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mnsoldier89

How bad was my exam?

Question

Just got the notes tonight, he didn't seem very friendly..I think this did not go well:

Is this DBQ being completed in conjunction with a VA 21-2507, 
    C&P Examination
    Request?
    [X] Yes  [ ] No
    

                                   SECTION I:
                                   ----------
    1. Diagnosis
    ------------
    a. Does the Veteran now have or has he/she ever been diagnosed 
    with a mental
       disorder(s)?
       [X] Yes  [ ] No
       
       If the Veteran currently has one or more mental disorders 
       that conform to
       DSM-5 criteria, provide all diagnoses:
       
       Mental Disorder Diagnosis #1: Unspecified Anxiety Disorder 
       with Panic
       Attacks Specifier
       ICD code: F41.9

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

    2. 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
       
    3. Occupational and social impairment
    -------------------------------------
    a. Which of the following best summarizes the Veteran's level of 
    occupational
       and social impairment with regards to all mental diagnoses? 
       (Check only
       one)
       
       [X] Occupational and social impairment due to mild or 
       transient symptoms
           which decrease work efficiency and ability to perform 
           occupational
           tasks only during periods of significant stress, or; 
           symptoms
           controlled by medication

    b. For the indicated level of occupational and social 
    impairment, is it
       possible to differentiate what portion of the occupational 
       and social
       impairment indicated above is caused by each mental disorder?
       [ ] Yes  [ ] No  [X] No other mental disorder has been 
       diagnosed
       
    c. If a diagnosis of TBI exists, is it possible to differentiate 
    what portion
       of the occupational and social impairment indicated above is 
       caused by the
       TBI?
       [ ] Yes  [ ] No  [X] No diagnosis of TBI
       
                                   SECTION II:
                                   -----------
                               Clinical Findings:
                               ------------------
    1. Evidence Review
    ------------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)


    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, 
    military, and
       post-military):
       
         The veteran was born and raised in Minnesota but moved 
         around a lot,
         ending up in various places in MN. His father was not in 
         his life very
         much. His mother worked for international Dairy Queen and 
         later as a
         pharmacy technician. His parents divorced when he was about 
         6 and he
         remained with his mother. He noted a couple of stepfathers 
         in his life
         and they were generally okay. He has 2 sisters and 2 
         brothers. He
         described a good childhood.

         He has never been married. He has 1 child, 1, with his 
         girlfriend and
         she has a child, 5. He and his girlfriend and children live 
         in
         Janesville.
         
    b. Relevant Occupational and Educational history (pre-military, 
    military, and
       post-military):
       
         The veteran graduated from high school in 2008. He attended 
         basic
         training during the summer of his junior year; June and 
         July 2007,
         finished school, then went back for AIT in September 2008 
         until December
         2008. He was trained as an aviation operations specialist.

         Following discharge from the Air National Guard he tried 
         school a few
         times but dropped out. He said he has worked numerous jobs 
         but because
         of anxiety and panic attacks isn't able to keep them. For 
         the last year
         he has been working with the Geek squad which he said is 
         generally going
         okay.
         
    c. Relevant Mental Health history, to include prescribed 
    medications and
       family mental health (pre-military, military, and post-
       military):
       
         The veteran noted that his father possibly had some mental 
         health issues
         as well as being alcoholic.

         The veteran said he has never been hospitalized 
         psychiatrically nor had
         any counseling.

         He said he started medications in 2011, on Paxil and Xanax 
         when
         necessary. He is currently on Lexapro, Wellbutrin, and 
         hydroxyzine as
         needed. 

         
         
    d. Relevant Legal and Behavioral history (pre-military, 
    military, and
       post-military):
       
         The veteran noted that he was charged with careless driving 
         in 2007 as
         his blood alcohol was 0.07. He was also arrested in 2012 
         for driving
         without insurance and missing a court date. In 2017 his ex-
         girlfriend
         went out of state with their child and they had a domestic 
         incident. He
         is on probation for 2 years. 

         He denied any homicidal ideation. He said he had some 
         suicidal thoughts
         on and off since he was 17. He is not currently suicidal.
         
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
       
         The veteran noted that he used marijuana at times 
         recreationally but not
         for the past 3 years. He noted social drinking in the past 
         but said he
         never drank heavily.
         
    f. Other, if any:
    
         The veteran served in the Air National Guard, completing 
         basic training
         between June 2007 and August 2007 and AIT from September 
         2008 until
         December 2008. He was trained as a aviation operations 
         specialist. 

         He left the Air National Guard in 2014. He said he broke 
         down in front
         of his CO noting that he could no longer deal with the 
         service because
         he felt that the weekend drills had become "mentally 
         torturing."




         The veteran submitted in his statement:

         During our training in 2007 there was a soldier threatening 
         to kill us
         by hiding M16 rounds. That soldier was brought into the 
         Drill sergeants
         office and a fight broke out. He was sent to a Mental 
         Hospital by MP's
         for the entirety of our training most likely longer. 
         Between that
         incident
         and the numerous heat casualties I was witnessing on a near 
         daily basis
         I began feeling like I was going to faint all the time 
         along with
         difficulty breathing 
and heart palpitations. I checked 
         myself into
         Winder Medical Clinic on Ft. Benning and spoke to a female 
         doctor. She
         said I may have vertigo and proceeded to transfer me to a 
         hospital
         through an ambulance since I was having a sever panic 
         attack. I received
         treatment at both facilities and ever since I have had 
         recurring issues
         on a daily basis with Anxiety/PTSD. Standing in formation 
         would make
         me feel like I'm going to faint or cause a panic attack 
         where I would be
         forced to sit down no matter the consequence. There were 
         two deaths
         of heat strokes possibly more during my stay at Ft. 
         Benning.
         
    3. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply 
    to the
    Veteran's diagnoses:
    
       [X] Anxiety
       [X] Panic attacks that occur weekly or less often
       [X] Chronic sleep impairment
       [X] Disturbances of motivation and mood
       [X] Difficulty in establishing and maintaining effective work 
       and social
           relationships
       [X] Difficulty in adapting to stressful circumstances, 
       including work or a
           worklike setting

    4. Behavioral observations
    --------------------------
    The veteran was casually dressed, appropriately groomed. Affect: 
    Congruent
    and oddly engaging.  Oriented X 4.  Thought processes, generally 
    goal
    directed. There were no perceptual disturbances.

    The veteran noted that he is anxious "24/7" though I noted he 
    did not appear
    anxious today. He said that is because he is on medications and 
    also does
    meditation. He notes panic attacks occurring at least weekly. He 
    notes low
    motivation at times to do things.

    Voice and speech, within normal limits. Intelligence level 
    likely average.
    There was no psychomotor agitation nor retardation observed. 
    Memory,
    generally intact.

    He goes to bed about 9 PM with some sleep continuity 
    disturbance, noting that
    they have a 1-year-old. His appetite is poor though weight has 
    been stable.
    Concentration is difficult at times. His mood is lethargic. His 
    energy level
    is low.

    He gets up about 6 AM. He works full time. He socializes on a 
    limited basis
    noting he has difficulty with relationships and can't do a lot 
    of things
    because of his anxiety. He said he stays home a lot. 

    He notes current stressors involve being on probation and 
    difficulty dealing
    with people.
    
    
    5. Other symptoms
    -----------------
    Does the Veteran have any other symptoms attributable to mental 
    disorders
    that are not listed above?
    [X] Yes  [ ] No
    
        If yes, describe:
        There are likely personality disorder issues; deferred, and 
        not diagnosed
        at this time.
        
    6. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
    [X] Yes  [ ] No
    
    7. Remarks (including any testing results), if any:
    ---------------------------------------------------
    STRs note the veteran was seen in July 2007 during basic 
    training reporting
    chest pain. Records note he was told he had a small heart murmur 
    but it was
    nothing serious. He was reportedly referred to his PCP.

    There is also a reference during a periodic health assessment 
    about July 2007
    indicating that he reacted to bee stings with "swell up, hives, 
    and anxiety."
    There were no mental health issues noted in that report or 
    others.




    Veteran seen at the Family Medical Center in 2011 noting anxiety 
    and panic
    attacks in class.




    Records from Lakeview in 2013-14 note diagnoses of generalized 
    anxiety
    disorder and panic disorder.

    The veteran has continued to be seen at Lakeview with diagnoses 
    of
    generalized anxiety disorder and panic attacks.  The intake exam 
    noted no
    history of depression, mania, or psychosis. He reported no 
    suicidal thoughts
    or suicidal intention. He reported no substance abuse. He noted 
    at that time
    that he had been diagnosed with anxiety in the military at age 
    18.





    In summary, the veteran meets ICD 10 diagnostic criteria for 
    Unspecified
    Anxiety Disorder with Panic Attacks Specifier. This condition is 
    less likely
    than not related to the veteran's report of anxiety in the 
    service noting
    that there are no references to anxiety during his service time 
    other than
    chest pains, possibly related to a small heart murmur. Records 
    suggest that
    his primary anxiety issues began in 2011, much of it related to 
    work,
    relationships, and psychosocial stressors. 

 

the doctor notes that Records 
    suggest that
    my primary anxiety issues began in 2011, much of it related to 
    work,
    relationships, and psychosocial stressors.
However he never asked me how i was after basic training until that time like monthly drills and annual training. I was very disorganized and spacy, anxious, and reclusive. frequently missing drills, I told myself my mental health is more important than 
them being mad at me for staying home.  That was the case for everything including work and relationships, and still is to this day.  I feel like i'm off to a terrible start to this claim.

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    This condition is 
    less likely
    than not related to the veteran's report of anxiety in the 
    service. This is a denial in my eyes maybe someone else might chime in but that statement means not service connected

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It sucks. Others will chime in with advice, I have not had the time to upgrade a lot of Windows 10 stuff Microsoft wants me to do -maybe why I had a few PC problems here lately.

At first glance however:

"frequently missing drills," indicates inservice MH issues, in my opinion.

Do you have copies of your SMRs (I am sure you do) but also your 201 Personnel file?

 

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In my smr's I told the doctor I had dizziness and chest pain, also difficulty standing in formation without feeling like I'll faint. She diagnosed me with vertigo but I gave her anxiety symptoms I was only 17 at the time. How do I get my 201 file? I developed a severe anxiety condition which effectively ruined my life which Is why I submitted a claim. Its unfortunate she diagnosed me with vertigo in basic and not anxiety. Establishing a Nexus is proving to be difficult.

I was discharged from the military with a general discharge - honorable conditions due to "unsatisfactory participation"

One weekend I sat down with my CO and first seargent and basically broke down saying I can't do it anymore.

In my eyes my mental health was more important than the consequences.  I don't have the money for a lawyer, and am just trying to get through this nightmare of a process.

Ignore the quote on bottom, I dont know how to delete it.

 

9 hours ago, Berta said:

 

Edited by mnsoldier89

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" I don't have the money for a lawyer, and am just trying to get through this nightmare of a process."

Vet lawyers do not charge up front fees.

Was this a claim for PTSD or for the specific diagnosis in the DBQ?

Does any Vet org hold your POA yet?

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Has the VA questioned your eligibility at all?

I suggest you use my search link here and read over some of their decisions regarding "unsatisfactory participation" as there is more to your situation- than we know here- with the limited information you gave us.

https://www.index.va.gov/search/va/bva_search.jsp?QT=unsatisfactory+participation+&EW=&AT=&ET=&RPP=10&DB=2017&DB=2016&DB=2015&DB=2014&DB=2013

You can add more years to the search as well.

 

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