Jump to content
VA Disability Community via Hadit.com

VA Disability Claims Articles

Ask Your VA Claims Question | Current Forum Posts Search | Rules | View All Forums
VA Disability Articles | Chats and Other Events | Donate | Blogs | New Users

fatheryabueloDE9

Seaman
  • Posts

    27
  • Joined

  • Last visited

Everything posted by fatheryabueloDE9

  1. Hi I appreciate your reply. re SSDI: In 2002, about the same time, I applied for CA workmens comp And SSDI primarily for carpal tunnel syndrome. But I was also having depression etc, dealing with authorities. I am now about 68 and of course the SSDI in now regular SS retirement income. In 2002, my WC lawyer was a very experienced WC atty; did not expect me to win SSDI. He even offered to "help" my appeal for SSDI upon being denied by S.Sec. When awarded SSDI ( approved in 4 months) Lawyer said approval had to be for something other than Carpel T. For several years, I had been getting rx's for depression, etc. I do not know if the VA has my SSDI records. In my VA claim I mentioned the SSDI started at 55 years of age. In my claim were my statements about having job issues (loss of jobs, etc. thanks for reply.
  2. I recently had my C & P exam by a VA psychologist, and downloaded it from My healthevet. Note: For over 40 years, I kept to myself most of the traumatic Vietnam combat related experiences, especially the MST. I never reported the MST while in the RVN to Military, later to the VA, nor any civilian doctors. I kept the MST violations internally, never informing my wife until 2014 when seeking VA mental health treatment. I am still continuing MH counseling from the VA. It appears the Opinions (NEXUS) by the C & P examiner are favorable, yese's for both PTSD Combat and MST, and Service Connected. However, I do not agree with the Rating given for "Occupational and social impairment " (30%) I realize that other factors beside the C & P are use for the overall ratings. Any educated guesses on what Rating might be given by the Rating person based on the C & P below? Combined Ratings ? Below is about 98% of the actual C & P Report by the VA psychologist. Slight edits were made to the for clarity or anominity. _______ Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: XXXXX SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 (F43.10) 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder ICD code: 309.81 (F43.10) Mental Disorder Diagnosis #2: Alcohol Use Disorder ICD code: 305.00 (F10.10) b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): deferred to medical providers 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: The symptoms of each disorder overlap and occur in a concurrent and reciprocal relationship. It is not possible to accurately separate them without resorting to mere speculation. 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 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 [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: The symptoms of each disorder overlap and occur in a concurrent and reciprocal relationship. It is not possible to accurately separate the impairments without resorting to mere speculation. 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: recent medical records 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? [X] Yes [ ] No If yes, describe: cfile, medical records 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): He lives with his wife of 35 + years. He reports their relationship has had discord but he states they are currently getting along "fine." He reports increased agitation at home. He reports he prefers to stay around the house but they eventually enjoy going out to organized activities together at their senior community. They attend dances. He reports he also enjoys watching television and going for walks. He also enjoys running He reports his relationship with his children is "pretty good." He has a friend from his community. He enjoys playing a dominos game with another couple once a week. b. Relevant Occupational and Educational history (premilitary, military, and post-military): He last worked in 2002. He reports he applied for social security disability during 2002.(when 54 years old.) He had been working for a college in CA as an administrator. He had been working for them for 2 years. He states he was terminated related to budget cuts. He states he perceives he was fired for whistle blowing on the President of the School who he states had misapropriated funds. Prior to that he was unemployed for 3 years. Prior to working for another university as an assistant finance controller for 3.5 years. He states he was terminated due to poor performance. He states he percieves he was terminated again related to whistle blowing. He states he had reports to management that another employee had not completed their job correctly and he perceives the administration was more loyal to the other employee. He attended college and obtained a bachelors degree in business in 197x. He served IN … from JUN of 1968 until MAR of 1970. His job was …. He was honorably discharged at the rank of E4. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and postmilitary): He sought treatment at the ….CBOC during FEB of 2014. His diagnosis at that time was Major Depressive Disorder, Anxiety Disorder NOS, ADHD, and rule out PTSD. He continued to received treatment. During 2014 the diagnoses of PTSD and Alcohol Use Disorder were added. He is prescribed bupropion for psych symptoms. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): denied e. Relevant Substance abuse history (pre-military, military, and post-military): He reports he uses alcohol 2 days/week and drinks 4 drinks per sitting. He states he has a history of excessive alcohol use but in 2003 he quit drinking alcohol after attending an alcohol rehab program. He began drinking again in 2009 and has been moderation drinking. He reports prior to 2003 he was drinking 10 beers per day for 30 years. He reports during his military service he used amphetamine, alcohol, and cannabis. He states he has not used cannabis or amphetamine for 40 years. f. Other, if any: No response provided. 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or postmilitary): a. Stressor #1: He served in Vietnam. He witnessed a plane crash with loss of life. There were episodes of incoming rounds. 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: He reports two incidents of MST. One of suspected sodomy while he was passed out and another of non- consensual oral sex. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: it is related to MST Is the stressor related to personal assault, e.g. military sexual trauma? [X] Yes [ ] No If yes, please describe the markers that may substantiate the stressor. Service treatment records confirm service in Chu Lai from 68-69; Complaints of "thinking bad" and feeling tense, thoughts of going UA; c/o frequent trouble sleeping and nervous trouble after 16 months of service. Military Personnel File notes a decrease in performance scores in March of 1969 and contains letter from veteran noting that he does not feel proud to be in the uniform after his tour in RVN. 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) 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). 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 the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [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] Hypervigilance. [X] Exaggerated startle response. [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] Depressed mood [X] Anxiety [X] Chronic sleep impairment [X] Disturbances of motivation and mood 6. Behavioral Observations -------------------------- Patient is oriented to all spheres. Patient's affect is congruent with stated mood and symptoms. Veteran was relatively calm and responsive. Speech is of normal rhythm and content. Veteran maintained focus on topics and responded appropriately to questions. There is no evidence of a formal thought disorder. Insight and judgment were grossly intact. Active suicidal ideation, planning, and intent was denied. Protective factors were identified. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: there is agitation without behavioral aggression. 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- No remarks provided. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. ************************************************************************** ** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: xxxxx 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 If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: recent medical records MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: The Veteran is claiming service connection for PTSD. Please evaluate and provide an opinion as to whether or not the veteran has a current diagnosis of posttraumatic stress disorder that is related to his conceded stressor of fear of hostile military activity. If a diagnosis of PTSD is made, the examiner needs to determine if the Veteran's claimed stressor is related to the Veteran's fear of in-service hostile military or terrorist activity. The current worksheet/template is otherwise adequate to encompass the new regulation. The initial PTSD examination is to be conducted by a VA psychiatrist or psychologist. "Fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstances that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others and the Veteran's response to the event or circumstances involved a psychological or psychophysiological state of fear, helplessness, or horror. The event or circumstances include, but are not limited to, the following: (1) Actual or potential improvised explosive device; (2) Vehicle-embedded explosive device; (3) Incoming artillery, rocket, or mortar fire; (4) Small arms fire, including suspected sniper fire; or (5) Attack upon friendly aircraft. ***IF NO TO OPINION ABOVE, PLEASE PROVIDE AN OPINION REGARDING PSTD DUE TO MST BELOW - THANK YOU*** MST OPINION - Please review the veteran's entire claims file and medical records and provide an opinion as to whether it is at least as likely as not that the VETERAN'S RECORDS SUPPORT THE OCCURRENCE of a military sexual assault. Please do not provide opinion #2, unless you have provided opinion #1. Opinion #2 If YES to opinion #1, please provide an opinion as to whether the veteran's current mental health condition is at least as likely as not related to the military sexual assault. Opinion #3 If NO to opinion #1, please provide an opinion as to whether it is at least as likely as not that the veteran's current mental health condition had its onset in military service. If you find that this condition pre-existed the veteran's military service, please indicate if the treatment during service shows this condition was aggravated beyond it's normal level of progression by military service. Rationale must be provided in the appropriate section. If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder. b. Indicate type of exam for which opinion has been requested: Initial PTSD TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed inservice injury, event or illness. c. Rationale: To reiterate, the veterans PTSD is MOST LIKELY related to both his fear of hostile military and terrorist activity as well as to MST. The record MOST LIKELY supports the occurance of MST. Finally, the veterans symptoms did MOST LIKELY have onset while in the military. Opinion is based on clinical experience and research, clinical interview data, DSM5 criteria, behavioral observation, and supporting service and medical records. ********************************************************* **************** xxxxxxx, PSY.D. STAFF PSYCHOLOGIST, C&P Signed: 03/xx/2015 07:36
×
×
  • Create New...

Important Information

Guidelines and Terms of Use