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Found 157 results

  1. http://www.benefits.va.gov/PREDISCHARGE/DOCS/disexm58.pdf 12 page guideline the VA docs must use for a TBI assessment. Review this along with the ratings guide for 8045 to be well prepared for the C & P exam. http://www.benefits.va.gov/WARMS/docs/regs/38cfr/bookc/part4/s4_124a.doc After the exam, go to the Release of Information office at the VAMC & request a copy of the exam be mailed to you. Or MyHealth E Vet website Blue Button feature will allow you to view it in 3 days. Check over the exam report to make sure doc wrote down correctly what you said. If not, you can fill out a form to request a correction of your medical records.
  2. I requested connection for psoriatic arthritis of the right hand, left wrist, and both feet. In addition to these joints the RO requested a C&P exam of shoulder, hip, elbow, wrist, knee, and ankle. I have no idea why they did this but it is possibly beneficial to me. I'll attach this part from my c-file at the bottom on this post. The VA only decided on the four claimed joints. The other joints that the VA put in the C&P request were never evaluated or referenced in anyway. This includes no mention in rating decision letter or during the C&P. Fast forward to 2015 I report for a VA requested future exam for the four SC joints. I made the complaint of joint pain in 11 joints to include the joints stated above from the 2009 C&P. These were recorded in the results as pain. In addition to the documentation in the 2015 exam, they VA acknowledged the additional joint pain and suggested I contact them if I wished to claim these. I stupidly did not see this until recently. Would I be able to get these joints connected and EED back dated to 2009 or 2015 based on an inferred issue and that no decision was made on the other joints? Again the VA is the one that requested the additional joints to be evaluated in 2009 and not me. Then they were never addressed. I am interested in this because I have been finding information on claims being considered open if the VA never renders a decision. While they rarely miss a veteran claim they often miss inferred issues. This seems like a pretty obvious inferred miss to me. The VA specifically requested the additional joints. Might be a stretch but this would be significant retro.
  3. Like the title says, i go to have an exam for fibro, gerd, and eczyma. Now the last one is a toss up, and the gerd maybe too i don't know. A doctor outside the VA diagnosed me with fibro a few years back. He was an idiot though so i don't know if it was documented(probably, but i also have 30 percent for p.s.t.d. so i'm probably being paranoid). Then again this doctor told me it was my weight blah blah blah. I told him multiple times that a few years prior i was going to the gym alot and the pain has become worse as i age amking it harder to be as active. I try to eat good(chicken and rice, oatmeal) most of the times but we are human. So back to the exam, i have only had one for the p.t.s.d. I was in Iraq day one of the war(March 2003). I was around burn pits and was exposed to the aftermaths of exploded tanks and buildings(hell some we even enter to make sure nobody was hiding or any wmd. I'm registered for the burn pits. I just don't know what to expect, will it be questions, will it be a physical? It's an outside contractor, so i'm hoping less va bias. I'm also too the point of drowning in debt. It's trigger my p.t.s.d. to the point my wife can't even sleep due to my nightmares and waking up with night terrors. I have become much angrier and lashing out. Not physically though, but i don't know what state i'll be in if i get another denial(btw with what i mentioned, i have a bva for freaking tinnitus even though i have stated where i have been. I was also a cavalry scout in the army so i was trained for combat. I have lay statements from a battle buddy, mom, wife, ex and a friend. I just need to know what to expect or what else i need to do to have a shot at an approval? I'm also filed for apnea, va diagnosed me and i have a cpap. Never had a chance to have any of this documented in service due to being told to man up.
  4. So, as some know I have been having a little war with the VA and my VSO, the American Legion, about getting my DBQ's. So today I went to the VSO's office in the VARO building during their "walk in" hours since I could not get them to give me an appointment. On the door was as sign saying the office was closed for the week for training and left the 800 number for Washington DC office. I knock on the door anyway. Two ladies answer. Tell them what I want and that I need them to do it today. They invite me into the office. I hand them a typed sheet with the Dates and Dr's of my C&P's and a list of documents for each one that I need. The first lady says she doesn't know why I am there. The second lady says she will help me. The first lady says show me how we do this. Okay I tell them again what I want and the 2nd lady says why do you want to file a NOD, I tell her. She says you don't need these files to file an appeal.......The VA already has them. I tell her I need to know exactly what the DBQ says and what the letters to and from VA says. I also need the code sheets as they existed at each point for each approved and denied C&P. She tells me no i don't and if I insist on filing a NOD I should just file an HLR.. I told her no, that would not work for this and the HLR results are not typically veteran friendly. She then spends 20 minutes more telling me that I need to listen to her because veterans don't know what they want and don't know anything about the VA and how to win their claim. She then says "We work for the VA not for you, and the VA knows what it is doing". this of course makes me mad and I say to her " I am asking you to get me these files. nothing more. I have heard your opinion and all you need to do is get me copies of these files." She then starts in again trying to convince me not to file. I get more insistent and tell her that i heard her but I expect her to do exactly as I requested, nothing more. She then says "Well you don't need those files so let me file the NOD" I tell her NO. Resoundingly empathically NO> She then tells me I know how to file a NOD. She then remembers I am filing a CUE and says "you shouldn't file a CUE because you will never win and then the VA will be mad at you"...... Just f'ing wow. Then I tell her once again to do what I asked her to do and to stop trying to dissuade me from what I want. I tell her she is wasting her time and mine and that all I want is her to get those documents. She then yells to the other woman to get "Bill". Man comes in and says "those are VA files you don't get to have them". I tell him he is wrong and ask who he is. He refuses to answer. I look at woman 2 and say Please tell me your full name so I have a record. She wants to know why. I tell her point blank, that the next time I speak to AL in DC I am going to reference her and what she has said and not done. I then look at "Bill" and ask his name. He tells me 'you don't need to know that". I tell him I do because saying "Bill from AL means nothing to anyone". He snaps back 'I don't work for AL I work for VFW". I ask him why he is sticking his nose into an AL situation? He gets mad and leaves. She writes down her name, at least I think it is her name, date and time . Then says all she is going to do is fill out a FOIA. At this point I decide to let her do that and get a copy to submit with my complaint to the AL. She then asks me what I want. Types that I want my C-file and the files on the attached sheet, prints it, shoves it at me and says to Sign it. I tell her no it is not accurate and ask for a pen and write explicitly what I want. She literally tries to argue with me. I tell her to stop arguing and write the FOIA the way I tell her. She writes it wrong in her own phrasing and i made her redo it. Then I made her add Time is of the essence on the form. When she handed it to me. I initialed before and after the typing and drew a line threw the blank space. She gasped and asked why I did that. I said "its blank space and anyone could add words to that blank space. She then started to say, and got half way through saying 'I needed to put more stuff...." and then shut up as she realized she was admitting to falsifying a FOIA over my signature. I am not sure which is worse, having the people with my POA try and screw me over or having the VA which is supposed to be on my side try and Screw me over.
  5. I am serviced connected for ankylosing spondylitis back in 1985. I had a C&P exam on 7-7-19 since I am asking for an increase in my cervical, thoracic, and lumbosacral ratings. After speaking with the DAV to find out progress and info on my exam, the Rep. noted sort of what I expected. Radiculopathy was noted and ROM was 0-15 for cervical, and 0-25 for back. I am currently rated as Cervical 30%, Thoracic 10%, and Lumbosacral 40%. The main question that I have is relating to the thoracic 10% and lumbosacral 40%. I am confused on these two. Is Lumbosacral separate from the thoracic/others ? Since my back ROM is at 0-25, does this mean that my thoracic might increase from the 10% to a higher rating ? I am confused how they break down my ratings from cervical at 30%, Thoracic at 10%, and Lumbosacral at 40%. Did the VA make changes to the names of the spine regions after I was rated and how they would rate each one?....because I don't see Thoracic as a region now. I only see cervical and thoracolumbar. I'm not sure how they would rate/increase me...totally confused. Also, with the radiculopathy, is this something that they will rate also ? I am currently at 90% total combined for all my disabilities. I hope this helps for someone to give me advice/answers.
  6. I just discovered that a C&P exam was held without me even knowing about it on August 16th. I just happened to see it in my Blue Button VA medical record download today. I have submitted a few claims last year. One in May and another in October. The VA combined my claims and back dated them to May 2018. The estimated completion date has jumped around 4 times. In July it jumped to an estimated completion date of 9 May 2019. At the beginning of August it jumped to 22 May 2019. It's still in the "Evidence gathering, review, and decision" phase. Does anybody know why they did a C&P without notifying me? Does anybody know what this means regarding my increase requests for the following? - VA exam for sleep apnea (Increase) -I'm trying to service connect my sleep apnea- I submitted Statements in Support of claim dating back to 2007. - VA exam for headaches (Increase)- I've been hospitalized twice in the past year diagnosed with hemiplegic migraines. They mimic strokes and can mess you up just like strokes. And exertional headaches. The worst headaches ever. I originally submitted a claim for TIA and stroke and got a 'not service connected'. Got the migraine diagnosis after they denied the claim, after the 2nd "stroke" episode. - 4138 and MTR for esophageal (Increase)- Not sure what this is for., but I di have a disc replacement in my neck....and my GERD is the weapon of demons.
  7. Welp, Just found out they closed my claim. Surprise surprise, nothing changed EXCEPT they reduced my GERD from 60% down to 10%! WHY and What the?! So apparently that random C&P without my knowledge played a significant part. So my questions are the following: 1. Should I reopen my claims or file an appeal? 2. How do I go about getting ALL of my C&P claim notes, especially whatever was said from this C&P without my knowledge? 3. Should I even attempt to ask for the much qualified for increase on other areas of my body, that have gotten worse, or fight this last round of let downs? I try to explain to everyone when you retire or get out and become a veteran, your own company (the VA) treat you like used tissue. Nobody has any use for used tissue...tossed to the side.
  8. Hi Everyone, In my most recent C&P the examiner noted and measured 2 scars on my neck and jaw. I've read the rating info for scars of the Head/Face/Neck and filled in the chart they had because the first rating option didn't apply. Can someone confirm for me that according to the rating info below, it would qualify me for 30%. There's pain noted in the C&P with each scar in addition to the characteristics noted below. "If there are 6 or more Characteristics, it is rated 80%. If there are 4 or 5 Characteristics, it is rated 50%. If there are 2 or 3 Characteristics, it is rated 30%. If there is 1 Characteristic, it is rated 10%." In addition, during the same C&P the examiner documented and agreed (50% more than likely service related) that I had TMD secondary to broken jaw, painful motion of mandible, reduced ROM, surgical wire in right mandible Thanks in advance! Randy
  9. My husband was just denied SC for hearing loss and tinnitus. I would have expected 0% hearing loss for left ear and 10% tinnitus. I attached the C&P resultsAudiology DBQ.docx - it seems to me like the audiologist contradicts herself in her rationale - or maybe I am just confused? But overall it does seem to say he has tinnitus and its linked to service? Not sure what to think of this. Any insight would be appreciated! Thank you!
  10. Hey brothers and sisters, So I just had my C&P for my right shoulder secondary to my left shoulder injury. Since I've injured I tend to put more strain on my right shoulder to compensate for functional loss. This has caused me to have pain and limited ROM in both shoulders. This scumbag at the VA left his opinion. Even though all my tests showed limited ROM and pain on movement of right shoulder. What's next? MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's shoulder condition right at least as likely as not (50 percent or greater probability) proximately due to or the result of rotator cuff tendonitis, left shoulder (non dominant)? b. Indicate type of exam for which opinion has been requested: RIGHT SHOULDER TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] b. The condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: Within the concept of a pathologic entity of one specific site or joint of the human body (right shoulder in this case) it is very hypothetical to theorize or to try to conceptualize that such a pathologic process would be secondary to a SC pathological process at a separate site such as ROTATOR CUFF TENDONITIS, LEFT SHOULDER (NON DOMINANT). To ascribe a distant pathologic entity (RIGHT SHOULDER) to be secondary to the already mentioned SC condition, does not fit within the realm of a peer reviewed logical manifestation of diseases as written over centuries in the medical books. Even trying to force a connection between such SC condition and the RIGHT SHOULDER condition imperils the scientific knowledge in medicine that tries to explain disease processes and their interconnections in the most logical, reasonable and responsible ways. There is no evidence in the scientific medical literature of such connection. Therefore, the claimed condition is less likely than not proximately due to or the result of the Veteran's service connected condition. And the SC condition neither aggravates the RIGHT SHOULDER condition.
  11. I recently (October 2018) made my first claim and was examined and rated @ 10% for Tinnitus. Immediately afterwards, I received a letter from the VA stating that they had made an appointment for me for back pain that was from a claim in March of 2000. (I left the USAF in January, 2000). This is the result of that C&P exam. I was also sent a letter about foot pain that I had claimed in 2000. I ended up filling out more paperwork to explain condition, and sending in medical records from private doctors. I believe that they combined the foot pain, and the back pain into one claim. I cannot see anything on eBenefits regarding the status these claims since they are so old (that's what they told me). I am also soliciting opinions as to what the effective date for these claims would be. Please let me know what you think regarding this DBQ from a C&P exam: Thank you VERY much! Thanks! mhv_Xxxxxxxx_.pdf
  12. Hello everyone and thank you for accepting me in to the forum. Last year I filed a new claim for Generalized Anxiety Disorder and Major Depression. For the past 3 years, I have been seeing a civilian psychiatrist for my anxiety and depression. She had already diagnosed me with GAD and Major Depression, and I have been on anti-anxiety medications, antidepressants, and sleep medication. I was on differing types of the same medications since coming out of the service, but it wasn't until about 3 years ago, that I admitted to myself that I needed mental help, and that is when I started seeing my civilian psychiatrist, and that is when I first heard of GAD and Major Depression, when she said she had diagnosed me with them. It was at her suggestion, that I file a claim with the VA for GAD and Major Depression. She said she very much felt like my conditions were associated with my time in the service. When it was finally time to have my C&P exam, I was interviewed by a VA psychologist. I told her about my civilian psychiatrist, and her diagnosis for me, and the medications she had me on. I also talked to her about my time in the service, me being overseas in the Gulf War, and me being in a humanitarian mission in Ecuador. I told her about my friend who was with me during basic training. And how he was shot and killed right in front of me, in a horrible accident, during one of our live ammunition training exercises. I told her how all this had affected me from those moments on, all the way until now. At the end of our meeting, she told me that she felt like my condition was more PTSD, rather than Generalized Anxiety Disorder and Major Depression. At the time I didn't think anything of what she said; that is until I was sent my denial letter. In my denial, it stated that my 2 claims for GAD and Major Depression, was changed to GAD (to include PTSD) and Major Depression (to include PTSD). So the VA psychiatrist did what she said she would. She essentially changed what I had claimed, and added (to include PTSD) on each of my 2 claims. So, for the basis of PTSD, there has to be a proven stressor. The VA used what I had talked to the psychiatrist about the death of my friend during boot camp, as my stressor. The VA said they searched records during the time I was at boot camp, and found no incidents related to what I was saying. So, because the VA psychiatrist took it upon herself, to change my claimed conditions from GAD and Major Depression, to GAD (to include PTSD) and Major Depression (to include PTSD), now it was up to me to prove a stressor, because with claims associated with PTSD, you must prove your stressor. I knew from talking to other Army buddies of mine, how difficult it could be sometimes to find old records of deaths. The death of my friend during boot camp happened in 1962 at Ft. Jackson, SC. My civilian psychiatrist never suggested to me that I had PTSD. She always said it was Generalized Anxiety Disorder and Major Depression. If I had wanted to file a claim for PTSD, I would have done so. But I knew how difficult it would be for the VA to search for and find any record of the death of my friend at boot camp. So I filed GAD and Major Depression, because I was told those claims did not require a specific stressor (exact time, place, person, etc). I was told that GAD and Major Depression, could be claims based on your entire military career, with everything you've done and everything you've experienced, all amounting to intense anxiety and depression. So that is why I claimed GAD and Major Depression, over that of PTSD. But because the VA psychiatrist took it upon herself to change my 2 claimed conditions, and added the words (to include PTSD) to each of my claimed conditions, it was not just GAD and Major Depression any longer; it includes PTSD, which requires a specific and provable stressor. I had a stressor, and very specific one - the death of my friend during live ammunition exercises during our time at Ft. Jackson, SC boot camp in the summer of 1962. But the VA said neither they nor the JSRRC could find any record of that taking place. If my 2 claims had remained what they were suppose to be, simply GAD and simply Major Depression, I do not think I would have been denied. But because the VA psychiatrist added PTSD to each of my conditions, the VA asked for my stressor, the VA and JSRRC said they could find no record of my stressor, so my claims were denied. I believe I would have been approved if not for the VA psychiatrist adding PTSD to my 2 claimed conditions. So with all that said (and I apologize for the length of it), is there any hope for me, if I appeal my denial? And do any of you know how I would go about appealing it? Would I simply say to the VA that I disagree with the VA psychiatrist adding PTSD to my 2 claims, when I never claimed PTSD myself?; that that was her decision entirely. I have had a VA Disability Representative for the past couple of years, but he was utterly useless. He never answered my calls or emails. He basically never helped me at all. I did most all myself over eBenefits. But now, since I've had this recent denial, I have considered hiring a VA Disability Law Firm to take my case. I've spoken with 2 so far. They both told me I had a very strong case and that I could win. But they also said they couldn't take my case because of their huge client load. I think it was simply that they could probably win my case, but there wouldn't have been much in the line of backpay, so they wouldn't have gotten much compensation for their work for me. So I guess I will continue searching for other VA Disability Lawyers, or I may have to appeal my denied claim myself over eBenefits. Could any of you, please help me with this? I have read many questions on here regarding GAD and Major Depression, but I haven't come across one yet, where they filed a claim for GAD and Major Depression, and then the VA psychiatrist during the C&P exam, decided to change the claim (to include PTSD), thereby changing the criteria for acceptance, by now making me prove a specific stressor, instead of it she had just left my 2 claimed conditions alone, without including PTSD to them, then no specific stressor was required - it would simply go by your overall experiences while in service. I am a 20 year Veteran by the way, with most of my time served in the National Guard. But I was activated numerous times during my 20 years, including during the Gulf War. It isn't my fault that the death of my friend during boot camp, isn't something the VA or JSRRC can locate in records. If the VA psychiatrist had just left my 2 claimed conditions alone, instead of tacking on (to include PTSD), then the VA wouldn't have even had to search for a specific incident, they would have just based my conditions on my overall military experiences. Thank you for any help, assistance, or advice you might be able to give. Donald
  13. Hello all I am fairly new to this forum however I get the majority of my insight here Currently I'm rated at 90% overall , out of that my depression is currently rated at 50% , about 6 or 7 more disabilities each rated at between 10-30% as well ranging from back ,feet and hip problems and recently I have submitted my claim for tdiu back in October 2018 and this past Feb 2019 I had my c&p exam and I was wanting to seek feedback based on what my examiner wrote in the notes in the results I've copied and pasted the portion that stuck out to me most Do I have a good chance at tdiu? Its a very scary process facilities. Encounter Date/Time Encounter Type Encounter Description Reason Provider Source :here are some of key things that stuck out from my examiners notes- At the time of the last exam she was experiencing a high level of work stress. This continued until her discharge in 9/19. She enrolled in College but only went to a day of school. She recalls, "it was pretty stressful, the wear and tear. Some of the classes were upstairs. Mentally I couldn't focus. I was excited, but when I went I felt overwhelm[ed], 'I can't do this.'" She has looked for work she could do at home but was unable to find anything. Has not had paid work since her d/c from military service. The veteran's depression is quite severe and would impact her performance in any job. She would be vulnerable to regular absenteeism and low productivity in any job. She would avoid social interaction and would particularly struggle to perform in jobs that involved extensive social interaction (e.g., team based jobs, customer facing jobs). She would likely struggle to tolerate the routine stress of most jobs or get through a work week without displaying obvious signs of depression and anxiety
  14. I have my PTSD claim C&P scheduled for Thursday. The exam was set up by VES. The examiner is a PHd out of Las Vegas/Arizona/CA that does C&P exams. My question: Can my wife sit in the exam? She knew me before, during, and after the Army. We were married the last few years of service, and after my incidents.
  15. I am beyond frustrated right now!!!! My claim is now preparation for decision and my fear is that it will be denied and I will have to appeal. I filed for my non-service connected Fibro as caused or aggravated by the service connected IBS and/or service connected PTSD on an as likely as not basis. See my screen shot attached of my original claim in July 2018. I had my first C&P exam in September 2018 and it was negative based on the examiner stated there was no causation of my s/c PTSD to my Fibro. See the screen shot below. I will note that he did a separate C&P exam for Fibro and agreed I had Fibro. Never looked at aggravation and never looked at the possibility of IBS. I sent a statement in support of claim pointing this out to the rater. I get another C&P exam in December 2018 BUT by now I have THREE positive medical opinions from BOTH my RA and MH doctor. Both state my Fibro is aggravated by my PTSD and my MH doctor also states my Fibro is aggravated by my IBS. SEE ATTACHED 2 of the 3 letters. When I went to the second C&P exam, it was with the same doctor and he refused to look at the medical opinions. He also once again did not look at aggravation. Again a negative C&P exam. Then the rater asked for clarification/review of conflicting medical opinions. Here is what the rater asked, Per III.iv.3.D.3.a. and III.iv.3.D.3.d. We need clarification/review and reconciliation of conflicting evidence for claim for fibromyalgia secondary to SC PTSD. Negative MO received on 09/28/2018 (TAB A) stated that fibromyalgia was not secondary to PTSD. Received positive MO on 12/05/2018 (TAB B) relating fibromyalgia as secondary to SC PTSD and IBS. Negative MO received on 12/05/2018 (TAB D) stated that fibromyalgia was not secondary to IBS. Examination dated 12/05/2018 (TAB C) shows a diagnosis for fibromyalgia. Per reference please request clarification of conflicting MO for fibromyalgia as secondary to PTSD and IBS with rationale. This medical opinion was done last week w/o me present and once again the medical opinion was negative and doesn't address anything the rater asked. In fact, his statement is laughable. While he states he reviewed conflicting medical evidence, he sites PT notes and doesn't refute the positive medical opinions. Here is what it says: I HAVE REVIEWED THE CONFLICTING MEDICAL EVIDENCE AND AM PROVIDING THE FOLLOWING OPINION:All medical records were reviewed. Physical therapy note on 8/15/2018 by XXXXX documents diagnosis of fibromyalgia and PTSD. The exact cause of fibromyalgia isunknown but has associations with IBS, temporomandibular joint disorder, interstitial cystitis, vulvodynia, and tension headaches. Literature review reveals fibromyalgia along withits associated pain syndromes are clearly different and separable from depression and anxiety. The claimant's fibromyalgia is not secondary to the claimant's claimed PTSDcondition. The VA continues to miss the fact that I asked in my original claim either causation or aggravation. So on Monday, when I went to PFD, I sent the attached statement and uploaded in Ebenefits pointing out once again they are not looking at aggravation. My rep said if it comes back denied, which I am sure it will, we will file an NOD pointing out the fact that they are missing aggravation. MH positive opinion.pdf RA positive medical opinion.pdf
  16. For Starters, I want to thank anyone who takes the time to read this and give me a little perspective. I just got my final C&P results after a series of claims. Currently I am 94% combined rating if I include my Sleep apnea claim (The Dr. wrote it was medically neccesary to use the CPAP, so I do expect the 50%. This C&P below was conducted to separate my anxiety disorder from my TBI disorder. Currently I have a 70% rating for Anxiety with residuals of TBI. I was wondering if anyone could read this and tell me if they think I can expect a separate rating for TBI memory loss based on the Dr's opinion stating that my issue is 80% anxiety and 20% TBI (see note 2b below). If I can get at least a 10% for TBI in addition to the 70% for anxiety, It should push me over the threshhold of 100% schedular. The only edits I made to this was to remove names. Again, thank you for your time and expertise 70% Anxiety (Trauma with TBI residuals) 50% Sleep Apnea 20% Degenerative Disc Disease 20% Upper Neuropathy Right / 20% Upper Neuropathy Left 10% Lower Radiculopathy Right / 10% Lower Radiculopathy Left 0% TBI Migraines LOCAL TITLE: COMP AND PEN NOTE STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 28, 2019@14:30 ENTRY DATE: JAN 30, 2019@11:11:26 AUTHOR: *********** E EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Name of patient/Veteran: ***** Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes [ ] No ICD code: 300.00 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Unspecifed Anxiety disorder, chronic, severe disorder. ICD code: 300.00 Comments, if any: Vet had been seen initially on 2/11/18 for Mental Health C+P exam done by Dr. *****(which proposed "Anxiety disorder, NOS" then, while f/u C+P exam on 2/16/14 had proposed Other specified trauma and stressor related disorder(as vet had been in IED blast in 2006 - see Mental Disorder diagnosis #2 below. Unspecified anxiety disorder is synonymous with Neurosis - which vet is already 70% SC for, in combination with residuals of TBI apparently). I am therefore not intending to change his Neurosis condition now, but Unspecified anxiety disorder is most accurate diagnosis consistent with DSM-V, as I see it now. Mental Disorder Diagnosis #2: Cognitive disorder due to Closed Head iInjury(CHI), due to 6/1/2006 "double-attacked anti-tank mine" IED blast. ICD code: 294.9 Comments, if any: Vet was in 2nd Iraq combat deployment - out of 3 tours he served there - when 6/1/06 IED hit his heavy equipment vehicle(which vet had referred to as 'palitizing loading system'). b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Vet is already 0% SC for migraine headaches. Comments, if any: Vet is already SC for migraine headaches. Vet is already 20% SC for Intervertebral DIsc Syndrome, 20% SC for Paralysis of musculospiral nerve(x2), 10% SC fo paralysis of sciatic nerve(x2). Vet also apparently had a 2/15/18 sleep study done that indicated a mild sleep apnea condition. 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 Symptoms(i.e., anxiety, sleep problmes) are due to Unspecified anxiety disorder, while symptoms(memory problems, headaches) are due to Cognitive disorder due to CHI. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed d. Is it possible to differentiate what symptom(s) is/are attributable to TBI and any non-TBI mental health diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A) If yes, list which symptoms are attributable to TBI and which symptoms are attributable to a non-TBI mental health diagnosis see 2b above. 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 deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [X] Yes [ ] No [ ] Not Applicable (N/A) If yes, list which occupational and social impairment is attributable to each diagnosis About 80% of vet's current occupational and social impairment is due to Unspecified anxiety disorder while about 20% is due to Cognitive disorder due to CHI. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [X] Yes [ ] No [ ] Not Applicable (N/A) If yes, list which impairment is attributable to TBI and which is attributable to any non-TBI mental health diagnosis see 3b above. SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS [X] Other (please identify other evidence reviewed): Vet broiught a 4 page typed letter 1/12/19 done by himself describing in detail his current ongoing issues("I did not want to forget to tell you something important"), and vet admits it took him severalhours to complete(and which he kept revising many times). He brought a 2 page letter dated 1/27/19 done by his wife ******, a 2 page typed letter dated 1/17/19 done by mother ********, and a 1 page typed letter dated 1/27/19 done by vet's friend/combat comrade(served together in Iraq) named *******, and all 4 letter were reviewed by me. Evidence Comments: CPRS was reviewed by me and included my(***** MD) 12/5 18 Review TBI C+P exam report, as well as 5/16/14 C+P exam report done by Dr *****(sa well as Initial 2/18/11 MH C+P exam aslo done by Dr. ******. VBMS was reviewed by me and included vet's Army DD-214 signed b ***** which included MOS(88M30) Mortor Vehicle Operator,as well as E-6 discharge rank. His medals included CAB - among others, and he had Iraq combat dates of 1/03 - 7/03, 8/05 - 8/06, and 3/08 - 6/09 - for his 3 seperate Iraq combat tours. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Vet is married ****(and they have 2 sons(around ages 5 and nearly 7). b. Relevant Occupational and Educational history (pre-military, military, and post-military): Vet has been working in his current Passport Agency job since 2015(was at an administrative clerk(for a different agency) before that. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Vet has been on sertraline 150mg since 9/10/18 - it takes the "edge" off my problems, but he apparently has been having some sexual side effects(delayed ejaculation) related to that . d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Vet has had no legal problems(and no jail time) since the 5/14/16 C+P exam report date. e. Relevant Substance abuse history (pre-military, military, and post-military): Vet has had no alcohol misuse disorder problems sicne 5/16/14. He has used no street drugs since 16/14. 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] Anxiety [X] Suspiciousness [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Obsessional rituals which interfere with routine activities 4. Behavioral observations -------------------------- Vet was totally genuine at the 1/28/19 Review Mental Health C+P exam. 5. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [X] Yes [ ] No If yes, describe: Vet admits to having anger difficulties, 'spacing out' at times, and general feeling of being confused/overwhelmed. He reports having lost his social "filter" abilities. He reports previously having been very "easygoing" prior to the military. Vet still gets nervous if seeing sandbags lying on the side of the road - left by construction crew(as that is what he looked for over in Iraq as being a potential IED.) He has to reorganize plates/trays a certain way, either at home or when leaving a restaurant, respectively. He denies having any suicidal thoughts("No, I'm addicted to life, I love breathing".). 6. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 7. Remarks (including any testing results), if any: --------------------------------------------------- Vet owns a pistol. He does not hunt - only tried it once, but did not get anything then. He denied having any current active suicidal or homicidal ideation.
  17. I would like to thank you all for the information that helped me gather my information in my other question. Took most of the year, but finally filed PTSD due to personal trauma, early Jan 2019. Intent to file was running out. I did file some secondary conditions as well. I have just been called by VES to have my C&P PTSD exam in March. A question and answer exam I was told, 30-45 min. Glad I have researched similar exams here. Berta, Andy, Buck, Geekysquid, Thanks for the help and guidance. Was able to a buddy statement, CID records, VET center records from before I was discharged and current, and other current discipline records from work. Good statements from my wife and I as well.
  18. I recently did a new C&P for PTSD when I filed for I.U. He neglected to mark a lot of my symptoms. I am currently rated at 50% PTSD, was wondering if you think this keeps me a the same or warrants an increase. He did forget to mark my suicidal ideations and a few other symptoms though so I am worried I won't be rated correctly. Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.10 Mental Disorder Diagnosis #2: Panic Disorder ICD Code: F41.0 Mental Disorder Diagnosis #3: Major Depressive Disorder, Recurrent ICD Code: F33.1 Mental Disorder Diagnosis #4: No Axis II disorder b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: The PTSD is currently the more severe and responsible for the veteran's current level of impairment; the clinical depression and the Panic Disorder are certainly significant, however. The depression and Panic Disorder are seen as more likely than not caused by the chronic PTSD symptoms. It is difficult to ferret out the contribution of the three disorders due to the overlap of symptoms and variability of degree; at times any of the three disorders may be the more severe, but the PTSD is responsible for the current level of impairment. 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 [X] No [ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The PTSD is currently the more severe and responsible for the veteran's current level of impairment; the clinical depression and the Panic Disorder are certainly significant, however. The depression and Panic Disorder are seen as more likely than not caused by the chronic PTSD symptoms. It is difficult to ferret out the contribution of the three disorders due to the overlap of symptoms and variability of degree; at times any of the three disorders may be the more severe, but the PTSD is responsible for the current level of impairment. 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. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Veteran received his previous PTSD C&P on Mar 2016. At that time he was living in an aparments. He still lives in but has moved to a different aprtment. He lives with a roommate. He is not in a relationship. The veteran is not employed. His typical day consists of going to school, "I have classes five days a week but "I only go two days a week because of panic attacks. When I'm home I sometimes lay in bed and cry or think about everything." He noted he does not sleep much at all. He said he only gets out for school; is roommate will cook and get most of the groceries. b. Relevant Occupational and Educational history: The veteran has not worked since he was discharged from the Air Force in 2016. He has applied for jobs and tried to do a work study but quit because of panic attacks; at times he will scream and hit his back pack. He started there in August and is taking 12 units. He is schedule to attend classes five days a week but rarely makes all five days. "I'm close to failing a couple of classes for attendance. c. Relevant Mental Health history, to include prescribed medications and family mental health: The veteran is current being followed by a staff psychologist every two weeks; he has being seeing her since August. He is also followed by a staff psychiatrist who prescribes: prazosin and Celexa. He has taken other medications. He said they help only a little bit. d. Relevant Legal and Behavioral history: Denied by the veteran. He did say he got into an altercation about two weeks ago at the gym when he through a dumbbell at the floor; he was kicked out. e. Relevant Substance abuse history: The veteran has not drank alcohol for over one years; he denied ever abusing it. He does not use illegal substances. 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 symptom s below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Intense or prolonged psychological distress at exposure 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, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. 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] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Panic attacks more than once a week [X] Mild memory loss, such as forgetting names, directions or recent events [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Neglect of personal appearance and hygiene 5. Behavioral observations -------------------------- No unusual behaviors observed. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: The veteran reports having suicidal thoughts 3-4 times a week but doesn't dwell on them. He said he would never attempt suicided because of his kids. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- No remarks provided.
  19. Only musculoskeletal DBQs (back upper and lower, knees, feet, hips, shoulders, arms, hands, etc.). Nothing else. The VA does them for FREE but if you need help (i.e. your claim is taking too long, VA will not examine you, or you need a second opinion), this guy I believe is among the best most qualified orthopedic surgeons I've seen in my life. He will be fair so please bring all your evidence to him. He will get paid no matter the outcome (favorable or unfavorable) of the exam. I felt he was fair on my exam. His contact information: Regional Orthopaedic Medicine: Weiss David DO Address: 201 Woolston Dr, Morrisville, PA 19067, United States Phone:+1 215-736-2410 IMPORTANT: His time is very limited because this practice is very busy. He did 3 (2 for claims for increase and one for new claim) DBQs for me and assured me that he could help other Veterans in a limited basis. He charged me $500 for all 3 which I thought was good. He also prepared a medical opinion for one of them. You should be LOCAL (NJ, PA, or even NY, DE, WV, or be willing to travel or flight to include hotel). You can tell him if you want to that I referred you to him. Please be patient with him as I think he is a really good doctor but found the process with DBQs to be a bit tough, but he did them for me, and said he will help other Veterans if they call and adjust to his busy practice. Just wanted to provide this information in case any Veteran needs it.
  20. C&P Exam PTSD:MST Eating Disorder.pdf ^^^^^^Well the attached report indicates to me a 10% PTSD rating. I am currently 30% and I do not understand how this happened but I might be in for a reduction. I thought the exam went well. I had a PTSD and Eating Disorder C&P. Regarding the occupational/social impairment she checked the one that resembles 10% and for "b" she marks YES and goes on to say my trauma impacts my occupational/social impairment. Look at the symptoms she notes: Anxiety; Panic Attacks more than once a week; Chronic sleep impairment; difficulty in establishing and maintaining effective work and social relationships She even stated in the exam that I was BDD (Body Dysmorphic Disorder) but her reports indicates while I have BDD characteristics I don't warrant the BDD rating. She states for the VA established diagnosis of SPECIFIED TRAUMA AND STRESSOR RELATED DISORDER, there is NO CHANGE in the diagnosis. At this time the claimant's condition is active. Does this Exam mean I am going to be reduced or would I fall under the below??? 3.344 Stabilization of disability evaluations. (a) Examination reports indicating improvement. Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and Department of Veterans Affairs regulations governing disability compensation and pension. It is essential that the entire record of examinations and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. This applies to treatment of intercurrent diseases and exacerbations, including hospital reports, bedside examinations, examinations by designated physicians, and examinations in the absence of, or without taking full advantage of, laboratory facilities and the cooperation of specialists in related lines. Examinations less full and complete than those on which payments were authorized or continued will not be used as a basis of reduction. Ratings on account of diseases subject to temporary or episodic improvement, e.g., manic depressive or other psychotic reaction, epilepsy, psychoneurotic reaction, arteriosclerotic heart disease, bronchial asthma, gastric or duodenal ulcer, many skin diseases, etc., will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Ratings on account of diseases which become comparatively symptom free (findings absent) after prolonged rest, e.g. residuals of phlebitis, arteriosclerotic heart disease, etc., will not be reduced on examinations reflecting the results of bed rest. Moreover, though material improvement in the physical or mental condition is clearly reflected the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. When syphilis of the central nervous system or alcoholic deterioration is diagnosed following a long prior history of psychosis, psychoneurosis, epilepsy, or the like, it is rarely possible to exclude persistence, in masked form, of the preceding innocently acquired manifestations. Rating boards encountering a change of diagnosis will exercise caution in the determination as to whether a change in diagnosis represents no more than a progression of an earlier diagnosis, an error in prior diagnosis or possibly a disease entity independent of the service-connected disability. When the new diagnosis reflects mental deficiency or personality disorder only, the possibility of only temporary remission of a super-imposed psychiatric disease will be borne in mind. (b) Doubtful cases. If doubt remains, after according due consideration to all the evidence developed by the several items discussed in paragraph (a) of this section, the rating agency will continue the rating in effect, citing the former diagnosis with the new diagnosis in parentheses, and following the appropriate code there will be added the reference “Rating continued pending reexamination ___ months from this date, §3.344.” The rating agency will determine on the basis of the facts in each individual case whether 18, 24 or 30 months will be allowed to elapse before the reexamination will be made. (c) Disabilities which are likely to improve. The provisions of paragraphs (a) and (b) of this section apply to ratings which have continued for long periods at the same level (5 years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. Reexaminations disclosing improvement, physical or mental, in these disabilities will warrant reduction in rating.
  21. How do I get an IG investigation into why the VA Medical Division cannot produce the copies of OPTR that have been removed from my C&P file. At my BVA hearing, in response to the question of how to get the needed probative documents, the BVA Judge responded, "LOL, we can't even get them." The reason is itself very probably probative. Such as we were unwitting subjects in research and the researchers were too lazy to make the double original copies. West Los Angeles VA Medical Center had its Research Credential abruptly revoked in 1999. I suspect the documents I'm trying to get from 1990 and 1991 are involved. I either need the documents or the reason I can't get them. So far, even disputing the RBA at the CAVC has garnered neither and the Clerk has closed the dispute without getting his order to the Appellee filed. Something suspicious in the way I was treated by the Clerk and the VA attorney in the hearing on the subject. They claimed documents probative to the diagnosis of seizures were not relative to an increase in the TBI rating increase in appeal because there was a diagnosis of pseudo seizures. The reason the documents are needed is to prove the diagnosis of pseudo seizures is erroneous and that I was treated with a drug, Tegretol, that was expected to often make the type of seizures I have, Temporal Lobe atypical absence and complex partial seizures, worse, even often causing generalized (grand mall) seizures. PDR 1990 through the present. The warnings are more severe in the current PDR.
  22. Hey all just want to share what I think of is good news, even though I still have to sit and wait. On 8//16/2018 I had a C&P review for my PTSD which was 70% with 10% Tinnitus rating. I was initially rated in 2013 and I had made no requests for adjustments. VA just mandated this C&P. Today, 8/24/2018 ebenefits was up and down all day so I could not really read anything on my statuses until 6 pm PST. I went in and I am, according to ebenefits, at 100% and in the letters I see my rating is P&T. I am over the moon. This RO must be the rocket docket or the QTC doc really wrote a solid case for the bump. or both. Either way I am now in the "watch the mailbox" phase since I won't believe it until i either get paid or the packet arrives. Thanks for all the input from everyone on other posts and my rambling questions.
  23. 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.
  24. Hello, I have a rating decision for PTSD 70%,IBS 30% and Tinnitus 10% the rating decision was 6/23/2015 and the va decision has effective date of 10/29/2013(FDC),I was moved from TDRL to PDRL at 70% due to Combat related PTSD. My question is when the VA revaluates me,which shows scheduled for June/2020 as per VA letter ,will the rating be considered stable from the effective date or from the decision date? Does the DBQ the DOD did to move me to PDRL stating my PTSD is stable and not likely to improve have any weight on the VA reevaluation? I currently see VA Psychiatrist monthly and have since before being rated Other ratings: 50% SA(secondary to PTSD) 30% Pes Cavus (bilateral feet) 10% Lumbar DDD 10% Radicuapthy (secondary to Lumbar) Thank you for any information.
  25. I suffered a back injury while in the ARMY years ago. My back has continuously given me problems. I am SC for DDD and was wondering how can i go about service connecting Diabetes 2? Any information or case studies will be of great help.
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