cablinginar

Received my 100% P&T now working on getting a schedule S

I was IRR and recalled for the 1st Gulf War yes some people was in a combat zone then and I am an E-4 Spealist received two ranks while I was there corrected on a dd215

No I just have IU this was C&P for 100% PTSD

I am now 70% PTSD, 40% Fibro, 30% IBS, 10% tinntius = 90% getting 100%IU .....SSDI for PTSD Symptoms only I just had this C&P to bump my rating to 100% TDIU or P&T These are my results form my C&P anyone have any comments that would help me understand this .....He seems to rate me at 50%.....then all of the rest seems to lean towards a P&T rating LOCAL TITLE: C&P EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 13, 2014@08:00 ENTRY DATE: JAN 14, 2014@11:46:23 AUTHOR: VAN PELT,DAVID M EXP COSIGNER: URGENCY: STATUS: COMPLETED CONFIDENTIAL Page 14 of 26 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Post-Traumatic Stress Disorder (PTSD) Mental Disorder Diagnosis #2: Psychological Factors Affecting Other Medical Conditions Mental Disorder Diagnosis #3: Major Depressive Disorder Mental Disorder Diagnosis #4: Alcohol Use Disorder in remission (per self-report) b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): fibromyalgia, irritable bowel syndrome, sleep apnea, tinnitus, hypertension and potential chronic fatigue syndrome (per self-report) 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: Mr. Turnbow has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the requisite criteria for this diagnosis. He also meets the criteria for Major Depressive Disorder, Psychological Factors Affecting Other Medical Conditions, and Alcohol Use Disorder, which is in remission per his report. These problems coalesce to exacerbate his symptoms of anxiety and depression. The symptoms are overlapping and intermingled and this makes it difficult to differentiate the symptoms to each CONFIDENTIAL Page 15 of 26 diagnosis. 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 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: has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the requisite criteria for this diagnosis. He also meets the criteria for Major Depressive Disorder, Psychological Factors Affecting Other Medical Conditions, and Alcohol Use Disorder, which is in remission per his report. These problems coalesce to exacerbate his symptoms of anxiety and depression. The symptoms are overlapping and intermingled and this makes it difficult to differentiate the symptoms to each diagnosis. The symptom picture presented comes together to cause substantial impairment in his social and occupational functioning. 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 ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: CONFIDENTIAL Page 16 of 26 ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file reviewed? [X] Yes[ ] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [ ] Yes[ ] No If yes, describe: 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: is currently married and has been for 5 years. He described the relationship with his wife as positive and said, "I have a fairly good relationship with her. She understands me." He has 2 daughters and one son. He has no contact with his son or oldest daughter. His youngest daughter lives at home with him and he described the relationship with her is great. He also noted how he and his wife are raising their 5-year-old granddaughter. He described the relationship with his granddaughter as "good." has one adopted brother but has not had contact with him currently. Both of his parents are living and he described having a positive relationship with them. He noted seeing them one time a week and said the relationship is "good now but in the past and not so good." b. Relevant Occupational and Educational history: graduated high school in 1986 in Elgin, Illinois. He CONFIDENTIAL Page 17 of 26 attended one semester of college but did not receive a degree. He is currently unemployed. His last job was as a cable technician where he worked for one year. He has not work since 2010 and his wife said, "It was before he got his disability." said he was fired for "taking my VA meds." His wife noted how he fell asleep at the wheel and also fell asleep one time in a meeting." When asked that his current limitations or restrictions to employment he said, "I couldn't deal with people and my physical disabilities. I have fibromyalgia and I hurt all the time." c. Relevant Mental Health history, to include prescribed medications and family mental health: assessed his current health as "poor" and said his current medical conditions consist of fibromyalgia, irritable bowel syndrome, sleep apnea, tinnitus, hypertension and he believes he has chronic fatigue syndrome. All of his current medications are prescribed by the VA and he noted taking medications as prescribed. He is experiencing a side effect of dry mouth with his current medication regimen He denied being hospitalized for physical reasons and last 5 years. was hospitalized for psychiatric reasons in 2011 due to suicidal ideation. He said the hospitalization was for one day and his wife commented, "That was about the time my youngest son got killed in a car accident. He fell asleep behind the wheel." is currently receiving mental health treatment at the Poplar Bluff VA facility. He works with a social worker and psychiatrist and is in group counseling. He has been receiving treatment for approximately 5 years. noted having suicidal ideations 2 or 3 times a month but denied any attempt at taking his life. He said, "I have a daughter who needs me." He noted having recurrent homicidal thoughts as well and said this involves "the person who raped my daughter and the police who screwed over my stepson. I have a list of 10 people who if I had 3 months to live I would do what I had to do." He denied any attempt at taking another's life. d. Relevant Legal and Behavioral history: currently possesses a valid driver's license but does not CONFIDENTIAL Page 18 of 26 operate a vehicle on a regular basis. He was cited with a DUI and was under the influence of prescription medication. The offense occurred in 2013 and he is currently on probation "until I pay a fine and complete the SATOP program." He is on 2 years supervised probation and when this coursework is completed he will be changed to unsupervised probation. e. Relevant Substance abuse history: denied smoking cigarettes currently. He currently uses smokeless tobacco at a rate of one can a day and has been engaged in this habit for 10 years. His current alcohol consumption is, "hardly any anymore; maybe a beer one time every 3 months." When drinking his heaviest he was consuming "a 30 pack and a fifth a day." He drank at this rate for 1.5 years and reduced his use approximately 3 years ago. He experimented with marijuana "once or twice" but denied regular use of this substance. He denied use of crack, cocaine, amphetamines, psychedelic substances, or heroin. He also denied history of prescription drug abuse. f. Other, if any: When asked about his current psychological and mental health difficulties, said, "its nightmares and flashbacks. I have these about 3 or 4 times a week. Sometimes I get stuck in my dreams. It I can't get out of the dream. He noted sleeping approximately 5 hours during the night and is not refreshed upon waking. "I've also heard voices every once in a great while. I can't make them out it Arabic speaking. I have a lot of pain and that doesn't help the other stuff. I can do anything. The more physical I do the more I have to relax. I stay at home all the time. The only place I go is to the VA or my parents. I let her (wife) do all the shopping." He went on to say, "this is my forth marriage and this is better. I spout my 15 minutes and then I'm all better. I'm not cool with the authority figures. I'm not cool with cops whatsoever." He noted having anger problems, concentration problems and "short-term and loss. He denied hypervigilance or an exaggerated startle response. . I was recalled to the gulf war." He was a light vehicle mechanic and he attained a rank of E4. He denied having he article 15's or other disciplinary action. He reported heavy alcohol consumption while in military but denied drug usage. When asked about injuries he described how he broke his right ankle but does not remember the date of the injury or which ankle it was. He was deployed to Iraq from January 1991 until March 1991. He reported being exposed to combat while in this region. reflects on his service in the military "2-3 times a day." indicated being exposed to actual or threatened death and serious injury by directly experiencing a traumatic event or witnessing, in person, a traumatic event that occurred with others. This series of events, which are stated elsewhere in this report, occurred while he was in the military service. There have been recurrent, involuntary, and intrusive distressing recollections of the trauma; recurrent distressing dreams in which the content or effect of the dream is related to that trauma event; and dissociative reactions and flashbacks in which there is a feeling that the traumatic event is reoccurring. He indicated having an avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma along an avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with events. He has a persistent negative emotional state; a markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; and a persistent inability to experience positive emotions. Additionally, he has irritable behavior and angry outbursts with little or no provocation; hypervigilance and an exaggerated startle response. He also noted having problems with concentration and difficulty falling asleep, staying asleep and/or restless sleep. was administered the PTSD Checklist-M (PCL-M), which is a 17-item inventory that assesses the degree which an individual has experienced specific symptoms of PTSD in response to "stressful military experiences" over the past month. The results of the PCL-M reveal a raw score of 74. This score is above the recommended cut score of 56 for Veterans assessed in a VA Mental Health Clinic and suggests he does meet the requisite criteria for this Post-Traumatic Stress Disorder (PTSD). He indicated suffering from pain in one or more anatomical sites and this is the predominant focus of the clinical presentation. His level CONFIDENTIAL Page 20 of 26 of pain is of sufficient severity to warrant clinical attention. His pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The symptoms indicated above do appear to be significantly impairing his social or occupational functioning. has lived in Northeast Arkansas for approximately 4 years. His social support consists of his wife and daughter and mental health workers. His activities of pleasure relaxation are limited to "watching TV, reading books and I'll go out and pet the dog." His religious affiliation is "none now." When queried about his strengths he said, "I am loyal, I am a good father, and that's all I know." described his mood today as, "a low esteem mood; a mentally draining mood." He said his mood most days is "like this, not much