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Found 146 results

  1. I filed my NOD four years ago, next month. Still waiting for a decision from the DRO. I am wondering how long other Veterans here, have been waiting for an answer on their RO Appeal.
  2. I am currently rated at 50% for PTSD and just had my C&P exam for an increase. Below is my current C&P results. Also I suffer from Major Depression and Erectile Dysfunction due to my medication. Could these two items be filed as secondary since the examiner did not list them in my C&P exam.Any input would be appreciated on to what my outcome may be. Thank you SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD, moderate to severe, chronic Comments, if any: The trauamtic event was learning that a close friend of his killed two older female civilians. PTSD also causes secondary panic attacks 2-3 times per week. 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 ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: On 11/25/2014, Dr. XXX conducted a C&P Initial Evaluation for PTSD and diagnosed the veteran with PTSD with panic attacks. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Mr. XX is currently married to his wife of 10 years. He describes the quality of his current marriage as, "loving - but my wife puts up with me." He reports his irritability and anger can stress his wife. He adopted his wife's 14 year old daughter. He reports he has no friends of his own, but he reports he is friendly with many of his wife's friends. He tends to avoid crowds and group social activities. He is quite close with his parents. His main hobby is drumming and working on computers. Overall his social support is limited. He reports that the primary effect of his psychiatric symptoms on his social relationships are tension and distance caused by irritability, rage (including yelling, swearing, and very occasional violence towards inanimate objects - like punching a hole in the door), withdrawal, and emotional numbing. b. Relevant Occupational and Educational history: Mr. XXX highest level of education is some college. He served in the Airforce. He is currently employed as a cyber security analyst at XXX a telecommunications company called XXX. He has worked at XXX since 2011. In 2012, he was written up for "going off on a customer." He reports he works from home or calls in sick 4-5 days a month due to feeling stressed. He reports during times of stress he impulsively loses his temper when talking with customers or makes careless mistakes. He is a lead, and he has five other analysists who report to him. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mr. XXX denied history of psychiatric hospitalization, receiving out-patient therapy, receiving any type of psychopharmacological treatment, or prior suicide attempts. He has been referred to a psychiatrist by his PCP but he is not currently engaged in therapy. He receives medication management from his private PCP, and he is currently maintained on a regimen of Zoloft, hydroxyzine, prazosin and diazepam. d. Relevant Legal and Behavioral history: No arrests. Received an article 15 in the military after he learned of the murders. e. Relevant Substance abuse history: No response provided. f. Other, if any: No response provided. 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 Criteria 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 violation, in one or more of the following ways: [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 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). 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] 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] 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] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 5. Behavioral Observations: --------------------------- Mr. XXX was casually dressed, and was cooperative throughout the examination. His speech was fluent. His psychomotor behavior was appropriate. His affect was constricted and his mood was anxious. His insight was intact. Thought process was linear, goal directed, and future oriented. No reported hallucinations or delusions. No reported homicidal or suicidal ideation. 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: --------------------------------------------------- Veteran's PTSD and panic attacks currently cause moderate socio-occupational impairment.
  3. I filed a claim sometime in early October for an increase of my PTSD, a foot injury, as well as put in for 2 new conditions and one secondary condition. While I am largely very happy with how the claims for my physical disabilities has gone (my examiner told me within the first 5 minutes he was going to connect me for all the new stuff and that I rated an increase for the foot issue - after that I just had to actually do the C&P! My PTSD exam and resulting DBQ however were not nearly as smooth as my other C&P's had gone. Honestly I was actually kind of shocked when I finally got around to pulling it off myhealthevet and reading it. A big reason I was so surprised is that as far as "evidence" goes I've been piling it up over the last year. To get to how this all went down I have to run it back a little bit and explain my situation. I ran into a rough time around February of last year...... So I had my big sob story all typed up and then chickened out. Sufficed to say that I lost everything. Not only did I lose my wife and kids, I lost the dream property we had worked so hard to get to. I just walked away from it, I couldn't bring myself to walk back into the cabin. I literally just left everything I'd worked for the last 6 years of my life at 9,000 feet on the side of a mountain and just walked away. Sufficed to say I crashed and burned really hard. For about 3 weeks I spent every waking moment doing everything I could to make the pain go away, up to and including multiple attempts at OD'ing. I finally was able to get my wits together, did some searching online and ended up in a VA domiciliary program in Texas. While I've never identified myself as a drug addict, I definitely needed some help getting the wheels back on so the first thing I did was enroll myself in a 45 day substance abuse program. After that I was able to put in 3 1/2 months of inpatient trauma treatment, followed by 2 months of inpatient PTSD treatment. It's been about 9 months but I'm glad I did it, I honestly don't think I would have made it through to the New Year if I hadn't come here. Anyhow, after 9 months of inpatient therapy which included almost 6 months of trauma/PTSD treatment, daily group meetings, twice weekly counselor/psychologist one on ones, and intensive medication programs to help me through everything, I kinda thought I had a decent chance of getting an increase from 30%. I've tried for increases in the past but I haven't been the most consistent person over the years. I have a hard time following through on treatment and in addition to that due to having a non-combat trauma I haven't had a very easy time getting the VA to accept my diagnosis, at least on the disability side. The treatment side has no issue with it. Anyhow, like I said I had hope because in the past I had been told that I wasn't getting increases in my rating because I wasn't following through on treatment and because of that it made it difficult for me to build much of a case. Everything was simply my word as to how things were, or how I was getting by, but I didn't have anyone respectable to back me up about the things that I was going through and the troubles I have. So this leads me to my most recent C&P/DBQ. I've cut out a decent amount of personal information and trauma narrative stuff, but the meat and potatoes should be in there for anyone that's familiar with these things. I've been service connected since 2004 and my trauma is most definitely legitimate. I really hope there's a possible sunny side to all of this. I've done a massive amount of googling over the last few days and I've seen posts where people say that just because the examiner says one thing doesn't mean that's the direction the rater is going to go with things. I'm really discouraged right now. I've had a very contentious relationship with the VA for a long time. I have a very hard time trusting the VA anymore. I've had some very bad caregivers who were telling me one thing to my face while shredding me in their notes after I'd left (We have access to those you know....) One LCSW in particular went out of here way to push a personality disorder diagnosis on me, essentially getting the diagnosis put in my chart by filling up my psychiatrist with a lot of crap; all the while telling me how much she was trying to help me. Now here I am again. I feel like I'm really getting the short end of the stick by the VA and in particular this examiner, after I did have a pretty awesome doctor for my physical C&Ps and lord knows I'm not the first one to get the un-greased by the wonderful VA. That being said I'm just frustrated because I've really put in so much effort into my recovery and treatment. I'm working the DBT, mindfulness and challenging beliefs far more than I'm comfortable with, but I'm doing it. Anyhow I went from erasing my sob story to writing a whole new one. Thanks for taking the time to read through this and pass on any info/experience/ideas you might have. Thanks in advance, OGG The following is an excerpt from another thread I started about a DBQ for my back that ended up digressing a little. I figured there's no reason to type it all out again new so I just copy and pasted the "important" parts. Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire SECTION I: --------------------- 1. Diagnostic Summary -------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses: ------------------- Mental Disorder Diagnosis #1: PTSD Mental Disorder Diagnosis #2: Cannabis Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #3: Alcohol Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #4: Inhalant Use Disorder, In Early Remission, In a Controlled Environment Alright I'm definitely not proud of the huffing. All I can say is that my life had fallen to pieces. My wife took my kids and left me while I was getting the car fixed overnight. She filed false abuse charges against me to keep me from the kids. I'm no saint but I never abused my wife or my kids. Up until this moment I hadn't had a drink in 5 years... I just smoked pot - which I was prescribed. Also I think this would be a good time to put what my actual working diagnosis list for a little bit of contrast. This list was pulled straight off my myhealthevet file and reflects 9 months of inpatient treatment. I can't help but feel like this lady was snowballing me. Yes there's some overlap. What's the difference between PTSD and Chronic PTSD? I don't know. Why do I have 2 types of insomnia DX'd? I don't know that either. #1)Chronic post-traumatic stress disorder (SCT 313182004) #2)Posttraumatic stress disorder (SCT47505003) #3) Anxiety (SCT 48694002) - symptom of PTSD #3) Depressive disorder (SCT 35489007) - symptom of PTSD #4) Insomnia (SCT 193462001) - symptom of PTSD #5) Psychophysiologic insomnia (SCT 425832009) - symptom of PTSD #6) Cannabis dependence (SCT 85005007) #7) Alcohol dependence (SCT 66590003) 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? [X] Yes[ ] No[ ] Not applicable (N/A) I have a problem with this part. Just how is she going differentiate between my various diagnosis which all are attributed to the PTSD? (besides the substance abuse issues) 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. I have a problem with this as well. I haven't been able to work in 6 years. I've tried but it always ends up being a failed attempt. I usually end up getting myself too worked up about social situations, get too depressed to get out of bed, get fired for being late because I have serious sleep problems which sometimes lead me to not being able to wake up for my alarm, etc etc. In addition I barely go out. Hell I went out of my way to move 10 miles from the closest power poll 9,000' above sea level just to find myself some peace. I can't handle large groups, I psych myself out when I'm out at night, I see danger and trouble everywhere. Anyhow back to getting smeared. 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? [X] Yes[ ] No[ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Symptoms of PTSD and substance use contribute to social and occupational impairment. However, symptoms of PTSD have not increased in severity since the veteran's last C&P exam in 2013. A quick side note A: I've been in a treatment facility for almost a year now, I'm pretty sure my "substance abuse" isn't contributing to my issues. I smoked cannabis medicinally and I don't even drink. Why do I smoke pot because it helps with my PTSD as well as a laundry list of other issues. That being said I've been "clean" for a year now. So... now that she's basically said I barely have PTSD, and my troubles are simply because I'm a drug addict, let's get on to the next section. 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 Criteria 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 violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).d [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to 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 to 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. That last one is my favorite! Not only does she say that my disturbances are NOT attributable to substances be it medication or drugs nor are they attributed to another medical condition. She also manages to manages to assess me with 20 out of 24 possible sub-criteria or disturbances in the diagnosis of PTSD. I'm sure I'm reading into this wrong and I can't look at things like this but that certainly feels like more than 30% disabling. I dunno. 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 6. Other symptoms ---------------- In this section she just goes about telling whatever version of my life story she could piece together from old treatment records. Spends a lot of time on the fact that I smoke pot, that I didn't have a relationship with my father and various other fun facts that do a lot to distract you from the lack of a cohesive narrative or making any of what she wrote mean anything as far as the DBQ goes. She doesn't list a single "other symptom" like the line below talks about. She just kinda makes me out to be a flaky loser. 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? [ ] Yes[X] No At this point she pulls out some more fun facts from my medical record. She says that "I frequently go on spending sprees", and brings up how when I was 25 and got my first backpay check and I blew it on fun stuff like a car, and a computer and whatnot (I was single going to university at the time). What this cluck of a woman doesn't see in her precious computer is that other than my time here at the VA facility I'd been able to support my wife and two kids on my 50% SC. Trust me there's no spending sprees going on there. 8. Remarks, (including any testing results) if any: -------------------------------------------------- Psychological Testing: A test of response bias specifically related to PTSD symptoms was administered to the veteran during this examination to assess the credibility of his self report. The name of this measure is withheld in this report in order to protect the integrity of the test. This test was specifically standardized on a sample of veterans applying for financial remuneration for a claim of disability resulting from PTSD. The veteran's score on this test was below the established cutoff, indicating that his performance was consistent with individuals responding in a valid manner. As such, he did not appear to be intentionally exaggerating signs and symptoms of PTSD or attempting to appear worse off that he actually is. Ahh what a finish eh? I think she should spend less time worrying about my credibility and a little more about hers. Well, last but not least let's hear her final word on the subject: Signed: 10/30/2015 13:35 11/03/2015 ADDENDUM STATUS: COMPLETED PTSD is less likely than not a result of military duties. /es/ Her Name Goes Here, PSYCHOLOGIST Signed: 11/03/2015 15:22 So yeah that's essentially where I'm at. I'm just hoping that whoever rates my PTSD takes what she says with a grain of salt and also takes time to look at the 1200 pages of treatment records I've added to my medical record in the last year as well as the weakly psychologist appointments, 20 page typed trauma narrative, the countless notes that were put in on my behalf. I hope they also see the weekly PCL-5s averaging between 65 and 72, the by weekly CAPs averaging around 66, the PHQ9 score of 23, the gad-7 score of 20 - All of which were administered by a Doctor or LCSW. Yah I've got this one too; World Health Organization Disability Assessment Schedule 2.0 Cognition: 75 Mobility: 12 Self-care: 70 Getting along: 83 Life activities (household): 100 Life activities (work/school): 85 Participation: 79 Summary: 70 *Range is 0 to 100 where 0 indicates no disability and 100 means full disability I realize I'm probably putting too much hope into all of this. I know that the disability tests and rating exams probably don't amount to anything as far as determining anything with the VA. If the particular examiner is up on their stuff they might know the significance of the WHODAS 2.0 or put stock in the CAPs screening but really they don't have to look at them at all. Hopefully at the very least I can use all I've put together to apply for SSDI. If you've gotten this far thank you so much for reading my rant and hopefully pulling out the important bits from what I did post of my DBQ. Hopefully I haven't over edited it but I just didn't think what she wrote was particularly applicable to the questions that the DBQ was asking and I generally feel she was just trying to prove out whatever she had come to believe based on small glimpses of my medical record. I really wish I had been afforded the opportunity to address some of the conclusions she was making about me and the picture she was painting.
  4. Hello everyone, I wanted some help with my recent exam, because it seems to me that she addressed all my NSC's but never touched my SC issues?! I have a DBQ from an IMO as well. The link below will take you to the exam. I am open to any advice. C&P 02-14-18
  5. After going over my progress notes from c&p I noticed some answers to questions that had different answers that I gave. For instance he said i have tingling down my left leg and not my right leg. After seeing my medical records and knowing how both my legs feel I'm wondering why he said one leg and not both. I know i told him both legs experience about the same amount of pain. I was awarded 10% for my left leg and nothing for my right leg. How shall I confront this issue?
  6. Hey I'm new to the forum and really need help trying to understand what my last C&P means for my rating.. I have been waiting on this since 2010 on appeal and finally got a C&P after remand to RO. Can anyone tell me what possible rating I might receive Semper Fi. Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No Evidence Comments: BOARD REMAND 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No Cervical Spine Common Diagnoses: No diagnosis provided. Diagnosis #1: CERVICO-OCCIPITAL NEURALGIA ICD code: == Date of diagnosis: 9/28/2015 Diagnosis #2: CERVICAL RADICULOPATHY WITH BULGING DISC ICD code: == Date of diagnosis: 2016 Diagnosis #3: MECHANICAL CERVICAL PAIN SYNDROME ICD code: == Date of diagnosis: 4/29/2015 If there are additional diagnoses that pertain to cervical spine (neck) conditions, list using above format: CERVICAL VERTEBRAE(NECK MUSCLE SPASM), DATE OF DIAGNOSIS, 6/25/1996. CERVICAL HERNIATED AND BULGING DISC, MUSCLE SPASM, AND CORD CONTUSION WITH COMPRESSION MYELOMALACIA, 8/14/12 CERVICAL SPONDYLOSIS AND DEGENERATIVE DISC DISEASE, 9/25/2014. On today's C&P examination, 11/21/17, Veteran reports several incidents in 1992-1995 of blunt trauma including carrying 50 caliber machine gun barrels and ammunition. Involved in ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Also went to Bethesda for back school(approx. week). Currently, Veteran reports daily neck pain. Denies neck surgery. Denies no recent physical therapy. Uses Flexeril, Ibuprofen, Oxycodone, and Tens unit for pain relief. Last treated by chiropractor in 2016(Tampa Bay, Florida). b. Dominant hand: [ ] Right [ ] Left [X] Ambidextrous c. Does the Veteran report flare-ups of the cervical spine (neck)? [ ] Yes [X] No d. Does the Veteran report having any functional loss or functional impairment of the cervical spine (neck) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: Can't do much of any type of physical activity, that's really limited. Obviously a hindrance, job related stuff. Multiple days off from work(pain, stiffness). Can't do lawn activities. Can't wash dishes. Can't play with your kids like you want to. Sleeping is impossible-Sometimes you have to sleep sitting up in a chair. 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0-45): 0 to 46 degrees Extension (0-45): 0 to 15 degrees Right Lateral Flexion (0-45): 0 to 23 degrees Left Lateral Flexion (0-45): 0 to 14 degrees Right Lateral Rotation (0-80): 0 to 48 degrees Left Lateral Rotation (0-80): 0 to 44 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: Limited bending. Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Forward flexion, Extension, Right lateral flexion, Left lateral flexion, Right lateral rotation, Left lateral rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine (neck)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Tenderness on palpation of the cervical spine. b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [ ] Yes [X] No If no, please provide reason: Unable to perform due to severe pain. c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent nor inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: This examiner is unable to opine and would otherwise be speculating to state whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Therefore this examiner cannot describe any such additional limitation due to pain, weakness, fatigability or incoordination. Furthermore, such opinion is also not feasible to give degrees of additional ROM loss due to "pain on use or during flare-ups" without speculation. d. Flare-ups Not applicable e. Guarding and muscle spasm Does the Veteran have guarding, or muscle spasm of the cervical spine? [X] Yes [ ] No Muscle spasm [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Guarding [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Less movement than normal due to ankylosis, adhesions, etc. Please describe: Decreased ROM. 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Elbow flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Elbow extension Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Abduction Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [X] Yes [ ] No If muscle atrophy is present, indicate location: Upper Arm Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk: Normal side: 37.5 cm. Atrophied side: 36 cm. 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatomes) testing: Shoulder area (C5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Hand/fingers (C6-8): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No If yes, complete the following section: a. Indicate location and severity of symptoms (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of C8/T1 nerve roots (lower radicular group) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 8. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 9. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities related to a cervical spine (neck) condition (such as bowel or bladder problems due to cervical myelopathy)? [ ] Yes [X] No 10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the cervical spine? [X] Yes [ ] No b. If yes to question 10a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 12. Remaining effective function of the extremities ---------------------------------------------------- Due to a cervical spine (neck) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. 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? [ ] Yes [X] 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. 14. Diagnostic testing ---------------------- a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No b. Does the Veteran have a vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. 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): 9/25/2014,MRI Cervical spine:Visibility of the central canal of the cord at the C5 level with diameter of 2mm, not considered to reflect significant syringohydromyelia and not associated with mass or abnormal enhancement. Spondylosis and degenerative disc disease of the cervical spine. Right-sided predominant disc osteophyte complex at C6-7 causes mild right central canal and moderate right neural foraminal stenosis at this level. No other central canal stenosis with milder areas of neural foraminal encroachment detailed above. C2-3:Focal shallow central to right paracentral disc protrusion. No central canal or neural foraminal stenosis. C3-4:Mild generalized disc bulge. Mild right than left neural foraminal stenosis with central canal patent. C6-7:Mild generalized disc bulge with more focal disc osteophyte complex in the right paracentral, right subarticular, and right lateral stations. C7-T1:Negative for disc herniation. 8/14/2012, MRI Cervical spine:Herniated disk C3/4, C5/6, and C6/7 levels. Bulging disk C2/3 and C4/5 levels. Diffuse spondylitic changes. Straightened alignment suggesting muscle spasm. Focal area of cord contusion or compression myelomalacia at C5 level. 15. Functional impact ---------------------- Does the Veteran's cervical spine (neck) condition impact on his or her ability to work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's cervical spine (neck) conditions, providing one or more examples: Veteran is capable of limited lifting, carrying, and bending. 16. Remarks, if any: -------------------- NOTE:Veteran performed neck flexion repeition which reduced ROM to 32deg. Unable to perform any further repetition for other ROM maneuvers. ************************************************************************* Additional exam request information: For any joint condition, examiners should test the contralateral joint, unless medically contraindicated, and the examiner should address pain on both passive and active motion, and on both weightbearing and non- weightbearing. In addition to the questions on the DBQ, please respond to the following questions: 1. Is there evidence of pain on passive range of motion testing? YES 2. Is there evidence of pain when the joint is used in non-weight bearing? YES **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: 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 Evidence Comments: BOARD REMAND MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: (a) Please state all diagnoses as to the Veteran's cervical spine, and address all diagnoses already of record: herniated disk and bulging disk of the cervical spine and spondylitic changes, muscle spasm and contusion/compression, spondylosis and degenerative disc disease of the cervical spine, mechanical cervical pain syndrome and radiculopathy. (b) Please provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed cervical spine disability was caused by or etiologically related to active duty. Please specifically address the back injuries and complaints of back pain noted in the STRs. (c) Please specifically address the Veteran's lay statements that he has suffered cervical spine pain since service, and that in service he suffered injury to his neck while carrying heavy equipment and continuous wear of duty gear. (d) Please address the conflicting evidence of record and offer a clarifying opinion, notably the February 2013 VA examination positing a negative nexus, and the April 2016 private opinion positing a positive nexus. b. Indicate type of exam for which opinion has been requested: NECK 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: Upon review of all available medical evidence, including eVBMS, virtual VA, and Board Remand, the following pertinent information is obtained and reported in 'Evidence Comments': Prior VA Examination, 6/25/96, reports Mr. served in the Marine Corps. he was inducted in 1990 and received separation with an honorable discharge in 1996. Medical History-In 1992, he had onset of pain in the neck area diagnosed at Quantico. Xrays were negative. Impression was muscle spasm and stress. Enlistment RME/RMH for national guard, 4/13/98, reported no neck problems and normal exam of the spine. Miami VAMC, Outpatient clinic, 5/6/2005:Assessment is chronic neck and low back pain-Will get plain films and MRI, does not want any meds. 2/28/2013, VA examination opines "Unable to find SMR evidence of significant neck injury or complaint in service. No evidence to support chronicity of problem for over 10 years post-discharge." THIS OPINION IS GIVEN LOW WEIGHT BECAUSE IT IS NEITHER SUPPORTED NOR CONSISTENT WITH THE RECORDS IN FILE THAT SHOW COMPLAINTS OF NECK PAIN INDICATING A CHRONIC CONDITION. 4/29/15, DBQ neck was completed providing a diagnosis of mechanical cervical pain syndrome and radiculopathy. As received 4/8/16, VA physician, , states that the Veteran suffers from cervico-occipital neuralgia and cervical radiculopathy with bulging disc "are as likely as not a direct result of blunt trauma received during the patient's military career. His conditions are a severe occupational impairment to the veteran and has been exacerbated by many years of continuous wear of duty gear related to his profession." On today's C&P examination, 11/21/17, Veteran is a credible historian and reports several incidents in 1992-1995 of blunt trauma, involving ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Veteran also reported chronic neck pain during service was due to carrying 50 caliber machine gun barrels and ammunition. He also went to Bethesda for back school(approx. week). In summary, the Veteran has been under chronic medical care for neck pain first reported during service(6/25/96) and the condition has progressed from cervical muscle spasm to mechanical cervical pain syndrome and radiculopathy, cervical herniated and bulging disc with muscle spasm, cord contusion/compression myelomalacia, cervical spondylosis and degenerative disc disease, cervico-occipital neuralgia, and cervical radiculopathy with bulging disc. A nexus has been established. Therefore, it is at least as likely as not that the claimed condition has direct service connection.
  7. When I logged in ebenefits it shows they have reviewed the document they requested (C&P exam request). Now there is a new request for me this time. It says they are requesting my service medical records. I submitted all of these already when I submitted my claim online. Do I resubmit the documents I already submitted online? I have to request my C&P exam/ cray results since I dont have a premium account. Wouldn’t they have already reviewed my medical records before the exam? Not sure if this order of things is a bad sign or good sign about the way the claim is shaping. it looks like they are requesting my original medical service records. Not sure why they allow you to upload them if they want the originals. I thought they would have done this very first thing.
  8. I have some questions and wondering what some of your observations are. I had a c and p exam recently and got ahold of the DBQ. All the boxes the doctor checked were good for me. She checked all the right boxes and checked that I had PTSD and all the symptoms they went with it but in some of the comments she made, they seem really bad. So I'm wondering what matters more, the doctors observations or the boxes she checked? I'm rated at 60% currently with anxiety NOS and Tinnitus. I did not initiate the exam for an increase. It was one of the random c&p to see how things are going. This is from the PTSD initial DBQ that she filled out 1) yes 2) PTSD, paranoid personality disorder with avoidant features, other specified anxiety disorder with depressive symptoms 3) a. Yes. B.no 4.) A.Occupational and social impairment with deficiencies In most areas work, school , family relations...etc B. Yes--most impairment is attributed to PTSD and anxiety disorder with paranoia secondary. Under PTSD criteria she checked 2 in A, 3 in b, 2 in c, 6 in D and 4 in E . 6) Argumentative and irritable veteran who is hiding behind his wife and looks at her instead of the examiner; has poor eye contact; unable to tolerate questions without interrogating examiner about "meaning" of question; makes people want to avoid him due to his paranoid arguing. Hopeless attitude; does not accept hopeful comments; arrogant and appears to think he knows more than others; thinking was designed to perceived threat, not to answer questions; emotional overactivity; exaggerated affect; affect constricted; everything annoys him; meds do not touch symptoms and he does not sleep; problems with lack of trust. 7) " he may be playing this up out of a desire to avoid working at jobs that are low pay---he has no job skills and comes from a highly educated family --father is lawyer, sister a geophysicist; he may prefer the sick role, rather than go back to school and stretch himself; there is an element of malingering and playing to an audience." I found this highly offensive because I've been going to the VA for at least 5 years. I didn't initiate the exam so I'm not trying to get more money. However, I wasn't honest in my first c&p in 2011 because I was ashamed and held back a lot of the really bad things I experienced. This time around I made sure that I was brutally honest. I know that I'm supposed to tell them about my "worst" day and how bad it really is and I did. And now my sincerity is questioned? The lady was incredulous that my wife married me even though I didn't have a job and still don't. I said that I don't believe I can work which I don't think that I can because I barely can stand to leave the house and that I hate being around people because I'm constantly thinking in my head that I'm going to be attacked or have to attack someone else. I also don't sleep, I have diagnosed insomnia from the VA. Because of all this I don't think I'd be able to hold down a serious job. Is that crazy? I haven't worked in a long time. I stay at home and take care of our kids. I said something like at least I can feel useful like that. The woman seemed stunned by this. I'll admit I was extremely uncomfortable during the exam because I hate talking about this stuff and prefer to not think about it. And she interpreted it in the way above. Her comments seem contradictory to all of the boxes she checked. If I'm "malingering and playing to an audience" why did she check all of the other boxes? It's driving me crazy. This feels really bad for me. I'm having anxiety attacks almost daily thinking about this. Am I crazy to worry about how this will turn out for me? This woman was in her late 70s or early 80s. The exam was through VES and was done at her in home practice
  9. I have some questions and wondering what some of your observations are. I had a c and p exam recently and got ahold of the DBQ. All the boxes the doctor checked were good for me. She checked all the right boxes and checked that I had PTSD and all the symptoms they went with it but in some of the comments she made, they seem really bad. So I'm wondering what matters more, the doctors observations or the boxes she checked? I'm rated at 60% currently with anxiety NOS and Tinnitus. I did not initiate the exam for an increase. It was one of the random c&p to see how things are going. This is from the PTSD initial DBQ that she filled out 1) yes 2) PTSD, paranoid personality disorder with avoidant features, other specified anxiety disorder with depressive symptoms 3) a. Yes. B.no 4.) A.Occupational and social impairment with deficiencies In most areas work, school , family relations...etc B. Yes--most impairment is attributed to PTSD and anxiety disorder with paranoia secondary. Under PTSD criteria she checked 2 in A, 3 in b, 2 in c, 6 in D and 4 in E . 6) Argumentative and irritable veteran who is hiding behind his wife and looks at her instead of the examiner; has poor eye contact; unable to tolerate questions without interrogating examiner about "meaning" of question; makes people want to avoid him due to his paranoid arguing. Hopeless attitude; does not accept hopeful comments; arrogant and appears to think he knows more than others; thinking was designed to perceived threat, not to answer questions; emotional overactivity; exaggerated affect; affect constricted; everything annoys him; meds do not touch symptoms and he does not sleep; problems with lack of trust. 7) " he may be playing this up out of a desire to avoid working at jobs that are low pay---he has no job skills and comes from a highly educated family --father is lawyer, sister a geophysicist; he may prefer the sick role, rather than go back to school and stretch himself; there is an element of malingering and playing to an audience." I found this highly offensive because I've been going to the VA for at least 5 years. I didn't initiate the exam so I'm not trying to get more money. However, I wasn't honest in my first c&p in 2011 because I was ashamed and held back a lot of the really bad things I experienced. This time around I made sure that I was brutally honest. I know that I'm supposed to tell them about my "worst" day and how bad it really is and I did. And now my sincerity is questioned? The lady was incredulous that my wife married me even though I didn't have a job and still don't. I said that I don't believe I can work which I don't think that I can because I barely can stand to leave the house and that I hate being around people because I'm constantly thinking in my head that I'm going to be attacked or have to attack someone else. I also don't sleep, I have diagnosed insomnia from the VA. Because of all this I don't think I'd be able to hold down a serious job. Is that crazy? I haven't worked in a long time. I stay at home and take care of our kids. I said something like at least I can feel useful like that. The woman seemed stunned by this. I'll admit I was extremely uncomfortable during the exam because I hate talking about this stuff and prefer to not think about it. And she interpreted it in the way above. Her comments seem contradictory to all of the boxes she checked. If I'm "malingering and playing to an audience" why did she check all of the other boxes? It's driving me crazy. Am I crazy to worry about how this will turn out for me? This woman was in her late 70s or early 80s. The exam was through VES and was done at her in home practice
  10. I'm currently rated 100% schedular (non P&T) for a single medical condition with a follow up C&P exam scheduled for early 2019. I have no open claims at the moment. My condition is managed through a private doctor. Would it be a good idea for me to send my doctor visit records to the VA so that they can see continued evaluation for the condition? ...Or is it better to wait until the C&P exam and show my documentation to the examiner? Sending the records seemed like a good idea at first, but then I wondered if that's like poking the VA with a stick - maybe they'll decide to move my C&P exam up. Any advice is appreciated. Thanks!
  11. Hi Folks Had a C&P for lower back injury related to MST in 1975. C&P examiner a PHD/PA with an impressive resume also retired Rear Admiral filed his report less likely than not a couple of weeks ago. The report was full of misspellings, information discrepancies and a lie or two! This gentleman had me on the wrong ship, took very poor notes and many of the doctors I've seen as well as dates & times totally wrong. He tried to dispute my IMO from Dr David Anaise by saying I never told Dr Anaise I had a motorcycle accident after my separation from the Navy, that was an outright lie and I had the proof in emails that in fact I did tell Dr Anaise about the motorcycle accident. It's clearly obvious this PA pencil whipped this report and hit send, does anyone think my IMO will carry more weight than this sloppy inadequate C&P report? I have uploaded a rebuttal to my ebenny case file. Thanks Rob
  12. How's it going fellow vets, I am writing in reference to my up coming C&P exam. I submitted my claim on August 30 and just recieved a call from the VA to schedule my C&P exam for GERD/Hiatal hernia, Asthma and Severe Sleep Apnea. I am currently rated at 30% sc for asthma. Has anyone taken any of these exams? What should I expect? How can I prepare myself for the exam and questioning? Has anyone had to deal with the VA hospital In Manhattan? Just looking for whatever advise I can get, thanks.
  13. Hello all! So I was browsing around E-Benefits a few days ago and came across my digital C&P exam on my BlueButton list. The Doctor checked the "Total social and occupational impairment" box. What are the odds of that translating to me getting a 100% rating? Thanks for any and all help. - Phil
  14. Just looked up my C&P exam results from Wednesday (6 Sept). Trying to figure out the results. It seems there may be an error in the first "B" and "C". Any thoughts? Thank you in advance. TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: Based on interview and examination of the Veteran, review of the Veteran's VBMS case file, review of the Veteran's VHA medical records, and review of relevant medical references the Veteran's LEFT hips conditions as described in the Hip Conditions DBQ are as least likely as not (50% or greater probability) incurred during his military service as documented as complaints of LEFT hip pain & assessment of LEFT iliotibial band syndrome are documented in his STRs. As directed nexus is reasonably demonstrated the secondary nexus question proximally is rendered moot. 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 interview and examination of the Veteran, review of the Veteran's VBMS case file, review of the Veteran's VHA medical records, and review of relevant medical references the Veteran does not have current symptoms of plantar fasciitits. His current symptoms are attributable to LEFT cuboid syndrome. The Veteran's LEFT cuboid syndrome is as likely as not (50% or greater probability) proximately due to or the result of leg length discrepancy due to altered gait biomechanics caused by the leg length discrepancy.
  15. I just submitted my first claim for PTSD from MST. When I was overseas, I was on guard duty was an infantryman. When in a guard tower, he exposed his penis and started playing with it. He was looking at me and wanted to me "help" him out. We were locked and loaded so I was fearful on what this man was going to do next. I just froze. I told his SGT and he was detained and sent back to garrison. The rules changed and I was looked at a different way since the incident. There was no touching but this incident has impacted my life and my sense of security. I'm fearful of everything and what's worse is that it's now effecting my children and my marriage and that's why I'm now filing. I haven't talked about it openly with my friends and now I'm expected to talk about it with a stranger for my c&p appointments? Any advice on what to expect and how long the whole process take.
  16. What weight would a private psychologist have on my claim for PTSD. The VA keeps ducking saying it was due to childhood trauma. I am trying to get them to admit it exasperated any preexisting condition. I had a Top Secret Clearance from 92 to 96 and would (back n those days) NEVER received it with any hint of mental issues. I feel if I can get a professional to say this into my medical record I might have a fighting chance. I have been denied twice I think. Link for so many of us it has been a long journey... Thoughts? Also does anyone know of a Veteran friendly Private Psychologist in South West Florida?
  17. I received my C&P over the weekend. My exam was nearly three hours and I think the report is accurate and fair and represents how things are. I was as honest as I could be with the examiner and despite being nervous to the point of an anxiety attack about it the day before calmed down a bit and was OK during the visit. The doctor did a good job asking questions and made me feel at ease which is saying something. The report ended up being 18 pages which surprised me. I had PMd the results to a handful of people here on HADIT and a couple recommended I post it for more input. I was hesitant to do so but decided my desire for more information is more important than my paranoia of posting it. I'd really like to get the opinions of some senior HADIT posters like Berta and others. I'm thinking this is a good C&P for my claim but would like a more seasoned opinion than my own completely inexperienced one. I've posted the opinion and rationale below. . Thank you. JW. ___________________________________ 5. Symptoms For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Chronic sleep impairment [X] 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] Suicidal ideation REQUESTED OPINION: Based on information from the clinical interview, review of records (C-file and VA medical records), and psychological assessment measures, It is my opinion that the veteran meets DSM-5 diagnostic criteria for (1) Post-Traumatic Stress Disorder (PTSD) due to childhood sexual trauma with delayed onset, and (2) Major Depressive Disorder (MDD), Recurrent, with Mood-Congruent Psychotic Features secondary to PTSD. While his PTSD and MDD were less likely than not to have been caused by an in-service stressor, both conditions were more likely than not incurred in service (i.e., delayed onset with clinically significant symptom presentation beginning while on active duty). PSYCHOLOGICAL ASSESSMENT / OBJECTIVE TESTING: Objective psychological assessment measures administered: -- Personality Assessment Inventory (PAI): valid profile without any evidence to suggest inattention, inconsistency, or negative/positive impression management; primary code type - DEP/ARD (97T/85T) * Summary/interpretation of results: Briefly, the veteran's responses on the PAI were suggestive of significant tension, unhappiness, and pessimism, with various stressors (past and/or present) contributing to low mood and self-esteem. Individuals with similar profiles often see themselves as ineffectual and powerless to change the direction of their lives and feel uncertain about goals, priorities, and what the future may hold. In addition to depression, the veteran endorsed significant distress on measures of suicidal thoughts, traumatic stress, and social discomfort or detachment. His profile was most consistent with major depression, and while some traumatic stress concerns were indicated, he did not endorse the full range of concerns typically seen among individuals with PTSD. RATIONALE FOR OPINION: 1. The veteran's symptoms meet DSM-5 diagnostic criteria for PTSD due to childhood sexual trauma. The veteran's history of childhood sexual abuse is well-documented across multiple sources and during the current evaluation, he endorsed the full range of trauma-related symptoms meeting criteria for a diagnosis of PTSD. He was first diagnosed with PTSD while on active duty in xxxx by a DOD psychiatrist and mental health records (private and VA) dating back to xxxx also show that multiple mental Health providers have diagnosed and treated PTSD. Although the veteran experienced some symptoms immediately following the assault (bed wetting, night terrors), these symptoms largely resolved by the time he was in middle school due to reported "traumatic amnesia." His only residual symptoms throughout the remainder of middle school and high school were associated with a chronic mistrust of others and related social detachment. His enlistment exam was silent for any relevant concerns, as were STRs from the time of his enlistment in xxxx until the first disclosure of the assault and associated symptoms in xxxx and xxxx. Thus, there is no evidence to suggest that the veteran was experiencing clinically significant symptoms of PTSD prior to his enlistment and thus the question of aggravation is moot. Records clearly document onset of symptoms while the veteran was on active duty and indicate chronic trauma-related symptoms and impairments since then. 2. The veteran's current mental health symptoms also meet DSM-5 diagnostic criteria for Major Depressive Disorder (MDD), Recurrent, with Mood-Congruent Psychotic Features, secondary to underlying PTSD. His current depressive symptoms are a continuation of those first diagnosed in service as Dysthymic Disorder, and the veteran has been treated for MDD by multiple mental health providers (private and VA) since at least xxxx. As indicated above (Rationale #1), there is no evidence to suggest Clinically significant symptoms of depression prior to military service, and he was first diagnosed with a depressive disorder while psychiatrically hospitalized in service (xxxx). Subsequent records indicate chronic problems with depression since his discharge from active duty. 3. The veteran's history is suggestive of some underlying Personality features which are likely contributing to some of his on-going concerns (e.g., schizoid and avoidant features). Although he was diagnosed with a personality disorder in service, there is insufficient evidence to warrant a personality disorder diagnosis at present, as some of his on-going symptoms can be attributed to underlying PTSD (e.g., mistrust of others, social/interpersonal detachment, avoidance of intimate relationships). 4. The veteran showed no signs of significant exaggeration/feigning or minimization of mental health symptoms on objective testing, during the interview, or when comparing his self-report to the evidence in the record. As such, information from this evaluation is believed to be an accurate reflection of the veteran's current mental health concerns and relevant background.
  18. Hello all! So the long and short of my story is that I have bipolar disorder. My doctor checked 100% service-connected (diathesis-stress theory and all). I can't drive after 7pm and try not to drive after 6:00pm due to medication side effects (clumsiness from Seroquel and confusion from Lamictal). In the last 2 years, I have probably driven after 7pm about 10-15 times. I tried switching to Vraylar and it was gosh-awful. I mean, you know, people here know. The worst... Anyway, I have failed out of school for the last 4 semesters despite being of average smarts. I have lost 2 very good friends due to my manic states (one was my best friend for 8 years, the other was my 2nd best Army buddy). During the Winter I am usually totally "combat ineffective", as in I can barely leave the house, and do laundry every 3 weeks (instead of every week) and shower every 3 days. I also go for groceries probably every 5 weeks instead of every 3. I am submitting my claim through the DAV and my doctor has checked off deficiencies in: "work, school, family relations, thinking, mood" on one of their special forms. Anyway, I know, it's just a lot of wah, wah, wah on my part (and I'm sorry to the vets who are straight-up paralyzed), and don't get me wrong, I am very lucky to not be a Vietnam vet who has been wronged, or a vet who has lost both both arms... but, can anyone guess what my rating will be? I will not hold it againstanyone even remotely. My C&P exam is on Wednesday and I am pretty anxious. I expect to hear my rating in about 3 months. I think I will be placed at 70%. Any "wake up calls" or advice is welcome. Best regards, Hemi
  19. Hello everyone, It has been a while but I finally received my C&P examination for mental health. Currently am 50% for Major Depression, seeking 70%. I went to my examination in stained sweats, faded shirt, flip flops, unshaven, and hair frizzy and not brushed. For some reason, I believe my C&P examiner was wishing I did not come so she could go to lunch early based on her reaction to my arrival and her BSing with the receptionist prior. Anyway, I feel angry after reading her assessment and would like to know what you all think. I think she checked the box for 30% which is a decrease but all the symptoms are 70% looking. It feels really bad she is trying to make me out to be a liar when she doesn't know how I really feel. I have been suicidal, I have made attempts, I have researched the best methods, made plans, etc. The closest I have come is purchasing roper, tying it in a noose, and testing out a bar at work to see if it could support me in hanging myself. But I have really been feeling like crap and feel I have to fight really hard to not let my thoughts become the truth. All things she did not ask. What do you think will happen based on the below exam results? I thank you for your time and responses. CaliBay Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: - - - - - - - - - - 1. Diagnosis - - - - - - - - - - - - a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder? [X] Yes [ ] No ICD code: F33.2 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Major Depressive Disorder, severe, recurrent ICD code: F33.2 Mental Disorder Diagnosis #2: Generalized Anxiety Disorder, with panic attacks ICD code: F41.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): severe sleep apnea 2. 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? [X] Yes [ ] No [ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses Depression - depressed mood, not feeling pain, poor motivation, nightmares, few friends, feel worthless and helpless. Anxiety: doesn't like to leave his house, uncomfortable in crowds, some paranoia shakes c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 3. Occupational and social impairment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [X] No [ ] No other mental disorder has been diagnosed If no, provide a reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: symptoms of GAD and MDD overlap and it is nearly impossible to differentiate between disorders. 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 2. History - - - - - - - - - - a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran has been married for 25 years, and they have 4 children ages 17, 12, and 7. His father lives at their home, but he is self-sufficient and assists caring for the children. His spouse works at Kohls. b. Relevant Occupational and Educational history (pre-military, military, and post-military): He works for the Federal Government as Transportation Specialist at the GS-11 pay grade. He stated that his supervisor has made a verbal accommodation for his mental disabilities to let him come and go as he pleases including arriving late and leaving early for work for appointments. He states he does not know exactly what he does at work but feels like a government worker that is unqualified for his position and got lucky to obtain his current job. He states he answers email correspondence all day and surfs the Internet. He stated that his duties are not really defined and much of his job requires little effort mentally or physically. He creates spreadsheets in Excel and analyzes financial data for travel. He works from 8:00 am to 5:00 pm. He stated that he has used his all of his vacation and sick time because of his disability. He was out of work on FMLA for three months to receive mental health care and has returned in May 2017 with difficulty adjusting. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): He stated that he was feeling better during for two months in a 12-month period. Since he returned to work, his depression has increased and has frequent panic on a daily basis. He stated that he feels paranoid that someone is out to get him. He feels like he is worthless at work even though his managers have never told him his performance is poor. He does not recall periods of remission and stated that he only remembers all the bad things that have happened to him. He uses a CPAP machine but states he rips it off his face every night due to nightmares. He has always had nightmares of when his daughter passed away and escorting human remains off of military cargo planes. He estimates waking up every hour to check on his children to see if they are still alive. He self-admitted to a Mental Health Hospital for 3 months. He was suicidal and very depressed. He has not seen a Therapist but he has spoken to his Psychiatrist. Nightmares: never decreased, nightly or every other night. His nightmares are of the same theme. No exercise Medical records review: DBQ from private provider Statement from veteran Treatment records from Private Hospital Treatment records from Mental Hospital These records are consistent with a diagnosis of Major Depressive Disorder, and Generalized Anxiety Disorder. Many medications have been tried. He is at low risk of suicide at this point. Current Medication: Wellbutrin Abilify Prozac d. Relevant Legal and Behavioral history (pre-military, military, and post-military): None e. Relevant Substance abuse history (pre-military, military, and post-military): He drinks occasionally and states he is a “light weight” in consuming alcoholic beverages. Sometimes he inhales CO2 from whip cream to get a temporary high. f. Other, if any: No response provided. 3. Symptoms - - - - - - - - - - - For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Chronic sleep impairment [X] Flattened affect [X] Disturbances of motivation and mood [X] Suicidal ideation 4. Behavioral observations - - - - - - - - - - - - - - - - - - - - - - - - - - No response provided. 5. Other symptoms - - - - - - - - - - - - - - - - - Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [ ] Yes [X] No 6. Competency - - - - - - - - - - - - - Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 7. Remarks (including any testing results), if any: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - This 45-year-old veteran still struggles with depression and anxiety. I cannot diagnose him with PTSD because it appears to be secondary to MDD. He has not seeked therapy other than admitting himself to a Mental Health Facility. The veteran has been advised to get help for his symptoms and he has not complied. There doesn't appear to be any changes in his mental health status. The fact that this veteran continues to work without incident suggests that he may be functioning better than what he is showing. I recommend that this veteran receives intensive therapy and be re-evaluated after a year of consistent treatment.
  20. I was given a medical discharge for depression from the service about 20 years ago and have a 20 year history of ongoing mental health treatment. I finally decided to file for VA benefits (I've always worked) and had my C&P exam a couple weeks ago and wondered if this was a normal experience. The exam lasted almost three hours and I had to take a long test of a couple hundred questions. The doctor (psychologist) was very nice and he seemed interested in my case but asked a lot of questions about my childhood. My case involved childhood MST and repressed memories of it until a flashback while I was on active duty brought everything out. I was tossed in the hospital and given a medical discharge for depression, existing prior to entry, service aggravated condition per the medical board. I'm a bit worried the doctors focus on my childhood means he was trying to say I was depressed prior to the service which isn't the case. With the repressed memory of the rape I had a pretty normal growing up experience after the event and had friends and a stable family. He seemed to be trying to get me to say my current problems with trusting people were related to what happened then. Obviously they are but I was concerned he spent hardly any time on the in-service stressor that led to the flashback or the fact I've been pretty miserable since then. I had a friend tell me not to worry that it's normal and he may be trying to figure out what percentage of my disability was existing prior to entry versus how much was service aggravated. I've got the service connection thing taken care of with the "service aggravated" note on the medical board and my private psychiatrist wrote a nexus letter and completed a DBQ stating my conditions are related to my service. I'm thinking I have enough medical evidence to show it but I'm concerned about the C&P examiners report. Do you think I need to worry about this? (I have anxiety issues too). Is a three hour exam normal? Do you think the examiner was just being detailed and it'll be OK? He said it would be a couple weeks to view his report and I'm still waiting but I'm a nervous wreck. JW in MN
  21. Ok so I checked my ebenefits today for my disability clam and it's at : Preparation for notification. This was really fast but my question: is there anywhere on ebenefits I can see how much they rated my disability ? or if I got denied ? I look at the pending disabilities and it just shows them as new clams still. Is there any way I can find out before they send out the package ?
  22. Hi everyone! Hope all is well. I just wanted to stop in and say hello. I haven't been on here since late last year. Life is going good. As most know my story and it was a doozy, I finally got everything I deserved! Overall 90% and I couldn't be happier. It took a lot of hard work and sleepless nights and a lot of C&P exams and fighting the VA but I prevailed. I was thankful for this sight b/c without it I would have never met a great guy that helped me with the final phase of my rating. I am now just waiting on an EED for my contentions but I am really not really worried about it and if it happens great and if not, I am good. Don't give up EVER!
  23. History, Going on for over 12+ years since left the militray .First raiting 50% Went for increase this was from my DBQ C&P .. Thoughts all? See below Is this 70 (most would say 70). could it sway 100%? If you think 100% do you believe sched or temp? I did not apply for IU but I am told they have to consider it anyways. The doctor also used some verbage that was interesting It is not possible to differentiate what portion of each symptom is attributable to each diagnosis because all of the veteran'schronic PTSD and bipolar symptoms have been chronic, progressive, biologically and behaviorally interactive, and thesymptoms are concurrent and overlapping. The veteran’s alcohol abuse is in remission but was a result of maladaptive copingand dealing with the PTSD an bipolar symptoms.Per DSM-5 Individuals with PTSD are 80% more likely than those without PTSD to have symptoms that meet diagnosticcriteria for at least one other mental disorder (e.g. depressive, bipolar, anxiety, or substance use disorders) (p 280)It is not possible to differentiate what portion of the impairment is attributable to each diagnosis because all of the veteran'schronic PTSD and bipolar symptoms have been chronic, progressive, biologically and behaviorally interactive, and the symptomsare concurrent and overlapping. The veteran’s alcohol abuse is in remission but was a result of maladaptive coping and dealingwith the PTSD an bipolar symptoms. [X] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinkingand/or mood. 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 Criteria 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 violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Witnessing, in person, the traumatic event(s) as they occurred to others Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related No criterion in this section met. Page 6 of 8 Contractor: VES 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). 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). Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). No criterion in this section met. Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(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). No criterion in this section met. 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: 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). 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”). Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to 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. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) No criterion in this section met. 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. Reckless or self-destructive behavior. [X] Hypervigilance. Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). No criterion in this section met. Criterion F: [X] Duration of the disturbance (Criteria B, C, D and E) is more than 1 month. Veteran does not meet full criteria for PTSD Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The PTSD symptoms described above do NOT cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Veteran does not meet full criteria for PTSD Criterion H: For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks that occur weekly or less often Panic attacks more than once a week 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 Impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks Memory loss for names of close relatives, own occupation, or own name Flattened affect Circumstantial, circumlocutory or stereotyped speech Speech intermittently illogical, obscure, or irrelevant Difficulty in understanding complex commands [X] Impaired judgment Impaired abstract thinking Gross impairment in thought processes or communication [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 work like setting Inability to establish and maintain effective relationships Suicidal ideation Obsessional rituals which interfere with routine activities [X] Impaired impulse control, such as unprovoked irritability with periods of violence Spatial disorientation Persistent delusions or hallucinations Grossly inappropriate behavior Persistent danger of hurting self or others [X] Neglect of personal appearance and hygiene [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene Disorientation to time or place IF YOU HAVE PROVIDED ANY ADDITIONAL DIAGNOSES, OR IF THE ESTABLISHEDDIAGNOSIS HAS CHANGED IN ANY WAY, PLEASE SELECT AT LEAST ONE FROM THEFOLLOWING:A. THERE IS NO CHANGE IN THE SERVICE CONNECTED DIAGNOSIS AND NOADDITIONAL DIAGNOSES HAVE BEEN RENDERED.B. THE NEW DIAGNOSIS IS A CORRECTION OF THE PREVIOUS DIAGNOSIS.C. THERE IS A WORSENING OF THE VETERAN’S SYMPTOMS HOWEVER NO CHANGETO THE SERVICE CONNECTED DIAGNOSIS AND NO ADDITIONAL DIAGNOSES HAVE BEENRENDERED.D. ADDITIONAL CONDITIONS WERE FOUND WHICH ARE DIRECTLY DUE TO ORRELATED TO THE SERVICE CONNECTED DIAGNOSIS (I.E. A PROGRESSION).E. ADDITIONAL CONDITIONS WERE FOUND WHICH ARE UNRELATED TO THESERVICE CONNECTED DIAGNOSIS (I.E. A NEW AND SEPARATE CONDITION).***FOR OPTION E, PLEASE SPECIFY WHICH OF THE VETERAN’S SYMPTOMS AND/ORFINDINGS CORRESPOND WITH EACH DIAGNOSIS, IF FEASIBLE.***F. THE SERVICE CONNECTED DIAGNOSIS HAS RESOLVED. Answer Question 1: C. There is a worsening of the veterans symptoms however no change to the service connected diagnosisD. Additional diagnosis is alcohol use disorder in partial remission which is a new and separate conditionbut is related to the service connected conditionsAdditional Question 2: FOR OPTIONS OTHER THAN A AND C PLEASE PROVIDE YOUR MEDICAL RATIONALE. Answer Question 2: D. It is related as alcohol use disorder is often secondary to his PTSD and bipolar disorder and is currentlyin remission but was a result of maladaptive coping with his symptoms in the past and he still hasoccasional relapses./ THE VETERAN’S ESTABLISHED DIAGNOSIS IS POST-TRAUMATIC STRESS DISORDERWITH BIPOLAR DISORDER .IF YOU HAVE PROVIDED ANY ADDITIONAL DIAGNOSES, OR IF THE ESTABLISHEDDIAGNOSIS HAS CHANGED IN ANY WAY, PLEASE SELECT AT LEAST ONE FROM THEFOLLOWING:A. THERE IS NO CHANGE IN THE SERVICE CONNECTED DIAGNOSIS AND NOADDITIONAL DIAGNOSES HAVE BEEN RENDERED.B. THE NEW DIAGNOSIS IS A CORRECTION OF THE PREVIOUS DIAGNOSIS.C. THERE IS A WORSENING OF THE VETERAN’S SYMPTOMS HOWEVER NO CHANGETO THE SERVICE CONNECTED DIAGNOSIS AND NO ADDITIONAL DIAGNOSES HAVE BEENRENDERED.D. ADDITIONAL CONDITIONS WERE FOUND WHICH ARE DIRECTLY DUE TO ORRELATED TO THE SERVICE CONNECTED DIAGNOSIS (I.E. A PROGRESSION).E. ADDITIONAL CONDITIONS WERE FOUND WHICH ARE UNRELATED TO THESERVICE CONNECTED DIAGNOSIS (I.E. A NEW AND SEPARATE CONDITION).***FOR OPTION E, PLEASE SPECIFY WHICH OF THE VETERAN’S SYMPTOMS AND/ORFINDINGS CORRESPOND WITH EACH DIAGNOSIS, IF FEASIBLE.***F. THE SERVICE CONNECTED DIAGNOSIS HAS RESOLVED.Answer Question 1: C. There is a worsening of the veterans symptoms however no change to the service connected diagnosisD. Additional diagnosis is alcohol use disorder in partial remission which is a new and separate conditionbut is related to the service connected conditionsAdditional Question 2: FOR OPTIONS OTHER THAN A AND C PLEASE PROVIDE YOUR MEDICAL RATIONALE.Answer Question 2: D. It is related as alcohol use disorder is often secondary to his PTSD and bipolar disorder and is currentlyin remission but was a result of maladaptive coping with his symptoms in the past and he still hasoccasional relapses.
  24. 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: CH PTSD b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): PARKINSON'S, HIGH TRYGLYCERIDE. HEARING LOSS. 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 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 [ ] 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): STRESSOR NOTE. Evidence Comments: TALKED WITH HIS WIFE MELINDA. SHE STATES THAT GRADUALLY HAS BECOME MORE IRRITABLE, LOOSES HIS TEMPER VERY EASILY, SNAPPS AT HIS KIDS, ARGUMENT. AT NIGHT HE IS RESTLESS IN BED, YELLING AND STARTS SWINGING HIS HANDS AND FEW TIME HE HIT HER IN THE SLEEP. WHEN HE IS OFF MEDS, HE IS MORE WITHDRAWN, LESS ACITVE PHYSICALLY AND MORE IRRITABLE. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military) THIS VET ARRIVED HERE FROM SIGNAL MOUNTAIN, TN, DRIVEN HERE BY HIS WIFE.HE WAS BORN IN FRANCE, HIS FATHER WAS IN ARMY. RAISED IN JASPER, TN. HE WAS RAISED BY BOTH PARENTS. HE HAS ONE BROTHER AND ONE SISTER.NO HX OF ANY KIND OF ABUSE.HE IS MARRIED FOR 31 YRS, ONLY MARRAIGE. THEY HAVE 3 CHILDREN. HE JOINED THE AIR FORCE IN 1985 AND DCED IN 2008 WHEN HE WAS DXED WITH PARKINSON'S. HE HAD 6 TO 7 YRS OF ACTIVE AIRFORCE, STATIONED IN KUWAIT AND IRAQ. HE WAS DCED FROM AIRFORCE RESERVE IN 2008. HIS RANK AT DCED WAS MASTER SERGEANT. b. Relevant Occupational and Educational history (pre-military, military, and post-military): COMPLETED HIGH SHCOLL IN JASPER. HAS BACHELOR IN ORGANIZATIONAL MANAGEMENT.HE WORKED FOR TVA IN NUCLEAR PLANT AND DID ROOT COUSE ANALYSIT. HE WORKED LAST SEPTEMBER 2016 BECAUSE OF PARKINSON's. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): HE DID NOT RECEIVE ANY MH CARE BEFORE HE JOINED THE AIRFORCE, NONE WHILE IN AIRFORCE BUT AFTER DCED FROM AIRFORCE, HAD TO SEEK HELP AT CHATTANOOGA CLINIC.HE WAS THEN DEPRESSED, HIS MOTHER PASSED AWAY, COULD NOT HANDLE THE LOSS, HAD TO GIVE UP WORKING AND FELT HOPLESS AND HELPLESS.HE FELT LOW ELF ESTEEM.HE WAS THEN PRESCRIBED AND NOW HE IS STILL FOLLOWED BY PSYCHIATRIST AT CHATTANOOGA CLINIC.HE STILL FEELS DEPRESSED, SOME ARGUMENT WITH HIS WIFE.HE FREQUENTLY CRIES, FEELS HOPLESS AND SOME TIME GOES THROUGH MOOD SWING BUT DENIES ANY MANIC EPISODES.HE KEEP UP WAKING UP AT NIGHT, FIGHTS IN HIS SLEEP, FEW TIME HE HIT HIS WIFE IN SLEEP AND HAS HEPPENDED FREQUENTLY, FEELS GUILTY ABOUT.HIS WIFE TELLS HIM HE CRIES IN HIS SLEEP AND SCEAMING BUT HE DOES NOT REMEMBER DOING THESE. REPORTS THAT HE AVOIDS CROWD, FEELS MORE SAFE AT HOME. IF HE IS IN UNFAMILIAR SITUATION, DOES GET UNCOMFORTABLE.HE GETS FRIGHETEN IF THERE IS LOUD NOISE.VERY LIMITED SOCIAL LIFE, ONLY TIME GOES OUT WHEN HE ATTENDS THE CHURCH. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): NONE e. Relevant Substance abuse history (pre-military, military, and post-military): NONE f. Other, if any: HIS OWN PHSICAL CONDITION AND LEAD TO GIVING UP JOB AND ROLE REVERSAL WHEN HIS WIFE HAS TO WORK AND HE HAS TO STAY HOME. 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: 2001, AT AIRFORCE BASE IN QUATAR, WAS GOING TO DO PURCHASE WITH HIS PRCHASING AGENT, PERSON PULLS UP AT GATE AND PULLS OUT AK 47, START SHOOTING, HE WAS ONLY THIRD CAR FROM GATE., THIS PERSON WAS SHOTTO DEATH Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [X] Yes [ ] No If yes, please describe the markers that may substantiate the stressor. MIDDLE OF ATTACK. b. Stressor #2: WHEN HE WAS STATIONED IN SAUDI DURING DESERT STORM, THERE WAS GR 1 TORNADO NEAR THE BASE, BRITISH PILOT HAD TO EJECT HIM SELF FROM 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 s tressor. WITNESSING BRITISH PILOT EJECTING FROM AIRPLANE WHEN THERE WAS GR 1 TORNADO AT BASE. 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) [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). 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] 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] Hypervigilance. [X] Exaggerated startle response. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment[X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships 6. Behavioral Observations -------------------------- ALERT,ORIENTEDX3,COOPERATIVE, CASUALLY DRESSED, POOR EYE CONTACT, CONSTANTLY MOVING IN THE CHAIR, VERY FIDGITY. AFFECT IS CONSTRICTED, DECREASED INTENSITY, ANXIOUS MOOD. RATE OF SPEECH NORMAL, GOAL DIRECTED. NO AH/VH OR ANY PERCEPTUAL DISTURBANCES. NOT SUICIDAL OR HOMICIDAL. NO COGNITIVE DEFICIT. 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 VET DID EXPERINECE TRAMATIC STRESSORS AND HAS EXPERIENCED SXS OF PTSD WITH CO MORBID DEPRESSION AND UNDERGOING MH RX AT CHATTANOOGA CLINIC. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. ****************************************************************************
  25. I have a C&P on March 14, and wanted to know can i bring additional information to submit to the examiner to help with my claim? And If so do they suppose to take that into consideration?
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