ptsd (Updated with C&P results) Recently requested IU at MH providers suggestion

[WhyMista]

So I recently as of 20150412 applied for IU along with reopening my claims for migraines, vertigo and photosensitivity.

 

I was recently back in march given an increase on my PTSD rating so that I currently sit at 80%.  The breakdown being 70%-PTSD  10%-Left shoulder impingement 10%-Tinnitus  0%-mild ankle laxity

 

My claim for migraines is well supported by over 3yrs of treatment records showing that I have on average two a week that cause me to either be forced to take an abortive that renders me unable to function so as to relieve the nausea of being stuck in bed all day without lights or any sort of sounds.  There have been multiple medications I have been on and the last two times I was seen by my PCP they noted the migraines being debilitating and consistent and that basically there is nothing else to do besides deal with them as we currently are.  I did get a call from the RO that said they had approved my claim for migraines and that they were still working on my other contentions.  From everything I have seen doing research it seems as if I may be given a 50% rating due to the frequency and severity of them.

 

Now since my MH provider is the one who suggested I apply for IU based upon my PTSD, not even knowing about my migraines and knowing that since I have been treated there I have had multiple attempts to return to school and been unsuccessful due to having in the past year three hospitalizations as well as normal daily difficulties and only one seasonal temporary job this past christmas season does that bode well for my chances at getting IU.  Before I applied for IU I did my request for ptsd and migraines and was sent to a C&P for them earlier this summer which is why I am assuming they haven't requested another C&P.  

 

Thank you

Edited June 15, 2016 by WhyMista

[WhyMista]

So my claim finished yesterday.  I was rated at 50% for migraines with light sensitivity and 10% for TBI for a 90% overall rating.  So my new breakdown is as follows:

70%-PTSD

50%-Migraines with light sensitivity

10%-Tinnitus

10%-Left Shoulder dislocation with mild impingement

0%-Chronic right ankle sprain with laxity.

 

However I do not see IU listed as denied or deferred.  Other contentions I had which were denied like vertigo show "not service connected" and prior to my claim closing the last listed contention was IU.  I checked my AB8 letter so I know that I am rated at 90% and also being paid at the 90% rate meaning IU was not granted.  Obviously I'll need to wait for the BWI( I've never gotten a brown one from them) but I was wondering why it doesn't even show it being denied or deferred etc.

 

I will be going up to see my MH provider so that she can write a detailed statement about how my PTSD has over the past three or so years has impacted my work and academic life as she is the sole person I have seen for MH since somewhere in 2011.

 

[WhyMista]

I just rececently had C&Ps for both PTSD and TBI/Migraines.  Both were done at the VA after I repopened my claim for IU.  Since it was done in house should it not show up in myhealthevet?  I went back on ebenefits and it went from being estimated from 09/30/2016-02/01/2017 to being done sometime around august this year now that I just had my C&Ps on 20160607.  I'm assuming it changed because they received the needed documents but why can't I see them so I can try and assess my chances.

 

When I was speaking to both of them the last who was doing my tbi/migraines stated that he agreed my migraines are poorly controled and they should be trying more to reduce them from 4 a week and asked how I did in school and work when  I was not suffering from them which I did excellent when I wasn't suffering from them.  I'm hoping it comes back favorable

[Navy04]

Glad you made it thru the exams bud. I just put in a few weeks ago for PTSD increase and A&A. I already had the Psych exam 2 days ago thru the VES Civilian Doc, which I can not get copy of results, and today I saw a Civilian VES Doc for A&A. Those exams were brutal and neither exam report will be available to me. My claim shows to be completed from Aug-Oct 2016. So it is really hard to say what will happen. Good luck and keep us posted. God Bless

[WhyMista]

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

 CONFIDENTIAL Page 9 of 20

---------------
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) Date of diagnosis: 2005

2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's TBI

and
residuals attributable to TBI (brief summary):

The veteran is already SC for TBI.
he states that he was exposed to a IED blast in Iraq in 2005, which rendered him unconscious for a brief moment. he says migraine headache started soon after the explosion.

SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI

-----------------------------------------------------------------------------

1. Memory, attention, concentration, executive functions --------------------------------------------------------
[X] No complaints of impairment of memory, attention, concentration, or

executive functions

2. Judgment -----------
[X] Normal

3. Social interaction
---------------------
[X] Social interaction is routinely appropriate

4. Orientation
--------------
[X] Always oriented to person, time, place, and situation

 CONFIDENTIAL Page 10 of 20

5. Motor activity (with intact motor and sensory system) --------------------------------------------------------
[X] Motor activity normal

6. Visual spatial orientation -----------------------------
[X] Normal

7. Subjective symptoms
----------------------
[X] Three or more subjective symptoms that mildly interfere with work;

instrumental activities of daily living; or work, family or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate

headaches,
tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light

If the Veteran has subjective symptoms, describe (brief summary): Migraines, sensitivity to light, tinnitus (on right).

8. Neurobehavioral effects --------------------------
[X] No neurobehavioral effects

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)?
[X] Yes [ ] No

[X] Headaches, including Migraine headaches

2. Other pertinent physical findings, scars, complications, conditions, signs, symptoms and scars

 CONFIDENTIAL Page 11 of 20

-----------------------------------------------------------------------------
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?
[ ] Yes [X] 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? [ ] 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:
-------------------
Migraine headache and sensitivity to light are the only residuasl from TBI

in
service at this juncture.

****************************************************************************

Headaches (including Migraine Headaches) Disability Benefits Questionnaire

Name of patient/Veteran: 

 CONFIDENTIAL Page 12 of 20

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] Migraine including migraine variants Date of diagnosis: 2005

2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's

headache conditions (brief summary):
The veteran reports onset of severe recurrent headache right after the IED explosion in 2005.

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):

Topomax, Imitrex.

3. Symptoms
-----------
a. Does the Veteran experience headache pain?

[X] Yes [ ] No
[X] Pulsating or throbbing head pain [X] Pain on both sides of the head

 CONFIDENTIAL Page 13 of 20

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] Sensitivity to light
[X] Sensitivity to sound

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] Once every month

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?
[ ] Yes [X] 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?

 CONFIDENTIAL Page 14 of 20

[X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: Difficulty with concentration. 8. Remarks, if any: ------------------- No remarks provided. /es/ Physician, Compensation & Pension (PM&R) Signed: 06/07/2016 09:19

Date/Time:	07 Jun 2016 @ 0730
Note Title:	COMP & PEN MENTAL HEALTH/PSYCHOLOGY EXAM
Location:
Signed By:
Co-signed By:

 

 

I applied for IU and this is my C&P for my migraines and TBI which is correct save for them saying I only have prostrating migraines once a month its like 4 or 5 times a month.  Is there a way to get that corrected or should I wait and see and how do you think that looks with regards to my chances with getting IU.  Taking into account my C&P for PTSD done the same day

 

1. Diagnostic Summary

---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No

2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD

Comments, if any: The Veteran reported having the following PTSD

CONFIDENTIAL Page 15 of 20

symptoms at this time: Irritabiity and anger outbursts; sleep disturbance, with nightmares and related fatigue; troubling recall of combat events; hypervigilant thoughts and behaviors; exaggerated

startle
response; marital and family distress and avoidance of stimuli associated with his combat epxeriences.

Mental Disorder Diagnosis #2: Personality Disorder traits

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI):
No response provided.

3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes[X] No

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [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: The Veteran reported having the following PTSD symptoms at this time: Irritabiity and anger outbursts; sleep disturbance, with nightmares and related fatigue; troubling recall of combat events; hypervigilant thoughts and behaviors; exaggerated startle response; marital and family distress and avoidance of stimuli associated with his combat epxeriences.

Please refer to TBI exam for TBI relatedsequela.

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 reduced reliability and productivity

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

 CONFIDENTIAL Page 16 of 20

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: The Veteran reported having the following PTSD symptoms at this time:

Irritabiity
and anger outbursts; sleep disturbance, with nightmares and related fatigue; troubling recall of combat events; hypervigilant thoughts

and
behaviors; exaggerated startle response; marital and family distress and avoidance of stimuli associated with his combat epxeriences.

Please refer to TBI exam for TBI relatedsequela.

SECTION II:

----------- Clinical Findings: ------------------

1. Evidence review
------------------
In order to provide an accurate medical opinion, the Veteran's claims

folder
must be reviewed.

a. Medical record review:
-------------------------
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[ ] No

If no, check all records reviewed:

[ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination
[ ] Military separation examination

[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment

records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

 CONFIDENTIAL Page 17 of 20

[ ] No records were reviewed [ ] Other:

b. Was pertinent information from collateral sources reviewed? [ ] Yes[ ] No

2. Recent History (since prior exam) ------------------------------------
a. Relevant Social/Marital/Family history:

Please refer to previous C&P PTSD exams dated 5/7/2012 & 3/23/2015 for

additional background and history. Veteran married his current spouse in April 2016. Veteran has a 9 month old biological child and a 9 year old step child with current spouse. Veteran has a 6 year old daughter from first marriage and reported "very little" contact with

this child.
Veteran reported regular phone contact with his parents. Veteran

denied
any current hobby/interests other than "taking care of my

son".

b. Relevant Occupational and Educational history:
Veteran reported he is a Junior in college but last attended the University of Texas  in 2014. Veteran reported interest in resuming his college career in the future. Veteran denied any work history since previous C&P PTSD exam dated 3/23/2015.

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

Veteran's current psychotropic medication is lithium carbonate.

d. Relevant Legal and Behavioral history:
Veteran indicated he was arrested for DWI in 2007, and making a terroristic threat (non-felony) in 2011.

e. Relevant Substance abuse history:
Veteran acknowledged a history of excessive alcohol use in the past

but
denied any current difficulty related to alcohol use.

f. Other, if any:
No response provided.

3. PTSD Diagnostic Criteria

 CONFIDENTIAL Page 18 of 20

---------------------------
Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threateningsituat

ions (non-combat
related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms".

Criterion A: Exposure to actual or threatened a) death, b) serious injury,

c) sexual violation, 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] Recurrent distressing dreams in which the content and/or

affect of the dream are related to the traumatic

event(s).

Criterion C: Persistent avoidance of stimuli associated with the traumatic

the

of

"I

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

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)

the following:

[X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g.,

am bad,: "No one can be trusted,: "The world is completely

dangerous,: "My whole nervous system is permanently

ruined").
[X] Persistent negative emotional state (e.g., fear, horror,

 CONFIDENTIAL Page 19 of 20

of

anger, guilt, or shame).
[X] Markedly diminished interest or participation in

significant activities.
[X] Feelings of detachment or estrangement from others.

Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more)

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] Hypervigilance.
[X] Exaggerated startle response.
[X] Sleep disturbance (e.g., difficulty falling or staying

asleep or restless sleep).

Criterion F:
[X] The duration of the symptoms described above in Criteria

B, C, and D are more than 1 month.

Criterion G:
[X] The PTSD symptoms described above cause 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.

4. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Depressed mood
[X] Anxiety
[X] Chronic sleep impairment
[X] Flattened affect
[X] Disturbances of motivation and mood

5. Behavioral Observations: ---------------------------

The Veteran's thought process and communication skills appeared to be

within normal limits. The Veteran denied having any symptoms of delusions

or hallucinations and none were apparent. The Veteran was cooperative, maintained good eye contact, and exhibited no inappropriate behavior.

 CONFIDENTIAL Page 20 of 20

The Veteran denied having any current suicidal or homicidal ideation, plan, or intent. The Veteran appeared able to maintain personal hygiene and basic activities of daily living. The Veteran was well-oriented to all three spheres. The Veteran's short and long term memory appeared to be without gross deficits. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: ---------------------------------------------------