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Togore101

Seaman
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About Togore101

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  1. I read over it several times and I seen were they could deny the claim for an increase but im hoping for the best. @Grumpbox I definitely been trying not to pay any attention to it right now but something also tells me to look LOL, but i have gotten better with it. @L @Buck52 @Grumpbox thank you all for taking a look and i appreciate the feedback. I will let you guys know the outcome when i get it. Eben saying it will be between May and July. You all have a good day.
  2. I was in the Air Force six years. my MOS MP (Security Forces). Depolyed Iraq 2010. My current rating is 90% s/c. Honorable discharge. Going for increase in combat related PTSD. Injuries are below nequal leg length (acquired) 0% Service Connected 06/04/2014 post traumatic stress disorder with mood disorder NOS Active Psychosis/GW Mental left hip strain, claimed as nonallopathic lesions of pelvic region 10% Service Connected 06/04/2014 congenital foot deformity condition Not Service Connected bilateral hearing loss condition Not Service Connected plantar fasciitis, bilateral feet, claimed as plantar fasciitis, left foot 10% Service Connected 06/04/2014 scar, painful, residuals, right side of nose, claimed as laceration to face condition 10% Service Connected 06/04/2014 right wrist strain, claimed as right wrist pain 10% Service Connected 06/04/2014 scar, facial 0% Service Connected 06/04/2014 intervertebral disc syndrome (IVDS), claimed as low back degenerative disk disorder, nonallopathic lesions of lumbar region and sacral regions 20% Service Connected 06/04/2014 pseudofolliculitis barbae 0% Service Connected 06/04/2014 obstructive sleep apnea (OSA), claimed as sleep apnea with CPAP 50% Service Connected 06/04/2014 chipped toe and toe hallux limitus conditions Not Service Connected PTSD (post traumatic stress disorder) 50% Service Connected PTSD - Combat 07/06/2015 left wrist strain 10% Service Connected 06/04/2014 radiculopathy, involvement of the sciatic nerve, left lower extremity 20% Service Connected 06/04/2014 radiculopathy, involvement of the sciatic nerve, right lower extremity 10% Service Connected 06/04/2014 tinnitus 10% Service Connected 06/04/2014
  3. Hello everyone I am new to the site. And I recent submit a the dbq for an increase for my PTSD and I trying to understand it but im just not getting it. So I figured would ask you all. Below is what the examiner put in the record. Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: ========= Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: F43.1 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.1 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 [ ] No [X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity 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 Evidence Comments: MENTAL HEALTH OUTPATIENT FOLLOW UP NOTE [excerpts] DATE OF NOTE: MAR 05, 2018 AUTHOR: ========,NP NURSE PRACTITIONER CHIEF COMPLAINT: "same old same old" INTERVAL HISTORY: Veteran is here for 6 week follow up for PTSD, Alcohol Use Disorder, unspecified, episodic. At last appointment, low dose venlafaxine was added, aripiprazole, prazosin, and melatonin were continued. He reports symptoms are about the same. His wife is pregnant with twins, so he is trying to minimize arguments at home. He worries he will not be able to connect with the babies, because he struggled so much with his daughter and points to her persistence as the reason they are close now. He see no change in sleep, remains irritable, and more hypervigilant due To recent car break ins on his street. He has cut down on drinking, and denies any binges since last appointment. He continues to have fleeting SI, but denies intent. He often has thoughts of hurting others, but strongly denies acting on the thoughts. No recent hallucinations. He does talk to himself when he is trying to work something out, but denies hearing voices other than his own. It can be embarrassing as coworkers and wife have caught him. ASSESSMENT AND TREATMENT PLAN GOALS: DSM 5 Diagnostic Impression PTSD Alcohol Use Disorder, Unspecified, episodic Goals: 1. Decrease irritability and anger- does not interfere with home or work life more than one time per month, ongoing, improving 2. Improve feeling of connection with others- enjoying and developing relationships, ongoing, no change 3. Decrease avoidance of social situations/crowds- can tolerate Wal Mart, enjoy outings with family, ongoing, no change 4. Improve sleep- no difficulty falling asleep, sleep 6 to 8 hours nightly, ongoing, worsening PLAN AND PROGRESS TOWARDS TREATMENT PLAN GOALS: reviewed records and discussed options - increasing venlafaxine to 75 mg - continuing aripiprazole, prazosin, and melatonin - suggested individual supportive counseling at the Vet Center after Dr. Bhatia leaves. - monitoring labs at next appointment - Will continue to follow closely. RTC 6 weeks/PRN 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Last C&P PTSD DBQ May 2016 Lives in Moncks Corner, SC with wife of 9 years and daughter age 4. Daily routine: Lay down for bed 2100. Will fall asleep 2300. Wake frequently. "I have to do certain things to calm down. I need my gun next to me. I have to check the house make sure its locked. Make sure the alarm is on. If I hear something, it wakes me right up and I have to check it out." +Nightmares, night sweats. "Sometimes I'm swinging and yelling and talking in my sleep, so my wife leaves for a different room. I wake up and she's not there and it freaks me out." Prescribed melatonin for sleep, prazosin for nightmares. Abilify for PTSD. Diagnosed sleep apnea by sleep study in 2013, prescribed CPAP and is compliant. Relationship with wife: "We almost got divorced a few times. She didn't understand what was going on. She started reading up on it. The whole reason I went to mental health was because of her." Relationship with daughter: "She is scared of me. She has seen me Snap a few times. She is on guard. She doesn't know if I'm going to be up or down. She is my heart. She is the only thing that makes me feel normal." Will watch cartoons and read books together. Hobbies: play basketball, go to gym "but now I just sit in the House watch TV or just in the room." Likes anime. Support: father "he's been with me through everything." And is Veteran too, wife "but there is a wall there where I don't open up." b. Relevant Occupational and Educational history: Working for passport services for 3 years. "Its rough at times. There's a lot of people in there. They had to move my seat because I'm too jumpy. They moved it so I'm not around a lot of people. It is hard to focus. I have to use sticky notes. They have been pretty supportive. I've had good supervisors." Was counselled about days missing for work; "I had a blow up at my co-workers so they spoke to me about that." Miss 2-3 days per month. "When I get to work, I drive around the Building and if I see something I don't like, I just go home." Military history: E4, MP, Separated 2014, Honorable, Served about 6 years. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mental health treatment with prescriber and therapist. No history of hospitalizations. Was in group therapy "but I didn't like it." d. Relevant Legal and Behavioral history: "When I was in Japan I got us into trouble because of my alcohol abuse. I got into a car accident and hit 3 cars." Was sent to ADAP for anger and PTSD. A month ago got into a physical altercation with sister's boyfriend "I laid hands on him. So then I went to a hotel room and stayed there and then I went on a drink binge." e. Relevant Substance abuse history: Alcohol - "I abused it really bad. My PCM said it was affecting My liver." Was drinking4-5 25 oz beers, drink a bottle of liquor over The weekend. Now will drink 1-2 beers. Tobacco - 2-3/day Denies other substances. f. Other, if any: Current reported symptoms: Anger: "I black out and become very violent. I knock TVs off walls. My wife was ready to leave me." Triggers: "foggy day and rain." "Ignorant and stupid people." Social avoidance. "If a car is behind me too long, I start to think he is following me. There is a particular truck that I know and he gets too close to me. I got sick of it and one day I followed him home. I didn't do anything, but I blacked out mad. I knew I needed help." Flashbacks - "I was shopping with my wife, and this guy had a turban on his head and I thought I was back there. Its constant, its all the time." Hygiene - "My wife got on my because I went a week without washing And I didn't even realize it." Suicide - "I thought about driving into traffic at the light. One Time I sped up and got on railroad tracks when a train was coming. I thought, what am I doing? I went into store parking lot." Reports this occurred 2 weeks ago. "I keep a picture of my daughter in the car to keep me from [doing it]." 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors). 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 #6 - "Other symptoms". 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) [X] Witnessing, in person, the traumatic event(s) as they occurred to others Criterion B: Presence of (one or more) of the following intrusion Symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing Memories of the traumatic event(s). [X] 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] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause 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. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Flattened affect [X] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Suicidal ideation [X] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Neglect of personal appearance and hygiene 5. Behavioral observations -------------------------- Veteran was open and forthright with no evidence of exaggeration or feigning symptoms. Affect blunted. Minimal eye contact. Speech regular rate, tone, volume. Thought process linear, logical, goal directed. Thought content absent for delusions, hallucinations, paranoia or HI. Endorses SI with no active plan, but drove car onto train tracks last week. Discussed safety, crisis line, Veteran has MHC appointment next week. Veteran reports safety to return home today. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- PCL-5 score 72, indicating probable diagnosis of PTSD. Veteran continues to meet criteria for PTSD. He reports social withdrawal, sleep problems, memory problems, irritability, anger that is both verbal and physical, suicidal thoughts. He has work accommodations because of his PTSD symptoms. He misses several days of work a month because of his symptoms.
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