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philusmc

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About philusmc

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    E-3 Seaman

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    Ruskin, FLorida

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  1. Thanks. Where do I go to see what benefits are associated with a 80% rating?
  2. I JUST HAD MY C&P FOR ISCHEMIC HEART CONDITION AND THE RESULTS ARE BELOW. I got this off another webpage: A 60% rating is given if there is one or more of the following: 1) Two or more episodes of congestive heart failure in the past yearn (I've had only one episode) 2) The condition scores 4 or 5 METs and causes shortness of breath, fatigue, chest pain, dizziness or fainting (I scored 4. something) 3) Left ventricular dysfunction with an ejection fraction between 30 and 50% (I'm currently at 32%) AS I READ THE C&P exam report, I probably fall into #3. The comment at the end says "at least as likely as not (50% probability). I interpret this as in my favor and would be awarded 60% for this condition. I currently have 60% (combined VA math: 30% PTSD, 20% TypeII Diebetes, 10% peripheral neuropathy (right), 10% left) Assuming the VA will rule a 60% rating for the IHD, how would I calculate the final rating. I come up with 80%. Heart Conditions: (Including Ischemic & Non-ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a heart condition? [X] Yes [ ] No [X] Other heart condition, specify below Other diagnosis #1: CAD s/p stent placement ICD code: I25.1 Date of diagnosis: 2013 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's heart condition(s) (brief summary): Veteran reports that his claimed IHD condition began in 2013. He was hospitalized for chest pain and HTN. Cardiac cath was done. In January of this year, he had shortness of breath as well as chest pain. He went to the ER. He was admitted and had another cardiac cath and had 3 stents placed. He is currently under the care of his cardiologist. He takes Aspirin 81mg daily, Carvedilol 25mg, Bumex 1mg daily, b. Do any of the Veteran's heart conditions qualify within the generally accepted medical definition of ischemic heart disease (IHD)? [X] Yes [ ] No If yes, list the conditions that qualify: atherosclerosis Cad s/p stent placement c. Provide the etiology, if known, of each of the Veteran's heart conditions, including the relationship/causality to other heart conditions, particularly the relationship/causality to the Veteran's IHD conditions, if any: Heart condition #1: Provide etiology Age, gender, obesity, ao d. Is continuous medication required for control of the Veteran's heart condition? [X] Yes [ ] No If yes, list medications required for the Veteran's heart condition (include name of medication and heart condition it is used for, such as atenolol for myocardial infarction or atrial fibrillation): Aspirin 81mg daily Carvedilol 25mg Bumex 1mg daily, 3. Myocardial infarction (MI) ----------------------------- Not applicable 4. Congestive Heart Failure (CHF) --------------------------------- Not applicable 5. Arrhythmia ------------- Not applicable 6. Heart valve conditions ------------------------- Not applicable 7. Infectious heart conditions ------------------------------ Not applicable 8. Pericardial adhesions ------------------------ Not applicable 9. Procedures ------------- Has the Veteran had any non-surgical or surgical procedures for the treatment of a heart condition? [X] Yes [ ] No If yes, indicate the non-surgical or surgical procedures the Veteran has had for the treatment of heart conditions (check all that apply): [X] Percutaneous coronary intervention (PCI) (angioplasty) Indicate date of treatment or date of admission if admitted for treatment and treatment facility: 2/1/16 - CW Young VA hospital - with stent placement Indicate the condition that resulted in the need for this procedure/treatment: CAD 10. Hospitalizations -------------------- Has the Veteran had any other hospitalizations for the treatment of heart conditions (other than for non-surgical and surgical procedures described above)? [ ] Yes [X] No 11. Physical exam ----------------- a. Heart rate: 62 b. Rhythm: [X] Regular [ ] Irregular c. Point of maximal impact: [ ] Not palpable [ ] 4th intercostal space [X] 5th intercostal space [ ] Other, specify: d. Heart sounds: [X] Normal [ ] Abnormal, specify: e. Jugular-venous distension: [ ] Yes [X] No f. Auscultation of the lungs: [X] Clear [ ] Bibasilar rales [ ] Other, describe: g. Peripheral pulses: Dorsalis pedis: [X] Normal [ ] Diminished [ ] Absent Posterior tibial: [X] Normal [ ] Diminished [ ] Absent h. Peripheral edema: Right lower extremity: [X] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left lower extremity: [X] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ i. Blood pressure: 117/64 12. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. 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? [ ] Yes [X] No c. Comments, if any: No response provided 13. Diagnostic Testing ---------------------- a. Is there evidence of cardiac hypertrophy? [ ] Yes [X] No b. Is there evidence of cardiac dilatation? [X] Yes [ ] No If yes, indicate how this condition was documented: [ ] EKG [ ] Chest x-ray [X] Echocardiogram Date of test: 1/29/16 c. Diagnostic tests Indicate all testing completed; provide only most recent results which reflect the Veteran's current functional status (check all that apply): [X] Echocardiogram Date of echocardiogram: 5/10/2016 Left ventricular ejection fraction (LVEF): 32 % Wall motion: [ ] Normal [X] Abnormal, describe: global hypokinesis Wall thickness: [X] Normal [ ] Abnormal, describe: 14. METs Testing ---------------- Indicate all testing completed; provide only most recent results which reflect the Veteran's current functional status (check all that apply): a. [X] Exercise stress test Date of most recent exerc ise stress test: 3/24/16 Results: The stress test was stopped due to fatigue METs level the Veteran performed, if provided: 4.60 Did the test show ischemia? [ ] Yes [X] No If no, was the test terminated due to symptoms related to the cardiac condition? [X] Yes, the test was terminated due to symptoms that are related to the cardiac condition. [ ] No, the test was terminated due to symptoms that are not related to the cardiac condition. b. If an exercise stress test was not performed, provide reason: No response provided. c. [X] Interview-based METs test Date of interview-based METs test: 5/12/16 Symptoms during activity: The METs level checked below reflects the lowest activity level at which the Veteran reports any of the following symptoms attributable to a cardiac condition (check all symptoms that the Veteran reports at the indicated METs level of activity): [X] Dyspnea [X] Fatigue Results of interview-based METs test METs level on most recent interview-based METs test: [X] (>3-5 METs) This METs level has been found to be consistent with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph) d. Has the Veteran had both an exercise stress test and an interview-based METs test? [X] Yes [ ] No If yes, indicate which results most accurately reflect the Veteran's current cardiac functional level: [ ] Exercise stress test [X] Interview-based METs test [ ] N/A e. Is the METs level limitation provided above due solely to the heart condition(s) that the Veteran is claiming in the Diagnosis Section? [X] Yes [ ] No If yes, skip Section 14f. f. What is the estimated METs level due solely to the cardiac condition(s) listed above? (If this is different than METs reported above because of co-morbid conditions, provide METs level and Rationale below.) No response provided. g. Comments, if any: No response provided. 15. Functional impact --------------------- Does the Veteran's heart condition(s) impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's heart conditions, providing one or more examples: Difficulty with moderate/severe physical labor No sedentary restrictions 16. Remarks, if any ------------------- No remarks provided. **************************************************************************** COMPENSATION AND PENSION EXAMINATION MEDICAL OPINION ==================================== A STANDARD MEDICAL OPINION WAS REQUESTED. PROVIDERS RESTATEMENT OF REQUESTED MEDICAL OPINION. THIS IS NOT THE MEDICAL OPINION ITSELF: Does the Veteran have a diagnosis of (a) ISCHEMIC HEART DISEASE INCLUDING STENTS that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) AO exposure during service? WERE PRIVATE MEDICAL RECORDS REVIEWED: No WERE SERVICE MEDICAL RECORDS REVIEWED: Yes WERE VETERANS ADMINISTRATION RECORDS REVIEWED: Yes WERE OTHER RECORDS REVIEWED: No (STANDARD EXAMINERS MEDICAL OPINION) THE CONDITION/DISABILITY: It is as least as likely as not (50 percent or greater probability)that the veterans claimed ISCHEMIC HEART DISEASE INCLUDING STENTS incurred in or caused by AO exposure during service. RATIONALE FOR OPINION GIVEN: The vets complete VIRTUAL VA, VBMS and CPRS records were reviewed. Vietnam service was verified and Agent Orange exposure is conceded by the regional office. Agent orange exposure is presumed to be the cause of the vets IHD by the dept
  3. you were spot on, just got my notice today -- retro pay is $32,948.58 -- great calculations. thanks for your input. semper fi -- phil
  4. Thanks USMC_HVEQ. I simply could not understand how they calculate the retro pay. This really helps me to understand it. I surely appreciate you taking the time to educate me on this. Have a great day. semper fi phil
  5. I spoke with my DAV rep this morning to inquire about the status of my claims and he said that a rating decision had been made for both claims: 20% neuropathy (10% each leg) and 30% for PTSD. The claim still has to go through further processing for them to prepare my letter and to calculate retro pay which he said may take some time. I filed my claim for neuropathy in February 2011 and for PTSD in July 2011. I currently receive 20% for diabetes. If my calculations are correct for the "combined" rating, I figure my combined rating should be 60% (I think). Now, trying to figure out my retro pay for neuropathy and PTSD rating is beyond my pea brain. Does anyone know how the VA calculator works in this regard. Semper Fi Phil
  6. THanks Berta for your well reasoned response. I was in country just in time for the TET in 1968 and left Feb 1969. I appreciate the VA and grateful for the service I get from them but I'm just a little suspicious as to whether the C&P folks really have the Vets interest at heart.
  7. After waiting 3 years in appeal, I finally had my C&Ps on Dec 4 and Dec 10 (neuropathy and PTSD). Today I noticed on EBenefits that my appeal shows: Decision & Claims File Dispatch: This indicates that BVA mailed the decision to you (and your representative, if any) and transferred your case to another location. I spoke with BVA and they indicated my file had been sent back to the RO for the "authorization stage". I never got a letter from BVA. I know all of this is a process where patience is required but just interested of anyone's experience with this stage in the process. semper fi phil (email me if you like at plhusmc@gmail.com)
  8. Thanks for your input. Gastone: the DBQ notes "suicidal ideation: in past; homicidal ideation: none; persistent danger of hurting self or others: none. This that help or hurt? Semper Fi
  9. don't give up -- you are worthy -- you're a patriot and that says everything. don't let anyone tell you differently. I agree with some of the previous advice, get into a good vet-to-vet group, they have always helped me maintain. semper fi
  10. I have PTSD and diagnosed as bi-polar too. Personally, I think the bi-polar is not correct but, hey, I'm not a doctor. I missed my C&P exam in Houston TX in Oct 2011 (I moved back to Florida in August 2011 and did not get the notice). ANyway, I got notice in Dec 2011 that my claim for PTSD had been denied because I missed the exam. I went to my county VA office and the "&D&&" filed to wrong request -- he filed an appeal instead of requesting my case be reopened and requesting a new C&P date. Fast forward 3 years and here I am. I had my C&P exam this last Wednesday and personally don't know how it went. The doc was very straight laced with no personality (I think that's the way they're supposed to be). Hadn't slept well in about two-three days and only got about 1 hour on Tuesday night before the exam at 8:00am. I muddled through with the doc -- lasted about 45 min. and the took the mmpi2. The mmpi test results were "questionable validity with some validity scales elevated to the extent that profile interpretation is of limited utility". " Veteran endorsed many psychological symptons on a variety of clinical scales, often reporting moderate to severe levels of intensity. Overall this response pattern may indicate a sense of feeling overwhelmed, though exaggeration of psychological distress cannot be ruled out." Here's the summary of my C&P exam and I'd appreciate any feedback. Semper Fi. 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: 309.28 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD Mental Disorder Diagnosis #2: ALCOHOL USE DISORDER Comments, if any: moderate Mental Disorder Diagnosis #3: MOOD DISORDER, NOS b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): SEE CPRS 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: SYMPTOMS OVERLAP 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 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 [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: SYMPTOMS OVERLAP 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: ------------------------- 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? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: ALL RELEVANT RECORDS REVIEWED 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 f. Other, if any: MILITARY HISTORY Service Discharge Type (Last): HONORABLE Service Branch (Last): MARINE CORPS 1967- 69, 69-79 Service Discharge Type (NTL): HONORABLE Service Branch (NTL): MARINE CORPS Service Entry Date (NTL): Did the veteran have combat experience: YES Combat service location: Vietnam 1968-69 Duties: Were combat wounds sustained: no Any mental health tx: 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: SEE MILTARY HISTORY 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] 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] Inability to remember an important aspect of the traumatic event(s)(typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). [X] Persistent negative emotional state (e.g., fear, horror, anger,guilt, or shame). [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] 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] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- OTHER PSYCHIATRIC SYMPTOMS Today the veteran reports "I'm very agitated, didn't sleep well. Nerves raw" Current stressors: health The veteran described/endorsed the following symptoms associated with depression: Withdrawn, isolation, anhedonia, depressed mood, low energy, poor sleep, poor attention and concentration, forgetfulness, change in appetite, crying spells, guilt, helpless, hopeless, and worthless. Frequency of Symptoms: 4-5 days a week Duration of Symptoms: hours Onset of Symptoms: years Severity of Symptoms: mild to moderate The veteran described/endorsed the following symptoms associated with anxiety: restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance, excessive worrying, second guesses, what if?, difficulties with decisions Frequency of Symptoms: frequently Duration of Symptoms: minutes Onset of Symptoms: years Severity of Symptoms: mild to moderate The veteran described/endorsed the following symptoms associated with Mania: inflated self esteem, decreased need for sleep, pressured speech, FOI, distractibility, increased goal-directed activities, reckless behaviors Frequency of Symptoms: no recent manic episdoes, often has bouts of depression Duration of Symptoms: hours Onset of Symptoms:years Severity of Symptoms:mild to moderate Denies psychosis MENTAL STATUS EXAM: Appearance: clean, neatly groomed, casually dressed Orientation: AOX4 Mood: subdued, mildly agitated Affect: constricted Attitude: cooperative Speech rate and tone: Unremarkable Language: Good Thought content and progression: Unimpaired Tangentiality: none Circumstantiality: none Loose associations: none Flight of ideas: none Delusional: none Difficulty in understanding complex commands: none Gross impairment in thought processes or communication: none Hallucinations: not present Delusions: not present Grossly inappropriate behavior: none Memory: Mild memory loss, such as forgetting names, directions or recent events Attention and concentration: "its shot" Fund of knowledge: Good Intelligence: average Insight and judgment: fair Abstract Reasoning: wnl and a function of intelligence not reduced by mood Obsessive-compulsive: used to be organized , now less so. Sleep impairment: chronic difficulties with delayed onset, has sleep apnea ADLs: no impact from mental disorder Suicidal ideation: in past Homicidal ideation: none Persistent danger of hurting self or others: none Relationships: limited to partner (see social history for details) Has difficulty with people, easily irritated in dealing with others. 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 -------------------------------------------------- MMPI2 RF- profile of questionable validity with some validity scales elevated to the extent that profile interpretation is of limited utility. Veteran endorsed many psychological symptoms on a variety of clinical scales, often reporting moderate to severe levels of intensity. Overall this response pattern may indicate a sense of feeling overwhelmed, though exaggeration of psychological distress cannot be ruled out. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. =========================================================================
  11. 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: 309.28 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD Mental Disorder Diagnosis #2: ALCOHOL USE DISORDER Comments, if any: moderate Mental Disorder Diagnosis #3: MOOD DISORDER, NOS b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): SEE CPRS 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: SYMPTOMS OVERLAP 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 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 [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: SYMPTOMS OVERLAP 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: ------------------------- 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? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: ALL RELEVANT RECORDS REVIEWED 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 f. Other, if any: MILITARY HISTORY Service Discharge Type (Last): HONORABLE Service Branch (Last): MARINE CORPS 1967- 69, 69-79 Service Discharge Type (NTL): HONORABLE Service Branch (NTL): MARINE CORPS Service Entry Date (NTL): Did the veteran have combat experience: YES Combat service location: Vietnam 1968-69 Duties: Were combat wounds sustained: no Any mental health tx: 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: SEE MILTARY HISTORY 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] 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] Inability to remember an important aspect of the traumatic event(s)(typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). [X] Persistent negative emotional state (e.g., fear, horror, anger,guilt, or shame). [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] 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] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- OTHER PSYCHIATRIC SYMPTOMS Today the veteran reports "I'm very agitated, didn't sleep well. Nerves raw" Current stressors: health The veteran described/endorsed the following symptoms associated with depression: Withdrawn, isolation, anhedonia, depressed mood, low energy, poor sleep, poor attention and concentration, forgetfulness, change in appetite, crying spells, guilt, helpless, hopeless, and worthless. Frequency of Symptoms: 4-5 days a week Duration of Symptoms: hours Onset of Symptoms: years Severity of Symptoms: mild to moderate The veteran described/endorsed the following symptoms associated with anxiety: restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance, excessive worrying, second guesses, what if?, difficulties with decisions Frequency of Symptoms: frequently Duration of Symptoms: minutes Onset of Symptoms: years Severity of Symptoms: mild to moderate The veteran described/endorsed the following symptoms associated with Mania: inflated self esteem, decreased need for sleep, pressured speech, FOI, distractibility, increased goal-directed activities, reckless behaviors Frequency of Symptoms: no recent manic episdoes, often has bouts of depression Duration of Symptoms: hours Onset of Symptoms:years Severity of Symptoms:mild to moderate Denies psychosis MENTAL STATUS EXAM: Appearance: clean, neatly groomed, casually dressed Orientation: AOX4 Mood: subdued, mildly agitated Affect: constricted Attitude: cooperative Speech rate and tone: Unremarkable Language: Good Thought content and progression: Unimpaired Tangentiality: none Circumstantiality: none Loose associations: none Flight of ideas: none Delusional: none Difficulty in understanding complex commands: none Gross impairment in thought processes or communication: none Hallucinations: not present Delusions: not present Grossly inappropriate behavior: none Memory: Mild memory loss, such as forgetting names, directions or recent events Attention and concentration: "its shot" Fund of knowledge: Good Intelligence: average Insight and judgment: fair Abstract Reasoning: wnl and a function of intelligence not reduced by mood Obsessive-compulsive: used to be organized , now less so. Sleep impairment: chronic difficulties with delayed onset, has sleep apnea ADLs: no impact from mental disorder Suicidal ideation: in past Homicidal ideation: none Persistent danger of hurting self or others: none Relationships: limited to partner (see social history for details) Has difficulty with people, easily irritated in dealing with others. 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 -------------------------------------------------- MMPI2 RF- profile of questionable validity with some validity scales elevated to the extent that profile interpretation is of limited utility. Veteran endorsed many psychological symptoms on a variety of clinical scales, often reporting moderate to severe levels of intensity. Overall this response pattern may indicate a sense of feeling overwhelmed, though exaggeration of psychological distress cannot be ruled out. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. ========================================================================= I have PTSD and diagnosed as bi-polar too. Personally, I think the bi-polar is not correct but, hey, I'm not a doctor. I missed my C&P exam in Houston TX in Oct 2011 (I moved back to Florida in August 2011 and did not get the notice). ANyway, I got notice in Dec 2011 that my claim for PTSD had been denied because I missed the exam. I went to my county VA office and the "&D&&" filed to wrong request -- he filed an appeal instead of requesting my case be reopened and requesting a new C&P date. Fast forward 3 years and here I am. I had my C&P exam this last Wednesday and personally don't know how it went. The doc was very straight laced with no personality (I think that's the way they're supposed to be). Hadn't slept well in about two-three days and only got about 1 hour on Tuesday night before the exam at 8:00am. I muddled through with the doc -- lasted about 45 min. and the took the mmpi2. The mmpi test results were "questionable validity with some validity scales elevated to the extent that profile interpretation is of limited utility". " Veteran endorsed many psychological symptons on a variety of clinical scales, often reporting moderate to severe levels of intensity. Overall this response pattern may indicate a sense of feeling overwhelmed, though exaggeration of psychological distress cannot be ruled out." Here's the summary of my C&P exam and I'd appreciate any feedback. Semper Fi.
  12. I Had My C&p Exam Last Week And I'd Appreciate Any Feedback On My Exam Summary. Semper Fi Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire Name of patient/Veteran: HOLLOWAY, Phillip Lamar Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional 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? [ ] 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 [X] 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: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with diabetic peripheral neuropathy? [X] Yes [ ] No Diagnosis #1: Diabetic neuropathy ICD code: 357.2 Date of diagnosis: 2011 2. Medical history ------------------ a. Does the Veteran have diabetes mellitus type I or type II? [X] Yes [ ] No b. Describe the history (including cause, onset and course) of the Veteran's diabetic peripheral neuropathy: The veteran states he was diagnosed with Diabetes about 10 years ago. He states he started getting numbness, tingling and burning sensations in his bilateral forefeet about 2011. He states this is worse at night and often it will wake him up while sleeping. He states he is now on Gabapentin daily for his symptoms. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% c. Dominant hand [X] Right [ ] Left [ ] Ambidextrous 3. Symptoms ----------- a. Does the Veteran have any symptoms attributable to diabetic peripheral neuropathy? [X] Yes [ ] No If yes, indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe b. [ ] Other symptoms (describe symptoms, location and severity): No response provided. 4. Neurologic exam ------------------ a. Strength Rate strength according to the following scale: 0/5 No muscle movement 1/5 Visible muscle movement, but no joint movement 2/5 No movement against gravity 3/5 No movement against resistance 4/5 Less than normal strength 5/5 Normal strength Elbow flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Elbow extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Grip: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Pinch (thumb to index finger): Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Deep tendon reflexes (DTRs) Rate reflexes according to the following scale: 0 Absent 1+ Decreased 2+ Normal 3+ Increased without clonus 4+ Increased with clonus Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Lef t: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ c. Light touch/monofilament testing results: Shoulder area: Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm: Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Hand/fingers: Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Knee/thigh: Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Ankle/lower leg: Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes: Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent d. Position sense (grasp index finger/great toe on sides and ask patient to identify up and down movement) [X] Not tested e. Vibration sensation (place low-pitched tuning fork over DIP joint of index finger/IP joint of great toe) Right upper extremity: [X] Normal [ ] Decreased [ ] Absent Left upper extremity: [X] Normal [ ] Decreased [ ] Absent Right lower extremity: [ ] Normal [X] Decreased [ ] Absent Left lower extremity: [ ] Normal [X] Decreased [ ] Absent f. Cold sensation (test distal extremities for cold sensation with side of tuning fork) [X] Not tested g. Does the Veteran have muscle atrophy? [ ] Yes [X] No h. Does the Veteran have trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to diabetic peripheral neuropathy? [X] Yes [ ] No If yes, describe: 1.) Dystrophic toe-nails. %%%%%%%%%%%%%%%%%%%%%%%%%%%%% 5. Severity ----------- a. Does the Veteran have an upper extremity diabetic peripheral neuropathy? [ ] Yes [X] No b. Does the Veteran have a lower extremity diabetic peripheral neuropathy? [X] Yes [ ] No If yes, indicate nerve affected, severity and side affected: Sciatic nerve Right: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [X] Mild [ ] Moderate [ ] Moderately Severe [ ] Severe, with marked muscular atrophy Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [X] Mild [ ] Moderate [ ] Moderately Severe [ ] Severe, with marked muscular atrophy Femoral nerve (anterior crural) Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis 6. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. 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? [ ] Yes [X] No b. 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? [ ] Yes [X] No 7. Diagnostic testing --------------------- a. Have EMG studies been performed? [ ] Yes [X] No b. If there are other significant findings or diagnostic test results, provide dates and describe: HgA1c 6.5% - 06/14/2012 6.5% - 02/04/2013 7.4% - 08/22/2013 6.4% - 07/28/2014 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 8. Functional impact -------------------- Does the Veteran's diabetic peripheral neuropathy impact his or her ability to work? [ ] Yes [X] No 9. Remarks, if any: ------------------- 1.) Mild diabetic peripheral neuropathy of the distal bilateral lower extremities. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% **************************************************************************** COMPENSATION AND PENSION EXAMINATION MEDICAL OPINION ==================================== A STANDARD MEDICAL OPINION WAS REQUESTED. PROVIDERS RESTATEMENT OF REQUESTED MEDICAL OPINION. THIS IS NOT THE MEDICAL OPINION ITSELF: Is it as likely as not that the veteran's Neuropathy of the lower extremities was caused by his Service Connected Diabetes. Is it due to or a result of Service Connected Diabetes? WERE PRIVATE MEDICAL RECORDS REVIEWED: No WERE SERVICE MEDICAL RECORDS REVIEWED: No WERE VETERANS ADMINISTRATION RECORDS REVIEWED: Yes WERE OTHER RECORDS REVIEWED: No (STANDARD EXAMINERS MEDICAL OPINION) THE CONDITION/DISABILITY Is it as likely as not that the veteran's Neuropathy of the lower extremities was caused by his Service Connected Diabetes. IT IS AS LEAST AS LIKELY AS NOT (50/50 PROBABILITY) CAUSED BY OR A RESULT OF Service Connected Diabetes. RATIONALE FOR OPINION GIVEN: The veteran has had diabetes for approximately 10 years. His Hga1c levels show spikes indicating less than optimal control. His current complaint of neuropathic like symptoms to the distal feet is consistent with early onset mild diabetic neuropathy. It is as least as likely as not (50/50 probability) that the veteran's Neuropathy of the lower extremities was caused by or is related to his Service Connected Diabetes.
  13. Here's the summary of my PTSD C&P and would appreciate any insight as to how you think the rating will go. I have no confidence in the VA in this regard and suspect that I will get little if anything. (Sorry to be a cynic) but I've been waiting 3 years for this exam. Got a letter of notice on Wednesday dec 3 stating that I had an C&P Exam scheduled for MONDAY DEC 1. I spent a week trying to get a new exam rescheduled before being sent back to the end of the line. Fortunately, I had one schedule for this last Wednesday. Let me know what you think. Semper Fi 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: 309.28 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD Mental Disorder Diagnosis #2: ALCOHOL USE DISORDER Comments, if any: moderate Mental Disorder Diagnosis #3: MOOD DISORDER, NOS b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): SEE CPRS 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: SYMPTOMS OVERLAP 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 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 [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: SYMPTOMS OVERLAP 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: ------------------------- 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? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: ALL RELEVANT RECORDS REVIEWED 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 f. Other, if any: MILITARY HISTORY Service Discharge Type (Last): HONORABLE Service Branch (Last): MARINE CORPS 1967- 69, 69-79 Service Discharge Type (NTL): HONORABLE Service Branch (NTL): MARINE CORPS Service Entry Date (NTL): Did the veteran have combat experience: YES Combat service location: Vietnam 1968-69 Duties: Were combat wounds sustained: no Any mental health tx: 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: SEE MILTARY HISTORY 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] 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] Inability to remember an important aspect of the traumatic event(s)(typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). [X] Persistent negative emotional state (e.g., fear, horror, anger,guilt, or shame). [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] 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] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- OTHER PSYCHIATRIC SYMPTOMS Today the veteran reports "I'm very agitated, didn't sleep well. Nerves raw" Current stressors: health The veteran described/endorsed the following symptoms associated with depression: Withdrawn, isolation, anhedonia, depressed mood, low energy, poor sleep, poor attention and concentration, forgetfulness, change in appetite, crying spells, guilt, helpless, hopeless, and worthless. Frequency of Symptoms: 4-5 days a week Duration of Symptoms: hours Onset of Symptoms: years Severity of Symptoms: mild to moderate The veteran described/endorsed the following symptoms associated with anxiety: restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance, excessive worrying, second guesses, what if?, difficulties with decisions Frequency of Symptoms: frequently Duration of Symptoms: minutes Onset of Symptoms: years Severity of Symptoms: mild to moderate The veteran described/endorsed the following symptoms associated with Mania: inflated self esteem, decreased need for sleep, pressured speech, FOI, distractibility, increased goal-directed activities, reckless behaviors Frequency of Symptoms: no recent manic episdoes, often has bouts of depression Duration of Symptoms: hours Onset of Symptoms:years Severity of Symptoms:mild to moderate Denies psychosis MENTAL STATUS EXAM: Appearance: clean, neatly groomed, casually dressed Orientation: AOX4 Mood: subdued, mildly agitated Affect: constricted Attitude: cooperative Speech rate and tone: Unremarkable Language: Good Thought content and progression: Unimpaired Tangentiality: none Circumstantiality: none Loose associations: none Flight of ideas: none Delusional: none Difficulty in understanding complex commands: none Gross impairment in thought processes or communication: none Hallucinations: not present Delusions: not present Grossly inappropriate behavior: none Memory: Mild memory loss, such as forgetting names, directions or recent events Attention and concentration: "its shot" Fund of knowledge: Good Intelligence: average Insight and judgment: fair Abstract Reasoning: wnl and a function of intelligence not reduced by mood Obsessive-compulsive: used to be organized , now less so. Sleep impairment: chronic difficulties with delayed onset, has sleep apnea ADLs: no impact from mental disorder Suicidal ideation: in past Homicidal ideation: none Persistent danger of hurting self or others: none Relationships: limited to partner (see social history for details) Has difficulty with people, easily irritated in dealing with others. 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 -------------------------------------------------- MMPI2 RF- profile of questionable validity with some validity scales elevated to the extent that profile interpretation is of limited utility. Veteran endorsed many psychological symptoms on a variety of clinical scales, often reporting moderate to severe levels of intensity. Overall this response pattern may indicate a sense of feeling overwhelmed, though exaggeration of psychological distress cannot be ruled out. 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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