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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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Okemos_Veteran74

VA Ordered a Second C&P But Did Not Use The Results

Question

I had a C&P last September. The PhD diagnosed me as having anxiety, depression secondary to the tbi.
In my latest results there is no mention of this C&P. It would appear that the rater did not give any merit to these new diagnoses.
Is it a common occurrence for a rater to 'pick and choose' or do they have to go with the diagnoses that give the benefit to the veteran.

This of course requires that the two C&P exams were performed by equally competent professionals. Or is there something else I am missing?


I am trying to deal with what I consider a loss (by writing and talking about it). I appreciate any input.


Thank you

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In December you stated

“  I am waiting on a TDIU claim.   I was recently awarded SSDI, and I submitted my acceptance letter to strengthen my TDIU claim.  I have been told that my claim is in "Preparation for Decision" (or something like that)”:

http://community.hadit.com/topic/68711-will-anything-get-done-this-week/#comment-422953

And there are other posts from you but in different topics……

That makes your main questions hard to follow. I usually don't reply to posts that are the same vet, but different threads....too confusing

What is your VA Rating now and what for?

What is the rating for TBI?

What is the SSDI award for?

 You stated:

"This of course requires that the two C&P exams were performed by equally competent professionals. Or is there something else I am missing?"

Do you mean they gave you a C & P for the TBI and one for the PTSD?

Have you been able to get copies of the initial C & P exam?

If so can you scan and attach it here ( cover C file prior to scanning it)

"I am trying to deal with what I consider a loss (by writing and talking about it). I appreciate any input."

We all understand that.

I will check out your past posts when I get time because  something is 'missing ' here for me to understand what is going on with VA and your claim.

 


 

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Below is the C&P exam that I took in September.  I don't think that the VA used this report because  'Benefits' only shows the Tinnutus as being rated.

  I removed the doctors at the Battle Creek VA.

 

 

--------------- MY HEALTHEVET PERSONAL INFORMATION REPORT ---------------
                    *************CONFIDENTIAL*************
                    Produced by the VA Blue Button (v12.10)
                               04 Jan 2017 @ 0905

This summary is a copy of information from your My HealtheVet Personal
Health Record. Your summary may include:
- information that you entered (self reported)
- information from your VA health record
- your military service information from the department of defense (DoD).

***Note: Your health care team may not have all of the information from
your Personal Health Record unless you share it with them. Contact your
health care team if you have questions about your health information.***

Key:  Double dashes (--) mean there is no information to display.


------------------------ DOWNLOAD REQUEST SUMMARY -----------------------

System Request Date/Time:  04 Jan 2017 @ 0905
File Name:                 mhv_MAYS_20170104_0905.txt

Date Range Selected:       26 Sep 2016 to 26 Sep 2016
Data Types Selected:
  My HealtheVet Account Summary
  VA Notes

--------------------- MY HEALTHEVET ACCOUNT SUMMARY ---------------------

Source: VA

Authentication Status:         Authenticated
Authentication Date:           18 Apr 2014
Authentication Facility ID:    506
Authentication Facility Name:  VA ANN ARBOR HEALTHCARE SYSTEM

   VA Treating Facility                     Type
   --------------------                     ------  
   VBA BRLS                                 na
   VA IDENTIFY PROOFING                     na
   VETERANS ID CARD SYSTEM                  na
   VBA CORP                                 na
   BATTLE CREEK MI VAMC                     na
   DEPARTMENT OF DEFENSE DEERS              na
   ENROLLMENT SYSTEM REENGINEERING          na
   AUSTIN MHV                               na
   ST. LOUIS MO VAMC-JC DIVISION            na
   VA ANN ARBOR HEALTHCARE SYSTEM           na

------------------------------- VA NOTES --------------------------------

Source: VA
Last Updated: 03 Jan 2017 @ 0919

Sorted By: Date/Time (Descending)

VA Notes from January 1, 2013 forward are available 3 calendar days after 
they have been completed and signed by all required members of your VA 
health care team. If you have any questions about your information please 
visit the FAQs or contact your VA health care team. 

=========================================================================
Date/Time:               26 Sep 2016 @ 1430
Note Title:              C&P MENTAL DISORDERS
Location:                BATTLE CREEK MI VAMC
Signed By:              
Co-signed By:           
Date/Time Signed:        26 Sep 2016 @ 1813
-------------------------------------------------------------------------

 LOCAL TITLE: C&P MENTAL DISORDERS                               
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE: SEP 26, 2016@14:30     ENTRY DATE: SEP 26, 2016@18:13:28      
      AUTHOR:      EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     


                                 Medical Opinion
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Mays, Franklin Eugene
    
    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    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 provided a copy of a letter from the Department of Health and
          Human Services, dated 9/8/16, describing his occupational impairments,
          which will be forwarded to the regional office.


    MEDICAL OPINION SUMMARY
    -----------------------
    RESTATEMENT OF REQUESTED OPINION: 

    a. Opinion from general remarks: **CLAIM TYPE: INCREASE ONLY
    **SPECIAL CONSIDERATIONS: NOT APPLICABLE
    **INSUFFICIENT EXAM: NO

 

    Date of claim: 03/09/2016

    Days pending: 170

    Veteran has a power of attorney.

    Please send a courtesy copy of the exam notice letter to AMERICAN LEGION

    Attention C&P Service's staff - This exam request was scheduled at your 
    location based on the claimant's residing zip code and ERRA instructions

    The Veteran will need to report for the following exam(s) unless the ACE 
    process is utilized. Clinician: If using the ACE process to complete the 
    DBQ, please explain the basis for the decision not to examine the Veteran, 
    and identify the specific materials reviewed to complete the DBQ. Also if 
    the exam is completed using ACE, please review the Veteran's claims folder 
    and indicate so in the exam report.

    DBQ AUDIO Hearing Loss and Tinnitus
    DBQ NEURO Central Nervous System
    DBQ NEURO Headaches (including migraine headaches)

    An in-person examination is required for the following exam(s). ACE process 
    must not be used to complete the DBQ.

    DBQ PSYCH Mental disorders
    DBQ PSYCH PTSD Initial
    ____________________________________________________________________________

    The following contentions need to be examined:

    Tinnitus
    Traumatic brain injury
    Headaches and visual impairment (related to: PTSD - Non-Combat)
    Major depression and anxiety (related to: PTSD - Personal Trauma)
    PTSD personal trauma
    Major depression and anxiety (related to: PTSD - Personal Trauma)

    Active duty service dates:

    Branch: Army

    EOD: 09/01/1994

    RAD: 12/31/1996

    DBQ AUDIO Hearing Loss and Tinnitus:

    MEDICAL OPINION

    Type of medical opinion requested:  Direct service connection

    Contention: Claimed Condition: tinnitus

    The Veteran is claiming that his tinnitus is related to TBI. 

    Opinion Requested:
    Is the veteran's tinnitus at least as likely as not (50 percent or greater 
    probability) incurred in or caused by TBI.  

    Please fill out the direct medical opinion template in the DBQ and review 
    the following tabbed evidence. Your review is not limited to the evidence 
    identified on this request form, or tabbed in the claims folder. If an 
    examination or additional testing is required, obtain them prior to 
    rendering your opinion.

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    POTENTIALLY RELEVANT EVIDENCE:

    NOTE:  Your (examiner) review of the record is NOT restricted to the 
    evidence listed below.  This list is provided in an effort to assist the 
    examiner in locating potentially relevant evidence.

    Tab A (DD Form 214 in VBMS): Letter - Verification of Service dated 
    4/30/2014

    Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016

    ****************************************************************************
    DBQ NEURO Central Nervous System:

    The Veteran is service connected for traumatic brain injury which is 
    currently evaluated at 40%. Please evaluate for the current level of 
    severity of the Veteran's service connected disability. If the diagnosis 
    rendered is different from the disability for which the Veteran is service 
    connected, please indicate whether the Veteran's current diagnosis is a 
    progression of the service connected disability or the original diagnosis 
    was in error. If the diagnosis was in error, please provide a rationale 
    supported by the clinical evidence of record that refutes the previous exam
    (s) which diagnosed the condition.

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    POTENTIALLY RELEVANT EVIDENCE:

    NOTE:  Your (examiner) review of the record is NOT restricted to the 
    evidence listed below.  This list is provided in an effort to assist the 
    examiner in locating potentially relevant evidence.

    Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016

    ****************************************************************************

    DBQ NEURO Headaches (including migraine headaches):

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    MEDICAL OPINION REQUEST

    TYPE OF MEDICAL OPINION REQUESTED: Direct service connection

    OPINION: Direct service connection

    Contention: Claimed Condition: headaches

    The Veteran is claiming that "his" headaches (related to: PTSD - Non-Combat 
    was incurred in or caused by "his" TBI that occurred 09/01/1994 - 
    12/31/1996.

    Does the Veteran have a diagnosis of (a) headaches (related to: PTSD - Non-
    Combat) that is at least as likely as not (50 percent or greater 
    probability) incurred in or caused by (the) TBI during service?

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    Rationale must be provided in the appropriate section.

    POTENTIALLY RELEVANT EVIDENCE:

    NOTE:  Your (examiner) review of the record is NOT restricted to the 
    evidence listed below.  This list is provided in an effort to assist the 
    examiner in locating potentially relevant evidence.

    Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016

    ****************************************************************************

    DBQ PSYCH Mental disorders:

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    MEDICAL OPINION REQUEST

    TYPE OF MEDICAL OPINION REQUESTED: Direct service connection

    OPINION: Direct service connection

    Cont
ention: Claimed Condition: PTSD

    The Veteran is claiming that "his" PTSD was incurred in or caused by "his" 
    personal trauma that occurred 09/01/1994 - 12/31/1996.

    Does the Veteran have a diagnosis of (a) major depression and anxiety 
    (related to: PTSD - Personal Trauma) that is at least as likely as not (50 
    percent or greater probability) incurred in or caused by (the) TBI during 
    service?

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    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.


    POTENTIALLY RELEVANT EVIDENCE:

    NOTE:  Your (examiner) review of the record is NOT restricted to the 
    evidence listed below.  This list is provided in an effort to assist the 
    examiner in locating potentially relevant evidence.

    Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016

    ****************************************************************************

    DBQ PSYCH PTSD Initial:

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    MEDICAL OPINION REQUEST

    TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.

    OPINION REQUESTED: Secondary Service Connection.

    Contention: Claimed Condition: PTSD

    The Veteran is claiming that "his" PTSD was incurred in or caused by "his" 
    TBI that occurred 09/01/1994 - 12/31/1996.

    Is the Veteran's PTSD personal trauma at least as likely as not (50 percent 
    or greater probability) proximately due to or the result of traumatic brain 
    injury?

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    Rationale must be provided in the appropriate section.

    MEDICAL OPINION REQUEST

    TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.

    OPINION REQUESTED: Secondary Service Connection.

    Is the Veteran's major depression and anxiety (related to: PTSD - Personal 
    Trauma) at least as likely as not (50 percent or greater probability) 
    proximately due to or the result of traumatic brain injury?

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report.

    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.

    POTENTIALLY RELEVANT EVIDENCE:

    NOTE:  Your (examiner) review of the record is NOT restricted to the 
    evidence listed below.  This list is provided in an effort to assist the 
    examiner in locating potentially relevant evidence.

    Tab B (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab C (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab D (STRs in VBMS): STR - Medical - Photocopy dated 1/16/2013

    Tab E (Federal treatment record in VBMS): CAPRI Records dated 6/13/2016

 


    b. Indicate type of exam for which opinion has been requested: PTSD Initial

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE
    CONNECTION ]

    a. The condition claimed is at least as likely as not (50% or greater
    probability) proximately due to or the result of the Veteran's service
    connected condition.     

    c. Rationale: Based on clinical experience and expertise, review of VBMS
    database, Virtual VA, and available records, and examination of veteran, who
    presented credibly and consistently in treatment records, clinical interview
    and on trauma checklist, IT IS AT LEAST AS LIKELY AS NOT that veteran meets
    criteria for diagnoses of PTSD, anxiety, and depression that are caused by 
or
    the result of the TBI he incurred due to a parachuting accident during
    training in 1995, and to is resulting educational and occupational
    impairment. 

    Veteran was interviewed on 9/26/16 from 1:55 - 2:55 p.m.  


    *************************************************************************


****************************************************************************


                  Initial Post Traumatic Stress Disorder (PTSD)
                        Disability Benefits Questionnaire
                         * Internal VA or DoD Use Only *

    Name of patient/Veteran:  Mays, Franklin Eugene
    
                                   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: Post Traumatic Stress Disorder
           ICD code: 309.81
           Comments, if any:
              Secondary to the parachuting accident that caused his TBI
              diagnosis.

       Mental Disorder Diagnosis #2: Other Specified Depressive Disorder
           ICD code: 311
           Comments, if any:
              Secondary to the parachuting accident that caused his TBI
              diagnosis.

       Mental Disorder Diagnosis #3: Other Specified Anxiety Disorder
           ICD code: 300.09
           Comments, if any:
              Secondary to the parachuting accident that caused his TBI
              diagnosis.

       Mental Disorder Diagnosis #4: Alcohol Use Disorder, Moderate-to-Severe, 
In
          Sustained Remission
           ICD code: 303.90
           Comments, if any:
              Secondary to the parachuting accident that caused his TBI
              diagnosis.

       If additional diagnoses, describe (using above format):
              Mental Disorder Diagnosis #5: Unspecified Cannabis-Related 
Disorder
              ICD code: 292.9
              Comments, if any: In remission. Secondary to the parachuting
              accident that caused his TBI diagnosis.

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): TBI with Loss of Consciousness;
       AD/HD, Predominately Inattentive Type; PTSD (per CPRS medical records).

    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?
       [ ] 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:


              Veteran's diagnoses are comorbid and have overlapping features,
              reducing differentiation of symptoms to speculation. His alcohol
              and cannabis use disorders (in remission) were secondary.
              
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [X] Yes   [ ] No   [ ] Not shown in records reviewed
       
    d. 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:
              Veteran's diagnoses are comorbid and have overlapping features,
              reducing differentiation of symptoms to speculation. His alcohol
              and cannabis use disorders (in remission) were secondary. Per his
              review TBI evaluation, dated 9/26/16, veteran is experiencing
              headaches, including migraine headaches, in addition to mental
              disorders as residuals of his TBI diagnosis. His TBI examiner
              opined, "It is also least least likely as not that the Veteran's
              psychiatric issues are connected to his TBI. Veteran has had
              moodiness, anxiety, depression, irritability, and impaired
              awareness.Veteran has extensive comprehension difficulties. He has
              had extensive psychiatric issues since his TBI. It is more of the
              cognitive difficulties that impair working."
              
              
    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?
       [ ] 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:
              Veteran's diagnoses are comorbid and have overlapping features,
              reducing differentiation of social and occupational impairment to
              speculation. His alcohol and cannabis use disorders (in remission)
              were secondary.
              
    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?
       [X] Yes   [ ] No   [ ] No diagnosis of TBI
       
           If yes, list which portion of the indicated level of occupational and
           social impairment is attributable to each diagnosis:
              Veteran's diagnoses are comorbid and have overlapping features,
              reducing differentiation of social and occupational impairment to
              speculation. His alcohol and cannabis use disorders (in remission)
              were secondary. Per his review TBI evaluation, dated 9/26/16,
              veteran is experiencing headaches, including migraine headaches, 
in
              addition to mental disorders as residuals of his TBI diagnosis. 
His
              TBI examiner opined, "It is also least least likely as not that 
the
              Veteran's psychiatric issues are connected to his TBI. Veteran has
              had moodiness, anxiety, depression, irritability, and impaired
              awareness.Veteran has extensive comprehension difficulties. He has
              had extensive psychiatric issues since his TBI. It is more of the
              cognitive difficulties that impair working."
              
              
                                   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 provided a copy of a letter from the Department of Health and
          Human Services, dated 9/8/16, describing his occupational impairments,
          which will be forwarded to the regional office.


    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
       post-military):
          The following are history and status as related by veteran, and as
          obtained from review of available records. 

          Veteran underwent his last C&P evaluation for mental disorders on
          3/4/14. Please refer to that examination for further background
          information. Veteran was born and raised in Georgia by  his biological
          parents, along with 1 brother. He described his upbringing as 
"normal,"
          and his current relationships with members of his family of origin as
          "fine." He has been married for 15 years, fathering 3 children.
          Overall, he described his marriage as "good," but did report
          frustration and anger secondary to his TBI, adding he turns his anger
          inward toward himself. He added he becomes "excited easily," leading
          his wife to think he is yelling. He did say that his wife is
          supportive, and that she encouraged him to give up alcohol use. 
Veteran
          also reported that his anxiety continues to be driven by his youngest
          son, who has Down's Syndrome, resulting in "a lot of behavioral
          issues." Socially, veteran reported that he still has friends from
          before his accident, who live in other states, but denied making
          friends since his accident. He added he has been experiencing
          difficulty leaving his home. 
          
          
    b. Relevant Occupational and Educational history (pre-military, military, 
and
       post-military):
          Veteran graduated high school, describing himself as an "A, B, C
          student," who was active in many sports, and got along "very good" 
with
          teachers and peers. He denied ever being suspended or expelled. 
Veteran
          also reported a Bachelor's degree from the University of Georgia,
          adding he was pursuing his degree at that time in order to become an
          officer in the Army. He stated he was an academic scholarship cadet,
          but that his grades significantly declined after his accident in 1995.
          He did say he earned his degree in History in 1998. He also has a
          Bachelor's degree from the University of Michigan, Flint. His second
          degree is in elementary education, finished in 2007. He stated he was
          better able to focus while earning his second degree, as the class
          sizes were smaller. Occupationally, veteran worked as a life guard, 
and
          then was offered a job with an after school program during the school
          year from the same employer. He added he held this job while he was in
          college the first time. After his accident, he reported that he began
          using cannabis daily, cut his foot at work necessitating a drug test,
          which he refused because he knew he would screen as positive. In
          addition, parents started complaining that he became "too intense" and


          "keyed up" with the children. Instead of firing him outright, his
          employer opted to give him no more hours of work. Veteran served in 
the
          Army from 1994-1996. Overall, he stated he "loved it," citing a family
          tradition of Army service. He added, being an officer in the Army was
          "all I ever wanted to do," and stated, "My life just crumbled" after
          the accident cut his military career short. Following graduation from
          college, veteran went to work for a plumbing warehouse, adding he was
          having difficulties with alcohol use, causing him to miss a day of
          work, stating he left that job shortly thereafter. Next, he sold
          insurance door-to-door. He stated he enjoyed the sense of "roaming" 
and
          "exploring" that job brought him, adding he was also able to learn the
          history of the places he visited to sell insurance. He stated he quit
          that job when he moved to Michigan in 2000. In Michigan, veteran
          reported work via temporary agencies, prior to signing up for
          AmeriCorps. He stated 9/11 caused him to lose interest in AmeriCorps,
          and everything else, adding he was "not fired, but kindly let go."
          Next, veteran attempted to further his education at Michigan State
          University, but experienced difficulties due to the large class sizes,
          transferring to U of M Flint (as above) after 3 semesters. He added he
          attended classes three-quarters time at U of M Flint, which he stated
          was also a benefit. Veteran then began student teaching. He added he
          struggled in this, as he could not get along with the teacher to whom
          he was assigned, had difficulty writing and organizing lesson plans,
          and had problems keeping track of the students in classes. Following 
an
          argument with his teacher, the principal let him go. Veteran stated he
          was then placed at a different student teaching location, where he
          "frustrated" the teacher due to his difficulties with organization and
          making other mistakes, which confused the children. At his third
          student teaching placement, veteran reported that he performed better,
          as the teacher to whom he was assigned was supportive, and he only
          taught 1 class, which better allowed him to stay organized and 
focused.
          Veteran then found employment as a teacher at a charter school in
          Flint, Michigan, where he remained for 5 months, prior to being asked
          not to return. He explained that he was not able to remain organized 
as
          he was teaching Spanish to students from kindergarten - 8th grade,
          adding it was "too much for me." Next, veteran taught for the Lansing
          School District from 2008-2014, teaching Spanish immersion to
          pre-schoolers. He added he also had to take classes to earn a specific
          certification, and held that position for 2.5 years. At the same time,
          he reportedly obtained a medical marijuana card, and decided to stop
          taking his other psychiatric medications. He stated he lost interest 
in
          pre-school, and was transferred to a different program in the Lansing
          School District. He stated he ultimately returned to the 
pre-schoolers,
          but was let go from that position because he never earned the
          certification he needed. Veteran was involved in vocational
          rehabilitation from 2015-2016, until increased stress lead to 2 
suicide
          attempts. He stated he taught classes at an independent living center
          for 40 hours/week, adding he had "a lot of trouble with that." He went
          on to say he felt he had "too much on his plate, and not enough time 
to
          think," in addition to difficulties with his youngest child. His
          psychiatrist reportedly urged him to reduce his hours to 20/week or
          less, with veteran moving into farming. He stated he enjoyed farming,
          initially, until he experienced vertigo, and a third suicide attempt 
in
          July. The Social Security Administration found that veteran was not
          disabled, but did find that he was experiencing symptoms of an Anxiety
          Disorder, and Affective Disorder, and an Organic (memory) Disorder. 
          
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
          Veteran denied any pre-military involvement in mental health 
treatment,
          and no mental health-related conditions were endorsed on veteran's
          Reports of Medical History, dated 4/14/94 or 6/21/95. Records show a
          hospitalization from 9/12-9/21/95 secondary to veteran's fall. During
          the course of that hospitalization, he was found to experience a fair
          amount of short-term memory return, no significant long-term memory
          problems, and his cerebellar activities were returning toward normal. 
A
          Department of the Army memo, dated 9/14/95, revealed that veteran was
          involved in a serious accident on 9/12/95 when he was an ROTC cadet.
          That memo noted that he hit his head, was taken to the hospital, and
          diagnosed with a concussion. It was also noted on that memo that
          veteran was in and out of deep sleep, not responding like he should,
          could remember names but not associations, and was confused. Notes 
from
          Par Rehab Services, dated 4/3/07, revealed residual impairment in
          spatial perception, visual memory skills, and higher level executive
          functioning, all of which involved organization, prioritization,
          cognitive flexibility, and an ability to move from task to task while
          tolerating distractions. It was also noted the the Par examiner that
          veteran was developing an increased degree of anxiety and depression
          secondary to his underlying cognitive problems. He was diagnosed at 
Par
          with a cognitive disorder secondary to his TBI, as well as an
          Adjustment Disorder with Mixed Anxiety and Depressed Mood. Records 
also
          show that veteran was treated for symptoms of anxiety and PTSD at
          Michigan State University in 2012. Veteran underwent his last C&P
          evaluation for mental disorders on 3/4/14, when he was diagnosed with
          Other Specified Anxiety Disorder, and an initial TBI C&P evaluation on
          3/26/14. A Hope Network Physician Treatment Note, dated 7/10/14,
          reflected diagnostic impressions of mild neurocognitive disorder due 
to
          TBI, with attention and memory impairments, PTSD, delayed ejaculation,
          and occupational impairment. He met with a VA social worker in 2014
          secondary to symptoms of PTSD and TBI. He was involved in individual
          psychotherapy with a VA psychologist in 2015, secondary to diagnoses 
of
          Anxiety Disorder NOS, Depression NOS, and a history of PTSD. Veteran 
is
          participating in a peer support group facilitated by a VA provider.
          Veteran underwent inpatient mental health treatment from 2/9-2/17/15. 
A
          letter found among he electronic records, penned by Dr. Dykema on
          6/22/16, noted a TBI due to a parachuting accident during ROTC in 
1995,
          which was diagnosed in 2007. Dr. Dykema also noted that veteran is
          experiencing significant impairment in occupational functioning, as he
          is "unable to work to expectations in numerous past jobs." In 
addition,
          Dr. Dykema found that veteran felt overwhelmed by responsibility, and


          described chronic depression and anxiety symptoms due to education 
and
          occupational difficulties secondary to his TBI. Dr. Dykema also noted 
a
          hospitalization in 2015, secondary to suicidal ideation, revealing 
that
          he has attempted suicide on numerous occasions. Dr. Dykema diagnosed
          veteran with depression and anxiety secondary to his TBI. Veteran is
          currently prescribed Sertraline HCL and Lisdexamfetamine Dimesylate
          (Vyvanse, for AD/HD). He stated counseling has been good, as it gives
          him someone to talk to, adding his inpatient treatment was also
          helpful. He was uncertain about medication management, citing his 3
          suicide attempts over the last year.

          NOTE: Veteran's records show that he is currently flagged as being at
          high risk for suicide. 
          
          
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          Denied.
          
          
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          Veteran reported that his alcohol use became problematic following his
          parachuting accident, stating, "I couldn't handle it the way I could."
          He added alcohol had a bigger impact on him following the accident, 
but
          stated he used alcohol in an attempt to make himself "numb." He
          described himself as a "binge drinker," consuming a half-gallon of gin
          during a given weekend. He denied alcohol use since 2000. Veteran also
          reported that he began using cannabis following the accident, stating
          he never wanted to use that substance prior. Following the accident, 
he
          thought, "Why not?" He stated cannabis calmed him down, and distracted
          him from thoughts of the accident and its' resulting limitations. He
          reportedly held a medical marijuana card for 2 years, but began to 
feel
          that cannabis "made things worse." As a result, he stated he quit the
          use of cannabis in 2012. He denied the use/abuse of any other
          substances. 
          
          
    f. Other, if any:
          Subjective Report of Symptoms: 

          Veteran reported that he experiences panic, triggered by what he has
          forgotten or has not done. He also reported sadness, due to the
          accident, and its' impact on his teaching career. Veteran also noted
          feelings of guilt, due to his unemployment. He added he also wonders
          about the status of his VA claims. During times of increased stress,
          veteran reported that he smells the odor of burning cannabis. In
          addition to the panic described above, veteran reported anxiety
          triggered by unexpected loud noises, surprises (including unexpected
          touching from his family), feeling like his TBI is getting worse
          (stating the harder he tries the worse it gets), and the future. He
          reported daily panic attacks, for which he uses cognitive behavioral
          and breathing techniques learned in treatment. Veteran reported 3
          suicide attempts over the last year, via carbon monoxide poisoning 
(x2)
          and overdose on medications. He denied any current plan/intent to harm
          himself, reporting a "scale" of "45%" suicidal ideation vs. "55%"
          desire to live. He denied homicidal ideation. He described his 
appetite
          as "fine." At night, veteran reported that he was prescribed Trazodone
          during his last evaluation, which has allowed him to feel better
          rested. When his sleep is interrupted, he stated the Trazodone allows
          him to more easily return to sleep. Despite his medication, he 
reported
          that he will sometimes wake up and think about all he has done wrong 
or
          is not good at. He also reported dreams, which he described as being
          like "impressions" of his impact with the ground, adding he 
experiences
          goose bumps when they occur. Veteran denied flashbacks, stating he
          "tries not to think about it." Regarding his memory, veteran reported
          that he makes lists and write things down. 
          
          
    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: Veteran reported that he remembers his first training jump,
          thinking, "Wow...I'm still here." He went on to describe vague 
memories
          of being on the aircraft and or taxying down the runway for his second
          jump, and then nothing further until waking up in the hospital. In the
          hospital, veteran reported that he remembers having some 
conversations,
          but did not trust that memory, as he also remembered speaking to his
          deceased grandmother at that time.
          
          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
          
              If no, explain:
                Training accident, as evidenced by Army and hospital records
                describing his parachuting accident.
                
          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 Criterion 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 Criterion 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 violence, in one or more of the following ways:
                    
                   [X] Directly experiencing the traumatic event(s)

       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] 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] Inability to remember an important aspect of the 
traumatic
                       event(s) (typically due to dissociative amnesia and not 
to
                       other factors such as head injury, alcohol, or drugs).
                   [X] Persistent and exaggerated negative beliefs or
                       expectations about oneself, others, or the world (e.g., 
"I
                       am bad,: "No one can be trusted,: "The world is 
completely
                       dangerous,: "My whole nervous system is permanently
                       ruined").
                   [X] Persistent, distorted cognitions about the cause or
                       consequences of the traumatic event(s) that lead the
                       individual to blame himself/herself or others.
                   [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

    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Depressed mood
       [X] Anxiety
       [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] 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] Suicidal ideation

    6. Behavioral Observations
    --------------------------
    Veteran is a 42 year old, Caucasian male, who presented early for 
evaluation,
    casually dressed and appropriately groomed.  He was alert and fully 
oriented.
    He was able to correctly spell "WORLD" forward and backward. He was not able
    to accurately complete serial 7s (e.g., "100-93-86-79-73-67"). He was able 
to
    recall 2/3 words after delay, which did not improve with prompting. He was
    cooperative with the assessment process.  Veteran's mood and affect were
    dysphoric and anxious.  He displayed good eye contact. Veteran's speech was
    reflective of anxiety, but spontaneous and goal-directed. His thought
    processes were generally organized with no evidence of hallucinations,
    delusions, mania, or obsessive-compulsive features. He appears to be of
    average intelligence, with capacity for abstract thought, and fair insight
    into his emotional functioning.

    7. Other symptoms
    -----------------
    Does the Veteran have any other symptoms attributable to PTSD (and other
    mental disorders) that are not listed above?
       [X] Yes   [ ] No
       
           If yes, describe:
              Testing Results:

              The PTSD Checklist- 5 (PCL-5) was administered to gauge current
              signs and symptoms of traumatic stress. Currently, there are no
              normative data available for the PCL-5, and the instrument was
              completed as a self-report measure of the severity of reported 
PTSD
              symptoms. Veteran endorsed the following symptoms as bothering him
              Extremely: Feeling very upset when something reminded him of the
              stressful experience; Trouble remembering important parts of the
              stressful experience; Having strong negative beliefs about 
himself,
              others, or the world; Blaming himself or someone else for the
              stressful experience or what happened after; Being "super alert" 
or
              watchful or on guard; Feeling jumpy or easily startled; and 
Trouble
              falling or staying asleep.

              Veteran endorsed the following symptoms as bothering him Quite A
              Bit: Repeated, disturbing, and unwanted memories of the stressful
              experience; Suddenly feeling or acting as if the stressful
              experience were actually happening again; Having strong physical
              reactions when something reminded him of the stressful experience;
              Avoiding memories, thoughts, or feelings related to the stressful
              experience; Avoiding external reminders of the stressful
              experience; Having strong negative feelings such as fear, horror,
              anger, guilt, or shame; Loss of interest in activities he used to
              enjoy; Feeling distant or cutoff from others; Trouble experiencing
              positive feelings; Irritable behavior, angry outbursts, or acting
              aggressively; and Having difficulty concentrating. 

              Veteran endorsed the following symptom as bothering him 
Moderately:
              Taking too many risks or doing things that could cause self-harm.


              The remaining symptom was endorsed by veteran as bothering him A
              Little Bit (e.g., Repeated, disturbing dreams of the stressful
              experience). 
              
              
    8. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
       [X] Yes   [ ] No
       
    9. Remarks, (including any testing results) if any
    --------------------------------------------------
       Integrated Summary and Clinical Impressions:

       Veteran is a 42 year old, married Caucasian male, who received a TBI
       following a parachuting accident in 1995. Results of current examination
       revealed evidence of signs and symptoms of PTSD, depression, and anxiety,
       secondary to his TBI, and resulting educational and occupational
       limitations. His accident has also contributed to social functioning, as
       veteran denied making any new friends since his accident. The above
       symptoms were more likely than not present at the time of his last C&P
       evaluation for mental disorders in 2014. Veteran also reported a pattern
       of heavy alcohol, as well as cannabis, use since his TBI, both of which
       are in states of sustained remission. Prognosis for substantial
       improvement of psychiatric symptoms and functional status is guarded, due
       to veteran's TBI symptoms, exacerbated to his symptoms of PTSD, anxiety,
       and depression, resulting in an ongoing reciprocal relationship between
       TBI and mental health sequelae, as attested to by medical documentation
       since his accident, and his current flag as being at high risk for
       suicide.
       
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

 
/es/ Joseph C Bolton, PsyD
Psychologist
Signed: 09/26/2016 18:13
-------------------------------------------------------------------------

=========================================================================
Date/Time:               26 Sep 2016 @ 1230
Note Title:              C&P MENTAL DISORDERS
Location:                BATTLE CREEK MI VAMC
Signed By:               
Co-signed By:           
Date/Time Signed:        26 Sep 2016 @ 1347
-------------------------------------------------------------------------

 LOCAL TITLE: C&P MENTAL DISORDERS                               
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE: SEP 26, 2016@12:30     ENTRY DATE: SEP 26, 2016@13:47:16      
      AUTHOR:         EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     


        Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI)
                       Disability Benefits Questionnaire 
                         * Internal VA or DoD Use Only*

    Name of patient/Veteran:   Franklin Eugene Mays
    
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes  [ ] No
    

    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS


    SECTION I: Diagnosis and medical history
    ----------------------------------------
    
    1. Diagnosis
    ------------
    Does the Veteran now have or has he/she ever had a traumatic brain injury
    (TBI) or any residuals of a TBI?
    [X] Yes   [ ] No
    
       [X] Traumatic brain injury (TBI)
              ICD code:  S06.2       Date of diagnosis:   Sep 12, 1995

    2. Medical history
    ------------------
    Describe the history (including onset and course) of the Veteran's TBI and
    residuals attributable to TBI (brief summary):
       On Sept 12, 1995 the Veteran suffered a parachute accident. He landed 
hard
       and was unconscious for 10-15 minutes. He had dizziness, headache, and
       vision problems when he woke up. He was noted to have cerebellar
       dysfunction which was noted by balance issues and confirmed by a MRI. He
       was taken to Fort Benning, Georgia hospital where he was hospitalized 
from
       Sept 12 to Sept 21, 1995. He was diagnosed with a closed head injury, 
mild
       Diabetic insipidus, and Cranial nerve IV bilaterally. He also was noted 
to
       have mild edema of the left parietal lobe and cerebellum. He was placed 
on
       light duty until his discharge 2 years later. He has continued to have
       vertigo, balance problems, memory dysfunction, problems organizing tasks.
       He went to to Hope Network in 2011 where he was treated. He was treated
       extensively for cognitive dysfunction from his TBI. He also had problems
       anxiety, substance abuse, and depression requiring treatment. He was
       diagnosed again with continued problems with his TBI in 2007 b by Dr
       Fabiano. He currently is prescribed wellbutrin 450mg XL po qam. He was on
       Vivance 70mg per day until He stopped it recently. He is on Trazadone 
25mg
       po qhs. 
       
       
    SECTION II: Assessment of facets of TBI-related cognitive impairment and
    subjective symptoms of TBI
    
-----------------------------------------------------------------------------
    
    1. Memory, attention, concentration, executive functions
    --------------------------------------------------------
    [X] Objective evidence on testing of moderate impairment of memory,
        attention, concentration, or executive functions resulting in moderate
        functional impairment
        
        If the Veteran has complaints of impairment of memory, attention,
        concentration or executive functions, describe (brief summary):
        He has extensive testing at Hope Network which ahs shown short term
        memory dysfunction. He also has had post traumatic amnesia for the time
        around the head injury. 
        
        
    2. Judgment
    -----------
    [X] Normal
    
    3. Social interaction
    ---------------------
    [X] Social interaction is occasionally inappropriate
    
        If the Veteran's social interaction is not routinely appropriate,
        describe (brief summary):
        He lives with his wife and 3 children, ages 12, 10, and 8. After the
        military to college, struggling with classes, and he barely finished his
        degree. He is applyng for socially security disability. He has been
        having trouble with maintaining his teaching ceritificate credits. He 
was
        having trouble performing the needed skills. He also has received 
support
        from Michigan rehabilation services. He has been in job jeopardy for a
        while. Both Michigan VA and the VA rehab services do not feel that he is
        employable due to the extent of his cognitive deficits from his TBI.
        
    4. Orientation
    --------------
    [X] Always oriented to person, time, place, and situation
    
    5. Motor activity (with intact motor and sensory system)
    --------------------------------------------------------
    [X] Motor activity is normal most of the time, but mildly slowed at times 
due
        to apraxia (inability to perform previously learned motor activities,
        despite normal motor function)
        
        If the Veteran has any abnormal motor activity, describe (brief 
summary):
        He has had jerks and cleched jaw reflexes since the head injury that was
        noted after the head injury on Oct 12, 1995 by Dr David R Rivera, MD, a
        Ophthamology who also noted some memory dysfunction, decreased stamina,
        bliateral 4th cranial nerve palsies, balance problems, and cogwheel
        pursuit.
        
    6. Visual spatial orientation
    -----------------------------
    [X] Moderately impaired: Usually gets lost in unfamiliar surroundings, has
        difficulty reading maps, following directions, and judging distance. Has
        difficulty using assistive devices such as GPS (global positioning
        system)
        
        If the Veteran has impaired visual spatial orientation, describe (brief
        summary):
        Veteran gets lost periodically. He went to the wrong building before he
        got to this appointment. 
        
        
    7. Subjective symptoms
    ----------------------
    No response provided.
    
    8. Neurobehavioral effects
    --------------------------
    [X] One or more neurobehavioral effects that occasionally interfere with
        workplace interaction, social interaction, or both but do not preclude
        them
        
        If the Veteran has any neurobehavioral effects, describe (brief 
summary):
        Veteran has had moodiness,a nxiety, depression, irritablity, and 
impaired
        awareness.
        
    9. Communication
    ----------------
    [X] Comprehension or expression, or both, of either spoken language or
        written language is only occasionally impaired. Can communicate complex
        ideas.
        
        If the Veteran is not able to communicate by or comprehend spoken or
        written language, describe (brief summary):
        Veteran has extensive comphrension difficulties.
        
        
    10. Consciousness
    -----------------
    [X] Normal
    
    SECTION III: Additional residuals, other findings, diagnostic testing,
    functional impact and remarks
    
-----------------------------------------------------------------------------
    
    1. Residuals
    ------------
    Does the Veteran have any subjective symptoms or any mental, physical or
    neurological conditions or residuals attributable to a TBI (such as migraine
    headaches or Meniere's disease)?
    [X] Yes   [ ] No
    
       [X] Headaches, including Migraine headaches
       [X] Mental disorder (including emotional, behavioral, or cognitive)

    2. Other pertinent physical findings, scars, 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?
       [X] Yes  [ ] 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
       
    c. Comments, if any:
       No response provided
       
    3. Diagnostic testing
    ---------------------
    a. Has neuropsychological testing been performed?
       [ ] Yes   [X] No
       
    b. Have diagnostic imaging studies or other diagnostic procedures been
       performed?
       [ ] Yes   [X] No
       
    c. Has laboratory testing been performed?
       [ ] Yes   [X] No
       
    d. Are there any other significant diagnostic test findings and/or results?
       [X] Yes   [ ] No
       
       If yes, provide type of test or procedure, date and results (brief
       summary):
       see records from VBMS which extent the extent of his cognitive deficits
       due to his TBI. 
       
       
    4. Functional impact
    --------------------
    Do any of the Veteran's residual conditions attributable to a traumatic 
brain
    injury impact his or her ability to work?
    [X] Yes   [ ] No
    
       If yes, describe impact of each of the Veteran's residual conditions
       attributable to a traumatic brain injury, providing one or more examples:
       Veteran has had significant difficulty due to his TBI. Job jeopardy for a
       while, now on long term disability. 
       
       
    5. Remarks, if any:
    -------------------
    No remarks provided.
    


****************************************************************************


                                 Medical Opinion
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Franklin Eugene Mays
    
    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS


    MEDICAL OPINION SUMMARY
    -----------------------
    RESTATEMENT OF REQUESTED OPINION: 

    a. Opinion from general remarks: Does the Veteran continue to have a TBI 
with
    associated headaches??


    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
    CONNECTION ] 

    a. The condition claimed was at least as likely as not (50% or greater
    probability) incurred in or caused by the claimed in-service injury, event 
or
    illness.   

    c. Rationale: It is least likely as not that Veteran has a TBI with
    associated headaches, mood disturbances, anxiety, and depression. On Sept 
12,
    1995 the Veteran suffered a parachute accident. He landed hard and was
    unconscious for 10-15 minutes. He had dizziness, headache, and vision
    problems when he woke up. He was noted to have cerebellar dysfunction which
    was noted by balance issues and confirmed by a MRI. He was taken to Fort
    Benning, Georgia hospital where he was hospitalized from Sept 12 to Sept 21,
    1995. He was diagnosed with a closed head injury, mild Diabetic insipidus,
    and Cranial nerve IV bilaterally. He also was noted to have mild edema of 
the
    left parietal lobe and cerebellum.He was placed on light duty until his
    discharge 2 years later. He has continued to have vertigo, balance problems,
    memory dysfunction, problems organizing tasks. He went to to Hope Network in
    2011 where he was treated. He was treated extensively for cognitive
    dysfunction from his TBI. He also had problems anxiety, substance abuse, and
    depression requiring treatment. He was diagnosed again with continued
    problems with his TBI in 2007 b by Dr Fabiano. He currently is prescribed
    wellbutrin 450mg XL po qam. He was on Vivance 70mg per day until he stopped
    it recently. He is on Trazadone 25mg po qhs. He has extensive testing at 
Hope
    Network which ahs shown short term memory dysfunction. He also has had post
    traumatic amnesia for the time around the head injury. He lives with his 
wife
    and 3 children, ages 12, 10, and 8. After the military to college, 
struggling
    with classes, and he barely finished his degree. 
    He is applyng for socially security disability. He has been having trouble
    with maintaining his teaching ceritificate credits. He was having trouble
    performing the needed skills. He also has received support from Michigan
    rehabilation services. He has been in job jeopardy for a while. Both 
Michigan
    VA and the VA rehab services do not feel that he is unemployable due to the
    extent of his cognitive deficits from his TBI. Veteran gets lost
    periodically. He went to the wrong building before he got to this
    appointment. 

    It is also least least likely as not that the Veteran's psychiatric issues
    are connected to his TBI. Veteran has had moodiness,anxiety, depression,
    irritablity, and impaired awareness.Veteran has extensive comphrension
    difficulties. He has had extensive psychiatric issues since his TBI. It is
    more of the cognitive difficulties that impair working. He has had jerks and
    clenched jaw reflexes since hte head injury that was noted after the head
    injury on Oct 12, 1995 by Dr David R Rivera, MD, a Ophthamology who also
    noted some memory dysfunction, decreased stamina, bliateral 4th cranial 
nerve
    palsies, balance problems, and cogwheel pursuit. I also recommend an Eye
    exam. 

 


    *************************************************************************


****************************************************************************


                    Headaches (including Migraine Headaches)
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Franklin Eugene Mays
    
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes   [ ] No
    

    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS


    1. Diagnosis
    ------------
    Does the Veteran now have or has he/she ever been diagnosed with a headache
    condition?
    [X] Yes   [ ] No
    
       [X] Other (specify type of headache):  mixed
              ICD code: R51                  Date of diagnosis: sept, 1995
              
    2. Medical History
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
       headache conditions (brief summary):
         Sept 21, 1995. He was diagnosed with a closed head injury, mild 
Diabetic
         insipidus, and Cranial nerve IV bilaterally. He also was noted to have
         mild edema of the left parietal lobe and cerebellum. He was placed on
         light duty until his discharge 2 years later. He has continued to have
         vertigo, balance problems, memory dysfunction, problems organizing
         tasks. He went to to Hope Network in 2011 where he was treated. He was
         treated extensively for cognitive dysfunction from his TBI. He also had
         problems anxiety, substance abuse, and depression requiring treatment.
         He was diagnosed again with continued problems with his TBI in 2007 b by


         Dr Fabiano. He currently is prescribed wellbutrin 450mg XL po qam. He
         was on Vivance 70mg per day until he stopped it recently. He is on
         Trazadone 25mg po qhs.
         
    b. Does the Veteran's treatment plan include taking medication for the
       diagnosed condition?
       [X] Yes   [ ] No
       
       If yes, describe treatment (list only those medications used for the
       diagnosed condition):
         Headache meds make him groggy,
         
    3. Symptoms
    -----------
    a. Does the Veteran experience headache pain?
       [X] Yes   [ ] No
       [X] Constant head pain
       [X] Pulsating or throbbing head pain
       [X] Pain on both sides of the head
    b. Does the Veteran experience non-headache symptoms associated with
       headaches? (including symptoms associated with an aura prior to headache
       pain)
       [X] Yes   [ ] No
       [X] Nausea
       [X] Changes in vision (such as scotoma, flashes of light, tunnel vision)
    c. Indicate duration of typical head pain
       [X] Less than 1 day
    d. Indicate location of typical head pain
       [X] Both sides of head

    4. Prostrating attacks of headache pain
    ---------------------------------------
    a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating
       attacks of migraine / non-migraine headache pain?
       [X] Yes   [ ] No
       
       If yes, indicate frequency, on average, of prostrating attacks over the
       last several months:
       [X] With less frequent attacks

    b. Does the Veteran have very prostrating and prolonged attacks of
       migraines/non-migraine pain productive of severe economic inadaptability?
       [ ] Yes   [X] No
       
    5. 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?
       [X] Yes   [ ] 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
       
    c. Comments, if any:
         No response provided.
         
    6. Diagnostic testing
    ---------------------
    Are there any other significant diagnostic test findings and/or results?
    [ ] Yes   [X] No
    
    7. Functional impact
    --------------------
    Does the Veteran's headache condition impact his or her ability to work?
    [X] Yes   [ ] No
    
      If yes, describe the impact of the Veteran's headache condition, providing
      one or more examples:
        It is more of the cognitive difficulties that impair working.
        
    8. Remarks, if any:
    -------------------
       No remarks provided.
       

 

Staff Psychiatrist
Signed: 09/26/2016 13:47
-------------------------------------------------------------------------

=========================================================================
Date/Time:               26 Sep 2016 @ 1100
Note Title:              C&P AUDIOLOGY EVALUATION
Location:                BATTLE CREEK MI VAMC
Signed By:               
Co-signed By:            
Date/Time Signed:        26 Sep 2016 @ 1401
-------------------------------------------------------------------------

 LOCAL TITLE: C&P AUDIOLOGY EVALUATION                           
STANDARD TITLE: AUDIOLOGY C & P MULTIPLE EXAM NOTE              
DATE OF NOTE: SEP 26, 2016@11:00     ENTRY DATE: SEP 26, 2016@14:01:46      
      AUTHOR:           EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     


                            Hearing Loss and Tinnitus
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Mays, Franklin E
    0567
    
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes   [ ] No
    

    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    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):
          Self reported history:
          Chief complaint: Bilateral constant tinnitus, most noticeable in quiet
          settings, onset following TBI for which he is service connected.  He 
is
          uncertain about hearing loss but does report difficulty hearing others
          at a distance.
          Situations of greatest difficulty:  concentration problems and
          awareness problems with tinnitus, bothersome only in quiet.  Hearing
          trouble at a distance. 
          Pertinent Service History: US Army 8-1994 to 12-1996, ROTC non- combat. 

          MOS:  AIT training only, qualified for weapons training. Place and
          Condition of claimed hearing disturbance:  Parachute accident during
          ROTC training, hit back of head and suffered LOC for several minutes,
          hospitalized.  Diagnosed with mild TBI.
          Military noise exposure: training weapons. M16 rifle, field field
          artillery training with Howitzers and W/Raps.
          Occupational noise exposure: teacher 2008-2015, currently on
          disability.  Prior to this denied any industrial or hazardous noise
          exposure vocational history. 
          Recreational Noise exposure:  lawn care equipment < 1hour with HPDs,
          some power tool use and chainsaw operation with HPDs.
          Medical/Health History:
          Negative for the following:  perforated TM, familial hearing loss,
          vertigo, temporary/sudden changes in hearing and all other on history
          form.  Positive for: ear infection 1985, head injury with LOC during
          military service ROTC training, equilibrium problems he feels is
          related to TBI, history of alcohol abuse for 5 years, medication use
          for anxiety, depression, hospitalized for suicide attempt 2016.
          

    Evidence Comments:
      VBMS review:

      Review of Record:  EOD 9-1-1994 RAD 12-31-1996 non-combat
      11-9-2012  Statement in support of claim:The current symptoms of 
disability
      that I am aware of are as follows Head Injury possible TBI with secondary
      conditions of depression and anxiety
      Psychology/Neuro: CH[closed head injury] Sept 1995 Please evaluate
      Martin Army Comm Hospital 9-12-1995, injury during a parachute landing
      fall- Closed head injury.
      12-12-1995 severe concussion due to hard PLF
      Admission note 9-12-1995 to discharge 9-21-1995
      6-21-1995 Apppointment Report of ME
      REF audiogram 6-23-1995
            500    1000      2000      3000     4000      6000Hz
      R      15      05        05        00       00        25dBHL
      L      15      10        05        05       05        20dBHL
      5/5/1994
      R      05       05       10        05       10         15dBHL
      L      05       00       05        10       15         15dBHL

      AA C&P exam TBI -Neuropsych   Does the Veteran have any subjective 
symptoms
      or any mental, physical or neurological conditions or residuals
      attributable to a TBI (such as migraine 
      headaches or Meniere's disease)? 
      [ ] Yes [X] No Has neuropsychological testing been performed? 
      [X] Yes [ ] No 
      Results: 
      There is no mention of anxiety associated with his military-related 
      parachuting accident until 2007, though that appeared to be remitted 
      by 2009. 
      His current mild anxieties are related to the assault he sustained in 
      2011; therefore, his current diagnosis of Other Specified Anxiety Disorder 

      is less than likely as not (less than 50/50 probability) caused by or a
      result 
      of his military service and there is no evidence to suggest that his
      current 
      anxieties were aggravated by his past parachuting accident.
      to determine if he sustained a mild vs. moderate TBI given the lack of 
      records but suspected that it may have been moderate in severity. the vet 
      did see opthy in 1995 and was noted to have bilat cn4 palsy which which was 

      noted to resolve in a 1996 follow up visit. 
      the vet did complete 2 college degrees since his injury. during today's 
      routine neuropsychometric testing, he performed worse than the 2007 eval 
      noted in VBMS. He scored high in anxiety during today's eval. Based on his 

      history, repeated neuropsychmetric evals, and the natural history of TBI,
      is 
      is less likely than not that his current issues are related to his TBI 
      history

      Capri  ROTC cadet
      6-28-2014 10-10 REg. PCP note, HEEnT no hearing problems.
      TBI consult 10-24-2014 Patient has mild hearing difficulty
      A lengthy discussion was held with the patient regarding our impressions,
      consistent with our C&P evaluation in March, and the medical record. We
      described the expected trajectory of recovery from a mild to moderate TBI
      without brain bleed, reviewed his imaging history, his educational 
history,
      and spent a considerable time talking about the influence of anxiety, PTSD
      and
      his symptoms associated with PTSD in significantly interfering with
      cognitive
      performance.
      He was attentive to this discussion, did not raise objections, although
      clearly
      was a bit uncomfortable with a notion that he does not suffer with
      lingering and
      permanent brain damage. He raised his history of ongoing TBI
      care outside of the VA, and we acknowledged our difference of opinion with
      these practitioners.
      Further, we reiterated that he should have made a good recovery from his
      concussion, and that he is had at least 3 or 4 years of repeated cognitive
      rehabilitation both in speech and OT so that he has had comprehensive 
rehab
      services. He is currently working with MRS re school job placement.
      The patient has a strong attribution of his head injury as a permanent
      cause
      for his functional deficits.
      As a telling example of his symptom presentation, he volunteered at the
      conclusion of our discussion that he has been having a pressure type
      feeling
      around the side and top of his head "since my injury", but also 
volunteered
      that
      "for many years I never noticed it but then recently someone suggested to
      me
      that I could have pain from my head injury and then I noticed it".

      7-28-2014
      1. Traumatic brain injury with loss of consciousness
      2. Attention deficit hyperactivity disorder, predominantly inattentive
      type
       3. Posttraumatic stress disorder  secondary to a mugging

      9-7-2016 AA VAMC ENT
      He reports spinning vertigo since June.  Exacerbated by hot temperatures
      while 
       working on a farm.  Bending down and picking things up freque
ntly caused a 
      pressure headache and dizziness.  He also reports a separate sensation
      described 
       as objects in the environment moving up and down.  He also recently felt 
      unsteady while walking up a bridge. Associated increase in ringing
      tinnitus 
      occurrs at times centrally. He started taking trazodone in July and also
      takes 
      pyshotropic drugs Bupropion and Lisdexamfetamine dimesylate. H/o TBI and
      loss of 
      consciousness for 5-15 minutes.  Denies fluctuations in hearing,
      associated 
      aural pressure, h/o ear surgery, otalgia. + h/o ear infection in
      childhood. 
      Episodes have significantly decreased over the last month since stopping
      work on 
      the farm, and now typically only occur outside while exerting himself in
      the 
      heat. Impression: Possible psychotropic drug side effect causing nystagmus
      creating 
      difficulty focusing eyes leading to mild limiting dyesquilibrium with
      walking 
      over a bridge lately.  No audiological symptoms to suggest peripheral
      cause to 
      dizziness, but he does have b/l tinnitus. Also consider h/o TBI as
      contributing 
       factor.
      

    This exam is for: Tinnitus only (audiologist or non-audiologist clinician)
    

                              SECTION 2:  TINNITUS
                              --------------------
    1. Medical history
    ------------------
    Does the Veteran report recurrent tinnitus: Yes
       Date and circumstances of onset of tinnitus: The veteran reported
       bilateral tinnitus, noticeable in quiet settings only.  He did report 
that
       he notices the tinnitus whenever he concentrates on it.  This report is
       consistent with constant non-bothersome tinnitus.  
       The veteran reported tinnitus following head injury during military
       service.  The veteran has a longstanding diagnosis of TBI due to a
       parachute/fall incident during Army ROTC training.
       
    2. Etiology of tinnitus
    -----------------------
    At least as likely as not (50% probability or greater) due to a known
    etiology (such as traumatic brain injury).
      Etiology and rationale: The medical records reviewed were silent for c/o
      tinnitus following TBI injury in 1995 and all STRs silent for tinnitus
      complaint.  Late onset tinnitus is unlikely due to noise exposure and the
      veteran had negative report of acoustic trauma from military service.
      However, tinnitus is related to head injury and the veteran's STRs have
      longstanding history of TBI.  Therefore, tinnitus is at least as likely as
      not due to head injury diagnosed and presently service connected.  
However,
      besides TBI the veteran has had significant alterations in personality and
      behavior, including anxiety and depression, all he believes is due to his
      TBI injury.  However, clinical notes from C&P neuropsychology exam below
      suggest that the veteran's anxiety was due to an assult in 2011, following
      military service.
      AA VAMC Neuropsych exam C&P There is no mention of anxiety associated with
      his military-related parachuting accident until 2007, though that appeared
      to be remitted 
      by 2009. His current mild anxieties are related to the assault he 
sustained
      in 
      2011; 


      The veteran has some concerns today about his disequillibrium and was more
      than surprised when examiner indicated that late onset vertigo or
      disequillibrium due to head injury is uncommon and veteran may instead be
      suffering from medication side effects.  Previous notes from AA VAMC
      Neuropsychologist would suggest that the veteran is pre-occupied with the
      notion that he has a lifetime head injury and lingering permanent brain
      damage.  In fact today the veteran indicated that he is sure that he has
      had multiple head injuries since the parachute accident, because he was
      told that from a TBI you can sustain multiple head injuries.
      The veteran is well versed in TBI symptomology.

      The veteran's dysequillibrium may be a side effect of drug interactions
      according to ENT note, AA VAMC 9-7-2016 or TBI contributing factors.
      For this reason the veteran is filing a claim for his imbalance.  He was
      assisted with this by examiner today to file for ear condition with ENT 
and
      a balance evaluation with a specialized audiology department.  Battle 
Creek
      VAMC does not conduct balance evaluations. The veteran should be evaluated
      by posturography at the very least.
      
    3. Functional impact of tinnitus
    --------------------------------
    Does the Veteran's tinnitus impact ordinary conditions of daily life,
    including ability to work: Yes
      If yes, describe impact in the Veteran's own words: Only noticeable in
      quiet environments.
      
    4. Remarks, if any, pertaining to tinnitus:
    -------------------------------------------
       the above report would suggest non-bothersome tinnitus.  Veteran was
       advised to use sound management in quiet settings to reduce awareness of
       tinnitus.

       C&P request dated 8-26-2016. The veteran is claiming tinnitus is related
       to TBI.

       In regard to hearing loss:  No hearing loss found on exam.  Comparing
       first exam 1994 to last exam REference exam 6-1995 no STS noted for 
either
       ear.  Today's hearing thresholds slight hearing change noted for left ear
       today, unrelated to military service noise exposure or head injury.
       
    NOTE:  VA may request additional medical information, including additional
           examinations if necessary to complete VA's review of the Veteran's
           application.

 

Signed: 09/26/2016 14:01
-------------------------------------------------------------------------


----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------

Edited by Okemos_Veteran74
remove a doctor's name

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Here is a copy of my C&P from March of 2014

--------------- MY HEALTHEVET PERSONAL INFORMATION REPORT ---------------
                    *************CONFIDENTIAL*************
                    Produced by the VA Blue Button (v12.10)
                               04 Jan 2017 @ 0945

This summary is a copy of information from your My HealtheVet Personal
Health Record. Your summary may include:
- information that you entered (self reported)
- information from your VA health record
- your military service information from the department of defense (DoD).

***Note: Your health care team may not have all of the information from
your Personal Health Record unless you share it with them. Contact your
health care team if you have questions about your health information.***

Key:  Double dashes (--) mean there is no information to display.


Name: MAYS, FRANKLIN EUGENE         Date of Birth: 21 Sep 1974

------------------------ DOWNLOAD REQUEST SUMMARY -----------------------

System Request Date/Time:  04 Jan 2017 @ 0945
File Name:                 mhv_MAYS_20170104_0945.txt

Date Range Selected:       01 Mar 2014 to 01 Apr 2014
Data Types Selected:
  My HealtheVet Account Summary
  VA Notes

--------------------- MY HEALTHEVET ACCOUNT SUMMARY ---------------------

Source: VA

Authentication Status:         Authenticated
Authentication Date:           18 Apr 2014
Authentication Facility ID:    506
Authentication Facility Name:  VA ANN ARBOR HEALTHCARE SYSTEM

   VA Treating Facility                     Type
   --------------------                     ------  
   VBA BRLS                                 na
   VA IDENTIFY PROOFING                     na
   VETERANS ID CARD SYSTEM                  na
   VBA CORP                                 na
   BATTLE CREEK MI VAMC                     na
   DEPARTMENT OF DEFENSE DEERS              na
   ENROLLMENT SYSTEM REENGINEERING          na
   AUSTIN MHV                               na
   ST. LOUIS MO VAMC-JC DIVISION            na
   VA ANN ARBOR HEALTHCARE SYSTEM           na

------------------------------- VA NOTES --------------------------------

Source: VA
Last Updated: 04 Jan 2017 @ 0908

Sorted By: Date/Time (Descending)

VA Notes from January 1, 2013 forward are available 3 calendar days after 
they have been completed and signed by all required members of your VA 
health care team. If you have any questions about your information please 
visit the FAQs or contact your VA health care team. 

=========================================================================
Date/Time:               26 Mar 2014 @ 1050
Note Title:              TRAUMATIC BRAIN INJURY - TBI - CONSULT
Location:                VA HEALTHCARE SYSTEM
Signed By:               
Co-signed By:            
Date/Time Signed:        26 Mar 2014 @ 1051
-------------------------------------------------------------------------

 LOCAL TITLE: TRAUMATIC BRAIN INJURY - TBI - CONSULT             
STANDARD TITLE: TBI CONSULT                                     
DATE OF NOTE: MAR 26, 2014@10:50     ENTRY DATE: MAR 26, 2014@10:50:58      
      AUTHOR: PANGILINAN,PERCIVAL  EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     

for c/p details, please see c/p dated 3/26/14
 
/es/ 
Attending Physician, PM&R
Signed: 03/26/2014 10:51
-------------------------------------------------------------------------

=========================================================================
Date/Time:               26 Mar 2014 @ 0937
Note Title:              PSYCHOLOGY NEUROPSYCHOL  CONSULT
Location:                VA ANN ARBOR HEALTHCARE SYSTEM
Signed By:               
Co-signed By:            
Date/Time Signed:        26 Mar 2014 @ 1103
-------------------------------------------------------------------------

 LOCAL TITLE: PSYCHOLOGY NEUROPSYCHOL  CONSULT                   
STANDARD TITLE: PSYCHOLOGY CONSULT                              
DATE OF NOTE: MAR 26, 2014@09:37     ENTRY DATE: MAR 26, 2014@09:37:35      
      AUTHOR:  EXP COSIGNER:       
     URGENCY:                            STATUS: COMPLETED                     

   *** PSYCHOLOGY NEUROPSYCHOL  CONSULT Has ADDENDA ***

The patient was seen today for a neuropsychological screening evaluation in the 
context of his C&P examination for TBI. All testing was completed. Report to 
follow. 
 
/es/  PhD
Psychology Postdoctoral Fellow
Signed: 03/26/2014 11:03
 
/es/ , PhD
Attending Psychologist
Cosigned: 03/27/2014 11:40

03/27/2014 ADDENDUM                      STATUS: COMPLETED
Report of Psychological Evaluation
Neuropsychology Section, Mental Health Service - 116B
VA Ann Arbor Healthcare System, Ann Arbor, MI 48105

Date Seen:   03/26/2014
Report Date: 03/27/2014

Name:        MAYS, Franklin
SS#:         -0567
DOB:         09/21/1974
Age:         39 
Education:   16 years 
Occupation:  Preschool teacher

Background and History: This Veteran has a history of a suspected mild traumatic 

brain injury from a parachuting accident in 1995. For a detailed history please 
see the associated TBI Clinic Consult. 
 
Referral:  This is a report of brief, routine neuropsychological screening in 
the context of Compensation and Pension examination for TBI. It provides only 
general estimates of level of cognitive abilities and baseline data against 
which future changes in cognition can be compared. 

Tests Administered:
Peabody Picture Vocabulary Test, 4th Edition (PPVT-4), Montreal Cognitive 
Assessment (MoCA), Wechsler Adult Intelligence Scale 4th Edition (WAIS-IV) Digit 

Span, Trail Making Test, Stroop Color Word Test, California Verbal Learning 
Test, Short Form (CVLT), TOMM Test of Memory, Rey 15-Item Memory Test, Modified 
Somatic Perception Questionnaire (MSPQ), Hospital Anxiety and Depression Scale, 
PTSD Checklist Military Version (PCL-M), Insomnia Severity Index, CAGE alcohol 
consumption measure, Brief Pain Inventory.

(Mean and Standard Deviation)

PPVT                                116    (100+/-15)
MoCA  (23/30)                     -0.78    (0+/-1) 
Digit Span Total (5F, 4B, 4S)         7    (10+/-3)
Forward                               9    (10+/-3)
Backward                              7    (10+/-3)
Sequencing                                 (10+/-3)
Trails A (39 sec, 0 errors)          30    (50+/-10)
Trails B (112 sec, 0 errors)         27    (50+/-10)
Stroop
       Word                          30    (50+/-10)
       Color                         33    (50+/-10)
       Color-Word                    42    (50+/-10)
       Interference                  54    (50+/-10)
CVLT
       Trials 1-4                    32    (50+/-10)
       LDFR                        -2.5    (0+/-1)
       Recognition                 -2.5    (0+/-1)
       F/C                          89%
Hospital Anxiety and Depression Scale
     Anxiety                         15    (Severe)
     Depression                      10    (Mild)
Brief Pain Inventory current severity 5/10
MSPQ                                 22 
Other Tests of Cognitive and Emotional Function 
     Positive PCL-M (63), negative ISI (11), positive CAGE (2)

Comments: The Veteran demonstrated somewhat variable task engagement on stand-
alone and embedded tests of effort, suggesting that his performance on cognitive 

testing may underestimate his current cognitive abilities. Results are therefore 

interpreted with caution. In the context of estimated high-average premorbid 
intellectual functioning, the Veteran demonstrated low-average performance on a 
general cognitive screening instrument (MoCA). Performance was in the low-
average range on tests of simple attention and working memory. He performed in 
the borderline impaired range on measures of visuomotor speed, immediate verbal 
learning and memory, speeded color naming, and speeded word reading. He 
performed in the mildly impaired range on tests of set-switching and delayed 
verbal memory recall and recognition. A measure of selective attention could not 

be interpreted due to the Veteran's slow word reading and color naming 
performances. 

With respect to psychiatric concerns, the Veteran endorsed severe symptoms of 
anxiety, mild symptoms of depression, and significant symptoms of PTSD, and 
alcohol abuse. Upon further examination of his responses regarding alcohol use, 
his score may reflect past problems as did not report weekly alcohol use in the 
past month. He endorsed a significant number of somatic symptoms beyond those 
reported by individuals with chronic pain, suggesting a tendency toward somatic 
preoccupation. He did not endorse significant symptoms of insomnia. 

The etiology of the Veteran's complaints of poor memory, concentration, and 
irritability are likely multifactorial. Variability in task engagement may have 
resulted in poorer performances on cognitive testing, which complicates the 
determination of the severity and etiology of the Veteran's subjective memory 
and concentration problems. Behavioral health factors may impact the Veteran's 
ability to fully engage in testing, and he may benefit from engagement in mental 

health treatment to address anxiety, depression, and PTSD, if not already 
considered. The results are not consistent with the recovery from a mild TBI 
from a parachuting accident in 1995. Findings were discussed with the TBI team. 

 

              Linas Bieliauskas, PhD ABPP-CN
Neuropsychology Resident           Staff Psychologist

Patient testing time including scoring was 1.5 hours, plus interpretation/ 
report time of 0.5 hours. 

 
/es/ JENNIFER MAROLA, PhD
Psychology Postdoctoral Fellow
Signed: 03/27/2014 15:16
 
/es/ LINAS A BIELIAUSKAS, PhD
Attending Psychologist
Cosigned: 04/03/2014 10:36

04/07/2014 ADDENDUM                      STATUS: COMPLETED
I have reviewed and edited this report and agree with the report of test data 
and interpretation.
 
/es/ LINAS A BIELIAUSKAS, PhD
Attending Psychologist
Signed: 04/07/2014 10:16
-------------------------------------------------------------------------

=========================================================================
Date/Time:               26 Mar 2014 @ 0800
Note Title:              COMPENSATION & PENSION 
Location:                VA ANN ARBOR HEALTHCARE SYSTEM
Signed By:               
Co-signed By:            
Date/Time Signed:        26 Mar 2014 @ 1050
-------------------------------------------------------------------------

 LOCAL TITLE: COMPENSATION & PENSION                             
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE: MAR 26, 2014@08:00     ENTRY DATE: MAR 26, 2014@10:50:36      
      AUTHOR:   EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     


       Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) 
                       Disability Benefits Questionnaire 
                         * Internal VA or DoD Use Only*

    Name of patient/Veteran:   mays, franklin e
    
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence review
    ---------------
    Was the Veteran's VA claims file reviewed?
    [X] Yes   [ ] No
    
      If yes, list any records that were reviewed but were not included in the
      Veteran's VA claims file:
      
        crps
        
    SECTION I: Diagnosis and medical history
    ----------------------------------------
    1. Diagnosis
    ------------
    Does the Veteran now have or has he/she ever had a traumatic brain injury
    (TBI) or any residuals of a TBI? (This is the condition the Veteran is
    claiming or for which an exam has been requested)
    [X] Yes   [ ] No
    
       [X] Traumatic brain injury (TBI)
             ICD code:     854
             Date of diagnosis:    1995

    2. Medical history
    ------------------
    Describe the history (including onset and course) of the Veteran's TBI and
    residuals attributable to TBI (brief summary):
       39 y-o man who was in the army/rotc who was involved in a parachute 
event.
       his last memory was getting onto the airplane for the jump and his next
       memory was waking up in the hospital.  he was in the hospital for 1.5
       weeks.  likely had LOC and has poor memory of hospitalization.  did not
       need surgery.  he states that he tried to return to ROTC but was not
       allowed to return.  returned to college in sept 1996 to complete degree.
       remembers feeling anxiety in classes especially taking exam.  then took
       job working in hardware store for several months. then took job selling
       insurance door to door for about 1.5 years.  about fall 2000 moved to MI
       and worked several jobs short term until returning to college for 2nd
       degree in elem education.  he reports having diffculting completeing this
       but did eventually complete degree and did work as a traveling early elem
       teacher.
       
    SECTION II: Assessment of facets of TBI-related cognitive impairment and
    subjective symptoms of TBI
    
-----------------------------------------------------------------------------
    
    1. Memory, attention, concentration, executive functions
    --------------------------------------------------------
    [X] Objective evidence on testing of mild impairment of memory, attention,
        concentration, or executive functions resulting in mild functional
        impairment
        
        If the Veteran has complaints of impairment of memory, attention,
        concentration or executive functions, describe (brief summary):
        
        04/03/2007 where it was asserted that "it appears that he is developing 
a
            greater degree of anxiety and depression likely due to the 
underlying
        cognitive problems he is encountering" and he was diagnosed at that
        time with
            an "Adjustment Disorder with Mixed Anxiety and Depressed Mood."
        
        
    2. Judgment
    -----------
    [X] Mildly impaired judgment: For complex or unfamiliar decisions,
        occasionally unable to identify, understand, and weigh the alternatives,
        understand the consequences of choices, and make a reasonable decision
        
        If the Veteran has impaired judgment, describe (brief summary):
        
        reports problems making decisions because of an impaired "thinking
        process"
        
    3. Social interaction
    ---------------------
    [X] Social interaction is routinely appropriate
    4. Orientation
    --------------
    [X] Always oriented to person, time, place, and situation
    
    5. Motor activity (with intact motor and sensory system)
    --------------------------------------------------------
    [X] Motor activity normal
    
    6. Visual spatial orientation
    -----------------------------
    [X] Mildly impaired: Occasionally gets lost in unfamiliar surroundings, has
        difficulty reading maps or following directions. Is able to use 
assistive
        devices such as GPS (global positioning system)
        
        If the Veteran has impaired visual spatial orientation, describe (brief
        summary):
        
        stays in familar areas but uses google maps
        
    7. Subjective symptoms
    ----------------------
    [X] Subjective symptoms that do not interfere with work; instrumental
        activities of daily living; or work, family or other close 
relationships.
        Examples are: mild or occasional headaches, mild anxiety
        
        If the Veteran has subjective symptoms, describe (brief summary):
        
        feels guilt about getting hurt and not being able to return to rotc/army
        
    8. Neurobehavioral effects
    --------------------------
    [X] One or more neurobehavioral effects that do not interfere with workplace
        interaction or social interaction.
        
        If the Veteran has any neurobehavioral effects, describe (brief 
summary):
        
        commpleted 2 college degrees after injury and works as pre-school 
teacher
        currently
        
    9. Communication
    ----------------
    [X] Able to communicate by spoken and written language (expressive
        communication) and to comprehend spoken and written language.
        
    10. Consciousness
    -----------------
    [X] Normal
    
    SECTION III: Additional residuals, other findings, diagnostic testing,
    functional impact and remarks
    
-----------------------------------------------------------------------------
    1. Residuals
    ------------
    Does the Veteran have any subjective symptoms or any mental, physical or
    neurological conditions or residuals attributable to a TBI (such as migraine
    headaches or Meniere's disease)?
    [ ] Yes   [X] No
    
    2. Other pertinent physical findings, scars, complications, conditions, 
signs
    and/or symptoms
    
-----------------------------------------------------------------------------
    a. 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
       
    b. Does the Veteran have any other pertinent physical findings,
       complications, conditions, signs and/or symptoms?
       [ ] Yes   [X] No
       
    3. Diagnostic testing
    ---------------------
    a. Has neuropsychological testing been performed?
       [X] Yes   [ ] No
       
       Results:
       There is no mention of anxiety associated with his military-related
       parachuting accident until 2007, though that appeared to be remitted
       by 2009.
       His current mild anxieties are related to the assault he sustained in
       2011;
       therefore, his current diagnosis of Other Specified Anxiety Disorder
       is less
       than likely as not (less than 50/50 probability) caused by or a result
       of his
           military service and there is no evidence to suggest that his current
           anxieties were aggravated by his past parachuting accident.
           

        
       /es/ MICHAEL RANSOM PHD
       Staff Psyc
hologist, Compensation and Pension
       Signed: 03/16/2014 12:22

       4/2007
       04/03/2007 where it was asserted that "it appears that he is developing a
           greater degree of anxiety and depression likely due to the underlying
       cognitive problems he is encountering" and he was diagnosed at that
       time with
           an "Adjustment Disorder with Mixed Anxiety and Depressed Mood."

       
       
    b. Are there any other significant diagnostic test findings and/or results?
       [ ] Yes   [X] No
       
    4. Functional impact
    --------------------
    Do any of the Veteran's residual conditions attributable to a traumatic 
brain
    injury impact his or her ability to work?
    [ ] Yes   [X] No
    
    5. Remarks, if any:
    -------------------
    the vet most likely sustained a tbi while in military training.  i am unable
    to determine if he sustained a mild vs. moderate TBI given the lack of
    records but suspected that it may have been moderate in severity.  the vet
    did see opthy in 1995 and was noted to have bilat cn4 palsy which which wsa
    noted to resolve in a 1996 follow up visit.  
    the vet did complete 2 college degrees since his injury.  during today's
    routine neuropsychometric testing, he performed worse than the 2007 eval
    noted in VBMS.  He scored high in anxiety during today's eval.  Based on his
    history, repeated neuropsychmetric evals, and the natural history of TBI, is
    is less likely than not that his current issues are related to his TBI
    history.
    

 
/es/ PERCIVAL PANGILINAN MD
Attending Physician, PM&R
Signed: 03/26/2014 10:50
-------------------------------------------------------------------------

=========================================================================
Date/Time:               04 Mar 2014 @ 0900
Note Title:              COMPENSATION & PENSION 
Location:                VA ANN ARBOR HEALTHCARE SYSTEM
Signed By:               
Co-signed By:            
Date/Time Signed:        16 Mar 2014 @ 1222
-------------------------------------------------------------------------

 LOCAL TITLE: COMPENSATION & PENSION                             
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE: MAR 04, 2014@09:00     ENTRY DATE: MAR 16, 2014@12:22:14      
      AUTHOR:   EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     


                                Mental Disorders
                     (other than PTSD and Eating Disorders)
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Franklin Mays is a 39 year old, right handed,
    married man who completed a DBQ Mental Disorder evaluation at the VAMC Ann
    Arbor on 03/04/2014.
    
                                   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
    
    If the Veteran currently has one or more mental disorders that conform to
    DSM-5 criteria, provide all diagnoses:
    
    Mental Disorder Diagnosis #1: Other Specified Anxiety Disorder related to 
the
    assault he sustained in 2011

    b. Medical diagnoses relevant to the understanding or management of the
          Mental Health Disorder (to include TBI): (per medical records) ADHD 
and
          hx of concussion (09/12/1995)
          

    2. Differentiation of symptoms
    ------------------------------
    a. Does the Veteran have more than one mental disorder diagnosed?
       [ ] Yes[X] No
       
    b. Is it possible to differentiate what symptom(s) is/are attributable to
       each diagnosis?
    No response provided.
    
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [X] Yes[ ] No[ ] Not shown in records reviewed
       
    d. 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:
           There is no evidence to suggest that any current psychological
           difficulties are related to his history of concussion.
           
    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] A mental condition has been formally diagnosed, but symptoms are not
           severe enough either to interfere with occupational and social
           functioning or to require continuous medication

    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?
       [X] Yes[ ] No[ ] No diagnosis of TBI
       
           If yes, list which portion of the indicated level of occupational and
           social impairment is attributable to each diagnosis:
           There is no evidence to suggest that any current psychological
           difficulties are related to his history of concussion.
           
                                   SECTION II:
                                   -----------
                               Clinical Findings:
                               ------------------
    1. Evidence review
    ------------------
    
    a. Medical record review:
    -------------------------
    Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? Yes
    Was the Veteran's VA claims file reviewed? Yes
    
      If yes, list any records that were reviewed but were not included in the
      Veteran's VA claims file:
      
    VA Records
    Psychological Testing
    
    b. Was pertinent information from collateral sources reviewed? No
    
      
    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
       post-military):
       The veteran stated that he grew up in Augusta, GA with his biological
       parents and his older brother (7 years). He added that he had a 
biological
       sister who died two years before the veteran was born. He reported that 
he
       had a "good" relationship with his family while growing up. He noted that
       his father was retired military and his mother was a teaching assistant
       until she was medically retired for hearing loss. He asserted that he had
       a "happy" childhood and denied abuse or neglect.

       He described his peer relationships growing up as good, noting that he 
had
       a solid group of friends and actually had more friends than he ever
       realized.

       He reported that he has been married 1 time and is currently married. He
       stated that he has 3 children (9 year old son, 7 year old daughter, 6 
year
       old son).  He described his relationships with wife as "good" and also
       "good" with his children. The veteran stated that he lives with his wife
       and children in Lansing, MI.

       The veteran reported that he had excellent relationships with his fellow
       soldiers while in the military.

       The veteran described his post-military/current social life as good.
       
    b. Relevant Occupational and Educational history (pre-military, military, 
and
       post-military):
       The veteran reported that he has completed 16 years of formal education
       and added that he has two bachelor's degrees. He stated that he struggled
       some with math growing up, but worked hard and eventually did well. He
       reported that he has a BA from Georgia in History (1998; GPA = 2.5) and a
       BS in Elementary Education (2007; GPA = 3.66) with three minors (Spanish,
       English Language Arts, and Social Studies) from UM-Flint. He added that 
he
       is currently working on an Early Childhood Endorsement now through a 
joint
       program (Lansing Community College and Ferris State University).

       The veteran reported that between high school and when he started the 
ROTC
       program, he did 2 years of school at Augusta College and completed the
       Military Science 1 & 2 courses.

       He stated that he enlisted into the Army ROTC and began his service on
       08/1994 and "made it as far as cadet." He reported separating from the
       military in 1996 following his parachuting accident. He reported that
       after his accident he was unable to participate in PT, struggled in
       classes, and ultimately failed a height/weight test. He stated that "I
       think" that failing the weight test was the official reason for his
       separation, because he was overweight.

       The veteran stated that post-service, he continued in school. He stated
       that he read in a manual that he had to wait 4-6 years to get back in to
       the military after his head injury and engaged in a significant amount of
       paperwork and "wrangling, talking to congressmen," which "created a lot 
of
       stress for me."

       However, a "MEMORANDUM FOR UNIVERSITY OF GEORGIA ROTC" dated 03/04/1996
       indicated that a "memorandum for Frank Mays medical board" was sent and
       asserted that the veteran would be seen later that month "and I hope to
       make a better determination of his prognosis. According to the
       regulations, however, since he had at least a mild head injury, he will
       require at least a two year period 
of observation prior to being eligible
       for further evaluation by a neurologist. During this time period he will
       not be eligible for induction into the active duty Army."

       He stated that he took some time off from school after his accident and
       went back home. He reported that he returned to school full time in
       January 1996 and noted that it was "a real struggle" academically.
       He reported that his academic/cognitive struggles continued until his
       graduation in 1998.

       He stated that he then obtained a job at a plumbing retail store for 3-4
       months, but was having trouble filling orders. He did not necessarily do
       well so went into commissioned sales (insurance) from 1998-2000. He
       reported that he moved to Michigan with his girlfriend (now wife) and
       worked various jobs to make money and then began substitute teaching. He
       joined AmeriCorp in 2001. He reported that he then began attending
       Michigan State University, but did not like how large the classes were 
and
       transferred to a smaller school. He stated that he then went to school
       full time and worked jobs on the side until he completed his degree in
       2007. He reported that he had been making the Dean's list academically,
       but had troubles with the student teaching aspects of his program
       secondary to poor organizational issues. 

       He reported that he has been working as a Pre-School Spanish Immersion
       teacher since 2008. He asserted that his work performance has been "good"
       and noted that his principal is happy with him and his work.
       
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
       The veteran denied any mental health history prior to his enlistment in
       the military.

       He reported that he was participating in a parachuting exercise on
       09/12/1995 when he experienced "a hard fall" that resulted in a closed
       head injury. He reported that his "last clear memory is of the plane
       taxiing down the runway" and his next memory is "being in hospital." He
       denied having any memory for the accident itself, but has been told by
       others what they saw happen and he replays these events in his head, 
which
       upsets him emotionally.

       According to a sworn statement dated 02/14/1996 by William D. Harrison,
       the airborne/ground commander for an airborne operation at the time of 
the
       veteran's accident, the veteran appears to have been unconscious 
following
       his accident for approximately 5-7 minutes and was then groggy and
       confused, but verbalizing more, until he was medevac out approximately
       15-20 minutes after his injury. It was noted that "from the time of
       accident until the aircraft lifted off was 15-20 minutes. It is my 
opinion
       that Cadet Mays was unconscious for only the first 5-7 minutes, having
       regaining consciousness as he received medical aide."

       According to a sworn statement dated 02/14/1996 by SSG Terrance Murphy, a
       coach for the jump and first responder to the veteran, the veteran "was 
in
       an unconscious state, all of his limbs were rigid and unbendable. He
       remained in this state for about 6-7 minutes."

       Records indicate that he was hospitalized from 09/12/1995 through
       09/21/1995 and diagnosed with a closed head injury, mild diabetes
       insipidus, and CN IV palsey - bilat.

       09/20/1995
       Note indicated "MRI results show minor swelling of L temporal lobe 
without
       cerebellar damage."

       09/21/1995
       Discharge note
       "HOSPITAL COURSE: The patient was admitted to the ICU for observation.
       Repeat computerized axial tomography done approximately 36 hours later
       showed no change, and still no change, and still normal. The patient was
       seen by the Ophthalmology Service who diagnosed cranial nerve IV palsy, 
as
       well as some cerebellar dysfunction. The MRI confirmed this fact. The
       patient steadily improved and on the day of discharge was able to have a
       fair amount of short term memory return. There appeared to be no changed
       in his long term memory. Although certainly not back to normal, his
       cerebellar activities including gait and eating are returning toward
       normal." It went on to state, "DISPOSITION: The patient is discharged to
       home in the care of his parents. Letters have been given to him for
       staying out of school for one quarter. He will receive follow up care 
from
       the General Surgery Service on 16 Oct 95, the Ophthalmology Service at
       Martin Army Community Hospital on 16 Oct 95, as well as a referral to
       Emory
       Neuro-ophthalmology Service to see Dr. Newman. No medications given.
       Specific return instructions also given."

       10/12/1995
       Noted indicated that "CT and MRI have been negative."

       10/12/1995
       Opthamology note - Nancy Newman, MD
       "He was in his usual state of excellent health until September 12, 1995,
       when he was on an airborne jump and apparently landed on his head,
       presumably the occiput. There was definite loss of consciousness anywhere
       from 15 to 25 minutes. He remained confused thereafter and was
       hospitalized for one week. His mentation improved subsequently and he has
       been at home for the past three weeks. He now no longer has problems with
       short-term memory, although he has no recall of an entire week since the
       jump. His current complaints are that he has trouble seeing in that they
       are "jumbled" and "slanted."

       He has findings consistent with his head trauma. Specifically, he has
       bilateral IVth nerve palsies, as you indicated which is quite common 
after
       a head injury. He also has macro square-wave jerks which suggest
       involvement of the cerebellum and/or its connections. This would be
       related to his balance problems In addition, he has a refractive error
       which is an induced myopia. It is possible that he may have had this all
       along, although he says that he never needed glasses before. Therefore, 
it
       is conceivable, that this reflects induced myopia, perhaps from mild
       accommodative spasm that can occur with head injury. Many of these
       deficits, if not all, should improve over time, and I spent a great deal
       of time with the patient and his parents explaining this. They may wish 
to
       pursue obtaining a refraction and a glasses prescription."

       10/03/1996
       Neurosurgery consult
       "Franklin Mays a 21 year old white male was seen in the office on 5/24/96
       with the history that while in ROTC training he jumped from a airplane
       with a parachute and subsequently was rendered unconscious for a brief
       time. This had occurred in September 1995. He had to stop school after 
the
       incident. He has had memory loss and problems with balance which has
       slowly improved. He is currently attending Augusta State University and 
is
       on no medication. Past history reveals that before the current injury he
       was in good health. He denied drug allergies. According to the father at
       the time of the injury the CT scan was negative and he had bilateral 4th
       nerve palsy that gradually cleared. When seen and examined he was awake
       alert and oriented. His cranial nerve were now all intact. Pupils were
       round regular and reactive equally to light. Extraocular movements were
       normal. There was no papilledema Visual fields per confrontation were


       intact. Face was symmetrical. Cerebellar function was intact. Extremity
       strength reflexes and sensory were all intact. Gait was normal. We
       obtained copy of a hospital discharge summary from Fort Benning Georgia
       and this indicated that that he had had a closed head injury and the CT
       and MRI scan has showed a mild edema of the left parietal lobe and
       cerebellum. It is my impression this young man is doing fairly well at
       this time but continues with some post concussion symptoms.
       It is anticipated that this will persist for a long period of time along
       with some mild memory impairment as well as dizziness and light headiness
       may last for several months. He is to be seen back in follow-up in 6
       months.
       Very truly yours,
       John L. Williams, M.D.
       JLW/lnb"

       04/03/2007
       Neuropsychological Evaluation
       Responses "suggest an individual who is reporting a significant degree of
       depression and anxiety. These individuals often present with a long
       standing history of chronic worrying tension and depression. There is a
       propensity to convert emotional and psychological distress into physical
       or medical complications. These individuals often struggle with issues of
       self-confidence and self-esteem. They are prone to feelings of social
       alienation. Further assessment of mood on the BDI 2 resulted m a 
composite
       score of 22 which places this patient within the moderate range?" It went
       on to note that "the objective test results would point to areas of
       residual impairment most prominent in spatial perception, visual memory
       skills, and higher level executive functioning. In particular, this
       patient does have greater difficulty in higher order executive functions,
       which will involve organization, prioritization, cognitive flexibility,
       and the ability to move from task to task while tolerating distractions.
       It is little surprise that he has encountered problems in these areas as
       the test results would corroborate clear impairment, which likely is
       attributed to the past head trauma. Unfortunately, it appears that he is
       developing a greater degree of anxiety and depression likely due to the
       underlying cognitive problems he is encountering. These psychological
       factors can clearly exacerbate otherwise mild cognitive difficulties and
       result in a greater degree of disability. A number of structured
       interventions will be recommended to facilitate this patient's 
appropriate
       psychosocial and vocational adjustment." The veteran was diagnosed with
       "Cognitive Disorder Secondary to Traumatic Brain Injury" and "Adjustment
       Disorder with Mixed Anxiety and Depressed Mood."


       Available records from Michigan State University Clinical Center dating
       back to 2009 were reviewed. The first available was dated 10/23/2009 in
       the veteran appeared to be seen for asthma followup at that time.
       Prescriptions noted included Wellbutrin and Lexapro. The veteran was then
       seen on 11/20/2009 where it was noted that he was "doing well on the
       anxiety." In a note dated 01/14/2010 indicated that the veteran was 
"doing
       well on the Wellbutrin and Buspar now. Things are going well at work, and
       feels things are good at home, is resting well, feels he has developed
       better coping skills. And overall feels he is doing well." At that time,
       his medications were Buspirone HCL 30 mg twice daily and Wellbutrin XL 
300
       mg daily. 

       In a note dated 07/19/2010 indicated that the veteran was considering a
       move to Baltimore for a teaching position, though eventually declined
       this. He now reported that the veteran "states she isn't really looking
       forward to his third year of teaching at his preschool, states first year
       was exciting and as it was new, last year okay, but not really looking
       forward to next year. Discussed whether this was because of not being in
       position that he would like to be and, if it was depression, or some
       grieving over not taking the position effort."PHQ-9 depression screening
       was negative at that time. A note dated 08/13/2010 indicated that the
       veteran "denies depression, anxiety, suicidal ideation, hallucinations,
       paranoia, phobia, and confusion." 

       05/09/2011
       "states he feels better than he ever has. Notes that he stopped meds in
       Dec. felt they were making him groggy admits that he is getting medical
       marijuana gets a tincture and takes 3-4 gtts/day feels more confidence
       handling more responsibility at work and home well feels it has taken 
edge
       off"
       "Assessment: Improved
       The following medications were removed from the medication list
       Buspirone Hcl 30 Mg Tabs (Buspirone hcl) One daily
       Wellbutnn XI 300 Mg Tb24 (Bupropion hcl) One daily
       Is however doing medical marijuana from compassion club in Lansing"

       A note dated 06/14/2011 indicated "mood and affect appropriate and
       normally interactive."

       The veteran appeared to be doing well psychologically at this point of 
his
       history, though was reportedly "mugged" on 06/23/2011. Records indicate
       that he experienced minor physical injuries only, "however, emotionally,
       he's having a lot of anxiety, fear, worried-almost like reliving the
       incident, both during his waking hours and at times during sleep." The
       veteran reportedly "felt guilty since he's been mugged (that he is
       contributing to the social illness that result from a burgeoning 
marijuana
       initially) so he stopped it since 06/23/2011. Anxiety and depressive
       symptoms have coincidentally flared up during this time." A question of
       PTSD was raised by his provider and citalopram and alprazolam were
       prescribed at that time.

       It was reported on 07/26/2011 that the veteran "was walking and
       neighborhood in guys came up in mugged him, he gave up his wallet, cell
       phone, neighbor came to door and he yelled for help, the guys took off. 
No
       major physical injuries but has increased his anxiety. Had been off of 
the
       medical marijuana. Started on the Celexa and emotions were up and down."
       The veteran reportedly was "still having some difficulties dealing with
       the mugging. Feelings of guilt that he didn't do more. We emphasize the
       survival aspects and that the things are just things. He has enrolled in 
a
       self defense/martial arts and we also discussed his impact on the family
       safety and how he is projecting his concerns versus awareness."

       10/03/2011
       "no acute distress" 
       "Psych: mood and affect appropriate and cognition and judgment appear
       intact"

       11/22/2011
       Report indicated that the veteran was becoming "easily angered,
       frustrated, worried and fearful of walking around neighborhood or easily
       startled by loud noise" and also indicated that the veteran was seen a
       therapist at that time. PHQ-9 results: "Scoring Results Scoring does not
       suggest diagnosis of Major or Minor Depression. Total score is 8. Scoring
       suggests patient's functionality is not impaired."

       11/28/2011
       "Here for f/u on anxiety and ptsd. Has had a very difficult time lately
       increasing trouble with being on edge. Kid came up behind him and spoofed
       him, made him very anxious. Having trouble concentrating, staying
       organized, anxious about the personal space issues. Is seeing a 
counselor.
       Sees psychiatrist this week. Feels that he is not able to be patient with


       kids at school. Having same issues at home.

       Wife has also contacted me and states that he was doing well since the
       previous closed head injury, but since the mugging has had a big struggle
       again"

       Noted that he was using medical marijuana through a separate clinic.

       He received a letter from his primary care provider to assist him in 
being
       off work until evaluated by mental health, noting that he "may need a
       month or so to get therapy but established."

       12/21/2011
       The veteran was seen for follow up on anxiety and reportedly had stopped
       all of his medications, including medical marijuana, because he did not
       like the way he felt on any of the period she reportedly was feeling
       "really well right now," but they did discuss concerns about going back 
to
       work full-time and the stress that accompanies it. He was reportedly
       working with a therapist at that time. It was recommended that he return
       to work part time for 2 weeks.

       05/01/2012
       "was off work for some time during the winter went back to full time from
       Jan 24th till march 9th, not able to function well trying to organize his
       time, was so distracted between 2 schools total 15 classes, recently he
       expressed his wishes to his wife to kill himself before getting annual
       evaluation from his supervisor, went back on short time disability, been
       receiving counselling and followed by Psychiatry, and also OT thru hope
       health network. Wants to apply for part time Job for the rest of this
       school year, opening is available at Lansing school district."

       08/02/2012
       "When he last plummeted and had increased difficulties with being
       overwhelmed we referred him to psychiatry. Since then he has been on
       Zoloft and Ritalin for four months. He states that the Zoloft has helped
       with his depression and anxiety symptoms. He is happy with the current
       dose of 50mg. Frank states that the Ritalin seems to be helping with
       planning and organizational skills but that he may want to take a higher
       dose. He accidentally took a double dose last week and felt much better
       than he had on a single dose. He has taken up gardening and spending more
       time with his children. He is training a service dog to keep him company
       and seems to be enjoying this noting that walking with a dog in the
       neighborhood seems to really help him and that the dog is very good with
       ELI (his trisomy 21 son). He plans to return teaching preschool in a few
       weeks. He has been experiencing sexual side effects from the Zoloft but
       states that he can tolerate these because the medication is helping
       overall."

       09/14/2012
       A formal diagnosis of ADD was made at this time and his primary care note
       went on to state that "Psych: mood and affect appropriate cognition and
       judgment appear intact and normal attention span and concentration."

       "Problem # 1 ANXIETY (ICD 300 00)
       His updated medication list for this problem includes
       Alprazolam 0 25 Mg Tabs (Alprazolam) 1/2 to 1 tab po twice daily pm
       anxiety
       Sertraline Hcl 50 Mg Tabs (Sertraline hcl) One daily for depression
       symptoms

       Problem #2 ASTHMA SEASONAL (ICD-493 90)
       His updated medication list for this problem includes:
       Ventolin Hfa 108 (90 Base) Mcg/act Aers (Albuterol sulfate) Two puffs q 4
       hours pm for wheezing/shortness of breath
       Albuterol Sulfate (5 Mg/m1) 0 5% Nebu (Albuterol sulfate) One vial in hhn
       every 4-6h as needed

       Problem #3 ? of PTSD (ICD 309 81)
       Doing well therapy dog 9 has been very helpful

       Problem #4 ADD (ICD 314 00)
       Will add 5 mg at noon 1 00 time frame to help with afternoon symptoms f/u
       in few months if this is working well ok to refill"


       ************************

       The veteran reported that he was told he would never be a teacher by an
       MSU counselor, though he asserted that this drove him to succeed. He
       stated that things were going well for him, though he did struggle with
       the organizational aspects of student teaching and obtained career
       counselor at UM-Flint. He reported that he participated in HOPE network
       program and received assistance with organizational job skills. He stated
       that he was then "mugged and I just didn't handle it well." He added that
       a few months later a bank employee down the street was murdered. He 
stated
       "I panicked, felt anxiety."

       He reported that his overall anxiety began "a few months after my
       accident," as he was reportedly mad about his poor grades and things
       seemed to bother him more. He added that he began feeling depressed about
       being told he could not be in the Army. He reported that he has felt
       different after the accident, but could not explain how.

       He described his current mood as "pretty good," adding "I love my job!" 
He
       denied that he is currently depressed, asserting "I don't think I'm
       depressed, I don't really have time to be depressed right now." He added
       that after being diagnosed with ADD and beginning Vyvanse medication, he
       has experienced significant improvement of his symptoms.

       Regarding anxiety, the veteran reported that he "always has anxiety about
       my kids" and that he is worried about work, because he is missing 2 days
       this week. He added that he is also taking additional time away from work
       for a class he is completing. He stated that he tries to breath and says
       the rosary when he feels anxious, which calms him down.

       He reported that he does experience excessive anxiety and worry that he
       finds difficult to control. He stated that his initial worries used to
       revolve around not being able to get back into the Army, but that he
       pushed such thoughts out of his head and does not think about it anymore.
       He reported that after the mugging, "I have a service dog now because I
       don't like to be by myself, I'm more hypervigilant." He added that he
       stresses about his work situation, even though his boss gives him praise
       about his work performance. The veteran reported that "I centrate on
       something and that I guess is anxiety." He did not report any other
       symptoms of anxiety. He endorsed that he does have panic attacks at times
       and reportedly had one while in my office during the clinical interview.
       However, there was no indication of such an event from my observations, 
as
       the veteran appeared calm throughout the interview. He stated that he had
       the attack during a particular part of the interview, though he did not
       appear flustered or anxious in my observations of him during such time.

       Veteran reported that he is currently prescribed Zoloft and Vyvanse.
       
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
       The veteran denied any legal or behavioral difficulties prior to, during,
       or following his military service.
       
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
       Alcohol: The veteran denied any history of problem drinking, but also
       noted that his girlfriend (now wife) gave him an ultimatum of stop
       drinking or she would break up with him. He stated that he did not drink
       all the time, but "it was all or nothing" when he did, as he would drink
       to intoxication when he drank. He stated that last consumed alcohol in
       2000 and denied current alcohol intake.

 

       Tobacco use: Denied

       Illicit drug use/abuse: Denied
       
    f. Other, if any:
       No response provided.
       
    3. Symptoms
    -----------
    For VA rating purposes, check all symptoms that apply to the Veteran's
    diagnoses:
    
       [X] Anxiety

        Behavioral observations:
        MENTAL STATUS:
        Appearance:  casually/appropriately dressed, well-groomed
        Speech:  normal rate and rhythm
        Mood:  "pretty good"
        Affect:  Euthymic, no apparent anxiety in interview, polite, cooperative
        Thought Process:  logical and goal-directed
        Delusions:  No
        Hallucinations:  No
        Suicidal or homicidal ideation:  No
        Orientation:  x4
        Insight:  Fair
        Judgment:  Good
        
    4. Other symptoms
    -----------------
    Does the Veteran have any other symptoms attributable to mental disorders
    that are not listed above?
    [ ] Yes[X] No
    
    5. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
    [X] Yes[ ] No
    
    6. Remarks (including any testing results), if any:
    ---------------------------------------------------
    *********************PSYCHOMETRIC TESTING**********************

    To properly complete the evaluation, psychological testing was conducted. 
The
    veteran's scores were derived from objectively-scored tests, and these 
scores
    can be compared against known samples of individuals. Resultant scores can
    also be used as a basis of comparison for future assessments. Because some 
of
    the instruments in this battery cover a wide range of psychopathology, the
    results also serve as a screen for mental disorders that the veteran did not
    necessarily identify in the claim. 

    Mississippi Scale for Combat-Related PTSD (MISS): The veteran's score of 81
    on the MISS, if interpreted at face value, was not suggestive of clinically
    significant symptoms of PTSD. This score falls short of the suggested cutoff
    for PTSD and below that of the mean score among veterans with PTSD.

    PCLC: The veteran's self-reported PTSD symptoms on the PCL-Civilian
    (score=47) fell slightly below the criterion cut-off (cutoff=50) for the
    overall score and at a level below that obtained from patients diagnosed 
with
    PTSD (average score=64 +/- 14). Recent research in the Journal of
    Rehabilitation Research and Development suggested a more appropriate cutoff
    score of 60 for PTSD.  This patient's score of 47 is below this cut off. All
    symptom clusters necessary for a PTSD diagnosis were positive.

    AUDIT-C: The veteran's score of 0, if interpreted at face value, is a
    negative screen for problematic alcohol use over the past year.

    Beck Depression Inventory-II (BDI-II): The veteran's score of 15 on the
    BDI-II, if interpreted at face value, was reflective of a mild level of
    depressive symptoms.

    Beck Anxiety Index (BAI): The veteran's score of 13 on the BAI, if
    interpreted at face value, was reflective of a mild level of anxiety
    symptoms.

    MMPI-2 RF: The MMPI-2 RF is a structured, objectively-scored measure of
    personality and psychopathology. His responses random responding, though
    there was evidence of possible over-reporting of symptoms, indicated by an
    unusual combination of responses that is associated with non-credible
    reporting of somatic and/or cognitive symptoms, especially non-credible
    memory complaints. However, this was not necessarily to a degree that
    invalidated the overall response profile, though, it was interpreted with
    caution.

    The veteran's responses suggest that he is experiencing significant 
emotional
    distress and has a general sense of unhappiness and dissatisfaction with his
    current life circumstances. He endorsed items indicating that he experiences
    maladaptive anxiety, anger, and irritability as well as anxiety, insecurity,
    worry, and fear. Such individuals tend to report various negative emotional
    experiences and are usually self-critical, guilt-prone, and have self-doubt.
    They tend to be passive, indecisive, and inefficacious and often believe 
they
    are incapable of coping with current crises. They report above-average 
levels
    of stress or worry and tend to be stress-reactive, worry-prone, and often
    engage in excessive rumination. They may have fears that significantly
    restrict normal activity in and outside the home. Individuals with similar
    scores report not enjoying social situations and events and often dislike
    people and being around them. They often report multiple somatic complaints
    that may include head pain, neurological, and gastrointestinal symptoms.
    Individuals with similar response patterns usually present with multiple
    somatic complaints and are prone to developing physical symptoms in response
    to stress. They usually complain about headaches, chronic pain, and
    difficulty concentrating and tend to present with vague neurological
    complaints as well as a diffuse pattern of cognitive difficulties. These
    individuals often have low frustration tolerance.


    ****************************************************************

    Quote taken from Form 2507 from the Regional Office:
    "CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER.

    ALL DOCUMENTS AVAILABLE IN VBMS

    Please examine the veteran for the present status of his claimed depression
    and anxiety and opine whether it is as least as likely as not caused by, due
    to, or aggravated by head injury documented in service.

    Aggravation:
    If not caused, but aggravated by service, please provide the following
    information:
    1.  The baseline manifestations of the aggravation which are due to the
    effects of the disease or injury.
    2.  The increased manifestations which, in your opinion, are proximately due
    to the service connected disability based on medical considerations. The
    medical considerations supporting an opinion, that increased manifestations
    of a non-service connected disease or injury are proximately due to the
    service connected disability."


    ****************************************************************

    OPINION:
    The veteran completed psychometric testing, underwent a clinical interview,
    and the medical record was reviewed. The medical record does not indicate 
the
    presence of pre-existing psychiatric problems at the time of his entry into
    the military or at the time of his separation.

    The veteran reported that he was frustrated with his cognitive difficulties
    following his parachuting injury, though there is no mention of 
psychological
    difficulties in any of the medical records from that time period. The first
    mention of such difficulties was in a neuropsychological report dated
    04/03/2007 where it was asserted that "it appears that he is developing a
    greater degree of anxiety and depression likely due to the underlying
    cognitive problems he is encountering" and he was diagnosed at that time 
with
    an "Adjustment Disorder with Mixed Anxiety and Depressed Mood."

    However, available medical records from Michigan State University Clinical
    Center dating back to 2009 were reviewed and by 11/20/2009 it was noted that
    the veteran was "doing well on the anxiety." A note dated 01/14/2010
    indicated that the veteran was "doing well on the Wellbutrin and Buspar now.
    Things are going well at work, and feels things are good at home, is resting
    well, feels he has developed better coping skills. And overall feels he is
    doing well." A note dated 07/19/2010 reported a PHQ-9 depression screen as


    negative and on 08/13/2010 it was reported that the veteran "denies
    depression, anxiety, suicidal ideation, hallucinations, paranoia, phobia, 
and
    confusion." On 05/09/2011 it was reported that the veteran "states he feels
    better than he ever has. Notes that he stopped meds in Dec. felt they were
    making him groggy admits that he is getting medical marijuana gets a 
tincture
    and takes 3-4 gtts/day feels more confidence handling more responsibility at
    work and home well feels it has taken edge off;" it went on to assert that
    the clinical impression was that the veteran had "Improved" and all
    psychotropic medications were officially removed from his medication list.

    The veteran appeared to be doing extremely well psychologically until he was
    reportedly "mugged" on 06/23/2011, which reportedly resulted in him "having 
a
    lot of anxiety, fear, worried-almost like reliving the incident, both during
    his waking hours and at times during sleep." The veteran reportedly "felt
    guilty since he's been mugged (that he is contributing to the social illness
    that result from a burgeoning marijuana initially) so he stopped it since
    06/23/2011. Anxiety and depressive symptoms have coincidentally flared up
    during this time." A question of PTSD was raised by his provider and
    citalopram and alprazolam were prescribed at that time. The veteran reported
    in the current clinical interview that after he was mugged, "I just didn't
    handle it well" and he added that a few months later a bank employee down 
the
    street from his home was murdered, which added to his anxious fears that
    developed following his assault. A noted dated 07/26/2011 indicated that the
    veteran had "feelings of guilt that he didn't do more. We emphasize the
    survival aspects and that the things are just things. He has enrolled in a
    self defense/martial arts and we also discussed his impact on the family
    safety and how he is projecting his concerns versus awareness."

    Diagnostically, the veteran described his current mood as "pretty good,"
    adding "I love my job!" He denied that he is currently depressed and
    asserted, "I don't think I'm depressed, I don't really have time to be
    depressed right now" and he denied any current symptoms of depression. He
    added that after being diagnosed with ADHD and beginning Vyvanse medication,
    he has experienced significant improvement of his symptoms, which most 
likely
    indicates that several of his difficulties were actually secondary to a
    lifetime history of undiagnosed ADHD, as opposed to anything else.

    Regarding anxiety, the veteran stated that he initially had worries about 
not
    being able to get back into the Army, but asserted that he has pushed such
    thoughts out of his head and does not think about it anymore. He stated that
    his current anxieties are "about my kids" and that he is worried about work,
    because he is missing 2 days this week, even though he reported that his
    superiors are happy with his work performance. He stated that when he
    experiences any kind of anxiety he utilizes interventions (e.g., tries to
    breath and says the rosary when he feels anxious, which calms him down) to
    assuage such symptoms. He reported in the current clinical interview that
    after the mugging, "I just didn't handle it well" and following the murder
    that occurred down the street from his home, "I panicked, felt anxiety." He
    noted that he has a "service dog now because I don't like to be by myself,
    I'm more hypervigilant." Psychometric testing revealed low levels of current
    anxiety and suggests that the veteran tends to somaticize and that he tends
    to be stress-reactive, worry-prone, and often engages in excessive
    rumination. Based upon such information, a DSM-5 diagnosis of Other 
Specified
    Anxiety Disorder related to the assault he sustained in 2011 is warranted.

    There is no mention of anxiety associated with his military-related
    parachuting accident until 2007, though that appeared to be remitted by 
2009.
    His current mild anxieties are related to the assault he sustained in 2011;
    therefore, his current diagnosis of Other Specified Anxiety Disorder is less
    than likely as not (less than 50/50 probability) caused by or a result of 
his
    military service and there is no evidence to suggest that his current
    anxieties were aggravated by his past parachuting accident.
    

 
/es/ 
Staff Psychologist, Compensation and Pension
Signed: 03/16/2014 12:22
-------------------------------------------------------------------------


----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------

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  • 0

Thanks! That helps.....There is no doubt that your TBI Nexus is solid and also I feel you definitly have PTSD and the initial exam says that...(I assume the exam wording should be "at least as likely as not" and holds a typo---others Please chime in.

 "It is also least least likely as not that the Veteran's psychiatric issues
    are connected to his TBI. Veteran has had moodiness,anxiety, depression,
    irritablity, and impaired awareness.Veteran has extensive comphrension
    difficulties. He has had extensive psychiatric issues since his TBI. It is
    more of the cognitive difficulties that impair working. He has had jerks and
    clenched jaw reflexes since hte head injury that was noted after the head
    injury on Oct 12, 1995 by Dr David R Rivera, MD, a Ophthamology who also
    noted some memory dysfunction, decreased stamina, bliateral 4th cranial 
nerve
    palsies, balance problems, and cogwheel pursuit. I also recommend an Eye
    exam.  "

But then in the Hearing and Tinnitus Exam...some d--k head states this in the C & P

 " Results: 
      There is no mention of anxiety associated with his military-related 
      parachuting accident until 2007, though that appeared to be remitted 
      by 2009. 
      His current mild anxieties are related to the assault he sustained in 
      2011; therefore, his current diagnosis of Other Specified Anxiety Disorder 

      is less than likely as not (less than 50/50 probability) caused by or a
      result 
      of his military service and there is no evidence to suggest that his
      current 
      anxieties were aggravated by his past parachuting accident.
      to determine if he sustained a mild vs. moderate TBI given the lack of 
      records but suspected that it may have been moderate in severity. the vet 
      did see opthy in 1995 and was noted to have bilat cn4 palsy which which was 

      noted to resolve in a 1996 follow up visit." ???????

 

I need to re read all of this again... and hope others will as well....

What right does a doctor have, in a DBQ for hearing/Tinnitus, question the veteran's TVI and it's nexus to his VA diagnosed PTSD?

Sometimes I think I have seen it all.

More eyes needed on all this here. 

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Berta;

 

To answer your questions:

 

What is your VA Rating now and what for? TBI

 

What is the rating for TBI? 40%

What is the SSDI award for?

TBI, affective disorders, anxiety and depression, adult ADHD.

 

I did have my treating psy.  write a nexus letter linking the Anxiety and Depression as secondary to the TBI.  

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