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  • 14 Questions about VA Disability Compensation Benefits Claims

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    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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Alex Googe

Comp & Pen Exam results

Question

Hi everyone so I'm new to this I had my Comp & Pen exam for PTSD on October 27 2016. I check Ebenefits on the status of my claim which still in gathering evidence phase and I also got my Comp & Pen exam from Ebenefits also. I'm 50% for depression, 30% for Ankle, 30% for scars and 10% for left foot arthritis. Here's my comp & Pen can any help me with the results. I got diagnosis at the VA for both Depression and PTSD and I'm also do individual treatment the VA for PTSD I'm doing Cognitive Processing Therapy right going on my 9th session.

 

C&P MENTAL DISORDERS

 

This writer met with veteran for C&P exam. He reported significant increase

In MDD and PTSD symptoms, and expresesd daily passive suidical ideation. He

contracted with this writer for safety, and stated that he gave his firearms to

his brother. However, he continues to experience ongoing ideation and remains at

high risk.

 

Mental Disorders

(other than PTSD and Eating Disorders)

Disability Benefits Questionnaire

Name of patient/Veteran: Alex Googe

Is this DBQ being completed in conjunction with a VA 21-2507, C&P

Examination

Request?

[X] Yes [ ] No

 

SECTION I:

 

----------

1. Diagnosis

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

a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes [ ] No

ICD code: F43.1

If the Veteran currently has one or more mental disorders that conform to

DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: PTSD

ICD code: F43.1

Mental Disorder Diagnosis #2: Major Depressive Disorder, Severe

ICD code: F33.4

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

Mental Health Disorder (to include TBI):

No response provided.

 

 

2. Differentiation of symptoms

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

a. Does the Veteran have more than one mental disorder diagnosed?

[X] Yes [ ] No

b. Is it possible to differentiate what symptom(s) is/are attributable to

each diagnosis?

[ ] Yes [X] No [ ] Not applicable (N/A)

If no, provide reason that it is not possible to differentiate what

portion of each symptom is attributable to each diagnosis and discuss

whether there is any clinical association between these diagnoses:

Significant overlap

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records reviewed

 

3. 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] 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?

 

[ ] Yes [X] No [ ] No other mental disorder has been diagnosed

If no, provide reason that it is not possible to differentiate what

portion of the indicated level of occupational and social impairment

is attributable to each diagnosis:

Signficant overlap.

 

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

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

Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA)

[X] CPRS

[X] Other (please identify other evidence reviewed):

Veteran brought in Statement in Support of PTSD and a handwritten

letter as well.

This was given to Ricardo Sealy for scanning.

 

 

 

 

2. History

----------

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

post-military):

Veteran stated that he continues to live with his wife, but in separate

bedrooms. "It's been rough the past two months, I haven't

been speaking to anyone.

I haven't been at work for two weeks, since that incident.

It's been hell - the anxiety, don't want to be around poeple. I had time

Driving here, my dad was supposed to drive me here last week. But I had to take

myself here, since he went on vacation.

 

I don't talk to anyone -not at all. Since the incidnet, at work, I

haven't been able to go back. I feel that people are out to get me."

 

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

and post-military):

 

"I've been struggling at work for the past three months. It

Was something that triggered my episode. I was Dunkin Donuts, and a guy

threatened this young lady. She kept apologizing, he was going to stab

her. I had a confrontation with him, I didn't care if I lived or

died. She grabbed my hand, but when I turned around she was gone.

I've had that happen a couple of times [witnessing someone being

threatened].

 

 There was a veteran shouting at the secretary, and I lost

it. I went home early that day. I was going home early from work about

4 times per week. The incident at work was when a veteran got mad at me and threatened my

life. I thought I was going to lose it, come after him. They've

been calling me to come back to work, but I can't talk to them, I

can't go back there."

 

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

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

"I haven't been to work since then [the incident two weeks

ago]. They have been trying not contact me, but I don't talk to anyone. I last

saw psychologist in Newington last week. I'm struggling, I take the

bus, I have anxiety.

 

I eat once in a while - lost 25 pounds. I haven't taken a bath in a

Few days. In the same clothes for the past three days. In the last weeks, I

only sleep for two hours per night. I wake up tired, wiht nightmares

about my friend. Flashbacks - that's why I'm not driving. I had one at a stop

sign. People blowing horns, then there was a cop on my window. I haven't

driven since the last day I went to work. I had to drive myself here.

 

Suicidal - I think about it every day, my brother had my firearms for

now.I feel safe to go home otday. agreed to call crisis line. Declined

immediat support, did not want to be walked to the psych ER.

Mood - anxious, depressed most of the time. I feel like I have no

Energy to do anything."

 

The PTSD reported developed after veteran and his close friend

Witnessed a fight at a bar near Andrews AFB in May 1985. They intervened to help

the ladies, and his friend was shot and killed. Veteran was holding his

friend in his arms, as he died immediately.

3. Symptoms

-----------

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

Veteran's diagnoses:

 

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Near-continuous panic or depression affecting the ability to function

independently, appropriately and effectively

[X] Chronic sleep impairment

[X] 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

work like setting

[X] Inability to establish and maintain effective relationships

[X] Suicidal ideation

[X] Neglect of personal appearance and hygiene

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

including maintenance of minimal personal hygiene

4. Behavioral observations

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

Mental Status and Behavioral Observations:

-ORIENTATION: Alert and oriented x3.

-PRESENTATION: Appropriately dressed in casual attire and well-groomed.

-RAPPORT: Cooperative and open with his concerns.

-MOOD/AFFECT: Mood appeared dysthymic; affect congruent with mood or

excessively flat.

-THOUGHTS: Linear and goal-directed.

-SPEECH: Flatt and sparse in terms of rate, rhythm, and volume.

-INSIGHT AND JUDGMENT: Fair insight and judgment.

5. Other symptoms

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

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[ ] Yes [X] No

6. Competency

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

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

7. Remarks (including any testing results), if any:

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

Veteran meets criteria for PTSD as well as MDD, based on report sympotms and

chart review. He experienced an incident at work about 2 weeks ago, and

since

that time he has been impaired in his emotional functioning, communication,

abilities, and ADLs.

 

 LOCAL TITLE: C&P PTSD, INITIAL EVALUATION                      

STANDARD TITLE: PSYCHIATRY C & P EXAMINATION CONSULT           

DATE OF NOTE: DEC 22, 2016@08:31:12  ENTRY DATE: DEC 22, 2016@08:31:12     

      AUTHOR: ROGINSKY,BINA        EXP COSIGNER:                          

     URGENCY:                            STATUS: COMPLETED                    

 

COMPENSATION AND PENSION EXAMINATION REPORT (FREE TEXT)

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

 

 

 

MEDICAL OPINION REQUEST

 

TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.

 

OPINION REQUESTED: Secondary Service Connection.

 

Is the Veteran's PTSD at least as likely as not (50 percent or greater

probability) proximately due to or the result of Major depression?

 

Rationale must be provided in the appropriate section.

 

If more than one mental disorder is diagnosed please comment on their

relationship to one another and, if possible, please state which symptoms

are attributed to each disorder.

 

If your examination determines that the Veteran does not have diagnosis of

PTSD and you diagnose another mental disorder, please provide an opinion as

to whether it is at least as likely as not that the Veteran's diagnosed

mental disorder is a result of an in-service stressor related event.

 

West Haven VA exam dated 10/27/2016, diagnosed PTSD and noted that PTSD has

a significant overlap of symptoms with service connected Major Depression.

 

Question for Clarification:

 

Is the diagnosis of PTSD a progression of the Veteran's service connected

Major Depression condition?

 

RESPONSE:

The veteran's PTSD is at least as likely as not(50 percent or greater)

proximately due to his major depressive symptoms.  Based on the most recent

examination, it appears that he had presenting as primarily depressive, but his PTSD symptoms of hypervigilance, recklessness, and signficant social deficits have been activated to a highly dressing level in the past few months. This has affected him in all areas of his life, especially at home and his ability to interact with others in a work setting.

 

Both PTSD and Major Depressive Disorder are valid diagnoses, and the increase in PTSD symptoms should be treated as the progression of a the former disability. In this writer's opinion, this should be viewed as a secondary service connection.

Edited by Alex Googe
added medical opionion

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70 percent for PTSD to include major depression...maybe 100%

Edited by MrVSRguy

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