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awgv001

PTSD(MST) w/ TBI - complication/comorbity concerns

Question

Here are the posted results of my latest C&P exam for PTSD/MST (w/ parts of TBI included)

Been performing my own research and in the fight for 4+ years now.

Seems to me after researching this falls in an "unusual" area of the majority of VA claims, and I don't like it one bit.

There's a lot of "gray" area to this exam IMO.

There's several issues inside this doc that speak of uncertainties - to all of which I find myself nervous of the resolution.

I don't know how this issue will be rated, nor how it will affect my pending TBI claim as well...

I am hoping somebody may be able to help me better understand and/or prepare for the worst.

Help guide me to the light and set my worries free.

 

Sorry for the long read, and Thank you, in advance!

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

Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
Name of patient/Veteran: ---------------
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: 309.81
Mental Disorder Diagnosis #2: unspecified depressive d/o
ICD code: 311.00
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): migraine headache (SC) (TBI hx
related tx) , ulnar nerve hx
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
shared sx presesntation, depression secondary to trauma d/o
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[X] Yes [ ] No [ ] Not shown in records reviewed
Comments, if any:
relating to fall and blackout on active duty, VA treatment noted
with correspondance in VMBS verifiying treatment
d. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis:
there is hx of headache, but concentration/attention problems not
easily differentially attributable.
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 [X] No [ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis:
noted above
c. If a diagnosis of TBI exists, is it possible to differentiate what
portion of the occupational and social impairment indicated above is caused by
the
TBI?
[ ] Yes [X] No [ ] No diagnosis of TBI
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis:
noted above
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
Evidence Comments:
buddy statement is reviewed, indicating some verification of assault and
Vet's reaction while in service, noting behavior change consistent
with
trauma aftermath
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
***Information Errated for privacy*** please note - no negative pre military markers, kay? :-)
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
graduated HS
enlisted in MC out of high school
xxxx to xxxx
XX
MOS XXXXXXX
honorable DC
XXXX XXXXX
air support Gulf war
after DC...."nothing but part time"...."half a dozen jobs....keep
bouncing around"; longest as a maintenance tech....1 1/2 yrs;
that ended with "injury" as vet fell "several times at work"....had been out
on workers comp.....had surgical intervention on bulging disc.
"there was a worker's comp settlement"
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
XXXXXXX VA clinic
ongoing for the last 2 yrs
notes indicate focus on exposure therapy for PTSD
as well as TBI intervention.
Meds: Sertraline, Gabapentin
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
no charges
notes that police came to his house recently....due to his kids
"wandering" the neighborhood....DCS investigation - no charges
e. Relevant Substance abuse history (pre-military, military, and
post-military):
no problem described.
f. Other, if any:
No response provided.
3. Stressors
------------
Describe one or more specific stressor event(s) the Veteran considers
traumatic (may be pre-military, military, or post-military):
a. Stressor #1: during first attachment....approximately first 18
months....repeated hazing....harassment.....hog tied....several
occasions....."more than three quarters of the time" involved MST...
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[X] Yes [ ] No
Is the stressor related to the Veteran's fear of hostile military
or terrorist activity?
[ ] Yes [X] No
If no, explain:
MST....and related abuse.
vet notes that he was assaulted "at least a half dozen
times" over that time period.
they had a particular ritual known as the ***errated***
Is the stressor related to personal assault, e.g. military sexual
trauma?
[X] Yes [ ] No
If yes, please describe the markers that may substantiate the
stressor.
one notation administrative remark
4. PTSD Diagnostic Criteria
---------------------------
Please check criteria used for establishing the current PTSD diagnosis. Do
NOT mark symptoms below that are clearly not attributable to the Criterion A
stressor/PTSD. Instead, overlapping symptoms clearly attributable to other
things should be noted under #7 - Other symptoms. The diagnostic criteria
for PTSD, referred to as Criterion A-H, are from the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Criterion A: Exposure to actual or threatened a) death, b) serious
injury, c) sexual violence, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)
[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] Intense or prolonged psychological distress at exposure
to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
[X] Marked physiological reactions to internal or external
cues that symbolize or resemble an aspect of the
traumatic event(s).
Criterion C: Persistent avoidance of stimuli associated with the
traumatic event(s), beginning after the traumatic events(s) occurred,
as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with
the traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts,
or feelings about or closely associated with the traumatic
event(s).
Criterion D: Negative alterations in cognitions and mood associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of the following:
[X] Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Markedly diminished interest or participation in
significant activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction,
or loving feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
Criterion F:
[X] Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
Criterion G:
[X] The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
Criterion H:
[X] The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or
another medical condition.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Flattened affect
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Suicidal ideation
6. Behavioral Observations
--------------------------
alert, oriented and cooperative.
flat affect and narrow affective range.
related hx of suicidal thoughts, without urge or intent.
7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
findings meet dx criteria for PTSD with depression.
findings are consistent with someone who has struggled with the aftermath
of assault and MST; as treatment interventions and dx support same, with
some delayed component to multiple PTSD sx onset.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.

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Is anyone else having problems with the reply area superimposed on the C & P exam?

I could not read the whole exam.

You do have the PTSD diagnosis and what I feel is favorable evidence.....however-do you have your SMRs and 201 Military Personnel file? The 201 file can be very helpful in these types of claims.

The TBI...was that noted on your discharge certificate...this was from a fall? Did it have anything to do with the harrassment or MST incidents?Or did you faint? If so, what happened next...meaning did you get documented medical care for it in the Mil, and if so, what did they attribute the fainting to?

I could not read anything after part of Criterion E.

 

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One more question......what is the 50% SC for?

 

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5 minutes ago, Berta said:

You do have the PTSD diagnosis and what I feel is favorable evidence.....however-do you have your SMRs and 201 Military Personnel file? The 201 file can be very helpful in these types of claims.

The TBI...was that noted on your discharge certificate...this was from a fall? Did it have anything to do with the harrassment or MST incidents?Or did you faint? If so, what happened next...meaning did you get documented medical care for it in the Mil, and if so, what did they attribute the fainting to?

 

I'll repeat the post filling in the Crit E block a second time and forward for you. :-)

I have a copy of ALL paperwork regarding my claims and AD records - just not a copy of my C-File at the moment, although I'd love to obtain a disc copy of it so I can fiddle through for any missing docs I could submit.

TBI was not noted on my discharge cert - was not diagnosed via AD - simply incurred and untreated except for in 2012 when I was outsourced to civilian Nuerology Depts. - This was from a rather bad fall, yes. Also, it had nothing to do with the harrassment or MST - it was completely seperate and at a different time (technically in between) of the assaults that occurred for my PTSD/MST.

No AD docs, nothing to attribute to the fainting - They (corpsman) wanted me to get it looked into - I merely had my entire squadron present for witnessing the incident that occurred, which through observational report, was enough to determine TBI due to LOC <30min.

I have yet to have TBI SC'd at the moment.

I have a 50% rating currently for

%30 Migraines

%10 Left Ulnar nerve status

%10 Left Wrist strain

%10 Tinnitus

%0 Scars

%0 Flat feet

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*****Re-submission due to web error(?)*****
 
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
Criterion F:
[X] Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
Criterion G:
[X] The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
Criterion H:
[X] The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or
another medical condition.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Flattened affect
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Suicidal ideation
6. Behavioral Observations
--------------------------
alert, oriented and cooperative.
flat affect and narrow affective range.
related hx of suicidal thoughts, without urge or intent.
7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
findings meet dx criteria for PTSD with depression.
findings are consistent with someone who has struggled with the aftermath
of assault and MST; as treatment interventions and dx support same, with
some delayed component to multiple PTSD sx onset.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.

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Thanks...I think this is a very favorable C & P exam...for PTSD.....

I only hope the VA rater knows how to read  (I am serious)

The 30 % migraines.....did the VA attribute that to the fall????

They lump in stuff like that for TBI. There is a lot here on TBI in that forum.

Are you employed?

"I was outsourced to civilian Nuerology Depts. - This was from a rather bad fall, yes. Also, it had nothing to do with the harrassment or MST - "

Do you have those records, and if so does the VA have them?

Do you get SSDI for any or all of this?

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