I was Active duty in the Army for 6 years and have two deployments to Iraq. I have been lurking on this site for a while and have learned so much! I recently got out and had all of my exams completed, and my claim is currently in the preparation for determination phase. I was wondering if i could get some advice on two of my exams and see what everyone thought.
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a central
nervous system (CNS) condition?
[X] Yes [ ] No
[X] Brain tumor Date of diagnosis: 04/2013
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
central
nervous conditions (brief summary):
veteran had a brain MRI due to c/o abnormal thyroid function. The MRI was
done on 4/2/2013 and showed 14mm thin rim enhancing pineal gland lesion
consistent with pineal cyst vs pineocytoma vs epidermoid. He subsequently
had several more MRI's ( 5/13. 11/13, and 5/15) which were unchanged. It
was felt that his symptoms were not related to the cyst.
Veteran feels that his current symptoms which include vision changes,
headaches, dizziness, nausea and memory problems are related to his
benign
cyst. He has been seem for memory loss and found to have no deficits.
Seen
by eye clinic diagnosed with benign retinal tuft and Myopic astigmatism.
b. Does the Veteran's central nervous system condition require continuous
medication for control?
[ ] Yes [X] No
c. Does the Veteran have an infectious condition?
[ ] Yes [X] No
If yes, is it active?
[ ] Yes [ ] No
d. Dominant hand
[X] Right [ ] Left [ ] Ambidextrous
3. Conditions, signs and symptoms
---------------------------------
a. Does the Veteran have any muscle weakness in the upper and/or lower
extremities?
[ ] Yes [X] No
b. Does the Veteran have any pharynx and/or larynx and/or swallowing
conditions?
[ ] Yes [X] No
c. Does the Veteran have any respiratory conditions (such as rigidity of the
diaphragm, chest wall or laryngeal muscles)?
[ ] Yes [X] No
d. Does the Veteran have sleep disturbances?
[ ] Yes [X] No
e. Does the Veteran have any bowel functional impairment?
[ ] Yes [X] No
f. Does the Veteran have voiding dysfunction causing urine leakage?
[ ] Yes [X] No
g. Does the Veteran have voiding dysfunction causing signs and/or symptoms
of
urinary frequency?
[ ] Yes [X] No
h. Does the Veteran have voiding dysfunction causing findings, signs and/or
symptoms of obstructed voiding?
[ ] Yes [X] No
i. Does the Veteran have voiding dysfunction requiring the use of an
appliance?
[ ] Yes [X] No
j. Does the Veteran have a history of recurrent symptomatic urinary tract
infections?
[ ] Yes [X] No
k. Does the Veteran (if male) have erectile dysfunction?
[ ] Yes [X] No
4. Neurologic exam
------------------
a. Speech
[X] Normal [ ] Abnormal
b. Gait
[X] Normal [ ] Abnormal, describe:
c. Strength
Rate strength according to the following scale:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
d. Deep tendon reflexes (DTRs)
Rate reflexes according to the following scale:
0 Absent
1+ Decreased
2+ Normal
3+ Increased without clonus
4+ Increased with clonus
e. Does the Veteran have muscle atrophy attributable to a CNS condition?
[ ] Yes [X] No
f. Summary of muscle weakness in the upper and/or lower extremities
attributable to a CNS condition (check all that apply):
Right upper extremity muscle weakness:
[X] None
Left upper extremity muscle weakness:
[X] None
Right lower extremity muscle weakness:
[X] None
Left lower extremity muscle weakness:
[X] None
5. Tumors and neoplasms
--------
---------------
a. Does the Veteran have a benign or malignant neoplasm or metastases
related
to any of the diagnoses in the Diagnosis section?
[X] Yes [ ] No
b. Is the neoplasm:
[X] Benign [ ] Malignant
c. Has the Veteran completed treatment or is the Veteran currently
undergoing
treatment for a benign or malignant neoplasm or metastases?
[ ] Yes [X] No; watchful waiting
d. Does the Veteran currently have any residual conditions or complications
due to the neoplasm (including metastases) or its treatment, other than
those already documented in the report above?
[ ] Yes [X] No
6. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
-----------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to any conditions
listed in the Diagnosis Section above?
[ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above?
[ ] Yes [X] No
7. Mental health manifestations due to CNS condition or its treatment
---------------------------------------------------------------------
a. Does the Veteran have depression, cognitive impairment or dementia, or
any
other mental health conditions attributable to a CNS disease and/or its
treatment?
[ ] Yes [X] No
8. Differentiation of Symptoms or Neurologic Effects
----------------------------------------------------
Are you able to differentiate what portion of the symptomatology or
neurologic effects above are caused by each diagnosis?
[ ] Yes [X] No
9. Assistive devices
--------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion, although occasional locomotion by other methods may be
possible?
[ ] Yes [X] No
10. Remaining effective function of the extremities
---------------------------------------------------
Due to a CNS condition, is there functional impairment of an extremity such
that no effective function remains other than that which would be equally
well served by an amputation with prosthesis? (Functions of the upper
extremity include grasping, manipulation, etc., while functions for the
lower
extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
11. Diagnostic testing
----------------------
a. Have imaging studies been performed?
[X] Yes [ ] No
If yes, provide most recent results, if available:
Several brain MRI's since intial one in 4/2013 unchanged as described
in medical history
b. Have PFTs been performed?
[ ] Yes [X] No
c. If PFTs have been performed, is the flow-volume loop compatible with
upper
airway obstruction?
[ ] Yes [ ] No
d. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [ ] No
12. Functional impact
---------------------
Do the Veteran's central nervous system disorders impact his or her ability
to work?
[ ] Yes [X] No
13. Remarks, if any:
--------------------
No remarks provided.
I have some issues for this because I Have documented insomnia issues since 2011 and the exam states no sleep disturbances, also the examiner say no to ED, which i was diagnosed in service with and was also in my DBQ for it. The examiner was aware that i have not had an MRI in a year and did not think it mattered, also the examiner only spend a total of 5 minutes with me total.
PTSD CnP
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
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): hypothyroid, migraine headaches,
low back pain
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [X] No [ ] Not shown in records reviewed
Comments, if any:
the veteran described no clear incident of TBI
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 occasional decrease in work
efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily,
with normal routine behavior, self-care and conversation
b. For the indicated level of occupational and social impairment, is it
possible to differentiate what portion of the occupational and social
impairment indicated above is caused by each mental disorder?
[ ] Yes [ ] No [X] No other mental disorder has been diagnosed
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?
[ ] Yes [X] 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
[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] No
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
The veteran said that his life at home when he was growing up was
good,
no history of abuse. His father is a Catholic Deacon so family worked
with the church. He was pretty well behaved in high school.
Bought a house with his brother prior to joining the Army. That
brother's son also lives with them now. The veteran stated that he
"hates" the current arrangement. His nephew is very active and "drives
me nuts." The veteran said that he feels like he has no time to relax.
Never married and no children.
The veteran reported that he served in the Army from 2009-2016. His
job
was in satellite communications. He deployed to Iraq in 2011 and 2014.
His 2011 deployment was during the drawdown so not lot of security
available. He experienced a lot of indirect fire. Rockets came in by
his housing area during 1 incident, landing and exploding about 15
meters away. Alarms went off, one round came in, then another, third
was very close. He jumped to the ground and slammed his head on a wall
locker. No LOC.
He described having a "near death" expereince from an IED. He was
traveling to a green zone and the vehicle hit an IED. He said there
were no injuries but "that scared the shit out of me." Lot of
experience with indirect fire, he felt under constant threat. He
started having bad sleep issues during his first deployment. He said
that he did not want to go to sleep because all fire came in at night.
During his 2014 deployment he was in an apache attack helicopter
batallian. He said that he had very little security at that time, were
under constant threat, and had a very heavy workload, averaging 16
hour
days. He ran all the apache feeds, drone feeds, worked in strike cell,
saw over 100 strikes through video feeds on Isis where people were
injured or killed.
Thinks about deployments daily, including "how shitty it was there."
He
said those thoughts put him into a bad mood. He said that he thinks
about many near death experiences, and being desensitized to violence.
He said that he has violent dreams about weekly. Avoids crowds,
traffic
jams, and fireworks. He said the driving gives him panic. Nothing that
is particularly hard to talk about from his experiences. No real
guilt.
Can't connect with others like he used to. Can only get along with a
few people that he knew from the Army. Since he got out he hasn't
talked to anyone other than who he has to. Feels detached from others.
Lost interest in many things. Used to like sports, exercise, and video
games but he doesn't do those things anymore. Goes to school, comes
home, and then "I just sit there." No positive feelings. He frequently
feels paranoid about people, such as strangers who are walking around.
Paranoid about vehicles that look run down or like something is heavy
in the car. Concentration not good. Stays up for a day or two then
crashes, and will sleep 4-5 hours before waking again. He said that
his
mind races during times when he stays up, but not making bad decisions
during those times. Not happier than usual during those times.
He said that a pineal gland tumor was discovered
in 2012. His thyroid
lab values were off, did brain scan to look at pituitary. Tumor on or
near the pineal gland. Told that he would likely either have more
physical or mental symptoms. No treatment for that tumor. Plan was to
monitor it.
Memory issues have gotten worse over last 1.5 years. Mid sentence he
forgets things. Needs notes to remember. Will drive and realize he
doesn't remember the route, like zoning out "but at the extreme."
Conversations depend on how important the topic was. Memory gaps in
his
life, like his family's birthdays. Has blurred memory for some events
from Iraq, things that he feels that he should remember but can't.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The veteran said that he did poorly in school. He said "everything was
hard, even gym." He said that he learned to read without difficulty
and
never repeated a grade. He recalled being placed in a special study
group with a teachers aid. Graduated from high school in 2008. Now
going to MATC for criminial justice. Not enjoying it, grades are
middle
of the road. Doesn't like being there, including getting irritated
with
"kids that are self-entitled." They are rude and he gets upset because
they didnt have to serve in the Army to be able to go to school. Used
profanity once to tell a student to stop talking and was reprimanded
by
the teacher.
The veteran said that he has not worked since being discharged from
the
Army. Wants to work in law enforcement eventually.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
When asked about his current mood the veteran said "I'm in a miserable
state all the time." He said that he is felt like that for over a
year.
Same issues when he was in active duty. He said that he began
treatment
through mental health in the military in 2012. Knew he was having
issues after his first deployment. His brother encouraged him to seek
help. He said that he had a few sessions with a psychologist but
indicated that he doesn't like to talk so did not continue that
treatment. Saw a psychiatrist monthly. No meds were really helpful,
only adderall, which he has been on for year. Sleep meds don't work.
He
said that he has taken many SSRIs but they dont help and he said that
he doesn't feel depressed anyway. Taken anxiety medication but that
didn't help either.
No mental health treatment since he was discharged from the military.
Mood most days is irritable, like an emotional roller coaster. The
constant in his life is being annoyed. Doesn't have good days, just
worse days. Worries about himself or other people getting injured. If
he is in a scenario he pictures people getting injured in various
ways,
he said "I make things up in my mind." He said that he isn't accident
prone so he doesn't know why he is thinking about such catastrophes.
Took adderall in middle school into high school, stopped becasue he
thought he couldn't take that medication in the Army. He started that
treatment again in the Army.
Hearing has gotten worse since his last deployment when he was on an
airfield. Hears things that aren't there such as talking and noises.
Inaudible talking. Not threatening. No one giving him prescription for
Adderall presently.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
denied.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
No alcohol now for one year. Was drinking heavily in 2012, not daily,
but he binged on the weekends. No recreational drugs. Started drinking
heavily in the Army.
f. Other, if any:
Before he leaves the house he checks every faucet multiple times, goes
out door, goes back in, to make sure that no water is running. He said
that he has a fear of flooding the house. Makes sure he locks the door
four times before he leaves. Likes to have everything a certain way,
and he doesn't deviate from that way. "Freaks out" if things are
messed
up.
Gets sweaty with racing heart and feeling flushed during panic times.
He said that his mind races at times, which happens frequently when he
is driving. Sometimes he can talk himself down, sometimes not. Tries
to
get himself out of situations that make him panic. Doesn't do anything
in his free time. Gets panicked on Sunday nights about homework and
does it at the last minute. Hates himself for procrastinating because
he will need to stay up all night doing work.
He said that he was assaulted in 2012. He said that he was in a bar
and
his buddy was saying derogatory things that got a group of people
upset. Vet tried to stop them going after his buddy. He tried
shielding
him, but took a few hits to the head. Not really unconscious but felt
like "the lights were on and off." Confused after that incident and
had
a headache and his jaw hurt. Didn't report it because he was underage.
Happened when he was in the Army.
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: being close to a rocket attack
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: his vehicle was hit by an IED
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: witnessing enemy deaths via drone feeds
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
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
Criterion B: Presence of (one or more) of the following intrusion
symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
[X] Intense or prolonged psychological distress at exposure to
internal
or external cues that symbolize or resemble an aspect of the
traumatic event(s).
[X] Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
Criterion C: Persistent avoidance of stimuli associated with the
traumatic
event(s), beginning after the traumatic events(s) occurred,
as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid 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] Markedly diminished interest or participation in significant
activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
toward people or objects.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
Criterion F:
[X] 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 that occur weekly or less often
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[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
6. Behavioral Observations
--------------------------
The veteran arrived on time for the evaluation. He ambulated independently
and was casually dressed. Speech and comprehension were within normal
limits.
His affect was mildly restricted and his mood appeared depressed. There was
no obvious evidence for psychosis. His thought process was grossly logical
and linear. Insight into his condition was intact. His cognitive functioning
appeared within normal limits.
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
--------------------------------------------------
The veteran scored in the low average range on a test of his intellectual
functioning. Verbal comprehension was average, perceptual reasoning was
borderline, working memory was average, and processing speed was low
average. He demonstrated low average ability to learn a story over trials
and average ability to recall the material after a delay. His recognition
memory for that information was average. He showed average ability to
learn a list of words over trials and his recall of the material after a
delay was mildly impaired. His recognition memory for that information
was
mildly impaired. He showed moderately impaired ability to copy a complex
figure and borderline ability to recall the material immediately and
after
a delay. His recognition memory for that information was average. Word
reading was average range. He scored in the low average range on a test
of
attention and visual scanning and in the average range on a related
measure of mental flexibility. His performance on a test of
conceptualization was borderline and he had tendency to lose his train of
thought on that measure. He had difficulty on a measure of sustained
attention. The veteran endorsed symptoms of severe level depression and
significant symptoms of PTSD. He reported significant inattention both as
an adult and a child. He performed poorly on a test of effort. On a
measure of personality functioning he showed evidence of magnifying the
severity of his psychiatric difficulties. He also reported preoccupation
with his physical functioning, anxiety, depression, suspicion of other
people, isolation, and an aggressive attitude. His overall profile was
most suggestive of PTSD.
In summary, this was an abnormal neuropsychological profile. The veteran
performed poorly on a test of effort and had difficulty on measures of
his
visual-perceptual skills, thought processing speed, memory,
conceptualization, sustained attention, and planning. His poor effort
likely accounts for those findings. It is more likely than not that the
veteran has PTSD that is due to hostile military or terrorist activity.
Based on his report and review of records, the veteran had no incident
of
head injury with clear loss of consciousness; therefore, is less likely
than not that he has any residual difficulties due to head injury. It is
less likely than not that his reported pineal gland tumor or cyst has any
impact on his current cognitive or psychiatric functioning. His claimed
memory difficulty is likely a symptom of PTSD.
Question
mskallday
Hello all,
I was Active duty in the Army for 6 years and have two deployments to Iraq. I have been lurking on this site for a while and have learned so much! I recently got out and had all of my exams completed, and my claim is currently in the preparation for determination phase. I was wondering if i could get some advice on two of my exams and see what everyone thought.
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a central
nervous system (CNS) condition?
[X] Yes [ ] No
[X] Brain tumor Date of diagnosis: 04/2013
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
central
nervous conditions (brief summary):
veteran had a brain MRI due to c/o abnormal thyroid function. The MRI was
done on 4/2/2013 and showed 14mm thin rim enhancing pineal gland lesion
consistent with pineal cyst vs pineocytoma vs epidermoid. He subsequently
had several more MRI's ( 5/13. 11/13, and 5/15) which were unchanged. It
was felt that his symptoms were not related to the cyst.
Veteran feels that his current symptoms which include vision changes,
headaches, dizziness, nausea and memory problems are related to his
benign
cyst. He has been seem for memory loss and found to have no deficits.
Seen
by eye clinic diagnosed with benign retinal tuft and Myopic astigmatism.
b. Does the Veteran's central nervous system condition require continuous
medication for control?
[ ] Yes [X] No
c. Does the Veteran have an infectious condition?
[ ] Yes [X] No
If yes, is it active?
[ ] Yes [ ] No
d. Dominant hand
[X] Right [ ] Left [ ] Ambidextrous
3. Conditions, signs and symptoms
---------------------------------
a. Does the Veteran have any muscle weakness in the upper and/or lower
extremities?
[ ] Yes [X] No
b. Does the Veteran have any pharynx and/or larynx and/or swallowing
conditions?
[ ] Yes [X] No
c. Does the Veteran have any respiratory conditions (such as rigidity of the
diaphragm, chest wall or laryngeal muscles)?
[ ] Yes [X] No
d. Does the Veteran have sleep disturbances?
[ ] Yes [X] No
e. Does the Veteran have any bowel functional impairment?
[ ] Yes [X] No
f. Does the Veteran have voiding dysfunction causing urine leakage?
[ ] Yes [X] No
g. Does the Veteran have voiding dysfunction causing signs and/or symptoms
of
urinary frequency?
[ ] Yes [X] No
h. Does the Veteran have voiding dysfunction causing findings, signs and/or
symptoms of obstructed voiding?
[ ] Yes [X] No
i. Does the Veteran have voiding dysfunction requiring the use of an
appliance?
[ ] Yes [X] No
j. Does the Veteran have a history of recurrent symptomatic urinary tract
infections?
[ ] Yes [X] No
k. Does the Veteran (if male) have erectile dysfunction?
[ ] Yes [X] No
4. Neurologic exam
------------------
a. Speech
[X] Normal [ ] Abnormal
b. Gait
[X] Normal [ ] Abnormal, describe:
c. Strength
Rate strength according to the following scale:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
Elbow flexion:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Elbow extension:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist flexion:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist extension:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Grip:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Pinch (thumb to index finger):
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee extension:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion:
Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
d. Deep tendon reflexes (DTRs)
Rate reflexes according to the following scale:
0 Absent
1+ Decreased
2+ Normal
3+ Increased without clonus
4+ Increased with clonus
Biceps:
Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Triceps:
Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Brachioradialis:
Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Knee:
Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
e. Does the Veteran have muscle atrophy attributable to a CNS condition?
[ ] Yes [X] No
f. Summary of muscle weakness in the upper and/or lower extremities
attributable to a CNS condition (check all that apply):
Right upper extremity muscle weakness:
[X] None
Left upper extremity muscle weakness:
[X] None
Right lower extremity muscle weakness:
[X] None
Left lower extremity muscle weakness:
[X] None
5. Tumors and neoplasms
--------
---------------
a. Does the Veteran have a benign or malignant neoplasm or metastases
related
to any of the diagnoses in the Diagnosis section?
[X] Yes [ ] No
b. Is the neoplasm:
[X] Benign [ ] Malignant
c. Has the Veteran completed treatment or is the Veteran currently
undergoing
treatment for a benign or malignant neoplasm or metastases?
[ ] Yes [X] No; watchful waiting
d. Does the Veteran currently have any residual conditions or complications
due to the neoplasm (including metastases) or its treatment, other than
those already documented in the report above?
[ ] Yes [X] No
6. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
-----------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to any conditions
listed in the Diagnosis Section above?
[ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above?
[ ] Yes [X] No
7. Mental health manifestations due to CNS condition or its treatment
---------------------------------------------------------------------
a. Does the Veteran have depression, cognitive impairment or dementia, or
any
other mental health conditions attributable to a CNS disease and/or its
treatment?
[ ] Yes [X] No
8. Differentiation of Symptoms or Neurologic Effects
----------------------------------------------------
Are you able to differentiate what portion of the symptomatology or
neurologic effects above are caused by each diagnosis?
[ ] Yes [X] No
9. Assistive devices
--------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion, although occasional locomotion by other methods may be
possible?
[ ] Yes [X] No
10. Remaining effective function of the extremities
---------------------------------------------------
Due to a CNS condition, is there functional impairment of an extremity such
that no effective function remains other than that which would be equally
well served by an amputation with prosthesis? (Functions of the upper
extremity include grasping, manipulation, etc., while functions for the
lower
extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
11. Diagnostic testing
----------------------
a. Have imaging studies been performed?
[X] Yes [ ] No
If yes, provide most recent results, if available:
Several brain MRI's since intial one in 4/2013 unchanged as described
in medical history
b. Have PFTs been performed?
[ ] Yes [X] No
c. If PFTs have been performed, is the flow-volume loop compatible with
upper
airway obstruction?
[ ] Yes [ ] No
d. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [ ] No
12. Functional impact
---------------------
Do the Veteran's central nervous system disorders impact his or her ability
to work?
[ ] Yes [X] No
13. Remarks, if any:
--------------------
No remarks provided.
I have some issues for this because I Have documented insomnia issues since 2011 and the exam states no sleep disturbances, also the examiner say no to ED, which i was diagnosed in service with and was also in my DBQ for it. The examiner was aware that i have not had an MRI in a year and did not think it mattered, also the examiner only spend a total of 5 minutes with me total.
PTSD CnP
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
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): hypothyroid, migraine headaches,
low back pain
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [X] No [ ] Not shown in records reviewed
Comments, if any:
the veteran described no clear incident of TBI
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 occasional decrease in work
efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily,
with normal routine behavior, self-care and conversation
b. For the indicated level of occupational and social impairment, is it
possible to differentiate what portion of the occupational and social
impairment indicated above is caused by each mental disorder?
[ ] Yes [ ] No [X] No other mental disorder has been diagnosed
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?
[ ] Yes [X] 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
[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] No
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
The veteran said that his life at home when he was growing up was
good,
no history of abuse. His father is a Catholic Deacon so family worked
with the church. He was pretty well behaved in high school.
Bought a house with his brother prior to joining the Army. That
brother's son also lives with them now. The veteran stated that he
"hates" the current arrangement. His nephew is very active and "drives
me nuts." The veteran said that he feels like he has no time to relax.
Never married and no children.
The veteran reported that he served in the Army from 2009-2016. His
job
was in satellite communications. He deployed to Iraq in 2011 and 2014.
His 2011 deployment was during the drawdown so not lot of security
available. He experienced a lot of indirect fire. Rockets came in by
his housing area during 1 incident, landing and exploding about 15
meters away. Alarms went off, one round came in, then another, third
was very close. He jumped to the ground and slammed his head on a wall
locker. No LOC.
He described having a "near death" expereince from an IED. He was
traveling to a green zone and the vehicle hit an IED. He said there
were no injuries but "that scared the shit out of me." Lot of
experience with indirect fire, he felt under constant threat. He
started having bad sleep issues during his first deployment. He said
that he did not want to go to sleep because all fire came in at night.
During his 2014 deployment he was in an apache attack helicopter
batallian. He said that he had very little security at that time, were
under constant threat, and had a very heavy workload, averaging 16
hour
days. He ran all the apache feeds, drone feeds, worked in strike cell,
saw over 100 strikes through video feeds on Isis where people were
injured or killed.
Thinks about deployments daily, including "how shitty it was there."
He
said those thoughts put him into a bad mood. He said that he thinks
about many near death experiences, and being desensitized to violence.
He said that he has violent dreams about weekly. Avoids crowds,
traffic
jams, and fireworks. He said the driving gives him panic. Nothing that
is particularly hard to talk about from his experiences. No real
guilt.
Can't connect with others like he used to. Can only get along with a
few people that he knew from the Army. Since he got out he hasn't
talked to anyone other than who he has to. Feels detached from others.
Lost interest in many things. Used to like sports, exercise, and video
games but he doesn't do those things anymore. Goes to school, comes
home, and then "I just sit there." No positive feelings. He frequently
feels paranoid about people, such as strangers who are walking around.
Paranoid about vehicles that look run down or like something is heavy
in the car. Concentration not good. Stays up for a day or two then
crashes, and will sleep 4-5 hours before waking again. He said that
his
mind races during times when he stays up, but not making bad decisions
during those times. Not happier than usual during those times.
He said that a pineal gland tumor was discovered
in 2012. His thyroid
lab values were off, did brain scan to look at pituitary. Tumor on or
near the pineal gland. Told that he would likely either have more
physical or mental symptoms. No treatment for that tumor. Plan was to
monitor it.
Memory issues have gotten worse over last 1.5 years. Mid sentence he
forgets things. Needs notes to remember. Will drive and realize he
doesn't remember the route, like zoning out "but at the extreme."
Conversations depend on how important the topic was. Memory gaps in
his
life, like his family's birthdays. Has blurred memory for some events
from Iraq, things that he feels that he should remember but can't.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The veteran said that he did poorly in school. He said "everything was
hard, even gym." He said that he learned to read without difficulty
and
never repeated a grade. He recalled being placed in a special study
group with a teachers aid. Graduated from high school in 2008. Now
going to MATC for criminial justice. Not enjoying it, grades are
middle
of the road. Doesn't like being there, including getting irritated
with
"kids that are self-entitled." They are rude and he gets upset because
they didnt have to serve in the Army to be able to go to school. Used
profanity once to tell a student to stop talking and was reprimanded
by
the teacher.
The veteran said that he has not worked since being discharged from
the
Army. Wants to work in law enforcement eventually.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
When asked about his current mood the veteran said "I'm in a miserable
state all the time." He said that he is felt like that for over a
year.
Same issues when he was in active duty. He said that he began
treatment
through mental health in the military in 2012. Knew he was having
issues after his first deployment. His brother encouraged him to seek
help. He said that he had a few sessions with a psychologist but
indicated that he doesn't like to talk so did not continue that
treatment. Saw a psychiatrist monthly. No meds were really helpful,
only adderall, which he has been on for year. Sleep meds don't work.
He
said that he has taken many SSRIs but they dont help and he said that
he doesn't feel depressed anyway. Taken anxiety medication but that
didn't help either.
No mental health treatment since he was discharged from the military.
Mood most days is irritable, like an emotional roller coaster. The
constant in his life is being annoyed. Doesn't have good days, just
worse days. Worries about himself or other people getting injured. If
he is in a scenario he pictures people getting injured in various
ways,
he said "I make things up in my mind." He said that he isn't accident
prone so he doesn't know why he is thinking about such catastrophes.
Took adderall in middle school into high school, stopped becasue he
thought he couldn't take that medication in the Army. He started that
treatment again in the Army.
Hearing has gotten worse since his last deployment when he was on an
airfield. Hears things that aren't there such as talking and noises.
Inaudible talking. Not threatening. No one giving him prescription for
Adderall presently.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
denied.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
No alcohol now for one year. Was drinking heavily in 2012, not daily,
but he binged on the weekends. No recreational drugs. Started drinking
heavily in the Army.
f. Other, if any:
Before he leaves the house he checks every faucet multiple times, goes
out door, goes back in, to make sure that no water is running. He said
that he has a fear of flooding the house. Makes sure he locks the door
four times before he leaves. Likes to have everything a certain way,
and he doesn't deviate from that way. "Freaks out" if things are
messed
up.
Gets sweaty with racing heart and feeling flushed during panic times.
He said that his mind races at times, which happens frequently when he
is driving. Sometimes he can talk himself down, sometimes not. Tries
to
get himself out of situations that make him panic. Doesn't do anything
in his free time. Gets panicked on Sunday nights about homework and
does it at the last minute. Hates himself for procrastinating because
he will need to stay up all night doing work.
He said that he was assaulted in 2012. He said that he was in a bar
and
his buddy was saying derogatory things that got a group of people
upset. Vet tried to stop them going after his buddy. He tried
shielding
him, but took a few hits to the head. Not really unconscious but felt
like "the lights were on and off." Confused after that incident and
had
a headache and his jaw hurt. Didn't report it because he was underage.
Happened when he was in the Army.
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: being close to a rocket attack
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: his vehicle was hit by an IED
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: witnessing enemy deaths via drone feeds
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
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
Criterion B: Presence of (one or more) of the following intrusion
symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
[X] Intense or prolonged psychological distress at exposure to
internal
or external cues that symbolize or resemble an aspect of the
traumatic event(s).
[X] Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
Criterion C: Persistent avoidance of stimuli associated with the
traumatic
event(s), beginning after the traumatic events(s) occurred,
as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid 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] Markedly diminished interest or participation in significant
activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
toward people or objects.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
Criterion F:
[X] 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 that occur weekly or less often
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[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
6. Behavioral Observations
--------------------------
The veteran arrived on time for the evaluation. He ambulated independently
and was casually dressed. Speech and comprehension were within normal
limits.
His affect was mildly restricted and his mood appeared depressed. There was
no obvious evidence for psychosis. His thought process was grossly logical
and linear. Insight into his condition was intact. His cognitive functioning
appeared within normal limits.
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
--------------------------------------------------
The veteran scored in the low average range on a test of his intellectual
functioning. Verbal comprehension was average, perceptual reasoning was
borderline, working memory was average, and processing speed was low
average. He demonstrated low average ability to learn a story over trials
and average ability to recall the material after a delay. His recognition
memory for that information was average. He showed average ability to
learn a list of words over trials and his recall of the material after a
delay was mildly impaired. His recognition memory for that information
was
mildly impaired. He showed moderately impaired ability to copy a complex
figure and borderline ability to recall the material immediately and
after
a delay. His recognition memory for that information was average. Word
reading was average range. He scored in the low average range on a test
of
attention and visual scanning and in the average range on a related
measure of mental flexibility. His performance on a test of
conceptualization was borderline and he had tendency to lose his train of
thought on that measure. He had difficulty on a measure of sustained
attention. The veteran endorsed symptoms of severe level depression and
significant symptoms of PTSD. He reported significant inattention both as
an adult and a child. He performed poorly on a test of effort. On a
measure of personality functioning he showed evidence of magnifying the
severity of his psychiatric difficulties. He also reported preoccupation
with his physical functioning, anxiety, depression, suspicion of other
people, isolation, and an aggressive attitude. His overall profile was
most suggestive of PTSD.
In summary, this was an abnormal neuropsychological profile. The veteran
performed poorly on a test of effort and had difficulty on measures of
his
visual-perceptual skills, thought processing speed, memory,
conceptualization, sustained attention, and planning. His poor effort
likely accounts for those findings. It is more likely than not that the
veteran has PTSD that is due to hostile military or terrorist activity.
Based on his report and review of records, the veteran had no incident
of
head injury with clear loss of consciousness; therefore, is less likely
than not that he has any residual difficulties due to head injury. It is
less likely than not that his reported pineal gland tumor or cyst has any
impact on his current cognitive or psychiatric functioning. His claimed
memory difficulty is likely a symptom of PTSD.
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flores97
Mskallday, I agree with Dot09, they should assign a rating between 50-70% for PTSD. I believe the raters rely more on "For VA rating purposes, check all symptoms that actively apply to the veterans di
mskallday
Thanks for the input Flores97!
Navy4life
I agree 50-70% PTSD rating and denial on the other issues based on this report
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