Jessamine

Hey all. I have 2 claims, a RAMP appeal and a new one for conditions the RAMP appeal evolved into. There wasn't a whole lot of movement. On my RAMP I had a C&P on 1/31 that basically proved my new claim moreso than what it was actually for, and then yesterday on my new one a "Request 3, exam request processing" popped up and then an hour later went to "Request 3 closed. No longer needed. Date: Not available"
 
Err.. so do I have pending appointments or did they review my other evidence? I only ask because I am supposed to be moving from PA to WV and I have been trying to hold off until exams, if needed, are done. If they don't need them anymore, I know I have extensive records provided and would be wanting to move ASAP. I didn't want to jump off of my sinking ship until they had everything they needed, if that makes sense. So what does the no longer needed thing mean? Is it as obvious as it sounds and they don't need another exam? 
 
DAV guy 1 said I had pending exams,  DAV guy 2 said nope, you're good on exams. Errr... anyone have this happen? And if it matters, there are DBQ's on file as well.
 
Thanks

So the day yours closed on ebenefits your rating increase changed too. My appeal closed today and my rating remained the same so I guess my appeal was denied : no increase in rating. 

I would call the 1-800-827-1000 number and see if they will shed any light on this.  Then I would contact your closest VA hospital and talk to the people setting up C&P's.

That is great, when there are two conflicting medical opinions they are supposed to resolve reasonable doubt in the favor of the veteran.  The RO might not do this but BVA usually does, not that you want to have to go that far.

I looked at your exam and quickly rated it. It looks like you should expect 40% overall. 10 for skin, 10 for right ankle, 10 for left ankle and 20 for thoracolumbar spine. Unless this is a pre-discharge claim, the knee condition will probably be denied because there was no mention of treatment in service. BTW, I'm a rating specialist at VA. 

I cannot stress how important it is to have a doctor state it is more than likely than not that your RA is related to your ankle injury that occurred in service.  If he is out for your best interests he should add this to your DBQ or IMO.  Your C&P examiner eluded to this but did not come out and say it but if your doctor is willing to say this it brings up reasonable doubt and that is supposed to be done in the veteran's best interest.  Please speak to your doctor and see if he is willing to add this.

It looks to me like an inadequate C&P exam. The examiner clearly and unmistakably fails to use the legal terminology to substantiate your claim.
I don't see the minimum threshold of "at least as likely as not" the veteran's condition is due to or the result of military service/SC condition. The rationale is insufficient.
This will most likely delay the process and will get sent back to the examiner for clarification. It's not a granted or denied claim. That's the good news.
If it does get denied. You'll need to appeal immeadiately on the basis that the examiner failed to provide the legal terminology to substantiate your claim.
 

I really appreciate how the VA is able to miss records that are in our favor.  If your records that are referenced as missing are important I would get with your VSO and resubmit them.  Even so, when your case is completed by the RO look to see if these records were included in evidence used to make decision.  That could be the basis of a CUE.  I know it is a little late but it is good to have these records available at a C&P incase the doctor says he does not have them. 
Reading the exams the doctor states "Upon review for this case, it becomes apparent that the multiple joint complaints while AD are consistent with Rheumatoid Arthritis even though it was not diagnosed while active duty."  This sounds like a good exam where the doctor is trying to say you had RA in service.  I think the doctor is new to the VA and how they do things though.  A really good statement would be something like "it is more likely then not".  They are trying to relate your RA to service in my opinion but we do not know if the raters know how to read when it is not in their preferred format.  The second issue I see with your C&P is that the examiner notes that pain is your most prevalent feature.  The VA is supposed to take this into consideration but they do not recognize pain a lot of times.  If you have strong civilian evidence that is a good thing.  Does your civilian doctor state you had RA in service?  If they do it would be nice to see if they are willing to state "it is more likely then not that the Veteran had RA in service" in a DBQ or IMO.
Buck, Broncovet?

It would be good if we could see the whole letter, redacted of course.  If a C&P doctor wrote this it might mean that you would be eligible for benefits.

Hi all! This is so confusing to me. It seems like the box she checked is in direct conflict with the symptoms she chose. I feel like that lowballed me, am I looking at this right?  Took almost 2.5 hrs and this is what I got:
 
 I removed doctors names and personal information but again, I don't understand what this means. Can someone please take a look and tell me? I am sorry it is long, I am just really confused by the language of it. In a PCL-5, what is a 72 out of 38? This is all jibberish to me. Can someone please help? 


Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * 

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 2. Current Diagnoses --------------------
a. Mental Disorder Diagnosis #1: Post Traumatic Stress Disorder
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): 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] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation
b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed
c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI  



SECTION II: ----------- Clinical Findings: ------------------ 

1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): The veteran brought civilian records of diagnoses and procedures to session. 

2. History ----------
a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran was referred for a DBQ Initial PTSD evaluation for Post  Traumatic Stress Disorder. Information in this assessment is based on the veteran's self-report unless otherwise indicated. The veteran is a 32 year old divorced female. She said that her mother had her when she was 14 years old. She described her childhood as abusive and very difficult. Her mother was "a junkie." Her mother was very abusive emotionally and physically, and two of her stepfathers were also abusive. She said that she tended to take the punishment for her two younger brothers. Her mother was stabbed to death by her brothers' father when the veteran was 9 years old, and she and her brothers witnessed the stabbing. Her own father was declared unfit, so she went into foster care. She has 14 siblings total, but was only raised with the two younger brothers. She is still in contact with some of her siblings. Her brother lives with her. One sister committed suicide recently due to the deaths of her husband and children in a car accident. The veteran has been married 3 times. She stated that she married the first time in order to get her brother out of foster care. He came to live with her and her husband. They had no children. She married a second time and they had 2 sons, now ages 11 and 9. She had one daughter with her third husband, age 4. She stated, "Sometimes I marry people because I'm bored and I don't have friends." She is currently involved in a relationship with her fianc?, FUTURESPOUSE. She stated that this is a good relationship and that he is loving and supportive. He lives in the household with her, her brother, and her 3 children. When asked about friends, she stated that she doesn't have any friends. She considers FUTURE SPOUSE and her little brother to be her friends. She does not associate with anyone else. She stated that she does not like to go out and does not like to interact with people. When asked about an average day, she stated that she works and cares for her children and FUTURESPOUSE. She enjoys reading. 



b. Relevant Occupational and Educational history (pre-military, military, and post-military): The veteran has a bachelor's degree in Business, and an associate's degree in Criminal Justice. She would like to continue her education to get a master's degree in Emergency and Disaster Management. Although she claims to have ADHD, she denied having any symptoms of it during childhood and denied having any academic difficulties. Her high school transcripts indicate that she had a B average. She stated that her grades have been good throughout her academic career and that she was always on the dean's list in college. She currently works in administration and operations. She stated that it is a small company and she does everything - HR, IT, and finance for it. She has held this position for 10 months. She stated that she anticipates that she will be fired soon due to missing a lot of work. Because it is a small company, it does not honor FMLA policies. She said that she misses work because she does not sleep well. When she has a rough night, she knows that she will be irritable so she does not go in the next day. Prior to her current position, she worked at Comcast. She had maintained that position for one year. She said that she had difficulties with attendance at that job too. She served in the U.S. Army. She was released for medical reasons due to a fractured ankle. She cited an incident of MST during her service that occurred in March 2004. She stated that she had gone to a party, had been drinking, and was sleeping it off. She awoke to find one man having sex with her, another putting his pants on, and a third masturbating beside her. She stated that she became pregnant from this encounter and had an abortion. There is do cumentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression.  


c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran was psychiatrically hospitalized at the Meadows in 1997 and 1998, then again in 2008. She has had two suicide attempts. There is documentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression. She received mental health treatment on an outpatient basis in the community until recently.  CPRS records indicate that she attended intake appointments at the VA in June 2016 with a psychiatrist,, and a social worker, but did not make any follow up appointments due to a stated need to refrain from missing work. Her CPRS chart indicates diagnostic impressions of anxiety and chronic depression. She stated that she had been prescribed Adderall and Xanax in the community but Dr  would not refill these and she has not taken any psychotropic medication since April 2016. He had offered psychological testing to confirm ADHD but she declined his offer. She said that she had taken several SSRIs in the past but they did not help. She endorsed current symptoms indicative of Post Traumatic Stress Disorder.  

d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The veteran denied any past or current problems in this area.  

e. Relevant Substance abuse history (pre-military, military, and post-military): The veteran stated that she had problems with alcohol beginning in the military. She drank more after the rape in 2004. There is documentation in her record that she was drinking a pint of whiskey every two days. She said that she currently drinks once per month, and stated that she drinks 1 or 2 drinks. She was noted to have 2 cups each containing 31 ounce Starbucks coffees with her to this interview. She stated that she needs a lot of caffeine during the day because she cannot sleep at night. She usually drinks 4-6 of these 31 ounce drinks per day, indicating that she is getting 1120 to 1680mg of caffeine per day. She does not consider this to be a problem. Family history is significant in that her mother "was a junkie." 


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 post-military): 

a. Stressor #1: Sexual Assault in March 2004 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 

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.  

There is documentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression.  There is documentation of an elective abortion dated 6/14/04, with the comments, "Conception the result of documented sexual assault. Both post operative instructions and sexual assault support group documentation provided."  


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 Criterion 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 Criterion 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 violence, 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). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 

[X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). 

[X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

[X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).  


Criterion C:  Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: 

[X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).  

Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 

[X] Persistent 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] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

[X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities.

[X] Feelings of detachment or estrangement from others. [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] Reckless or self-destructive behavior.

[X] Hypervigilance. 

[X] Exaggerated startle response.

[X] Problems with concentration. 

[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).  

Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.  

Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.  


Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.  


Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: 
[X] Stressor #1 5. Symptoms -----------  Veteran's diagnoses: 
[X] Depressed mood 
[X] Anxiety 
[X] Suspiciousness 
[X] Chronic sleep impairment 
[X] Disturbances of motivation and mood 
[X] Difficulty in establishing and maintaining effective work and social relationships
[X] Difficulty in adapting to stressful circumstances, including work or a worklike setting 
[X] Inability to establish and maintain effective relationships 
[X] Suicidal ideation  


6. Behavioral Observations -------------------------- The veteran was alert and responsive, and oriented to time, person, and place. She was cooperative throughout interview. Eye contact was adequate. Affect was constricted, mood anxious. She was jittery and had difficulty sitting still. Speech was fluent, spontaneous, and goal-directed. Rate, rhythm, and volume were within normal limits. Thought processes were coherent. She denied perceptual disturbances. Memory was adequate for both recent and remote events. Fund of information was adequate. Attention and concentration were adequate. Thinking was abstract. She denied having any current suicidal or homicidal thoughts or plans. Judgment and insight were adequate.  


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  -------------------------------------------------- This was not an ACE examination. The veteran was evaluated in person. All available electronic records, including VBMS file were reviewed. The PCL-5 was administered to the veteran during this evaluation. She obtained a score of 72, significantly above the cut off score of 38, suggestive of a PTSD diagnosis.Based on Veteran's self-report, review of all available electronic records, clinical interview, and the scores on the above assessment, she meets DSM-5 criteria for Post Traumatic Stress Disorder. It is believed that her mood and attentional symptoms are manifestations of PTSD and do not represent separate, discrete disorders. Her symptoms are significantly interfering with her daily activities and her social and occupational functioning. It is at least as likely as not (50 percent or greater probability) that this disorder was caused or exacerbated by the military sexual trauma events she experienced during her military service.