IA11B

Ok, I planned on going to the deferred c&p. I was just worried about losing 100% p&t for a claim that I didn't file.

Yes I am still working. GBArmy the deferred appoinment is for a new condition. During my c&p for my back I assume the doctor noted this. The exam was from qtc and I received a letter a few weeks after the exam saying the deferred condition was asked to be reviewed it was a record only review. So this will actually be the 3rd c&p for this in 2 months.

I just received my letter from the VA and was rated as 100% p&t. My claim was split into 2 and I have a follow up c&p next week for the one thing deferred. Could my rating change following this c&p? It's actually for something I didn't claim. The c&p I'm going to is for left lower extremity sciatica. A bonus question if anyone can help me with VA math. I am worried that I'm actually not 100% but 90% and don't want to be over paid. My ratings: \-20% back \-20% right shoulder \-70% ptsd \-10% tinnitus \-30% bilateral pes planus \-30% post traumatic headaches \-10% right arm scar/fragments \-10% left hand

Yes, I filed for TBI, vertigo, and migranes also. I have another c and p this week but it doesn't say what for I know I still have shoulders and back I need a c and p for which I assume is what this next appointment is for.

I have a few questions what does all this mean? And I saw he checked the box for my diagnosis of TBI but did he attribute all syptoms of TBI to PTSD? And did he diagnose me with PTSD also I know while I was active they diagnosed me I think. Thank you I am lost with this any help would be greatly appreciated. 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: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: F43.10 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): TBI in September, 2011 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis: No behavioral, emotional, or cognitive symptoms are the result of TBI residuals. 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 occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation 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? [X] Yes [ ] No [ ] No diagnosis of TBI If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The impairment level noted above is attributable to PTSD. SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: 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 [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran was born and raised in Missouri. While growing up his household included his biological parents and 3 younger brothers. Growth and development were regarded to be unremarkable. He denied any abuse or neglect during his childhood and described his childhood as "Good." He reported positive relationships and a good social adjustment while growing up. He denied any social adjustment problems upon entering the military. He married in 2010 and the couple have a 9 month old daughter. They have been living with his mother-in-law in Grimes, Iowa while they search for a house to buy. He described his marriage as stable and supportive. He keeps in contact with some military friends and has made a couple friends at the Vets Center at Iowa State University. He and his wife go out socially about once a week for dinner. He does not belong to any clubs or organizations. He does not have leisure time activities as most of his time is spent on school. The veteran reported being able to complete all ADLs and IADLs on an independent level b. Relevant Occupational and Educational history (pre-military, military, and post-military): The veteran graduated from high school in 2007, earning average grades and denying any learning disabilities or disciplinary problems. He worked for a while as a ranch hand in Wyoming and then worked for a plumbing company in Iowa. He completed freshman classes at Des Moines Area Community College, earning mostly Bs, and then entered the Army, serving from 4/5/10 to 7/15/14. He had an OEF deployment in 2011 and then again in 2013-2014. He is now attending Iowa State University in Ames, majoring in finance. He reported earning Bs and not having problems attending lectures in classrooms. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post- military): Family Psychiatric History: None. The veteran denied having any mental health services prior to his military service time. He was diagnosed with Adjustment Disorder with Anxiety in September, 2012 about one year after his injury from a grenade in Afghanistan, attended appointments with a psychiatric Social Worker, and was prescribed trazodone for sleep. He was also being treated in the TBI clinic at the time. He is not currently prescribed any psychoactive medications. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): None. e. Relevant Substance abuse history (pre-military, military, and post-military): 1. Caffeine: about 1 soda a day. 2. Tobacco: denied. Quit about 6 months ago. 3. ETOH: about 1 beer a month. 4. Street drugs: denied. f. Other, if any: None. 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: September, 2011 injured from shrapnel from a grenade during an ambush. 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? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: Participated in several firefights, seeing others severely injured or killed during combat. 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? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 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 Criteria 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 Criteria 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 violation, 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, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) 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 [X] Stressor #2 5. 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] Mild memory loss, such as forgetting names, directions or recent events 6. Behavioral Observations -------------------------- 1. General Appearance: Neatly groomed, appropriately dressed. 2. Psychomotor Activity/Mannerisms/Behaviors: appeared mildly anxious. 3. Orientation: alert and fully oriented. 4. Speech: Spontaneous, coherent, goal directed. 5. Attitude Toward Examiner: Cooperative. 6. Affect: Appropriate. 7. Mood: "Ok, some good days, some bad days." ANXIETY: Panic attacks about once a week, trouble relaxing, some irritability. Takes over an hour to calm self after intrusive memories of combat. DEPRESSION: credibly denied thought of harm to self or others. Denied significant symptoms of depression. Sleep 4-5 hours a night, sufficient energy during the day. Wife says he screams and talks in his sleep and is restless. Nightmares about once a week. Sometimes cries when he recalls friends who were killed in action. MANIC: No symptoms or episodes. 8. Obsessive/Ritualistic Behavior: None. 9. Attention: Spelling reversals and digits forwards/backwards were within normal limits. Described some problems with concentration and needing to utilizing list making more often. 10. Memory: able to recall 3/3 items after one minute delay. Able to recall remote and recent events during interview. 11. Thought Process and content: No hallucinations, delusions or signs of thought disorder. 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 -------------------------------------------------- The veteran is a 25 year old male seen for a psychological evaluation on 11/3/14 in regard to his application for a service connected disability rating for a mental condition to include PTSD. Veteran arrived on time for the interview, reporting that he drove himself to the facility. He was informed of the purpose of the evaluation and provided verbal consent to participate. He was interviewed for approximately 60 minutes. He was cooperative with the interview and responded to all questions. There were no indications of malingering or symptom exaggeration. The Veteran was informed of the Veterans Crisis Line number: 1-800-273-TALK (8255).

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