Okemos_Veteran74

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About Okemos_Veteran74

  • Rank
    E-3 Seaman

Previous Fields

  • Service Connected Disability
    TBI
  • Branch of Service
    US Army Reserve
  1. Has anyone had a referral to the BRS Program? I am a candidate for it and I am wondering if some of the services of this program have been helpful to others.
  2. question retracted.
  3. I have a question about how retroactive compensation. The rater finds that I have a disability at 70%. I know that over 70% disability I am paid at the TDIU rate. Would I receive retro compensation at the rate of 70% or at 100%?
  4. I received some new information this afternoon. Apparently the DRO thought that the claim for ptsd and IU were for an appeal. So they did not include the rating in the rating that I just received. I'm not sure I buy this completely. It sounds like I am being told that the C&P exams were going to be used for an appeal. However one of the one condition that I was rated for was Tinnitus. The tinnitus C&P was given at the same appointment that the PTSD and IU was. According to my VSO the DRO told her that they had made a mistake, and it would take a month or two to correct it. So I think my rating will go back to 40% , and I will loose the Tinnitus 10% and SMC-K. At least now I have my SSD.
  5. LOL. Thank you Berta for listening to me. I have heard that the SSD decision and the TDUI need to "line up" (Same conditions for both). I didn't get any opinions on the ADHD thing, because it was the last thing that was listed on my SSD decision. I thought that having the brain injury as the primary disabling condition was good enough. If this doesn't come back the way I want, then I am going to hire legal representation. I'm thankful that my disability % went from 40% to 50%, but I believe I deserve higher.
  6. Berta; To answer your questions: What is your VA Rating now and what for? TBI What is the rating for TBI? 40% What is the SSDI award for? TBI, affective disorders, anxiety and depression, adult ADHD. I did have my treating psy. write a nexus letter linking the Anxiety and Depression as secondary to the TBI.
  7. Here is a copy of my C&P from March of 2014 --------------- MY HEALTHEVET PERSONAL INFORMATION REPORT --------------- *************CONFIDENTIAL************* Produced by the VA Blue Button (v12.10) 04 Jan 2017 @ 0945 This summary is a copy of information from your My HealtheVet Personal Health Record. Your summary may include: - information that you entered (self reported) - information from your VA health record - your military service information from the department of defense (DoD). ***Note: Your health care team may not have all of the information from your Personal Health Record unless you share it with them. Contact your health care team if you have questions about your health information.*** Key: Double dashes (--) mean there is no information to display. Name: MAYS, FRANKLIN EUGENE Date of Birth: 21 Sep 1974 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 04 Jan 2017 @ 0945 File Name: mhv_MAYS_20170104_0945.txt Date Range Selected: 01 Mar 2014 to 01 Apr 2014 Data Types Selected: My HealtheVet Account Summary VA Notes --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 18 Apr 2014 Authentication Facility ID: 506 Authentication Facility Name: VA ANN ARBOR HEALTHCARE SYSTEM VA Treating Facility Type -------------------- ------ VBA BRLS na VA IDENTIFY PROOFING na VETERANS ID CARD SYSTEM na VBA CORP na BATTLE CREEK MI VAMC na DEPARTMENT OF DEFENSE DEERS na ENROLLMENT SYSTEM REENGINEERING na AUSTIN MHV na ST. LOUIS MO VAMC-JC DIVISION na VA ANN ARBOR HEALTHCARE SYSTEM na ------------------------------- VA NOTES -------------------------------- Source: VA Last Updated: 04 Jan 2017 @ 0908 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Date/Time: 26 Mar 2014 @ 1050 Note Title: TRAUMATIC BRAIN INJURY - TBI - CONSULT Location: VA HEALTHCARE SYSTEM Signed By: Co-signed By: Date/Time Signed: 26 Mar 2014 @ 1051 ------------------------------------------------------------------------- LOCAL TITLE: TRAUMATIC BRAIN INJURY - TBI - CONSULT STANDARD TITLE: TBI CONSULT DATE OF NOTE: MAR 26, 2014@10:50 ENTRY DATE: MAR 26, 2014@10:50:58 AUTHOR: PANGILINAN,PERCIVAL EXP COSIGNER: URGENCY: STATUS: COMPLETED for c/p details, please see c/p dated 3/26/14 /es/ Attending Physician, PM&R Signed: 03/26/2014 10:51 ------------------------------------------------------------------------- ========================================================================= Date/Time: 26 Mar 2014 @ 0937 Note Title: PSYCHOLOGY NEUROPSYCHOL CONSULT Location: VA ANN ARBOR HEALTHCARE SYSTEM Signed By: Co-signed By: Date/Time Signed: 26 Mar 2014 @ 1103 ------------------------------------------------------------------------- LOCAL TITLE: PSYCHOLOGY NEUROPSYCHOL CONSULT STANDARD TITLE: PSYCHOLOGY CONSULT DATE OF NOTE: MAR 26, 2014@09:37 ENTRY DATE: MAR 26, 2014@09:37:35 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED *** PSYCHOLOGY NEUROPSYCHOL CONSULT Has ADDENDA *** The patient was seen today for a neuropsychological screening evaluation in the context of his C&P examination for TBI. All testing was completed. Report to follow. /es/ PhD Psychology Postdoctoral Fellow Signed: 03/26/2014 11:03 /es/ , PhD Attending Psychologist Cosigned: 03/27/2014 11:40 03/27/2014 ADDENDUM STATUS: COMPLETED Report of Psychological Evaluation Neuropsychology Section, Mental Health Service - 116B VA Ann Arbor Healthcare System, Ann Arbor, MI 48105 Date Seen: 03/26/2014 Report Date: 03/27/2014 Name: MAYS, Franklin SS#: -0567 DOB: 09/21/1974 Age: 39 Education: 16 years Occupation: Preschool teacher Background and History: This Veteran has a history of a suspected mild traumatic brain injury from a parachuting accident in 1995. For a detailed history please see the associated TBI Clinic Consult. Referral: This is a report of brief, routine neuropsychological screening in the context of Compensation and Pension examination for TBI. It provides only general estimates of level of cognitive abilities and baseline data against which future changes in cognition can be compared. Tests Administered: Peabody Picture Vocabulary Test, 4th Edition (PPVT-4), Montreal Cognitive Assessment (MoCA), Wechsler Adult Intelligence Scale 4th Edition (WAIS-IV) Digit Span, Trail Making Test, Stroop Color Word Test, California Verbal Learning Test, Short Form (CVLT), TOMM Test of Memory, Rey 15-Item Memory Test, Modified Somatic Perception Questionnaire (MSPQ), Hospital Anxiety and Depression Scale, PTSD Checklist Military Version (PCL-M), Insomnia Severity Index, CAGE alcohol consumption measure, Brief Pain Inventory. (Mean and Standard Deviation) PPVT 116 (100+/-15) MoCA (23/30) -0.78 (0+/-1) Digit Span Total (5F, 4B, 4S) 7 (10+/-3) Forward 9 (10+/-3) Backward 7 (10+/-3) Sequencing (10+/-3) Trails A (39 sec, 0 errors) 30 (50+/-10) Trails B (112 sec, 0 errors) 27 (50+/-10) Stroop Word 30 (50+/-10) Color 33 (50+/-10) Color-Word 42 (50+/-10) Interference 54 (50+/-10) CVLT Trials 1-4 32 (50+/-10) LDFR -2.5 (0+/-1) Recognition -2.5 (0+/-1) F/C 89% Hospital Anxiety and Depression Scale Anxiety 15 (Severe) Depression 10 (Mild) Brief Pain Inventory current severity 5/10 MSPQ 22 Other Tests of Cognitive and Emotional Function Positive PCL-M (63), negative ISI (11), positive CAGE (2) Comments: The Veteran demonstrated somewhat variable task engagement on stand- alone and embedded tests of effort, suggesting that his performance on cognitive testing may underestimate his current cognitive abilities. Results are therefore interpreted with caution. In the context of estimated high-average premorbid intellectual functioning, the Veteran demonstrated low-average performance on a general cognitive screening instrument (MoCA). Performance was in the low- average range on tests of simple attention and working memory. He performed in the borderline impaired range on measures of visuomotor speed, immediate verbal learning and memory, speeded color naming, and speeded word reading. He performed in the mildly impaired range on tests of set-switching and delayed verbal memory recall and recognition. A measure of selective attention could not be interpreted due to the Veteran's slow word reading and color naming performances. With respect to psychiatric concerns, the Veteran endorsed severe symptoms of anxiety, mild symptoms of depression, and significant symptoms of PTSD, and alcohol abuse. Upon further examination of his responses regarding alcohol use, his score may reflect past problems as did not report weekly alcohol use in the past month. He endorsed a significant number of somatic symptoms beyond those reported by individuals with chronic pain, suggesting a tendency toward somatic preoccupation. He did not endorse significant symptoms of insomnia. The etiology of the Veteran's complaints of poor memory, concentration, and irritability are likely multifactorial. Variability in task engagement may have resulted in poorer performances on cognitive testing, which complicates the determination of the severity and etiology of the Veteran's subjective memory and concentration problems. Behavioral health factors may impact the Veteran's ability to fully engage in testing, and he may benefit from engagement in mental health treatment to address anxiety, depression, and PTSD, if not already considered. The results are not consistent with the recovery from a mild TBI from a parachuting accident in 1995. Findings were discussed with the TBI team. Linas Bieliauskas, PhD ABPP-CN Neuropsychology Resident Staff Psychologist Patient testing time including scoring was 1.5 hours, plus interpretation/ report time of 0.5 hours. /es/ JENNIFER MAROLA, PhD Psychology Postdoctoral Fellow Signed: 03/27/2014 15:16 /es/ LINAS A BIELIAUSKAS, PhD Attending Psychologist Cosigned: 04/03/2014 10:36 04/07/2014 ADDENDUM STATUS: COMPLETED I have reviewed and edited this report and agree with the report of test data and interpretation. /es/ LINAS A BIELIAUSKAS, PhD Attending Psychologist Signed: 04/07/2014 10:16 ------------------------------------------------------------------------- ========================================================================= Date/Time: 26 Mar 2014 @ 0800 Note Title: COMPENSATION & PENSION Location: VA ANN ARBOR HEALTHCARE SYSTEM Signed By: Co-signed By: Date/Time Signed: 26 Mar 2014 @ 1050 ------------------------------------------------------------------------- LOCAL TITLE: COMPENSATION & PENSION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAR 26, 2014@08:00 ENTRY DATE: MAR 26, 2014@10:50:36 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) Disability Benefits Questionnaire * Internal VA or DoD Use Only* Name of patient/Veteran: mays, franklin e Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: crps SECTION I: Diagnosis and medical history ---------------------------------------- 1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Traumatic brain injury (TBI) ICD code: 854 Date of diagnosis: 1995 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): 39 y-o man who was in the army/rotc who was involved in a parachute event. his last memory was getting onto the airplane for the jump and his next memory was waking up in the hospital. he was in the hospital for 1.5 weeks. likely had LOC and has poor memory of hospitalization. did not need surgery. he states that he tried to return to ROTC but was not allowed to return. returned to college in sept 1996 to complete degree. remembers feeling anxiety in classes especially taking exam. then took job working in hardware store for several months. then took job selling insurance door to door for about 1.5 years. about fall 2000 moved to MI and worked several jobs short term until returning to college for 2nd degree in elem education. he reports having diffculting completeing this but did eventually complete degree and did work as a traveling early elem teacher. SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI ----------------------------------------------------------------------------- 1. Memory, attention, concentration, executive functions -------------------------------------------------------- [X] Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary): 04/03/2007 where it was asserted that "it appears that he is developing a greater degree of anxiety and depression likely due to the underlying cognitive problems he is encountering" and he was diagnosed at that time with an "Adjustment Disorder with Mixed Anxiety and Depressed Mood." 2. Judgment ----------- [X] Mildly impaired judgment: For complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision If the Veteran has impaired judgment, describe (brief summary): reports problems making decisions because of an impaired "thinking process" 3. Social interaction --------------------- [X] Social interaction is routinely appropriate 4. Orientation -------------- [X] Always oriented to person, time, place, and situation 5. Motor activity (with intact motor and sensory system) -------------------------------------------------------- [X] Motor activity normal 6. Visual spatial orientation ----------------------------- [X] Mildly impaired: Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system) If the Veteran has impaired visual spatial orientation, describe (brief summary): stays in familar areas but uses google maps 7. Subjective symptoms ---------------------- [X] Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples are: mild or occasional headaches, mild anxiety If the Veteran has subjective symptoms, describe (brief summary): feels guilt about getting hurt and not being able to return to rotc/army 8. Neurobehavioral effects -------------------------- [X] One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. If the Veteran has any neurobehavioral effects, describe (brief summary): commpleted 2 college degrees after injury and works as pre-school teacher currently 9. Communication ---------------- [X] Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. 10. Consciousness ----------------- [X] Normal SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks ----------------------------------------------------------------------------- 1. Residuals ------------ Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)? [ ] Yes [X] No 2. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms? [ ] Yes [X] No 3. Diagnostic testing --------------------- a. Has neuropsychological testing been performed? [X] Yes [ ] No Results: There is no mention of anxiety associated with his military-related parachuting accident until 2007, though that appeared to be remitted by 2009. His current mild anxieties are related to the assault he sustained in 2011; therefore, his current diagnosis of Other Specified Anxiety Disorder is less than likely as not (less than 50/50 probability) caused by or a result of his military service and there is no evidence to suggest that his current anxieties were aggravated by his past parachuting accident. /es/ MICHAEL RANSOM PHD Staff Psyc hologist, Compensation and Pension Signed: 03/16/2014 12:22 4/2007 04/03/2007 where it was asserted that "it appears that he is developing a greater degree of anxiety and depression likely due to the underlying cognitive problems he is encountering" and he was diagnosed at that time with an "Adjustment Disorder with Mixed Anxiety and Depressed Mood." b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 4. Functional impact -------------------- Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work? [ ] Yes [X] No 5. Remarks, if any: ------------------- the vet most likely sustained a tbi while in military training. i am unable to determine if he sustained a mild vs. moderate TBI given the lack of records but suspected that it may have been moderate in severity. the vet did see opthy in 1995 and was noted to have bilat cn4 palsy which which wsa noted to resolve in a 1996 follow up visit. the vet did complete 2 college degrees since his injury. during today's routine neuropsychometric testing, he performed worse than the 2007 eval noted in VBMS. He scored high in anxiety during today's eval. Based on his history, repeated neuropsychmetric evals, and the natural history of TBI, is is less likely than not that his current issues are related to his TBI history. /es/ PERCIVAL PANGILINAN MD Attending Physician, PM&R Signed: 03/26/2014 10:50 ------------------------------------------------------------------------- ========================================================================= Date/Time: 04 Mar 2014 @ 0900 Note Title: COMPENSATION & PENSION Location: VA ANN ARBOR HEALTHCARE SYSTEM Signed By: Co-signed By: Date/Time Signed: 16 Mar 2014 @ 1222 ------------------------------------------------------------------------- LOCAL TITLE: COMPENSATION & PENSION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAR 04, 2014@09:00 ENTRY DATE: MAR 16, 2014@12:22:14 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Name of patient/Veteran: Franklin Mays is a 39 year old, right handed, married man who completed a DBQ Mental Disorder evaluation at the VAMC Ann Arbor on 03/04/2014. 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 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Other Specified Anxiety Disorder related to the assault he sustained in 2011 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): (per medical records) ADHD and hx of concussion (09/12/1995) 2. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? No response provided. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes[ ] No[ ] Not shown in records reviewed d. 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: There is no evidence to suggest that any current psychological difficulties are related to his history of concussion. 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] 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 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[ ] No[X] No other mental disorder has been diagnosed 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? [X] Yes[ ] No[ ] No diagnosis of TBI If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: There is no evidence to suggest that any current psychological difficulties are related to his history of concussion. SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? Yes Was the Veteran's VA claims file reviewed? Yes If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VA Records Psychological Testing b. Was pertinent information from collateral sources reviewed? No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran stated that he grew up in Augusta, GA with his biological parents and his older brother (7 years). He added that he had a biological sister who died two years before the veteran was born. He reported that he had a "good" relationship with his family while growing up. He noted that his father was retired military and his mother was a teaching assistant until she was medically retired for hearing loss. He asserted that he had a "happy" childhood and denied abuse or neglect. He described his peer relationships growing up as good, noting that he had a solid group of friends and actually had more friends than he ever realized. He reported that he has been married 1 time and is currently married. He stated that he has 3 children (9 year old son, 7 year old daughter, 6 year old son). He described his relationships with wife as "good" and also "good" with his children. The veteran stated that he lives with his wife and children in Lansing, MI. The veteran reported that he had excellent relationships with his fellow soldiers while in the military. The veteran described his post-military/current social life as good. b. Relevant Occupational and Educational history (pre-military, military, and post-military): The veteran reported that he has completed 16 years of formal education and added that he has two bachelor's degrees. He stated that he struggled some with math growing up, but worked hard and eventually did well. He reported that he has a BA from Georgia in History (1998; GPA = 2.5) and a BS in Elementary Education (2007; GPA = 3.66) with three minors (Spanish, English Language Arts, and Social Studies) from UM-Flint. He added that he is currently working on an Early Childhood Endorsement now through a joint program (Lansing Community College and Ferris State University). The veteran reported that between high school and when he started the ROTC program, he did 2 years of school at Augusta College and completed the Military Science 1 & 2 courses. He stated that he enlisted into the Army ROTC and began his service on 08/1994 and "made it as far as cadet." He reported separating from the military in 1996 following his parachuting accident. He reported that after his accident he was unable to participate in PT, struggled in classes, and ultimately failed a height/weight test. He stated that "I think" that failing the weight test was the official reason for his separation, because he was overweight. The veteran stated that post-service, he continued in school. He stated that he read in a manual that he had to wait 4-6 years to get back in to the military after his head injury and engaged in a significant amount of paperwork and "wrangling, talking to congressmen," which "created a lot of stress for me." However, a "MEMORANDUM FOR UNIVERSITY OF GEORGIA ROTC" dated 03/04/1996 indicated that a "memorandum for Frank Mays medical board" was sent and asserted that the veteran would be seen later that month "and I hope to make a better determination of his prognosis. According to the regulations, however, since he had at least a mild head injury, he will require at least a two year period of observation prior to being eligible for further evaluation by a neurologist. During this time period he will not be eligible for induction into the active duty Army." He stated that he took some time off from school after his accident and went back home. He reported that he returned to school full time in January 1996 and noted that it was "a real struggle" academically. He reported that his academic/cognitive struggles continued until his graduation in 1998. He stated that he then obtained a job at a plumbing retail store for 3-4 months, but was having trouble filling orders. He did not necessarily do well so went into commissioned sales (insurance) from 1998-2000. He reported that he moved to Michigan with his girlfriend (now wife) and worked various jobs to make money and then began substitute teaching. He joined AmeriCorp in 2001. He reported that he then began attending Michigan State University, but did not like how large the classes were and transferred to a smaller school. He stated that he then went to school full time and worked jobs on the side until he completed his degree in 2007. He reported that he had been making the Dean's list academically, but had troubles with the student teaching aspects of his program secondary to poor organizational issues. He reported that he has been working as a Pre-School Spanish Immersion teacher since 2008. He asserted that his work performance has been "good" and noted that his principal is happy with him and his work. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran denied any mental health history prior to his enlistment in the military. He reported that he was participating in a parachuting exercise on 09/12/1995 when he experienced "a hard fall" that resulted in a closed head injury. He reported that his "last clear memory is of the plane taxiing down the runway" and his next memory is "being in hospital." He denied having any memory for the accident itself, but has been told by others what they saw happen and he replays these events in his head, which upsets him emotionally. According to a sworn statement dated 02/14/1996 by William D. Harrison, the airborne/ground commander for an airborne operation at the time of the veteran's accident, the veteran appears to have been unconscious following his accident for approximately 5-7 minutes and was then groggy and confused, but verbalizing more, until he was medevac out approximately 15-20 minutes after his injury. It was noted that "from the time of accident until the aircraft lifted off was 15-20 minutes. It is my opinion that Cadet Mays was unconscious for only the first 5-7 minutes, having regaining consciousness as he received medical aide." According to a sworn statement dated 02/14/1996 by SSG Terrance Murphy, a coach for the jump and first responder to the veteran, the veteran "was in an unconscious state, all of his limbs were rigid and unbendable. He remained in this state for about 6-7 minutes." Records indicate that he was hospitalized from 09/12/1995 through 09/21/1995 and diagnosed with a closed head injury, mild diabetes insipidus, and CN IV palsey - bilat. 09/20/1995 Note indicated "MRI results show minor swelling of L temporal lobe without cerebellar damage." 09/21/1995 Discharge note "HOSPITAL COURSE: The patient was admitted to the ICU for observation. Repeat computerized axial tomography done approximately 36 hours later showed no change, and still no change, and still normal. The patient was seen by the Ophthalmology Service who diagnosed cranial nerve IV palsy, as well as some cerebellar dysfunction. The MRI confirmed this fact. The patient steadily improved and on the day of discharge was able to have a fair amount of short term memory return. There appeared to be no changed in his long term memory. Although certainly not back to normal, his cerebellar activities including gait and eating are returning toward normal." It went on to state, "DISPOSITION: The patient is discharged to home in the care of his parents. Letters have been given to him for staying out of school for one quarter. He will receive follow up care from the General Surgery Service on 16 Oct 95, the Ophthalmology Service at Martin Army Community Hospital on 16 Oct 95, as well as a referral to Emory Neuro-ophthalmology Service to see Dr. Newman. No medications given. Specific return instructions also given." 10/12/1995 Noted indicated that "CT and MRI have been negative." 10/12/1995 Opthamology note - Nancy Newman, MD "He was in his usual state of excellent health until September 12, 1995, when he was on an airborne jump and apparently landed on his head, presumably the occiput. There was definite loss of consciousness anywhere from 15 to 25 minutes. He remained confused thereafter and was hospitalized for one week. His mentation improved subsequently and he has been at home for the past three weeks. He now no longer has problems with short-term memory, although he has no recall of an entire week since the jump. His current complaints are that he has trouble seeing in that they are "jumbled" and "slanted." He has findings consistent with his head trauma. Specifically, he has bilateral IVth nerve palsies, as you indicated which is quite common after a head injury. He also has macro square-wave jerks which suggest involvement of the cerebellum and/or its connections. This would be related to his balance problems In addition, he has a refractive error which is an induced myopia. It is possible that he may have had this all along, although he says that he never needed glasses before. Therefore, it is conceivable, that this reflects induced myopia, perhaps from mild accommodative spasm that can occur with head injury. Many of these deficits, if not all, should improve over time, and I spent a great deal of time with the patient and his parents explaining this. They may wish to pursue obtaining a refraction and a glasses prescription." 10/03/1996 Neurosurgery consult "Franklin Mays a 21 year old white male was seen in the office on 5/24/96 with the history that while in ROTC training he jumped from a airplane with a parachute and subsequently was rendered unconscious for a brief time. This had occurred in September 1995. He had to stop school after the incident. He has had memory loss and problems with balance which has slowly improved. He is currently attending Augusta State University and is on no medication. Past history reveals that before the current injury he was in good health. He denied drug allergies. According to the father at the time of the injury the CT scan was negative and he had bilateral 4th nerve palsy that gradually cleared. When seen and examined he was awake alert and oriented. His cranial nerve were now all intact. Pupils were round regular and reactive equally to light. Extraocular movements were normal. There was no papilledema Visual fields per confrontation were intact. Face was symmetrical. Cerebellar function was intact. Extremity strength reflexes and sensory were all intact. Gait was normal. We obtained copy of a hospital discharge summary from Fort Benning Georgia and this indicated that that he had had a closed head injury and the CT and MRI scan has showed a mild edema of the left parietal lobe and cerebellum. It is my impression this young man is doing fairly well at this time but continues with some post concussion symptoms. It is anticipated that this will persist for a long period of time along with some mild memory impairment as well as dizziness and light headiness may last for several months. He is to be seen back in follow-up in 6 months. Very truly yours, John L. Williams, M.D. JLW/lnb" 04/03/2007 Neuropsychological Evaluation Responses "suggest an individual who is reporting a significant degree of depression and anxiety. These individuals often present with a long standing history of chronic worrying tension and depression. There is a propensity to convert emotional and psychological distress into physical or medical complications. These individuals often struggle with issues of self-confidence and self-esteem. They are prone to feelings of social alienation. Further assessment of mood on the BDI 2 resulted m a composite score of 22 which places this patient within the moderate range?" It went on to note that "the objective test results would point to areas of residual impairment most prominent in spatial perception, visual memory skills, and higher level executive functioning. In particular, this patient does have greater difficulty in higher order executive functions, which will involve organization, prioritization, cognitive flexibility, and the ability to move from task to task while tolerating distractions. It is little surprise that he has encountered problems in these areas as the test results would corroborate clear impairment, which likely is attributed to the past head trauma. Unfortunately, it appears that he is developing a greater degree of anxiety and depression likely due to the underlying cognitive problems he is encountering. These psychological factors can clearly exacerbate otherwise mild cognitive difficulties and result in a greater degree of disability. A number of structured interventions will be recommended to facilitate this patient's appropriate psychosocial and vocational adjustment." The veteran was diagnosed with "Cognitive Disorder Secondary to Traumatic Brain Injury" and "Adjustment Disorder with Mixed Anxiety and Depressed Mood." Available records from Michigan State University Clinical Center dating back to 2009 were reviewed. The first available was dated 10/23/2009 in the veteran appeared to be seen for asthma followup at that time. Prescriptions noted included Wellbutrin and Lexapro. The veteran was then seen on 11/20/2009 where it was noted that he was "doing well on the anxiety." In a note dated 01/14/2010 indicated that the veteran was "doing well on the Wellbutrin and Buspar now. Things are going well at work, and feels things are good at home, is resting well, feels he has developed better coping skills. And overall feels he is doing well." At that time, his medications were Buspirone HCL 30 mg twice daily and Wellbutrin XL 300 mg daily. In a note dated 07/19/2010 indicated that the veteran was considering a move to Baltimore for a teaching position, though eventually declined this. He now reported that the veteran "states she isn't really looking forward to his third year of teaching at his preschool, states first year was exciting and as it was new, last year okay, but not really looking forward to next year. Discussed whether this was because of not being in position that he would like to be and, if it was depression, or some grieving over not taking the position effort."PHQ-9 depression screening was negative at that time. A note dated 08/13/2010 indicated that the veteran "denies depression, anxiety, suicidal ideation, hallucinations, paranoia, phobia, and confusion." 05/09/2011 "states he feels better than he ever has. Notes that he stopped meds in Dec. felt they were making him groggy admits that he is getting medical marijuana gets a tincture and takes 3-4 gtts/day feels more confidence handling more responsibility at work and home well feels it has taken edge off" "Assessment: Improved The following medications were removed from the medication list Buspirone Hcl 30 Mg Tabs (Buspirone hcl) One daily Wellbutnn XI 300 Mg Tb24 (Bupropion hcl) One daily Is however doing medical marijuana from compassion club in Lansing" A note dated 06/14/2011 indicated "mood and affect appropriate and normally interactive." The veteran appeared to be doing well psychologically at this point of his history, though was reportedly "mugged" on 06/23/2011. Records indicate that he experienced minor physical injuries only, "however, emotionally, he's having a lot of anxiety, fear, worried-almost like reliving the incident, both during his waking hours and at times during sleep." The veteran reportedly "felt guilty since he's been mugged (that he is contributing to the social illness that result from a burgeoning marijuana initially) so he stopped it since 06/23/2011. Anxiety and depressive symptoms have coincidentally flared up during this time." A question of PTSD was raised by his provider and citalopram and alprazolam were prescribed at that time. It was reported on 07/26/2011 that the veteran "was walking and neighborhood in guys came up in mugged him, he gave up his wallet, cell phone, neighbor came to door and he yelled for help, the guys took off. No major physical injuries but has increased his anxiety. Had been off of the medical marijuana. Started on the Celexa and emotions were up and down." The veteran reportedly was "still having some difficulties dealing with the mugging. Feelings of guilt that he didn't do more. We emphasize the survival aspects and that the things are just things. He has enrolled in a self defense/martial arts and we also discussed his impact on the family safety and how he is projecting his concerns versus awareness." 10/03/2011 "no acute distress" "Psych: mood and affect appropriate and cognition and judgment appear intact" 11/22/2011 Report indicated that the veteran was becoming "easily angered, frustrated, worried and fearful of walking around neighborhood or easily startled by loud noise" and also indicated that the veteran was seen a therapist at that time. PHQ-9 results: "Scoring Results Scoring does not suggest diagnosis of Major or Minor Depression. Total score is 8. Scoring suggests patient's functionality is not impaired." 11/28/2011 "Here for f/u on anxiety and ptsd. Has had a very difficult time lately increasing trouble with being on edge. Kid came up behind him and spoofed him, made him very anxious. Having trouble concentrating, staying organized, anxious about the personal space issues. Is seeing a counselor. Sees psychiatrist this week. Feels that he is not able to be patient with kids at school. Having same issues at home. Wife has also contacted me and states that he was doing well since the previous closed head injury, but since the mugging has had a big struggle again" Noted that he was using medical marijuana through a separate clinic. He received a letter from his primary care provider to assist him in being off work until evaluated by mental health, noting that he "may need a month or so to get therapy but established." 12/21/2011 The veteran was seen for follow up on anxiety and reportedly had stopped all of his medications, including medical marijuana, because he did not like the way he felt on any of the period she reportedly was feeling "really well right now," but they did discuss concerns about going back to work full-time and the stress that accompanies it. He was reportedly working with a therapist at that time. It was recommended that he return to work part time for 2 weeks. 05/01/2012 "was off work for some time during the winter went back to full time from Jan 24th till march 9th, not able to function well trying to organize his time, was so distracted between 2 schools total 15 classes, recently he expressed his wishes to his wife to kill himself before getting annual evaluation from his supervisor, went back on short time disability, been receiving counselling and followed by Psychiatry, and also OT thru hope health network. Wants to apply for part time Job for the rest of this school year, opening is available at Lansing school district." 08/02/2012 "When he last plummeted and had increased difficulties with being overwhelmed we referred him to psychiatry. Since then he has been on Zoloft and Ritalin for four months. He states that the Zoloft has helped with his depression and anxiety symptoms. He is happy with the current dose of 50mg. Frank states that the Ritalin seems to be helping with planning and organizational skills but that he may want to take a higher dose. He accidentally took a double dose last week and felt much better than he had on a single dose. He has taken up gardening and spending more time with his children. He is training a service dog to keep him company and seems to be enjoying this noting that walking with a dog in the neighborhood seems to really help him and that the dog is very good with ELI (his trisomy 21 son). He plans to return teaching preschool in a few weeks. He has been experiencing sexual side effects from the Zoloft but states that he can tolerate these because the medication is helping overall." 09/14/2012 A formal diagnosis of ADD was made at this time and his primary care note went on to state that "Psych: mood and affect appropriate cognition and judgment appear intact and normal attention span and concentration." "Problem # 1 ANXIETY (ICD 300 00) His updated medication list for this problem includes Alprazolam 0 25 Mg Tabs (Alprazolam) 1/2 to 1 tab po twice daily pm anxiety Sertraline Hcl 50 Mg Tabs (Sertraline hcl) One daily for depression symptoms Problem #2 ASTHMA SEASONAL (ICD-493 90) His updated medication list for this problem includes: Ventolin Hfa 108 (90 Base) Mcg/act Aers (Albuterol sulfate) Two puffs q 4 hours pm for wheezing/shortness of breath Albuterol Sulfate (5 Mg/m1) 0 5% Nebu (Albuterol sulfate) One vial in hhn every 4-6h as needed Problem #3 ? of PTSD (ICD 309 81) Doing well therapy dog 9 has been very helpful Problem #4 ADD (ICD 314 00) Will add 5 mg at noon 1 00 time frame to help with afternoon symptoms f/u in few months if this is working well ok to refill" ************************ The veteran reported that he was told he would never be a teacher by an MSU counselor, though he asserted that this drove him to succeed. He stated that things were going well for him, though he did struggle with the organizational aspects of student teaching and obtained career counselor at UM-Flint. He reported that he participated in HOPE network program and received assistance with organizational job skills. He stated that he was then "mugged and I just didn't handle it well." He added that a few months later a bank employee down the street was murdered. He stated "I panicked, felt anxiety." He reported that his overall anxiety began "a few months after my accident," as he was reportedly mad about his poor grades and things seemed to bother him more. He added that he began feeling depressed about being told he could not be in the Army. He reported that he has felt different after the accident, but could not explain how. He described his current mood as "pretty good," adding "I love my job!" He denied that he is currently depressed, asserting "I don't think I'm depressed, I don't really have time to be depressed right now." He added that after being diagnosed with ADD and beginning Vyvanse medication, he has experienced significant improvement of his symptoms. Regarding anxiety, the veteran reported that he "always has anxiety about my kids" and that he is worried about work, because he is missing 2 days this week. He added that he is also taking additional time away from work for a class he is completing. He stated that he tries to breath and says the rosary when he feels anxious, which calms him down. He reported that he does experience excessive anxiety and worry that he finds difficult to control. He stated that his initial worries used to revolve around not being able to get back into the Army, but that he pushed such thoughts out of his head and does not think about it anymore. He reported that after the mugging, "I have a service dog now because I don't like to be by myself, I'm more hypervigilant." He added that he stresses about his work situation, even though his boss gives him praise about his work performance. The veteran reported that "I centrate on something and that I guess is anxiety." He did not report any other symptoms of anxiety. He endorsed that he does have panic attacks at times and reportedly had one while in my office during the clinical interview. However, there was no indication of such an event from my observations, as the veteran appeared calm throughout the interview. He stated that he had the attack during a particular part of the interview, though he did not appear flustered or anxious in my observations of him during such time. Veteran reported that he is currently prescribed Zoloft and Vyvanse. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The veteran denied any legal or behavioral difficulties prior to, during, or following his military service. e. Relevant Substance abuse history (pre-military, military, and post-military): Alcohol: The veteran denied any history of problem drinking, but also noted that his girlfriend (now wife) gave him an ultimatum of stop drinking or she would break up with him. He stated that he did not drink all the time, but "it was all or nothing" when he did, as he would drink to intoxication when he drank. He stated that last consumed alcohol in 2000 and denied current alcohol intake. Tobacco use: Denied Illicit drug use/abuse: Denied f. Other, if any: No response provided. 3. Symptoms ----------- For VA rating purposes, check all symptoms that apply to the Veteran's diagnoses: [X] Anxiety Behavioral observations: MENTAL STATUS: Appearance: casually/appropriately dressed, well-groomed Speech: normal rate and rhythm Mood: "pretty good" Affect: Euthymic, no apparent anxiety in interview, polite, cooperative Thought Process: logical and goal-directed Delusions: No Hallucinations: No Suicidal or homicidal ideation: No Orientation: x4 Insight: Fair Judgment: Good 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [ ] Yes[X] 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: --------------------------------------------------- *********************PSYCHOMETRIC TESTING********************** To properly complete the evaluation, psychological testing was conducted. The veteran's scores were derived from objectively-scored tests, and these scores can be compared against known samples of individuals. Resultant scores can also be used as a basis of comparison for future assessments. Because some of the instruments in this battery cover a wide range of psychopathology, the results also serve as a screen for mental disorders that the veteran did not necessarily identify in the claim. Mississippi Scale for Combat-Related PTSD (MISS): The veteran's score of 81 on the MISS, if interpreted at face value, was not suggestive of clinically significant symptoms of PTSD. This score falls short of the suggested cutoff for PTSD and below that of the mean score among veterans with PTSD. PCLC: The veteran's self-reported PTSD symptoms on the PCL-Civilian (score=47) fell slightly below the criterion cut-off (cutoff=50) for the overall score and at a level below that obtained from patients diagnosed with PTSD (average score=64 +/- 14). Recent research in the Journal of Rehabilitation Research and Development suggested a more appropriate cutoff score of 60 for PTSD. This patient's score of 47 is below this cut off. All symptom clusters necessary for a PTSD diagnosis were positive. AUDIT-C: The veteran's score of 0, if interpreted at face value, is a negative screen for problematic alcohol use over the past year. Beck Depression Inventory-II (BDI-II): The veteran's score of 15 on the BDI-II, if interpreted at face value, was reflective of a mild level of depressive symptoms. Beck Anxiety Index (BAI): The veteran's score of 13 on the BAI, if interpreted at face value, was reflective of a mild level of anxiety symptoms. MMPI-2 RF: The MMPI-2 RF is a structured, objectively-scored measure of personality and psychopathology. His responses random responding, though there was evidence of possible over-reporting of symptoms, indicated by an unusual combination of responses that is associated with non-credible reporting of somatic and/or cognitive symptoms, especially non-credible memory complaints. However, this was not necessarily to a degree that invalidated the overall response profile, though, it was interpreted with caution. The veteran's responses suggest that he is experiencing significant emotional distress and has a general sense of unhappiness and dissatisfaction with his current life circumstances. He endorsed items indicating that he experiences maladaptive anxiety, anger, and irritability as well as anxiety, insecurity, worry, and fear. Such individuals tend to report various negative emotional experiences and are usually self-critical, guilt-prone, and have self-doubt. They tend to be passive, indecisive, and inefficacious and often believe they are incapable of coping with current crises. They report above-average levels of stress or worry and tend to be stress-reactive, worry-prone, and often engage in excessive rumination. They may have fears that significantly restrict normal activity in and outside the home. Individuals with similar scores report not enjoying social situations and events and often dislike people and being around them. They often report multiple somatic complaints that may include head pain, neurological, and gastrointestinal symptoms. Individuals with similar response patterns usually present with multiple somatic complaints and are prone to developing physical symptoms in response to stress. They usually complain about headaches, chronic pain, and difficulty concentrating and tend to present with vague neurological complaints as well as a diffuse pattern of cognitive difficulties. These individuals often have low frustration tolerance. **************************************************************** Quote taken from Form 2507 from the Regional Office: "CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER. ALL DOCUMENTS AVAILABLE IN VBMS Please examine the veteran for the present status of his claimed depression and anxiety and opine whether it is as least as likely as not caused by, due to, or aggravated by head injury documented in service. Aggravation: If not caused, but aggravated by service, please provide the following information: 1. The baseline manifestations of the aggravation which are due to the effects of the disease or injury. 2. The increased manifestations which, in your opinion, are proximately due to the service connected disability based on medical considerations. The medical considerations supporting an opinion, that increased manifestations of a non-service connected disease or injury are proximately due to the service connected disability." **************************************************************** OPINION: The veteran completed psychometric testing, underwent a clinical interview, and the medical record was reviewed. The medical record does not indicate the presence of pre-existing psychiatric problems at the time of his entry into the military or at the time of his separation. The veteran reported that he was frustrated with his cognitive difficulties following his parachuting injury, though there is no mention of psychological difficulties in any of the medical records from that time period. The first mention of such difficulties was in a neuropsychological report dated 04/03/2007 where it was asserted that "it appears that he is developing a greater degree of anxiety and depression likely due to the underlying cognitive problems he is encountering" and he was diagnosed at that time with an "Adjustment Disorder with Mixed Anxiety and Depressed Mood." However, available medical records from Michigan State University Clinical Center dating back to 2009 were reviewed and by 11/20/2009 it was noted that the veteran was "doing well on the anxiety." A note dated 01/14/2010 indicated that the veteran was "doing well on the Wellbutrin and Buspar now. Things are going well at work, and feels things are good at home, is resting well, feels he has developed better coping skills. And overall feels he is doing well." A note dated 07/19/2010 reported a PHQ-9 depression screen as negative and on 08/13/2010 it was reported that the veteran "denies depression, anxiety, suicidal ideation, hallucinations, paranoia, phobia, and confusion." On 05/09/2011 it was reported that the veteran "states he feels better than he ever has. Notes that he stopped meds in Dec. felt they were making him groggy admits that he is getting medical marijuana gets a tincture and takes 3-4 gtts/day feels more confidence handling more responsibility at work and home well feels it has taken edge off;" it went on to assert that the clinical impression was that the veteran had "Improved" and all psychotropic medications were officially removed from his medication list. The veteran appeared to be doing extremely well psychologically until he was reportedly "mugged" on 06/23/2011, which reportedly resulted in him "having a lot of anxiety, fear, worried-almost like reliving the incident, both during his waking hours and at times during sleep." The veteran reportedly "felt guilty since he's been mugged (that he is contributing to the social illness that result from a burgeoning marijuana initially) so he stopped it since 06/23/2011. Anxiety and depressive symptoms have coincidentally flared up during this time." A question of PTSD was raised by his provider and citalopram and alprazolam were prescribed at that time. The veteran reported in the current clinical interview that after he was mugged, "I just didn't handle it well" and he added that a few months later a bank employee down the street from his home was murdered, which added to his anxious fears that developed following his assault. A noted dated 07/26/2011 indicated that the veteran had "feelings of guilt that he didn't do more. We emphasize the survival aspects and that the things are just things. He has enrolled in a self defense/martial arts and we also discussed his impact on the family safety and how he is projecting his concerns versus awareness." Diagnostically, the veteran described his current mood as "pretty good," adding "I love my job!" He denied that he is currently depressed and asserted, "I don't think I'm depressed, I don't really have time to be depressed right now" and he denied any current symptoms of depression. He added that after being diagnosed with ADHD and beginning Vyvanse medication, he has experienced significant improvement of his symptoms, which most likely indicates that several of his difficulties were actually secondary to a lifetime history of undiagnosed ADHD, as opposed to anything else. Regarding anxiety, the veteran stated that he initially had worries about not being able to get back into the Army, but asserted that he has pushed such thoughts out of his head and does not think about it anymore. He stated that his current anxieties are "about my kids" and that he is worried about work, because he is missing 2 days this week, even though he reported that his superiors are happy with his work performance. He stated that when he experiences any kind of anxiety he utilizes interventions (e.g., tries to breath and says the rosary when he feels anxious, which calms him down) to assuage such symptoms. He reported in the current clinical interview that after the mugging, "I just didn't handle it well" and following the murder that occurred down the street from his home, "I panicked, felt anxiety." He noted that he has a "service dog now because I don't like to be by myself, I'm more hypervigilant." Psychometric testing revealed low levels of current anxiety and suggests that the veteran tends to somaticize and that he tends to be stress-reactive, worry-prone, and often engages in excessive rumination. Based upon such information, a DSM-5 diagnosis of Other Specified Anxiety Disorder related to the assault he sustained in 2011 is warranted. There is no mention of anxiety associated with his military-related parachuting accident until 2007, though that appeared to be remitted by 2009. His current mild anxieties are related to the assault he sustained in 2011; therefore, his current diagnosis of Other Specified Anxiety Disorder is less than likely as not (less than 50/50 probability) caused by or a result of his military service and there is no evidence to suggest that his current anxieties were aggravated by his past parachuting accident. /es/ Staff Psychologist, Compensation and Pension Signed: 03/16/2014 12:22 ------------------------------------------------------------------------- ----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------
  8. Below is the C&P exam that I took in September. I don't think that the VA used this report because 'Benefits' only shows the Tinnutus as being rated. I removed the doctors at the Battle Creek VA. --------------- MY HEALTHEVET PERSONAL INFORMATION REPORT --------------- *************CONFIDENTIAL************* Produced by the VA Blue Button (v12.10) 04 Jan 2017 @ 0905 This summary is a copy of information from your My HealtheVet Personal Health Record. Your summary may include: - information that you entered (self reported) - information from your VA health record - your military service information from the department of defense (DoD). ***Note: Your health care team may not have all of the information from your Personal Health Record unless you share it with them. Contact your health care team if you have questions about your health information.*** Key: Double dashes (--) mean there is no information to display. ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 04 Jan 2017 @ 0905 File Name: mhv_MAYS_20170104_0905.txt Date Range Selected: 26 Sep 2016 to 26 Sep 2016 Data Types Selected: My HealtheVet Account Summary VA Notes --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 18 Apr 2014 Authentication Facility ID: 506 Authentication Facility Name: VA ANN ARBOR HEALTHCARE SYSTEM VA Treating Facility Type -------------------- ------ VBA BRLS na VA IDENTIFY PROOFING na VETERANS ID CARD SYSTEM na VBA CORP na BATTLE CREEK MI VAMC na DEPARTMENT OF DEFENSE DEERS na ENROLLMENT SYSTEM REENGINEERING na AUSTIN MHV na ST. LOUIS MO VAMC-JC DIVISION na VA ANN ARBOR HEALTHCARE SYSTEM na ------------------------------- VA NOTES -------------------------------- Source: VA Last Updated: 03 Jan 2017 @ 0919 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Date/Time: 26 Sep 2016 @ 1430 Note Title: C&P MENTAL DISORDERS Location: BATTLE CREEK MI VAMC Signed By: Co-signed By: Date/Time Signed: 26 Sep 2016 @ 1813 ------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL DISORDERS STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: SEP 26, 2016@14:30 ENTRY DATE: SEP 26, 2016@18:13:28 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Mays, Franklin Eugene ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): Veteran provided a copy of a letter from the Department of Health and Human Services, dated 9/8/16, describing his occupational impairments, which will be forwarded to the regional office. MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: **CLAIM TYPE: INCREASE ONLY **SPECIAL CONSIDERATIONS: NOT APPLICABLE **INSUFFICIENT EXAM: NO Date of claim: 03/09/2016 Days pending: 170 Veteran has a power of attorney. Please send a courtesy copy of the exam notice letter to AMERICAN LEGION Attention C&P Service's staff - This exam request was scheduled at your location based on the claimant's residing zip code and ERRA instructions The Veteran will need to report for the following exam(s) unless the ACE process is utilized. Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete the DBQ. Also if the exam is completed using ACE, please review the Veteran's claims folder and indicate so in the exam report. DBQ AUDIO Hearing Loss and Tinnitus DBQ NEURO Central Nervous System DBQ NEURO Headaches (including migraine headaches) An in-person examination is required for the following exam(s). ACE process must not be used to complete the DBQ. DBQ PSYCH Mental disorders DBQ PSYCH PTSD Initial ____________________________________________________________________________ The following contentions need to be examined: Tinnitus Traumatic brain injury Headaches and visual impairment (related to: PTSD - Non-Combat) Major depression and anxiety (related to: PTSD - Personal Trauma) PTSD personal trauma Major depression and anxiety (related to: PTSD - Personal Trauma) Active duty service dates: Branch: Army EOD: 09/01/1994 RAD: 12/31/1996 DBQ AUDIO Hearing Loss and Tinnitus: MEDICAL OPINION Type of medical opinion requested: Direct service connection Contention: Claimed Condition: tinnitus The Veteran is claiming that his tinnitus is related to TBI. Opinion Requested: Is the veteran's tinnitus at least as likely as not (50 percent or greater probability) incurred in or caused by TBI. Please fill out the direct medical opinion template in the DBQ and review the following tabbed evidence. Your review is not limited to the evidence identified on this request form, or tabbed in the claims folder. If an examination or additional testing is required, obtain them prior to rendering your opinion. Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) 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 A (DD Form 214 in VBMS): Letter - Verification of Service dated 4/30/2014 Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016 **************************************************************************** DBQ NEURO Central Nervous System: The Veteran is service connected for traumatic brain injury which is currently evaluated at 40%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error. If the diagnosis was in error, please provide a rationale supported by the clinical evidence of record that refutes the previous exam (s) which diagnosed the condition. Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) 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 B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016 **************************************************************************** DBQ NEURO Headaches (including migraine headaches): 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 Contention: Claimed Condition: headaches The Veteran is claiming that "his" headaches (related to: PTSD - Non-Combat was incurred in or caused by "his" TBI that occurred 09/01/1994 - 12/31/1996. Does the Veteran have a diagnosis of (a) headaches (related to: PTSD - Non- Combat) that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) TBI during service? Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. Rationale must be provided in the appropriate section. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) 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 B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016 **************************************************************************** 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 Cont ention: Claimed Condition: PTSD The Veteran is claiming that "his" PTSD was incurred in or caused by "his" personal trauma that occurred 09/01/1994 - 12/31/1996. Does the Veteran have a diagnosis of (a) major depression and anxiety (related to: PTSD - Personal Trauma) that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) TBI during service? Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. 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. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) 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 B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016 **************************************************************************** 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: Secondary Service connection. OPINION REQUESTED: Secondary Service Connection. Contention: Claimed Condition: PTSD The Veteran is claiming that "his" PTSD was incurred in or caused by "his" TBI that occurred 09/01/1994 - 12/31/1996. Is the Veteran's PTSD personal trauma at least as likely as not (50 percent or greater probability) proximately due to or the result of traumatic brain injury? Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. Rationale must be provided in the appropriate section. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection. OPINION REQUESTED: Secondary Service Connection. Is the Veteran's major depression and anxiety (related to: PTSD - Personal Trauma) at least as likely as not (50 percent or greater probability) proximately due to or the result of traumatic brain injury? Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. 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. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) 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 B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013 Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016 b. Indicate type of exam for which opinion has been requested: PTSD Initial TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: Based on clinical experience and expertise, review of VBMS database, Virtual VA, and available records, and examination of veteran, who presented credibly and consistently in treatment records, clinical interview and on trauma checklist, IT IS AT LEAST AS LIKELY AS NOT that veteran meets criteria for diagnoses of PTSD, anxiety, and depression that are caused by or the result of the TBI he incurred due to a parachuting accident during training in 1995, and to is resulting educational and occupational impairment. Veteran was interviewed on 9/26/16 from 1:55 - 2:55 p.m. ************************************************************************* **************************************************************************** Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: Mays, Franklin Eugene SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Post Traumatic Stress Disorder ICD code: 309.81 Comments, if any: Secondary to the parachuting accident that caused his TBI diagnosis. Mental Disorder Diagnosis #2: Other Specified Depressive Disorder ICD code: 311 Comments, if any: Secondary to the parachuting accident that caused his TBI diagnosis. Mental Disorder Diagnosis #3: Other Specified Anxiety Disorder ICD code: 300.09 Comments, if any: Secondary to the parachuting accident that caused his TBI diagnosis. Mental Disorder Diagnosis #4: Alcohol Use Disorder, Moderate-to-Severe, In Sustained Remission ICD code: 303.90 Comments, if any: Secondary to the parachuting accident that caused his TBI diagnosis. If additional diagnoses, describe (using above format): Mental Disorder Diagnosis #5: Unspecified Cannabis-Related Disorder ICD code: 292.9 Comments, if any: In remission. Secondary to the parachuting accident that caused his TBI diagnosis. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): TBI with Loss of Consciousness; AD/HD, Predominately Inattentive Type; PTSD (per CPRS medical records). 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? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Veteran's diagnoses are comorbid and have overlapping features, reducing differentiation of symptoms to speculation. His alcohol and cannabis use disorders (in remission) were secondary. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed d. 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: Veteran's diagnoses are comorbid and have overlapping features, reducing differentiation of symptoms to speculation. His alcohol and cannabis use disorders (in remission) were secondary. Per his review TBI evaluation, dated 9/26/16, veteran is experiencing headaches, including migraine headaches, in addition to mental disorders as residuals of his TBI diagnosis. His TBI examiner opined, "It is also least least likely as not that the Veteran's psychiatric issues are connected to his TBI. Veteran has had moodiness, anxiety, depression, irritability, and impaired awareness.Veteran has extensive comprehension difficulties. He has had extensive psychiatric issues since his TBI. It is more of the cognitive difficulties that impair working." 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 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: Veteran's diagnoses are comorbid and have overlapping features, reducing differentiation of social and occupational impairment to speculation. His alcohol and cannabis use disorders (in remission) were secondary. 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? [X] Yes [ ] No [ ] No diagnosis of TBI If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Veteran's diagnoses are comorbid and have overlapping features, reducing differentiation of social and occupational impairment to speculation. His alcohol and cannabis use disorders (in remission) were secondary. Per his review TBI evaluation, dated 9/26/16, veteran is experiencing headaches, including migraine headaches, in addition to mental disorders as residuals of his TBI diagnosis. His TBI examiner opined, "It is also least least likely as not that the Veteran's psychiatric issues are connected to his TBI. Veteran has had moodiness, anxiety, depression, irritability, and impaired awareness.Veteran has extensive comprehension difficulties. He has had extensive psychiatric issues since his TBI. It is more of the cognitive difficulties that impair working." SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): Veteran provided a copy of a letter from the Department of Health and Human Services, dated 9/8/16, describing his occupational impairments, which will be forwarded to the regional office. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The following are history and status as related by veteran, and as obtained from review of available records. Veteran underwent his last C&P evaluation for mental disorders on 3/4/14. Please refer to that examination for further background information. Veteran was born and raised in Georgia by his biological parents, along with 1 brother. He described his upbringing as "normal," and his current relationships with members of his family of origin as "fine." He has been married for 15 years, fathering 3 children. Overall, he described his marriage as "good," but did report frustration and anger secondary to his TBI, adding he turns his anger inward toward himself. He added he becomes "excited easily," leading his wife to think he is yelling. He did say that his wife is supportive, and that she encouraged him to give up alcohol use. Veteran also reported that his anxiety continues to be driven by his youngest son, who has Down's Syndrome, resulting in "a lot of behavioral issues." Socially, veteran reported that he still has friends from before his accident, who live in other states, but denied making friends since his accident. He added he has been experiencing difficulty leaving his home. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran graduated high school, describing himself as an "A, B, C student," who was active in many sports, and got along "very good" with teachers and peers. He denied ever being suspended or expelled. Veteran also reported a Bachelor's degree from the University of Georgia, adding he was pursuing his degree at that time in order to become an officer in the Army. He stated he was an academic scholarship cadet, but that his grades significantly declined after his accident in 1995. He did say he earned his degree in History in 1998. He also has a Bachelor's degree from the University of Michigan, Flint. His second degree is in elementary education, finished in 2007. He stated he was better able to focus while earning his second degree, as the class sizes were smaller. Occupationally, veteran worked as a life guard, and then was offered a job with an after school program during the school year from the same employer. He added he held this job while he was in college the first time. After his accident, he reported that he began using cannabis daily, cut his foot at work necessitating a drug test, which he refused because he knew he would screen as positive. In addition, parents started complaining that he became "too intense" and "keyed up" with the children. Instead of firing him outright, his employer opted to give him no more hours of work. Veteran served in the Army from 1994-1996. Overall, he stated he "loved it," citing a family tradition of Army service. He added, being an officer in the Army was "all I ever wanted to do," and stated, "My life just crumbled" after the accident cut his military career short. Following graduation from college, veteran went to work for a plumbing warehouse, adding he was having difficulties with alcohol use, causing him to miss a day of work, stating he left that job shortly thereafter. Next, he sold insurance door-to-door. He stated he enjoyed the sense of "roaming" and "exploring" that job brought him, adding he was also able to learn the history of the places he visited to sell insurance. He stated he quit that job when he moved to Michigan in 2000. In Michigan, veteran reported work via temporary agencies, prior to signing up for AmeriCorps. He stated 9/11 caused him to lose interest in AmeriCorps, and everything else, adding he was "not fired, but kindly let go." Next, veteran attempted to further his education at Michigan State University, but experienced difficulties due to the large class sizes, transferring to U of M Flint (as above) after 3 semesters. He added he attended classes three-quarters time at U of M Flint, which he stated was also a benefit. Veteran then began student teaching. He added he struggled in this, as he could not get along with the teacher to whom he was assigned, had difficulty writing and organizing lesson plans, and had problems keeping track of the students in classes. Following an argument with his teacher, the principal let him go. Veteran stated he was then placed at a different student teaching location, where he "frustrated" the teacher due to his difficulties with organization and making other mistakes, which confused the children. At his third student teaching placement, veteran reported that he performed better, as the teacher to whom he was assigned was supportive, and he only taught 1 class, which better allowed him to stay organized and focused. Veteran then found employment as a teacher at a charter school in Flint, Michigan, where he remained for 5 months, prior to being asked not to return. He explained that he was not able to remain organized as he was teaching Spanish to students from kindergarten - 8th grade, adding it was "too much for me." Next, veteran taught for the Lansing School District from 2008-2014, teaching Spanish immersion to pre-schoolers. He added he also had to take classes to earn a specific certification, and held that position for 2.5 years. At the same time, he reportedly obtained a medical marijuana card, and decided to stop taking his other psychiatric medications. He stated he lost interest in pre-school, and was transferred to a different program in the Lansing School District. He stated he ultimately returned to the pre-schoolers, but was let go from that position because he never earned the certification he needed. Veteran was involved in vocational rehabilitation from 2015-2016, until increased stress lead to 2 suicide attempts. He stated he taught classes at an independent living center for 40 hours/week, adding he had "a lot of trouble with that." He went on to say he felt he had "too much on his plate, and not enough time to think," in addition to difficulties with his youngest child. His psychiatrist reportedly urged him to reduce his hours to 20/week or less, with veteran moving into farming. He stated he enjoyed farming, initially, until he experienced vertigo, and a third suicide attempt in July. The Social Security Administration found that veteran was not disabled, but did find that he was experiencing symptoms of an Anxiety Disorder, and Affective Disorder, and an Organic (memory) Disorder. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Veteran denied any pre-military involvement in mental health treatment, and no mental health-related conditions were endorsed on veteran's Reports of Medical History, dated 4/14/94 or 6/21/95. Records show a hospitalization from 9/12-9/21/95 secondary to veteran's fall. During the course of that hospitalization, he was found to experience a fair amount of short-term memory return, no significant long-term memory problems, and his cerebellar activities were returning toward normal. A Department of the Army memo, dated 9/14/95, revealed that veteran was involved in a serious accident on 9/12/95 when he was an ROTC cadet. That memo noted that he hit his head, was taken to the hospital, and diagnosed with a concussion. It was also noted on that memo that veteran was in and out of deep sleep, not responding like he should, could remember names but not associations, and was confused. Notes from Par Rehab Services, dated 4/3/07, revealed residual impairment in spatial perception, visual memory skills, and higher level executive functioning, all of which involved organization, prioritization, cognitive flexibility, and an ability to move from task to task while tolerating distractions. It was also noted the the Par examiner that veteran was developing an increased degree of anxiety and depression secondary to his underlying cognitive problems. He was diagnosed at Par with a cognitive disorder secondary to his TBI, as well as an Adjustment Disorder with Mixed Anxiety and Depressed Mood. Records also show that veteran was treated for symptoms of anxiety and PTSD at Michigan State University in 2012. Veteran underwent his last C&P evaluation for mental disorders on 3/4/14, when he was diagnosed with Other Specified Anxiety Disorder, and an initial TBI C&P evaluation on 3/26/14. A Hope Network Physician Treatment Note, dated 7/10/14, reflected diagnostic impressions of mild neurocognitive disorder due to TBI, with attention and memory impairments, PTSD, delayed ejaculation, and occupational impairment. He met with a VA social worker in 2014 secondary to symptoms of PTSD and TBI. He was involved in individual psychotherapy with a VA psychologist in 2015, secondary to diagnoses of Anxiety Disorder NOS, Depression NOS, and a history of PTSD. Veteran is participating in a peer support group facilitated by a VA provider. Veteran underwent inpatient mental health treatment from 2/9-2/17/15. A letter found among he electronic records, penned by Dr. Dykema on 6/22/16, noted a TBI due to a parachuting accident during ROTC in 1995, which was diagnosed in 2007. Dr. Dykema also noted that veteran is experiencing significant impairment in occupational functioning, as he is "unable to work to expectations in numerous past jobs." In addition, Dr. Dykema found that veteran felt overwhelmed by responsibility, and described chronic depression and anxiety symptoms due to education and occupational difficulties secondary to his TBI. Dr. Dykema also noted a hospitalization in 2015, secondary to suicidal ideation, revealing that he has attempted suicide on numerous occasions. Dr. Dykema diagnosed veteran with depression and anxiety secondary to his TBI. Veteran is currently prescribed Sertraline HCL and Lisdexamfetamine Dimesylate (Vyvanse, for AD/HD). He stated counseling has been good, as it gives him someone to talk to, adding his inpatient treatment was also helpful. He was uncertain about medication management, citing his 3 suicide attempts over the last year. NOTE: Veteran's records show that he is currently flagged as being at high risk for suicide. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Denied. e. Relevant Substance abuse history (pre-military, military, and post-military): Veteran reported that his alcohol use became problematic following his parachuting accident, stating, "I couldn't handle it the way I could." He added alcohol had a bigger impact on him following the accident, but stated he used alcohol in an attempt to make himself "numb." He described himself as a "binge drinker," consuming a half-gallon of gin during a given weekend. He denied alcohol use since 2000. Veteran also reported that he began using cannabis following the accident, stating he never wanted to use that substance prior. Following the accident, he thought, "Why not?" He stated cannabis calmed him down, and distracted him from thoughts of the accident and its' resulting limitations. He reportedly held a medical marijuana card for 2 years, but began to feel that cannabis "made things worse." As a result, he stated he quit the use of cannabis in 2012. He denied the use/abuse of any other substances. f. Other, if any: Subjective Report of Symptoms: Veteran reported that he experiences panic, triggered by what he has forgotten or has not done. He also reported sadness, due to the accident, and its' impact on his teaching career. Veteran also noted feelings of guilt, due to his unemployment. He added he also wonders about the status of his VA claims. During times of increased stress, veteran reported that he smells the odor of burning cannabis. In addition to the panic described above, veteran reported anxiety triggered by unexpected loud noises, surprises (including unexpected touching from his family), feeling like his TBI is getting worse (stating the harder he tries the worse it gets), and the future. He reported daily panic attacks, for which he uses cognitive behavioral and breathing techniques learned in treatment. Veteran reported 3 suicide attempts over the last year, via carbon monoxide poisoning (x2) and overdose on medications. He denied any current plan/intent to harm himself, reporting a "scale" of "45%" suicidal ideation vs. "55%" desire to live. He denied homicidal ideation. He described his appetite as "fine." At night, veteran reported that he was prescribed Trazodone during his last evaluation, which has allowed him to feel better rested. When his sleep is interrupted, he stated the Trazodone allows him to more easily return to sleep. Despite his medication, he reported that he will sometimes wake up and think about all he has done wrong or is not good at. He also reported dreams, which he described as being like "impressions" of his impact with the ground, adding he experiences goose bumps when they occur. Veteran denied flashbacks, stating he "tries not to think about it." Regarding his memory, veteran reported that he makes lists and write things down. 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: Veteran reported that he remembers his first training jump, thinking, "Wow...I'm still here." He went on to describe vague memories of being on the aircraft and or taxying down the runway for his second jump, and then nothing further until waking up in the hospital. In the hospital, veteran reported that he remembers having some conversations, but did not trust that memory, as he also remembered speaking to his deceased grandmother at that time. 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: Training accident, as evidenced by Army and hospital records describing his parachuting accident. 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 Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] 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). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] 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 the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] 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 #1 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [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] Suicidal ideation 6. Behavioral Observations -------------------------- Veteran is a 42 year old, Caucasian male, who presented early for evaluation, casually dressed and appropriately groomed. He was alert and fully oriented. He was able to correctly spell "WORLD" forward and backward. He was not able to accurately complete serial 7s (e.g., "100-93-86-79-73-67"). He was able to recall 2/3 words after delay, which did not improve with prompting. He was cooperative with the assessment process. Veteran's mood and affect were dysphoric and anxious. He displayed good eye contact. Veteran's speech was reflective of anxiety, but spontaneous and goal-directed. His thought processes were generally organized with no evidence of hallucinations, delusions, mania, or obsessive-compulsive features. He appears to be of average intelligence, with capacity for abstract thought, and fair insight into his emotional functioning. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: Testing Results: The PTSD Checklist- 5 (PCL-5) was administered to gauge current signs and symptoms of traumatic stress. Currently, there are no normative data available for the PCL-5, and the instrument was completed as a self-report measure of the severity of reported PTSD symptoms. Veteran endorsed the following symptoms as bothering him Extremely: Feeling very upset when something reminded him of the stressful experience; Trouble remembering important parts of the stressful experience; Having strong negative beliefs about himself, others, or the world; Blaming himself or someone else for the stressful experience or what happened after; Being "super alert" or watchful or on guard; Feeling jumpy or easily startled; and Trouble falling or staying asleep. Veteran endorsed the following symptoms as bothering him Quite A Bit: Repeated, disturbing, and unwanted memories of the stressful experience; Suddenly feeling or acting as if the stressful experience were actually happening again; Having strong physical reactions when something reminded him of the stressful experience; Avoiding memories, thoughts, or feelings related to the stressful experience; Avoiding external reminders of the stressful experience; Having strong negative feelings such as fear, horror, anger, guilt, or shame; Loss of interest in activities he used to enjoy; Feeling distant or cutoff from others; Trouble experiencing positive feelings; Irritable behavior, angry outbursts, or acting aggressively; and Having difficulty concentrating. Veteran endorsed the following symptom as bothering him Moderately: Taking too many risks or doing things that could cause self-harm. The remaining symptom was endorsed by veteran as bothering him A Little Bit (e.g., Repeated, disturbing dreams of the stressful experience). 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- Integrated Summary and Clinical Impressions: Veteran is a 42 year old, married Caucasian male, who received a TBI following a parachuting accident in 1995. Results of current examination revealed evidence of signs and symptoms of PTSD, depression, and anxiety, secondary to his TBI, and resulting educational and occupational limitations. His accident has also contributed to social functioning, as veteran denied making any new friends since his accident. The above symptoms were more likely than not present at the time of his last C&P evaluation for mental disorders in 2014. Veteran also reported a pattern of heavy alcohol, as well as cannabis, use since his TBI, both of which are in states of sustained remission. Prognosis for substantial improvement of psychiatric symptoms and functional status is guarded, due to veteran's TBI symptoms, exacerbated to his symptoms of PTSD, anxiety, and depression, resulting in an ongoing reciprocal relationship between TBI and mental health sequelae, as attested to by medical documentation since his accident, and his current flag as being at high risk for suicide. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. /es/ Joseph C Bolton, PsyD Psychologist Signed: 09/26/2016 18:13 ------------------------------------------------------------------------- ========================================================================= Date/Time: 26 Sep 2016 @ 1230 Note Title: C&P MENTAL DISORDERS Location: BATTLE CREEK MI VAMC Signed By: Co-signed By: Date/Time Signed: 26 Sep 2016 @ 1347 ------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL DISORDERS STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: SEP 26, 2016@12:30 ENTRY DATE: SEP 26, 2016@13:47:16 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI) Disability Benefits Questionnaire * Internal VA or DoD Use Only* Name of patient/Veteran: Franklin Eugene Mays Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS SECTION I: Diagnosis and medical history ---------------------------------------- 1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI? [X] Yes [ ] No [X] Traumatic brain injury (TBI) ICD code: S06.2 Date of diagnosis: Sep 12, 1995 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): On Sept 12, 1995 the Veteran suffered a parachute accident. He landed hard and was unconscious for 10-15 minutes. He had dizziness, headache, and vision problems when he woke up. He was noted to have cerebellar dysfunction which was noted by balance issues and confirmed by a MRI. He was taken to Fort Benning, Georgia hospital where he was hospitalized from Sept 12 to Sept 21, 1995. He was diagnosed with a closed head injury, mild Diabetic insipidus, and Cranial nerve IV bilaterally. He also was noted to have mild edema of the left parietal lobe and cerebellum. He was placed on light duty until his discharge 2 years later. He has continued to have vertigo, balance problems, memory dysfunction, problems organizing tasks. He went to to Hope Network in 2011 where he was treated. He was treated extensively for cognitive dysfunction from his TBI. He also had problems anxiety, substance abuse, and depression requiring treatment. He was diagnosed again with continued problems with his TBI in 2007 b by Dr Fabiano. He currently is prescribed wellbutrin 450mg XL po qam. He was on Vivance 70mg per day until He stopped it recently. He is on Trazadone 25mg po qhs. SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI ----------------------------------------------------------------------------- 1. Memory, attention, concentration, executive functions -------------------------------------------------------- [X] Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary): He has extensive testing at Hope Network which ahs shown short term memory dysfunction. He also has had post traumatic amnesia for the time around the head injury. 2. Judgment ----------- [X] Normal 3. Social interaction --------------------- [X] Social interaction is occasionally inappropriate If the Veteran's social interaction is not routinely appropriate, describe (brief summary): He lives with his wife and 3 children, ages 12, 10, and 8. After the military to college, struggling with classes, and he barely finished his degree. He is applyng for socially security disability. He has been having trouble with maintaining his teaching ceritificate credits. He was having trouble performing the needed skills. He also has received support from Michigan rehabilation services. He has been in job jeopardy for a while. Both Michigan VA and the VA rehab services do not feel that he is employable due to the extent of his cognitive deficits from his TBI. 4. Orientation -------------- [X] Always oriented to person, time, place, and situation 5. Motor activity (with intact motor and sensory system) -------------------------------------------------------- [X] Motor activity is normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function) If the Veteran has any abnormal motor activity, describe (brief summary): He has had jerks and cleched jaw reflexes since the head injury that was noted after the head injury on Oct 12, 1995 by Dr David R Rivera, MD, a Ophthamology who also noted some memory dysfunction, decreased stamina, bliateral 4th cranial nerve palsies, balance problems, and cogwheel pursuit. 6. Visual spatial orientation ----------------------------- [X] Moderately impaired: Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS (global positioning system) If the Veteran has impaired visual spatial orientation, describe (brief summary): Veteran gets lost periodically. He went to the wrong building before he got to this appointment. 7. Subjective symptoms ---------------------- No response provided. 8. Neurobehavioral effects -------------------------- [X] One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them If the Veteran has any neurobehavioral effects, describe (brief summary): Veteran has had moodiness,a nxiety, depression, irritablity, and impaired awareness. 9. Communication ---------------- [X] Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas. If the Veteran is not able to communicate by or comprehend spoken or written language, describe (brief summary): Veteran has extensive comphrension difficulties. 10. Consciousness ----------------- [X] Normal SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks ----------------------------------------------------------------------------- 1. Residuals ------------ Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)? [X] Yes [ ] No [X] Headaches, including Migraine headaches [X] Mental disorder (including emotional, behavioral, or cognitive) 2. Other pertinent physical findings, scars, complications, conditions, signs, symptoms and scars ------ ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [X] Yes [ ] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 3. Diagnostic testing --------------------- a. Has neuropsychological testing been performed? [ ] Yes [X] No b. Have diagnostic imaging studies or other diagnostic procedures been performed? [ ] Yes [X] No c. Has laboratory testing been performed? [ ] Yes [X] No d. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): see records from VBMS which extent the extent of his cognitive deficits due to his TBI. 4. Functional impact -------------------- Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's residual conditions attributable to a traumatic brain injury, providing one or more examples: Veteran has had significant difficulty due to his TBI. Job jeopardy for a while, now on long term disability. 5. Remarks, if any: ------------------- No remarks provided. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Franklin Eugene Mays ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Does the Veteran continue to have a TBI with associated headaches?? TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: It is least likely as not that Veteran has a TBI with associated headaches, mood disturbances, anxiety, and depression. On Sept 12, 1995 the Veteran suffered a parachute accident. He landed hard and was unconscious for 10-15 minutes. He had dizziness, headache, and vision problems when he woke up. He was noted to have cerebellar dysfunction which was noted by balance issues and confirmed by a MRI. He was taken to Fort Benning, Georgia hospital where he was hospitalized from Sept 12 to Sept 21, 1995. He was diagnosed with a closed head injury, mild Diabetic insipidus, and Cranial nerve IV bilaterally. He also was noted to have mild edema of the left parietal lobe and cerebellum.He was placed on light duty until his discharge 2 years later. He has continued to have vertigo, balance problems, memory dysfunction, problems organizing tasks. He went to to Hope Network in 2011 where he was treated. He was treated extensively for cognitive dysfunction from his TBI. He also had problems anxiety, substance abuse, and depression requiring treatment. He was diagnosed again with continued problems with his TBI in 2007 b by Dr Fabiano. He currently is prescribed wellbutrin 450mg XL po qam. He was on Vivance 70mg per day until he stopped it recently. He is on Trazadone 25mg po qhs. He has extensive testing at Hope Network which ahs shown short term memory dysfunction. He also has had post traumatic amnesia for the time around the head injury. He lives with his wife and 3 children, ages 12, 10, and 8. After the military to college, struggling with classes, and he barely finished his degree. He is applyng for socially security disability. He has been having trouble with maintaining his teaching ceritificate credits. He was having trouble performing the needed skills. He also has received support from Michigan rehabilation services. He has been in job jeopardy for a while. Both Michigan VA and the VA rehab services do not feel that he is unemployable due to the extent of his cognitive deficits from his TBI. Veteran gets lost periodically. He went to the wrong building before he got to this appointment. It is also least least likely as not that the Veteran's psychiatric issues are connected to his TBI. Veteran has had moodiness,anxiety, depression, irritablity, and impaired awareness.Veteran has extensive comphrension difficulties. He has had extensive psychiatric issues since his TBI. It is more of the cognitive difficulties that impair working. He has had jerks and clenched jaw reflexes since hte head injury that was noted after the head injury on Oct 12, 1995 by Dr David R Rivera, MD, a Ophthamology who also noted some memory dysfunction, decreased stamina, bliateral 4th cranial nerve palsies, balance problems, and cogwheel pursuit. I also recommend an Eye exam. ************************************************************************* **************************************************************************** Headaches (including Migraine Headaches) Disability Benefits Questionnaire Name of patient/Veteran: Franklin Eugene Mays Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a headache condition? [X] Yes [ ] No [X] Other (specify type of headache): mixed ICD code: R51 Date of diagnosis: sept, 1995 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): Sept 21, 1995. He was diagnosed with a closed head injury, mild Diabetic insipidus, and Cranial nerve IV bilaterally. He also was noted to have mild edema of the left parietal lobe and cerebellum. He was placed on light duty until his discharge 2 years later. He has continued to have vertigo, balance problems, memory dysfunction, problems organizing tasks. He went to to Hope Network in 2011 where he was treated. He was treated extensively for cognitive dysfunction from his TBI. He also had problems anxiety, substance abuse, and depression requiring treatment. He was diagnosed again with continued problems with his TBI in 2007 b by Dr Fabiano. He currently is prescribed wellbutrin 450mg XL po qam. He was on Vivance 70mg per day until he stopped it recently. He is on Trazadone 25mg po qhs. b. Does the Veteran's treatment plan include taking medication for the diagnosed condition? [X] Yes [ ] No If yes, describe treatment (list only those medications used for the diagnosed condition): Headache meds make him groggy, 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Constant head pain [X] Pulsating or throbbing head pain [X] Pain on both sides of the head b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain) [X] Yes [ ] No [X] Nausea [X] Changes in vision (such as scotoma, flashes of light, tunnel vision) c. Indicate duration of typical head pain [X] Less than 1 day d. Indicate location of typical head pain [X] Both sides of head 4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [X] Yes [ ] No If yes, indicate frequency, on average, of prostrating attacks over the last several months: [X] With less frequent attacks b. Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [ ] Yes [X] No 5. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [X] Yes [ ] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided. 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: It is more of the cognitive difficulties that impair working. 8. Remarks, if any: ------------------- No remarks provided. Staff Psychiatrist Signed: 09/26/2016 13:47 ------------------------------------------------------------------------- ========================================================================= Date/Time: 26 Sep 2016 @ 1100 Note Title: C&P AUDIOLOGY EVALUATION Location: BATTLE CREEK MI VAMC Signed By: Co-signed By: Date/Time Signed: 26 Sep 2016 @ 1401 ------------------------------------------------------------------------- LOCAL TITLE: C&P AUDIOLOGY EVALUATION STANDARD TITLE: AUDIOLOGY C & P MULTIPLE EXAM NOTE DATE OF NOTE: SEP 26, 2016@11:00 ENTRY DATE: SEP 26, 2016@14:01:46 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Hearing Loss and Tinnitus Disability Benefits Questionnaire Name of patient/Veteran: Mays, Franklin E 0567 Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): Self reported history: Chief complaint: Bilateral constant tinnitus, most noticeable in quiet settings, onset following TBI for which he is service connected. He is uncertain about hearing loss but does report difficulty hearing others at a distance. Situations of greatest difficulty: concentration problems and awareness problems with tinnitus, bothersome only in quiet. Hearing trouble at a distance. Pertinent Service History: US Army 8-1994 to 12-1996, ROTC non- combat. MOS: AIT training only, qualified for weapons training. Place and Condition of claimed hearing disturbance: Parachute accident during ROTC training, hit back of head and suffered LOC for several minutes, hospitalized. Diagnosed with mild TBI. Military noise exposure: training weapons. M16 rifle, field field artillery training with Howitzers and W/Raps. Occupational noise exposure: teacher 2008-2015, currently on disability. Prior to this denied any industrial or hazardous noise exposure vocational history. Recreational Noise exposure: lawn care equipment < 1hour with HPDs, some power tool use and chainsaw operation with HPDs. Medical/Health History: Negative for the following: perforated TM, familial hearing loss, vertigo, temporary/sudden changes in hearing and all other on history form. Positive for: ear infection 1985, head injury with LOC during military service ROTC training, equilibrium problems he feels is related to TBI, history of alcohol abuse for 5 years, medication use for anxiety, depression, hospitalized for suicide attempt 2016. Evidence Comments: VBMS review: Review of Record: EOD 9-1-1994 RAD 12-31-1996 non-combat 11-9-2012 Statement in support of claim:The current symptoms of disability that I am aware of are as follows Head Injury possible TBI with secondary conditions of depression and anxiety Psychology/Neuro: CH[closed head injury] Sept 1995 Please evaluate Martin Army Comm Hospital 9-12-1995, injury during a parachute landing fall- Closed head injury. 12-12-1995 severe concussion due to hard PLF Admission note 9-12-1995 to discharge 9-21-1995 6-21-1995 Apppointment Report of ME REF audiogram 6-23-1995 500 1000 2000 3000 4000 6000Hz R 15 05 05 00 00 25dBHL L 15 10 05 05 05 20dBHL 5/5/1994 R 05 05 10 05 10 15dBHL L 05 00 05 10 15 15dBHL AA C&P exam TBI -Neuropsych Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)? [ ] Yes [X] No Has neuropsychological testing been performed? [X] Yes [ ] No Results: There is no mention of anxiety associated with his military-related parachuting accident until 2007, though that appeared to be remitted by 2009. His current mild anxieties are related to the assault he sustained in 2011; therefore, his current diagnosis of Other Specified Anxiety Disorder is less than likely as not (less than 50/50 probability) caused by or a result of his military service and there is no evidence to suggest that his current anxieties were aggravated by his past parachuting accident. to determine if he sustained a mild vs. moderate TBI given the lack of records but suspected that it may have been moderate in severity. the vet did see opthy in 1995 and was noted to have bilat cn4 palsy which which was noted to resolve in a 1996 follow up visit. the vet did complete 2 college degrees since his injury. during today's routine neuropsychometric testing, he performed worse than the 2007 eval noted in VBMS. He scored high in anxiety during today's eval. Based on his history, repeated neuropsychmetric evals, and the natural history of TBI, is is less likely than not that his current issues are related to his TBI history Capri ROTC cadet 6-28-2014 10-10 REg. PCP note, HEEnT no hearing problems. TBI consult 10-24-2014 Patient has mild hearing difficulty A lengthy discussion was held with the patient regarding our impressions, consistent with our C&P evaluation in March, and the medical record. We described the expected trajectory of recovery from a mild to moderate TBI without brain bleed, reviewed his imaging history, his educational history, and spent a considerable time talking about the influence of anxiety, PTSD and his symptoms associated with PTSD in significantly interfering with cognitive performance. He was attentive to this discussion, did not raise objections, although clearly was a bit uncomfortable with a notion that he does not suffer with lingering and permanent brain damage. He raised his history of ongoing TBI care outside of the VA, and we acknowledged our difference of opinion with these practitioners. Further, we reiterated that he should have made a good recovery from his concussion, and that he is had at least 3 or 4 years of repeated cognitive rehabilitation both in speech and OT so that he has had comprehensive rehab services. He is currently working with MRS re school job placement. The patient has a strong attribution of his head injury as a permanent cause for his functional deficits. As a telling example of his symptom presentation, he volunteered at the conclusion of our discussion that he has been having a pressure type feeling around the side and top of his head "since my injury", but also volunteered that "for many years I never noticed it but then recently someone suggested to me that I could have pain from my head injury and then I noticed it". 7-28-2014 1. Traumatic brain injury with loss of consciousness 2. Attention deficit hyperactivity disorder, predominantly inattentive type 3. Posttraumatic stress disorder secondary to a mugging 9-7-2016 AA VAMC ENT He reports spinning vertigo since June. Exacerbated by hot temperatures while working on a farm. Bending down and picking things up freque ntly caused a pressure headache and dizziness. He also reports a separate sensation described as objects in the environment moving up and down. He also recently felt unsteady while walking up a bridge. Associated increase in ringing tinnitus occurrs at times centrally. He started taking trazodone in July and also takes pyshotropic drugs Bupropion and Lisdexamfetamine dimesylate. H/o TBI and loss of consciousness for 5-15 minutes. Denies fluctuations in hearing, associated aural pressure, h/o ear surgery, otalgia. + h/o ear infection in childhood. Episodes have significantly decreased over the last month since stopping work on the farm, and now typically only occur outside while exerting himself in the heat. Impression: Possible psychotropic drug side effect causing nystagmus creating difficulty focusing eyes leading to mild limiting dyesquilibrium with walking over a bridge lately. No audiological symptoms to suggest peripheral cause to dizziness, but he does have b/l tinnitus. Also consider h/o TBI as contributing factor. This exam is for: Tinnitus only (audiologist or non-audiologist clinician) SECTION 2: TINNITUS -------------------- 1. Medical history ------------------ Does the Veteran report recurrent tinnitus: Yes Date and circumstances of onset of tinnitus: The veteran reported bilateral tinnitus, noticeable in quiet settings only. He did report that he notices the tinnitus whenever he concentrates on it. This report is consistent with constant non-bothersome tinnitus. The veteran reported tinnitus following head injury during military service. The veteran has a longstanding diagnosis of TBI due to a parachute/fall incident during Army ROTC training. 2. Etiology of tinnitus ----------------------- At least as likely as not (50% probability or greater) due to a known etiology (such as traumatic brain injury). Etiology and rationale: The medical records reviewed were silent for c/o tinnitus following TBI injury in 1995 and all STRs silent for tinnitus complaint. Late onset tinnitus is unlikely due to noise exposure and the veteran had negative report of acoustic trauma from military service. However, tinnitus is related to head injury and the veteran's STRs have longstanding history of TBI. Therefore, tinnitus is at least as likely as not due to head injury diagnosed and presently service connected. However, besides TBI the veteran has had significant alterations in personality and behavior, including anxiety and depression, all he believes is due to his TBI injury. However, clinical notes from C&P neuropsychology exam below suggest that the veteran's anxiety was due to an assult in 2011, following military service. AA VAMC Neuropsych exam C&P There is no mention of anxiety associated with his military-related parachuting accident until 2007, though that appeared to be remitted by 2009. His current mild anxieties are related to the assault he sustained in 2011; The veteran has some concerns today about his disequillibrium and was more than surprised when examiner indicated that late onset vertigo or disequillibrium due to head injury is uncommon and veteran may instead be suffering from medication side effects. Previous notes from AA VAMC Neuropsychologist would suggest that the veteran is pre-occupied with the notion that he has a lifetime head injury and lingering permanent brain damage. In fact today the veteran indicated that he is sure that he has had multiple head injuries since the parachute accident, because he was told that from a TBI you can sustain multiple head injuries. The veteran is well versed in TBI symptomology. The veteran's dysequillibrium may be a side effect of drug interactions according to ENT note, AA VAMC 9-7-2016 or TBI contributing factors. For this reason the veteran is filing a claim for his imbalance. He was assisted with this by examiner today to file for ear condition with ENT and a balance evaluation with a specialized audiology department. Battle Creek VAMC does not conduct balance evaluations. The veteran should be evaluated by posturography at the very least. 3. Functional impact of tinnitus -------------------------------- Does the Veteran's tinnitus impact ordinary conditions of daily life, including ability to work: Yes If yes, describe impact in the Veteran's own words: Only noticeable in quiet environments. 4. Remarks, if any, pertaining to tinnitus: ------------------------------------------- the above report would suggest non-bothersome tinnitus. Veteran was advised to use sound management in quiet settings to reduce awareness of tinnitus. C&P request dated 8-26-2016. The veteran is claiming tinnitus is related to TBI. In regard to hearing loss: No hearing loss found on exam. Comparing first exam 1994 to last exam REference exam 6-1995 no STS noted for either ear. Today's hearing thresholds slight hearing change noted for left ear today, unrelated to military service noise exposure or head injury. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. Signed: 09/26/2016 14:01 ------------------------------------------------------------------------- ----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------
  9. Today I received an update on my claim. It was actually lower than what I thought. I had filed for PTSD and had been given a C&amp;P for PTSD. My new disability does not show any rating for PTSD. Does this mean the claim is not finished?
  10. I had a C&P last September. The PhD diagnosed me as having anxiety, depression secondary to the tbi. In my latest results there is no mention of this C&amp;P. It would appear that the rater did not give any merit to these new diagnoses. Is it a common occurrence for a rater to 'pick and choose' or do they have to go with the diagnoses that give the benefit to the veteran. This of course requires that the two C&amp;P exams were performed by equally competent professionals. Or is there something else I am missing? I am trying to deal with what I consider a loss (by writing and talking about it). I appreciate any input. Thank you
  11. My TDIU claim is closer to a resolution. I called the "800 Number for Ebenefits" today. My claim is still in the Preparing for a Decision phase. However my claim was worked on today and the note attached to my claim said that the "statement of case" is/needs "promulgating". I don't understand what this means. Could anyone shed some light? I have been approved for SSD for the same conditions for SC conditions of TBI (Organic Brain Injury in SSD-Talk) , Anxiety, Depression.
  12. Good luck jfrei. My claim also went from gathering evidence to preparation for decision in about a week. I have been told from the "800" number that the VA has everything that they need to make a decision. MPsgt: Thank you for your input. I think that a VA doctor's letter does help a claim. I was fortunate to have my VA doctor write a letter for me stating that I could only work 20hrs per week. Then I have a letter from Chpt 31 stating that because of mental health issues (i.e. : service connected) that I was unemployable at this time. I also have a letter from the state rehabilitation agency stating that I am unemployable at this time.
  13. Hello, I am waiting on a TDIU claim. I was recently awarded SSDI, and I submitted my acceptance letter to strengthen my TDIU claim. I have been told that my claim is in "Preparation for Decision" (or something like that). My question is this; Would it be uncommon for a regional office to process a TDIU and award it? I know that all claims are different. I'm just wondering is it common for VA regional office employees to take time between Christmas and New Years off. I know that in many other government agencies this is the norm, but is it true for a VA regional office?
  14. Hello. I don't think that I was administered a MOREL test. The person who saw me for the C&P was a Ph.D. I was relieved that he diagnosed me with having PTSD from my TBI. Originally PTSD, Anxiety, and Depression were denied as not being service connected.
  15. There, I posted the C&P for the mental disorders secondary to the tbi. I was really grateful for the examiner writing that my mental disorders were more likely than not present at the time of my first C&P.