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Ptsd, Tbi, Insomnia, Unemployability Exam Results. Opinion Of Possible Rating?

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15032BCT2ID

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Just trying to get an idea of what possible rating I might be able to receive. This is only from the last exam I had. I just finished my last 3 exams yesterday for audiology, neurology, and a general examination for Irritabal bowl syndrome, hemmoroids, sinusitis. This exam results are from my mental health c and p exam.

skipping some info and going straight to military history.

MILITARY HISTORY: This vetern has an extensive military history. He has 10 hand-written pages in his C-File. The following are the most salient experiences that the veteran has had. The veteran had gread difficulty in relating his military history due to emotional upset. The veteran reported that he had returned from a convoy mission when he heard an explosion. He stated that he ran down the stairs of the barracks and grabbed a stretcher. He stated that at eh traffic control point, a truck of Iraqi soldiers was hit by a vehicle borne IED. Nine to 10 Iraqis were in the vehicle. The veteran observed grotesquely wounded and dead bodies. The veteran stated there were body parts everywhere. The veteran recalled that he had to take a black trash bag and start picking up body parts. He recalled that the bag became so heavy, he could hadly lift it. The veteran stated this was the first tiem he had ever seen brain matter. The veteran stated that while on a convoy, a truck in the back of the convoy was hit by multiple IEDs. The veteran's convoy turned around and went back to attempt to sucure the area. The veteran recalled there were bodies on the ground.This veteran ran under fire to help wounded soldiers. He started administering first aid and running from man to man. The veteran worked on 2 injured soldiers.(side note-all more information about this event was for some reason left out by the evaluator) For the veteran's heroism, he received the bronze star with v device. The veteran reported that on 05/24/2005 while on convoy, he was seated in the passenger seat. He stated there was an IED explosion outside of his door. He was wearing a helmet at the time. He denied any loss of consciousness. He noted mental confusion for several seconds. The veteran denied hitting his head. He had ringing in his ears that continues currently. The veteran had headaches for several months after this incident. The veteran estimateds he has been involved in 5 to 8 blast. He noted balance problems and mental confusion for approximately 24 hours after the explosion and denied any other sequelae of traumatic brain injury. This veteran stated he never received medical treatment and was returned to duty. In the veteran's medical chart, there is a comment about the veteran falling from a truck; this is noted in the TBI screen. The veteran stated that this event never occurred(cant remember) As stated, this veteran has multiple traumatic incidents which he experienced in Iraq. Please see the veteran C-File for extensive details of events experienced.

MENTAL STATUS EXAM AND EVALUATION: The veteran was administered the SLUMS, a brief cognitive exam, on which he scored a 23 out of a possible 30 points. The veteran had difficulties with both attention and recall. The veteran appeared his stated age of 26. He was of tall stature and well built. He was casually but appropriately dressed in jeans, a T-shirt, and a cap. He had tattoos on his arm. The veterans affect was dysphoric and he was tearfull throughout the evaluation. His tone and rate of speech were normal. His eye contact was good. The veteran was cooperative. He appeared to be of average intelligence. Gross motor functioning was intact. The veteran demonstrated adequate insight and judgment. He was a reasonable historian for his past and recent history and he was able to relate that history in a logical and sequential manner. he did not appear to be reponding to any internal stimuli and he was oriented to date, time, and place.

CURRENT SYMPTOMS REPORTED: The veteran endorsed the following depressive symtoms to include general sadness, loss of interest in activities to include socializing, sleep disturbance with both prolonged sleep latency and midcycle wakening on a nightly basis. With the use of sleep medications, the veteran will still have midcylcle wakening and averages 4 hours of sustained sleep per night. He endorsed low energy levels and low self'esteem. The veteran stated he is homeless right now and never thought he would be here. he denied andy suicidal ideation. He has lack of motivation for most activities. This veteran engages in self'isolative behaviors. In regards to post trauma symptoms, this veteran had recurrent images or thoughts on a daily basis. he reported night mares 3 to 4 times a week. He has physiological reactivity to the smell of something burning to include trash or leaves. The veteran has low frustration tolerance and has had physical altercations in the last year with coworkers. The veteran will avoid talking about events experienced. The veteran stated he does not like relating the events he experienced in Iraq and thus has written 10 pages which he will hand to providers at the VA when they ask about his experiences. The veteran has lost interest in socializing, playing pool, and bowling. He stated he has difficulty forming relationships and does not want a relationship. The veteran endures hyperarousal symptoms which overlap with deprssive symptoms to include sleep disturbance and anger and irritablility. This veteran engages in constant scanning of the environment. He stated that he used to sleep with a knife in his bed. He has exxagerated startle response to loud sudden noises.

In regards to cognitive difficulties, the veteran has forgetfullness for common objects to include his keys. He has difficulties with recall of names and recent conversations. The veteran stated he has difficulty sustaining concentration and will lose his train of thought. He reported slowed thinking and ringing in his ears constantly. He dinied any manic symptoms and no panic attacks reported. He denied auditory or visual hallucinations or delusions. There were no obsessive or ritualistic behaviors noted. The veteran has never had a suicide attempt. He denied any past or recent experiences of suicidal or homicidal ideation. The veteran does not currnetly have access to weapons. He has never been diagnosed with a traumatic brain injury prior to service.

NEROLOGICAL EVALUATION OF TEST RESULTS: The veteran received a 23 out of a possible 30 points on the SLUMS. This score is consistent with his level of educational or occupational achievement. The veteran recognized 49 out of 50 items in trial 1 of the memory malingering. This suggest adequate effort. In addition, the effort index from the RBANS was also consistent with adequate effort. I believe the results obtained were accurate and reflect the veteran's current leverl of cognitive functioning.

The veteran's estimated full scale IQ score based on the results of the Shipley-2 scale of 98 is consistent with his level of educational and occupational achievements. His vocabulary score of T-score =53 and his distraction score of T-score=56, there is not any evidence of decline in overall educational ability.

RBANS; immediate memery: Index score 81, 10 percentile, performance in the low range

Visuospatial construction: Index score was 96, 45 percentile, performance in the average range

Language: Index score was 78, 7th percentile, performance in the low range

Attention: Index score was 68, 2nd percentile, performance in the low range

Delayed Memory: Index score was 56, .2 percentile, performance in the low range

Total score: Index score was 69, 2nd percentile, performance in the low range

SUMMARY STATEMENT OF TESTING: The veteran did evidence difficulty with immediate memory, delayed memory and attention during testing. He appears to have cognitive disorder NOS secondary to mild traumatic brain injury as a result of nearness to mortar blast experienced in iraq.

CHANGES IN SYMPTOMS OVER THE PAST YEAR: The veterans symptoms have remained consistent

COMPETENCY: For Va purposes, this veteran is able to manage his VA funds.

EMPLOYABILITY STATUS: This veteran is able to be employed from a psychiatric standpoint. Based on currently information from my most recent examination and clinical notes, the veteran retains the cognitive behavioral and emotional capacities to do simple work tasks in a loosely supervised work environment. This veteran should avoid working closely with others or with the public due to low frustration tolerance.

PROGNOSIS FOR IMPROVEMENT: The veteran should be able to maintain his current lever of functioning. with contimued compliance with psychotropic medications, this veteran would greatly benefit from regular psychotherapy to address his PTSD, depression and alcohol abuse, in remisssion. The veteran has severe symptoms of PTSD, depression and alcohol abuse, in remission, and cognitive disorder NOS, which are described above. The veteran is employable from a psychiatric standpoint. For VA purposes, this veteran will be able to manage any VA funds he may receive.

DSM-IV DIAGNOSES:

AXIS I: 1. Posttraumatic stress disorder as likely as not related to fear of hostile or terrorist activity.

2. Alcohol abuse in remission as likely as not secondary to posttraumatic stress disorder diagnosis.

3. Depressive disorder, NOS, As likely as not secondary to PTSD diagnosis

4. Cognitive disorder, NOS, As likely as not secondary to TBI

AXIS II: None

AXIS III: Please see claims folder

AXIS 4: Homeless, financial problems, and limited social support.

AXIS 5: Global Assessment of Functioning for Axis I diagnosis is 51

( can someone tell me what all this means)

SEVERITY STATEMENT: PTST, depression, and cognitive impairment signs and symptoms result in deficiencies in most of the following areas: Work, school, family relations, judgement, thinking, and mood. The veteran experiences depressed mood, intrusive thoughts, detachmetn form others, sleep problems, and hypervigilant behaviors. The veteran does require continous medication to address his mental health issues.

DISCUSSION AND SUMMARY: As a result of mental health issues, the veteran is able to maintain activities of daily living, including personal hygiene. He has not experienced a significant trauma over the last year. There has been a worsening of his condition. There has not been remission of symptoms during the past year and his symptoms are continuous. He does have problems with alcohol abuse. There is not inappropriate behavior currently and there has not been inappropriate behavior over the past year. This veteran is not in treatment but is taking medications for mental health symptoms. Thought processes and communication are impaired as this veteran is self isolative and has low frustration tolerance of others. Employment is impacted due to PTSD as described above.

TRAUMATIC BRAIN INJURY STATEMENT: Traumatic brain injury occurred between 2004 and 2005 as a result of multiple blast with 0 minutes loss of consciousness.

COGNITIVE PROBLEMS: The veteran describes some problems in concentration as related to tbi issues.

EXECUTIVE PROBLEMS: The veteran describes some problems with judgement, decision making, and organization which are likely related to mental health issues. ( the drug use and other issues i have were said to be likely related to my PTSD)

There are some symptoms which have affected the veteran's employment as related to mental health issues, but no symptoms which have affected the veterans ADLs.

CLINICAL INTERVIEW OF SUBJECTIVE ESTIMATIONS OF COGNITIVE FUNCTIONING: MEMORY, ATTENTION, CONCENTRATION, EXECUTIVE FUNCTION: Score is deemed to 2- objective evidence and testing of mild impairment of memory, attention, concentration, or executive function resulting in mild functional impairment as related to traumatic brain injury issues.

Judgment is deemed to be 0- normal as related to tbi issues.

Social interaction is deemed to be 0- social interaction is routinely appropriate as related to tbi issues.

Orientation is deemed to be 0- always oriented to person, time, place and situation as related to tbi issues.

Visual spation orientation is deemed to be 0- normal as related to tbi issues.

NEUROBEHAVIORAL EFFECTS: Examples of neurobehavioral effects are irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects. Score is deemed to be 1- one or more neurobehavior effects that occasionally interfere with workplace interaction, social interaction, or both but do not proclude them as related to traumatic brain injury issues.

the initial PTSD questionnaire reflects the evaluators statements. She did tell me that her PERSONAL OPINION was that i had severe ptsd and that it is related to my service. I also did get my claim expedited due to being homeless and combat oif vet. My claim started feb 10 2011 and my last C and P exam was may 10 2011 and was told that i should have a rating in about 3 weeks( I know its the VA, stuff usually takes time so I dont have my hopes up too high) any insight into what percentage rating i might be able to receive would be great.

Edited by 15032BCT2ID
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  • HadIt.com Elder

What ever rating you get less than 70% file an appeal. Stay in treatment at the VA. I think you may want an independent medical opinion. If you are not working file for for TDIU. I got 70% with a GAF of 50. The C&P doctor is saying you have severe PTSD and mild TBI, but that you are capable of working. If you are homeless with severe PTSD I don't see how you can work. You do need treatment for the PTSD. You must insist on it from VA. Even if you have to go to inside program for PTSD and get help for homelessness and alcohol abuse. It is VA responsibility to help you.

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Hey thanks for the response. I am getting treatment at the va now. The va is helping with the homeless issue and I havent had a drink in about a year so I have my life on track now. Im just waiting now for the yellow envelope to come in the mail so I can resolve the homeless issue. I just now have to find something to do to keep my mind busy. I hate waiting but when dealing with the va you gotta get used to it. I do still have questions with the nerological testing portion of the exam regarding tbi. The results for CLINICAL INTERVIEW OF SUBJECTIVE ESTIMATIONS OF COGNITIVE FUNCTIONING and NEUROBEHAVIORAL EFFECTS portion of my c and p exam. I also want to thank hadit.com for all the information I obtained from this site. It made understanding the va and the claim process much more easier. You guys provide a great service to veterans and their families. Information=Power

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