Now Waiting Game For Me?

[bojack]

This veteran's C&P exam was recently completed by MSLA, under the

national DEM contract. Please refer to the C&P exam, which has been emailed in a PDF

format to the initiating Regional Office.

I just finished all my C&P exams 2 weeks ago.

More TBI follow up....

CC/HPI: h/o TBI. In 2005 fell 2 stories when stairway collapsed, loc unknown

duration. Was awoken and helped up by colleague. Was evaluated in field and then

sent back out. In 2007 fell 2+ stories from ladder of guard tower more than 2

stories, loc (unknown duration) and woke up on ground. Was evaluated in field

then sent back out.

**reports extreme light and glare sensitivity indoors and outdoors. Reports the

new sunglasses he got do not help him enough. LEE 4/11/14 VA LB.

**reports much difficulty with near work, especially reading. Reports letters

float on page, int diplopia, blur, headache and at times nausea when attempting

to read for long periods of time

INCOMING OCULAR HISTORY: photophobia

FAMILY OCULAR HISTORY:

(-) Glaucoma

(-) Blindness

(-) Age Related Macular Degeneration

OCULAR MEDICATIONS: none

INCOMING SYSTEMIC/PSYCHOLOGICAL HISTORY:

Computerized Problem List is the source for the following:

1. Laceration NEC (ICD-9-CM E928.9) 10/05/11 HECHANOVA,DEM

2. Headache 02/06/14 LEE,SE-YOUNG

3. Tinnitus 02/06/14 LEE,SE-YOUNG

4. Neck pain 02/06/14 LEE,SE-YOUNG

5. Chronic low back pain 02/06/14 LEE,SE-YOUNG

6. Foot pain 02/06/14 LEE,SE-YOUNG

7. Knee pain 02/06/14 LEE,SE-YOUNG

8. Insomnia 02/06/14 LEE,SE-YOUNG

9. Chronic rhinitis 02/06/14 LEE,SE-YOUNG

10. Traumatic brain injury with brief loss of 03/05/14 HAGER,GILBERT

P

consciousness

11. Other Signs and Symptoms Involving Cognition 03/05/14 HAGER,GILBERT

P

12. Posttraumatic stress disorder (SNOMED CT 05/29/14 HAGER,GILBERT

P

47505003)

13. Pain in joint involving shoulder region 05/29/14 HAGER,GILBERT

P

14. MDD, Recurrent, Moderate 07/17/14 WANGEN,KERRY

E

SYSTEMIC MEDICATIONS:

Active Outpatient Medications (including Supplies):

CONFIDENTIAL Page 25 of 205 Active Outpatient Medications Status

=========================================================================

1) CETIRIZINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE

DAILY FOR ALLERGY

2) FLUNISOLIDE 0.025% 200D NASAL INH SPRAY INHALE 2 ACTIVE

SPRAYS IN EACH NOSTRIL TWICE A DAY FOR NASAL

ALLERGY

3) MIRTAZAPINE 15MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE

BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT

CONSULTING YOUR PROVIDER.

4) PAROXETINE HCL 40MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE

BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT

CONSULTING YOUR PROVIDER. ** NOTE DOSE INCREASE **

.

5) PRAZOSIN HCL 2MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE

BEDTIME FOR 7 DAYS, THEN TAKE TWO CAPSULES AT

BEDTIME FOR 7 DAYS, THEN TAKE THREE CAPSULES AT

BEDTIME ** MUST CONTACT/SEE VA PROVIDER FOR REFILL

**

6) TOPIRAMATE 25MG TAB TAKE ONE TABLET BY MOUTH TWICE A ACTIVE

DAY FOR 4 WEEKS, THEN TAKE TWO TABLETS TWICE A DAY

AVOID DEHYDRATION

7) TRAZODONE HCL 100MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE

BEDTIME

ALLERGIES:

Patient has answered NKA

INCIDENT HISTORY:

Presumed/confirmed traumatic brain injury/acquired brain injury due to: series

of head traumas

When did the incident occur (OEF, OIF, OND, other): 2007

Type of TBI injury (blast, penetrating, intraocular, etc): blunt force and blast

induced

Any ocular or periocular injury to the eyes: N

History of treatment for traumatic brain injury (VA facility, Dept. of

Defense or elsewhere): evaluated in field but sent out shortly after

PRIOR VISUAL HISTORY:

1. When was your last eye examination? 4/11/14, VA LB (no DFE yet)

2. Do you wear glasses or contacts? N

3. How old is your most recent eyeglasses or contact lens prescription?

4. Any history of lazy eye/amblyopia, eye turn, patching, or vision therapy? N

5. Any history of face turn or head tilt? N

6. Any history of eye surgery/injury? N

7. Did you use personal protective eye wear in the service? Y

CONFIDENTIAL Page 26 of 205URGENT VISUAL CONDITIONS (if sudden):

(-) Flashes

(+) Floaters

(+) Missing part of visual field/restricted field of vision: sometimes

(+) Bumping into objects/walls while moving: sometimes

(-) Covering/closing one eye

(-) Decreased night vision

(-) Curtain/shade over vision

(-) Inability to completely close eyes

(-) Double vision

(-) Wandering eye

(+) Pain in or around the eyes- associated with light

(-) Pain with movement of eyes

VISUAL SYMPTOMS (PRE/POST ABI)

1. Blurred vision at distance (with glasses if rx'ed): N

2. Blurred vision at near (with glasses if rx'ed): Y

3. Pulling or tugging of eyes: Y

4. Face or head turn: N

5. Covering/closing an eye: N

6. Photosensitivity

When indoors: Y

When outdoors: Y

Glare from indoor OR outdoor surfaces: Y

Light adapted: N

7. Decreased night vision: Y

8. Do you have dry eye symptoms: N

9. Headache or browache associated with vision: Y

10. Bothered by movement in spatial world: Y

11. Bothered by noises in environment: Y

12. Dizziness or balance problems Y, postural changes

When riding in moving vehicle:

Walking down a hall or aisle in store:

Concentration at near:

Walking in crowd:

Approaching busy intersections:

13. Do you seem to neglect/not notice objects, people, doorways to one side

or the other when walking or moving in wheelchair? Is it to the right or left?

Comment further. N

14. Do you notice postural shifts when standing and/or walking? Y

READING SYMPTOMS (WITH GLASSES):

1. Fatigue while reading: Y

2. Strain while reading: Y

3. Skip or lose place while reading:

4. Have difficulty finding next line:

5. Note doubling of words: Y

6. Words float off page: Y

7. Transient blur while reading: Y

8. Unable to sustain near work/reading: Y

9. Blur in distance after reading: N

CONFIDENTIAL Page 27 of 20510. Difficulty shifting focus from near to far/far to near: N

11. Browache/headache associated with reading: Y

12. Poor reading comprehension: N

13. Easily distracted/decreased attention span: Y

14. Poor concentration: Y

-----------------------------------------------------------------------------

LENSOMETRY:

CURRENT SPECTACLES

OD: pl sph

OS: pl sph

COMMENTS: sunglasses, amber tint?, from last exam (says they do not help enough

to block out the sun)

VISUAL ACUITY (cc/primary gaze): Snellen

OD: 20/20

OS: 20/20

OU: 20/20

NVA (cc) OU: 20/20

ENTRANCE TESTING

Cover test: ortho at D, 4 XP at near

EOMs: Full range of motion (-)pain/diplopia

Confrontation VF: (peripheral, simultaneous)

Fixation: un/steady

OD: Full to finger counting

OS: Full to finger counting

PUPILS: ERRL, (-) APD

_____________________________________________________________________

REFRACTIVE DATA

Subjective Refraction:

OD: pl sph

OS: pl sph

Binocular balance:

OD: pl sph

OS: pl sph

TRIAL FRAME/FINAL RX:

OD: pl sph 20/20

OS: pl sph 20/20

BINOCULAR VA: 20/20

____________________________________________

_________________________

OCULOMOTOR, VESTIBULAR, ACCOMODATIVE, VERGENCE ASSESSMENT

CONFIDENTIAL Page 28 of 205Step Vergences

Distance Base In: x/4/1

Distance Base Out: x/4/1

Near Base In: x/6/2

Near Base Out: x/4/1

**patient very sensitive to testing and tiring towards end of exam

Accommodation Testing

Method Used:

(X)Push Up

( )Pull Away

( )Minus Lens

( )Fused Cross Cyl (FCC)

OD: 25 cm (4D)

OS: 25 cm (4D)

Near point of convergence (break/recovery): 13cm/20 cm

Facility Testing

Method Used:

+/-1.00 Flippers

OU: difficulty clearing minus, 5 cpm (very slow)

RECOMMENDED GLASSES: leader wrap sunglasses (dark tinted) and near reading

glasses with 0.5 BI prism OD and OS, grey tint 1 and AR coat

_____________________________________________________________________________

GENERAL HEALTH ASSESSMENT

SLIT LAMP FINDINGS:

Lids & Lashes: clear OU

Conjunctiva: white & quiet OU

Cornea: clear OU

Angles: open OU

Ant Chamber: deep & quiet OU

Iris findings: flat, avascular OU

Lens: clear OU (undilated)

INTRAOCULAR PRESSURE (mmHg)

( )GAT (x)Tonopen @ 9:40am

OD: 11

OS: 11

OPHTHALMOSCOPY FINDINGS

(X)UNDILATED

( )DILATED WITH 1% T AND 2.5% PE OU-PT ED ON SIDE EFFECTS

C/D Ratios:

OD: 0.20

OS: 0.20

Optic Nerve Head Evaluation:

PARK, JU EUN CONFIDENTIAL Page 29 of 205 OD: (-) pallor with distinct margins, pink & healthy rim tissue

OS: (-) pallor with distinct margins, pink & healthy rim tissue

***patient defers dilation today due to light sensitivity. Will bring someone to

drive him at next appointment for DFE.

Assessment:

1. H/o traumatic brain injury

- photophobia and glare sensitivity

- convergence insufficiency and accommodative insufficiency

2. Essential emmetropia OU

Plan:

Order separate sunglasses and near work glasses. Near work glasses to have

0.5 base in prism in each eye, with grey tint 1 and anti-reflective coat.

Sunglasses to be leader with wrap and dark tint.

***Return in 1 month for dilation and check on progress with glasses

Final Rx:

OD: pl sph

OS: pl sph

See consult for glasses information

_____________________________________________________________________

Assessment and plan reviewed and approved by Staff Attending

Disclaimer: Because the acuities and fields in this evaluation were taken

using special techniques and lighting NOT contained in the VA Physician Guide

Disability Evaluation Examination, they cannot be used for rating purposes.

[bojack]

Also, my case mangers and PTSD doctor is trying to get me a PTSD service dog since I got 85/85 on my PCLM test.

BRIEF ASSESSMENT: CV waiting for C&P exam. Writer requested this

CONFIDENTIAL Page 77 of 205opportunity to

follow up with CV. He reports things are going better. His place of employment

has made changes and he is unable to advance due to his s/s PTSD. However, they

are currently working with the CV to sustain employment. CV states Dr. Wangen in

PTSD Clinic has been so helpful and understanding. CV is feeling more

safe/secure and non threaten in his therapy. He states Dr. Wangen mention the

possibility of a service dog. However, CV declined stating he does not want to

take away from a blind veteran. Writer educated CV on the difference between a

PTSD service dog and a dog for the blind. Writer also recommend that CV have a

conversation regarding reconsidering utilizing a PTSD service dog.

CASE MANAGEMENT INTERVENTIONS:

1. Writer provided a safe and clean environment

2. Writer listen to CV needs/concerns

3. Writer provided education, support, and encouragement

PLANS/RECOMMENDATIONS:

1/ Medical/Mental Health Plans: continue following recommendation from PCP, MH,

TBI, PTSD

2/Transitional/Vocational Plans: continue following recommendation from employer

such as continue therapy.

EDUCATION:

1. Educated CV on PTSD service dogs: they allow for the CV to feel safe and

protected within their environment. Recovering from PTSD is an on going process.

Evidence-based treatments for PTSD help CVs do things they have been avoiding

because of their PTSD, such as standing close to a stranger or going into a

building without scanning it for danger first. Evidence-based treatments can

also help CVs feel better emotionally and physically. Dogs can help CVs deal

with some parts of living with PTSD, but they are not a substitute for effective

PTSD treatment.

[bojack]

More PTSD results

Military MOS:

0311 Rifleman, light infantry, heavy machine gunner, turret

gunner, attached to a helicopter company

Rank/Rate During Deployment: E4 corporal

Responsible/Accountable for How Many:

35 "I was a barracks NCO, even downrange"

Service Connected Disability: NSC:

Financial: GMT COPAY REQUIRED

Employment: EMPLOYED PART TIME

Occupation: COUNTY EMPLOYEE

Religion/Spiritual Connection: CHRISTIAN (NON-SPECIFIC)

Race/Ethnicity/Cultural Background: ASIAN

Primary Care Provider: LEE,SE-YOUNG

PTSD Score(s): Date Instrument Raw Trans Scale

07/17/2014 09:00 PCLC 85 Total

02/06/2014 14:00 PC PTSD 2 Total

PCP: LEE,SE-YOUNG

Next Appt. w/: JUL 17,2014@09:00 LB MH: PTSD JONAS

SEP 11,2014@15:00 LB PULM: SLEEP FOLLOW UP

OCT 1,2014@15:00 LB NEURO: CABLE

Mental Health Missed Appts.: MH Appointments Missed Last 10 Days

No Missed Appointments Found

Problem List: Computerized Problem List is the source for the following:

1. Laceration NEC (ICD-9-CM E928.9) 10/05/11 HECHANOVA,DEM

2. Headache 02/06/14 LEE,SE-YOUNG

3. Tinnitus 02/06/14 LEE,SE-YOUNG

4. Neck pain 02/06/14 LEE,SE-YOUNG

5. Chronic low back pain 02/06/14 LEE,SE-YOUNG

6. Foot pain 02/06/14 LEE,SE-YOUNG

7. Knee pain 02/06/14 LEE,SE-YOUNG

8. Insomnia 02/06/14 LEE,SE-YOUNG

9. Chronic rhinitis 02/06/14 LEE,SE-YOUNG

10. Traumatic brain injury with brief loss of 03/05/14 HAGER,GILBERT P

consciousness

11. Other Signs and Symptoms Involving Cognition 03/05/14 HAGER,GILBERT P

12. Posttraumatic stress disorder (SNOMED CT 05/29/14 HAGER,GILBERT P

47505003)

13. Pain in joint involving shoulder region 05/29/14 HAGER,GILBERT P

Medications: Active Outpatient Medications (including Supplies):

CETIRIZINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH DAILY FOR ACTIVE

ALLERGY

FLUNISOLIDE 0.025% 200D NASAL INH SPRAY INHALE 2 SPRAYS IN ACTIVE

EACH NOSTRIL TWICE A DAY FOR NASAL ALLERGY

MIRTAZAPINE 15MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE (S)

BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT

CONSULTING YOUR PROVIDER.

PAROXETINE HCL 40MG TAB TAKE ONE TABLET BY MOUTH AT PENDING

BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT

CONSULTING YOUR PROVIDER.

PRAZOSIN HCL 2MG CAP TAKE ONE CAPSULE BY MOUTH AT BEDTIME ACTIVE (S)

FOR 7 DAYS, THEN TAKE TWO CAPSULES AT BEDTIME FOR 7

DAYS, THEN TAKE THREE CAPSULES AT BEDTIME ** MUST

CONTACT/SEE VA PROVIDER FOR REFILL **

TRAZODONE HCL 100MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE

BEDTIME

Language/Language Preference: English

Referred by: MH Dr. Glass

Identifiers and Chief Complaints:

1. "Headache really really bad migraine, sometimes I have to lay down in a

pitch

dark in my room my windows are just blacked out, I wear sunglasses when

I walk around indoors."

2."My headache gets bad, it affects my job, I'm a deputy for the

sherrif's

department."

3. I don't get sleep I'm always up on guard, I'm very detached, an

inmate

committed suicide in front of me, it doesn't bother me at all."

4. "my chest hurts alot, I wake up in the middle of the night time and I

puke

sometimes."

CONFIDENTIAL Page 106 of 2055. "I think I don't get enough some kind of oxygen flow, and I

puke."

6. "I lost 40 lbs, sometimes I gain 45 pounds sometimes I don't eat and

lose 45

pounds."

7. " I get depressed alot, I used to be outgoing used to have a good

relationship with females my family."

8. "I just don't care about alot of things, ever since I got out of

deplyoment."

9. 'I get angry easily, I can't sleep without my gun,"

10. "I worried that I want to have a family, but scared because I have to

sleep

with a gun."

11. "I think I found a girl, but worried about my conditions, maybe if she

finds

out down the road, maybe that's why I'm depressed too."

12. "I think alot about things, I have running thoughts."

Deployments: 3

Total length in Combat Zone: 20months

Physical Injuries (combat related):

***fall >his height, gunshot wounds and concussion injury

"I took a 1 bullet to the chest, 1 bullet to the right leg went through my

pant

and grazed my right leg. got ambusshed fell d9own the stairs. I fell down fromn

2 story high the stairs collapsed on my I smashed my head on the humvee

windshield. Someone threw a flare with a barbeque propane tank through the

window and hit me on the head. I fell down the cliff while I was in philippines,

the rope snapped, I hit my head and my back in a bunch of rocks."

History of concussion, number, and if loss of consciousness occurred:

"2 or 3 times, I think"

Legal Status (any current charges, probation, parole?) No

SPECIFY}

none, **vet on work probabation***

Developmental History:

Education:

"2 Associate degrees, Accounting and Human Behavior, just want

to get it to get a job"

Social History: Describe family relationships, romantic relationships, friends?

CONFIDENTIAL Page 107 of 205 pre-military:

"it was good I went to baseball games, pool parties,

concerts regular stuff dances. Family we had good times, friendly

outgoing meet new people, it was good."

non-combat military:

"marine corps life was tough but it was still

good, everybody life is tough but my

family was supportive, no I didn't really drink."

post-military:

"My family is supportive still but I don't really talk

about anything with my family, (girlfriend) she asks me stuff but I just

don't give her the answer, I just go around it I don't really

answer too

much. i don't have any friends now. Coworkers) they're just my

coworkers, I don't really call them after work. I only call 2 of

them

because they are vets, and their son's in army too, other than vets

I

don't talk to anyone else, because they talk shit about me."

Work History:

pre-military:

"highschool, I worked at a golf course and I helped my family

business, they used to own a little shoe store"

post-military:

"Sheriff's deputy, went to school used my GI Bill, I'm a

correctiona

l officer, I want to go to field but psych will not let me pass."

Nutrition Screening:

The patient notes an unintentional weight gain.

Amount: 44 lbs "Because of the medicine they gave me I'm not

able

to eat."

Most recent measurements:

Measurement DT WEIGHT

LB(KG)[bMI]

06/25/2014 08:20 149(67.59)[23]

05/28/2014 08:27 152(68.95)[24]

02/06/2014 13:52 171.9(77.97)[27]

Edited August 12, 2014 by bojack (see edit history)

[bojack]

I might lose my job maybe, I am scared VA might low ball me even with all these evidence to back it up.... I just hope my claim gets setted fast because San Diego RO did tell me she is going to try to end my claim by this year.

[bojack]

This patient was seen last week and I had asked him to return to evaluate meds -

he says he doesnt want to see me since I am threatening to him - he seems to

remember the evaluation very different from my memories and I am surprised by

his description to OEF-OIF case manager the next day - he is indeed paranoid -

he has apparantly been reassigned to a different psychiatrist who cannot see him

today - he wants to report that the

temazepam 30 mg qhs

had no effect what so ever and he was very wide awake a couple of hours later

and he has decided that he needs to be on medications - I suggested that his new

doctor may have different ideas about insomnia but he asked if he could pick up

something else in the way of medication while he awaited the new doctor. I gave

Temazepam 100 mg qhs

I told him that it was an antidepressant that was very sedating and it had the

anticholinergic side effects of having a dry mouth the next morning but it is

always good to increase fluids when you wake up - all he had to say was that I

was too intimidating - I wished him well but I do have concerns about his need

to have a gun with him and his seeing things in the shadows and he is easily up

set. He seems to hear things that were not there too!

[georgiapapa]

Welcome to Hadit. Sounds like you have a lot on your plate. Hopefully other Hadit members with situations similar to yours can be of assistance.

I would suggest you provide specific questions or concerns that you have regarding the information you listed in your posts.

Good luck.

[NavyWife]

Yep, It is just a waiting game now.

Now that your C&P exams are all completed, there is really nothing else you can do except wait for their decision.

They have to look over ALL the information in your records, Your C&P exams as well as your treatment notes from VA, Plus your in-service treatment records.

[bojack]

Do you guys think I will have chance winning ptsd claim?

3x combat deployment as sniper and machine gunner as well.

[bojack]

Just littleb nervous since my job is looking into me lately m

[bojack]

I filed for ptsd, tbi, depression, insomnia, titinnitus, knee, foot, chest, back, neck, and shoulder pain, sleep apnea, and hearing loss.

Tbi, I received 50% greater than my injuries were service related.

[Navy04]

Just have to wait and see bud. God Bless and good luck. Keep us posted

[mrmark1999]

Please don't stress out too much here is the requirements for ptsd {{{{ http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp }}}} you seem to hit a lot of them . but yes it is a waiting game if it is compensation you are looking for there were many things listed " in service" that could be filed for all are deserved but it will be a pain in the ass

Semper Fi hurry up and wait same old shit but be prepared to follow up with any denied calm

[bojack]

Regional office called me today, my claim just went to decision phase and RO told me I am going to get my decision bwithin 14 days from now on.... crossing my fingers

[NavyWife]

Wow, that's really fast! I hope you get a good rating!

[bojack]

Thank you, most of my records are from VA treatment and service records. I do have few treatments from my private doctors, but most of my treatments came from VA hospital. Also, they received all my C&P results 08/06/214. I just hope they dont ask for more evidence since I do not have more to give or offer.

[NavyWife]

Once they make a decision, you can go on Ebenefits under "Download VA letters". click on any of those links and see if your percentage has changed.

[bojack]

Thank you

I am so nervous right now, but I know they cant deny my ptsd and tbi for sure

[bojack]

VA sleep clinic juat gave me cpap machine today for my sleep apnea, but c&p examier thinks I don't have sleep apnea.

[THOMAS89031]

Bojack, you should apply for Social Security Disability. With all the meds you are on, and your medical records, I would think it would go thru without a hitch. jmho. As for sleeping with a gun, I can't remember how many years it took me to not sleep with one. But in todays society, it might be a good idea to start again!! (tongue in cheek) I decided to sleep with a can of wasp spray and a butane lighter on my nightstand. It make a terrific flamethrower!! Good Luck and Semper Fi !!!

[bojack]

Can I qualify for social security disability when I am still working full time job?

[bojack]

My ptsd doctor just upgraded all my medication to stronger dosage.