N/A)
If no, provide reason:
It is not feasible to parse out the veteran's level of
occupational/social impairment (a global assessment of impairment)
into diagnostic categories as the conditions have a significant,
bidirectional impact on one another with significant overlap in
symptoms.
NOTE: The overall functional impairment of this veteran is best
conceptualized via the chosen statement above in Section 1, Item 4a
("occupational and social impairment...") and NOT the symptoms
checklist at the conclusion of this report (see section 2, Item 3 -
"Symptoms") as symptom endorsement alone do not capture the
frequency or severity of their presence.

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
[X] Other (please identify other evidence reviewed):
Veteran's electronic C-File (through VBMS) and CPRS medical records
were reviewed. Particular attention was directed to 
previous C&P examination 

You were not diagnosed with PTSD. But, you were diagnosed with the two mental health conditions above. I'm not trying to give you false hope, but it appears you received a favorable decision.

#1. You met the in-service stressor criteria

#2. You met the diagnosis criteria

#3. You met the minimum threshold of "at least as likely as not" as the result of an in-service
stressor related event. And a rationale was provided.

 

Look in Ebenefits in the "Disabilities" menu and see if your conditions were deemed service-connected or not service-connected. They will probably combine the "Other Specified Trauma- and Stressor-Related
Disorder with Panic Disorder" together . 

Why were they combined this way? It is a big no-no to pyramid conditions in VA disability claims. 

Best wishes.

Edited by doc25

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---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[ ] Yes [X] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Other Specified Trauma- and Stressor-Related
Disorder
ICD code: F43.8
Comments, if any:
Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD.
While the veteran did experience a Criterion A trauma event
(physical assault by significant other), her other significant
stressor in the service does NOT meet Criterion A (sexual
harassment), though the latter appears to have had a more long-term
impact on her functioning. She does NOT endorse, exhibit, and there
is no record of her experiencing core symptoms (arousal) that are
essential to a PTSD diagnosis based on the Criterion A stressor
(her arousal is far more closely related to her reported sexual
harassment). However, the veteran DOES meet DSM 5 diagnostic
criteria for Other Specified Trauma- and Stressor-Related Disorder.

It is AT LEAST AS LIKELY AS NOT that the Other Specified Trauma and Stressor-Related Disorder is the result of an in-service
stressor related event.

Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia
ICD code: F41.0
Comments, if any: Veteran also meets full DSM 5 diagnostic criteria for Panic

Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that
the veteran's Panic Disorder is SECONDARY TO her Other Specified
Trauma- and Stressor-Related Disorder.
Mental Disorder Diagnosis #3: Unspecified Depressive Disorder
ICD code: F32.9 

Comments, if any:
Veteran also meets full DSM 5 diagnostic criteria for Unspecified
Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the
veteran's Unspecified Depressive Disorder is SECONDARY TO her Other
Specified Trauma- and Stressor-Related 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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
PTSD Symptoms: 
* Sleep disturbance due to nightmares 
* Recurring/intrusive thoughts about his/her trauma(s). 
* Arousal symptoms, including hypervigilance, exaggerated startle
response; irritability/angry outbursts; difficulty remembering
specifics related to the trauma event(s); 
* Avoidance symptoms of avoiding reminders of the trauma(s);
having strong reactions when aspects of the trauma(s) are
encountered/experienced.
* Negative alterations in cognitions and mood associated with the
traumatic event(s)
Symptoms associated with veteran's depressive disorder include:
* depressed mood most of the day, nearly every day
* markedly diminished interest in or pleasure in all, or almost
all, activities most of the day, nearly every day
* significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in
appetite nearly every day
* insomnia or hypersomnia nearly every day
* psychomotor agitation or retardation nearly every day
(observable to others)
* fatigue or loss of energy nearly every day
* feelings of worthlessness or excessive or inappropriate guilt
nearly every day
* diminished ability to think or concentrate, or indecisiveness,
nearly every day
* recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation or suicidality
OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not
limited to:
sleep problems (related to onset and maintenance);
fatigue;
concentration difficulties; difficulties experiencing
positive
emotions; feeling isolated or disconnected from others;
loss of
interest in previously enjoyable activities; having
strong negative
beliefs about oneself, the world, others. As well as
feelings of
worthlessness or excessive or inappropriate guilt nearly
every day.
Symptoms associated with veteran's panic disorder include:
* palpitations, pounding heart, or accelerated heart rate
* excessive perspiration/sweating
* trembling or shaking
* sensation of shortness of breath or smothering
* feelings of choking
* chest pain or discomfort
* nausea or abdominal distress
* feeling dizzy, unsteady, light-headed, or faint  chills or heat sensations
* derealization (feelings of unreality) or depersonalization
(being detached from one-self)
* fear of losing control or "going crazy"
* fear of dying
* persistent fear or worry about additional panic attacks or their
consequences
* significant maladaptive change in behavior related to the
attacks
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 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?
[ ] Yes [X] No [ ] Not Applicable (N/A)

If no, provide reason:
It is not feasible to parse out the veteran's level of
occupational/social impairment (a global assessment of impairment)
into diagnostic categories as the conditions have a significant,
bidirectional impact on one another with significant overlap in
symptoms.

NOTE: The overall functional impairment of this veteran is best
conceptualized via the chosen statement above in Section 1, Item 4a
("occupational and social impairment...") and NOT the symptoms
checklist at the conclusion of this report (see section 2, Item 3 -
"Symptoms") as symptom endorsement alone do not capture the
frequency or severity of their presence.

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
[X] Other (please identify other evidence reviewed):
Veteran's electronic C-File (through VBMS) and CPRS medical records
were reviewed. Particular attention was directed to 
previous C&P examination ] dated: n/a
prior mental health notes: CPRS 

VBMS documents including, but not limited to: buddy/lay statement

DD-214; STRs (negative for psych, depression, anxiety)
VA Form 21-0781 
VA Form 21-526EZ
No collateral information was available in C-file and no collaterals
joined veteran to C&P evaluation. 
Evidence Comments:
DBQ PSYCH PTSD Initial:

Please review the Veteran's electronic folder in VBMS and state that it was 
reviewed in your report. MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION: Direct service connection
Does the Veteran have a diagnosis of (a) post traumatic Stressor disorder 
that is at least as likely as not (50 percent or greater probability) 
incurred in or caused by (the) personal trauma during service?
Rationale must be provided in the appropriate section.
If more than one mental disorder is diagnosed please comment on their 
relationship to one another and, if possible, please state which symptoms 
are attributed to each disorder.
If your examination determines that the Veteran does not have diagnosis of 
PTSD and you diagnose another mental disorder, please provide an opinion as 
to whether it is at least as likely as not that the Veteran's diagnosed 
mental disorder is a result of an in-service stressor related event.

Additional remarks for the examiner:
Tab B (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 
Tab C (Stressor Statement in VBMS) Stessor Statement VAF 21-0781

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: sexual harrasment (mainly verbal with some physical
posturing)
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[ ] Yes [X] No
Is the stressor related to the Veteran's fear of hostile military or
terrorist activity?
[ ] Yes [X] No
If no, explain:
sexual harrassment
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.
MST event

b. Stressor #2: physical assault while pregnant by significant other (which
prompted her military discharge)
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:
personal assault
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.
see above
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] No criterion in this section met.
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] 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 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.
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] 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 #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] Panic attacks more than once a week
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Difficulty in adapting to stressful circumstances, including work or a
worklike setting
[X] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[X] Neglect of personal appearance and hygiene
[X] Intermittent inability to perform activities of daily living,
including maintenance of minimal personal hygiene.

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
--------------------------------------------------
As part of this C&P evaluation, veteran was administered the PTSD
Checklist - DSM 5 (PCL-5) & Beck Depression Inventory - Second Edition
(BDI-II). 
The PTSD Checklist - DSM 5 is a 20-item self-report instrument for
measuring the severity of criteria for posttraumatic stress disorder. Ms.(......)
PCL score of 68 is above the recommended score that is typically
indicative of PTSD symptomatology (31-33 based on Bovin et al., 2015,
Psych Assessment; maximum score of 80). No previous administration(s) of
this instrument were located in the veteran's records. The PCL is
considered a screening measure and does NOT include validity scales. As
such, it is susceptible to positive and negative impression management.
The Beck Depression Inventory - Second Edition (BDI-II) is a 21-item
self-report instrument for measuring the severity of depression in adults
and adolescents aged 13 years and older. Ms. (........) BDI-II score of 46 is
indicative of severe depressive symptoms being endorsed at the present
time. No previous administration(s) of this instrument were located in the
veteran's records. The BDI-2 is considered a screening measure and does
NOT include validity scales. As such, it is susceptible to positive and negative impressions.

Timeline

C and p exam done Monday 12/31/2018 

Results ready/claim status change to prep for decision on        Thursday 01/03/2019

Friday 01/04/2019 pending decision approval

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