mightytyke

I was in the Pentagon on 9/11. I was diagnosed with PTSD by civilian doctors. All of the panic attacks/anxiety started out of the blue in 2012. I had to quit my job and go on SSDI. I included contact information for all of the doctors that I went to. The dr that interviewed me left out a few things that would've been relevant to the claim and twisted my wording on other stuff. I also have something else in for another thing that it seems the VA overlooked entirely. It's hard for me to get my medical records to upload them since I no longer live in Virginia.

Was able to pull up the report from my C & P. Sent a copy to my rep, she's livid and is going to contact some people. The C & P was only like 30 minutes long. His report is terrible. He left out some of the stuff that I told him. L SECTION I: --------- 1. Diagnostic Summary -------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran does not have a mental disorder that conforms with DSM-5 criteria 2. Current Diagnoses ------------------- No response provided 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)? [ ] Yes [X] No [ ] 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] No mental disorder diagnosis b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ---------- Clinical Findings: ----------------- 1. Evidence review ----------------- 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: [X] Military service treatment records [X] Military service personnel records [X] 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: 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): indicated that he was born and raised in the Northwest part of Ohio. He was raised by both parents along with his older sister. He reported that childhood was good with no type of abuse. He indicated that he was involved in various activities in childhood; boy scouts, baseball, and band. He reported having adequate friendships growing up. indicated that he lived in Virginia from 1999-2014. He recently re-located to OH. He stated that he recently applied for Social security and fears that he will not be able to return to work. He has never been married and has no kids. He reports interest in having a family someday. He reported that his longest relationship was around 2004-05 that he reports his anger difficulties led to some of the reason for the dissolution of the relationship. He indicated that he has not attempted to have a relationship since around 2012 noting "I am not well enough." b. Relevant Occupational and Educational history (pre-military, military, and post-military): reported being a "OK" student in school. He denied ever being held back a grade or being diagnosed with a learning disability. He held several part-time jobs while in school, including a paper route, dishwasher, and as a pizza cook. He denied any difficulties with work. At age 18 and after graduating high school he worked as a factory worker for about 3.5 years prior to entering the military. indicated that he joined the Army in 1997 and served until 2002. He reported that he worked in tech control providing services for communication lines. Overall, he indicated that he enjoyed his military experiences and that his time was "rewarding" and that he had few difficulties. stated that he was located at the Pentagon during the attacks of September 11, 2001 working at the control center. He stated that he recalls feeling overwhelmed by the anxiety and terrified by the events. He recalled trying to evacuate through a cloud of smoke and people. He remembers hearing explosions and feeling uncertain about what was happening and hearing stories of another plane being bound for them at the Pentagon. He reported that he had a friend that was a casualty of the attack at the Pentagon. He reported that he has forgotten details about parts of his experience. reported that the majority of his symptoms remained underneath the surface until about 2 years later following the events. He specifically noted a increase in irritability and "panic attacks" that followed 2 years after the events at the Pentagon. He reported that the symptoms slowly intensified until he stopped working in 2013 due to the increase in panic attacks. After he left the military he worked for as a contractor in Virginia until about 2013. Mr. Tyson indicated that he has was forced to quit his job in 2013 due to the anxiety. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): indicated that he first initiated mental health treatment in 2012 due to increasing anxiety and panic like symptoms that was interfering with his work. He reported that his anxiety in 2012 appeared all of a sudden stating "came out of the blue." He noted to have difficulties wit h panic attacks everyday and difficulties operating at work with loud noises. He st that he started to feel as he does today that he just wants to "curl up and cry." He reported that he started to miss significant amount of time from work and that due to his anxiety discontinued working. He reported that he limits himself from leaving the house due to anxiety and fear noting "constant doom. He reports tyring to avoid being out in public and no longer enjoys activities such as going to restaurants, museum's, or the movies for fear of panic. He reports chronic difficulties with heart palpitations and sweat. He indicated that his sleep is disturbed and that his mind constantly races. He stated that once he is able to fall asleep he sleeps continuously for 6-8 hours and feels rested. He reports that his appetite fluctuates and that he has someday where he doesnt feel like eating. He has had thoughts of SI in the past but denied any recently. He is hopeful and hopes to get better. He reports significant concentration/attention problems. He reports that at times he feels "dead inside and numb," in addition to feeling very hard on himself. He reports that these symptoms of guilt and anxiety make it difficult for him to have relationships with people outside of the family. He did report moving to as he has friends that live by in the area and reports good relationships with friends and family but stated he is somewhat isolative from them lacking motivation to engage. He reports that he does not feel dread or fear that he is going to lose control or go crazy. He has been engaged in treatment outside of the VA since 2012 and stated he receives psychotherapy as well as psychotropic medications. He indicated that he is currently prescribed Seroquel, Zoloft, Topamax, Klonopin, and buspar. He denied any family history of mental health problems. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): denied any behavioral or legal difficulties past or present. e. Relevant Substance abuse history (pre-military, military, and post-military): Mr. Tyson denied any excessive use of alcohol. He denied any use of illicit substances. f. Other, if any: No response provided. 3. Stressors ----------- No response provided 4. PTSD Diagnostic Criteria -------------------------- No response provided 5. Symptoms ---------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks more than once a week [X] Flattened affect 6. Behavioral Observations ------------------------- was on-time for appointment. He was casually dressed with good hygiene. He was cooperative but guarded. His affect appeared anxious and restricted. No SI/HI. No evidence of thought disorder. No spontaneous speech but thoughts were logical. 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 ------------------------------------------------- Military service records provide high remarks of service. In November 2000 he was promotoed to Seargeant for his "valor, fidelity, and provessional excellence." Additional review of his performance records indicated that performed in the range of "excellence" with high marks in most areas of responsiblities. In April, 2002 he was awarded the Army Commendation Medal. indicated in his written VA 21-0781 claim for PTSD that he has "nightmares about that day," but specifically denied any nightmares during today's evaluation and again noted that once he falls asleep he is able to maintain his sleep without interuption. 3 There does not appear to be any immediate red flags or change in functioning following the events in September 2001. appeared to function at a high level until he abrubtly began to have anxiety and panic in 2012, and his significant anxiety according to was the result of his experiences at the Pentagon in 2001. It could be plausable that this is the case and current anxiety levels and panic is related to his experiences while at the Pentagon. However, the only mental health records I have available is a list of his psychiatric prescriptions that was uploaded in VBMS. Unfortanetly, without his outside mental health treatment records I can only speculate for the cause and severity of his current anxiety. should make those records available for review as he reported that he has been in continous psychological treatment for anxiety since 2012. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.

Thanks for welcoming me aboard. Just checked ebennies today it has been moved to the preperation for decision phase. Am not able to find the C and P notes, but saw that it was mentioned earlier that VA is not posting it on ehealth for the veterans to see.

Just found this board the other day, looks good. I had my c and p exam for PTSD yesterday. I have been out of work since late 2012, had to quit my job due to anxiety/panic attacks. I was awarded SSDI last year. The exam seemed like it went pretty quick, he asked about what happened, when some of the issues that I have started. When it ended he stated that he would write up his report and it would be up to the rater.