Full C&P Exam Review - VA Disability Claims Research - VA Disability Community via Hadit.com Jump to content
VA Disability Community via Hadit.com
  • ask-your-va-disability-claims-question.png

    27-year-anniversary-leaderboard.png

    advice-disclaimer.jpg

  • 01-2024-stay-online-donate-banner.png

  • 0

Full C&P Exam Review

Rate this question


Xab5575

Question

Please tell me what you think...ptsd increase 70%-100%

SECTION I - DIAGNOSTIC SUMMARY

1.    DIAGNOSTIC SUMMARY

NOTE: This section should be completed based on the current examination and clinical findings.

Does the Veteran now have or has he/she ever been diagnosed with PTSD?

[X] Yes D No

Ifyes, continue to complete this Questionnaire.

Ifno diagnosis of PTSD, and the Veteran has another Mental Disorder, then continue to complete this Questionnaire and/or the Eating Disorder Questionnaire.

2.    CURRENT DIAGNOSES

2A. Mental Disorders Diagnosis #I:

1 Post-Traumatic Stress Disorder

!CD Code:      F  4�3_.l                      

Comments, ifany:

 

 

Comments, if any:

 

Mental Disorders Dia_gnosis #3:

!CD Code:                                     

Comments, ifan

 

Mental Disorders Dia_g_nosis #4:

!CD Code:

Comments1 ifan

 

Ifadditional diagnoses, describe using above format:

 

2B. Medical diagnoses relevant to the understanding or management ofthe Mental Health Disorder (to includ e TB!):

none

!CD Code:

Comments, ifan

 

3.    DIFFERENTIATION OF SYMPTOMS

3A. Does the Veteran have more than one mental disorder diagnosed? [X]Yes []No

(If ''Yes," complete Item JB)

3B. ls it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [] Yes [X] No []Not applicable

(If "No," provide reason):

 

PTSD Disability Benefits Questionnaire Page 2 of8

 

 

Many symptoms of the two disorders overlap, but nightmares and intrusive thoughts of his military experiences are unique to his

PTSD.

(If "Yes," list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between

these dia1<noses)_:

 

 

 

 
 

 

 

 

3C. Does the Veteran have a diagnosed traumatic brain injury (TB!)?

[] Yes [X] No [] Not shown in records reviewed

(If "Yes," complete Item 3D)

(Comments, if any):                                                                                                                                                                                                                         

 

 
 

 

 

3D. Is it possible to differentiate what symptom(s) is/are attributable to TB! and any non-TB! mental  health diagnosis? [] Yes [] No [X] Not applicable

 
   


(If "No," provide reason):

 

 

4.    OCCUPATIONAL AND SOCIAL IMPAIRMENT

4A. Which of the following best summarizes the Veteran's level ofoccupational and social impairment with regards to all mental diagnoses? (Check only one)

[] No mental disorder diagnosis

[] 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

[] 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 medication

[] 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

[] Occupational and social impairment with reduced reliability and productivity

[] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking

and/or mood

[X] Total occupational and social impairment

 

4B. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impainnent indicated above is caused by each mental disorder?

[X]  Yes [] No [] Not applicable

(If "No," provide reason):

 

  airment.

4C. If a diagnosis ofTBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by

the TB!?

[] Yes [] No [X] Not applicable

(If "No," provide reason):

 

(If "Yes," list which impairment is attributable to TB! and which is attributable to any non-TB! mental health diagnosis):

 

 

PTSD Disability Benefits Questionnaire Page 3 of8

 

SECTION II - CLINICAL FINDINGS

1.    EVIDENCE REVIEW

In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed.

 

 

Evidence reviewed (check all that apply): [] Not requested

[] VA claims file (hard copy paper C-file)

[X] VA e-folder [] CPRS

[] Other (please identify other evidence reviewed):

 

 

[] No records were reviewed

 

 

Evidence comments:

I Records show diagnosis ofPTSD and bipolar disorder

 

2.    RECENT HISTORY (since prior exam)

2A. Relevant Social/Marital/Family history:

The Veteran reports he remains married to his wife of 14 years. They have eight children. He said his relationship with all of his

family members is very problematic. He reports he socializes with no one.

 

2B. Relevant Occupational and Educational history:

The Veteran continues to work for the DoD in a civilian capacity. He has worked in supply for five years and has been written up,

counseled, and moved many times.

 

2C. Relevant Mental Health history, to include prescribed medications and family mental health:

The Veteran is followed in mental health at the VA. He takes aripiprazole, valproic acid, and prazosin.

 

 

 

 

2E. Relevant Substance Abuse history:

The Veteran denies any alcohol use in about three years. He denies illicit drug use.

 

2F. Other, ifany:

 

 

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 violation, in one or more ofthe following ways:

[X] Directly experiencing the traumatic event(s)

[] Witnessing, in person, the traumatic event(s) as they occurred to others

[] Leaming that the traumatic event(s) occurred to a close family member or close friend; cases ofactual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details ofchild abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related

[] No criterion in this section met.

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:

 

PTSD Disability Benefits Questionnaire Page 4 of8

 

4.         SYMPTOMS

For VA rating purposes, check all symptoms that apply to the Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[] Panic attacks that occur weekly or less often [] Panic attacks more than once a week

[] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively

[X] Chronic sleep impairment

[] Mild memory loss, such as forgetting names, directions or recent events

[] Impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks

[] Memory loss for names of close relatives, own occupation, or own name

[] Flattened affect

[] Circumstantial, circumlocutory or stereotyped speech [] Speech intermittently illogical, obscure, or irrelevant [] Difficulty in understanding complex commands

[] Impaired judgment

[] Impaired abstract thinking

[] Gross impairment in thought processes or communication

[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 work like setting

[X] Inability to establish and maintain effective relationships

[X] Suicidal ideation

[] Obsessional rituals which interfere with routine activities

[X]  Impaired impulse control, such as unprovoked irritability with periods of violence [] Spatial disorientation

[] Persistent delusions or hallucinations

[] Grossly inappropriate behavior

[] Persistent danger of hurting self or others

[] Neglect of personal appearance and hygiene

[] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene [] Disorientation to time or place

 

5.         BEHAVIORAL OBSERVATIONS

The Veteran arrived early for his appointment. He was fully cooperative. Eye contact was limited. He displayed marked anxiety.

Mood was anxious, depressed, and angry; affect was appropriate to content. Speech was pressured. He was oriented in all spheres

and memory was grossly intact. Insight was limited and judgment was adequate. He denied current suicidal or homicidal intent.

 

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

(If "Yes," describe):

 

 

 
 

 

 

 

7.         COMPETENCY

Is the Veteran capable of managing his or her financial affairs? [X]Yes []No

(If "No," explain}:                                                                                                                                                                                                                   

 

 

 
 

 

 

 

8.        
 
 

REMARKS, (including any testing results) IF ANY:

The Veteran indicated he had a mental health appointment at the VA this afternoon and said he was planning on keeping that

appointment. He said he was hoping to have his medications assessed and possibly adjusted and said he wanted to get more intensive

 

 

PTSD Disability Benefits Questionnaire Page 6 of8

 

 

 

 

[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).

[] 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). [] No criterion in this section met.

 

Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(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).

[] 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).

[] No criterion in this section met.

 

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:

[] 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 to 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.)

[] No criterion in this section met.

 

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.

[] Reckless or self-destructive behavior.

[X] Hypervigilance.

[] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). [] No criterion in this section met.

 

Criterion F:

[X] Duration of the disturbance (CriteriaB, C, D and E) is more than  1 month. [] Veteran does not meet full criteria for PTSD

 

Criterion G:

[X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

[] The PTSD symptoms described above do NOT cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning.

[] Veteran does not meet full criteria for PTSD

 

Criterion H:

[X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical

condition.

[] No criterion in this section met.

 

 

PTSD Disability Benefits Questionnaire Page 5 of8

 

 

 

 

therapy.

 

Additional comments regarding suicidal ideation, if any:

In the text box below please provide specific details on whether you feel the veteran is considered to be a current imminent risk (active ideation with current plan and/or intent) or increased but not current imminent risk (no current plan or intent to take action) of harm to him/herself.

NOTE: If you believe the veteran is a current imminent risk please contact your local authorities (police, 911, etc) and

document in the Remarks section that vou have done so.

I The Veteran is not a current imminent suicide or homicide risk.                                                                                                                                                                                                                    I

 

[X] I do not believe this Veteran/Service Member should be considered a current imminent or increased risk.

 

Please advise whether the Veteran was eouinned with the VA crisis line (800-273-TALK):

I  The Veteran said he alreadv  had contact information for the VA crisis line and had called it many times.                                                                                                                                                                                                                    I

 

Is there a need for the Veteran to follow up with his/her primary care provider regarding any life threatening findings in this examination (not limited to claimed condition(s))?

[] Yes [X] No

 

 

Additional Question I:

 

 

 

 

Answer Question 1:

 

 

Additional Question 2:

Answer Question 2:

 

THE VETERAN'S ESTABLISHED DIAGNOSIS IS POST-TRAUMATIC STRESS DISORDER WITH BIPOLAR DISORDER.

 

IF YOU HAVE PROVIDED ANY ADDITIONAL DIAGNOSES, OR IF THE ESTABLISHED DIAGNOSIS HAS CHANGED IN ANY WAY, PLEASE SELECT AT LEAST ONE FROM THE FOLLOWING:

 

A.                    THERE IS NO CHANGE IN THE SERVICE CONNECTED DIAGNOSIS AND NO ADDITIONAL DIAGNOSES HAVE BEEN RENDERED.

B.                    THE NEW DIAGNOSIS IS A CORRECTION OF THE PREVIOUS DIAGNOSIS.

C.                    THERE IS A WORSENING OF THE VETERAN'S SYMPTOMS HOWEVER NO CHANGE TO THE SERVICE CONNECTED DIAGNOSIS AND NO ADDITIONAL DIAGNOSES HAVE BEEN RENDERED.

D.                    ADDITIONAL CONDITIONS WERE FOUND WHICH ARE DIRECTLY DUE TO OR RELATED TO THE SERVICE CONNECTED DIAGNOSIS (I.E. A PROGRESSION).

E.                    ADDITIONAL CONDITIONS WERE FOUND WHICH ARE UNRELATED TO THE SERVICE CONNECTED DIAGNOSIS (I.E. A NEW AND SEPARATE CONDITION).

***FOR OPTION E, PLEASE SPECIFY WHICH OF THE VETERAN'S SYMPTOMS AND FINDINGS CORRESPOND WITH EACH DIAGNOSIS, IF FEASIBLE.***

F.                    THE SERVICE CONNECTED DIAGNOSIS HAS RESOLVED.

 

There is a worsening of the Veteran's symptoms, however, no change in the service-connected diagnosis and no additional diagnoses have been rendered.

 

FOR OPTIONS OTHER THAN A AND C PLEASE PROVIDE YOUR MEDICAL RATIONALE.

NIA

 

 

 

 

 

 

 

 

 

 

 

 

 

Link to comment
Share on other sites

  • Answers 1
  • Created
  • Last Reply

Top Posters For This Question

Top Posters For This Question

1 answer to this question

Recommended Posts

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...

Important Information

Guidelines and Terms of Use