hypertension IU

[Coach Edgar]

HELLO EVERYONE MY NAME IS EDGAR I SERVED IN THE ARMY FROM 2002-2005. I AM CURRENTLY AT 80% RATE, RECENTLY IN JULY I GOT AWARED 80% FOR  

unspecified trauma and stressor related disorder with major depressive disorder (previously addressed as major depression)

50%

bilateral hearing loss

40%

hypertension

10%

tinnitus

10%

I have been unemployed since 2015 and when i was awared the 80% in July 2016 the DAV sent me a letter that i could apply for TDIU so i called the DAV and told them that i have not been working since Febuary 2015, i went ahead and submitted a claim for TDIU VA received my claim in July 29, 2016. I had two C&P exams done one in September 2016 and one in November 2016, the first C&P exam was a psychairatrist was at a doctors office that was set up by QTC, that doctor did my evaluation and stated that i have symptom of PTSD, and he recommened me to follow up on this, so then in November my other C&P exam was with the VA doctor there the VA doctor did the evaluation and this is what he put.

 Please comment on the effect of the Veteran's service connected
       disabilities on his or her ability to function in an occupational
       environment and describe any identified functional limitations. Please
       refrain from opining on if the veteran is unemployable or employable; 
       instead focus and reflect on the functional impairments and how these
       impairments impact occupational and employment activities.

       Comment: The veteran is able to function independently and engage in
       activities of daily living. He is able to drive an automobile and 
research
       jobs or prepare for job interviews. However, symptoms of depression and
       trauma-and stressor-related disorder would negatively impact his
       motivation. Problems sleeping and tiredness may negatively impact
       performance and productivity. Irritability may cause interpersonal
       problems on the job.
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

 

\

 

[Gastone]

Did you file the 7/29/16 IU claim as an FDC, if so, your Decision could be arriving at any moment. Uncomplicated FDC's have been getting Decisions in under 6 mos.

Regardless of you being currently unemployed since 2015, an IU award will be determined by your inability to do even "Sedentary" work that could provide Earned Income above the VA SGI Level of $12,400 per yr.

Usually a Retro Deposit will hit your Bank or CU a number of weeks before you receive the actual Award Letter. Be sure your Direct Deposit account is set up to Txt & Email you real-time, regarding all financial transactions.

Did you ever file for PTSD, ever had a VA  Forensic PTSD exam? What exactly was the 11/16 C & P for? Was this C & P Exam done at your VMC?

If so, you should be able to see a Copy of the C & P DBQ in your MHV Clinician Notes. The DBQ number and Heading will be stated. It would be very informative if you could post a redacted copy of the 11/16 DBQ.

Semper Fi

[Gastone]

Forgot to ask, any Dr say anything about you possibly having SA (Sleep Apnea)?

Semper Fi

[Coach Edgar]

HEY GASTONE, GOOD EVENING I SUBMIT A CLAIM FOR PTSD BACK IN O5 WHEN THE VA DOCTOR DIAGNOSED ME WITH PTSD, BUT THE VA DENIED ME FOR PTSD IN 06, NOW THAT I HAVE MY RECORDS AND EVEN MY LAST C&P EVAULATION IT SAYS I HAVE PTSD, 

Posttraumatic Stress Disorder (ICD-9-CM 309.81)
Date/Time Entered:  16 May 2005 @ 1200
Location:           VA S. Texas Health Care System
Status:             ACTIVE
Provider:           BARREIRO,MARIBEL B

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

    Name of patient/Veteran:  Edgar Sandoval
    
                                   SECTION I:
                                   ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
    based on today's evaluation?
    [ ] Yes   [X] No
    
    If no diagnosis of PTSD, check all that apply:
    
       [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under
           DSM-5 criteria
       [X] Veteran has another Mental Disorder diagnosis.  Continue to complete
           this Questionnaire and/or the Eating Disorder Questionnaire:

    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: unspecified trauma-and stressor-related
       disorder
           ICD code: F43.9

       Mental Disorder Diagnosis #2: persistent depressive disorder
           ICD code: F34.1

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): deferred to medical

    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:
              symptom overlap
              
              
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [ ] Yes   [X] No   [ ] Not shown in records reviewed
       
    4. Occupational and social impairment
    -------------------------------------
    a. Which of the following best summarizes the Veteran's level of 
occupational
       and social impairment with regards to all mental diagnoses? (Check only
       one)
       [X] Occupational and social impairment with occasional decrease in work
           efficiency and intermittent periods of inability to perform
           occupational tasks, although generally functioning satisfactorily,
           with normal routine behavior, self-care and conversation

    b. For the indicated level of occupational and social impairment, is it
       possible to differentiate what portion of the occupational and social
       impairment indicated above is caused by each mental disorder?
       [ ] Yes   [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:
              symptom overlap
              
              
    c. If a diagnosis of TBI exists, is it possible to differentiate what 
portion
       of the occupational and social impairment indicated above is caused by 
the
       TBI?
       [ ] Yes   [ ] No   [X] No diagnosis of TBI

[Coach Edgar]

MY LAST C&P EXAM 11-22-2016

    SECTION II:
                                   -----------
                               Clinical Findings:
                               ------------------
    1. Evidence Review
    ------------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS

    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
       post-military):
          He was born in Weslaco, Texas and raised in Alamo by his biological
          parents. He has one brother. He stated that his father was an 
alcoholic
          and would "talk down at [him]." He was also physically abusive. He got
          along with peers and teachers and played sports in school.

          The veteran was living with his wife, daughter, age two and 8-year-old
          son, but they separated and he is now living with a friend. He visits
          with his children regularly.  He stated that he was arguing and
          irritable with his spouse and that he was "swearing" in front of his
          children. "I was getting mad for no reason." His mother died in a
          nursing home with stroke (09/2016) and his father died of "alcoholism"
          (10/2016). He stated the symptoms of depression have increased since
          they died. "The whole world's on top of me." He continues to coach
          softball with teenage girls on the weekends.  

          Relationships were good in the military.
          
    b. Relevant Occupational and Educational history (pre-military, military, 
and
       post-military):
          He graduated high school with average grades. There were no learning 
or
          attentional problems. He worked part-time at a department store during
          his teenage years.
           
          He was active duty Army (2002-2005) with highest rank SPC and rank at
          discharge of PFC due to disciplinary problem. Discharge was honorable.
          He received GWOT, NDSM, Global war on terrorism expeditionary medal. 
He
          was in Southwest Asia (2004).

          Post-military, he received a certificate for medical Assistant (2015).
          He has been unemployed since February 2015 after having productivity
          problems in a position as heavy equipment operator.
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
          He did not report pre-military mental health issues or family history
          of psychiatric problems, though his father drank heavily.

          Records indicate he was admitted to John Randolph Medical Center in
          January 2005 with "depression." Recent VA records show he has been
          receiving mental health treatment for trauma-related disorder and
          depression since January 2016. He has received both group and
          individual therapy. The veteran stated that symptoms of depression 
have
          been increased since his parents died 1-2 months ago.  

          Currently, he reports symptoms of depression including feelings of
          guilt, decreased pleasure and interest in activities, decreased 
energy,
          irritability, tiredness, and problems sleeping. He stated that he 
feels
          guilty for not being with his parents anymore or with his family. 

          He reports symptoms of trauma- and stressor- related disorder 
including
          occasional distressing dreams or intrusive memories, reactions to cues
          in the environment (seeing people with Middle Eastern clothing"),
          decreased interest in activities, irritability, hypervigilance, and
          problems sleeping.

          Medications: Buspirone, lisinopril.
          
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          none
          
          
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          6-pack of beer per month. 
       
   
          
    f. Other, if any:
       No response provided.
       
    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: Feeling that his life was threatened during deployment with
          danger of being killed.
          
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [X] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [X] Yes  [ ] No
          
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [X] No
          
    b. Stressor #2: Seeing "dead bodies" when coming back from Iraq.
    
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [X] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [X] Yes  [ ] No
          
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [X] No
          
    c. Stressor #3: Hearing that one of his SM friends was killed.
    
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [X] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [X] Yes  [ ] No
          
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [X] No
          
    4. PTSD Diagnostic Criteria
    ---------------------------
    Please check criteria used for establishing the current PTSD diagnosis. Do
    NOT mark symptoms below that are clearly not attributable to the 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)
                   [X] Learning that the traumatic event(s) occurred to a close
                       family member or close friend; cases of actual or
                       threatened death must have been violent or accidental; 
or,
                       experiencing repeated or extreme exposure to aversive
                       details of the traumatic events(s) (e.g., first 
responders
                       collecting human remains; police officers repeatedly
                       exposed to details of child abuse); this does not apply 
to
                       exposure through electronic media, television, movies, or
                       pictures, unless this exposure is work related.

       Criterion B: Presence of (one or more) of the following intrusion 
symptoms
                    associated with the traumatic event(s), beginning after the
                    traumatic event(s) occurred:
                    
                   [X] Recurrent, involuntary, and intrusive distressing 
memories
                       of the traumatic event(s).
                   [X] Recurrent distressing dreams in which the content and/or
                       affect of the dream are related to the traumatic 
event(s).
                   [X] 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:
                    No response provided.
                    
       Criterion D: Negative alterations in cognitions and mood associated with
                    the traumatic event(s), beginning or worsening after the
                    traumatic event(s) occurred, as evidenced by two (or more) 
of
                    the following:
                    
                   [X] Persistent negative emotional state (e.g., fear, horror,
                       anger, guilt, or shame).
                   [X] Markedly diminished interest or participation in
                       significant activities.

       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] Sleep disturbance (e.g., difficulty falling or staying
                       asleep or restless sleep).

       Criterion F:
       
                   [X] Duration of the disturbance (Criteria B, C, D, and E) is
                       more than 1 month.

       Criterion G:
       
                   [X] The disturbance causes clinically significant distress or
                       impairment in social, occupational, or other important
                       areas of functioning.

       Criterion H:
       
                   [X] The disturbance is not attributable to the physiological
                       effects of a substance (e.g., medication, alcohol) or
                       another medical condition.

       Criterion I: Which stressor(s) contributed to the Veteran's PTSD
                    diagnosis?:
                    
                   [X] Stressor #1
                   [X] Stressor #2
                   [X] Stressor #3

    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Depressed mood
       [X] Anxiety
       [X] Chronic sleep impairment
       [X] Disturbances of motivation and mood
       [X] Difficulty in establishing and maintaining effective work and social
           relationships
       [X] Difficulty in adapting to stressful circumstances, including work or 
a
           worklike setting

    6. Behavioral Observations
    --------------------------
    MENTAL STATUS EXAMINATION
    Appearance: Casual, appropriate. 
    Behavior:  cooperative. 
    Speech: WNL
    Mood/Affect: WNL, appropriate to content. 
    Orientation: Oriented to all spheres. 
    Cognitions: WNL, not formally tested. 
    Safety: Danger to self/others? NO
            Safe to return home? YES
    Risk Factors assessment:
    [NO] Patient has current thoughts of hurting or killing themselves? 
    [NO] Patient has current thoughts of hurting or killing someone else? 
    [NO] Patient has is looking for a way to kill themselves or has a plan?
    [NO] Patient has taken actions to activate plan? 
    [NO] Patient has history of compromised impulse control?    
    Judgment: FAIR
    Insight: FAIR

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

    8. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
       [X] Yes   [ ] No
       
    9. Remarks, (including any testing results) if any
    --------------------------------------------------
       Please comment on the effect of the Veteran's service connected
       disabilities on his or her ability to function in an occupational
       environment and describe any identified functional limitations. Please
       refrain from opining on if the veteran is unemployable or employable; 
       instead focus and reflect on the functional impairments and how these
       impairments impact occupational and employment activities.

       Comment: The veteran is able to function independently and engage in
       activities of daily living. He is able to drive an automobile and 
research
       jobs or prepare for job interviews. However, symptoms of depression and
       trauma-and stressor-related disorder would negatively impact his
       motivation. Problems sleeping and tiredness may negatively impact
       performance and productivity. Irritability may cause interpersonal
       problems on the job.
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

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

                                 Medical Opinion
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Edgar Sandoval
    
    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 have a diagnosis of (a)
    unspecified trauma and stressor related disorder with major depressive
    disorder that is at least as likely as not (50 percent or greater
    probability) incurred in or caused by (the) friend killed in action during
    service?

    b. Indicate type of exam for which opinion has been requested: DBQ PSYCH 
PTSD
    INITIAL

    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: STRs show treatment for depression during service (2005). He
    served in Southwest Asia, feared for his life and found out that a SM friend
    of his was killed in service. He currently reports symptoms of depression 
and
    trauma-and stressor-related disorder, such as irritability, low energy,
    problems sleeping, intrusive memories, distressing dreams, reactions to cues
    in the environment. 

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

 
/es/ Paul Loflin, PhD
Clinical Psychologist
Signed: 11/23/2016 12:21
-------------------------------------------------------------------------
 

[Coach Edgar]

FOR MY IU I DID SUBMITT A FORM TO MY LAST EMPLOYER TO FILL OUT AND I SENT IT TO THE VA IN JULY.

 

[Coach Edgar]

I WAS DENIED SLEEP APNEA IT WAS NOT SERVICE CONNECTED BUT YET I HAVE A CPAD MACHINE GIVING BY THE VA