awgv001 Posted May 24, 2017 Share Posted May 24, 2017 Here are the posted results of my latest C&P exam for PTSD/MST (w/ parts of TBI included) Been performing my own research and in the fight for 4+ years now. Seems to me after researching this falls in an "unusual" area of the majority of VA claims, and I don't like it one bit. There's a lot of "gray" area to this exam IMO. There's several issues inside this doc that speak of uncertainties - to all of which I find myself nervous of the resolution. I don't know how this issue will be rated, nor how it will affect my pending TBI claim as well... I am hoping somebody may be able to help me better understand and/or prepare for the worst. Help guide me to the light and set my worries free. Sorry for the long read, and Thank you, in advance! ------------------------------------------------------------------------------------------------------------ Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: --------------- 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: PTSD ICD code: 309.81 Mental Disorder Diagnosis #2: unspecified depressive d/o ICD code: 311.00 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): migraine headache (SC) (TBI hx related tx) , ulnar nerve hx 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: shared sx presesntation, depression secondary to trauma d/o c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed Comments, if any: relating to fall and blackout on active duty, VA treatment noted with correspondance in VMBS verifiying treatment d. 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: there is hx of headache, but concentration/attention problems not easily differentially attributable. 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 reduced reliability and productivity 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: noted above 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 [X] No [ ] No diagnosis of TBI 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: noted above SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Evidence Comments: buddy statement is reviewed, indicating some verification of assault and Vet's reaction while in service, noting behavior change consistent with trauma aftermath 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): ***Information Errated for privacy*** please note - no negative pre military markers, kay? :-) b. Relevant Occupational and Educational history (pre-military, military, and post-military): graduated HS enlisted in MC out of high school xxxx to xxxx XX MOS XXXXXXX honorable DC XXXX XXXXX air support Gulf war after DC...."nothing but part time"...."half a dozen jobs....keep bouncing around"; longest as a maintenance tech....1 1/2 yrs; that ended with "injury" as vet fell "several times at work"....had been out on workers comp.....had surgical intervention on bulging disc. "there was a worker's comp settlement" c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): XXXXXXX VA clinic ongoing for the last 2 yrs notes indicate focus on exposure therapy for PTSD as well as TBI intervention. Meds: Sertraline, Gabapentin d. Relevant Legal and Behavioral history (pre-military, military, and post-military): no charges notes that police came to his house recently....due to his kids "wandering" the neighborhood....DCS investigation - no charges e. Relevant Substance abuse history (pre-military, military, and post-military): no problem described. 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: during first attachment....approximately first 18 months....repeated hazing....harassment.....hog tied....several occasions....."more than three quarters of the time" involved MST... 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: MST....and related abuse. vet notes that he was assaulted "at least a half dozen times" over that time period. they had a particular ritual known as the ***errated*** Is the stressor related to personal assault, e.g. military sexual trauma? [X] Yes [ ] No If yes, please describe the markers that may substantiate the stressor. one notation administrative remark 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] Witnessing, in person, the traumatic event(s) as they occurred to others Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred. [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid 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] 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] 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] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Flattened affect [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Suicidal ideation 6. Behavioral Observations -------------------------- alert, oriented and cooperative. flat affect and narrow affective range. related hx of suicidal thoughts, without urge or intent. 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 -------------------------------------------------- findings meet dx criteria for PTSD with depression. findings are consistent with someone who has struggled with the aftermath of assault and MST; as treatment interventions and dx support same, with some delayed component to multiple PTSD sx onset. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. I am not an Attorney or VSO, any advice I provide is not to be construed as legal advice. You're never out of the fight. Semper Fidelis Link to comment Share on other sites More sharing options...
0 Berta Posted May 24, 2017 Share Posted May 24, 2017 Is anyone else having problems with the reply area superimposed on the C & P exam? I could not read the whole exam. You do have the PTSD diagnosis and what I feel is favorable evidence.....however-do you have your SMRs and 201 Military Personnel file? The 201 file can be very helpful in these types of claims. The TBI...was that noted on your discharge certificate...this was from a fall? Did it have anything to do with the harrassment or MST incidents?Or did you faint? If so, what happened next...meaning did you get documented medical care for it in the Mil, and if so, what did they attribute the fainting to? I could not read anything after part of Criterion E. GRADUATE ! Nov 2nd 2007 American Military University ! When thousands of Americans faced annihilation in the 1800s Chief Osceola's response to his people, the Seminoles, was simply "They(the US Army)have guns, but so do we." Sameo to us -They (VA) have 38 CFR ,38 USC, and M21-1- but so do we. Link to comment Share on other sites More sharing options...
0 Berta Posted May 24, 2017 Share Posted May 24, 2017 One more question......what is the 50% SC for? GRADUATE ! Nov 2nd 2007 American Military University ! When thousands of Americans faced annihilation in the 1800s Chief Osceola's response to his people, the Seminoles, was simply "They(the US Army)have guns, but so do we." Sameo to us -They (VA) have 38 CFR ,38 USC, and M21-1- but so do we. Link to comment Share on other sites More sharing options...
0 awgv001 Posted May 24, 2017 Author Share Posted May 24, 2017 5 minutes ago, Berta said: You do have the PTSD diagnosis and what I feel is favorable evidence.....however-do you have your SMRs and 201 Military Personnel file? The 201 file can be very helpful in these types of claims. The TBI...was that noted on your discharge certificate...this was from a fall? Did it have anything to do with the harrassment or MST incidents?Or did you faint? If so, what happened next...meaning did you get documented medical care for it in the Mil, and if so, what did they attribute the fainting to? I'll repeat the post filling in the Crit E block a second time and forward for you. :-) I have a copy of ALL paperwork regarding my claims and AD records - just not a copy of my C-File at the moment, although I'd love to obtain a disc copy of it so I can fiddle through for any missing docs I could submit. TBI was not noted on my discharge cert - was not diagnosed via AD - simply incurred and untreated except for in 2012 when I was outsourced to civilian Nuerology Depts. - This was from a rather bad fall, yes. Also, it had nothing to do with the harrassment or MST - it was completely seperate and at a different time (technically in between) of the assaults that occurred for my PTSD/MST. No AD docs, nothing to attribute to the fainting - They (corpsman) wanted me to get it looked into - I merely had my entire squadron present for witnessing the incident that occurred, which through observational report, was enough to determine TBI due to LOC <30min. I have yet to have TBI SC'd at the moment. I have a 50% rating currently for %30 Migraines %10 Left Ulnar nerve status %10 Left Wrist strain %10 Tinnitus %0 Scars %0 Flat feet I am not an Attorney or VSO, any advice I provide is not to be construed as legal advice. You're never out of the fight. Semper Fidelis Link to comment Share on other sites More sharing options...
0 awgv001 Posted May 24, 2017 Author Share Posted May 24, 2017 *****Re-submission due to web error(?)***** Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Flattened affect [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Suicidal ideation 6. Behavioral Observations -------------------------- alert, oriented and cooperative. flat affect and narrow affective range. related hx of suicidal thoughts, without urge or intent. 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 -------------------------------------------------- findings meet dx criteria for PTSD with depression. findings are consistent with someone who has struggled with the aftermath of assault and MST; as treatment interventions and dx support same, with some delayed component to multiple PTSD sx onset. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. I am not an Attorney or VSO, any advice I provide is not to be construed as legal advice. You're never out of the fight. Semper Fidelis Link to comment Share on other sites More sharing options...
0 Berta Posted May 24, 2017 Share Posted May 24, 2017 Thanks...I think this is a very favorable C & P exam...for PTSD..... I only hope the VA rater knows how to read (I am serious) The 30 % migraines.....did the VA attribute that to the fall???? They lump in stuff like that for TBI. There is a lot here on TBI in that forum. Are you employed? "I was outsourced to civilian Nuerology Depts. - This was from a rather bad fall, yes. Also, it had nothing to do with the harrassment or MST - " Do you have those records, and if so does the VA have them? Do you get SSDI for any or all of this? GRADUATE ! Nov 2nd 2007 American Military University ! When thousands of Americans faced annihilation in the 1800s Chief Osceola's response to his people, the Seminoles, was simply "They(the US Army)have guns, but so do we." Sameo to us -They (VA) have 38 CFR ,38 USC, and M21-1- but so do we. Link to comment Share on other sites More sharing options...
0 awgv001 Posted May 24, 2017 Author Share Posted May 24, 2017 (edited) 32 minutes ago, Berta said: Thanks...I think this is a very favorable C & P exam...for PTSD..... I only hope the VA rater knows how to read (I am serious) The 30 % migraines.....did the VA attribute that to the fall???? They lump in stuff like that for TBI. There is a lot here on TBI in that forum. Are you employed? "I was outsourced to civilian Nuerology Depts. - This was from a rather bad fall, yes. Also, it had nothing to do with the harrassment or MST - " Do you have those records, and if so does the VA have them? Do you get SSDI for any or all of this? They did not relate the migraine to a fall, due to the fact that the fall wasn't the part reported, only the symptoms following - they simply attributed the migraines...Due to having migraines without a clear notation as to how they began to occur. I know that if I get a TBI sc that they will take the migraine rating and add it into any factors for the rating of the TBI. I am currently employed part time, as I have been off and on through the years beyond my end of service. I have buddy statements only in regard to my fall, no medical documents except what I mentioned from Nuero observation in 2012. The buddy statements were submitted years after all of this occurred. I had submitted for SSDI and was denied sometime last year ( this was also before I had statements from the doctors highlighting the words "DIAGNOSIS OF XXX" in regards to PTSD and TBI...Amongst other things I claimed.... It has been a long, and rough road, but the pieces are starting to form a picture now. Edited May 24, 2017 by awgv001 I am not an Attorney or VSO, any advice I provide is not to be construed as legal advice. You're never out of the fight. Semper Fidelis Link to comment Share on other sites More sharing options...
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awgv001
Here are the posted results of my latest C&P exam for PTSD/MST (w/ parts of TBI included)
Been performing my own research and in the fight for 4+ years now.
Seems to me after researching this falls in an "unusual" area of the majority of VA claims, and I don't like it one bit.
There's a lot of "gray" area to this exam IMO.
There's several issues inside this doc that speak of uncertainties - to all of which I find myself nervous of the resolution.
I don't know how this issue will be rated, nor how it will affect my pending TBI claim as well...
I am hoping somebody may be able to help me better understand and/or prepare for the worst.
Help guide me to the light and set my worries free.
Sorry for the long read, and Thank you, in advance!
------------------------------------------------------------------------------------------------------------
I am not an Attorney or VSO, any advice I provide is not to be construed as legal advice.
You're never out of the fight.
Semper Fidelis
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I'm going to be honest so don't get mad I had my TBI SC in 2010 Sc migraines rated by itself with dizziness and lightedness and tinnitus all this wasn't won until my appeal in 2016 it was retro to 201
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