Below is the C&P exam that I took in September. I don't think that the VA used this report because 'Benefits' only shows the Tinnutus as being rated.
I removed the doctors at the Battle Creek VA.
--------------- MY HEALTHEVET PERSONAL INFORMATION REPORT ---------------
*************CONFIDENTIAL*************
Produced by the VA Blue Button (v12.10)
04 Jan 2017 @ 0905
This summary is a copy of information from your My HealtheVet Personal
Health Record. Your summary may include:
- information that you entered (self reported)
- information from your VA health record
- your military service information from the department of defense (DoD).
***Note: Your health care team may not have all of the information from
your Personal Health Record unless you share it with them. Contact your
health care team if you have questions about your health information.***
Key: Double dashes (--) mean there is no information to display.
------------------------ DOWNLOAD REQUEST SUMMARY -----------------------
System Request Date/Time: 04 Jan 2017 @ 0905
File Name: mhv_MAYS_20170104_0905.txt
Date Range Selected: 26 Sep 2016 to 26 Sep 2016
Data Types Selected:
My HealtheVet Account Summary
VA Notes
--------------------- MY HEALTHEVET ACCOUNT SUMMARY ---------------------
Source: VA
Authentication Status: Authenticated
Authentication Date: 18 Apr 2014
Authentication Facility ID: 506
Authentication Facility Name: VA ANN ARBOR HEALTHCARE SYSTEM
VA Treating Facility Type
-------------------- ------
VBA BRLS na
VA IDENTIFY PROOFING na
VETERANS ID CARD SYSTEM na
VBA CORP na
BATTLE CREEK MI VAMC na
DEPARTMENT OF DEFENSE DEERS na
ENROLLMENT SYSTEM REENGINEERING na
AUSTIN MHV na
ST. LOUIS MO VAMC-JC DIVISION na
VA ANN ARBOR HEALTHCARE SYSTEM na
------------------------------- VA NOTES --------------------------------
Source: VA
Last Updated: 03 Jan 2017 @ 0919
Sorted By: Date/Time (Descending)
VA Notes from January 1, 2013 forward are available 3 calendar days after
they have been completed and signed by all required members of your VA
health care team. If you have any questions about your information please
visit the FAQs or contact your VA health care team.
=========================================================================
Date/Time: 26 Sep 2016 @ 1430
Note Title: C&P MENTAL DISORDERS
Location: BATTLE CREEK MI VAMC
Signed By:
Co-signed By:
Date/Time Signed: 26 Sep 2016 @ 1813
-------------------------------------------------------------------------
LOCAL TITLE: C&P MENTAL DISORDERS
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: SEP 26, 2016@14:30 ENTRY DATE: SEP 26, 2016@18:13:28
AUTHOR: EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: Mays, Franklin Eugene
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
[X] Other (please identify other evidence reviewed):
Veteran provided a copy of a letter from the Department of Health and
Human Services, dated 9/8/16, describing his occupational impairments,
which will be forwarded to the regional office.
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: **CLAIM TYPE: INCREASE ONLY
**SPECIAL CONSIDERATIONS: NOT APPLICABLE
**INSUFFICIENT EXAM: NO
Date of claim: 03/09/2016
Days pending: 170
Veteran has a power of attorney.
Please send a courtesy copy of the exam notice letter to AMERICAN LEGION
Attention C&P Service's staff - This exam request was scheduled at your
location based on the claimant's residing zip code and ERRA instructions
The Veteran will need to report for the following exam(s) unless the ACE
process is utilized. Clinician: If using the ACE process to complete the
DBQ, please explain the basis for the decision not to examine the Veteran,
and identify the specific materials reviewed to complete the DBQ. Also if
the exam is completed using ACE, please review the Veteran's claims folder
and indicate so in the exam report.
DBQ AUDIO Hearing Loss and Tinnitus
DBQ NEURO Central Nervous System
DBQ NEURO Headaches (including migraine headaches)
An in-person examination is required for the following exam(s). ACE process
must not be used to complete the DBQ.
DBQ PSYCH Mental disorders
DBQ PSYCH PTSD Initial
____________________________________________________________________________
The following contentions need to be examined:
Tinnitus
Traumatic brain injury
Headaches and visual impairment (related to: PTSD - Non-Combat)
Major depression and anxiety (related to: PTSD - Personal Trauma)
PTSD personal trauma
Major depression and anxiety (related to: PTSD - Personal Trauma)
Active duty service dates:
Branch: Army
EOD: 09/01/1994
RAD: 12/31/1996
DBQ AUDIO Hearing Loss and Tinnitus:
MEDICAL OPINION
Type of medical opinion requested: Direct service connection
Contention: Claimed Condition: tinnitus
The Veteran is claiming that his tinnitus is related to TBI.
Opinion Requested:
Is the veteran's tinnitus at least as likely as not (50 percent or greater
probability) incurred in or caused by TBI.
Please fill out the direct medical opinion template in the DBQ and review
the following tabbed evidence. Your review is not limited to the evidence
identified on this request form, or tabbed in the claims folder. If an
examination or additional testing is required, obtain them prior to
rendering your opinion.
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
POTENTIALLY RELEVANT EVIDENCE:
NOTE: Your (examiner) review of the record is NOT restricted to the
evidence listed below. This list is provided in an effort to assist the
examiner in locating potentially relevant evidence.
Tab A (DD Form 214 in VBMS): Letter - Verification of Service dated
4/30/2014
Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016
****************************************************************************
DBQ NEURO Central Nervous System:
The Veteran is service connected for traumatic brain injury which is
currently evaluated at 40%. Please evaluate for the current level of
severity of the Veteran's service connected disability. If the diagnosis
rendered is different from the disability for which the Veteran is service
connected, please indicate whether the Veteran's current diagnosis is a
progression of the service connected disability or the original diagnosis
was in error. If the diagnosis was in error, please provide a rationale
supported by the clinical evidence of record that refutes the previous exam
(s) which diagnosed the condition.
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
POTENTIALLY RELEVANT EVIDENCE:
NOTE: Your (examiner) review of the record is NOT restricted to the
evidence listed below. This list is provided in an effort to assist the
examiner in locating potentially relevant evidence.
Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016
****************************************************************************
DBQ NEURO Headaches (including migraine headaches):
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION: Direct service connection
Contention: Claimed Condition: headaches
The Veteran is claiming that "his" headaches (related to: PTSD - Non-Combat
was incurred in or caused by "his" TBI that occurred 09/01/1994 -
12/31/1996.
Does the Veteran have a diagnosis of (a) headaches (related to: PTSD - Non-
Combat) that is at least as likely as not (50 percent or greater
probability) incurred in or caused by (the) TBI during service?
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
Rationale must be provided in the appropriate section.
POTENTIALLY RELEVANT EVIDENCE:
NOTE: Your (examiner) review of the record is NOT restricted to the
evidence listed below. This list is provided in an effort to assist the
examiner in locating potentially relevant evidence.
Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016
****************************************************************************
DBQ PSYCH Mental disorders:
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION: Direct service connection
Cont
ention: Claimed Condition: PTSD
The Veteran is claiming that "his" PTSD was incurred in or caused by "his"
personal trauma that occurred 09/01/1994 - 12/31/1996.
Does the Veteran have a diagnosis of (a) major depression and anxiety
(related to: PTSD - Personal Trauma) that is at least as likely as not (50
percent or greater probability) incurred in or caused by (the) TBI during
service?
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
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.
POTENTIALLY RELEVANT EVIDENCE:
NOTE: Your (examiner) review of the record is NOT restricted to the
evidence listed below. This list is provided in an effort to assist the
examiner in locating potentially relevant evidence.
Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016
****************************************************************************
DBQ PSYCH PTSD Initial:
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.
OPINION REQUESTED: Secondary Service Connection.
Contention: Claimed Condition: PTSD
The Veteran is claiming that "his" PTSD was incurred in or caused by "his"
TBI that occurred 09/01/1994 - 12/31/1996.
Is the Veteran's PTSD personal trauma at least as likely as not (50 percent
or greater probability) proximately due to or the result of traumatic brain
injury?
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
Rationale must be provided in the appropriate section.
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.
OPINION REQUESTED: Secondary Service Connection.
Is the Veteran's major depression and anxiety (related to: PTSD - Personal
Trauma) at least as likely as not (50 percent or greater probability)
proximately due to or the result of traumatic brain injury?
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
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.
If your examination determines that the Veteran does not have diagnosis of
PTSD and you diagnose another mental disorder, please provide an opinion as
to whether it is at least as likely as not that the Veteran's diagnosed
mental disorder is a result of an in-service stressor related event.
POTENTIALLY RELEVANT EVIDENCE:
NOTE: Your (examiner) review of the record is NOT restricted to the
evidence listed below. This list is provided in an effort to assist the
examiner in locating potentially relevant evidence.
Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013
Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016
b. Indicate type of exam for which opinion has been requested: PTSD Initial
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE
CONNECTION ]
a. The condition claimed is at least as likely as not (50% or greater
probability) proximately due to or the result of the Veteran's service
connected condition.
c. Rationale: Based on clinical experience and expertise, review of VBMS
database, Virtual VA, and available records, and examination of veteran, who
presented credibly and consistently in treatment records, clinical interview
and on trauma checklist, IT IS AT LEAST AS LIKELY AS NOT that veteran meets
criteria for diagnoses of PTSD, anxiety, and depression that are caused by
or
the result of the TBI he incurred due to a parachuting accident during
training in 1995, and to is resulting educational and occupational
impairment.
Veteran was interviewed on 9/26/16 from 1:55 - 2:55 p.m.
*************************************************************************
****************************************************************************
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
Name of patient/Veteran: Mays, Franklin Eugene
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
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Post Traumatic Stress Disorder
ICD code: 309.81
Comments, if any:
Secondary to the parachuting accident that caused his TBI
diagnosis.
Mental Disorder Diagnosis #2: Other Specified Depressive Disorder
ICD code: 311
Comments, if any:
Secondary to the parachuting accident that caused his TBI
diagnosis.
Mental Disorder Diagnosis #3: Other Specified Anxiety Disorder
ICD code: 300.09
Comments, if any:
Secondary to the parachuting accident that caused his TBI
diagnosis.
Mental Disorder Diagnosis #4: Alcohol Use Disorder, Moderate-to-Severe,
In
Sustained Remission
ICD code: 303.90
Comments, if any:
Secondary to the parachuting accident that caused his TBI
diagnosis.
If additional diagnoses, describe (using above format):
Mental Disorder Diagnosis #5: Unspecified Cannabis-Related
Disorder
ICD code: 292.9
Comments, if any: In remission. Secondary to the parachuting
accident that caused his TBI diagnosis.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): TBI with Loss of Consciousness;
AD/HD, Predominately Inattentive Type; PTSD (per CPRS medical records).
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:
Veteran's diagnoses are comorbid and have overlapping features,
reducing differentiation of symptoms to speculation. His alcohol
and cannabis use disorders (in remission) were secondary.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[X] Yes [ ] No [ ] Not shown in records reviewed
d. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis:
Veteran's diagnoses are comorbid and have overlapping features,
reducing differentiation of symptoms to speculation. His alcohol
and cannabis use disorders (in remission) were secondary. Per his
review TBI evaluation, dated 9/26/16, veteran is experiencing
headaches, including migraine headaches, in addition to mental
disorders as residuals of his TBI diagnosis. His TBI examiner
opined, "It is also least least likely as not that the Veteran's
psychiatric issues are connected to his TBI. Veteran has had
moodiness, anxiety, depression, irritability, and impaired
awareness.Veteran has extensive comprehension difficulties. He has
had extensive psychiatric issues since his TBI. It is more of the
cognitive difficulties that impair working."
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 deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood
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:
Veteran's diagnoses are comorbid and have overlapping features,
reducing differentiation of social and occupational impairment to
speculation. His alcohol and cannabis use disorders (in remission)
were secondary.
c. If a diagnosis of TBI exists, is it possible to differentiate what
portion
of the occupational and social impairment indicated above is caused by
the
TBI?
[X] Yes [ ] No [ ] No diagnosis of TBI
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
Veteran's diagnoses are comorbid and have overlapping features,
reducing differentiation of social and occupational impairment to
speculation. His alcohol and cannabis use disorders (in remission)
were secondary. Per his review TBI evaluation, dated 9/26/16,
veteran is experiencing headaches, including migraine headaches,
in
addition to mental disorders as residuals of his TBI diagnosis.
His
TBI examiner opined, "It is also least least likely as not that
the
Veteran's psychiatric issues are connected to his TBI. Veteran has
had moodiness, anxiety, depression, irritability, and impaired
awareness.Veteran has extensive comprehension difficulties. He has
had extensive psychiatric issues since his TBI. It is more of the
cognitive difficulties that impair working."
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):
Veteran provided a copy of a letter from the Department of Health and
Human Services, dated 9/8/16, describing his occupational impairments,
which will be forwarded to the regional office.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
The following are history and status as related by veteran, and as
obtained from review of available records.
Veteran underwent his last C&P evaluation for mental disorders on
3/4/14. Please refer to that examination for further background
information. Veteran was born and raised in Georgia by his biological
parents, along with 1 brother. He described his upbringing as
"normal,"
and his current relationships with members of his family of origin as
"fine." He has been married for 15 years, fathering 3 children.
Overall, he described his marriage as "good," but did report
frustration and anger secondary to his TBI, adding he turns his anger
inward toward himself. He added he becomes "excited easily," leading
his wife to think he is yelling. He did say that his wife is
supportive, and that she encouraged him to give up alcohol use.
Veteran
also reported that his anxiety continues to be driven by his youngest
son, who has Down's Syndrome, resulting in "a lot of behavioral
issues." Socially, veteran reported that he still has friends from
before his accident, who live in other states, but denied making
friends since his accident. He added he has been experiencing
difficulty leaving his home.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Veteran graduated high school, describing himself as an "A, B, C
student," who was active in many sports, and got along "very good"
with
teachers and peers. He denied ever being suspended or expelled.
Veteran
also reported a Bachelor's degree from the University of Georgia,
adding he was pursuing his degree at that time in order to become an
officer in the Army. He stated he was an academic scholarship cadet,
but that his grades significantly declined after his accident in 1995.
He did say he earned his degree in History in 1998. He also has a
Bachelor's degree from the University of Michigan, Flint. His second
degree is in elementary education, finished in 2007. He stated he was
better able to focus while earning his second degree, as the class
sizes were smaller. Occupationally, veteran worked as a life guard,
and
then was offered a job with an after school program during the school
year from the same employer. He added he held this job while he was in
college the first time. After his accident, he reported that he began
using cannabis daily, cut his foot at work necessitating a drug test,
which he refused because he knew he would screen as positive. In
addition, parents started complaining that he became "too intense" and
"keyed up" with the children. Instead of firing him outright, his
employer opted to give him no more hours of work. Veteran served in
the
Army from 1994-1996. Overall, he stated he "loved it," citing a family
tradition of Army service. He added, being an officer in the Army was
"all I ever wanted to do," and stated, "My life just crumbled" after
the accident cut his military career short. Following graduation from
college, veteran went to work for a plumbing warehouse, adding he was
having difficulties with alcohol use, causing him to miss a day of
work, stating he left that job shortly thereafter. Next, he sold
insurance door-to-door. He stated he enjoyed the sense of "roaming"
and
"exploring" that job brought him, adding he was also able to learn the
history of the places he visited to sell insurance. He stated he quit
that job when he moved to Michigan in 2000. In Michigan, veteran
reported work via temporary agencies, prior to signing up for
AmeriCorps. He stated 9/11 caused him to lose interest in AmeriCorps,
and everything else, adding he was "not fired, but kindly let go."
Next, veteran attempted to further his education at Michigan State
University, but experienced difficulties due to the large class sizes,
transferring to U of M Flint (as above) after 3 semesters. He added he
attended classes three-quarters time at U of M Flint, which he stated
was also a benefit. Veteran then began student teaching. He added he
struggled in this, as he could not get along with the teacher to whom
he was assigned, had difficulty writing and organizing lesson plans,
and had problems keeping track of the students in classes. Following
an
argument with his teacher, the principal let him go. Veteran stated he
was then placed at a different student teaching location, where he
"frustrated" the teacher due to his difficulties with organization and
making other mistakes, which confused the children. At his third
student teaching placement, veteran reported that he performed better,
as the teacher to whom he was assigned was supportive, and he only
taught 1 class, which better allowed him to stay organized and
focused.
Veteran then found employment as a teacher at a charter school in
Flint, Michigan, where he remained for 5 months, prior to being asked
not to return. He explained that he was not able to remain organized
as
he was teaching Spanish to students from kindergarten - 8th grade,
adding it was "too much for me." Next, veteran taught for the Lansing
School District from 2008-2014, teaching Spanish immersion to
pre-schoolers. He added he also had to take classes to earn a specific
certification, and held that position for 2.5 years. At the same time,
he reportedly obtained a medical marijuana card, and decided to stop
taking his other psychiatric medications. He stated he lost interest
in
pre-school, and was transferred to a different program in the Lansing
School District. He stated he ultimately returned to the
pre-schoolers,
but was let go from that position because he never earned the
certification he needed. Veteran was involved in vocational
rehabilitation from 2015-2016, until increased stress lead to 2
suicide
attempts. He stated he taught classes at an independent living center
for 40 hours/week, adding he had "a lot of trouble with that." He went
on to say he felt he had "too much on his plate, and not enough time
to
think," in addition to difficulties with his youngest child. His
psychiatrist reportedly urged him to reduce his hours to 20/week or
less, with veteran moving into farming. He stated he enjoyed farming,
initially, until he experienced vertigo, and a third suicide attempt
in
July. The Social Security Administration found that veteran was not
disabled, but did find that he was experiencing symptoms of an Anxiety
Disorder, and Affective Disorder, and an Organic (memory) Disorder.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Veteran denied any pre-military involvement in mental health
treatment,
and no mental health-related conditions were endorsed on veteran's
Reports of Medical History, dated 4/14/94 or 6/21/95. Records show a
hospitalization from 9/12-9/21/95 secondary to veteran's fall. During
the course of that hospitalization, he was found to experience a fair
amount of short-term memory return, no significant long-term memory
problems, and his cerebellar activities were returning toward normal.
A
Department of the Army memo, dated 9/14/95, revealed that veteran was
involved in a serious accident on 9/12/95 when he was an ROTC cadet.
That memo noted that he hit his head, was taken to the hospital, and
diagnosed with a concussion. It was also noted on that memo that
veteran was in and out of deep sleep, not responding like he should,
could remember names but not associations, and was confused. Notes
from
Par Rehab Services, dated 4/3/07, revealed residual impairment in
spatial perception, visual memory skills, and higher level executive
functioning, all of which involved organization, prioritization,
cognitive flexibility, and an ability to move from task to task while
tolerating distractions. It was also noted the the Par examiner that
veteran was developing an increased degree of anxiety and depression
secondary to his underlying cognitive problems. He was diagnosed at
Par
with a cognitive disorder secondary to his TBI, as well as an
Adjustment Disorder with Mixed Anxiety and Depressed Mood. Records
also
show that veteran was treated for symptoms of anxiety and PTSD at
Michigan State University in 2012. Veteran underwent his last C&P
evaluation for mental disorders on 3/4/14, when he was diagnosed with
Other Specified Anxiety Disorder, and an initial TBI C&P evaluation on
3/26/14. A Hope Network Physician Treatment Note, dated 7/10/14,
reflected diagnostic impressions of mild neurocognitive disorder due
to
TBI, with attention and memory impairments, PTSD, delayed ejaculation,
and occupational impairment. He met with a VA social worker in 2014
secondary to symptoms of PTSD and TBI. He was involved in individual
psychotherapy with a VA psychologist in 2015, secondary to diagnoses
of
Anxiety Disorder NOS, Depression NOS, and a history of PTSD. Veteran
is
participating in a peer support group facilitated by a VA provider.
Veteran underwent inpatient mental health treatment from 2/9-2/17/15.
A
letter found among he electronic records, penned by Dr. Dykema on
6/22/16, noted a TBI due to a parachuting accident during ROTC in
1995,
which was diagnosed in 2007. Dr. Dykema also noted that veteran is
experiencing significant impairment in occupational functioning, as he
is "unable to work to expectations in numerous past jobs." In
addition,
Dr. Dykema found that veteran felt overwhelmed by responsibility, and
described chronic depression and anxiety symptoms due to education
and
occupational difficulties secondary to his TBI. Dr. Dykema also noted
a
hospitalization in 2015, secondary to suicidal ideation, revealing
that
he has attempted suicide on numerous occasions. Dr. Dykema diagnosed
veteran with depression and anxiety secondary to his TBI. Veteran is
currently prescribed Sertraline HCL and Lisdexamfetamine Dimesylate
(Vyvanse, for AD/HD). He stated counseling has been good, as it gives
him someone to talk to, adding his inpatient treatment was also
helpful. He was uncertain about medication management, citing his 3
suicide attempts over the last year.
NOTE: Veteran's records show that he is currently flagged as being at
high risk for suicide.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Denied.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
Veteran reported that his alcohol use became problematic following his
parachuting accident, stating, "I couldn't handle it the way I could."
He added alcohol had a bigger impact on him following the accident,
but
stated he used alcohol in an attempt to make himself "numb." He
described himself as a "binge drinker," consuming a half-gallon of gin
during a given weekend. He denied alcohol use since 2000. Veteran also
reported that he began using cannabis following the accident, stating
he never wanted to use that substance prior. Following the accident,
he
thought, "Why not?" He stated cannabis calmed him down, and distracted
him from thoughts of the accident and its' resulting limitations. He
reportedly held a medical marijuana card for 2 years, but began to
feel
that cannabis "made things worse." As a result, he stated he quit the
use of cannabis in 2012. He denied the use/abuse of any other
substances.
f. Other, if any:
Subjective Report of Symptoms:
Veteran reported that he experiences panic, triggered by what he has
forgotten or has not done. He also reported sadness, due to the
accident, and its' impact on his teaching career. Veteran also noted
feelings of guilt, due to his unemployment. He added he also wonders
about the status of his VA claims. During times of increased stress,
veteran reported that he smells the odor of burning cannabis. In
addition to the panic described above, veteran reported anxiety
triggered by unexpected loud noises, surprises (including unexpected
touching from his family), feeling like his TBI is getting worse
(stating the harder he tries the worse it gets), and the future. He
reported daily panic attacks, for which he uses cognitive behavioral
and breathing techniques learned in treatment. Veteran reported 3
suicide attempts over the last year, via carbon monoxide poisoning
(x2)
and overdose on medications. He denied any current plan/intent to harm
himself, reporting a "scale" of "45%" suicidal ideation vs. "55%"
desire to live. He denied homicidal ideation. He described his
appetite
as "fine." At night, veteran reported that he was prescribed Trazodone
during his last evaluation, which has allowed him to feel better
rested. When his sleep is interrupted, he stated the Trazodone allows
him to more easily return to sleep. Despite his medication, he
reported
that he will sometimes wake up and think about all he has done wrong
or
is not good at. He also reported dreams, which he described as being
like "impressions" of his impact with the ground, adding he
experiences
goose bumps when they occur. Veteran denied flashbacks, stating he
"tries not to think about it." Regarding his memory, veteran reported
that he makes lists and write things down.
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: Veteran reported that he remembers his first training jump,
thinking, "Wow...I'm still here." He went on to describe vague
memories
of being on the aircraft and or taxying down the runway for his second
jump, and then nothing further until waking up in the hospital. In the
hospital, veteran reported that he remembers having some
conversations,
but did not trust that memory, as he also remembered speaking to his
deceased grandmother at that time.
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:
Training accident, as evidenced by Army and hospital records
describing his parachuting accident.
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 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] 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] 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 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
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[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
[X] Difficulty in adapting to stressful circumstances, including work or
a
worklike setting
[X] Suicidal ideation
6. Behavioral Observations
--------------------------
Veteran is a 42 year old, Caucasian male, who presented early for
evaluation,
casually dressed and appropriately groomed. He was alert and fully
oriented.
He was able to correctly spell "WORLD" forward and backward. He was not able
to accurately complete serial 7s (e.g., "100-93-86-79-73-67"). He was able
to
recall 2/3 words after delay, which did not improve with prompting. He was
cooperative with the assessment process. Veteran's mood and affect were
dysphoric and anxious. He displayed good eye contact. Veteran's speech was
reflective of anxiety, but spontaneous and goal-directed. His thought
processes were generally organized with no evidence of hallucinations,
delusions, mania, or obsessive-compulsive features. He appears to be of
average intelligence, with capacity for abstract thought, and fair insight
into his emotional functioning.
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:
Testing Results:
The PTSD Checklist- 5 (PCL-5) was administered to gauge current
signs and symptoms of traumatic stress. Currently, there are no
normative data available for the PCL-5, and the instrument was
completed as a self-report measure of the severity of reported
PTSD
symptoms. Veteran endorsed the following symptoms as bothering him
Extremely: Feeling very upset when something reminded him of the
stressful experience; Trouble remembering important parts of the
stressful experience; Having strong negative beliefs about
himself,
others, or the world; Blaming himself or someone else for the
stressful experience or what happened after; Being "super alert"
or
watchful or on guard; Feeling jumpy or easily startled; and
Trouble
falling or staying asleep.
Veteran endorsed the following symptoms as bothering him Quite A
Bit: Repeated, disturbing, and unwanted memories of the stressful
experience; Suddenly feeling or acting as if the stressful
experience were actually happening again; Having strong physical
reactions when something reminded him of the stressful experience;
Avoiding memories, thoughts, or feelings related to the stressful
experience; Avoiding external reminders of the stressful
experience; Having strong negative feelings such as fear, horror,
anger, guilt, or shame; Loss of interest in activities he used to
enjoy; Feeling distant or cutoff from others; Trouble experiencing
positive feelings; Irritable behavior, angry outbursts, or acting
aggressively; and Having difficulty concentrating.
Veteran endorsed the following symptom as bothering him
Moderately:
Taking too many risks or doing things that could cause self-harm.
The remaining symptom was endorsed by veteran as bothering him A
Little Bit (e.g., Repeated, disturbing dreams of the stressful
experience).
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
Integrated Summary and Clinical Impressions:
Veteran is a 42 year old, married Caucasian male, who received a TBI
following a parachuting accident in 1995. Results of current examination
revealed evidence of signs and symptoms of PTSD, depression, and anxiety,
secondary to his TBI, and resulting educational and occupational
limitations. His accident has also contributed to social functioning, as
veteran denied making any new friends since his accident. The above
symptoms were more likely than not present at the time of his last C&P
evaluation for mental disorders in 2014. Veteran also reported a pattern
of heavy alcohol, as well as cannabis, use since his TBI, both of which
are in states of sustained remission. Prognosis for substantial
improvement of psychiatric symptoms and functional status is guarded, due
to veteran's TBI symptoms, exacerbated to his symptoms of PTSD, anxiety,
and depression, resulting in an ongoing reciprocal relationship between
TBI and mental health sequelae, as attested to by medical documentation
since his accident, and his current flag as being at high risk for
suicide.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
/es/ Joseph C Bolton, PsyD
Psychologist
Signed: 09/26/2016 18:13
-------------------------------------------------------------------------
=========================================================================
Date/Time: 26 Sep 2016 @ 1230
Note Title: C&P MENTAL DISORDERS
Location: BATTLE CREEK MI VAMC
Signed By:
Co-signed By:
Date/Time Signed: 26 Sep 2016 @ 1347
-------------------------------------------------------------------------
LOCAL TITLE: C&P MENTAL DISORDERS
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: SEP 26, 2016@12:30 ENTRY DATE: SEP 26, 2016@13:47:16
AUTHOR: EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Name of patient/Veteran: Franklin Eugene Mays
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
SECTION I: Diagnosis and medical history
----------------------------------------
1. Diagnosis
------------
Does the Veteran now have or has he/she ever had a traumatic brain injury
(TBI) or any residuals of a TBI?
[X] Yes [ ] No
[X] Traumatic brain injury (TBI)
ICD code: S06.2 Date of diagnosis: Sep 12, 1995
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's TBI and
residuals attributable to TBI (brief summary):
On Sept 12, 1995 the Veteran suffered a parachute accident. He landed
hard
and was unconscious for 10-15 minutes. He had dizziness, headache, and
vision problems when he woke up. He was noted to have cerebellar
dysfunction which was noted by balance issues and confirmed by a MRI. He
was taken to Fort Benning, Georgia hospital where he was hospitalized
from
Sept 12 to Sept 21, 1995. He was diagnosed with a closed head injury,
mild
Diabetic insipidus, and Cranial nerve IV bilaterally. He also was noted
to
have mild edema of the left parietal lobe and cerebellum. He was placed
on
light duty until his discharge 2 years later. He has continued to have
vertigo, balance problems, memory dysfunction, problems organizing tasks.
He went to to Hope Network in 2011 where he was treated. He was treated
extensively for cognitive dysfunction from his TBI. He also had problems
anxiety, substance abuse, and depression requiring treatment. He was
diagnosed again with continued problems with his TBI in 2007 b by Dr
Fabiano. He currently is prescribed wellbutrin 450mg XL po qam. He was on
Vivance 70mg per day until He stopped it recently. He is on Trazadone
25mg
po qhs.
SECTION II: Assessment of facets of TBI-related cognitive impairment and
subjective symptoms of TBI
-----------------------------------------------------------------------------
1. Memory, attention, concentration, executive functions
--------------------------------------------------------
[X] Objective evidence on testing of moderate impairment of memory,
attention, concentration, or executive functions resulting in moderate
functional impairment
If the Veteran has complaints of impairment of memory, attention,
concentration or executive functions, describe (brief summary):
He has extensive testing at Hope Network which ahs shown short term
memory dysfunction. He also has had post traumatic amnesia for the time
around the head injury.
2. Judgment
-----------
[X] Normal
3. Social interaction
---------------------
[X] Social interaction is occasionally inappropriate
If the Veteran's social interaction is not routinely appropriate,
describe (brief summary):
He lives with his wife and 3 children, ages 12, 10, and 8. After the
military to college, struggling with classes, and he barely finished his
degree. He is applyng for socially security disability. He has been
having trouble with maintaining his teaching ceritificate credits. He
was
having trouble performing the needed skills. He also has received
support
from Michigan rehabilation services. He has been in job jeopardy for a
while. Both Michigan VA and the VA rehab services do not feel that he is
employable due to the extent of his cognitive deficits from his TBI.
4. Orientation
--------------
[X] Always oriented to person, time, place, and situation
5. Motor activity (with intact motor and sensory system)
--------------------------------------------------------
[X] Motor activity is normal most of the time, but mildly slowed at times
due
to apraxia (inability to perform previously learned motor activities,
despite normal motor function)
If the Veteran has any abnormal motor activity, describe (brief
summary):
He has had jerks and cleched jaw reflexes since the head injury that was
noted after the head injury on Oct 12, 1995 by Dr David R Rivera, MD, a
Ophthamology who also noted some memory dysfunction, decreased stamina,
bliateral 4th cranial nerve palsies, balance problems, and cogwheel
pursuit.
6. Visual spatial orientation
-----------------------------
[X] Moderately impaired: Usually gets lost in unfamiliar surroundings, has
difficulty reading maps, following directions, and judging distance. Has
difficulty using assistive devices such as GPS (global positioning
system)
If the Veteran has impaired visual spatial orientation, describe (brief
summary):
Veteran gets lost periodically. He went to the wrong building before he
got to this appointment.
7. Subjective symptoms
----------------------
No response provided.
8. Neurobehavioral effects
--------------------------
[X] One or more neurobehavioral effects that occasionally interfere with
workplace interaction, social interaction, or both but do not preclude
them
If the Veteran has any neurobehavioral effects, describe (brief
summary):
Veteran has had moodiness,a nxiety, depression, irritablity, and
impaired
awareness.
9. Communication
----------------
[X] Comprehension or expression, or both, of either spoken language or
written language is only occasionally impaired. Can communicate complex
ideas.
If the Veteran is not able to communicate by or comprehend spoken or
written language, describe (brief summary):
Veteran has extensive comphrension difficulties.
10. Consciousness
-----------------
[X] Normal
SECTION III: Additional residuals, other findings, diagnostic testing,
functional impact and remarks
-----------------------------------------------------------------------------
1. Residuals
------------
Does the Veteran have any subjective symptoms or any mental, physical or
neurological conditions or residuals attributable to a TBI (such as migraine
headaches or Meniere's disease)?
[X] Yes [ ] No
[X] Headaches, including Migraine headaches
[X] Mental disorder (including emotional, behavioral, or cognitive)
2. Other pertinent physical findings, scars, 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?
[X] Yes [ ] 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
3. Diagnostic testing
---------------------
a. Has neuropsychological testing been performed?
[ ] Yes [X] No
b. Have diagnostic imaging studies or other diagnostic procedures been
performed?
[ ] Yes [X] No
c. Has laboratory testing been performed?
[ ] Yes [X] No
d. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
see records from VBMS which extent the extent of his cognitive deficits
due to his TBI.
4. Functional impact
--------------------
Do any of the Veteran's residual conditions attributable to a traumatic
brain
injury impact his or her ability to work?
[X] Yes [ ] No
If yes, describe impact of each of the Veteran's residual conditions
attributable to a traumatic brain injury, providing one or more examples:
Veteran has had significant difficulty due to his TBI. Job jeopardy for a
while, now on long term disability.
5. Remarks, if any:
-------------------
No remarks provided.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: Franklin Eugene Mays
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
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Does the Veteran continue to have a TBI
with
associated headaches??
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 in-service injury, event
or
illness.
c. Rationale: It is least likely as not that Veteran has a TBI with
associated headaches, mood disturbances, anxiety, and depression. On Sept
12,
1995 the Veteran suffered a parachute accident. He landed hard and was
unconscious for 10-15 minutes. He had dizziness, headache, and vision
problems when he woke up. He was noted to have cerebellar dysfunction which
was noted by balance issues and confirmed by a MRI. He was taken to Fort
Benning, Georgia hospital where he was hospitalized from Sept 12 to Sept 21,
1995. He was diagnosed with a closed head injury, mild Diabetic insipidus,
and Cranial nerve IV bilaterally. He also was noted to have mild edema of
the
left parietal lobe and cerebellum.He was placed on light duty until his
discharge 2 years later. He has continued to have vertigo, balance problems,
memory dysfunction, problems organizing tasks. He went to to Hope Network in
2011 where he was treated. He was treated extensively for cognitive
dysfunction from his TBI. He also had problems anxiety, substance abuse, and
depression requiring treatment. He was diagnosed again with continued
problems with his TBI in 2007 b by Dr Fabiano. He currently is prescribed
wellbutrin 450mg XL po qam. He was on Vivance 70mg per day until he stopped
it recently. He is on Trazadone 25mg po qhs. He has extensive testing at
Hope
Network which ahs shown short term memory dysfunction. He also has had post
traumatic amnesia for the time around the head injury. He lives with his
wife
and 3 children, ages 12, 10, and 8. After the military to college,
struggling
with classes, and he barely finished his degree.
He is applyng for socially security disability. He has been having trouble
with maintaining his teaching ceritificate credits. He was having trouble
performing the needed skills. He also has received support from Michigan
rehabilation services. He has been in job jeopardy for a while. Both
Michigan
VA and the VA rehab services do not feel that he is unemployable due to the
extent of his cognitive deficits from his TBI. Veteran gets lost
periodically. He went to the wrong building before he got to this
appointment.
It is also least least likely as not that the Veteran's psychiatric issues
are connected to his TBI. Veteran has had moodiness,anxiety, depression,
irritablity, and impaired awareness.Veteran has extensive comphrension
difficulties. He has had extensive psychiatric issues since his TBI. It is
more of the cognitive difficulties that impair working. He has had jerks and
clenched jaw reflexes since hte head injury that was noted after the head
injury on Oct 12, 1995 by Dr David R Rivera, MD, a Ophthamology who also
noted some memory dysfunction, decreased stamina, bliateral 4th cranial
nerve
palsies, balance problems, and cogwheel pursuit. I also recommend an Eye
exam.
*************************************************************************
****************************************************************************
Headaches (including Migraine Headaches)
Disability Benefits Questionnaire
Name of patient/Veteran: Franklin Eugene Mays
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 headache
condition?
[X] Yes [ ] No
[X] Other (specify type of headache): mixed
ICD code: R51 Date of diagnosis: sept, 1995
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
headache conditions (brief summary):
Sept 21, 1995. He was diagnosed with a closed head injury, mild
Diabetic
insipidus, and Cranial nerve IV bilaterally. He also was noted to have
mild edema of the left parietal lobe and cerebellum. He was placed on
light duty until his discharge 2 years later. He has continued to have
vertigo, balance problems, memory dysfunction, problems organizing
tasks. He went to to Hope Network in 2011 where he was treated. He was
treated extensively for cognitive dysfunction from his TBI. He also had
problems anxiety, substance abuse, and depression requiring treatment.
He was diagnosed again with continued problems with his TBI in 2007 b by
Dr Fabiano. He currently is prescribed wellbutrin 450mg XL po qam. He
was on Vivance 70mg per day until he stopped it recently. He is on
Trazadone 25mg po qhs.
b. Does the Veteran's treatment plan include taking medication for the
diagnosed condition?
[X] Yes [ ] No
If yes, describe treatment (list only those medications used for the
diagnosed condition):
Headache meds make him groggy,
3. Symptoms
-----------
a. Does the Veteran experience headache pain?
[X] Yes [ ] No
[X] Constant head pain
[X] Pulsating or throbbing head pain
[X] Pain on both sides of the head
b. Does the Veteran experience non-headache symptoms associated with
headaches? (including symptoms associated with an aura prior to headache
pain)
[X] Yes [ ] No
[X] Nausea
[X] Changes in vision (such as scotoma, flashes of light, tunnel vision)
c. Indicate duration of typical head pain
[X] Less than 1 day
d. Indicate location of typical head pain
[X] Both sides of head
4. Prostrating attacks of headache pain
---------------------------------------
a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating
attacks of migraine / non-migraine headache pain?
[X] Yes [ ] No
If yes, indicate frequency, on average, of prostrating attacks over the
last several months:
[X] With less frequent attacks
b. Does the Veteran have very prostrating and prolonged attacks of
migraines/non-migraine pain productive of severe economic inadaptability?
[ ] Yes [X] No
5. 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?
[X] Yes [ ] 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.
6. Diagnostic testing
---------------------
Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
7. Functional impact
--------------------
Does the Veteran's headache condition impact his or her ability to work?
[X] Yes [ ] No
If yes, describe the impact of the Veteran's headache condition, providing
one or more examples:
It is more of the cognitive difficulties that impair working.
8. Remarks, if any:
-------------------
No remarks provided.
Staff Psychiatrist
Signed: 09/26/2016 13:47
-------------------------------------------------------------------------
=========================================================================
Date/Time: 26 Sep 2016 @ 1100
Note Title: C&P AUDIOLOGY EVALUATION
Location: BATTLE CREEK MI VAMC
Signed By:
Co-signed By:
Date/Time Signed: 26 Sep 2016 @ 1401
-------------------------------------------------------------------------
LOCAL TITLE: C&P AUDIOLOGY EVALUATION
STANDARD TITLE: AUDIOLOGY C & P MULTIPLE EXAM NOTE
DATE OF NOTE: SEP 26, 2016@11:00 ENTRY DATE: SEP 26, 2016@14:01:46
AUTHOR: EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Hearing Loss and Tinnitus
Disability Benefits Questionnaire
Name of patient/Veteran: Mays, Franklin E
0567
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
[X] Other (please identify other evidence reviewed):
Self reported history:
Chief complaint: Bilateral constant tinnitus, most noticeable in quiet
settings, onset following TBI for which he is service connected. He
is
uncertain about hearing loss but does report difficulty hearing others
at a distance.
Situations of greatest difficulty: concentration problems and
awareness problems with tinnitus, bothersome only in quiet. Hearing
trouble at a distance.
Pertinent Service History: US Army 8-1994 to 12-1996, ROTC non- combat.
MOS: AIT training only, qualified for weapons training. Place and
Condition of claimed hearing disturbance: Parachute accident during
ROTC training, hit back of head and suffered LOC for several minutes,
hospitalized. Diagnosed with mild TBI.
Military noise exposure: training weapons. M16 rifle, field field
artillery training with Howitzers and W/Raps.
Occupational noise exposure: teacher 2008-2015, currently on
disability. Prior to this denied any industrial or hazardous noise
exposure vocational history.
Recreational Noise exposure: lawn care equipment < 1hour with HPDs,
some power tool use and chainsaw operation with HPDs.
Medical/Health History:
Negative for the following: perforated TM, familial hearing loss,
vertigo, temporary/sudden changes in hearing and all other on history
form. Positive for: ear infection 1985, head injury with LOC during
military service ROTC training, equilibrium problems he feels is
related to TBI, history of alcohol abuse for 5 years, medication use
for anxiety, depression, hospitalized for suicide attempt 2016.
Evidence Comments:
VBMS review:
Review of Record: EOD 9-1-1994 RAD 12-31-1996 non-combat
11-9-2012 Statement in support of claim:The current symptoms of
disability
that I am aware of are as follows Head Injury possible TBI with secondary
conditions of depression and anxiety
Psychology/Neuro: CH[closed head injury] Sept 1995 Please evaluate
Martin Army Comm Hospital 9-12-1995, injury during a parachute landing
fall- Closed head injury.
12-12-1995 severe concussion due to hard PLF
Admission note 9-12-1995 to discharge 9-21-1995
6-21-1995 Apppointment Report of ME
REF audiogram 6-23-1995
500 1000 2000 3000 4000 6000Hz
R 15 05 05 00 00 25dBHL
L 15 10 05 05 05 20dBHL
5/5/1994
R 05 05 10 05 10 15dBHL
L 05 00 05 10 15 15dBHL
AA C&P exam TBI -Neuropsych Does the Veteran have any subjective
symptoms
or any mental, physical or neurological conditions or residuals
attributable to a TBI (such as migraine
headaches or Meniere's disease)?
[ ] Yes [X] No Has neuropsychological testing been performed?
[X] Yes [ ] No
Results:
There is no mention of anxiety associated with his military-related
parachuting accident until 2007, though that appeared to be remitted
by 2009.
His current mild anxieties are related to the assault he sustained in
2011; therefore, his current diagnosis of Other Specified Anxiety Disorder
is less than likely as not (less than 50/50 probability) caused by or a
result
of his military service and there is no evidence to suggest that his
current
anxieties were aggravated by his past parachuting accident.
to determine if he sustained a mild vs. moderate TBI given the lack of
records but suspected that it may have been moderate in severity. the vet
did see opthy in 1995 and was noted to have bilat cn4 palsy which which was
noted to resolve in a 1996 follow up visit.
the vet did complete 2 college degrees since his injury. during today's
routine neuropsychometric testing, he performed worse than the 2007 eval
noted in VBMS. He scored high in anxiety during today's eval. Based on his
history, repeated neuropsychmetric evals, and the natural history of TBI,
is
is less likely than not that his current issues are related to his TBI
history
Capri ROTC cadet
6-28-2014 10-10 REg. PCP note, HEEnT no hearing problems.
TBI consult 10-24-2014 Patient has mild hearing difficulty
A lengthy discussion was held with the patient regarding our impressions,
consistent with our C&P evaluation in March, and the medical record. We
described the expected trajectory of recovery from a mild to moderate TBI
without brain bleed, reviewed his imaging history, his educational
history,
and spent a considerable time talking about the influence of anxiety, PTSD
and
his symptoms associated with PTSD in significantly interfering with
cognitive
performance.
He was attentive to this discussion, did not raise objections, although
clearly
was a bit uncomfortable with a notion that he does not suffer with
lingering and
permanent brain damage. He raised his history of ongoing TBI
care outside of the VA, and we acknowledged our difference of opinion with
these practitioners.
Further, we reiterated that he should have made a good recovery from his
concussion, and that he is had at least 3 or 4 years of repeated cognitive
rehabilitation both in speech and OT so that he has had comprehensive
rehab
services. He is currently working with MRS re school job placement.
The patient has a strong attribution of his head injury as a permanent
cause
for his functional deficits.
As a telling example of his symptom presentation, he volunteered at the
conclusion of our discussion that he has been having a pressure type
feeling
around the side and top of his head "since my injury", but also
volunteered
that
"for many years I never noticed it but then recently someone suggested to
me
that I could have pain from my head injury and then I noticed it".
7-28-2014
1. Traumatic brain injury with loss of consciousness
2. Attention deficit hyperactivity disorder, predominantly inattentive
type
3. Posttraumatic stress disorder secondary to a mugging
9-7-2016 AA VAMC ENT
He reports spinning vertigo since June. Exacerbated by hot temperatures
while
working on a farm. Bending down and picking things up freque
ntly caused a
pressure headache and dizziness. He also reports a separate sensation
described
as objects in the environment moving up and down. He also recently felt
unsteady while walking up a bridge. Associated increase in ringing
tinnitus
occurrs at times centrally. He started taking trazodone in July and also
takes
pyshotropic drugs Bupropion and Lisdexamfetamine dimesylate. H/o TBI and
loss of
consciousness for 5-15 minutes. Denies fluctuations in hearing,
associated
aural pressure, h/o ear surgery, otalgia. + h/o ear infection in
childhood.
Episodes have significantly decreased over the last month since stopping
work on
the farm, and now typically only occur outside while exerting himself in
the
heat. Impression: Possible psychotropic drug side effect causing nystagmus
creating
difficulty focusing eyes leading to mild limiting dyesquilibrium with
walking
over a bridge lately. No audiological symptoms to suggest peripheral
cause to
dizziness, but he does have b/l tinnitus. Also consider h/o TBI as
contributing
factor.
This exam is for: Tinnitus only (audiologist or non-audiologist clinician)
SECTION 2: TINNITUS
--------------------
1. Medical history
------------------
Does the Veteran report recurrent tinnitus: Yes
Date and circumstances of onset of tinnitus: The veteran reported
bilateral tinnitus, noticeable in quiet settings only. He did report
that
he notices the tinnitus whenever he concentrates on it. This report is
consistent with constant non-bothersome tinnitus.
The veteran reported tinnitus following head injury during military
service. The veteran has a longstanding diagnosis of TBI due to a
parachute/fall incident during Army ROTC training.
2. Etiology of tinnitus
-----------------------
At least as likely as not (50% probability or greater) due to a known
etiology (such as traumatic brain injury).
Etiology and rationale: The medical records reviewed were silent for c/o
tinnitus following TBI injury in 1995 and all STRs silent for tinnitus
complaint. Late onset tinnitus is unlikely due to noise exposure and the
veteran had negative report of acoustic trauma from military service.
However, tinnitus is related to head injury and the veteran's STRs have
longstanding history of TBI. Therefore, tinnitus is at least as likely as
not due to head injury diagnosed and presently service connected.
However,
besides TBI the veteran has had significant alterations in personality and
behavior, including anxiety and depression, all he believes is due to his
TBI injury. However, clinical notes from C&P neuropsychology exam below
suggest that the veteran's anxiety was due to an assult in 2011, following
military service.
AA VAMC Neuropsych exam C&P There is no mention of anxiety associated with
his military-related parachuting accident until 2007, though that appeared
to be remitted
by 2009. His current mild anxieties are related to the assault he
sustained
in
2011;
The veteran has some concerns today about his disequillibrium and was more
than surprised when examiner indicated that late onset vertigo or
disequillibrium due to head injury is uncommon and veteran may instead be
suffering from medication side effects. Previous notes from AA VAMC
Neuropsychologist would suggest that the veteran is pre-occupied with the
notion that he has a lifetime head injury and lingering permanent brain
damage. In fact today the veteran indicated that he is sure that he has
had multiple head injuries since the parachute accident, because he was
told that from a TBI you can sustain multiple head injuries.
The veteran is well versed in TBI symptomology.
The veteran's dysequillibrium may be a side effect of drug interactions
according to ENT note, AA VAMC 9-7-2016 or TBI contributing factors.
For this reason the veteran is filing a claim for his imbalance. He was
assisted with this by examiner today to file for ear condition with ENT
and
a balance evaluation with a specialized audiology department. Battle
Creek
VAMC does not conduct balance evaluations. The veteran should be evaluated
by posturography at the very least.
3. Functional impact of tinnitus
--------------------------------
Does the Veteran's tinnitus impact ordinary conditions of daily life,
including ability to work: Yes
If yes, describe impact in the Veteran's own words: Only noticeable in
quiet environments.
4. Remarks, if any, pertaining to tinnitus:
-------------------------------------------
the above report would suggest non-bothersome tinnitus. Veteran was
advised to use sound management in quiet settings to reduce awareness of
tinnitus.
C&P request dated 8-26-2016. The veteran is claiming tinnitus is related
to TBI.
In regard to hearing loss: No hearing loss found on exam. Comparing
first exam 1994 to last exam REference exam 6-1995 no STS noted for
either
ear. Today's hearing thresholds slight hearing change noted for left ear
today, unrelated to military service noise exposure or head injury.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
Signed: 09/26/2016 14:01
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