ptsd Ptsd Claim Opinion.

[jaszper]

Hello all and thanks in advance for any help. So I'll try and make this as clear and concise as I can. I'm 30% SC already for injuries that happened in the military. I put in my ptsd claim in 2010 and was given a 10 minute c&p that was terrible. I was originally denied for lack of stressor event proof. I put in my NOD and received another letter that said denied for lack of evidence of stressor event. So that's twice I've been denied because of lack of proof the events happened. One of my problems with it is that the reason I'm SC for the 30% is because of 2 separate incidents that happened in the military that caused and then made the PTSD worse. The first incident was in 2001 while in AIT I was walking and hit by a hit and run driver. Multiple injuries from that. 2 that I'm SC for. I then deploy to Iraq in 03 for the initial push. I have multiple incidents from that. The day I'm back from that deployment I end up getting attacked by other soldiers and wind up in the hospital for about 3 weeks. Multiple injuries once again 1 that I'm SC for. Sorry if I'm taking to long to get to the point. So I've been diagnosed by the VA for PTSD since 2004. I have been being treated and medicated for it off and on since that time. Fast forward back to the present and I submitted my form 9 back around the beginning of August of this year. I randomly received a call 3 weeks ago and was told I had a C & P exam for MH. I showed up and was honest and up front. I got a copy of the exam a few days ago and think it was in favor for rating me. If I can figure out how to post it here I will. If anyone needs anymore info about the situation please ask because I'm not sure I explained the situation very well.

My main questions are:

How can the va deny something happened that they SC me for?

Is it possible that the new c&p exam will reverse the decision and get me a rating before I go in front of the board? Timeline for that if possible? I'll post more details if anyone has questions. Thanks in advance.

[Navy04]

Welcome aboard bud, but without the C&P exam notes, it is hard to give you valid advice. Good luck

[jaszper]

I have a paper copy of the notes but I don't know how to get a digital copy. Any advice?

[Proudvet]

Go to www.myhealth,va.gov, click on personal information, then click on Download My Data health information.

Download My Data

Use the Blue Button to easily download your health information...
More »

Edited September 28, 2014 by Proudvet

[jaszper]

I tried to post my c&p exam but apparently my post was to long. Is there a specific part I can post to help with my questions?

[jaszper]

LOCAL TITLE: C&P EXAM

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: SEP 24, 2014@09:30 ENTRY DATE: SEP 24, 2014@17:06:49

AUTHOR: SCHLIEVERT,KIMBERLY EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

Name of patient/Veteran:

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD

ICD code: 309.81

Comments, if any:

Related to several traumatic events in the service, which are

detailed below, in the stressor section.

***The veteran was questioned in detail, about his family life,

growing up, because it stated that he had an "abusive family

life."

The record indicates that the veteran was "hit" as a child. When I

questioned him, regarding this, he said he "father hit him a

couple

of time, and was careful to clarify that it was a "hit 2x I think"

and not a beating or an assault. He does not appear to have the

s/s

of PTSD related to being hit, but does appear to have it, in

relation to the events in the service, with being hit by a car;

the

gas threats in Iraq, and being assaulted in Germany when he got

back from Iraq. For this reason, PTSD is diagnosed as service

related, and not an aggravation of a condition, beyond the usual

course of that disorder, by the service (i.e. because of his early

life experiences of being hit).

Mental Disorder Diagnosis #2: Borderline line personality disorder

ICD code: 301.83

Comments, if any:

Secondary to his early family life, that was led by a single

alcoholic father, who sometimes hit the veteran, a mother than

abandoned the family when the veteran was ages 2-3, and a

childhood

where he did not feel connected to his adoptive mother, and where

there was deprivation.

Personality Disorders:

Personality disorders are usually related to developmental

issues/lesions that occur in early childhood, and are both

pervasive and long-standing throughout the life-span. A

personality

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): Please see the remarks section

for a list of the CPRS problem list, and psychotropic medication, if

prescribed.

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:

PTSD: Re-experiencing; flashbacks; nightmares; intrusive thoughts;

avoidance; physiological correlates (increased heart rate,

diaphoresis, rapid breathing). Negative mood, affect, and

cognitions; and s/s of hyperarousal, sleep disturbance, and

guardedness.

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

Borderline personality disorder:

Personality Disorders:

Personality disorders are usually related to developmental

issues/lesions that occur in early childhood, and are both

pervasive and long-standing throughout the life-span. A

personality

Veteran has s/s of emotional dysregulation.

He has a hx of suicide gestures, cutting and burning.

Hx of substance abuse.

Hx of spending haphazardly.

Jealousy, fear of being abandoned.

Threatening to hurt others.

Feelings of emptiness.

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:

It should be stated that this percentage is only an estimate, as I

have not observed the veteran at work or in his social life, and

therefore this is not an empirically driven statistic, but an

attempt to quantify his disorders.

PTSD=70%

Borderline personality disorder=30%

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?

[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:

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:

There was a buddy statement by ----------, that was brief, but stated

that she remembers the veteran having a broken leg after he was attacked

in Germany, when they were both stationed in the barracks.

Also there was a buddy statement that talked about the assault on the

veteran in Germany, after just returning from Iraq (in August 2003). He

details the same information that was provided by the veteran, in

discussing this stressor.

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):

FAMILY-OF-ORIGIN:

LIST THE DIFFERENT FAMILY MEMBERS THAT WERE LIVING IN YOUR FAMILY

HOME,

AND WHAT CHILDHOOD WAS LIKE FOR YOU:

The records indicates that the veteran grew up in a difficult family;

his father was alcoholic, and the veteran often took care of him, when

he was intoxicated. Also according to the record, the veteran's mother

abandoned the family, when he was ages 2-3. The notes indicated that

there is an older sister (approximately two years older), as well as

step-sisters, and the veteran said they had typical sibling rivalry.

The veteran was "removed from his birth mother" (10-29-13 Clinical

Interview). He had an adoptive mother, that married his biological

father, but he does not feel close to them. "I lost every relationship

with everyone in the past year."

When questions about his family life, the veteran described being

raised by a single father (until he married the veteran's adoptive

mother), who was alcoholic, an whom he had to sometimes care for, when

he [the dad], was drunk. He had grandparents who he saw until he was

aged 10-11. "I did not want for anything."

The veteran indicated that there was some emotional abuse. He said

that

for the most part he was not fearful of his dad, nor did he worry

about

being in danger. He said that he was just aware, that when his dad

drank, he had to "behave in a certain way." When asked for more

information, he just tried to care for his dad, without upsetting him.

The biological mother, was "out of pic by the time the veteran was

ages

2-3. "My parents got divorced." He did not have visitation with his

mother; "she did not come back into my life, until later on, and only

for a short period of time." As a child, he said that he talked to her

once, and saw her once (ages 2-12). At 23, he saw her again.

INTACT, BROKEN, OR BLENDED FAMILY?Broken

WHAT DID YOUR FATHER DO FOR WORK? "He did not do much; he ran a

pro-shop and driving range "for awhile." The veteran stated that his

grandfather was wealthy, and left his father property, that he sold,

and they were able to get by.

WHAT DID YOUR MOTHER DO FOR WORK?IDK.

TERATOGENS IN UTERO:

Does not know if he was exposed to any teratogens during the prenatal

period.

PREGNANCY AND BIRTH:"IDK if it was normal or complicated.

HOW WAS DISCIPLINE HANDLED IN YOUR FAMILY?

The records indicated "he was hit as a kid," and the veteran verified

this, but it happened two times, and was not a regular occurrence. The

veteran was in sort of a role reversal with the dad, in that he would

sometimes care for him, rather than the father caring for the

children.

RELATIONSHIPS WITH FAMILY NOW? Stated that he is not seeing any of his

biological/childhood family.

ANY HX OF ABUSE (PHYSICAL, EMOTIONAL/MENTAL, SEXUAL, NEGLECT)?

***The records indicated "he was hit as a kid." As per above, "dad

would get drunk and hit me a couple of times; it was not an assault,

nor was it a beating."

10-29-13 Clinical Interview: He had an "abusive childhood" and made

his

first suicide attempt at 14 y.o.a.. The veteran stated that this was

not an actual suicide attempt; he was being somewhat reckless and took

a bunch of pills (someone else's, and drank cough medicine).

RELATIONSHIPS AS A YOUTH? "I had a decent amount of friends--I was

fairly popular. I would "hang out at other friend's houses, rather

than

having them come to my house." He described himself as "outgoing."

RELATIONSHIPS IN THE MILITARY?

In the early phase of his military career, he had good friends (i.e.

as

close as you can have in basic and AIT). "My relationships did not get

strained until right after we got back--it got weird. I was drinking a

lot." During the military, socializing was okay up to a point--after I

hit by car, and then when I came back from Iraq--there was a definite

downslide, in terms of friendships."

RELATIONSHIPS AFTER THE MILITARY?

"Married and divorced once, because his wife "was a civilian and

normal; she refused to see my issues as anything but weakness. I

wanted

to go to American Lake, for treatment, and she said "no you don't need

it. We divorced over it."

"It [the divorce] made me sad because of my kids-I wanted them to grow

up in a fully parented family, instead of broken family. As time goes

by, I think it is a good thing (that he is not there, but misses his

children). Two are his biological kids, and one other child, he has

been in her life "since she was a year old." He stated that the first

thing his ex did, was tell her daughter that the veteran wasn't her

father, and she [the child] was devastated.

CURRENT LIVING SITUATION?

Lives with a s/o. The relationship is "okay. We have set routines,

that

we have to do to function as a couple." Their routines have to do with

AA, counseling, medication [he is medicated, she is not]. His

significant other "suffers from PTSD." He said that they have the

benefit of understanding that they have PTSD and they "understand what

it takes for them to function normally. We have broken up 4-5 times in

the last year."

"Our relationship now, has somewhat stabilized. It is strained but it

works."

***The veteran eluded to his significant other having a C&P, but

there

was no bilateral discussion between the veteran and I, of anything

having to do with his significant other, other than what he told this

writer, about their relationship, in terms of functionality. The

veteran referred to her as his "significant other."

b. Relevant Occupational and Educational history (pre-military, military,

and

post-military):

EDUCATION AND WORK HISTORY:

DEVELOPMENTAL MILESTONES:"I have no idea."

ANY DOCUMENTED LEARNING DISABILITIES:"I was a smart as--denied

learning

disabilities.

SCHOOL YEARS:

"I did not start getting into trouble until the 7th and 8th grades. At

that time, I was being disruptive." He described his school

performance

as: "fairly successful--extremely smart; I could do work if I wanted

to." High School was at a military academy--"where I thrived until I

xxxxxx off." When asked if anything in particular occurred to

disenchant him with this school, but he said: "I cannot think of what

started this for me." He stated that he "took a bunch of pills and

cough syrup." Does not believe he was actively suicidal, nor does he

consider this to be an actual attempt.

"Math scared the shit out of me. I liked the science and history--both

made sense. With regard to "Abstract thinking," he stated: "I was good

at it, but I did not like it, so he tried not to do it." Has always

had

the ability to do well if he wanted. He stated: "I have a 10th grade

education."

DETENTION/SUSPENSIONS/EXPULSIONS FROM SCHOOL? Yes. First time was when

he was asked to leave military school for excess demerits. The second

time was d/t the event, where he took the different pills, as "they

frowned on that."

Cutting and burning his skin--that was later in life--in my late teens

and early 20's. "It was attention grabbing and it also was relieving,"

in terms of stress. He has tried to engage in "a lot of

introspection--trying to figure myself out, for a several years

now--and that is what is real about it." He stated that he realized at

some point, that he has gone from cutting/burning his skin to tatoos.

"Tatoos are the same thing (the pt said), but they allow me to get the

stress out, without cutting or burning." He has not engaged in

self-injurious behavior since his mid-20's.

TRADE SCHOOLS:

NONE

COLLEGE:

None that was successful. I have tried 4 times. I had panicked, the

frist time he tried to go (pulse increases, diaphoretic palms, and

rapid breathing, and dizziness). He felt if he went to school,

something bad would occur. Tried to go to college through vocational

rehab--online, but he stated that his PTSD was interfering, with him

trying to learn things on the computer. He stated that they "wanted

him

to have all these specific things in place, for him to continue

school--VA counseling (individual and/or group), and medication. He

began to cry, and said: "I honestly don't know if I could do it, even

with those things in place, but in any case, they weren't in place."

The veteran stated that he has a behavioral flag because of going in

and being desperate to get help from mental health, and then the

scheduler only could give him an appointment in October. He said:

"That

is why I lost it--I am a head case [how he refers to his PTSD], and

now

I have to have my little shadow (his police escort)."

EMPLOYMENT:

"I have tried to get a few different jobs. They did not work out

because I get combative with staff and customers. I would either freak

out and not go to work. Or if I did go to work, something would

happen,

and the day would get ruined to the point that he could not stay,

without blowing up on staff or a customer." This happened often, and

eventually he and his ex, agreed it would be best for him to be a stay

at home dad." Since coming to White City, he "started to work, and had

to quit one job." He works currently and "can get combative, or I

forget things." He stated further: "I was supposed to be on night

shift, and that was perfect--so that he did not have to be around

others." He stated that he was seriously assaulted, in the military,

and therefore, "cannot be around males, especially alpha males." "I

almost had to quit yesterday," after he "almost got physical with one

of the clients. I xxxxxxx wanted to kill him. Who knows how long this

will last--maybe another two xxxxxxx weeks. 4-6 months is usually my

limit, when everything starts to fall all apart."

"I work the "on track dad's program. I have almost 7 years of

sobriety.

I think it is a good time, unless I get furious, but then he needs to

not be there. He talked about the level of irritability he has, and

how: "I can go from thinking I want to kill him, to planning it, and

then wanting to do it." I questioned the veteran very throroughly, to

make sure that there wasn't an intended victim, or an absolute plan of

action, to hurt someone. Instead, he just tries to monitor himself,

and

if he gets bad [i.e. wanting to get into a verbal or physical

altercation], he must removed himself from the situation. He is sure

that this will happen in the future, where he becomes angry and has to

remove himself from the situation. "Sometimes it doesn't take much, if

someone looks weird at me, I feel like I want to go after him."

"If I could get some treatment, to xxxxxxx make this go away--I would.

I don't want to feel like that! I tried to get help, and they give me

a

date a month out, and now I have my little shadow to deal with [the

escort officer], whenever I need to come here.

WHAT DO YOU DO FOR SELF-CARE/FUN/HOBBIES CURRENTLY?

"NONE."

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

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

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

Any psychiatric evaluations, treatment, or psychotropic medications

BEFORE the military?

CD?Denied.

Outpatient? (Note from 10-29-13 Clinical Interview): He had an

"abusive

childhood" and made his first suicide attempt at 14 y.o.a. (1999 in

military school). With regard to this event, he stated that he was not

suicidal, but instead, just took a bunch of pills, and cough

medicine--I was not trying to kill myself, but my school still did not

appreciate it." He was found by staff at the military school.

Medications?Denied.

Inpatient?Denied.

***He also engaged in "self-injury" when he was a teen, and indicated

the last time he did this was in his 20's (10-29-13 Clinical

Interview).

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

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

Any psychiatric evaluations, treatment, or psychotropic medications

DURING the military?

CD? ADAPT C (for alcoholism)--"I checked myself in."

Outpatient? Denied

Medications?Denied

Inpatient?Denied

Any suicide attempts?Denied

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

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

Any psychiatric evaluations, treatment, or psychotropic medications

AFTER the military?

CD? Here at WCO, although he was sober at the time, and was here more

for PTSD tx and homelessness, not for SATP.

Outpatient? He stated that he has asked for treatment multiple times:

"The damn doctors--it is so stupid. The only thing they did when I had

episode, was what they always do--they threw more pills at me. I want

treatment. I want to talk about what happened. Presently taking

Celexa; Lamotrogine, and Abilify."

Medications? See above.

Inpatient?Denied psychiatric hospitalization.

Suicidal Attempts?Denied.

Current SI/HI?Denied right now. He "thinks about it often, but stated:

There is a difference between having an idea about it, and having an

intention to do it." He does not want to get to this point, but feels

like he could.

***NOTE:VETERAN HAS A DISRUPTIVE BEHAVIOR FLAG***

5-11-04: Veteran was evaluated, and said that he "was afraid of

everything." During this examination it was mentioned that the veteran

had some type of hx that included OCD, and feeling paranoid.

4-2008 (Per pt report), the veteran stated that he had suicidal

ideation with a plan.

10-20-08 "Came to get off medications."

9-17-13 TBI--has not been dx with it. Has a hx of anxiety, OCD, and

depression.

Audit C was negative for alcohol use.

9-19-13 Spiritual Assessment: Assembly of God as a youth, but the

veteran indicated that the church made him feel bad about himself. Has

attended Catholic, Protestant, and Buddhist places of worship. He has

an adoptive mother and a father (biological?) that are supportive of

him (at this point they are no longer talking-->9-24-14).

"Feels God gives him anxiety when he is making a bad decision. Does

not

believe that he is punished by God."

9-13-13: "He is a candidate for DCHV, but all the beds are full at

this

time." The veteran admitted to anxiety; sleep disturbance, but there

is

no paranoia; depression; no SI; no hallucinations, and he was alert

and

oriented.

9-25-13: PTSD scrEen positive (SCORE OF 4), Anhedonia and

depression--yes, nearly every day. History by veteran report includes:

bipolar disorder; MDD: PTSD and Borderline p.d.o. Denies psychiatric

hospitalization(s). There is a history of fights, as a civilian

(10-15), and in the military. Fight were often while he was

intoxicated. In the record it indicated that the veteran denied that

this had happened since 2007 (when he became clean and sober).

Has organized thoughts, without unusual content. No AH or VH. No

delusions. I&J fair. He was divorced by his spouse, and although

it

saddens him, he "knows it is for the best." The veteran stated: "I am

a determined and hard worker." Memory was found to be intact. Seeking

psychiatric care for PTSD and homelessness. Talked about discharging

to

Waldport, where his children live.

11-9-13 Dx with PTSD, chronic by Sylvia Green. Also Alcohol and

stimulant abuse (both in late full remission). He was not dx on Axis

II

(characterological disorder).

2-19-14 Suicide screen negative, except for the question having to due

with "previous suicide attempt(s), which he answered as yes.

2-20-14 Regular discharge from the SATP program.

8-13-14: "Actively suicidal, was going to put a pistol in his mouth

last night."

d. Relevant Legal and Behavioral history (pre-military, military, and

post-military):

ANY LEGAL HX?

CHILDHOOD? Ended up using drugs one time, brought home by PD. Does not

remember charges.

ADULTHOOD? "Yes, but always alcohol related." There were

assaults--some

reported and some not--Disorderly conduct; Drunk in public. "Just me

acting out. Any time I drink I get violent."

MILITARY LEGAL HX? Picked up a few times-alcohol related.

MISDEMEANOR OFFENSES:

FELONIES:

DUI'S:One 2006.

DOMESTIC VIOLENCE:

JAIL TIME:

PRISON TIME:

STATE HOSPITAL TIME?:

CHARGES EXPUNGED FROM RECORD?

e. Relevant Substance abuse history (pre-military, military, and

post-military):

SUBSTANCE ABUSE HISTORY:

CLEAN AND SOBER DATE:11-10-2007

HOW MANY CD PROGRAMS AND WHERE?In ADAPT C in the Army. Tx in 2007 and

2008 outpatient. He also took "Living environment training." He goes

to

AA meetings, has a sponsor who is also a veteran and is working the

steps. He has seen him go to the mmeting, but be unable to stay. He

walks in and it is a feeling, or someone looking at him, and the only

place it is a safe haven. I think about drinking latels, and I did not

used to do this for a long time. This is why he was adament about

getting help. ON bare edge sometomes. I can barely function.

WHEN DID THE VETERAN BEGIN USING TOBACCO? WHAT IS HIS/HER USE OF

TOBACCO NOW? 1 ppd. Quit for 13 months. "I was crazy to start again."

WHEN DID THE VETERAN BEGIN USING ALCOHOL? WHAT IS HIS/HER USE OF

ALCOHOL NOW? "Enough to put me into liver failure." 30 pk beer, and

depending on upwards of a pint as well.

11-10-2007.

WHEN DID THE VETERAN BEGIN USING CANNABIS? WHAT IS USE OF CANNABIS

NOW?

DOES THE VETERAN HAVE A MEDICAL CANNABIS CARD? NO

WHEN DID THE VETERAN BEGIN USING STIMULANTS? WHAT IS HIS/HER USE OF

STIMULANTS NOW? 11-10-. "I liked Meth, but it was not my thing--I like

drinking much more."

OTHER ILLICIT DRUG USE:

WHEN DID THE VETERAN BEGIN USING OPIATES? WHAT IS THE VETERAN'S USE OF

OPIATES NOW? (THIS CAN BE EITHER RX MEDICATION OR USE OF ILLICIT

OPIATES):

MISCELLANEOUS INFORMATION ABOUT CHEMICAL DEPENDENCY:

Alcohol Use Disorders Identification Test Consumption (AUDC)

Date Given: 06/06/2014/Gender: Male-Score: 0 points, which is a

negative result.

1. How often did you have a drink containing alcohol in the past

year?

Never

2. How many drinks containing alcohol did you have on a typical day

when you were drinking in the past year?

Not asked (patient reports no drinking in past year)

3. How often did you have six or more drinks on one occasion in the

past year?

Not asked (patient reports no drinking in past year)

f. Other, if any:

Previous PTSD examination performed by Dr. Sashkin,Ph.D. 10-27-10

The veteran was diagnosed with PTSD by this clinician.

AXIS I: PTSD

ACIS I: Depressive disorder secondary to the PTSD.

AXIS II: Deferred.

AXIS III: PLease see medical file.

AXIS IV: Psychosocial stressor--scoial

AXIS V: 45

[jaszper]

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: -----------"

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

Is the stressor related to personal assault, e.g. military sexual

trauma?

[ ] Yes [X] No

b. Stressor #2: ----------

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

Is the stressor related to personal assault, e.g. military sexual

trauma?

[ ] Yes [X] No

c. Stressor #3: -----------

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

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.

Buddy statements by Lorena Castro and Mr. Anderson.

Medical records in 2003, that appear to document the assault.

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)

[X] Witnessing, in person, the traumatic event(s) as they occurred to

others

[X] Learning that the traumatic event(s) occurred to a close family

member or close friend; cases of actual or threatened death must

have been violent or accidental; or, experiencing repeated or

extreme exposure to aversive details of the traumatic events(s)

(e.g., first responders collecting human remains; police officers

repeatedly exposed to details of child abuse); this does not apply

to exposure through electronic media, television, movies, or

pictures, unless this exposure is work related.

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 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] 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 #1

[X] Stressor #2

[X] Stressor #3

5. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks more than once a week

[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] 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] Obsessional rituals which interfere with routine activities

[X] Impaired impulse control, such as unprovoked irritability with

periods

of violence

[X] Spatial disorientation

[X] Grossly inappropriate behavior

[X] Persistent danger of hurting self or others

[X] Neglect of personal appearance and hygiene

[X] Intermittent inability to perform activities of daily living,

including maintenance of minimal personal hygiene

[X] Disorientation to time or place

6. Behavioral Observations

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

The veteran has a behavioral flag on his chart, because according to the

veteran he had "an episode" when he went to mental health, because "I felt

like I was losing it, and they gave me an appointment in October."

Apparently

his "episode" was that he "became combative and went off" according to the

veteran. When I looked into the chart, it became a little more clear as to

why he had a behavioral flag--he threatened to bring a gun to this VA, if he

was not given treatment. Because of the above event, the veteran was

escorted

to the appointment by VA police. I met for a moment with the veteran, in our

lobby area, to try to gauge whether or not I could see him without the

officer, and he agreed to cooperate to get this evaluation done. He did not

become hostile, rude, or threatening, and this writer used her therapeutic

tools, to know when to ask for more information, and when to back off, and

give the veteran a few moments to calm himself, so that we could go on.

Veteran is dressed in a sweat shirt, shorts, and tennis shoes. He wears

glasses and short hair. His grooming today was adequate, but apparently

there

are times, when the veteran will not shower for multiple days--sometimes as

long as a weeks. The veteran has tattoos all over his body. The veteran

stated that he recognized that his tatoos have taken the place, of the

cutting and burning he used to do. The veteran is very emotional, began to

cry when he told me of his assault; being hit by the car (hit and run), and

the gas attack threats in Iraq. He would try to calm himself down, but

coping

mechanisms were difficult for the veteran to use this day. At one point, he

seemed to need a break, thus I suggested he just clear his head for a

minute,

and he went out and smoked a cigarette, and then came back inside. In this

writer's opinion, the veteran had a difficult time during this evaluation,

and was under considerable stress. It did not appear to this writer, as if

the veteran was embellishing his report of the stressors, nor was he being

dramatic.

At the end of the interview, I asked him for a self-report of how he was

doing, and he was "upset, exhausted, but felt okay to leave." I told him

that

he could call the "veteran's crisis line" which he had the number memorized.

I also offered to take him over to triage, but he stated that he was okay to

go home. He had someone picking him up, and said he would be okay.

7. 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

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

CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER.

VA CLAIMS FOLDER FORWARDED FOR VA EXAMINER REVIEW AND CLARIFICATION.

Appeal Related Claim.

Issue on appeal: Service connection for post-traumatic stress disorder.

Veteran's Information:

Name:

Background:

VA exam report of 10/19/10 diagnosed PTSD in relation to an in-service

assault, the occurrence of which has not been conceded by the VA. During

that examination the veteran also mentioned being struck by a vehicle in

the

fall of 2001. He has provided a copy of the accident report from the

Richmond County Sheriff's Department which is of record (tabbed in

c-file).

In his PTSD report of 10/19/10 the VA examiner related veteran's PTSD to

the

unverified in-service event, but did not provide a medical opinion as to

whether any of the veteran's PTSD is or is not "at least as likely as not"

(50 percent or greater probability) attributable to the verified

in-service

hit and run vehicle accident. We are thus seeking clarification.

Requested Medical Opinion:

(1) VA examiner is asked to review the medical evidence of record

(including

treatment records from all VA medical facilities as noted in Virtual VA

and

CAPRI for this veteran) and then to provide a medical opinion as to

whether

veteran's current diagnosed mental health disability(s), to include PTSD

and

depression, is "at least as likely as not" (50 percent or greater

probability) medically attributable to the in-service vehicle accident on

9/02/01 as noted in the accident report from Richmond County Sheriff's

Department versus to other etiological factors. Please provide factual

basis and medical rationale supportive of your opinion.

(2) If more than one mental health disability is medically identified,

please outline whether it is possible to medically separate the symptoms

of

each identified mental disorder, or whether the symptoms are inextricably

intertwined and cannot be separated without resort to mere speculation.

(3) Please discuss impact of veteran's mental health diagnoses on

veteran's

occupational functioning.

Pertinent Evidence:

Tab A: Veteran's service personnel and service treatment records

Tab B: Veteran's statement(s)

Tab C: Accident report from Richmond County Sherriff's Department

Tab D: PTSD exam report of 10/19/10

Tab E: CAPRI records in Virtual VA

Note: VA examiner is not limited in review to the above-mentioned records

but is encouraged to review all evidence in the claims folder to make your

mental assessment and medical opinion.

Thank you.

VA exam req; D.Kocarnik, Dec.Rev.Officer, PH: 503-412-4608.

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

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

***THIS EXAM WAS COMPLETED USING DSM-V AS THE BASIS FOR DIAGNOSTIC

PURPOSES.***

*** This report was written using voice recognition software, therefore,

words may appear that either sound like the real word, or are similar

in terms of spelling.

__________________________________________________________________________

_________________

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

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

Current Service Connection Status at the time of this evaluation:

Lower leg condition-->10%

Scars-->0%

Clavicle, scapula, impairment of these regions-->10%

Limited flexion of the thigh-->10%

Limited flexion of the knee-->10%

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

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

BRIEF MEDICAL HISTORY: FROM CPRS

"Leg hurts on a daily basis,constant reminder of what happened."

"Head hurts a lot."

Chronic alcoholism in remission.

Polysubstance abuse.

Olecranon bursitis

Tobacco use

Knee pain

Non-specific reaction on the skin.

VITAL SIGNS:98.4, 89, 16, 115/62. Pain=4. Wt is 192.6. Ht=68

inches.

MEDICATIONS:

Psychotropic medications include:

Prazosin

Citalopram

Abilify

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

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

FAMILY HISTORY:

Father: He is alive (he does not see him).

Mother:Adoptive mother is alive (he does not see her).

Brothers:NONE

Sisters:Does not see biological sister or adoptive sisters.

Children: He has visitation with his children, but feels like he is

unable

to enjoy the time with them.

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

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

STR's in Record:

ALL STR'S REVIEWED

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

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

NEW INFORMATION PROVIDED BY THIS VETERAN TO INITIATE A SECOND C&P

EXAMINATION:

Proof of the veteran being hit and run, by a vehicle, during the

military.

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

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

INFORMED CONSENT:

Pursuant to providing the veteran was an informed consent, he was

informed

that the purpose of the current examination was to obtain information

related to his claim for service-connection, for PTSD. In addition, this

writer explained to the veteran that this C&P appointment, is not a

traditional psychological examination or psychotherapy session, where the

content is kept confidential, as my report, will be uploaded into his

electronic (CPRS) file, and eventually it will be examined by a rating

officer, at VBA, who will make the final decision as to whether or not he

has a service-connected disability, and if so, the rating associated with

that disability. I also told him, that if he wants a copy of the report,

he can go to ROI to obtain one, or it can be downloaded through

Myhealthevet, if he is registered and authenticated for this service.

I also explained that our meeting today, does not represent a traditional

doctor/patient relationship, as I am only seeing him for the examination,

and then my contribution, to his case, will be completed. He stated that

he understood all of these conditions, and wished to move forward with

the

examination.

I further explained that the information in this report could be subject

to public disclosure, if he should appeal his claim at the federal level.

Other limitations to confidentiality were discussed with regard to: 1)

danger to self/other, 2) and/or information regarding child abuse, and 3)

elder abuse. The veteran voiced understanding and acceptance of this

information and consented to participate in the examination.

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

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

Identifying Information:

The veteran is a 30 year old, divorced, Caucasian man, who presented

to

this writer, for a Compensation and Pension Examination for PTSD. This is

not the first C&P exam for this veteran--he had a previous C&P

examination, but was denied compensation or pension for PTSD, because the

stressors could not be verified. The veteran was on time for his

appointment. He was dressed in casual but clean clothing, and his

grooming

and hygiene was adequate, although he stated that there are days that he

does not shower or take care of his basic hygiene. He looked older his

stated age of 30. He had dark circles under his eyes, and looked very

tired. He said that he has not been sleeping well, but last night was

especially bad, as he knew that he would have to talk about his stressors

again, and how he has such a backlash, after he talks about them--this is

one of the reasons that he wants to get into therapy. When he entered

the

evaluation room, he sat closest to the door, and was very cooperative. He

would stop and listen, if there was noise in the hallway, though I did

not

see him fully startle, though a certain times this was reported by the

veteran to happen. The veteran appeared to be embarrassed about having

to

arrive by escort from the police.

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

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

MENTAL STATUS/EMOTIONAL STATE:

The veteran was alert and oriented X4. He could attend to, and

concentrate

on a task at hand, without difficulty today, although there are times

when

he must read a paragraph more than once, or he forgets to do something,

so

that concentration has been an ongoing issue, according to the veteran.

He

could calculate (when asked questions that required for him to

add/subtract in his head), do serial 7's, and he could abstract.

abstract.

In general, his memory seemed to be intact, for example when I asked him

to repeat sentences, numbers (backwards and forwards), or words.

However, on delayed recall, the veteran could not recall the words he was

asked to remember, and he was not helped by categorical hints. He had an

above average vocabulary, and intellectual functioning was estimated in a

range of high average, as well. He could name four presidents: Clinton,

Reagan, Washington, Jefferson, and Lincoln. His general fund of

information was intact, and comparable with someone in his own age group.

He could spell the word "WORLD" backwards and forwards without

difficulty.

He could repeat 7 digits forwards and 4 backwards. He could repeat both

simple and complex sentences after this writer said them: "No ifs ands

or

buts" (simple) and "The beginning movement revealed the composer's

intention" (complex).

Mr. McClenan had a depressed and anxious mood, and his affect was full in

range, and congruent to the topic at hand. He denied suicidal or

homicidal

ideation today, but does have SI and HI regularly. Insight and judgment

appeared within fair. Impulse control today was intact; he was not at

immediate risk for self-harm or the harm of others, when he left the

C&P

clinic on the day of the examination. He was reminded about the Veteran's

crisis line; the triage system here at SORCC, and suggested that he get

in

touch with his PCP and Mr. Hines, LCSW, who he last saw for mental health

issues. He said that he has called multiple times, but did not receive a

call back, and said that this lack of help, was what caused the problem

that led to the "behavioral flag" because he told scheduling, that he was

considering suicide by shooting himself, and was considering drinking

August 22, 2014), and was only offered an appointment in October. He

denied mood swings, mania, or any type of cycling in terms of his mood.

He

demonstrated psychomotor activity, which was within normal restless and

anxious.

The veteran's spontaneous speech was clear and coherent, and showed no

evidence of thought disorder or psychotic processes. There was no

paranoia, no ideas of reference, no delusions, and no hallucinations.

There was no evidence of depersonalization, derealization, or

dissociations. His thinking and speech appeared linear, goal-oriented,

and

contained cause and effect/hypothetical relationships. His speech

appeared normal in terms of rate, rhythm, and volume, without pressure or

severe intensity, until he would talk about the stressors, and then he

began loud, tearful, and had difficulty controlling his emotions. As

mentioned, at the conclusion of the occupational history, he had to leave

for a few minutes, and take a break with a cigarette, so that he could

continue on with the evaluation. There was no word blocking, anomia, or

evidence of Wernicke's or Broca's aphasia.

In addition, he could remember 4:4 words on immediate recall, but 0:4 on

delayed recall. His auditory sequencing appeared intact; he could listen

and process commands, carrying them out, for example, touching his nose,

clapping his hands, and stomping his foot on the ground, when requested

to

do so.

The veteran denied any eating disorders--there is no

purging/binging/restricting. He denied symptoms of psychosis.

/////////////////////////////

Other Diagnoses in the chart:

/////////////////////////////

/////////////////

Bipolar Disorder:

/////////////////

In addressing the diagnosis of Bipolar, he stated that he has been aware

of this diagnosis, but "cannot agree with the whole manic thing." He said

that he "most definitely has depression, but that the most manic I get is

having an okay day, instead of a totally shitty day." He stated that

sometimes when he drank or used Meth, he might seem manic, or feel

euphoric, but there is not a natural tendency to feel happy, and

certainly, he is not euphoric, nor are there regular cyclical moods that

are up and down. He stated that he "ups" are never as high, as his downs

are down. He denied mania, hypomania, and still does not agree with the

diagnosis of Bipolar disorder.

//////////////////////////

Major Depressive Episode:

/////////////////////////

The veteran has been diagnosed under DSM-IV with MDD, secondary to PTSD

in

his C&P done by Dr. Sashkin 10-27-10. At this time, since DSM-V was

not

in use yet, MDD secondarily related to PTSD, was often diagnosed

separately. Under DSM-V, the depression is often seen as a progression of

the PTSD, and is covered under criterion "D" negative emotions and

cognitions--thus this writer incorporated the MDD diagnosed in the

previous PTSD C&P, into the diagnosis of PTSD.

////////////////////

Chemical Dependency:

///////////////////

The veteran has been diagnosed with alcohol dependency, Methamphetamine

dependency, and polysubstance dependency, in the C-file. The veteran has

been clean and sober since 11-10-2007. He attends meetings regularly with

his significant other. He has a sponsor (who is also a veteran), and he

is

working the steps of AA to remain clean and sober. Since he has been

clean

and sober since 2007, he is not diagnosed formally at this time, as an

active disorder(s)--as when using the date of 2007, he would be

considered

in "full sustained remission" with regard to chemical dependency.

////////////////////////

Traumatic Brain Injury:

///////////////////////

From what I can determine, the veteran had claimed at one time, to be

suffering from TBI, from either the car hitting him, or the attack he

suffered in Germany. In the narrative, provided to the veteran on

03-16-2011, he was denied TBI, and this writer does not have any

additional information to add to the denial, in such a way as to justify

a

diagnosis of TBI. This writer is not credentialed to provide a TBI I or

II

examination, and thus the denial on the above date, for TBI, is upheld by

this writer, since an exam for TBI was not completed. In quoting that

narrative, "your service treatment records are completely negative for

any

treatment of complaints or treatment for or diagnosis of any head injury.

No medical evidence has been submitted which provides for any sort of

etiology of a head injury while in the service."

/////////////////////////////////

Borderline Personality Disorder:

////////////////////////////////

There is evidence, that the veteran could have a personality disorder,

and

the cutting and burning of his body, when he was in his teens and early

adulthood, and the taking of the pills at military school, certainly lend

evidence for a diagnosis of a personality disorder. Personality

disorders,

especially borderline personality disorder, can be related to early life

deprivation, abandonment, and what is referred to as "developmental

lesions." The veteran was removed from his biological mother, and was

raised by an single father (who was alcoholic), and sometimes hit the

veteran (although the veteran stated that he was not assaulted or beaten

by his father), and he was later adopted by his father's second wife,

with

whom the veteran stated that he never really felt connected. Given the

early life situation in his family, and his young adult behavior, it is

very likely that the veteran has Borderline personality disorder. Daniel

Sorensen, NP, mentioned in his 8-22-14 note, that the veteran came to the

attention of mental health because he threatened to bring a gun to the

VA,

if he could not receive treatment. In his note, he stated: "30 year old

male with borderline personality disorder, with symptoms partially

managed

with medications.

He saw Mr. Hines, LCSW, on 8-13-14, and at that time was presenting with

mania, and pressured speech. He talked about being suspicious of his

significant other, and checking her email and phone; it is well known

that

those afflicted with Borderline personality disorder, due to poor object

relations in early life, can be suspicious, believe that their partner

is

unfaithful, and pathological jealousy is often the result. This can be

especially true, if the patient has been left in the early years of life,

by a parent or close caretaker--this was the case with the veteran.

His evaluation on 10-27-10, by Dr. Shaskin, stated that an Axis II

personality disorder was deferred.

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

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

Psychological Testing:N/A

__________________________________________________________________________

_________________

///////////////////

Referral Question:

///////////////////

Does the veteran have PTSD related to the in-service stressor (the MVA),

in 9-2-01?

/////////////////////

Clinical Formulation:

/////////////////////

The veteran was hit by a car in the military, when he was only 17 years

old. He has reexperiencing, avoidance, negative cognition and mood, and

s/s of hyperarousal.

/////////

Opinion:

////////

It is at least as likely as not that the veteran's PTSD is related to the

event in the service where he was hit by a car. He also described feeling

scared that he was going to die in Iraq, from gassing threats, and the

fear of chemical weapons. This particular stressor is related to the fear

of hostile military and terrorist acts; the car/mva is not related to the

fear of hostile military and terrorist acts. THere was a third event,

where the veteran was assaulted along with his friend soldier ----------.

There are statements by Mr. --------, and a buddy statement by ----------

, corroborating the assault, thus there is PTSD related to this

incident as well, but it is related to fellow soldiers assaulting him,

and

not d/t hostile military or terrorist acts.

It is less likely than not, that the veteran's borderline personality

disorder is d/t the service, and more likely than not related to his

early

life experiences; abandonment by his mother, and a family of deprivation,

where his early needs were not met adequately.

////////////////////////////////////

Occupational and social functioning:

The veteran describes being unable to work, and having a very limited

social life, that basically consists of his significant other, and one

friend. He stated that he does not see his family, nor does he go out and

socialize with others.

In terms of work, there does appear to be a problem with the veteran

having difficulty getting along with others. He has yelled at staff, and

customers, and believes that it is just a matter of time, before he "is

let go again." He stated that he cannot work around others, and even when

he was supposed to be working night shift, so that he could avoid working

with others, he was placed on day shirt, and could not get along with

others. If the veteran worked in a position where he did not have to

interact with others, and had minimal supervision, he could probably

continue working. He said that he wants to work, but needs help, that he

has not received. He said: "I don't want to take the xxxxxxx pills; I

want

help--I need treatment. I want to work, and have a good life, but I need

help."

///////////////////////////////////

DIAGNOSTIC IMPRESSION:

309.81 PTSD related to his service (accident where he was hit by a car;

assault by other soldiers, after coming back from Iraq, and the fear of

hostile military and terrorist acts (most feared by the veteran was the

fear of gassing).

////////////////////////////////////////

301.83 Borderline Personality disorder: not related to his service.

///////////////////////////////////////

If you have any questions, or I can clarify anything in the examination,

please call me; I am always happy to discuss my findings with you.

Thank you