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Secondary Memory Loss PTSD
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JonathanAD
I am currently rated at 30% for PTSD. I filed a secondary claim for memory loss, because the medications I am on for PTSD cause me a lot of memory problems. I had a C&P that I wanted to upload with this, but When I try to attach it says "You do not have any existing attachments.".
Anyway, the claim status on ebenefits is currently "Pending Decision Approval", and I filed on 11/1/2018. I do not see a change in the VA Letters, or the Disabilities page. Has anyone else filed for memory loss secondary to PTSD, and I was wondering if someone could kinda guess what percentage they think I will get if any. I know that's hard to do without a copy of the C&P, so if someone can please tell me how to upload the PDF, that'd be awesome.
Edit: I figured out how to convert the scanned PDF to where I could copy/paste the text. The formatting isn't all the same, but here it is:
291 2018
LOCAL TITLE: EXAM
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: NOV 26, ENTRY DATE: NOV 26, AUTHOR: SIMONEAUX, BYRON J EXP COSIGNER:
URGENCY : STATUS : COMPLETED
Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire
Name of patient/ Veteran: Jonathan Durey
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request ?
Yes [ ) No
SECTION 1:
1. Diagnostic Summary
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes [ ) No
ICD Code: F43.1
2 . Current Diagnoses
a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.1
b. Medical diagnoses relevant to the understanding or management the
Mental Health Disorder (to include TBI) : No response provided.
3 . Differentiation of symptoms
a. Does the Veteran have more than one mental disorder diagnosed? No response provided.
b. Is it possible to differentiate what symptom (s) is/ are attributable to each diagnosis?
t Yes [ No [X) Not applicable (N/A)
c. Does the Veteran have a diagnosed traumatic brain injury (TBI) ?
) Yes t ) 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
PATIENT NAME AND ADDRESS (Mechanical Imprinting, If available)
DUREY, JONATHAN ADAM
VISTA Electronic Medical Documentation
Printed at CENTRAL ARKANSAS HCS
Page 1
29, 2018
b.
c.
1 .
[X)
2 .a.
b.
one)
[X) Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication
For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder?
] Yes { ) No [X) Not Applicable (N/A)
If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ) No [X) Not Applicable (N/A)
SECTION 11:
Clinical Findings :
Evidence Review
Evidence reviewed (check all that apply) :
VA e-folder
CPRS
Recent History (since prior exam)
Relevant social/marital/family history:
The Veteran lives in Conway, AR with his wife of approximately 4 years and his two sons (ages 1 and 5) . This is his first marriage. The Veteran is originally from Warren, AR. His family still lives in Arkansas. He and his wife get along well. They enjoy spending time in their yard, taking pictures, shopping, travel ling. His five year old son has an autism spectrum disorder. He said that his family has had trouble adjusting. Mr. Durey enjoys playing guitar, but reported that he does not play frequently due to time limitations. He enjoys woodworking, but reported that he has not been able to do so due to lack of time. He rarely keeps in touch with his family members. He said that his parents and his wife do not get along well. They have problems with acceptance of his son. He denied any contacts with friends. He denied any partcipation in group—activities. The Veteran reported that he and his wife have been frustrated with his inability to remember conversations or tasks at home. He has to be reminded multiple times to remember things at the store.
Relevant occupational and educational history:
The Veteran works at Data Path. He and his wife both work there. He said that he has been working there for approximately 7—8 months. He
PATIENT NAME AND ADDRESS (Mechanical Imprinting, If available)
DUREY, JONATHAN ADAM
VISTA Electronic Medical Documentation
Printed at CENTRAL ARKANSAS BCS
Page 2
29. 2018
said that he has noticed problems with staying on task, doign projects at work. He said that this has happened multiple times. He has noticed more problems with memory since starting psychotropic medications
c. Relevant mental health history, to include prescribed medications and family mental health:
Mr. Durey reported that he sleeps approximately 4-5 hours of sleep per night. He wakes up frequently during the night. He has dreams occasionally and wakes up for no reason. When he wakes up, he notices persistent worries. He denied daytime napping. He gets drowsy at work and while driving, but denied sleeping at the wheel.
Appetite seems to be increased. His weight has increased approximately 10 pounds in the last six months .
The Veteran denied plans to harm himself or others .
d. Relevant legal and behavioral history:
None
e. Relevant substance abuse history:
The Veteran drinks approximately 4 beers per day. He denied using any illicit drugs. He denied any history of DUI.
f. Other, if any:
No response provided.
3 . PTSD Diagnostic Criteria
Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM—5) . The stressful •event can be due to combat, personal trauma, other life threatening situations (non—combat related stressors) . 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 #6 "Other symptoms .
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 beginning after the traumatic event (s) occurred:
PATIENT NAME AND ADDRESS (Mechanical Imprinting, if available)
DUREY, JONATHAN
VISTA Electronic Medical Documentation
Printed at CENTRAL ARKANSAS HCS
Page 3
29, 2018
[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) .
Criterion 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) .
Criterion Negative alterations in cognitions and mood associated with the traumatic event beginning or worsening after the traumatic event (s) occurred, as evidenced by two (or more) of the following:
[X) Markedly diminished interest or participation in significant activities.
[X] Feelings of detachment or estrangement from others .
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:
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) .
Criterion F:
No response provided.
Criterion G:
The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning .
Criterion H:
The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
4 . Symptoms
For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:
[X] Depressed mood
[X) Anxiety
PATIENT NAME AND ADDRESS (Mechanical Imprinting, if available)
DUREY, JONATHAN ADAM
VISTA Electronic Medical Documentation
Printed at CENTRAL ARKANSAS HCS
Page 4
29, 2018
[X] Chronic sleep impairment
[X) Mild memory loss, such as forgetting names, directions or recent events
5. Behavioral observations
No response provided.
6. Other symptoms
Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? t Yes [X) No
7 Competency
Is the Veteran capable of managing his or her financial affairs?
Yes t ) Nó
8. Remarks, (including any testing results) if any:
Based on the review of the record, and this interview, it is the opinion of this evaluator that symptoms meet the diagnostic criteria for PTSD which is, as likely as not a continuation of the service—connected condition.
/es/ BYRON J SIMONEAUX
PSYCHOLOGIST
Signed: 11/26/2018 10:58
Oh, I also followed up with this on the claim, since the evaluator did not mention my panic attacks.
In reference to the VA claim for the veteran Jonathan A. Durey (#########):
At the recent C&P examination on 11/26/2018, the evaluator did not ask about the veteran's panic attacks which occur at a frequency of at least once weekly, sometimes more. I, Jonathan A. Durey, the veteran, would like to go on record that I do experience these panic attacks which were not addressed at the C&P exam.
Edited by JonathanADForgot to add some info.
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