SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DMS-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 Comments, if any: The Veteran completed the Trauma Symptoms Inventory as a part of this evaluation. This inventory is an objective testing measure with well documented validity scales. Questions associated with depression and anxiety are imbedded in the test making it difficult to ascertain the purpose of each question. His test results are valid. He endorses chronic symptoms of anxious arousal, depression, anger and irritability, intrusive experiences, defensive avoidance, dissociation, sexual concerns and impaired selfreference. His depression scale score was moderately elevated on this inventory. These objective test results substantiate the clinical diagnosis of PTSD according to DSM-5 and DSM-IV diagnostic criteria. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): None contributing. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No 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 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 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? [ ] Yes [ ] No [X] No diagnosis of TBI 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 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 [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] 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: Objective test results from this examination. 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): He says that he was born in California and raised in Vancouver, Washington by primarily by his mother and step-father. He says that his biological parents divorced when he was about six years old in Kindergarten. He says that his mother when he was in the second grade (8 years old). He says that he was raised with a younger biological brother and one younger half-brother and two younger halfsisters. He says that he and his step-father tolerated each other for the most part but got along "okay". He says that his step-father was gone a lot while he was growing up. He says that his mother divorced him last year. He says that he is single and has never been married. He says that he does not have any biological children. He says that he presently lives alone. b. Relevant Occupational and Educational history (pre-military, military, and post-military): He graduated from high school prior to joining the military. He served in the Marine Corps from 03/06/95 to 03/05/99. He was discharged under honorable conditions at the rank of E-4 upon completion of required active service. He says that he then worked a couple of years at a steel mill, attended college obtaining his associates degree and then went to work with the railroad. He enlisted and served in the Army from 10/04/07 to 10/03/11. He was discharged under honorable conditions at the rank of E-4 as a unit supply specialist upon completion of required active service. He served in Iraq from 01/10/10 to 01/03/11. He says that he has been working since December of 2012 as a supply technician. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and postmilitary): He denies any history of diagnosis with or treatment for problems related to a mood disorder prior to or during his military service. Review of his military service records are silent for any complaint, treatment or diagnosis of a psychiatric condition to include depression or any mood disorder. He says that he first sought mental health treatment through the Jackson VA outpatient mental health clinic in 2013. Review of his CPRS mental health records found in VistaWeb Remote Data reveals that he was initially evaluated for problems with his mood and sleep on 05/20/13 through the Jackson VA outpatient mental health clinic. He has been diagnosed with "Adjustment disorder with depressed mood and PTSD symptoms." He is currently being followed through the Jackson VA outpatient mental health clinic approximately every two to three months for medication management and brief therapy. He was last seen on 02/12/14. His psychotropic medications include bupropion hcl 150mg daily for depression. He describes his mood as "Mostly flat. I won't say a bad mood but just not a good mood either." His affect is normal. He says that he has problems with a lot of anger, difficulty talking with people and gets upset easily. He says that he finds that he gets upset and angers quickly and easily even over small things. He says that sometimes his anger will last for only a short period of time but on occasion he will remain angry for a couple of weeks. He says that he has times when he gets emotional for almost no reason (or something reminds him of the past) and he will become easily tearful. He says that he has lost interest and pleasure in things that he used to enjoy. He says that he tends to stay at home and isolate more. He says that he really doesn't make the effort to talk with his parents or siblings much anymore. He says that it often seems to talk all of his energy just to make himself go to a movie. He says that he has some problems with sleep that revolve mostly around having bad dreams. He says that he will awaken from a bad dream and difficulty falling back to sleep after that. He says that he has bad dreams about two to three times per month. He says that he was diagnosed with mild obstructive sleep apnea and suggested to lose weight after recent sleep study. He says that he does have an occasional panic attack for no real reason. He says that he is easily startled by loud and/or unexpected noises. He says that he has had some thoughts of suicide with no plan or intent in the past. He says that these thoughts have resolved since he started his therapy last year with the VA psychologist. Results of the mental status examination are otherwise unremarkable. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): He denies any history of legal problems or behavioral issues. Thought I would get some opinions. My co-workers think between 10%-30% I agree with them. I was also wondering if it would be a good idea to submit more info like my CAB orders.