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Mental Health C&p Any Opinions Appreciated


This is for an appeal of my current VA 60% i was Retired @90% and am on SSDI due to SC issues Thanks for insight

Mental Disorders
(other than PTSD and Eating Disorders)
Disability Benefits Questionnaire

1. Diagnosis
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
[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: Bipolar I Disorder, Severe, Most Recent
Depressed (296.53)

Mental Disorder Diagnosis #2: Panic Disorder, without agoraphobia (300.01)

b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Deferred to medical provider.

Comments, if any:
The examinee reported a number of medical complaints that are beyond
the scope of this referral. Nonetheless, this writer would suggest
he be evaluated further by a qualified medical professional to address
such concerns.

2. Differentiation of symptoms
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes

b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[X] Yes

If yes, list which symptoms are attributable to each diagnosis:
The veteran's symptoms of mood instability, impulsivity,
and concentration difficulties are related to his diagnosis of
Disorder. His panic attacks are related to his diagnosis of Panic

3. Occupational and social impairment
a. Which of the following best summarizes the Veteran's level of
and social impairment with regards to all mental diagnoses? (Check only

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

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?
[X] Yes

If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
Based on the veteran's self-report and all available medical records,
the veteran's occupational and social impairment are linked primarily
to his Bipolar Disorder. He denied significant impact of his Panic
Disorder on his occupational and social impairment.

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:

Updated treatment records through Hampton VAMC. The veteran was previously
examined for "Bipolar Disorder" and "Anxiety Disorder." For this reason,
writer obtained information since his previous exam, dated in 2011. For
previous history, please refer back to his previous C&P report.

b. Was pertinent information from collateral sources reviewed? No

2. History
a. Relevant Social/Marital/Family history (pre-military, military, and
Since 2011, the veteran has reported increased social isolation and
interpersonal conflict in connection with his Bipolar Disorder. The
veteran reported that he has stopped talking to "everyone" except his
and his brother. He reported detachment from family members with whom he
previously had positive relationships. According to the veteran, he
continues to be married and they have three children together. He
described his relationship with his wife as "good, I couldn't hold it
together without her." He noted dependence upon his wife for activities
daily living related to reported physical conditions. He reported that
Bipolar Disorder has prevented him from watching his children engage in
extracurricular activities, and feels that he is not as supportive as he
should be. He stated that he "can't tolerate" social situations, and
isolates in order to avoid conflict. According to the veteran, his "anger
and violence have gotten out of control." He reported continued physical
aggression since 2011. He estimated involvement in altercations twice per
week. He denied homicidal ideations, but rather impulsive reactions to
stressful situations. His medical record is consistent with this report.

b. Relevant Occupational and Educational history (pre-military, military,
The veteran denied steady employment during this review period. He
reported that he attempted to continue working as a mechanic, but due to
combination of mental and physical problems, he has experienced an
unsuccessful series of attempts to obtain/maintain employment. He stated
that engages in verbal conflicts with others, and ultimately has lost his
jobs. "They never last long, one didn't event last a week." He stated
he has attempted to work in manual labor jobs, but is physically unable
do so. He also noted conflicts with customers. He reported that he "tried
the vocational rehabilitation program" and is currently on social
security/disability related to his mental illness.

Regarding the veteran's educational history, he reported that he began
classes at ECPI in February 2013, and was planning to obtain a degree in
Network Security. However, his grade declined shortly after enrolling due
to distractibility and confusion. He reported an altercation with his
academic advisor, resulting in physical aggression. He reported that he
has not been legally charged because his advisor started the conflict. He
reported that after that
situation, he experienced significant confusion
surrounding his class schedule. He was reportedly asked to leave a class,
because he was sitting in the wrong class. When asked for further
the veteran responded that he still does not understand what happened,
he did not provide further clarification. However, he stated that he has
been unable to complete his class work, and recently dropped out of

c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
The veteran reported that since 2011, he has continued with medication
management through the Hampton VAMC (Virginia Beach CBOC). He is
prescribed Lithium, Valium, Ziprazidone, and Diazepam. He reported that
has requested individual psychotherapy since 2011, but has not yet
started. He denied any history of psychiatric hospitalizations or
emergency room visits related to his mental health conditions in the
current review period. Record review reveals a significant verbal
altercation with another veteran in the Virginia Beach CBOC waiting room
in October 2013. According to that record, he had experienced significant
stress related to his daughter's health condition at the time, and he was
easily provoked.

The veteran's medical record also indicates a history of panic attacks
engaging in "cutting" within the past few weeks as a method of relieving

d. Relevant Legal and Behavioral history (pre-military, military, and
Since 2011, he has continued to engage in physical fighting. However, he
denied legal charges related to his behavior. He received a speeding
ticket in December 2013, and got into a verbal altercation with the
officer. However, he was reportedly not charged for his behavior. "I
know why; I clearly was in the wrong. But I feel like I can't control it.
It comes out of nowhere."

e. Relevant Substance abuse history (pre-military, military, and
The veteran denied current use of alcohol or other substances since 2007.
He denied ever having a pattern of problematic or chronic use of
substances. He reported that he uses his medications as prescribed.

3. Symptoms
For VA rating purposes, check all symptoms that apply to the Veteran's

[X] Depressed mood
[X] Anxiety
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Flattened affect
[X] Speech intermittently illogical, obscure, or irrelevant
[X] Impaired judgment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
[X] Difficulty in adapting to stressful circumstances, including work or
worklike setting
[X] Impaired impulse control, such as unprovoked irritability with
of violence
[X] Grossly inappropriate behavior
[X] Persistent danger of hurting self or others

Behavioral observations:
Please refer to the remarks section below.

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

If no, explain:
The veteran has reported that he cannot be trusted with finances. In
addition, he reports that his wife is the designated payee for his
security check. His prior history of shopping sprees also lends
additional evidence of this assertion. Overall, the symptoms of his mood
disorder would significantly interfere with his ability to appropriately
budget and spend his financial resources. He is at high risk for
such money, or falling victim to a predator (as he has routinely
displayed impaired judgment during episodes of mania).

6. Remarks (including any testing results), if any:
The veteran was notified of the limitations inherent in the present
interview. The examinee was made aware that the undersigned was functioning
solely in the role of an assessor, and not as a treatment provider. The
nature of the examination, with respect to the pending claim/request, was
made clear. Further, the limited confidentiality of the present results was
explained, and the veteran understood that the present results would be
shared with individuals attempting to adjudicate his compensation claim.
Additionally, the examinee was informed of this writer's affirmative
responsibility to prevent either the respondent or others from being placed
in danger of harm. Specifically, information related to ongoing elder/child
abuse would be related to an appropriate protective services agency.
Additionally, the veteran was instructed that if it is believed that he is
imminent threat to either himself or others, the limits placed upon
confidentiality, as previously explained, will no longer apply. The veteran
demonstrated an understanding of this material and provided verbal consent
continue with the scheduled assessment.

Mr. Mallette presented on time and in fair spirits. Rapport with this writer
appeared easily established and social skills were fairly intact. Personal
hygiene was fair. He was alert and aware throughout the present contact. He
was an active participant throughout the evaluation. He was oriented to all
spheres and understood the nature of the present assessment. Speech was
within normal limits for volume and rate. He demonstrated difficulty in
responding to specific questions, as his answers were initially on topic,
eventually derailed. However, he demonstrated awareness of this and
unsuccessfully attempted to correct himself.

Cognitive skills presented as grossly intact. He was able to complete
multi-step tasks without noticeable difficulty. The veteran reported "dull"
mood and this is congruent with his nonverbal behaviors, which were
indicative of depression. Performance was within expected limits on all
measures of memory. He was able to remember current and past president's
names, and he was able to recall all three target words after a 10 minute
interval without prompting or assistance. Additional screens of memory
functioning and attention did not suggest the presence of impairment in
memory or concentration. He was able to complete serial number tasks without
difficulty and he was able to correctly spell a 5 letter word forwards and

Performance on a digit span type task was below expected limits, as he was
able to accurately recite five digits forward and four backward. Abstract
reasoning skills and general fund of information did not evidence noticeable
impairment. Intellectual dysfunction was not evident, nor suspected. No
symptoms of formal thought disorder were observed or reported. The veteran
also denied symptoms of psychosis, suicidal ideation, or homicidal ideation.

This compensation exam was conducted specifically to assess for the presence

of "Bipolar Disorder, Mixed." The veteran's medical record consisted of
diagnoses, including Bipolar Disorder, Bipolar II Disorder, ADHD, Anxiety
Disorder, Panic Disorder, and R/O Borderline Personality Disorder. His
exam in 2011 reveals a diagnosis of Bipolar Disorder, Mixed, and states that
his anxiety is attributed to his Bipolar Disorder. Most recent medical
documentation indicates Bipolar Disorder and Anxiety Disorder.

Regarding his mood disturbance, the veteran reported a "dull" mood most
However, he reported distinct episodes of mania and depression, with each
lasting anywhere from 2-3 weeks. He reported that during a manic phase, he
achieves approximately 3 hours of sleep per night with adequate energy.
However, when in a depressive phase, "I feel like crap" and "sleep all day."
During his manic phase, he experiences elevated sense of self-esteem,
decreased need for sleep, talkativeness, racing thoughts, distractibility,
increase in goal-directed activity, and involvement in risky behaviors
(including losing up to $3000 within 4 hours of gambling, which caused
financial problems for the family; and increased sex drive with prior sexual
indiscretions, although his current medications provide complications
to sex drive). He reported that his spending became such a problem that his
wife has been designated as his payee for Social Security, and she handles
all of the household finances. Regarding depressive symptoms, the veteran
reported episodes of sad mood, markedly diminished interest in previously
enjoyed activities, significant weight fluctuations due to variable
hypersomnia, fatigue, concentration difficulties, and psychomotor agitation.
The veteran meets criteria for Bipolar I Disorder, Severe, Most Recent
Episode Depressed. The veteran's reported symptoms are not suggestive of
mixed features, as he describes them as distinct episodes.

The veteran also reported many symptoms of anxiety, including panic attacks
beginning in 2007. He described these as including chest pain, difficulty
breathing, sweating, shaking, abdominal distress, dizziness, chills,
depersonalization, fear of losing control, and fear of dying. He stated that
these panic attacks are usually unexpected. He reported persistent concern
about having another attack. He also reported that when he first notices an
attack beginning, he tries to calm himself down. The veteran reported that
panic attacks occur in multiple settings. However, as a result of panic
attacks on the highway, he has begun to avoid highways when possible. He
reported that he can tolerate highways when his wife is driving, although he
experiences significant tension. Although he reported prior motorcycle
accidents, he denied direct correlation of symptoms to these accidents. He
denied intrusive or other PTSD symptoms related to his accidents. The
veteran's previous C&P report attributed the veteran's anxiety symptoms
his Bipolar Disorder. Although Bipolar Disorder with anxious distress
encompasses some feelings of restlessness and fear that something awful may
happen (DSM-5, p. 149), the veteran's reported symptoms are more reflective
of Panic Disorder, without Agoraphobia. He denied additional anxiety
that would warrant an additional anxiety diagnosis.

According to the veteran's medical record, prior test results reveal
responses congruent with Antisocial Personality Disorder. However, the
veteran was never diagnosed with Antisocial Personality Disorder. He denied
symptoms of conduct disorder during his childhood, and there is no evidence
of such in his medical record. In addition, he reported feeling remorse for
his actions until recently. "I'm concerned because I've started not to care
anymore. It's like I'm numb and I don't like that." In addition, the DSM-5
states that Antisocial Personality Disorder should not be diagnosed when
antisocial behavior occurs exclusively during the course of a bipolar
disorder (p. 662). The veteran also denied symptoms related to Borderline
Personality Disorder.

The veteran reported that his primary problems are related to his mood
disturbance, particularly his agitation, irritability, and lack of
concentration. He reported that they have contributed to significant
impairment in interpersonal relationships and his ability to obtain and
maintain employment. It is believed that the veteran experiences significant
impairment in judgment, motivation, and mood, resulting in significant
difficulties in occupational and social functioning.

As a mental health professional, I recognize that the determination on this
individuals claim is properly a matter for the VBA and/or the court to
decide. Therefore, the clinical opinions provided in this report in regard
these issues are of an advisory nature only. The medical of record in this
case was reviewed and considered in the overall assessment of the veteran.
appeared to freely acknowledge prior events and behaviors that may reflect
poorly upon him. As such, the results of the present clinical interview are
considered to be an accurate reflection of his current functioning. I will
glad to provide the referral source with any further information, records,
testimony that it may require. Please note that all diagnoses reflect DSM 5

(In short is there any hope. The VA requested my info from SSDI on the 7th which will show i recieved for SC injuries and that i am unemployable.

My othere C&P for my shoulders she cleared me for seditary work but she didnt take in concideration my MH) Please help

Thank You)

It seems as if she is with me then she falls off the wagon so to speak but then comes back really strong on some points. She requested i need further intensive followup with my provider before i left.

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looks like 70% to me

first dsm 5 I've seen. screw gaf scores and good luck

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as Jesusplay stated, you are looking @70%. with the possibility of automatic U.I. If you don't put in for it as soon as you get your rating. I think you may even get 100% if you are not currently or you cant hold a steady Job.

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70-100% definitely bud. Good luck and keep us posted.

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Now im just looking at a timeline of sorts. i did request IU when i filed NOD but since i didnt have a Disability rating for one high enough the 1800 said its not there. The P&T DR who did my main exam did state that not to worry i was worse than i was a year ago. but in the final notation notated that i could do seditary work without knowing my mental capacity i guess.

looks like 70% to me

first dsm 5 I've seen. screw gaf scores and good luck

jesusplay you refer to first dsm 5 you have seen what does that mean exactly./ Thank you all for your help

as Jesusplay stated, you are looking @70%. with the possibility of automatic U.I. If you don't put in for it as soon as you get your rating. I think you may even get 100% if you are not currently or you cant hold a steady Job.

My RO is straight forward and located in the winston salem office she stated as soon as i get that rating in my hands if its not 100 she said fax it to her and she will hand walk it in so i can get it hopefully fast tracked fingers crossed

I Have been on SSDI since before i was medically retired for medical reasons. i also have 3 other claims rated at 10% each wich looks like i will be increased to 20% min on them as well. The DRO requested a cd from my SSDI and i know i was a pproved for only SC items as i was in the WTU while i was approved a decision on my ssdi was reached in 7 days after a denial.

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its long but here are the other rted issues all currently @ 10% focus on shoulders the C&P requested i see my ortho as soon as possinble

DATE OF NOTE: JAN 14, 2014@08:00 ENTRY DATE: JAN 14, 2014@15:35:14

Disability Benefits Questionnaire

Name of patient/Veteran: Mallette,Michael Thomas

Indicate method used to obtain medical information to complete this
In-person examination

Evidence review
Was the Veteran's VA claims file reviewed: Yes
List any records that were reviewed but were not included in the Veteran's
VA claims file: xt shoulder today

1. Diagnosis
Does the Veteran have one or more scars anywhere on the body, or
disfigurement of the head, face, or neck? Yes
Diagnosis #1: Residual scars from 8 arthroscopies surgeries left shoulder
ICD code: 709.2
Date of diagnosis: 2006/2007/2008 and 2009/2010

Does the Veteran have any scars on the trunk or extremities (regions other
than the head, face or neck): Yes

Does the Veteran have any scars or disfigurement of the head, face or neck:

SECTION I: Scars of the trunk and extremities
1. Medical history
Describe the history (including cause/origin and course) of the Veteran's
scar(s) of the trunk or extremities, (brief summary): veteran had multiple
scars from arthroscopic surgeries to both shoulders
per veteran scars was itchy after surgeries
currently he reports scars not bothers

Are any of the scars of the trunk or extremities painful: No

Are any of the scars of the trunk or extremities unstable, with frequent
loss of covering of skin over the scar: No

Are any of the scars BOTH painful and unstable: No

Are any of the scars of the trunk or extremities due to burns: No

2. Physical exam for scars on the trunk and extremities
2-1. Details of scar findings for the trunk and extremities
Right upper extremity: Affected
Location of scars on right upper extremity and number them: shoulder
not clear small scars 1 cm x 1 cm
scar not pigmented,not adhered,not keloid,not painful
Types of scars and provide measurements:
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar #1: 1 X 1 cm Scar #2: 1 X 1 cm
Scar #3: 1 X 1 cm

Left upper extremity: Affected
Location of scars on left upper extremity and number them: shoulder with
not clear small scars 1 cm x 1 cm
scar not pigmented,not adhered,not keloid,not painful
Types of scars and provide measurements:
Deep non-linear
Length and width of each deep non-linear scar:
Scar #1: 1 X 1 cm Scar #2: 1 X 1 cm
Scar #3: 1 X 1 cm

Right lower extremity: Not affected

Left lower extremity: Not affected

Anterior trunk: Not affected

Posterior trunk: Not affected

2-2. Summary of nonlinear scar areas for the trunk and extremities
Superficial non-linear scars:
Right upper extremity: Approximate total area: 4 cm2
Left upper extremity: Approximate total area: 4 cm2

Deep non-linear scars: No response provided

SECTION II: Scars or other disfigurement of the head, face, or neck: No

SECTION III: Miscellaneous
1. Limitation of function/other conditions
Do any of the scars (regardless of location) or disfigurement of the head,
face, or neck result in limitation of function? No
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs and/or symptoms (such as muscle or nerve damage)
associated with any scar (regardless of location) or disfigurement of the
head, face, or neck? No

2. Color photographs
Color photographs for any scars or disfiguring conditions of the head, face,
or neck: Photographs not indicated

3. Functional impact
Does the Veteran's scar(s) (regardless of location) or disfigurement of the
head, face, or neck impact his or her ability to work? No

4. Remarks, if any:
Veteran reports he served Army from 2005 to 2011 active duty as in mechanic

he also was in Reserve from 3/2000 to 9/2002 also mechanic he worked auto
shop my whole life,working mechanic at age 17-18 (1995-1997)
His working stopped in 2/28/ 2011 after separation from Army and he was
approved SS disability since 2010 due to MH bipolar and anxiety and other
he attended vocational rehab few weeks ago,he used GI bill for school
studying net work security and he had issue with faculty
per veteran Dr Alphonso thinks he cannot work due to anger issue
he is married and had 3 children 10/6 and 3 ,wife is home maker ,it is
to live on VA pension 1200 and SS is 1031 and 200 for each child
he reports problem watching his children due to anxiety children played
each other daughter was pushed by another kid and had a concussion,the
grand father of his neighbor kid yelled at his son and each time seing
he had flash back
however veteran denies suicidal/homocidal
he also mentioned about almost lost his house and his wife not listed as
his dependence due to paper work not in place and became tearful
also he said PMD always prescribed pain pill and this caused him
he tried anger management not working due to group setting "stupid people
say something stupid that anger me ",awaiting Dr Becker individual
he reports last year he was in program by SS but after receiving paper
VAMC he was out of that program and told permanent program and he had
review change to 7 yrs
Per veteran he reports he used to have strong will but not anymore
he reports if he can provide to his hammily /kids then he will be be much
he admits anger for little things
also he reports he has 2 friends only and usually had lots of friends
he reports now in order not to take anger out to other he scratches
himself both forearms

NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's


Esophageal Conditions
(Including gastroesophageal reflux disease (GERD), hiatal hernia
and other esophageal disorders)
Disability Benefits Questionnaire

Name of patient/Veteran: Mallette,Michael Thomas

Indicate method used to obtain medical information to complete this
In-person examination

Evidence review
Was the Veteran's VA claims file
reviewed: Yes
List any records that were reviewed but were not included in the Veteran's
VA claims file: xt shoulder today

Does the Veteran now have or has he/she ever been diagnosed with an
esophageal condition? Yes
GERD ICD code: 530.81 Date of diagnosis: 2006/2007

Medical history
Description of the history (including onset and course) of the Veteran's
esophageal conditions: Veteran reports in 2006-2007 he had heartburn real
after meal and burning helped with drinking water
he saw Dr in service at Fort Sills and Fort Eustis,prescribed prilosec
prilosec helped sometimes
burping while running for PT
no nausea/vomitting
no abdominal pain
oily food/greasy caused abdominal cramps
no problem swalowing
no weight loss,weight fluctuates
He had gastric emptying scan 8/2011 revealed

Markedly delayed gastric emptying.

Primary Diagnostic Code: ABNORMALITY, ATTN. NEEDED

Primary Interpreting Staff:

Veteran board reviewed mentioned GERD

Does the Veteran's treatment plan include taking continuous medication for
the diagnosed condition: Yes
Medications used for the diagnosed condition: prilosec

Signs and symptoms
Does the Veteran have any of the following signs or symptoms due to any
esophageal conditions (including GERD)? Yes
Sign and Symptoms:
Pyrosis (heartburn)

Esophageal stricture, spasm and diverticula
Does the Veteran have an esophageal stricture, spasm of esophagus
(cardiospasm or achalasia) , or an acquired diverticulum of the esophagus?

Other pertinent physical findings, complications, conditions, signs and/or

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? No

Does the Veteran have any other pertinent physical findings, complications,
conditions, signs and/or symptoms related to any conditions listed in the
Diagnosis section above? No

Diagnostic Testing
Have diagnostic imaging studies or other diagnostic procedures been
performed? No

Has laboratory testing been performed? Yes
CBC Date of test: july 30/2012
Hemoglobin: 16.4
Hematocrit: 49.6
White blood cell count: 8.5
Platelets: 232,000

Are there any other significant diagnostic test findings and/or results? No

Functional impact
Do any of the Veteran's esophageal conditions impact on his or her ability
work? No

Remarks, if any: No response provided

NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's


Shoulder and Arm Conditions
Disability Benefits Questionnaire

Name of patient/Veteran: Mallette,Michael Thomas

Indicate method used to obtain medical information to complete this

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
the existing medical evidence provided sufficient information on which
prepare the DBQ and such an examination will likely provide no
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[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:

xt shoulder today

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
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:

1. Diagnosis
Does the Veteran now have or has he/she ever had a shoulder and/or arm
[X] Yes [ ] No

Diagnosis #1: Left shoulder recurrent dislocations s/p 4
arthroscopic surgeries,not helped
ICD code: 831
Date of diagnosis: 2006
Side affected: [ ] Right [X] Left [ ] Both

Diagnosis #2: right shoulder DJD s/p dislocation and 4 arthroscopic
ICD code: 715.91
Date of diagnosis: 2012
Side affected: [X] Right [ ] Left [ ] Both

Diagnosis #3: Left shoulder joint unstable
ICD code: 718.81
Date of diagnosis: 2014
Side affected: [ ] Right [X] Left [ ] Both

2. Medical history
a. Describe the history (including onset and course) of the Veteran's
shoulder and/or arm condition (brief summary):
Veteran reports he had injury to both shoulders
left shoulder injury in 2006 in combat training ,not sure what
but left shoulder went out socket in 2006 and he saw dr in service and
he had MRI in St Mary in Korea in 2006 told inconclusive
Few months later at boxing tournament left shoulder again dislocated
briefly he had left shoulder recurrent dislocations 8-9 time before
surgery in 2007,then in 2007 he 1st arthroscopy surgery at at Fort
Sill Oklahoma by military doctor,and another surgery followed 2
later by another surgery same shoulder,same hospital and by different
These 2 arthroscopy surgeries not fixing problem
left shoulder still dislocated now and then and he cannot raise left
arm above shoulder and 3rd surgery arthroscopy done dec 2007 and 4th
surgery done in 2008 also arthroscopy for arthritis left
shoulder,totaly 4 left shoulder arthroscpic surgeries.

He was dischaged from service/medical retired in 2011 with 80%.

Right shoulder problem also started in 2006 with dislocation while he
stationed in Korea and surgery not done since left shoulder get

treated first and in 2007 at Fort Sill while lifting a dumpster lid
and the wind blew lid back and his r arm "ripped the r shoulder joint
out "and he had dislocation,he saw Dr and had surgery in 2007 followed
by PT .

After that surgery 2007 r shoulder still painful and decreased ROM he
saw Dr at Fort Sills and had second surgery done in 2008 and he was
reclassified to aviation tech,he took training at Fort Eustis in
2008-2009 .

After training 2009 he was deployed to Korea and he was sent back due
to his lithium treatment for bipolar(started 2005) and other physical
limitations of shoulder,he stayed at Fort Eustis from 2009 to 2011
finally went to medical board in 2011.

In 2010 he had MRI and told labial tear and saw Orthopedist and had
arthroscopic surgery to r shoulder this followed by second surgery in
2010 to r shoulder 5 months later

At this time he is seing orthopedist at VAMC both contract orthopedist
Dr Watson and Dr Oppenheimer told not able to help
fee basis granted twice to 2 Private orthpedists outside also recently
in 2013 told not able to help either

Currently both shoulders painful daily 7-8/10 constant
with rainy weather pain was up to 9/10
He is not able to lift and carry anything >5 lbs
problem with driving
no problem with self care except taking bath he has problem with
reaching upper back and hair

He reports he is upset since not able to work or going to
school,vocational rehab was not continued since anxiety and anger

Exam today revealed left shoulder unstable with spontaneous
dislocations when he raised his arm himself
r shoulder also had limitation but not dislocated ROM somewhat better
Internal rotation he had to lower his head to reach back of head
external rotation he cannot reach higher than buttocks

After exam he leans against the wall to put his left shoulder back to

DATE OF NOTE: OCT 01, 2012@14:01 ENTRY DATE: OCT 01, 2012@14:01:20



History of both shoulder multiple dislocations.
Multiple surgeries on each. Right still hurts
but does not dislocate. Left still dislocates.
On tramadol now as well as ss disability. Reduces
it himself. Sent to fee base ortho but saw
several and no one would do surgery. At this
point has no had dislocation since August but
pain continues constantly. He would like a
cortisone shot at this for the pain and
realizes it will not relieve the dislocations.
However, subsequently he is noted to have
numerous apparently staph impetigo areas over
the shoulder so no injection is done. Possibly
pain meds or pain clinic evaluation should be
done. Has MRI cds which he may come in to
see Dr. Oppenheim for her further evaluation.
Otherwise advised heat or ice, shoulder brace
and analgesics.

Signed: 10/01/2012 14:23


Exm Date: APR 22, 2011@16:13
Service: Unknown

Proc Modifiers : LEFT, RIGHT
Reason for Study: Bilateral shoulder pain

Clinical History:
constant pain both shoulders. Hx of recurrent shoulder
dislocations with bilateral surgeries

Report Status: Verified Date Reported: APR 22,
Date Verified: APR 22,
Verifier E-Sig:/ES/H.I.MAHADEVAN M.D.

Bilateral shoulder:

Multiple views. No prior study.

Well-defined small lucencies with slightly sclerotic margins
seen in the glenoid on both sides. This finding is likely to be

postsurgical. No significant bony deformity or joint space
narrowing seen. Alignment is normal. No soft tissue
calcifications are noted.

Primary Diagnostic Code: NO ACUTE FINDINGS

Primary Interpreting Staff:


Exm Date: AUG 02, 2012@08:14
(Req'g Loc)
Service: Unknown

Proc Modifiers : LEFT
Reason for Study: Left shoulder Pain

Clinical History:
Urgent CT requested by outside consultant. Pt is pre-op. Needs
scan before surgery. Please do within 72 hours

Report Status: Verified Date Reported: AUG 02,
Date Verified: AUG 02,
Verifier E-Sig:/N M.D.

CT left shoulder:

Axial images are supplemented by coronal and sagittal reformats.

Images are reviewed in soft tissue and bone window settings. The
left glenoid shows multiple lucencies which may be postsurgical
defects and or subchondral cysts. There is mild sclerosis at the
articular margin of the glenoid. There is some narrowing of the
glenohumeral joint inferiorly and osteophyte formation is seen
the inferior anterior aspect of the head of the humerus.
high position of the head of the humerus noted. No definite
abnormality seen at the acromioclavicular joint. The remainder
the bony structures about the left shoulder appear unremarkable.

A couple of small lucencies are seen in the right glenoid also.
The visualized lower neck and upper mediastinum do not show any
definite abnormalities.

Postsurgical / degenerative changes in the left glenohumeral
joint. Probable postsurgical defects in the right glenoid.

Electronically Signed By: Mahadevan, Harihara I

Electronically Signed On: 08/02/2012 10:11:09

Primary Diagnostic Code:

Primary Interpreting Staff:

Today shoulders xr revealed


Exm Date: JAN 14, 2014@10:36
Req Phys: DO,TAM Pat Loc: HAM C&P DO
Service: Unknown

Proc Modifiers : BILATERAL EXAM
Reason for Study: for c and p shoulder

Clinical History:

Report Status: Verified Date Reported: JAN 14,
Date Verified: JAN 14,

Bilateral shoulder series:

Comparison: Bilateral shoulder series 4/22/2011


Left shoulder: Frontal views of the left shoulder in internal and

external rotation a coronal oblique view of the left shoulder
demonstrate multiple cystic lesions within the glenoid. No
fracture or dislocation. These have slightly progressed when
compared to the previous examination. An osteophyte projects off
of the humeral head. The visualized portion of the lung is

Right shoulder: Frontal views of the right shoulder in internal
and external rotation and a coronal oblique view of the right
shoulder demonstrates subchondral bone cysts in the humeral head
glenoid far fewer than on the contralateral side. No evidence of
acute fracture or dislocation. Mild degenerative changes in the
AC joint.


1. Subchondral bone cysts in the left greater than right glenoid
which may be secondary to prior surgical intervention or
degenerative changes. 2. Degenerative changes of the right AC

Electronically Signed By: Bergren, Lynn

Electronically Signed On: 01/14/2014 11:19:20

Primary Diagnostic Code:

Primary Interpreting Staff:
LYNN BERGREN, Staff Radiologist (Verifier)

Select an imaging exam...

b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous

3. Flare-ups
Does the Veteran report that flare-ups impact the function of the shoulder
and/or arm?
[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in
his or her own words:
flaring up left shoulder with rainy weather same ROM

4. Initial range of motion (ROM) measurements
a. Right shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[X] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

b. Right shoulder abduction

Select where abduction ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [X] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

c. Left shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [X] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

d. Left shoulder abduction

Select where abduction ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

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  • 0

as Jesusplay stated, you are looking @70%. with the possibility of automatic U.I. If you don't put in for it as soon as you get your rating. I think you may even get 100% if you are not currently or you cant hold a steady Job.

Been on ssdi was removed from thier ticket to work program last year due to as they stated Mental Capacities and place on the Total Permanant 7 yr review list

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  • Similar Content

    • By Togore101
      Hello everyone I am new to the site. And I recent submit a the dbq for an increase for my PTSD and I trying to understand it but im just not getting it. So I figured would ask you all. Below is what the examiner put in the record.
      Review Post Traumatic Stress Disorder (PTSD)
      Disability Benefits Questionnaire
      Name of patient/Veteran: =========
      Is this DBQ being completed in conjunction with a VA 21-2507, C&P
      [X] Yes [ ] No
      SECTION I:
      1. Diagnostic Summary
      Does the Veteran now have or has he/she ever been diagnosed with PTSD?
      [X] Yes [ ] No
      ICD Code: F43.1
      2. Current Diagnoses
      a. Mental Disorder Diagnosis #1: PTSD
      ICD Code: F43.1
      b. Medical diagnoses relevant to the understanding or management of the
      Mental Health Disorder (to include TBI):
      No response provided.
      3. Differentiation of symptoms
      a. Does the Veteran have more than one mental disorder diagnosed?
      [ ] Yes [X] No
      c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
      [ ] Yes [ ] No [X] Not shown in records reviewed
      4. Occupational and social impairment
      a. Which of the following best summarizes the Veteran's level of
      and social impairment with regards to all mental diagnoses? (Check only
      [X] Occupational and social impairment with reduced reliability and
      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
      of the occupational and social impairment indicated above is caused by
      [ ] Yes [ ] No [X] No diagnosis of TBI
      Clinical Findings:
      1. Evidence Review
      Evidence reviewed (check all that apply):
      [X] VA e-folder (VBMS or Virtual VA)
      [X] CPRS
      Evidence Comments:
      DATE OF NOTE: MAR 05, 2018
      CHIEF COMPLAINT: "same old same old"
      Veteran is here for 6 week follow up for PTSD, Alcohol Use Disorder,
      unspecified, episodic. At last appointment, low dose venlafaxine was
      added, aripiprazole, prazosin, and melatonin were continued.
      He reports symptoms are about the same. His wife is pregnant with twins,
      so he is trying to minimize arguments at home. He worries he will not be
      able to connect with the babies, because he struggled so much with his
      daughter and points to her persistence as the reason they are close now.
      He see no change in sleep, remains irritable, and more hypervigilant due
      To recent car break ins on his street. He has cut down on drinking, and
      denies any binges since last appointment. He continues to have fleeting
      SI, but denies intent. He often has thoughts of hurting others, but
      strongly denies acting on the thoughts. No recent hallucinations. He
      does talk to himself when he is trying to work something out, but denies
      hearing voices other than his own. It can be embarrassing as coworkers and wife
      have caught him.
      DSM 5 Diagnostic Impression
      Alcohol Use Disorder, Unspecified, episodic
      1. Decrease irritability and anger- does not interfere with home or work
      life more than one time per month, ongoing, improving
      2. Improve feeling of connection with others- enjoying and developing
      relationships, ongoing, no change
      3. Decrease avoidance of social situations/crowds- can tolerate Wal Mart,
      enjoy outings with family, ongoing, no change
      4. Improve sleep- no difficulty falling asleep, sleep 6 to 8 hours
      nightly, ongoing, worsening
      reviewed records and discussed options
      - increasing venlafaxine to 75 mg
      - continuing aripiprazole, prazosin, and melatonin
      - suggested individual supportive counseling at the Vet Center after Dr.
      Bhatia leaves.
      - monitoring labs at next appointment
      - Will continue to follow closely. RTC 6 weeks/PRN
      2. Recent History (since prior exam)
      a. Relevant Social/Marital/Family history:
      Last C&P PTSD DBQ May 2016
      Lives in Moncks Corner, SC with wife of 9 years and daughter age 4.
      Daily routine: Lay down for bed 2100. Will fall asleep 2300. Wake
      frequently. "I have to do certain things to calm down. I need my
      gun next to me. I have to check the house make sure its locked. Make sure
      the alarm is on. If I hear something, it wakes me right up and I have
      to check it out." +Nightmares, night sweats. "Sometimes
      I'm swinging and yelling and talking in my sleep, so my wife leaves for a different
      room. I wake up and she's not there and it freaks me out."
      melatonin for sleep, prazosin for nightmares. Abilify for PTSD.
      Diagnosed sleep apnea by sleep study in 2013, prescribed CPAP and is
      Relationship with wife: "We almost got divorced a few times. She
      didn't understand what was going on. She started reading up on it. The whole
      reason I went to mental health was because of her."
      Relationship with daughter: "She is scared of me. She has seen me
      Snap a few times. She is on guard. She doesn't know if I'm going
      to be up or down. She is my heart. She is the only thing that makes me feel
      normal." Will watch cartoons and read books together.
      Hobbies: play basketball, go to gym "but now I just sit in the
      House watch TV or just in the room." Likes anime.
      Support: father "he's been with me through everything."
      And is Veteran
      too, wife "but there is a wall there where I don't open
      b. Relevant Occupational and Educational history:
      Working for passport services for 3 years. "Its rough at times.
      There's a lot of people in there. They had to move my seat because I'm
      too jumpy. They moved it so I'm not around a lot of people. It is hard
      to focus. I have to use sticky notes. They have been pretty supportive.
      I've had good supervisors." Was counselled about days missing
      for work; "I had a blow up at my co-workers so they spoke to me about
      that." Miss 2-3 days per month. "When I get to work, I drive around the
      Building and if I see something I don't like, I just go home."
      Military history: E4, MP, Separated 2014, Honorable, Served about 6
      c. Relevant Mental Health history, to include prescribed medications and
      family mental health:
      Mental health treatment with prescriber and therapist. No history of
      hospitalizations. Was in group therapy "but I didn't like it."
      d. Relevant Legal and Behavioral history:
      "When I was in Japan I got us into trouble because of my alcohol
      abuse. I got into a car accident and hit 3 cars." Was sent to ADAP for
      anger and PTSD. A month ago got into a physical altercation with sister's
      boyfriend "I laid hands on him. So then I went to a hotel room and stayed there and
      then I went on a drink binge."
      e. Relevant Substance abuse history:
      Alcohol - "I abused it really bad. My PCM said it was affecting
      My liver." Was drinking4-5 25 oz beers, drink a bottle of liquor over
      The weekend. Now will drink 1-2 beers.
      Tobacco - 2-3/day
      Denies other substances.
      f. Other, if any:
      Current reported symptoms:
      Anger: "I black out and become very violent. I knock TVs off
      walls. My wife was ready to leave me."
      Triggers: "foggy day and rain." "Ignorant and stupid
      Social avoidance.
      "If a car is behind me too long, I start to think he is following
      me. There is a particular truck that I know and he gets too close to me. I
      got sick of it and one day I followed him home. I didn't do
      anything, but I blacked out mad. I knew I needed help."
      Flashbacks - "I was shopping with my wife, and this guy had a
      turban on his head and I thought I was back there. Its constant, its all the
      Hygiene - "My wife got on my because I went a week without washing
      And I didn't even realize it."
      Suicide - "I thought about driving into traffic at the light. One
      Time I sped up and got on railroad tracks when a train was coming. I
      thought, what am I doing? I went into store parking lot." Reports
      this occurred 2 weeks ago. "I keep a picture of my daughter in the car
      to keep me from [doing it]."
      3. PTSD Diagnostic Criteria
      Please check criteria used for establishing the current PTSD diagnosis. The
      diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
      of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
      combat, personal trauma, other life threatening situations (non-combat
      related stressors). Do NOT mark symptoms below that are clearly not
      attributable to the Criterion A stressor/PTSD. Instead, overlapping
      symptoms clearly attributable to other things should be noted under #6 - "Other
      Criterion A: Exposure to actual or threatened a) death, b) serious
      c) sexual violence, in one or more of the following ways:
      [X] Directly experiencing the traumatic event(s)
      [X] Witnessing, in person, the traumatic event(s) as they
      occurred to others
      Criterion B: Presence of (one or more) of the following intrusion
      Symptoms associated with the traumatic event(s), beginning after the
      traumatic event(s) occurred:
      [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).
      [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
      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
      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
      dangerous,: "My whole nervous system is permanently
      [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,
      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)
      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] 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] Suspiciousness
      [X] Chronic sleep impairment
      [X] Mild memory loss, such as forgetting names, directions or recent
      [X] Flattened affect
      [X] Impaired judgment
      [X] Disturbances of motivation and mood
      [X] Difficulty in adapting to stressful circumstances, including work or
      worklike setting
      [X] Suicidal ideation
      [X] Impaired impulse control, such as unprovoked irritability with
      of violence
      [X] Neglect of personal appearance and hygiene
      5. Behavioral observations
      Veteran was open and forthright with no evidence of exaggeration or
      feigning symptoms. Affect blunted. Minimal eye contact. Speech regular
      rate, tone, volume. Thought process linear, logical, goal directed.
      Thought content absent for delusions, hallucinations, paranoia or HI.
      Endorses SI with no active plan, but drove car onto train tracks last
      week. Discussed safety, crisis line, Veteran has MHC appointment next
      week. Veteran reports safety to return home today.
      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:
      PCL-5 score 72, indicating probable diagnosis of PTSD.
      Veteran continues to meet criteria for PTSD. He reports social
      withdrawal, sleep problems, memory problems, irritability, anger that is both verbal
      and physical, suicidal thoughts. He has work accommodations because of
      his PTSD symptoms. He misses several days of work a month because of his
    • By bc0311
      I'm new to this site, and somewhat novice with claims as I've ignored them since my discharge in 2012, but I have some questions that I've yet to find answers for that hopefully someone can help me with:
      In a nutshell, my story is I did my four years, two hellish combat tours to Afghan, got out in 2012, immediately filed my claims for a few disabilities like back and shoulder issues and got a 40% rating total. I've since not looked back as none of that concerns me. My issue now is that I was sent to a mandatory PTSD screening during one of my visits that year, and the examiner kind of went about the thing blase, and although I did tell her most of my traumatic experiences, she gave me 0% for "Combat PTSD not related to military service" as it says in their justification, whatever that means. I don't think they even attempted to listen to me as my experiences were extraordinarily traumatic and have been a detriment to my mental health and quality of life since. And yet I now have an effective date of a PTSD claim from day of discharge 6 years ago for 0%, says it right on eBenefits. I think you know where I'm going with this...
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    • By Andyman73
      Recently I was DX and granted SCD for PTSD due to personal trauma (MST). I have also noticed a dramatic reduction in performance capabilities as well. I have not mentioned this to any of my doctors, VA or private. It's been hard enough to admit to the MST, without having to add the ED to it. But I've reached a point where I can no longer ignore it.  I'm only 44 years old and have far too much life left to live to continue ignoring the ED. I'd like to hear any suggestions or guidance as to the best way to file a claim for this as secondary to my SCD PTSD. Any and all suggestions from all parties are welcome. Also, should I start with making an appointment with my PCP?  Thank you to all who read and respond to this delicate and humbling matter.
      Semper Fi
    • By tazntaylr
      I have been working with a VSO to file my claim. I am currently in the process of gathering information. Only thing, file for MST with PTSD or file PTSD. VSO was hung up on the sexual part of MST.
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    • By anxiousinMD
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      BLUF: I would appreciate some insight or just plain ol speculatin on why the VA raters would submit me for a lumbar strain increase (that I didn’t submit for) while working on my current claim? Also, are secondary conditions disqualified in the 60% calculation for SMC Housebound? I know it says the 60% must be separate from the 100% condition, but how does this work if I’m on IU, with secondary conditions? 
      I’m probably overthinking at 4am but why would they submit me for an increase for a condition when I didn’t ask them, and the increase has no bearing on the final rating due to VA math, unless it qualifies me for SMC, or they believe I should be qualified. I’ve never raised the issue of SMC and I’m still learning about it trying to figure out my claim, and I know they are supposed to do due diligence, but that’s not my first hunch since that’s why I’m still in this process.
      History: I filed a claim in 2015 for PTSD increase and TDIU, was granted increase in 2016 to 70% PTSD, denied TDIU. Combined, 80% with other SC conditions. BBE/VSO said I was denied increase to 100% even though I had a nexus statement from a psychologist saying total social and occupational impairment, at least as likely as not, etc., but they said because I was still employed (I was on long term disability leave but not yet “terminated” and yes they had the relevant evidence through my employer and insurance), and my VA treating provider’s opinion took precedence who didn’t feel my symptoms quite qualified me for total of course, though he‘s a CRNP versus a psychologist and I don’t think he even knows me. I thought they were supposed to take the rating and credentials that favor the Veteran but never mind me. I also survived and was approved for Social Security and life insurance premium waivers during this period without having to appeal, with the same medical information and evidence, with the same VA SC conditions, even coming from VA docs and providers.
      Of course I appealed the rating and TDIU denial (they can decide) in 2016. I also submitted a new claim for secondaries to PTSD, and in my fog, with that claim an increase for PTSD and TDIU, even though I already had those on appeal. I believe I read or was told somewhere (or maybe my brain made it up) that if I submitted new evidence, the raters could look back at the effective date and could EED to the original claim if the evidence shows and close the appeal. Or, they could approve me from the date of the new claim and the appeal could deal with the stuff before that. But what they did was what they are apparently supposed to do (according to Peggy and the VSOs): defer the appeal related claims to the appeal. DOH.
      Current Status: Early this month my claim progressed and I was granted an increase to 30% for IBS secondary to my 70% PTSD, and since I had a pre-existing 10% for nerve condition and 20% for lumbar strain, that brought me to 90%. My claim never went to complete and I never got the BBE, ebenefits bounced around from gathering of evidence to pending decision approval within days of my last C&P (I had one for PTSD and one for IBS). I’m not sure why they would give me a C&P for PTSD if they are deferring that part of my claim to appeal as I was told. Maybe they’re just giving me a checkup because my 30 appointments and inpatient stays and shock treatments over the past year weren’t enough medical evidence.
      I learned of the increase bc I got a small retro and my ebenefits letters and disabilities changed within days, but the claim stayed open. I found out by calling Peggy and VSO that it’s due to an increase for my lumbar strain that someone in the rating chain put in. I do have plenty of evidence in my medical records that show my back is also crap. I got sent to a C&P for my lumbar strain and now I wait in GOE. The C&P examiner, Peggy, VSOs specifically say I was submitted for an increase for my back, not a review. BTW, in ebenefiits in the disabilities section, the PTSD increase is still open, the TDIU disappeared, the IBS is rated, and the lumbar strain doesn’t appear. Yes, I know ebenefits is unreliable and I should find something else to do, but compulsively logging into ebenefits is an activity quite similar to playing a slot machine for me. Every 1 in 10000000 logins I might get a glimmer of hope, and it keeps me going lol.
      I Wonder: What difference does it make if I’m rated 20% or 30% for my lumbar strain? Why would this be raised since my overall rating won’t change from 90% either way? Trust me, I AM NOT COMPLAINING AND I AM GRATEFUL, anything they do (and they have been getting faster and more Vet-friendly it seems) positive for the Veteran that saves future agony and torture is an appreciated blessing. It would help in the future in qualifying for SMC, but I don’t qualify with the math now. Just wondering if they don’t have enough to do over there, because in the future I’d probably have to get another C&P. Also, I would have to have another condition at 30% for that math to work out, and I pray nothing else worsens enough for that to happen.
      Does “separate” mean it can’t affect the same body system or it can’t be a secondary condition? Because with secondaries, I could potentially qualify for SMC, and therefore the VA rater would be setting me up for success. Otherwise, it just seems like extra work for them when they could close my case and get their quota numbers and help another Vet...again, not complaining but whoever is on my file seems to be thorough regardless.
      I know they could be doing anything over there, and I’m glad they’re working on my claim, but just for s&g I’d appreciate any guesses or suggestions, and any help clarifying the SMC Housebound math thing please.
      Thank you all.
    • By hawkfire27
      Please delete
    • By Stick Slinger
      I was never diagnosed in service with OSA. I weigh 220 and I am 6' tall. I am rated at 70% for PTSD and the meds I take add to the OSA. I had my personal Dr. and the Psychiatrist I see both write letters to support that the meds I take add to and cause the OSA. My Dr filled out the DBQ and sent it in as well. I had a failed sleep study results sent in  with my claim. I also have documentation I sent it that back up the fact that OSA is tied to PTSD and is aggravated by PTSD. Then sleeping with the prescribed CPAP machine adds to the PTSD. Just curious if anyone has ever won this claim? I am going to appeal but wanted to get any advise here first if someone has any to share.. not sure if there is anyone who has gone this route before and won?
    • By kent101
      I see now the VA is using ecstasy on Veterans saying it helps cure mental illness. Ecstasy causes some major brain damage. The VA Hospital forcefully did lobotomies on 2000 WW2 Veterans and ruined their lives.
      Roman Tritz’s memories of the past six decades are blurred by age and delusion. But one thing he remembers clearly is the fight he put up the day the orderlies came for him.
      “They got the notion they were going to come to give me a lobotomy,” says Mr. Tritz, a World War II bomber pilot. “To hell with them.”
      The orderlies at the veterans hospital pinned Mr. Tritz to the floor, he recalls. He fought so hard that eventually they gave up. But the orderlies came for him again on Wednesday, July 1, 1953, a few weeks before his 30th birthday.
      This time, the doctors got their way.
      The U.S. government lobotomized roughly 2,000 mentally ill veterans—and likely hundreds more—during and after World War II, according to a cache of forgotten memos, letters and government reports unearthed by The Wall Street Journal. Besieged by psychologically damaged troops returning from the battlefields of North Africa, Europe and the Pacific, the Veterans Administration performed the brain-altering operation on former servicemen it diagnosed as depressives, psychotics and schizophrenics, and occasionally on people identified as homosexuals.
      The VA doctors considered themselves conservative in using lobotomy. Nevertheless, desperate for effective psychiatric treatments, they carried out the surgery at VA hospitals spanning the country, from Oregon to Massachusetts, Alabama to South Dakota.
        Roman Tritz talks about the scars from his lobotomy.  
      The VA’s practice, described in depth here for the first time, sometimes brought veterans relief from their inner demons. Often, however, the surgery left them little more than overgrown children, unable to care for themselves. Many suffered seizures, amnesia and loss of motor skills. Some died from the operation itself.
      Mr. Tritz, 90 years old, is one of the few still alive to describe the experience. “It isn’t so good up here,” he says, rubbing the two shallow divots on the sides of his forehead, bracketing wisps of white hair. 
      The VA’s use of lobotomy, in which doctors severed connections between parts of the brain then thought to control emotions, was known in medical circles in the late 1940s and early 1950s, and is occasionally cited in medical texts. But the VA’s practice, never widely publicized, long ago slipped from public view. Even the U.S. Department of Veterans Affairs says it possesses no records of the lobotomies performed by its predecessor agency.
      Musty files warehoused in the National Archives, however, show VA doctors resorting to brain surgery as they struggled with a vexing question that absorbs America to this day: How best to treat the psychological crises that afflict soldiers returning from combat.
        Between April 1, 1947, and Sept. 30, 1950, VA doctors lobotomized 1,464 veterans at 50 hospitals authorized to perform the surgery, according to agency documents rediscovered by the Journal. Scores of records from 22 of those hospitals list another 466 lobotomies performed outside that time period, bringing the total documented operations to 1,930. Gaps in the records suggest that hundreds of additional operations likely took place at other VA facilities. The vast majority of the patients were men, although some female veterans underwent VA lobotomies, as well.
      Lobotomies faded from use after the first antipsychotic drug, Thorazine, hit the market in the mid-1950s, revolutionizing mental-health care.
      The forgotten lobotomy files, military records and interviews with veterans’ relatives reveal the details of lives gone terribly wrong. There was Joe Brzoza, who was lobotomized four years after surviving artillery barrages on the beaches at Anzio, Italy, and spent his remaining days chain-smoking in VA psychiatric wards. Eugene Kainulainen, whose breakdown during the North African campaign the military attributed partly to a childhood tendency toward “temper tantrums and [being] fussy about food.” Melbert Peters, a bomber crewman given two lobotomies—one most likely performed with an ice pick inserted through his eye sockets.
      And Mr. Tritz, the son of a Wisconsin dairy farmer who flew a B-17 Flying Fortress on 34 combat missions over Germany and Nazi-occupied Europe.
      “They just wanted to ruin my head, it seemed to me,” says Mr. Tritz. “Somebody wanted to.”
      Counting the Patients
      A memo gives a partial tally of lobotomized veterans and warns of medical complications. A note about documents:
      Yellow highlighting has been added to some documents. The names of patients not mentioned in these articles have been redacted, along with other identifying details. All other marks are original.   The VA documents subvert an article of faith of postwar American mythology: That returning soldiers put down their guns, shed their uniforms and stoically forged ahead into the optimistic 1950s. Mr. Tritz and the mentally ill veterans who shared his fate lived a struggle all but unknown except to the families who still bear lobotomy’s scars.
      Mr. Tritz is sometimes an unreliable narrator of his life story. For decades he has meandered into delusions and paranoid views about government conspiracies.
      He speaks lucidly, however, about his wartime service and his lobotomy. And his words broadly match official records and interviews with family members, historians and a fellow airman.
      It isn’t possible to draw a straight line between Mr. Tritz’s military service and his mental illness. The record, nonetheless, reveals a man who went to war in good health, experienced the unrelenting stress of aerial combat—Messerschmitts and antiaircraft fire—and returned home to the unrelenting din of imaginary voices in his head.
      During eight years as a patient in the VA hospital in Tomah, Wis., Mr. Tritz underwent 28 rounds of electroshock therapy, a common treatment that sometimes caused convulsions so jarring they broke patients’ bones. Medical records show that Mr. Tritz received another routine VA treatment: insulin-induced temporary comas, which were thought to relieve symptoms.
      ‘Anxious to Start’
      The VA hospital in Tuskegee, Ala., asks permission to perform lobotomies. To stimulate patients’ nerves, hospital staff also commonly sprayed veterans with powerful jets of alternating hot and cold water, the archives show. Mr. Tritz received 66 treatments of high-pressure water sprays called the Scotch Douche and Needle Shower, his medical records say.
      When all else failed, there was lobotomy.
      “You couldn’t help but have the feeling that the medical community was impotent at that point,” says Elliot Valenstein, 89, a World War II veteran and psychiatrist who worked at the Topeka, Kan., VA hospital in the early 1950s. He recalls wards full of soldiers haunted by nightmares and flashbacks. The doctors, he says, “were prone to try anything.”
    • By FAVet777
      Thanks for reading this. I have been trying to find all the information that I can about getting re-examined. So I thought I would start here and I did my research on here. I am rated at 70% for PTSD with Major Depression Disorder long with a few other claims that rounds out to 80%. Ill mostly be disscussing my mental health award and not the others Since the that is my highest rating. My benefits where awarded in July of 2017 as far what e-benifits shows. that was my backpay date. In my award letter that I got in the mail it states for all my conditions even tinnitus that "since there is a likelihood of improvement, the assigned evaluation is not considered permanent and is subject to a future review examination". First let me state that I am beyond grateful of my award and I do not wish to try to try to increase my ratings or bring any attention to my file or profile with the VA. I am content with where I am at. I go to the VA every two weeks for my 1 on 1 with my Mental Health provider. So I am knocking out two birds with one stone as far as getting my treatment and showing the VA that I am seeking treatment. 
      Now...What are the circumstances of me getting Re-evualutated? Is it the luck of the draw and I might get randomly selected? I know plenty of people with lower ratings that are not TDIU or P&T that have been rated for over 4-5 years with no exams what so ever. Consider me being paranoid but I want to be Pre-emptive. Especially since my award letter clearly states that ALL my conditions "is subject to future review examination". When would the VA see that my condition has improved if it did? Would they get an alert from the VA Hospital that I am doing better? Or would it would it arise if i get selected for a review and they review my medical records? Like I said earlier im contempt at 80% and more than anything I just want to stay out of sight out of mind on the VA's raters radar and continue my treatment in peace. 
    • By Broken Cat
      I am in the process of putting together a claim package for mental health issues related to MST.  Try as I might, I cannot find a VSO with experience in my situation.  It's taken me years to accept that I need help and that I need to address this once and for all, so when I say that I cannot handle doing this twice (submitting a sub par claim and then doing appeals) I really mean it. From day to day, I vacillate between thinking my problems are actually other people's inability to cope OR feeling like there is no point to me and that I'm a burden.If it weren't for the whole not being able to pay bills and risking alienating my kids for all eternity, I'd be perfectly content letting the world turn while I hang out at home and being maladjusted and mean.
      In my perfect world, there would be a check list of things to submit for a fully developed claim. On this checklist, there would be a list of key phrases or high points that would help sway the decision makers into awarding adequate compensation. I haven't been able to find anyone that has had success doing this with a case like mine.  I have police reports from the MST.  I have trauma counseling records and AD medical records that clearly state a d/x for PTSD related to rape on X date. My counseling sessions identified dissociation behaviors, PTSD, and anxiety. One doctor even noted that I was combative and stated that I wished harm on my attackers. 
      Obviously, the Navy handled this clear cut case of rape, with evidence and my complete cooperation, like they do any scandal.  They buried it and came after me.  That might be a secondary stressor, but I've been warned that claiming a secondary stressor could hose up everything and to keep my mouth shut?  kind of amazing that the advice that is meant to help, sounds a lot like the advice that sent me careening out of control all those years ago.
      Anyhow, I survived, got married, got out, and went in and out of counseling.  Over the years, I've been diagnosed with PTSD, Chronic Depression, Chronic Adjustment Disorder, Agoraphobia, Generalized anxiety Disorder, and Dissociation Disorder.  I don't trust military medicine or the government, so most of my counseling was done through non-profit organizations and women's shelters. They're so secretive, that I felt it'd be safe to tell them what I went through and my statements wouldn't end up in the Navy's summary of Mishaps... again. So, I don't really have records of those, except for prescriptions that were reported to Tricare.   I do have my civilian medical records. It has page after page of doctors complaining that I broke down, was combative, emotional etc, etc.  I do have a few sessions with shrinks at MTFs in the last couple years. They were not keen on actual diagnostics, they just gave me the pills I asked for.
      I'm shopping shrinks to assess me and give diagnosis. I'm not sure I need a nexus letter, but I'm thinking it wouldn't hurt.  I have a letter from my ex boss describing how my work performance plummeted over the years and how he made accommodations to keep me on. I also have a letter from me, describing my bad days and my rituals to get through them. My husband and his best friend were witnesses to the fallout of my rape, in terms of the military's response to me.  They can verify in statements that I did report it and go into counseling. They can also verify that I'm socially isolated and very codepenedent on them to meet new people or get involved in activities.  I don't have a single friend that they didn't make for me, first.  I do not know how to people. I don't have friends from work. I don't have "my own" friends from church. I don't even have people who like me well enough, and include me in things, without my husband and his best friend acting as intermediaries.  
      oh, I also have the most recent sentencing transcripts for the ringleader of my attackers.  The judge stated that he felt this dude was unrepentant and a monster. He cited his past sex crimes, "both in the record and that didn't make it to trial" and his history of convincing others to help him conceal his crimes.  If that's not a shout out from the bench, I don't know what is.

      Anyhow, I guess my question is, has anyone here done a fully developed MST claim with multiple bullet points for anxiety, phobia, ptsd, and depression, and get 100% or at least, a high enough rating to qualify for unemployability?  Without having to go through appeals and lawyers?  Was a police report enough, even if the military dropped it?  Should I give the C&P my evidence, letters, and my personal statement too? I'm sure I have 1000 more questions,  but I'm mostly looking for someone who has done what I'm trying to do.
    • By nova
      New here. Found the community through google. I'm still learning to navigate the site, so please bear with me. Searching got me in the right direction but not close enough.
      I was recently diagnosed with Service connected PTSD through the VA. I have not done a C&P exam yet. On the same day I was diagnosed with obstructive sleep apnea through a VA sleep study. I've read that there is a slim chance to connect my sleep apnea as a secondary to my PTSD. My VA psych Dr said they aggrevate each other, but a pulmonologist opinion would have more power than his. I've seen some advice from other members talking about letter templates, DBQs and supporting articles. However, I haven't been able to find them here. 
      I've scheduled a civilian Dr. appointment with a pulmonologist in about 2 week and would like to come prepared with any information I can.
      Any help would be greatly appreciated. 
    • By kent101
      I'm reading this VA Citation :NR 1231506 and the VA is saying that because a Veteran with PTSD is getting improvement from his psychiatric medication, that he's showing less symptoms because of it, that he is having his rating reduced from 70% to 30% for PTSD. The VA did reverse the reduction at the BVA. Is this still something to worry about? At a C&P exam does the Veteran have to make it clear that the medication is the reason for improvements and needed to sustain them?   
      Citation NR: "
      An October 2009 VA medical record reflects that the Veteran reported that the medication he had been prescribed helped with ability to be out in public and that, while leery about being around people, he could go out in public much more easily. His mood overall was good, and he indicated that he continued to enjoy dining out with his wife and stopping by the VFW to socialize with friends. The examiner assigned a GAF score of 76-80".  
      Over at Veteran's Law Blog it says
      "As an example, say a Veteran has been able to service-connect Irritable Bowel Syndrome (DC 7319).
      Undiagnosed, the symptoms of IBS might be a component of Gulf War Illness
      With prescribed medication, our hypothetical Veteran’s condition moderates from a severe form of the disease to a milder form.
      The severe form of IBS is rated at 30% and the moderate form of IBS is rated by the VA at 10%.
      Let’s say the VA gives the Vet a rating of 10%, claiming that the Veteran’s medication limits her symptoms.
      Is that 10% rating correct?
      No . The Diagnostic Criteria in the VA Rating Schedule for Irritable Bowel Syndrome does not specifically list the effects of medication.
      Therefore, the VA is not allowed to consider the relief it provides when determining the degree of disability.
      Has this happened to you?
      When have you seen the VA use “improvement due to medication” as an excuse to give a lower rating"?
    • By PAR
      I filed a claim for PTSD back in 2014 and then had my C&P. At the C&P the outside VA examiner asked multiple questions and focused on my upbringing (which was good) and my Father almost insinuating that my MST really is from my Father. When I left there I was completed traumatized because of the line of questioning and that he didn't even ask about my military time and shortly after I was denied. At the same time I had already been diagnosed by my VA Mental health Dr and through a MST coordinator. I got the denial shortly after and because I was so upset just did nothing since I didn't want to go through it again. I still went to the VA for treatment and then 2017 I requested an increase for my TBI. They scheduled a C&P and I went and the VA this time and within 4 weeks I was went from 10% TBI to 70% for TBI/PTSD making my overall rating 100%.  A few days ago,  I received my narrative and  I immediately requested my original claim of PTSD reopened requesting an effective date change to my original claim that was denied . My question is that because I did nothing from 2014-2017 will they deny or is there anything I can do to have my effective date changed since the first C&P went so wrong.
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    • e-Benefits Status Messages 

      Claims Process – Your claim can go from any step to back a step depending on the specifics of the claim, so you may go from Pending Decision Approval back to Review of Evidence. Ebenefits status is helpful but not definitive. Continue Reading
      • 0 replies
    • I was rated at 10% for tinnitus last year by the VA. I went to my private doctor yesterday and I described to him the problems that I have been having with my sense of balance. Any sudden movement of my head or movement while sitting in my desk chair causes me to lose my balance and become nauseous. Also when seeing TV if there are certain scenes,such as movement across or up and down the screen my balance is affected. The doctor said that what is causing the problem is Meniere's Disease. Does any know if this could be secondary to tinnitus and if it would be rated separately from the tinnitus? If I am already rated at 10% for tinnitus and I could filed for Meniere's does any one know what it might be rated at? Thanks for your help. 68mustang
      • 15 replies
    • Feb 2018 on HadIt.com Veteran to Veteran. Sharing top posts and a few statistics with you.
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    • I have a 30% hearing loss and 10% Tinnitus rating since 5/17.  I have Meniere's Syndrome which was diagnosed by a VA facility in 2010 yet I never thought to include this in my quest for a rating.  Meniere's is very debilitating for me, but I have not made any noise about it because I could lose my license to drive.  I am thinking of applying for additional compensation as I am unable to work at any meaningful employment as I cannot communicate effectively because of my hearing and comprehension difficulties.  I don't know whether to file for a TDUI, or just ask for additional compensation.  My county Veterans service contact who helped me get my current rating has been totally useless on this when I asked her for help.  Does anyone know which forms I should use?  There are so many different directions to proceed on this that I am confused.  Any help would be appreciated.  Vietnam Vet 64-67. 
    • If you are new to hadit and have DIC questions it would help us tremendously if you can answer the following questions right away in your first post.

      What was the Primary Cause of Death (# 1) as listed on your spouse’s death certificate?

      What,if anything, was listed as a contributing cause under # 2?

      Was an autopsy done and if so do you have a complete copy of it?

       It can be obtained through the Medical Examiner’s office in your locale.

      What was the deceased veteran service connected for in his/her lifetime?

      Did they have a claim pending at death and if so what for?

      If they died from anything on the Agent Orange Presumptive list ( available here under a search) when did they serve and where? If outside of Vietnam, what was their MOS and also if they served onboard a ship in the South Pacific what ship were they on and when? Also did they have any major  physical  contact with C 123s during the Vietnam War?

      And how soon after their death was the DIC form filed…if filed within one year of death, the date of death will be the EED for DIC and also satisfy the accrued regulation criteria.
        • Like
      • 14 replies