bleggett29

Seaman
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About bleggett29

  • Rank
    E-3 Seaman
  • Birthday 07/06/1973

Profile Information

  • Location
    Southern Maryland

Previous Fields

  • Service Connected Disability
    100%
  • Branch of Service
    Army
  1. 1) Addressed with reply to Chuck 75 2) The C-File is a different animal than just medical records from the NPR archive. You have to request the C-File from the VA with a FOIA request. 3) This will be a no-go unless you already filed within 1 year of separation and were denied and have new and substantial evidence.
  2. Are you sure on this. I contacted the Veterans Choice directly and was told it didn't matter if the closer clinic provided the services I needed; If any clinic was within the established distance, no Veterans Choice. However, you may be able to get "pay basis" (not sure on the terminology), if your local provider accepts. You'll still need to start the process with your VA PCP.
  3. With the original VA hearing test, the ratings you were awarded are correct. 10% tinnitus and 0% bilateral hearing loss. With the new hearing test you should get 10% tinnitus and 10% bilateral hearing loss. That'll give you a combined rating of 20% (and just about double your monthly VA pay) if you don't have other SC disabilities.
  4. As some of you may know, I was recently awarded 100% P&T. I have a single 100% rating for Panic Disorder w/ Agoraphobia plus 10% Tinnitus and 0% Bilateral Hearing Loss. What do I need to do to claim A&A and Housebound? Thanks Brian
  5. More good news! Pending deposit of the expected retro amount drops tomorrow. I'll have access to it just after midnight Friday. 2 weeks from C&P to getting retro!
  6. Thanks, everyone! The VARO just called to let me know of the news. I should have the retro in my account within 5-7 business days.
  7. Just got my commissary letter on ebenefits. "This total disability is considered permanent. You are not scheduled for future examinations." Happy dance!!
  8. ebenefits is showing Preparation for Notification. That was pretty darn quick.
  9. Thanks, everyone! I also had another question on the other thread if the va will finalize one contention (this) of a claim before the rest of the claim (hearing loss, etc.). I emailed Under Secretary Hickey this same question. She says yes and shes contacting the local VARO to get it moving along.
  10. Thanks for the encouragement, pete992! What I'm concerned with is: 3. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks that occur weekly or less often [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [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 worklike setting [X] Impaired impulse control, such as unprovoked irritability with periods of violence
  11. In another part of this forum I had some questions about my recent mental health C&P. I had been asked to post the C&P notes, which can be found I decided to start a new post here because this area of the forum seems more appropriate and the other post seems to became stale. I am asking the likelihood the raiter agrees with the examiner and approves the claim. I am also asking opinions on which % rating will be applied. Initially, I was thinking 70% or 100%. But after getting and reviewing the notes, I fear 30% may be the rate applied. Thanks
  12. Above is the C&P exam DBQs. After further review, I am worried that the symptoms listed may limit me to 30%, despite that the examiner checked Total Occupational and Social Impairment.
  13. LOCAL TITLE: COMPENSATION ASSESSMENT COPY STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JUN 27, 2015@11:30 ENTRY DATE: JUN 29, 2015@08:41:22 AUTHOR: MARECK,SUSAN G EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Name of patient/Veteran: *********** SECTION I: ---------- 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes[ ] No ICD code: 300.01, 300.02 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Panic Diosrder ICD code: 300.01 Comments, if any: Veteran has a history Panic Attacks, with persistent concern about having another attack and significant maladaptive behavior change related to the panic attacks. Veteran's sleep disturbance is a symptom of Panic Disorder, he does not meet criteria for alcohol abuse or another stress disorder at this time. He does not meet criteria for a DSM IV or DMS 5 diagnosis of PTSD. Mental Disorder Diagnosis #2: Agorapobia ICD code: 300.02 Comments, if any: Veteran reports excessive axniety in using public transportation, being outside the home alone or being in enclosed places. Agoraphobia is secodary to Veteran's Panic Disorder. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): non identified 2. 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: Veteran's fear of leaving home is attributable to Agoraphobia and his recurrent panic attacks and maladaptive behavior change related to the panic attacks are attributable to panic disorder. Veteran also has symptoms suggestive of Generalized Anxiety Disorder and Social Phobia but does not meet full criteria for either condition. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[ ] No[X] Not shown in records reviewed 3. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Total occupational and social impairment b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[X] No[ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Both conditions significantly impact Veteran's social and occupational functioning. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ a. Medical record review: Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: efolder b. Was pertinent information from collateral sources reviewed? [ ] Yes[X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Veteran raised in an intact family with a younger brother, his parents divorced when he was about 16. He lived with his mother for about a year and then moved in with father. His father had re-married, Veteran had a younger step-sister in the home. No reported childhood abuse issues. He described his childhood, his father was in the Navy, would be gone for about 6 months of the year, most of his childhood, he lived overseas. He got along with other children and was active. He reports being evaluated at Walter Reed around age 10 due to some speech issues, but does not recall the outcome of the evaluation and he does not recall being in any special education classes. Veteran has been married since 2003, they have a 11 year old son and a 10 year old daughter. He reports his relationship with his wife is "very strained", "we have our ups and downs" depending on his mood. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran served in the USA from 1992-1998, he was given an Under Honorable Conditions Discharge as an E1. He lost rank, from E4 to E1 due to an DUI. His mos was combat engineer. Veteran graduated from high school, he recently attempted to take some college classes, he started in the fall of 2014, but reports not being able to pass any classes. After the military he worked in fast food restaurants, initially as a driver, then assistant manager. He was fired due to anxiety symptoms in 2012 and has not worked since. He reports kicking over a trash can and knocking over a few stacks of trays. He tried to return to work at Pizza Hut in July, 204 but reports not only lasting 2 days, he was not able to tolerate the noise. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Veteran reports a history of ADHD and behavioral problems in his son and a maternal cousin has severe anxiety problems. Veteran exit exam documented "SOB sometimes secondary to anxiety attacks". Veteran was involved in a MVC, he hit three other vehicles, on 4/9/98 while under the influence of alcohol. Veteran reports no treatment for anxiety until 2012. He would experience a panic attack about once a year until 2012, when he started having panic attacks one - two a day. He initially thought he was having heart problems. Veteran seen in the ER at St. Mary's Hospital on 2/16/12 with c/o chest pain, on 4/13/12 with a diagnosed of Anxiety Disorder, 6/19/13 with c/o Paresthesias in both hands and feet. Veteran was admitted to St. Mary's Hospital with a diagnosis of Anxiety Disorder, Suicidal Risk, and Depression in 10/2012. Medications included Paxil for mood and Trazodone for sleep with plan to f/u at Charlotte Hall CBOC. Veteran initially seen by PCP at the CH CBOC on 0/6/12, he reported a history of anxiety. He was referred to Psychiatry and see via tele-health on 10/3/12 by Dr. Shao who diagnosed Veteran with a Depressive Disorder NOS and Panic Disorder without Agoraphobia. He had previously been in treatment at Walden Sierra, a non VA clinic, for 8-9 months. He was next seen by Dr. Shao on 3/7/14, after f/u at the Baltimore Glen Burnie CBOC in 2013. He reports his son was being treated at St. Vincent's Villa for about a year, so Veteran would save gas by being able to visit his son and be seen at the clinic. Veteran is currently prescribed Paxil and Buspar by a non VAMC provider. He is currently followed by the Walden Sierra Clinic. He reports in Bosnia he was involved with helping the Bosnian Army remove land minds, he witnessed a local being killed by a land mind. Another time, they were woken up in the middle of the night and left camp, "I was panicking", he thought they were going to war and on the way back an MIAI accidently went off and stuck the vehicle behind it, Veteran was 2-3 three vehicles behind the struck vehicle. No one was injured, Veteran reports it was very frightening at the time. He does not report cuurent symptoms related to exposure to these incidents. He reports occasional thoughts of his deployment that are not intrusive, he does not endorse avoidance symptoms or alterations in cognition related to trauma exposure. Veteran reports on-going anxiety issues since the military. He reports being in a combat unit, drinking "seemed the thing to do", He reports no alcohol use prior to the military, his 2012 MH evaluation stated Veteran started drinking 2-3 months ago, and drinks 1-2 times a month. Veteran did not think that was accurate, he states they do not keep alcohol in the house and he does not drink. Veteran reports he is very irritable. He has trouble falling asleep and staying asleep. He reports leaving the house is a challenge. If he has to go by himself, he will go into the store, get what he needs and leaves. He is not able to go grocery shopping with his wife because he becomes to anxious. He reports when he "gets up the courage" to go to dinner, he has to sit in a corner with his back to the rest of the people, "I don't want to see people, "I have a fear of what people think of me". He reports isolating himself at home. He reports experiencing a panic attack at least once every two week. He worries about having a panic attack. He reports he is able to drive in his local area, but if he has to drive more than 15 miles, he will have a panic attack, "I don't like the uncertainty of not being able to get home when I need to". He has been offered free bus passes in his community but he has refused them, because "I can't leave when I need to". He reports when talking to people he avoids eye contact due to his anxiety. He reports avoiding doing work outside around the house because he does not like people watching him. He reports in 2012, he had thoughts of suicide by ingesting his Xanax, which led to his hospitalization in 10/2012. Prior to 2012 he also reports thoughts of death, he denies suicidal ideation since 2012. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran has a history of DUI in 1998. Denies current legal issues. He reports hitting his wife one time earlier this year, "I was almost arrested but my wife decided not to press charges". He reports having problems with anger and irritablity but has been to "stop myself" before acting out in anger. e. Relevant Substance abuse history (pre-military, military, and post-military): Veteran has a history of DUI in 1998, f. Other, if any: Veteran idenitified by full name and DOB; limits of confidently reveiwed. 3. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks that occur weekly or less often [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [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 worklike setting [X] Impaired impulse control, such as unprovoked irritability with periods of violence Behavioral observations: Behavioral observations: Veteran arrived on time for the evaluation. Orientation: Alert and oriented x 4 Behavior/relatedness: Cooperative and attentive Appearance: Appeared stated age, casually dressed, adequately groomed. Eye Contact: appropriate Psychomotor: WNL Communication Barriers: None apparent or reported Speech: WNL for rate, volume, production, prosody Mood/Affect: Mood appears very anxious, affect appropriate to context and content Thought Content: WNL, no auditory of visual hallucinations reported, no apparent delusions or paranoia. Thought Process: logical, linear, goal-directed, and coherent Judgment: Intact Insight: Intact Suicidal Ideation: Denied, reports history of suicidal ideation, last in 2012. Homicidal Ideation: Denied 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [X] Yes[ ] No 5. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 6. Remarks (including any testing results), if any: --------------------------------------------------- DBQ PSYCH Mental disorders: 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 mental disorder with depression, anxiety, sleep disturbances, alcohol abuse, and stress disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by events and/or activities that occurred during service? Rationale must be provided in the appropriate section. Additional remarks for the examiner: The Veteran's miliatary personnel file and DD 214 shows that he served in Saudi Arabia from 08/05/1993 to 12/06/1993 and in Bosnia from 03/20/1997 to 10/27/1997. The Veteran relates a stressor which began mid deployment to Bosnia in 1997. Veteran states that he performed mine clearing and lane proofing with an M60 Panther and was subject to frequent threats of attack from local citizens, witnessing 2 incidents of local military members being killed from a detonated mine while mine clearing. Veteran also states that he was near (2-3 miles) the Brcko riot on 08/26/1998. Veteran also describes an incident when he was woken in the middle of the night and instructed to be battle ready and were leaving camp within the hour. After traveling approximately 3-4 hours they arrived at a large open field, several hours later they began to return to camp, on the way back the COAX from a M113 behind the HMMWV was hit. The Veteran states that these events caused several minor anxiety attacks which he had never experienced prior to these events and that these anxiety attacks have increased in number and severity over time. ***Please comment on the effect of the Veteran's service connected disabilities on his or her ability to function in an occupational environment and describe any identified functional limitations. Please refrain from opining on if the veteran is unemployable or employable; instead focus and reflect on the functional impairments and how these impairments impacts occupational and employment activities. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection. OPINION REQUESTED: Secondary Service Connection. Is the Veteran's mental disorder with depression, anxiety, sleep disturbances, alcohol abuse, and stress disorder at least as likely as not (50 percent at least as likely as not (50 percent or greater probability) proximately due to or the result of bilateral hearing loss? Rationale must be provided in the appropriate section. ***Please comment on the effect of the Veteran's service connected disabilities on his or her ability to function in an occupational environment and describe any identified functional limitations. Please refrain from opining on if the veteran is unemployable or employable; instead focus and reflect on the functional impairments and how these impairments impacts occupational and employment activities. Potentially relevant evidence NOTE: The examiner's review of the record is NOT restricted to the evidence listed below. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Tab#1: STRs, Vol.#1, Pg.#56; Entrance Physical Examination dated 06/19/1992. Document ID# 2829/CACI_143153101P001020602.pdf Tab#2: Military Personnel Records Vol.#5, Pg.#7; DA Form 2-1, Personnel Qualification Record - Part II shows service in Saudi Arabia 08/05/1993 to 12/06/1993. Document ID# 2829/CACI_143153101P001020602.pdf Tab #3: DD 214 shows service in Bosnia from 03/20/1997 to 10/27/1997. Document ID# 2829/CACI_143153101P001020602.pdf Tab#4: STRs, Vol.#2, Pg.1; Separation Physical Examination dated 05/19/1998. Document ID# 2829/CACI_143153101P001020602.pdf VHA CAPRI data base to include VISTAWEB and DOD Records: Washington VAMC current problem list shows diagnosis for Anxiety, Depression , memory impairment and hearing loss. **************************************************************************** Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: *********** SECTION I: ---------- 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 If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Panic Diosrder ICD code: 300.01 Comments, if any: Veteran has a history Panic Attacks, with persistent concern about having another attack and significant maladaptive behavior change related to the panic attacks. Veteran's sleep disturbance is a symptom of Panic Disorder, he does not meet criteria for alcohol abuse or another stress disorder at this time. He does not meet criteria for a DSM IV or DMS 5 diagnosis of PTSD. Mental Disorder Diagnosis #2: Agorapobia ICD code: 300.02 Comments, if any: Veteran reports excessive axniety in using public transportation, being outside the home alone or being in enclosed places. Agoraphobia is secodary to Veteran's Panic Disorder. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): non identified 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: Veteran's fear of leaving home is attributable to Agoraphobia and his recurrent panic attacks and maladaptive behavior change related to the panic attacks are attributable to panic disorder. Veteran also has symptoms suggestive of Generalized Anxiety Disorder and Social Phobia but does not meet full criteria for either condition. 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 level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [X] No [ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Both conditions significantly impact Veteran's social and occupational functioning. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: e-folder b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Veteran raised in an intact family with a younger brother, his parents divorced when he was about 16. He lived with his mother for about a year and then moved in with father. His father had re-married, Veteran had a younger step-sister in the home. No reported childhood abuse issues. He described his childhood, his father was in the Navy, would be gone for about 6 months of the year, most of his childhood, he lived overseas. He got along with other children and was active. He reports being evaluated at Walter Reed around age 10 due to some speech issues, but does not recall the outcome of the evaluation and he does not recall being in any special education classes. Veteran has been married since 2003, they have a 11 year old son and a 10 year old daughter. He reports his relationship with his wife is "very strained", "we have our ups and downs" depending on his mood. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran served in the USA from 1992-1998, he was given an Under Honorable Conditions Discharge as an E1. He lost rank, from E4 to E1 due to an DUI. His mos was combat engineer. Veteran graduated from high school, he recently attempted to take some college classes, he started in the fall of 2014, but reports not being able to pass any classes. After the military he worked in fast food restaurants, initially as a driver, then assistant manager. He was fired due to anxiety symptoms in 2012 and has not worked since. He reports kicking over a trash can and knocking over a few stacks of trays. He tried to return to work at Pizza Hut in July, 204 but reports not only lasting 2 days, he was not able to tolerate the noise. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Veteran reports a history of ADHD and behavioral problems in his son and a maternal cousin has severe anxiety problems. Veteran exit exam documented "SOB sometimes secondary to anxiety attacks". Veteran was involved in a MVC, he hit three other vehicles, on 4/9/98 while under the influence of alcohol. Veteran reports no treatment for anxiety until 2012. He would experience a panic attack about once a year until 2012, when he started having panic attacks one - two a day. He initially thought he was having heart problems. Veteran seen in the ER at St. Mary's Hospital on 2/16/12 with c/o chest pain, on 4/13/12 with a diagnosed of Anxiety Disorder, 6/19/13 with c/o Paresthesias in both hands and feet. Veteran was admitted to St. Mary's Hospital with a diagnosis of Anxiety Disorder, Suicidal Risk, and Depression in 10/2012. Medications included Paxil for mood and Trazodone for sleep with plan to f/u at Charlotte Hall CBOC. Veteran initially seen by PCP at the CH CBOC on 0/6/12, he reported a history of anxiety. He was referred to Psychiatry and see via tele-health on 10/3/12 by Dr. Shao who diagnosed Veteran with a Depressive Disorder NOS and Panic Disorder without Agoraphobia. He had previously been in treatment at Walden Sierra, a non VA clinic, for 8-9 months. He was next seen by Dr. Shao on 3/7/14, after f/u at the Baltimore Glen Burnie CBOC in 2013. He reports his son was being treated at St. Vincent's Villa for about a year, so Veteran would save gas by being able to visit his son and be seen at the clinic. Veteran is currently prescribed Paxil and Buspar by a non VAMC provider. He is currently followed by the Walden Sierra Clinic. He reports in Bosnia he was involved with helping the Bosnian Army remove land minds, he witnessed a local being killed by a land mind. Another time, they were woken up in the middle of the night and left camp, "I was panicking", he thought they were going to war and on the way back an MIAI accidently went off and stuck the vehicle behind it, Veteran was 2-3 three vehicles behind the struck vehicle. No one was injured, Veteran reports it was very frightening at the time. He does not report cuurent symptoms related to exposure to these incidents. He reports occasional thoughts of his deployment that are not intrusive, he does not endorse avoidance symptoms or alterations in cognition related to trauma exposure. Veteran reports on-going anxiety issues since the military. He reports being in a combat unit, drinking "seemed the thing to do", He reports no alcohol use prior to the military, his 2012 MH evaluation stated Veteran started drinking 2-3 months ago, and drinks 1-2 times a month. Veteran did not think that was accurate, he states they do not keep alcohol in the house and he does not drink. Veteran reports he is very irritable. He has trouble falling asleep and staying asleep. He reports leaving the house is a challenge. If he has to go by himself, he will go into the store, get what he needs and leaves. He is not able to go grocery shopping with his wife because he becomes to anxious. He reports when he "gets up the courage" to go to dinner, he has to sit in a corner with his back to the rest of the people, "I don't want to see people, "I have a fear of what people think of me". He reports isolating himself at home. He reports experiencing a panic attack at least once every two week. He worries about having a panic attack. He reports he is able to drive in his local area, but if he has to drive more than 15 miles, he will have a panic attack, "I don't like the uncertainty of not being able to get home when I need to". He has been offered free bus passes in his community but he has refused them, because "I can't leave when I need to". He reports when talking to people he avoids eye contact due to his anxiety. He reports avoiding doing work outside around the house because he does not like people watching him. He reports in 2012, he had thoughts of suicide by ingesting his Xanax, which led to his hospitalization in 10/2012. Prior to 2012 he also reports thoughts of death, he denies suicidal ideation since 2012. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran has a history of DUI in 1998. Denies current legal issues. He reports hitting his wife one time earlier this year, "I was almost arrested but my wife decided not to press charges". He reports having problems with anger and irritablity but has been to "stop myself" before acting out in anger. e. Relevant Substance abuse history (pre-military, military, and post-military): Veteran has a history of DUI in 1998, f. Other, if any: Veteran idenitified by full name and DOB; limits of confidently reveiwed. 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: Deployed to Bosnia, witnessed a Bosnian SM killed, was on night mission, when a weapon accidently fired and hit another vehicle 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? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criteria 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 Criteria 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 violation, in one or more of the following ways: [X] Witnessing, in person, the traumatic event(s) as they occurred to others 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: No response provided. 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: No response provided. 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: No response provided. 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: No response provided. Criterion F: No response provided. Criterion G: No response provided. Criterion H: No response provided. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: No response provided. 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks that occur weekly or less often [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [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 worklike setting [X] Impaired impulse control, such as unprovoked irritability with periods of violence 6. Behavioral Observations -------------------------- Behavioral observations: Veteran arrived on time for the evaluation. Orientation: Alert and oriented x 4 Behavior/relatedness: Cooperative and attentive Appearance: Appeared stated age, casually dressed, adequately groomed. Eye Contact: appropriate Psychomotor: WNL Communication Barriers: None apparent or reported Speech: WNL for rate, volume, production, prosody Mood/Affect: Mood appears very anxious, affect appropriate to context and content Thought Content: WNL, no auditory of visual hallucinations reported, no apparent delusions or paranoia. Thought Process: logical, linear, goal-directed, and coherent Judgment: Intact Insight: Intact Suicidal Ideation: Denied, reports history of suicidal ideation, last in 2012. Homicidal Ideation: Denied 7. Other symptoms ----------------- Does the Veteran have any other symptoms at
  14. Broncover, below are from my Aug 2013 C&P: +=======================+ | RIGHT EAR | 96% | |=============+=========| | LEFT EAR | 96% | +=======================+ RIGHT EAR +==============================================================+ | A | B | C | D | E | F | G | |========+========+========+========+========+========+========+========+ | 500 | 1000 | 2000 | 3000 | 4000 | 6000 | 8000 | Avg Hz | | Hz* | Hz | Hz | Hz | Hz | Hz | Hz | (B-E)**| |========+========+========+========+========+========+========+========| | 20 | 30 | 50 | 65 | 60 | 60 | 55 | 51 | +=======================================================================+ LEFT EAR +==============================================================+ | A | B | C | D | E | F | G | |========+========+========+========+========+========+========+========+ | 500 | 1000 | 2000 | 3000 | 4000 | 6000 | 8000 | Avg Hz | | Hz* | Hz | Hz | Hz | Hz | Hz | Hz | (B-E)**| |========+========+========+========+========+========+========+========| | 15 | 30 | 45 | 70 | 80 | 75 | 75 | 56 | +=======================================================================+