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Examiners Report For 100% I/u,any Thoughts?


Oiler1995

Question

COMP AND PEN NOTE STANDARDTITLE: C& PEXAMINATIONNOTE DATEOFNOTE: FEB25, 2015@10:00 ENTRYDATE: FEB25, 2015@10:39:50: URGENCY: STATUS: COMPLETED

Review Post TraumaticStressDisorder (PTSD) Disability Benefits Questionnaire

SECTION I:

---------- 1 . D i a g n o s t i c Su m m a r y

--------------------- 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: Post traumatic stress disorder, chronic and

currently severe.

Mental Disorder Diagnosis #2: Alcohol use disorder, comorbid with him secondary to PTSD, currently in early remission.

Mental Disorder Diagnosis #3: Opiate use disorder, comorbid with him secondary to PTSD, currently in early remission.

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): This veteran has a history of a right heel injury.

3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed?

[X] Yes[ ] No

b.Isit 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: The veteran's PTSD is characterized by a full syndrome

symptoms consistent with DSM5 criteria. These include hyperarousal episodes, avoidance symptoms, reexperiencing symptoms and negative cognitions.

The veteran's history of both alcohol and opiate abuse have been ongoing attempts to self medicate his PTSD symptoms are secondary to that condition. The veteran has not abused alcohol since September

2014. The veteran has recently completed a Suboxone treatment for

opiate abuse. He is currently abstinent from opiates.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ] Not shown in records reviewed

4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of

occupat ional and social impairment with regards to all mental diagnoses? (Check only one)

[X] Total occupational and social impairment

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: The entirety ofwhat I assess to be ongoing and severe psychosocial and occupational impairment is the result of the veteran's posttraumatic stress disorder. His history secondary alcohol and opiate

abuse, which are both in early remission, had been ongoing attempts to self m e d i c a t e h i s P T SD s y m p t o m s .

c. If a diagnosis of TBI exists, is it possible to differentiate what port ion

the

of the occupational and social impairment indicated above is caused by

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 (VBMSor Virtual VA) reviewed? [X] Yes[ ] No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No

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 [X] 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] No0

2. Recent History (since prior exam) ------------------------------------ a.Relevant Social/Marital/Familyhistory:

There have been no significant changes in the veteran's psychosocial

to just

circumstances since he was last examined in July2014. He continues live by himself in a small house that he owns in a small community

outside of Binghamton NewYork.

b. Relevant Occupational and Educational history: There have been no changes in the veterans occupational status since

he

was last examined in July of 2014. When last seen he had been out of work and was awarded Social Security disability benefits because of a heel injury he suffered at his last job installing surveillance systems. . He currently supports himself on the 70% rating he currently gets for his posttraumatic stress disorder and money from a lawsuit related to his heel injury.

The veteran has had several jobs in the past. He has been fired from

lease 3 of them because of PTSD symptoms and his comorbid substance abuse.

c. Relevant Mental Health history, to include prescribed medications and family mental health:

This veteran continues to be in ongoing outpatient treatment for his

PTSD symptoms at the surgeon's VA Medical Center. He is part of a program that treats people with PTSD and related substance abuse issues so he does come up to Syracuse v.a as opposed to going to the clinic in Binghamton. He is seeing a social worker for psychotherapy on a regular basis. Whatever this treatment program is time limited and when it does end in several sessions of veteran likely seek treatment at the vet center in Binghamton.

The

The veteran also been seeing a psychiatrist at the Syracuse facility for his Suboxone treatment. He is no longer on the Suboxone and reports he we'll not continue to see the psychiatrist any longer.

veteran is currently not taking any psychotropic medications. In the past he has been on trazodone and venlafaxine but he did not like the side effects.

The veteran has been psychiatrically hospitalized at the Syracuse facility 3 times in the last 6 years. His most recent hospitalization occurred in September of 2014-2 and exacerbation of his PTSD symptoms and an intensification of his alcohol abuse.

The veteran has never made a suicide attempt. He does not currently present as an imminent suicidal or homicidal risk.

d. Relevant Legal and Behavioral history: This veteran has a past history of DWIs and a prison term and 2010. However he has not had any legal issues since he last exam. He is

not

on probation or parole.

e. Relevant Substance abuse history: As noted the veteran does have a history of alcohol and opiate abuse

as

away of self-medicating his PTSD symptoms. He is currently abstinent from alcohol since July2014. He has not used opiates for several months and is just gotten off the Suboxone he was taking to treat his opiate abuse. Both conditions are in early remission. He does occasionally attend AA or NA meetings.

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 relatedstressors.)DoNOTmarksymptomsbelowthat areclearlynot attributable to the Criteria A stressor/ PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms" .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

Criterion B: Presence of (one or more) of the following intrusion sympt oms

memories

event (s).

were with

to

t r au m at i c

associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

[X] Recurrent, involuntary, and intrusive distressing

of the traumatic event(s). [X] Recurrent distressingdreamsinwhichthecontent and/or

affect of the dream are related to the traumatic

[X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s)

recurring. (Suchreactionsmayoccuronacontinuum,

the most extreme expression being a complete loss of

awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure

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

event (s).

Criterion C: Persistent avoidance of stimuli associated with the t r au m at i c

the

or

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

traumatic event(s). [X] Avoidance of or efforts to avoid external reminders

(people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts,

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 theCONFIDENTIAL Page 23 of 418

of

or

of

thefollowing:

[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,

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)

thefollowing:

[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 restlesssleep).

Criterion F: [X] The duration of the symptoms described above in Criteria

B,C,andDaremorethan1month.

Criterion G: [X] ThePTSDsymptomsdescribedabovecauseclinically

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 actively apply to the

Veteran's diagnoses:

[X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent

event s [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social

traumatic event(s) occurred, as evidenced by two (or more[X] Difficulty in adapting to stressful circumstances, including work or

worklike setting [X] Inability to establish and maintain effective relationships

5. Behavioral Observations: ---------------------------

The veteran is a well-nourished white male of average height who looks some what younger than his stated age. His attire was casual,neat and appropriate. His hygiene and grooming were good. He was cooperative to the exam. He made good eye contact. His sensorium was in tact. The veteran's speech wasr elevant,coherent and productive. His thought process was rational and goal-directed. There was no evidence of a thought disorder. There was no evidence of hallucinations or delusions. During the exam the veteran was orientedx3. During the exam the veteran's basic cognitive functioning presented as grossly intact

interview and observational data. I would estimate the veterans

per

relat ionships

intellectual skills to be in the average range. The veteran's mood was

tense and anxious during the exam overtly he was pleasant. His affect was

appropriate with a full range noted.

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: ---------------------------------------------------

When compared to when the veteran was last examined for compensation and p e n s i o n p u r p o s e s i n Ju l y 2 0 1 4 t h e r e i s e v i d e n c e o f an i n c r e a s e i n t h e severity of his PTSD symptoms. When last seen they presented, per my interpretation of the report,as moderate to severe. They are now fully severe.

It is noted that the veteran is applying for individual unemployability secondarytohisposttraumaticstressdisorder. Withregardtoother veterans PTSD symptoms impact upon his occupational functioning I

rendered the following opinion based on my exam today:

Based on all the evidence available it is my opinion that the veteran does

present as totally and permanently disabled in terms of his occupational functioning secondary to his PTSDsymptoms. The chronicity Mark severity of the symptoms would preclude any capacity on this veteran's part whatsoever for maintaining even a marginal semblance of behavioral or emotional stability in any type of work setting, even a low stress 1, and the was sedentary or non-sedentary. His symptoms also severely impaired his capacity to carry out even simple work-related activities and a reliable and consistent manner.

The veteran psychosocial functioning is also quite severely impaired. He continues to have nightmares and flashbacks. He continues to be socially avoidant and hypervigilant in crowds or public situations. He continues to have irritability. A severe sleep disturbance is noted. The veteran is also severely isolated and withdrawn. Except for the ongoing contact with his father he essentially has no social support system were no other supportive social contacts. His ability to enjoy any daily activity with

her social or solitary is severely impaired.

The veteran should continue with his current treatment at discharge he is VA Medical Center until it and says it is time limited. After that the veteran does plan to seek treatment at either the VA clinic in Binghamton where he gets his primary care or the vet center in Binghamton.

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Just a lay opinion from a 70% PTSD IU T&P Nam Vet, Brother you are Fracked Up. I see IU with Retro back maybe a year prior to your filing date. Did I mention T & P? It has appeared to me that the VA is somewhat reluctant to award T & P for PTSD. Most VA as well as private Mental Health Clinicians seem to be of the opinion that with their treatment your symptoms will improve over time. Right or wrong, who knows????? If the VA rater believes your IU's strictly due to your PTSD and Secondary symptoms IU seems like a lock. The question of T & P may come down to a VA Policy "Jump Ball" situation. If your only SC is the PTSD, is there a possibility for improvement? If yes, probably future C&P exams will be scheduled. When I got my IU, the award stated T&P with No Future Exams Scheduled. I left my DRO Hearing knowing he had Awarded the IU, he never mentioned the T&P or No Future Exams. To say the least I was pleasantly surprised when I got the Official VA Award letter about a month later.

Semper Fi

Gastone

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Thanks for the input.If I get the 100%,that would be great,if I don't so be it.My family and I are more concerned about me getting well.Im grateful I got the 70%,so I can utilize the therapy the VA has to offer me.I am in a new study program which is 16 weeks.The VA is starting to realize PTSD,alcohol and substance abuse are related for a lot of us.I have 4 weeks to complete,and I must say,it has helped me tremendously,more then anything else.Meds etc.After completion,I'll be going inpatient at the VA in Batavia,New York.Then after that I will continue my care at the Vet Center.I know a lot of us has had problems with the VA,but I have to say,they really care and want to help us,I will forever be grateful for the care I been recieving.I want to give back,what was so freely givin to me.Eventually I would love to volunteer to help vets,especially the troops coming home from Iraq and Afganahstan.One day at a time,I feel like I'm getting my life back and so is my family.God bless to all with getting well.

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No retro, as this will be approved for an increase. I just went thru this bud, and it looks like we have a lot of bad in common. You will definitely get 100% PTSD, or the 70% PTSD and IU. Either way you will be granted. Hopefully we both find out good bad news soon. Good luck and God Bless!!! Please take care of your self and if you ever have to talk, please come on Hadit!!!

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thank you,will post once I get decision,examiner said 4 to 6 weeks but who knows.

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Go to my Healthvet blue button.You have to have a premium account to view your records.I had to do an in-person authentication,to get the premium account,I think that is standard.To check the progress of your claim,you can check that on E benefits.Hope this helps.

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Go to my Healthvet blue button.You have to have a premium account to view your records.I had to do an in-person authentication,to get the premium account,I think that is standard.To check the progress of your claim,you can check that on E benefits.Hope this helps.

Thanks, I have premium and checked out the blue button the other day. Not much there as of now.

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It took 3 days after my exam to show up on blue button,everybody's case is differant.My examiner did my report the same day,that's probably why it showed up so fast.

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It took 3 days after my exam to show up on blue button,everybody's case is differant.My examiner did my report the same day,that's probably why it showed up so fast.

When I click the blue button it gives me two options. The first one brings up some info but it has zero importance. The 2nd one''Download or send my Health Summary (VA CCD)'' says its updating. It has said this for weeks now. Im guessing this is the one I need to be looking at.

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