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.

 

\

 

[Coach Edgar]

back in may 2016 my C&P exam for ptsd

 

C&P MULTIPLE EXAM                                  
STANDARD TITLE: C & P MULTIPLE EXAM NOTE                        
DATE OF NOTE: MAY 26, 2016@13:00     ENTRY DATE: MAY 31, 2016@11:28:11      
      AUTHOR: ARTIAGA,MARIA T      EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     

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

    Name of patient/Veteran:  Edgar Julian 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 (309.9)
           Comments, if any:
              Veteran's symptoms did not meet full diagnostic criteria for PTSD.
              Intrusive symptoms associated with traumatic stressor were
              sporadic, with intrusive thoughts and memories occurring "like 
two,
              three times in the past four months." Criteria was not met for
              negative alterations in cognitions and mood and marked changes in
              arousal and reactivity related to reported traumatic events.
              Symptoms reported by Veteran during today's, May 26, 2016, C&P
              Examination did meet DSM-5 diagnostic criteria for Unspecified
              Trauma-and Stressor-Related Disorder.
              

       Mental Disorder Diagnosis #2: Major Depressive Disorder, in partial
          remission
           ICD code: F33.41 (296.35)
           Comments, if any:
              According to November 9, 2005 C&P Evaluation, Veteran was 
diagnosed
              with Major Depression, Recurrent, Severe without Psychotic Traits.
              Please refer to this document for further information.
              

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): obstructive sleep apnea;
       hypertension
         Comments, if any: Veteran has been diagnosed with obstructive sleep
         apnea; he stated he is not compliant with use of CPAP. He stated he 
uses
         CPAP "probably like three times a week."

         Please refer to Veterans Health Administration medical records (VA
         treatment records) for more information related to physical conditions.
         

    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:
              It is not possible to differentiate what portion of each symptom 
is
              attributable to each diagnosis due to the overlap in symptoms
              including occasional loss of interest in activities and
              irritability.
              
              
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [ ] Yes   [ ] No   [X] 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:
              Veteran reported that he experiences irritability with family
              members including his wife and son. It is not possible to
              differentiate what portion of each symptom is attributable to each
              diagnosis due to the overlap in symptoms including occasional loss
              of interest in activities and irritability.
              
              
    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]

continued may 2016 

 

   SECTION II:
                                   -----------
                               Clinical Findings:
                               ------------------
    1. Evidence review
    ------------------
    In order to provide an accurate medical opinion, the Veteran's claims folder
    must be reviewed.
    
    a. Medical record review:
    -------------------------
    Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
    [X] Yes   [ ] No
    
    Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
    [ ] Yes   [X] No
    
      If yes, list any records that were reviewed but were not included in the
      Veteran's VA claims file:
        
      If no, check all records reviewed:
      
        [X] Military service treatment records
        [ ] Military service personnel records
        [X] Military enlistment examination
        [ ] Military separation examination
        [X] Military post-deployment questionnaire
        [X] Department of Defense Form 214 Separation Documents
        [X] Veterans Health Administration medical records (VA treatment 
records)
        [X] Civilian medical records
        [ ] Interviews with collateral witnesses (family and others who have
            known the Veteran before and after military service)
        [ ] No records were reviewed
        [X] Other:
              VHA medical record (CPRS) and VA e-folder (VBMS records) were
              reviewed. There was no physical C-File available as all documents
              were available in e-folder per C&P exam instructions.
              
    b. Was pertinent information from collateral sources reviewed?
    [ ] Yes   [X] No
    
        
    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
       post-military):
          Pre-military: Veteran was born in Weslaco, Texas and raised in Alamo,
          Texas. He was raised by both parents and grew up with a brother.
          Veteran described his childhood as "okay, my mom was a stay at home
          
mother, my dad worked, and was also an alcoholic, always talking down
          to me and hitting my older brother when he was drunk." Veteran 
reported
          that he got along with other children and teachers while growing up. 
He
          participated in baseball and football while in school.

          Military: Veteran reported that he got along "pretty good" with other
          soldiers.

          Post-military: Veteran lives with his spouse and two children, seven
          year-old son and one year-old daughter. Veteran and his wife have been
          married since 2005. He described his relationship with his wife as
          "married, have our ups and downs." Veteran described his relationship
          with his children as "nice." He spends most of his time with his
          daughter. His hobby is to "coach a travel selected team for softball."
          He stated he spends time with friends "on the weekends" barbecuing.  
          
          
    b. Relevant Occupational and Educational history (pre-military, military, 
and
       post-military):
          Pre-military: Veteran obtained a high school degree from Pharr-San
          Juan-Alamo High School. He reported that his grades were average and
          denied having any learning or attention problems.

          Military: Veteran served active duty in the Army from April 17, 2002 
to
          April 16, 2005. MOS: 92F, Petroleum Supply Specialist. Rank at
          Discharge: E-3. Discharge: Honorable. Veteran was awarded the Army
          Lapel Button, National Defense Service Medal, Global War on Terrorism
          Expeditionary Medal, Global War on Terrorism Service Medal, Army
          Service Ribbon.
          Veteran served in Southwest Asia from February 7, 2004 to August 24,
          2004.

          Post-military: Veteran completed a certificate for medical assistant 
in
          2015 from Southern Careers Institute. Veteran is current unemployed; 
he
          was last employed February 2015. Veteran stated he was a heavy
          equipment operator for the city of Donna from December 2014 to 
February
          2015. He stated he was fired because his "director told [him] [his]
          position was no longer needed." He denied having disciplinary problems
          at this job.  
          
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
          Pre-military: Veteran denied mental health history including
          hospitalizations for mental health problems. Veteran reported that his
          father was "always drinking alcohol." 

          Military: Veteran stated that he was diagnosed with depression 
"January
          2004." He reported that he was hospitalized for two weeks at John
          Randolph hospital in Virginia. Veteran reported, "When I came back 
from
          my tour in 2004, I woke up one morning and decided to cut my wrist 
with
          my Gerber knife. Then I realized what the hell I was doing, I drove
          myself to the local hospital in Virginia."

          Veteran denied seeing anyone wounded, killed or dead during deployment
          when he completed September 2, 2003 Post-Deployment Health Assessment.
          He did endorse feeling like he was in great danger of being killed.
          Veteran denied having little interest in doing things, feeling
          depressed, nightmares, avoidance behavior, hypervigilance, and feeling
          detached from others. He reported that his health in general was "very
          good."

          According to Report of Consultation from John Randolph Medical Center
          dated January 19, 2005, Veteran was "admitted to psychiatric services
          with depression." According to the Behavioral Health Initial 
Assessment
          from John Randolph Medical Center dated January 15, 2005, "He is in 
the
          process of getting divorced from his wife who lives in Texas. He said
          that he has been feeling stressed since this past weekend and 
yesterday
          he held a knife in his hand and wanted to hurt himself. He reported
          feeling depressed, having decreased energy, decreased appetite,
          decreased sleep. He has been having some flashbacks and nightmares
          about the war in Iraq."

          Post-military: Veteran is prescribed Buspirone and Fluoxetine; he
          stated he is compliant with psychotropic medication. Veteran attended
          primary care mental health integration initial appointment on January
          19, 2016. He then attended mental health initial evaluation on 
February
          10, 2016. Veteran attended VPTT Consult on February 23, 2016. He was
          no-show to follow-up appointment for VPTT on May 2, 2016 and May 9,
          2016.

          Veteran denied current auditory and visual hallucinations. He denied
          current suicidal and homicidal ideation, intent, or plan. Nonetheless,
          he was provided with Veterans Crisis Line information. Veteran was
          instructed to monitor symptoms, including emergence of suicidal or
          homicidal ideation, and to utilize this number, call 911, or go to
          nearest ER at closest hospital, in case of mental health emergency.  
          
          
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          Pre-military: Veteran denied legal and behavioral history.

          Military: Veteran reported he lost rank "for being late so many 
times."
          He denied receiving Article 15s.

          Post-military: Veteran denied legal and behavioral history.  
          
          
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          Pre-military: Veteran denied substance use including alcohol and
          cigarettes.

          Military: Veteran reported that he drank alcohol "like every weekend."
          He stated that he smoked cigarettes "just the weekends probably like
          six or seven cigarettes." Veteran denied use of other substances.

          Post-military: Veteran reported that he drinks "2 - 3 beers a week." 
He
          stated he is no longer smoking cigarettes. Veteran denied use of other
          substances.  
          
          
    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: Veteran reported that he served in Kuwait and Iraq. He 
denied
          engaging in direct combat. Veteran reported, "We were, I was doing
          guard duty one night and we heard the patriotic missiles, there were
          SCUD missiles coming in," "cause we were near Camp Virginia," "and we
          had to put on MOPP [mission oriented protective posture] gear" 
"because
          there was blood pathogen in the air." He stated, "one of my friends
          getting killed" "something I heard about." "We saw some dead bodies on
          our way back from Iraq," "we were 50 miles close to border line, 
coming
          back to Kuwait."
          
          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
    ---------------------------
    No response provided

    5. Symptoms

    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Anxiety
       [X] Disturbances of motivation and mood
       [X] Difficulty in establishing and maintaining effective work and social
           relationships

    6. Behavioral Observations
    --------------------------
    Veteran was alert and oriented x3. Dress was casual but appropriate. 
Attitude
    was cooperative and polite. Speech was clear, coherent, and relevant. Mood
    was "pretty good." Affect was consistent with mood and topics discussed.
    Thought processes were logical, linear, and goal-oriented. Thought content
    was WNL, with no signs or reports of A/V hallucinations, delusions, 
paranoia,
    or homicidal ideation/plan/intent. Veteran denied current suicidal
    ideation/plan/intent. Memory appeared intact. Judgment appeared adequate.

    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 note that level of impairment is only based on Unspecified
       Trauma-and Stressor-Related Disorder and Major Depressive Disorder, in
       partial remission. Veteran has physical impairments, which were not
       assessed today.
       
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

 
/es/ MARIA T Artiaga, PsyD
Supervised Psychology Staff
Signed: 05/31/2016 11:28

Receipt Acknowledged By:
06/05/2016 16:22        /es/ DESI A. VASQUEZ, PHD                              
                             SUPERVISORY PSYCHOLOGIST                          
-------------------------------------------------------------------------
 

[Coach Edgar]

hey Gastone my claim for IU is a fully develpoed claim.

 

[Gastone]

Looks like a 30 or 50 % PTSD rating as long as the Rater goes along with 11/22/16 DBQ. Did you list the Friend that was Killed, name and date of death?

The discussion of your 2015 Med Assistant training probably hurts the IU claim, sounds like you have the ability to do some sort of "Sedentary Work."

You indicate your currently 80% SC, what was the MH Condition (Persistent Depressive Disorder) rated as? that Rating will likely be combined with the PTSD Rating, if Awarded.

Semper Fi

[Coach Edgar]

Gastone i didnt list my friends name nor date of death, 

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

50%

Service Connected

03/01/2016

[Gastone]

Let me play Devil's advocate. You were originally Denied A PTSD DX back in 05 using the current DSM V criteria. The 05 Forensic C & P was done by a Psychiatrist or a psychologist PhD.

The VA Rater's use the C & P DBQ's as a tool, both DBQ's reference your Depression, so that's a given.

Back in 05, you didn't claim the same Stressors? I could see the current Rater deciding verification of the current Claimed Stressors is required. If I were the Rater, I'd contact you requesting the Name of your Deceased friend.

Semper Fi