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Question
Navy04
I am Currently 30%SC for PTSD. I was Medically Retired Feb 25,2013 from the Navy. What do you guys think that I will get? Also if you look at bottom of report Psych C&P Examiner states that when I had my C&P in 2012, I met the Criteria for 70% PTSD, yet the VA low balled me at 30%. What can I do to let the VA know that I was screwed in 2012 by the VA and try to get back pay, or is it not worth fighting. Going by my recent 6 C&Ps, it looks like I will be 100% when this FDC is settled. I have 4 or 5 conditions that I am going to submit another C&P when this claim is complete. I want to make sure that I keep my 100% Schedular if I get it, and not deal with IU down the road. That is such a headache. Thanks again guys for your help.
Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder (PTSD)
Mental Disorder Diagnosis #2: Obsessive Compulsive Disorder (OCD)
Mental Disorder Diagnosis #3: Major Depressive Disorder (MDD)
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes[ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes[X] No[ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis: Current
symptoms overlap and are attributable to all three diagnoses, PTSD,
OCD, and MDD.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes[ ] No[X] Not shown in records reviewed
4. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of
occupational
and social impairment with regards to all mental diagnoses? (Check only
one)
[X] Occupational and social impairment with deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood
b. For the indicated level of occupational and social impairment, is it
possible to differentiate what portion of the occupational and social
impairment indicated above is caused by each mental disorder?
[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: Current
impairment is attributable to all three diagnoses, PTSD, OCD, and
MDD.
c. If a diagnosis of TBI exists, is it possible to differentiate what
portion
of the occupational and social impairment indicated above is caused by
the
TBI?
[ ] Yes[ ] No[X] No diagnosis of TBI
SECTION II:
Clinical Findings:
------------------
1. Evidence review
------------------
In order to provide an accurate medical opinion, the Veteran's claims
folder
must be reviewed.
a. Medical record review:
-------------------------
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[ ] Yes[X] No
Was the Veteran's VA claims 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 via CPRS
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?
[ ] Yes[X] No
If yes, describe:
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
Currently lives in Emory, Tx, about 100 miles from Bonham VA,
that's
where he does treatment. Lives with wife, married 10 years, today is
there anniversary, and 2 daughters, ages 8 and 5. Overall, getting
along with wife ok. Gets frustrated easily, helping with homework,
wife
does all that. Separated from wife for 6-7 months in 2012, related to
his mental health at the time.
On a typical day, does not sleep much, wife handles all his meds, wife
cooks him breakfast, she works 6:30-10:30am, watches the cooking
channel on tv, used to play sports, cars, not interested anymore. Does
not trust anybody.
Only leaves house for dr. appointments. Used to go to church, sports.
Now does not leave the house very often. No stores, restaurants. Goes
to trauma treatment.
Father does not believe in his emotional problems, not supportive.
Wife
is generally supportive but frustrated. No close friends nearby.
Does not use computers, rarely uses the phone. Does not have much
family. Brother has problems with drugs. Has an identical twin
brother,
does not talk to him.
b. Relevant Occupational and Educational history:
Active duty 9 years, separated from Navy in Feb. 2013, one year ago.
Deployments to Iraq, Afghanistan, went in went people got hurt.
Post:
Was working for the state as an agent, tracking sex offenders
Resigned
due to physical and mental issues, couldn't handle it. Has a
Bachelor's
in Criminal Justice and homeland security. Was working on
Master's
classes, dropped out in fall due to dropping grades. Has a few classes
left to finish MA. Started MA August 2012, completed 6 classes. Also
has BA in teaching.
Currently has SS disability claim. Not looking for work right now. No
school.
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
Individual therapy weekly. Psychiatrist every 3 months.
2012, 3 months in mental hospital, River Oaks mental hospital in New
Orleans, in the navy was sent there for suicidality. No psychiatric
hospital since then. 2 suicide attempts, first time overdosed on
Xanax,
stomach pumped. Pulled out in front of cement truck on a bridge, then
sent to hospital. MPs took him to hospital.
In 2012, was seeing faces of dead bodies.
Veteran describes current mood as "depressed." Crying spells
most days.
Hard to stop crying when he stops. Sometimes laughs during serious
conversations, can't control it.
DEPRESSION SX:
__x___Depressed mood daily
__x___Diminished interest/pleasure
in activities
__x___Weight loss/gain (sometimes gains/loses 20 lbs, has
Chrohn's
disease)
__x___Insomnia or hypersomnia
__x___Psychomotor agitation/retardation
__x___Fatigue/loss of energy
__x___Feelings of worthlessness/guilt (feels wo
rthless)
__x___Poor concentration/indecisiveness
__x___SI, plan or attempt (passive thoughts, denied plan or intent)
*Thinks about hurting people. Wants to hurt bad guys, going back
overseas and hurting people to feel better.
Sleep:
3-4 hours per night. On sleep meds, help him fall asleep, don't
help
him stay asleep. Wife says he's having nightmares, cries and
screams in
sleep. Has sleep apnea. Sometimes wakes up under beds and in closets.
Has hit his wife in sleep. Wakes up scared, trying to help people,
dreams of being wounded, paralyzed, related to deployments. Has TENS
unit and Alpha-Stim.
Trauma Treatment:
Started Sept. 2013, once per week, PTSD tx, nurse practitioner for
meds, counselor is Karen Davisson-Gerleman. Has psych meds, takes
every
day, prazosin for sleep and nightmares, alprazolam for anxiety,
temazepam for sleep, vanlafaxine for depression. Started meds in
Afghanistan in 2010, prescribed by Marine doctor, was taking a lot of
Xanax at the time.
Anxiety:
Counts stuff all the time, mind never stops. Thinks that he's in
multiple battles. Anxiety throughout day, muscle tension, tired a lot.
Panic attacks at least once per week, seems random. Anxiety during
day,
restlessness at night, checking the house a lot. Installed alarm
system, has not reduced anxiety. Diagnosed with OCD 3/2012, counting
rituals, touching rituals, tries to touch things in even numbers.
Don't
like people on the left side of his body. Paranoid, does not trust his
family.
AVH.
6-8 months ago, faces of dead children, they talk to him, criticizing
him for not doing enough. On a daily basis, on a bad day throughout
the
day, good day 2-3 times.
Anger:
Broke all the mirrors in the house, 6-7 mirrors, broke them with his
cane. He sees somebody he does not like. 3-4 times per month, feels
angry and aggressive, hits walls, throws something. Hits the dog.
Medical:
Chrohn's disease, erectile dysfunction
d. Relevant Legal and Behavioral history:
Denied.
e. Relevant Substance abuse history:
Denied current alcohol use. Denied any drug or alcohol use.
f. Other, if any:
No response provided.
3. PTSD Diagnostic Criteria
---------------------------
Please check criteria used for establishing the current PTSD diagnosis. The
diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
combat, personal trauma, other life threatening situations (non-combat
related stressors.) Do NOT mark symptoms below that are clearly not
attributable to the criteria A stressor/PTSD. Instead, overlapping symptoms
clearly attributable to other things should be noted under #5 - "Other
symptoms".
Criterion A: Exposure to actual or threatened a) death, b) serious
injury,
c) sexual violation, in on or more of the following ways:
[X] Directly experiencing the tramuatic 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] 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 to the
individual to blame himself/herself or others.
[X] Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Markedly diminished interest or participation in
significant activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction,
or
loving feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
[X] 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:
No response provided.
4. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Circumstantial, circumlocutory or stereotyped speech
[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] Suicidal ideation
[X] Obsessional rituals which interfere with routine activities
[X] Impaired impulse control, such as unprovoked irritability with
periods
of violence
5. Behavioral Observations:
---------------------------
This veteran is a 31 year old, married Hispanic male. Veteran appeared on
time, was well nourished and dressed in casual clothing. Veteran walked
with two knee braces and a cane, and was emotionally distressed
throughout
the exam, with frequent tearfulness. Veteran was alert and oriented x3.
Intellectual functioning estimated above average. Veteran was cooperative
and eye contact was appropriate. Thought processes were somewhat
circumstantial, yet he was easily redirected. Speech was within normal
limits regarding rate, rhythm, and volume. Mood was extremely depressed
and affect was congruent with depressed mood. Veteran's ability to
maintain minimal personal hygiene and other basic ADL's appeared
intact.
Veteran denied suicidal ideation, endorsed ideation of violence toward
enemies, yet denied plan or intent to harm himself or others. Veteran
endorsed daily auditory and visual hallucinations related to combat
stressors.
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:
---------------------------------------------------
Claims File was reviewed by examiner.
Mr. Kiefer is a 31-year-old, 80% Service Connected for various
conditions,
married Hispanic male evaluated for a PTSD review exam. The veteran's
VA
medical records, self-reports during the examination, and claims file
data
were reviewed in forming an opinion.
Veteran continues to meet both DSM-IV-TR and DSM-5 criteria for three
mental health disorders, Posttraumatic Stress Disorder (PTSD), Obsessive
Compulsive Disorder (OCD), and Major Depressive Disorder (MDD). Veteran
was orginally service-connected 30% for PTSD in the spring of 2012. Per
report in Claims File, prior C&P Initial Evaluation for PTSD dated
5/22/12
noted dx of PTSD, OCD, and Depressive Disorder with symptoms which are
associated with 70% impairment and a GAF score of 53. Veteran continues
to
have social and occupational impairment with deficiencies in most areas
such as work, school, family relations, judgment, thinking or mood due to
the combination of PTSD, OCD, and MDD. Veteran is currently treated with
weekly appointments at the trauma team at the Bonham VA, with counseling
and medication.
Upon direct questioning about whether he had any other comments or
information not covered in the interview, the veteran stated he had
nothing to add to any part of this report.
From 2507:
CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER.
***** OCR - One Year Initiative -EXPEDITE BY VA DIRECTIVE ***********
CLINICIAN: IF USING THE ACE PROCESS TO COMPLETE THE DBQ, PLEASE:
-EXPLAIN THE BASIS FOR THE DECSION NOT TO EXAMINE THE VETERAN AND
-IDENTIFY THE SPECIFIC MATERIALS REVIEWED TO COMPLETE THE DBQ
FULLY DEVELOPED CLAIM
C-FILE BEING SENT FOR REVIEW
MEDICAL OPINION: STATE C-FILE WAS REVIEWED
"Examiner, please note for this examination to be sufficient, a
review of
the claims
file, to include documentation that review was completed, is
100% PTSD
100% Back
60% Bladder Issues
50% Migraines
30% Crohn's Disease
30% R Shoulder
20% Radiculopathy, Left lower 10% Radiculopathy, Right lower
10% L Knee 10% R Knee Surgery 2005&2007
10% Asthma
10% Tinnitus
10% Damage of Cranial Nerve II
10% Scars
SMC S
SMC K
OEF/OIF VET 100% VA P&T, Post 911 Caregiver, SSDI
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