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PTSD recent c&P exam

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Born2dothis

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These are the notes from the doctor, Can you tell me what you think from the examiners notes.  Trying to see what do you guys think about the total and social impairment

 

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 been diagnosed with PTSD? [X] Yes [ ] No ICD Code: f43.1 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD Comments, if any: Note that veteran had a C&P done MAY 21 2013 which was a PTSD-inital exam. Although stressors and symptoms were documented, he was not offered a full diagnosis of PTSD, but rather anxiety NOS was offered, which has remained service-connected diagnosis.  This examiner refines the service connected diagnosis to PTSD. He saw recently a non-VA disability examiner who did an exam , who offered a report (this examiner includes data from said report), who offered a diagnosis of PTSD. In summary, this examienr refines the service connected from anxiety disorder to PTSD.  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? [ ] Yes [X] No 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] Total occupational and social impairment 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  

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13 hours ago, Born2dothis said:

These are the notes from the doctor, Can you tell me what you think from the examiners notes.  Trying to see what do you guys think about the total and social impairment

 

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 been diagnosed with PTSD? [X] Yes [ ] No ICD Code: f43.1 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD Comments, if any: Note that veteran had a C&P done MAY 21 2013 which was a PTSD-inital exam. Although stressors and symptoms were documented, he was not offered a full diagnosis of PTSD, but rather anxiety NOS was offered, which has remained service-connected diagnosis.  This examiner refines the service connected diagnosis to PTSD. He saw recently a non-VA disability examiner who did an exam , who offered a report (this examiner includes data from said report), who offered a diagnosis of PTSD. In summary, this examienr refines the service connected from anxiety disorder to PTSD.  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? [ ] Yes [X] No 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] Total occupational and social impairment 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  

Unfortunately, this exam is absent of a nexus of opinion, does not state the necessary minimum threshold of "at least as likely as not" your condition was due to or the result of military service and a rationale was not provided. Did your outside provider provide the nexus of opinion?

Which is going to be sent back to the examiner for clarification and an addendum. This will delay your claim two weeks or more depending on the examiner's response.

 

Here is the good news. The c&p examiner basically agreed with your outside provider on a diagnosis for PTSD and the examiner marked the criteria for a 100% rating.

Relax. Breathe. It appears your exam went well, it's just going to take a bit longer than expected. The longer it takes the more in retro pay you will receive.

Best wishes.

Edited by doc25
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This looks like a highly positive diagnosis.  

General Rating Formula for Mental Disorders:
Total occupational and social impairment, due to such symptoms as: gross impairment in
thought processes or communication; persistent delusions or hallucinations; grossly inappropriate
behavior; persistent danger of hurting self or others; intermittent inability to perform activities
of daily living (including maintenance of minimal personal hygiene); disorientation to
time or place; memory loss for names of close relatives, own occupation, or own name .......... 100
Occupational and social impairment, with deficiencies in most areas, such as work, school, family
relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional
rituals which interfere with routine activities; speech intermittently illogical, obscure, or
irrelevant; near-continuous panic or depression affecting the ability to function independently,
appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods
of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty
in adapting to stressful circumstances (including work or a worklike setting); inability to
establish and maintain effective relationships .............................................................................. 70

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7 hours ago, vetquest said:

This looks like a highly positive diagnosis.  

General Rating Formula for Mental Disorders:
Total occupational and social impairment, due to such symptoms as: gross impairment in
thought processes or communication; persistent delusions or hallucinations; grossly inappropriate
behavior; persistent danger of hurting self or others; intermittent inability to perform activities
of daily living (including maintenance of minimal personal hygiene); disorientation to
time or place; memory loss for names of close relatives, own occupation, or own name .......... 100
Occupational and social impairment, with deficiencies in most areas, such as work, school, family
relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional
rituals which interfere with routine activities; speech intermittently illogical, obscure, or
irrelevant; near-continuous panic or depression affecting the ability to function independently,
appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods
of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty
in adapting to stressful circumstances (including work or a worklike setting); inability to
establish and maintain effective relationships .............................................................................. 70

I stand corrected.lol.

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