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  • 14 Questions about VA Disability Compensation Benefits Claims

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    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
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  • Most Common VA Disabilities Claimed for Compensation:   

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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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lucaswlandon

C And P Exam Opinions

Question

SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Diagnosis #1: PTSD
ICD code: 309.81
Indicate the Axis category:
[X] Axis I [ ] Axis II
Diagnosis #2: Major Depressive Disorder, recurrent, severe, without
psychotic fearures
ICD code: 296.33
Indicate the Axis category:
[X] Axis I [ ] Axis II
Diagnosis #3: Alcohol Abuse
ICD code: 305.00
Indicate the Axis category:
[X] Axis I [ ] Axis II
b. Axis III - medical diagnoses (to include TBI): GERD
c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
Combat in Iraq
d. Axis V - Current global assessment of functioning (GAF) score: 60
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis:
The symptoms of these disorders overlap and any attempt to
separate
then would be mere
speculation.
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 due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication
Page 17 of 33 b. For the indicated level of occupational and social impairment, is it
possible to differentiate what portion of the occupational and social
impairment indicated above is caused by each mental disorder?
[ ] Yes [X] No [ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis:
The symptoms of these disorders overlap and any attempt to
separate
them would
be mere speculation.
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
------------------
a. Records reviewed (check all that apply):
[X] Claims folder (C-file):
[ ] Yes
[X] No
If no, provide reason C-file was not reviewed:
VBMS
b. Was pertinent information from collateral sources reviewed?
No response provided.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
He was born and raised in Columbus, Ohio. He had two parents, one
older
brother and
two younger sisters. He graduated from high school in 2000. He joined
the National
Guard in 2001. He deployed to Iraq on December 7, 2003 and served in
Iraq from
18 of 33 02/-08/04 until 02/02/05. He received the Combat Action Badge for
direct involve-
ment with the enemy on 04/19/04. He got an honorable discharge in
2009.
He got
married on 11/20/2010 and has two daughters and one son. He sleeps i n
a different
room because he has to have the TV on to sleep. He stays in a small
dark room
with the TV on.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
He worked for did father in high school painting and wallpaper. He was
a radio
operator for a medical unit in the service. He worked for Grant
Hospital for
5 years as a dispacher, Med Flight for 3 months, for his father-in-law
for a
year sandblasting, and back at Grant Hospital and is has been accused
of
creating a hostile work environment.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
He was treataed with Zoloft in 1998-1999 for a period of 6 months
following the break-up
with a girlfriend. He reported depression with insomnia in May 2004.
In
October, 2004, he
reported suicidal thoughts. He reported a suicide attempt (Tylenol and
Alcohol) in 2006
following service and was hospitalized for 2-3 days at Mt. Carmel East
in Columbus, Ohio.
He went home for a day and was then hospitalized at Riverside
Methodist
Hospital in
Columbus, Ohio, for 3 days. He has been seen at the Dayton VAMC for
the
last year in
the PTSD program. He saw Dr. Moon who has him on Celexa-40mg daily,
Vistaril-10mg tid
as needed for anxiety and Ambien-10mg/qhs.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
No legal issues
Page 19 of 33
e. Relevant Substance abuse history (pre-military, military, and
post-military):
He reported that he used to drink 6 beers at night in order to go to
sleep. No DUI's. He now
drinks socially and his last drink was 2 days ago (2 beers) at a
Veteran's Day party.
f. Sentinel Event(s) (other than stressors):
No response provided.
g. Other, if any:
No response provided.
3. Stressors
------------
a. Stressor #1: On 04/19/2004, I was assigned to Charlie Company, 118 Area
Support Medical BAttalion, and came into direct
involvement with the
emeny
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[X] Yes [ ] No
Is the stressor related to the Veteran's fear of hostile military
or
terrorist activity?
[X] Yes [ ] No
b. Stressor #2: On 11/13/2004, I was assigned to the Company and we got
mortared and Sgt. Catelina Dima was killed
Does this stressor meet Criterion A (i.e., is it adequate to support
the diagnosis of PTSD)?
[X] Yes [ ] No
Is the stressor related to the Veteran's fear of hostile military
or
terrorist activity?
[X] Yes [ ] No
4. PTSD Diagnostic Criteria
---------------------------
a. Please check criteria used for establishing the current PTSD diagnosis.
The diagnostic criteria for PTSD, referred to as Criteria A-F, are from
the Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV).
Criterion A: The Veteran has been exposed to a traumatic event where both
of the following were present:
Page 20 of 33 [X] The Veteran experienced, witnessed or was confronted with an event
that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others.
[X] The Veteran's response involved intense fear, helplessness or
horror.
Criterion B: The traumatic event is persistently reexperienced in 1 or
more of the following ways:
[X] Recurrent and distressing recollections of the event, including
images, thoughts or perceptions
[X] Recurrent distressing dreams of the event
[X] Intense psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event
[X] Physiological reactivity on exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event
Criterion C: Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
the
trauma), as indicated by 3 or more of the following:
[X] Efforts to avoid thoughts, feelings or conversations associated
with the trauma
[X] Efforts to avoid activities, places or people that arouse
recollections of the trauma
[X] Markedly diminished interest or participation in significant
activities
[X] Feeling of detachment or estrangement from others
[X] Restricted range of affect (e.g., unable to have loving feelings)
Criterion D: Persistent symptoms of increased arousal, not present before
the trauma, as indicated by 2 or more of the following:
[X] Difficulty falling or staying asleep
[X] Irritability or outbursts of anger
[X] Difficulty concentrating
[X] Hypervigilance
[X] Exaggerated startle response
Criterion E:
[X] The duration of the symptoms described above in Criteria B, C and
D
is more than 1 month.
Criterion F:
[X] The PTSD symptoms described above cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.
b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:
[X] Stressor #1
[X] Stressor #2
5. Symptoms
Page 21 of 33 -----------
For VA rating purposes, check all symptoms that apply to the Veterans
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] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Flattened affect
6. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[X] Yes [ ] No
If yes, describe:
Decreased appetite, energy level, interest in sex, concentration,
he snaps at
his wife and kids. He reported his depression as an 8-9 on a 0-10
scale where
0 is no depression and 10 is suicidal.
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
8. Remarks, if any
------------------
The Veteran meets DSM-IV-TR and DSM-5 criteria for PTSD related to his
in-service experiences.
His Major Depressive Disorder is related to his PTSD and depressive
symptoms in service were
early manifestations of the current disorder.

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With the CAB , OEF service, and this VA diagnosis of PTSD you should certainly expect a SC award,in my opinion.

The Veteran meets DSM-IV-TR and DSM-5 criteria for PTSD related to his

" His Major Depressive Disorder is related to his PTSD and depressive
symptoms in service were
early manifestations of the current disorder."
How soon after your discharge did you file this claim?
Reason I ask might not apply to you here......... but it pays to mention from time to time.......
Awards on claims filed within one year after discharge, use the day after the discharge as the EED (earliest effective date) for the retro.

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It sounds like a 30% rating to me since doctor describes your ptsd as mild. Once you get the SC for PTSD you can hire IME/IMO doctor to show your ptsd is not based on mild symptoms.

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