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Found 25 results

  1. I filed an agent orange cad claim by e-file using the option of a fully completed claim on March 5th. I received a 10 per cent disability decision this week. My mistake was I didn’t have my private physician Fill out a DBQ and complete the interview based METS section. My question is can I file another 21-526 EZ adding the new information for my approved 10 per cent by e-file? The approved 10 per cent is based upon medication only. I don’t want to appeal an approved claim and need to know how to correctly update that claim with new information .
  2. PTSD) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Antisocial personality disorder ICD Code: F60.2 Mental Disorder Diagnosis #2: Opioid use disorder ICD Code: F11.20 Mental Disorder Diagnosis #3: PTSD ICD Code: F43.10 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Deferred to medical 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) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Antisocial personality disorder is responsible for contentious interpersonal relationships including threats, aggression, assault; failure to accept responsibility; violation of social norms and law; impulsive decisions and behaviors; and affective instability. In the symptom list below antisocial personality disorder is responsible for impaired judgment, disturbance of motivation and mood, difficulty establishing and maintaining effective social/work relationships, difficulty adapting to stressful circumstances, and impaired impulse control. Opioid use disorder has been in institutional remission June 2018, and is not at this time contributing to the symptom picture. Substance use is well known to have deleterious effects on mood, cognition, and behavior. When active, however, these symptoms likely take a predominant role. PTSD is responsible for the remaining symptoms below, which include depressed mood, chronic sleep impairment, and flat affect. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated 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: As noted above regarding symptoms, Antisocial personality disorder is primary and PTSD is secondary. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS 2. Recent History (since prior exam) ------------------------------------ a. Relevant social/marital/family history: The veteran last completed a PTSD review DBQ 06/20/17, and he reported that since that exam he has moved from Columbus to Marysville. The veteran currently is in residential programming at Chillicothe VA, hoping for placement in the DOM. The veteran denied his family situation since last exam. Socially, the veteran said he is getting along well with other residents here. His girlfriend and mother visited him here. He said he is made some acquaintances in the programming as well as a couple friends. b. Relevant occupational and educational history: The veteran denied changes in education since last exam. He has completed a GED and some college, and has a license to work with fuel and chemicals for shipping. The veteran denied employment since May 2017. He worked in landscaping prior and occasionally for his mother after that. His mother's business is sales of retail and bank machines. He said his mother arranged his hours to suit him. c. Relevant mental health history, to include prescribed medications and family mental health: The veteran denied pre-military and military mental health treatment. Specifically, he denied a history of hospitalization, suicide attempt, outpatient therapy, and prescription of psychotropic medications prior to about 2001. CPRS and VBMS were reviewed with the following relevant mental health entries. 06/20/17: PTSD review DBQ. MSE: Mood and affect depressed, otherwise normal. Examiner opined significant impairment. 06/14/18: Medical certificate. The veteran requested admission due to depression, suicidal ideation, overdose attempt on Seroquel and alcohol last evening, and hearing voices telling him to kill himself every day. UDS was positive for oxycodone, Suboxone, and cannabinoids. DX: Cocaine dependence; alcohol abuse; cannabis dependence; opioid dependence; PTSD. 06/19/18: Medical certificate. Veteran seen for change in programming. MSE: Normal except for dysphoric affect. d. Relevant legal and behavioral histor y: The veteran denied arrest since last exam, however, he has 3 years and 3 months left on parole. As a juvenile, the veteran was arrested for trespassing, DUI, domestic dispute. He denied being remanded to juvenile detention. During military, the veteran was arrested for underage consumption. He also received NJPs for being late to work (up to 10 hours), possession of pornography, disrespect to a commanding officer, and drinking while on duty. After service, the veteran has been arrested for domestic violence 2, aggravated robbery 3, and theft. He served 10 years in ODRC. While in prison, the veteran reported that he ran the inmate "store" providing drugs, contraband items, and running gambling schemes. He received over 50 tickets for institutional rules violations while in prison. He was released in September 2016. e. Relevant substance abuse history: The veteran reported that historically he has rarely used alcohol, perhaps 1-2 times per month and none since June 2018. The veteran denied use of illicit drugs since June 2018. In the period immediately prior he primarily used narcotics and heroin. f. Other, if any: Nothing further. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non- combat related stressors). Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) 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). 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. 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] Hypervigilance. [X] Exaggerated startle response. [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] Chronic sleep impairment [X] Flattened affect [X] Impaired judgment [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] Impaired impulse control, such as unprovoked irritability with periods of violence 5. Behavioral observations -------------------------- The veteran presented as guarded. We were able to establish adequate rapport through time. He initiated conversation and elaborated on topics, often to highlight the frequency and severity of symptoms. He was easily re-directed, however. He was cooperative in that he answered all questions asked. The veteran's mood was neutral and stable. His affect was mildly flat and mildly irritable, with limited mobility in range and intensity. The veteran seldom smiled and laughed, and seldom responded to humor. He was not tearful. There was no hopelessness and helplessness evident in his comments. There was no objective evidence of facial flushing, vigilance, arousal, tremor, perspiration, or muscle tension. Speech, thought processes, orientation, attention, and memory all were within expectations. Psychomotor was remarkable for bouncing a leg. Given vocabulary, and educational, employment, and military history, I estimate his IQ in the average range. The veteran denied recent changes in sleep, noting he experiences nightmares about 70% of the time. He appeared alert and rested and did not report functional loss due to sleep problems. He said his appetite is unchanged with some weight increase with abstinence from drugs. Thought content was negative for objective signs of psychosis and the veteran denied same. He also denied suicidal and homicidal ideation, but added "They call it passive SI. I'm getting better at telling people about it." Given several opportunities, the veteran reported current symptoms of: Nightmares; not liking to think about the military event; staying away from crowds; inability to interact with people; increased stress with work; blaming himself for the event happening; being aware of his surroundings; isolating from others; not sleeping well; drug use. The veteran reported abilities indicating that he retains considerable cognitive capacity (physical capacity is not assessed here). When home, he enjoys gardening, growing roses, and mowing his sisters grass. He told that he can drive independently. The veteran said he can perform personal care independently. The veteran told that he can use a calendar, clock, calculator, telephone, and computer. He reported that he can manage money, appointments, and medications, as well as shop and pay bills. For enjoyment he watches TV on his laptop, works out, watches OSU football, and does some light reading. He had good social skills on exam. Socially, the veteran said he is getting along well with other residents here. His girlfriend and mother visited him here. He said he is made some acquaintances in the programming as well as a couple friends. 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: --------------------------------------------------- ****This forensic report is a legal document intended for the sole use of VBA in determining the veteran's eligibility for compensation and pension. This examination is very different from other psychological examinations, such as for treatment, with considerably different criteria and, thus, often with considerably different diagnoses and outcomes. As such, great caution is needed in interpreting this information and use of this report outside its intended purpose by VHA personnel, VSO, and/or the veteran is STRONGLY discouraged. This examination does not constitute a rating decision. Rating decisions are made solely by the Regional Office after all available data have been reviewed and verified. Note that "The examiner should not express an opinion regarding the merits of any claim or the percentage evaluation that should be assigned for a disability. Determination of service connection and disability ratings for VA benefits is exclusively a function of VBA" (VHA Directive 1046). Thus, any questions or concerns regarding rating decisions should be directed to the Regional Office or an Appeals Board.**** The veteran was seen today for this PTSD Review exam. I verbally provided the usual informed consent regarding: this being a VBA assessment, not treatment; the report becomes a legal document; the forensic role of VBA; the potential outcomes of a review exam; and limits to confidentiality. A written copy of Informed Consent was offered. Throughout the interview the veteran inserted nearly every symptom of PTSD listed in the DSM 5. He noted often that these symptoms are severe and prevent him from interacting with people and working with others. This was not particularly consistent with mental status and functional data. Some patterns of thought developed throughout the interview, such as when the veteran noted that when people try to enforce rules or consequences for his behavior he makes threats and blames them for causing him to use substances. He noted that all his criminal behavior and drug use is due to the military assault, even though he also reported that alcohol and drug use began at an early age, as did arrest. For example, the veteran said that the traumatic event in service caused and or heightened his drug use in response, but he also commented that "I figured out when I was younger that using drugs and alcohol makes problems like that go away." The veteran noted that he was found to have steroids in his jacket while at Bay Pines. He subsequently was discharged from the program. He then interpreted that as "people make me fail. That (being discharged from Bay Pines) put me in a bad place and made me attempt suicide. They deny my individual unemployability because they say I'll get better with treatment, then the treatment kicks me out and I'm worse now." This behavior and thinking is quite consistent with personality disorder. The veteran was diagnosed with PTSD in prior C&P exams, the diagnosis has been carried forward by treatment providers, and by his report continues with sufficient symptoms for the diagnosis. Thus the diagnosis of PTSD continues, as likely as not due to events in military service. Antisocial personality disorder was present well before military service, so it is less likely as not caused by military events, and there is no evidence that this disorder was exaggerated by military events. Also, alcohol and illicit drug use clearly was present prior to enrollment in military, so it is less likely as not caused by military service. There is no evidence that the veteran's substance use was due to events in military service nor has it progressed beyond the normal course for this disorder. Put another way, even if the military event had not occurred it is likely that the resulting pattern of substance use would have been present. Moreover, while there is some equivalence in the literature about the direction of causality when both mental disorder and substance use are present, DSM 5 does not acknowledge any substance use disorder as "due to mental illness," yet there are numerous "substance-induced" mental disorders. INDIVIDUAL UNEMPLOYABILITY The veteran retains considerable residual mental function (physical limitations, if any, are not assessed nor considered here). The veteran can perform personal care independently. He has a driver's license and drives independently. The veteran can use a calendar, clock, calculator, telephone, and computer. He can manage money, appointments, and medications, as well as pay bills. There is no mental disorder that prevents him from attending to, learning, and persisting to complete simple and complex tasks. There is no cognitive dysfunction that would prevent same. His performance on mental status in attention, concentration, memory, abstraction, and thought processes were within expectations for age. The veteran reported limited socialization. Yet, he dated, married, and maintains a current relationship (after divorcing). He maintains some contact with family. Moreover, the veteran was a quite bright, capable, pleasant, cooperative gentleman on exam, and his social skills here were excellent. He reported isolating at home, not liking to be around people, and having difficult relationships through time. The veteran is not a member of any clubs/organizations. Indeed, personality disorder is predictive of contentious interpersonal relationships and the affective instability and impulsive decisionmaking/behavior of the personality disorder may interfere with motivation and concentration.
  3. Hello everyone I am new to the site. And I recent submit a the dbq for an increase for my PTSD and I trying to understand it but im just not getting it. So I figured would ask you all. Below is what the examiner put in the record. Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: ========= Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: F43.1 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Evidence Comments: MENTAL HEALTH OUTPATIENT FOLLOW UP NOTE [excerpts] DATE OF NOTE: MAR 05, 2018 AUTHOR: ========,NP NURSE PRACTITIONER CHIEF COMPLAINT: "same old same old" INTERVAL HISTORY: Veteran is here for 6 week follow up for PTSD, Alcohol Use Disorder, unspecified, episodic. At last appointment, low dose venlafaxine was added, aripiprazole, prazosin, and melatonin were continued. He reports symptoms are about the same. His wife is pregnant with twins, so he is trying to minimize arguments at home. He worries he will not be able to connect with the babies, because he struggled so much with his daughter and points to her persistence as the reason they are close now. He see no change in sleep, remains irritable, and more hypervigilant due To recent car break ins on his street. He has cut down on drinking, and denies any binges since last appointment. He continues to have fleeting SI, but denies intent. He often has thoughts of hurting others, but strongly denies acting on the thoughts. No recent hallucinations. He does talk to himself when he is trying to work something out, but denies hearing voices other than his own. It can be embarrassing as coworkers and wife have caught him. ASSESSMENT AND TREATMENT PLAN GOALS: DSM 5 Diagnostic Impression PTSD Alcohol Use Disorder, Unspecified, episodic Goals: 1. Decrease irritability and anger- does not interfere with home or work life more than one time per month, ongoing, improving 2. Improve feeling of connection with others- enjoying and developing relationships, ongoing, no change 3. Decrease avoidance of social situations/crowds- can tolerate Wal Mart, enjoy outings with family, ongoing, no change 4. Improve sleep- no difficulty falling asleep, sleep 6 to 8 hours nightly, ongoing, worsening PLAN AND PROGRESS TOWARDS TREATMENT PLAN GOALS: reviewed records and discussed options - increasing venlafaxine to 75 mg - continuing aripiprazole, prazosin, and melatonin - suggested individual supportive counseling at the Vet Center after Dr. Bhatia leaves. - monitoring labs at next appointment - Will continue to follow closely. RTC 6 weeks/PRN 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Last C&P PTSD DBQ May 2016 Lives in Moncks Corner, SC with wife of 9 years and daughter age 4. Daily routine: Lay down for bed 2100. Will fall asleep 2300. Wake frequently. "I have to do certain things to calm down. I need my gun next to me. I have to check the house make sure its locked. Make sure the alarm is on. If I hear something, it wakes me right up and I have to check it out." +Nightmares, night sweats. "Sometimes I'm swinging and yelling and talking in my sleep, so my wife leaves for a different room. I wake up and she's not there and it freaks me out." Prescribed melatonin for sleep, prazosin for nightmares. Abilify for PTSD. Diagnosed sleep apnea by sleep study in 2013, prescribed CPAP and is compliant. Relationship with wife: "We almost got divorced a few times. She didn't understand what was going on. She started reading up on it. The whole reason I went to mental health was because of her." Relationship with daughter: "She is scared of me. She has seen me Snap a few times. She is on guard. She doesn't know if I'm going to be up or down. She is my heart. She is the only thing that makes me feel normal." Will watch cartoons and read books together. Hobbies: play basketball, go to gym "but now I just sit in the House watch TV or just in the room." Likes anime. Support: father "he's been with me through everything." And is Veteran too, wife "but there is a wall there where I don't open up." b. Relevant Occupational and Educational history: Working for passport services for 3 years. "Its rough at times. There's a lot of people in there. They had to move my seat because I'm too jumpy. They moved it so I'm not around a lot of people. It is hard to focus. I have to use sticky notes. They have been pretty supportive. I've had good supervisors." Was counselled about days missing for work; "I had a blow up at my co-workers so they spoke to me about that." Miss 2-3 days per month. "When I get to work, I drive around the Building and if I see something I don't like, I just go home." Military history: E4, MP, Separated 2014, Honorable, Served about 6 years. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mental health treatment with prescriber and therapist. No history of hospitalizations. Was in group therapy "but I didn't like it." d. Relevant Legal and Behavioral history: "When I was in Japan I got us into trouble because of my alcohol abuse. I got into a car accident and hit 3 cars." Was sent to ADAP for anger and PTSD. A month ago got into a physical altercation with sister's boyfriend "I laid hands on him. So then I went to a hotel room and stayed there and then I went on a drink binge." e. Relevant Substance abuse history: Alcohol - "I abused it really bad. My PCM said it was affecting My liver." Was drinking4-5 25 oz beers, drink a bottle of liquor over The weekend. Now will drink 1-2 beers. Tobacco - 2-3/day Denies other substances. f. Other, if any: Current reported symptoms: Anger: "I black out and become very violent. I knock TVs off walls. My wife was ready to leave me." Triggers: "foggy day and rain." "Ignorant and stupid people." Social avoidance. "If a car is behind me too long, I start to think he is following me. There is a particular truck that I know and he gets too close to me. I got sick of it and one day I followed him home. I didn't do anything, but I blacked out mad. I knew I needed help." Flashbacks - "I was shopping with my wife, and this guy had a turban on his head and I thought I was back there. Its constant, its all the time." Hygiene - "My wife got on my because I went a week without washing And I didn't even realize it." Suicide - "I thought about driving into traffic at the light. One Time I sped up and got on railroad tracks when a train was coming. I thought, what am I doing? I went into store parking lot." Reports this occurred 2 weeks ago. "I keep a picture of my daughter in the car to keep me from [doing it]." 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors). Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) [X] Witnessing, in person, the traumatic event(s) as they occurred to others Criterion B: Presence of (one or more) of the following intrusion Symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing Memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure To internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the Traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Flattened affect [X] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Suicidal ideation [X] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Neglect of personal appearance and hygiene 5. Behavioral observations -------------------------- Veteran was open and forthright with no evidence of exaggeration or feigning symptoms. Affect blunted. Minimal eye contact. Speech regular rate, tone, volume. Thought process linear, logical, goal directed. Thought content absent for delusions, hallucinations, paranoia or HI. Endorses SI with no active plan, but drove car onto train tracks last week. Discussed safety, crisis line, Veteran has MHC appointment next week. Veteran reports safety to return home today. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- PCL-5 score 72, indicating probable diagnosis of PTSD. Veteran continues to meet criteria for PTSD. He reports social withdrawal, sleep problems, memory problems, irritability, anger that is both verbal and physical, suicidal thoughts. He has work accommodations because of his PTSD symptoms. He misses several days of work a month because of his symptoms.
  4. Been quite awhile since I posted anything... (Last post was this Been in that hurry up and wait limbo status that everyone hates, but after 630 on appeal via DRO process (average time was somewhere between 311 and 400 days I think) I finally receive a letter informing me that I have a disability examination. Since this is my first time through this part of the process I would like some simplified translation of what all of this means. At face value it looks as if it means they are going to look at my records and do an exam. But I also, understand that some of these individuals aren't really working in the best interest of the vet. This fact pretty much is giving me an anxiety attack worrying about it. I know this is irrational, but, with hearing all of the horror stories it isn't surprising to feel this way. I want to be fair and honest going into this exam, but I also know, that by being too "helpful" can actually be detrimental to a claim and getting subsequent medical services (my knees and back are shot). Like with my back, flex, I can only bend about 12 Degrees before I have to bend at the waste. This was measured during therapy I was receiving through private insurance with a galvanometer. I know this doesn't mean a hill of beans when it comes to a VA disability examination. So any tidbits of sage advice would be greatly appreciated (as long as it doesn't mean committing fraud.) I don't know if this will be used as the C&P examination or if this just means a very small step in a "direction" (not necessarily favorable). Thanks for the advice and encouragement Joe
  5. Currently rated 10% for GERD and applied for an increase. Had my primary civilian doctor look over my medical records and asked if she would fill out a DBQ. Luckily she did because I know how some doctors would not. Anyone have any guess on if I could be getting an increase or not? Also, does anyone know if I will be scheduled for a C&P as well? It's no problem if I have to go but I just figured with a DBQ then it could easily be fast tracked without having to schedule a C&P since I had already been service connected. Thanks!
  6. I tried to find the DBQ for TBI from the download list. It is missing in action. Is this because of the revision in process of 38 CFR? I need it to get an neuropsychological assessment done by protocol by a local source. The VA is insisting they cannot use a local contractor and that I must travel to Denver, 3.5 hours away for the assessment. The remand didn't specify it be done by a VA qualified psychologist. Only that it be done in protocol which the last one wasn't. Looks like I'll have to go to the CAVC with this.
  7. 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?
  8. Hello team, I'm about to file my claim for Occipital Neuralgia. I want to use my private doctor with a DBQ. My issue is that I don't know which DBQ to use. There are two neurological DBQs that I think could be the one I need but, they don't list the occipital nerve on them. Can someone that is familiar with this help me? Peripheral Nerve Conditions http://www.vba.va.gov/pubs/forms/VBA-21-0960C-10-ARE.pdf Cranial Nerve Conditions http://www.vba.va.gov/pubs/forms/VBA-21-0960C-3-ARE.pdf I'll also have the doctor fill out the Headaches DBQ since this causes god awful headaches. Thank you in adanced, Stephens
  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. 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
  10. Are there any suggestions or preferred methods on how to approach an independent doctor to perform a VA evaluation for your conditions, service connect an event during service, and fill out a DBQ?
  11. I recently completed my C&P exam on 3/14/17. Can anyone give me some insight on this. Some information I relayed to the Dr. apparently went in one ear and out the other. Any information is helpful. ThanksDBQ ( back ).pdf
  12. I am 70% with ptsd and lumbar strain. I have sinced been diagnosed with DMII, Hypertention and sleep apnea with a cpap machine. How or can I SC any of my diagnoses. Any advice is greatly appreciated.
  13. HI everyone, I am helping my dad with his recently submitted claim. He requested an increase to his 30% rating from 2003, among other things. On ebennies it has DBQ PTSD Review recommended under "evidence needed." I sent quite a bit of evidence showing worsening conditions since 2003 when I submitted the FDC in December. Will not providing one hold up the process? Does he need to submit this DBQ? If he does, will it take him out of the Fully Developed Claims for submitting new evidence? Thanks for the help as usual.
  14. HI everyone, I am helping my dad with his recently submitted claim. He requested an increase to his 30% rating from 2003, among other things. On ebennies it has DBQ PTSD Review recommended under "evidence needed." I sent quite a bit of evidence showing worsening conditions since 2003 when I submitted the FDC in December. Will not providing one hold up the process? Does he need to submit this DBQ? If he does, will it take him out of the Fully Developed Claims for submitting new evidence? Thanks for the help as usual.
  15. I recently finished a series of C&Ps for various conditions and I was hoping to get some input on just what exactly it all means - I was wondering what if any kind of rating might I be looking at? Is there a possibility for getting back pay? What can I do (possibly in an appeal) to do more to strengthen my case? At this point my case should be done with the gathering evidence phase (I can't check because ebenefits is being weird). All C&P's are done and everything that needed to be turned in is (I hope). The first C&P/DBQ I'd like assistance with is my claim for "Lower Back Condition". Originally I had claimed "chronic lower back pain" only to later find out that really isn't a thing and thus I was denied. When I went in for this most recent exam the reviewing doctor first went to my C-File and saw that I had claimed "chronic lower back pain" back in 2004. He then went into my military treatment record and found considerable amounts of treatment records for several issues in my lumbar spine and beyond. "They should have connected you back in 2004" he said to me. Sufficed to say that his positive first impressions put me a little more at ease with the C&P (which normally turns me into an anxious, nervous wreck). I've now gained access to the DBQ and would like any information that you well informed folks could provide. I've cut it down as much as I thought I could. If a question is missing and/or option is missing assume it wasn't checked. All non-pertinent information I cut out and did some heavy editing as far as formatting goes. Here it is: Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VA medical records. 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: LS strain, chronic, with LLE radiculopathy Date of diagnosis: 2000s 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): During military service, the Veteran did develop chronic left lower back pain with radiation down the left buttock to the calf. On 6/10/2003, an MRI of the LS spine was performed with the following findings: Broad based posterior/central disc bulging at L4-5 without associated neural impingement. After service discharge in 2004, the Veteran continued with intermittent lower back and LLE problems. Repeat lumbar MRi in 2009 was read as normal. Currently he continues with chronic daily left lower back pain with LLE weakness and paresthesias. He is taking Ibuprofen and has a TENS unit as needed. He deniesbowel/bladder/sexual dysfunction related to his lower back. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: Increased pain and stiffness c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (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. Stiffness/LLE radiculopathy 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [X] Abnormal or outside of normal range Forward Flexion (0 to 90): 0 to 75 degrees Extension (0 to 30): 0 to 20 degrees Right Lateral Flexion (0 to 30): 0 to 30 degrees Left Lateral Flexion (0 to 30): 0 to 30 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes (please explain) [X] No Description of pain (select best response): Pain noted on exam on rest/non-movement If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): There is localized tenderness over the bilateral paralumbar muscles and the left SI joint and left sciatic notch. b. Observed repetitive use: Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No 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: [X] The examination is neither medically consistent or 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: Not currently flared up. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not currently flared up. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [X] Not resulting in abnormal gait or abnormal spinal contour Provide description and/or etiology: Left lower back muscle spasm is noted today. Localized tenderness: [X] Not resulting in abnormal gait or abnormal spinal contour Guarding: [X] None 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: [X] None 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 Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 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? [ ] Yes [X] No 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 Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] 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 L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [X] Left [ ] Both d. Indicate severity of radiculopathy and side affected: Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 10. Other neurologic abnormalities ---------------------------------- [ ] Yes [X] No 12. Assistive devices --------------------- [ ] Yes [X] No 13. Remaining effective function of the extremities --------------------------------------------------- [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [X] Yes [ ] No If yes, describe (brief summary): Vital signs are stable; Lungs are clear; Heart is without m/g/r; Abdomen is soft, and without masses or organomegaly or tenderness; Genitalia are normal, no hernias or testicular lesions, the testicles and epididymii are tender to touch bilaterally; 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 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [ ] Yes [X] No b. Does the Veteran have a thoracic 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): Repeat lumbar MRI has been ordered and is currently pending; when completed and reported, I will review it and add any additional comments as indicated. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: The Veteran's current lower back condition would limit his ability to perform repetitive heavy lifting, pushing or pulling. 17. Remarks, if any: -------------------- The Veteran is claiming service connection for a lower back condition. Opinion: It is as least as likely as not that the Veteran's current lower back condition is proximately due to or caused by military service. Rationale: The C file was reviewed. The STRs do document a two year history in 2002 of chronic lower back pain with LLE radiculopathy. This is also noted on separation exam in 2004. I was able to elicit the same symptoms ongoing today, as well as to confirm this on phyiscal examination. Repeat lumbar MRI has been ordered since the last study was in 2009; when completed and reported, I will review it and add any additional comments as indicated. Thus, the service connection is substantiated. 12/23/2015 ADDENDUM STATUS: COMPLETED The Veteran underwent a lumbar MRI on 12/21/2015 with the following findings: L3-4: Mild facet arthrosis with minimal posterior disc bulge L4-5: Mild facet arthrosis with minimal posterior disc bulge L5-S1: Mild facet arthrosis with minonal posterior disc bulge ------END------- Any help interpreting this would be greatly appreciated. The "service connection is substantiated" is pretty straight forward. I'm curious whether or not I have a chance at getting the SC backdated to my original claim. It seems to me (a total non expert) that the evidence is there to support it. I am also curious about whether or not I can refute some of the conclusions that this doctor came to. While an awesome C&P doctor a back expert he is not. Since the writing of the C&P I had a chiropractor evaluation who found several more things than this doctor did. I'm curious if any of it will be enough to make a 10% difference when the rating comes down. In addition I am curious if within my C&P as well as the most recent chiro consult if there isn't evidence for a possible future claim for nerve pain in my lower body. "Many times spinal conditions have other conditions that contribute to the severity of the spinal condition. For example, many spine conditions also cause radiculopathy. These secondary conditions can sometimes be independently ratable." In my C&P I believe I meet all these conditions. I am diagnosed with lumbosacral strain - chronic, as well as Lower Left Extremity radiculopathy. In addition the C&P also diagnosed me with LLE weakness and paresthesias. The following is a list of conditions that the Chiropractor diagnosed me with just 8 days after the C&P doctor finalized his report. ----------Chiropractic Evaluation-------------- LOCAL TITLE: PM&R CHIROPRACTOR CONSULT RESULT STANDARD TITLE: PHYSICAL MEDICINE REHAB CONSULT DATE OF NOTE: DEC 31, 2015@11:04 Midback pain: medial scapula, left worse than right Quality: Burning (small area "about the size of a dime") Radiating: Patient Denies 0-10: 9/10 Timing: Intermittent Worse: working in a "hunched" or bent over position. Better: Standing up /stretching Low Back Pain: Thoraco-lumbar and lower L4-5-S1. Quality: Dull/Ache/sometimes sharp/Throbbing Radiating: buttock/thigh and foot ("tasered"), left worse than right 0-10: 6-7/10 Timing: Intermittent Worse: Standing/coughing while bent over Better: changing positions/activities Trunk ROM: Flexion:Mod dec Pain:Severe Extension:Mild dec Pain:No pain Rotation:Mild dec Pain:No pain Lateral Flexion:Mild dec Pain:No pain Muscle Atrophy: No Seated SLR: Positive L Supine SLR: Positive R (low back pain) Hip hyperextension test: Positive R Kemps test: Negative R L Spinous Process Tenderness: T3-7, L2,3, Right SI Myofascial Tenderness: Bilateral Rhomboids, Thoraco-lumbar paraspinals bilaterally. Lumbar MRI 12/21/2015 Impression: 1. Mild facet arthrosis and minimal disc bulges of the lower lumbar spine without thecal sac or neuroforaminal stenosis. Oswestry Disability Index Questionnaire Section 1 -- Pain Intensity: 2. The pain is moderate at the moment. Section 2 -- Personal Care (Washing, Dressing, etc.): 2. It is painful to look after myself and I am slow and careful. Section 3 -- Lifting: 2. Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed e.g. on a table. Section 4 -- Walking: 1. Pain prevents me walking more than 1 mile. Section 5 -- Sitting: 3. Pain prevents me from sitting more than one-half hour. Section 6 -- Standing: 2. Pain prevents me from standing for more than 1 hour. Section 7 -- Sleeping: 2. Because of pain, I have less than 6 hours sleep. Section 8 -- Sex Life (if applicable): N/A Section 9 -- Social Life: 3. Pain has restricted my social life, and I do not go out very often. Section 10 -- Traveling: 2. Pain is bad but I manage journeys over two hours. DISABILITY INDEX SCORE: 38% Segmental Dysfunction: L3LP, RPIN, RAI_Sacrum, T3LP, T5LP Assessment: 1. Lumbar: Segmental dysfunction 2. Lumbar: strain 3. Pelvic: Segmental dysfunction 4. Sacrum: Segmental Dysfunction 5. Thoracic: Segmental dysfunction Alright. If you've made it this far thanks for taking the time to read this massive wall of text. If you have some information or experience to offer let me thank you in advance!
  16. Jay

    Dro Or Bva

    I have a TDIU claim that is awaiting to go to BVA since September 2011. I have a docket number. I recently put in a DBQ and IME saying I can't work at all and my condition is Catastrophic 100% disabling Permanent and total with reasonable medical certainty. I also have a Not Feasible for employment letter by Voc Rehab and am on social security. I now found out my case went to a DRO for review. Is this standard procedure for DRO to pull a case waiting for BVA and to relook at the case? Is this in my favor. I put in for TDIU could they give me Schedular rating instead. I still don't want to lose my place in line at BVA if the DRO denies some or part of my new DBQ, IME evidence. Thanks for any clarification
  17. On the Disability Benefits Questionnaire for my Doctor to complete (VA Form 21-0960N-1) (DBQ). It says select the veterans condition and then it has ICD code & Date of diagnosis. Is this the ICD code (Diag. Code) from my physician's statements? Can I submit to VA a copy of the physician's billing statement that has the diag. code on it along with a table of the explanation of the ICD CODE?
  18. 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.
  19. So I reopened my case for major depression disorder and the VA instead of using the DBQ provided my psychologist, they rather asked me to go in for another QTC appointment for evaluation (second time- 2012/2014). I have already been diagnosed and currently being treated for Major Depression Disorder with psychosis/schizophrenia by the VA. Can someone tell me what the DBQ from QTC means? Am trying to figure out the possible rating decision if am even going to get a positive one. Thanks SECTION I 1. Diagnosis Does the Veteran now have or has he/she ever been diagnosed with a mental disorder? [X] Yes [] No Mental Disorder Diagnosis #1: Major Depression Disorder, recurrent Medical condition relevant to the understanding or management of the Mental Health disorder (to include TBI): 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? [] Yes [] No [X] Not applicable (N/A) c. Does the veteran have diagnose traumatic brain injury TBI? [] Yes [X] No 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 [] No [X] No other mental disorder has been diagnosed SECTION II Clinical Findings Evidence review Medical Record Review a. Was the veteran’s VA claims file reviewed? [X] Yes [] No b. Was the pertinent information from collateral sources reviewed? [] Yes [X] No History Symptoms For VA rating purposes, check all that apply to the veteran’s diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Impaired judgment [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 [X] Inability to establish and maintain effective relationships [X] Suicidal ideation Other symptoms Does the veteran have any other symptoms attributable to mental disorders that are no listed above? [] Yes [X] No Competency Is the veteran capable of managing his or her financial affairs? [X] Yes [] No 6. Remarks MEDICAL OPINION (To be completed by the examiner) Definitions Restatement of requested opinion Insert request opinion … Indicate type of exam for which opinion has been requested (e.g. Skin Disease): PTSD Evidence review Medical opinion for direct service connection a. Direct service connection OPINION: The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rational in section c. c. Rationale: Based on the records provided, it is at least as likely as not that claimant’s major depression disorder was incurred during his military service. Furthermore, it was caused by consistent harassment during his military service. The medical records reviewed which include in service treatment records. Am not too sure why she said the indicated exam used was PTSD and MDD. Also, I was told by the VA (regional office) that my case was closed accidently without rating decision given and that they are reviewing it again for a decision.
  20. So I reopened my case for major depression disorder and the VA instead of using the DBQ provided my psychologist, they rather asked me to go in for another QTC appointment for evaluation (second time- 2012/2014). I have already been diagnosed and currently being treated for Major Depression Disorder with psychosis/schizophrenia by the VA. Can someone tell me what the DBQ from QTC means? Am trying to figure out the possible rating decision if am even going to get a positive one. Thanks SECTION I 1. Diagnosis Does the Veteran now have or has he/she ever been diagnosed with a mental disorder? [X] Yes [] No Mental Disorder Diagnosis #1: Major Depression Disorder, recurrent Medical condition relevant to the understanding or management of the Mental Health disorder (to include TBI): 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? [] Yes [] No [X] Not applicable (N/A) c. Does the veteran have diagnose traumatic brain injury TBI? [] Yes [X] No 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 [] No [X] No other mental disorder has been diagnosed SECTION II Clinical Findings Evidence review Medical Record Review a. Was the veteran’s VA claims file reviewed? [X] Yes [] No b. Was the pertinent information from collateral sources reviewed? [] Yes [X] No History Symptoms For VA rating purposes, check all that apply to the veteran’s diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Impaired judgment [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 [X] Inability to establish and maintain effective relationships [X] Suicidal ideation Other symptoms Does the veteran have any other symptoms attributable to mental disorders that are no listed above? [] Yes [X] No Competency Is the veteran capable of managing his or her financial affairs? [X] Yes [] No 6. Remarks MEDICAL OPINION (To be completed by the examiner) Definitions Restatement of requested opinion Insert request opinion … Indicate type of exam for which opinion has been requested (e.g. Skin Disease): PTSD Evidence review Medical opinion for direct service connection a. Direct service connection OPINION: The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rational in section c. c. Rationale: Based on the records provided, it is at least as likely as not that claimant’s major depression disorder was incurred during his military service. Furthermore, it was caused by consistent harassment during his military service. The medical records reviewed which include in service treatment records. Am not too sure why she said the indicated exam used was PTSD and MDD. Also, I was told by the VA (regional office) that my case was closed accidently without rating decision given and that they are reviewing it again for a decision.
  21. I figured out how to post my C&P exams to the board. I posted some of this in the MST forum but would like opinions as to what anyone thinks regarding my C&P for PTSD due to MST and my Eating Disorder C&P. I know now that the Eating Disorder (thanks to a nice member here on this forum) will be rated separately but I am more curious about the PTSD C&P exam. The examiner denies PTSD but goes on to say "veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire:" Thank you for any and all input! **************************************************************************************************************************************************************** Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: XXXXX SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Anorexia Nervosa, purging type due to MST Comments, if any: See Eating Disorder DBQ Mental Disorder Diagnosis #2: Other Specified Trauma and Stressor - Related Disorder due to MST Comments, if any: subclinical level of PTSD, which is difficult to determine given the severity of her eating disorder and the overlap in areas regarding the symptom profile presentation b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): ankle pain Comments, if any: fracture of ankle and injury of ankle inservice after syncope episode secondary to excessive compensatory behaviors 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) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Symptoms such as purging through the use of laxatives, excessive food restriction and distorted perceptions regarding body image, excessive weight loss and consistent worrying about weight control are directly related to Veteran's diagnosis of Anorexia Nervosa, binging/purging type. Symptoms such as intrusive memories related to the MST and avoidance of conversations, people, and places related in some way to the MST, guilt and shame related to MST and distorted cognitions about the cause of the MST that lead to individual blame are directly related to Veteran's Other Specified Trauma-and Stressor- Related Disorder. Her symptoms and resulting social and occupational impairments related to reported difficulty concentrating, anxiety and sleep disturbances are related to both disorders as Veteran reported experiencing anxiety and subsequent difficulty concentrating and sleeping secondary to persistent thoughts about her body image and some thoughts about the MST. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [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 such as purging through the use of laxatives, excessive food restriction and distorted perceptions regarding body image, excessive weight loss and consistent worrying about weight control are directly related to Veteran's diagnosis of Anorexia Nervosa, binging/purging type. Symptoms such as intrusive memories related to the MST and avoidance of conversations, people, and places related in some way to the MST, guilt and shame related to MST and distorted cognitions about the cause of the MST that lead to individual blame are directly related to Veteran's Other Specified Trauma-and Stressor- Related Disorder. Her symptoms and resulting social and occupational impairments related to reported difficulty concentrating, anxiety and sleep disturbances are related to both disorders as Veteran reported experiencing anxiety and subsequent difficulty concentrating and sleeping secondary to persistent thoughts about her body image and some thoughts about the MST. 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 theTBI? [ ] 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? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: C-file reviewed via VBMS/Virtual VA 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) [ ] 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: 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Prior Military: Veteran was raised by her mother until she was 11 years old. At that time her mother remarried, resulting in her gaining an older step-sister and a step-father. She described her relationship with her mother, step-sister and step-father as good. "He was the father I never had." Veteran denied any childhood sexual or physical abuse. She further reported having a normal childhood, overall. She reported engaging in normal childhood activities including various sports. Veteran denied getting married or having any children before enlisting in the military. During Military: Veteran reported maintaining contact with her family. She also reported getting along well with other service persons. Initially, during her leisure time she reported spending time with other military personnel and engaging in various social activities. However, shortly after boot camp, she reported a reduction in engaging in social activities secondary to her obsession with focusing on weight loss. Details will be provided in an eating disorder DBQ. Veteran reported getting married to her first husband in September 1990. To this union a child was born in June 1991. Shortly after their child was born, Veteran and her husband divorced. She attributed their divorce to them both being too young. Veteran remarried in December 1993. To this union her second child was born in February of 1996. Post Military: Veteran and her second husband were divorced in 2003 secondary to irreconcilable differences. Despite divorce, she reported maintaining a good relationship with her children. She is currently in a romantic relationship with her partner of 2 years. They have been in a relationship, which she describes as good, since 2012. During her leisure time she reported exercising 3-4 times for about an hour, spending time with friends, watching sports, and taking care of their dog. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Prior Military: Veteran reported graduating from high school on time and receiving and diploma. She reported maintaining a B average and denied being diagnosed with any learning or developmental Veteran denied any behavioral problems resulting in her being suspended or expelled from school. She reported participating in volleyball, track, softball, and the drama club. Veteran reported working at Sea World while in school and denied being terminated or reprimanded. Veteran reported completing one semester of college before enlisting in the military. "I flunked out. My father gave me the option of going to college or joining the military." During Military: Veteran served active duty in the US Navy from May 1990 - April 1996. Her MOS was Intel Specialist. She was honorably discharged as an E3 and denied any reduction in rank or pay. She denied receiving any Article 15s or negative counseling statements. In boot camp Veteran reported being berated for being overweight, which continued throughout her military service. This beratement had a negative impact on her emotional well-being. Veteran reported not being able to perform her job as she should and an increased amount of undocumented sick call visits in 1991-1993 secondary to MST, subsequent eating disorder, syncope and breaking of ankle due to compensatory behaviors utilized to control her weight. Post Military: Veteran attended and completed paralegal school. She reported working multiple jobs as an executive assistant and parlegal secondary to relocations. She denied ever being terminated or reprimanded. Veteran is currently working as a paralegal at Jaderisk, where she has worked for a year since she moved to Texas. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Prior Military: Veteran denied any personal or family history of any mental health disorder to which she is aware. She denied any personal or family history of suicide attempts. Veteran also denied any personal or family history of alcohol or drug addiction to which she is aware. During Military: Service treatment records dated Septebmer 1994, documented that Veteran was referred to the Psychology Clinic in Bethesda secondary to stress and signficant weight loss (approximately 30 pounds since February 1994). Service treatment records also confirm multiple episodes of unexplained syncope, ankle injuries, in addition to episodes of eating disorders and subsequent weight loss beginning in 1990s. During the current evaluation, Veteran reported multiple incidents of sexual harrassment after being transferred to Water Front Operations in San Diego, beginning in September of 1992. She further reported that harrassment eventually progressed to a sexual assault (rape) occuring in November 1992. Service treatment records also document Veteran's pregnancy and subsequent miscarriage in December 1992. During the current evaluation, Veteran reported that the pregnancy was the result of the MST occurring in November 1992. Veteran reported the following symptoms after the MST: difficulty initating and staying asleep secondary to her fear of having nightmares about MST. She additionally reported having a significant amount of difficulty sleeping secondary to taking laxatives excessively resulting in her having to use the restroom throughout the night and thoughts about controlling her body weight. She also reported experiencing anxiety, which she described as being fidgety, restless and unable to stay calm and racing thoughts about loosing weight. "I was constantly thinking about loosing weight. I was so engrossed in it. I constantly weighed myself and had been exercising too much over not eating. I couldn't get myself to throw up. But I could get myself to have loose stools." Post Military: Electronic records confirm that Veteran came to the VA as a walk-in through MH triage secondary to eating disorder issues in June 2014. She reported being depressed a couple of times a week in addition to the MST. The following diagnosis were given during her mental health history in July 2014: Anorexia nervosa with restricting and purging behaviors, mild BMI is 22.81 and Generalized Anxiety Disorder. It was also suggested that the following diagnosis be ruled out: PTSD due to MST, Unspecified depressive disorder with OCPD traits. Veteran was initially prescribed Fluoxetine (Prozac), Hydroxyzine, and Trazadone to manage her symptoms. Hydroxyzine was discontinued, but Veteran continues to take Prozac and Trazadone as prescribed. Veteran experiencing the following symptoms: anxiety about her weight and thoughts about the MST, difficulty initiating and maintaining sleep secondary to racing thoughts about MST and weight, excessive use of laxatives to manage weights, intermittent depressed mood which she describes as crying and withdrawal. She reports that it may last 2-3 days a week. Please note, that with regard to sleep CPRS records document that Veteran is sleeping well with Trazadone. Therefore, nightmares likely occur to a minimal degree at this time. "It just depends on if I am thinking about it. I try to block it out. But I knowthat going through therapy now I am going to have to deal with the issues." She also reported feeling guilty and the MST. "I sometimes feel as if it was my fault." She also reported becoming angry, which she describes as being emotionally angry. "I don't lash out at any other people. But I am angry at myself for having the eating disorder, but I am afraid to get fat. I am just emotional when I think about the sexual trauma. She denied major difficulty concentrating or manic symptoms. Veteran also reported continuing to have a significant amount of sadness because of the miscarriage. "Regardless of how it was conceived. I still have sadness because I lost my baby. Those thoughts will never leave my mind."Veteran denied SI/HI, AVH, psychiatric hospitalizations. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran denied any legal or behavioral problems, before during or after military. e. Relevant Substance abuse history (pre-military, military, and post-military): Veteran denied use of illegal drugs before during and after military service. She acknowledged occassional use of alcohol but denied abuse. She also denied receiving any DWIs, DUIs public intoxications, or attendance at any substance abuse treatment programs. Veteran also denied anyone ever telling her that she drank too much and needed to cut back. f. Other, if any: No response provided. 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: Veteran reported that in September of 1992, omitted the statement here to graphic and too personal.... Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [ ] Yes [X] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: non-combat related 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. 1) December 1992, documented pregnancy and miscarriage. 2) Reported attempts and documentation of her going to sick call,for miscarriage. Veteran also reported multiple sick call visits that are undocumented in order to avoid her perpetrator. 3) Reported documentation of significant loss of body weight over short periods of time ---loosing 20 pounds over in boot camp, which lasted 6-8 weeks, loosing 62 pounds over 5 months after birth of her daughter. 4) December 1991 seen in emergency room secondary to syncope, fractured ankle secondary to excessive use of compensatory behaviors to lose weight. 5) Service treatment records dated Septebmer 1994, documented that Veteran was referred to the Psychology Clinic in Bethesda secondary to stress and signficant weight loss (approximately 30 pounds since February 1994). b. Stressor #2: In November 1992, Veteran and her supervisor (1st class petty officer) again omitted the statement here as too graphic and personal but this is where I provided the details of the attack/rape Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: non combat related 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. 1) December 1992, documented pregnancy and miscarriage. 2) Reported attempts and documentation of her going to sick call, for miscarriage. Veteran also reported multiple sick call visits that are undocumented in order to avoid her perpetrator. 3) Reported documentation of significant loss of body weight over short periods of time ---loosing 20 pounds over in boot camp, which lasted 6-8 weeks, loosing 62 pounds over 5 months after birth of her daughter. 4) December 1991 seen in emergency room secondary to syncope, fractured ankle secondary to excessive use of compensatory behaviors to lose weight. 5) Service treatment records dated Septebmer 1994, documented that Veteran was referred to the Psychology Clinic in Bethesda secondary to stress and signficant weight loss (approximately 30 pounds since February 1994). 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 Criteria 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 Criteria 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 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). [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). 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 to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 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 [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 #2 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 6. Behavioral Observations -------------------------- Veteran arrived promptly for her scheduled evaluation. She self-identified as a 43 year old Caucasian female who appeared her stated age. Her grooming and hygiene were good. Her posture and gait were unremarkable. She maintained good eye contact. There were no abnormalities noted in psychomotor activity or gross motor activity. She was cooperative with no inappropriate behavior observed. Her rate and flow of communication was clear, logical, and coherent with no indications of irrelevant, illogical, or obscure speech patterns. Thought processes were clear, coherent and goal directed. Thought content was unremarkable and void of any perceptual or delusional disturbances. The veteran's mood was anxious and her affect was of full range. Veteran became tearful when discussing her military experiences including the military sexual trauma and constant beratement related to her weight. She denied current SI/HI. 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 -------------------------------------------------- Given the current predominance of Veteran's eating disorder, she does not currently meet full criteria for PTSD. Therefore, Veteran was diagnosed with Other Specified Trauma and Stressor Related Disorder (subclinical level of PTSD) which is at least as likely as not related to reported military sexual trauma. There is no prior evidence of a mental health disorder. The exacerbation of Veteran's eating disorder, which began in the military in response to beratement related to her weight, was a response to MST, documented pregnancy and miscarriage. STRs document referral to a psychology clinic due to stress and excessive weight loss over a short period of time. It is additionally documented that Veteran was hospitalized due to syncope, ankle fracture resulting from eating disorder. It should be noted that eating disorders often develop as a method of coping with a stressor of which an individual feels he/she has no control over. Veteran continues to engage in behaviors that have resulted in her diagnosis of an eating disorder in service. It is possible that Veteran has continued to engage in these compensatory behaviors to manage her weight because it is an aspect of her life she feels she can control, unlike the MST event. Rationale within in this section and the stressor section of this evaluation confirm that it is at least as likely that the reported MST occurred and restulted in current Other Specified Trauma and Stressor Related Disorder (subclinical level of PTSD)symptoms. It should be noted that once Veteran's eating disorder is treated, resulting in remission, it will be easier to more accurately access for the prescense of other mental health disorders. Please refer to the Eating Disorders DBQ for more specific details and medical opinions regarding Veteran's diagnosis of Anorexia Nervosa. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application ****************************************************************************************** *** COMP & PEN MENTAL HEALTH/PSYCHOLOGY EXAM Has ADDENDA *** Eating Disorders Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXX 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with an eating disorder(s)? [X] Yes [ ] No [X] Anorexia Date of diagnosis: 1992 ICD code: 307.1 Name of diagnosing facility or clinician: U.S. Military diagnosed eating disorder and VANTXHCS diagnosed Anxorexia Nervosa binging/purging type 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's eating disorder (brief summary): Veteran reported being constantly berated secondary to her weight in boot camp. As a result, in August/September 1990 she began engaging in compensatory behaviors to manage her weight including laxatives, food restriction, and excessive exercising. Veteran was 178 pounds at the beginning of boot camp, which lasts 6-8 weeks. At the end of boot camp she was 158 pounds. Between June 1991 and December 1991 she lost 62 pounds (200 to 138)through the use of diet pills, laxatives, exercise, and food restriction after the birth of her daughter. In December 1991, service treatment records also document an episode of fainting, which resulted in her fracturing her ankle, which was secondary to eating behaviors. She had another episode of syncope in 1993, which resulted in another injury to her ankle due to weakness. In 1992, Veteran was hospitalized for a complete shut down of her gastrointestinal system secondary to excessive use of compensatory behaviors to keep her weight low. In 1994 Veteran was referred to a psychology clinic in Bethesda secondary to stress and eating disorder. Veteran currently takes 8-10 ducolax per day despite restrictive eating behaviors. These behaviors induce approximately 6 loose stools per day. 3. Findings ----------- [X] Resistance to weight gain even when below expected minimum weight [X] Without incapacitating episodes 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to an eating disorder? [X] Yes[ ] No If yes, describe: Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health; intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weigh gain, even though at a significantly low weight; distubance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation. Eating small amounts of food and taking 8-10 laxatives (Ducolax) a day to prevent weight gain; history of loosing 62 pounds in 5 months; 20 pounds in 6-8 weeks during boot camp; emergency room visits seconday to syncope and subsequent fractured ankle as a result of extreme weight loss via laxatives, lack of food and energy. 5. Functional impact -------------------- Does the Veteran's eating disorder(s) impact his or her ability to work? [X] Yes[ ] No If yes, describe impact, providing one or more examples: Veteran has approximately 6 loose stools a day secondary to excessive use of laxatives. Though she can continue to work a full time job, her productivity may be negatively impacted by consistent diarrhea. 6. Remarks, if any: ------------------- Veteran's current diagnosis of Anorexia Nervosa, purging type, is most likely incurred in military service and a progression of Veteran's eating disorder diagnosed in service. There is no prior diagnosis or hospitalization for an eating disorder prior to service. Veteran's eating disorder was first documented in service. Additionally, episodes of syncope and excessive weight loss were also documented in the service treatment records. Emotional distress as a result of military sexual trauma and consistent berating because of her weight most likely resulted in Veteran utilizing purging behaviors to cope with stress. Veteran has recently sought treatment. However, she continues to take 8-10 Ducolax a day despite restrictive eating behaviors to control her weight. Despite acceptable weight, she continues to view herself as fat. It should also be noted that Veteran's Anorexia Nervosa is most likely related to military sexual trauma and berating of Veteran due to her weight beginning in boot camp. Rationale: There was an increase in purging behaviors and subsequent hospitalization after military sexual trauma, subsequent pregnancy and miscarriage in 1992. Refer to Initial PTSD DBQ for additional markers.
  22. So I was reading over my C&Ps report and the VA rater is asking the C&P examiner to provide "an opinion as to whether or not the veterans service connected disabilities render the veteran unable to secure or maintain substantially gainful employment." Does this seem like a question the VA rater should be answering the C&P examiner according to new FL 13-13? I have attached a Page from C&P, take a look at highlighted area, Thanks.
  23. Hello everyone, I have a question relating to the DBQ that is used for asthma claims (linked below). RESPIRATORY CONDITIONS (OTHER THAN TUBERCULOSIS AND SLEEP APNEA) DISABILITY BENEFITS QUESTIONNAIRE http://www.vba.va.gov/pubs/forms/VBA-21-0960L-1-ARE.pdf My DAV rep wants me to send in a DBQ and says it must be filled out completely, including the PFT values. My asthma was rated at 60% because I received 3+ courses of oral or parenteral corticosteroids within a 12 month period. Because my asthma is rated due to this criteria, not the PFTs, would I still need to have the PFT scores? Should my doc send in the DBQ without PFT's or should they simply enter the values of my most recent PFTs from about a year ago? Thanks
  24. I have a pending claim for multiple sclerosis and sinusitis. The claim has a thorough IMO, SMRs, MRI images on DVD, and buddy statements. It is a "fully-developed" claim, with no further evidence to submit. However, no DBQs were sent in with my claim (based on multiple opinions from trusted folks that said they were not going to add any value). Because I am living and working in Afghanistan, attending any C&P exams will be quite difficult for me. Thus, I called my VARO to find out what I could expect with how my claim would be processed. The VA rep I talked to said that the appropriate DBQs will be mailed to me for what I claim, and I would have 60 days to have them completed. I can have any qualified physician (I'll use my IMO doc, of course) complete these to submit back to the VA. Are these recently launched DBQs now being used in place of showing up for C&P exams? That would be great if that were the case. I am guessing the VA is doing this to fray some of the costs and time to process claims? Seem like this is too simple a process...
  25. Hello. I was wondering if anyone knows which DBQ form is used for lung cancer? Thanks. Mil T
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