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About Milehighvet

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  1. So first off I wanted to say hello to everyone, and without all the help i've had from lurking this site the last few months, I would have given up a while ago. Anyways, I recently had a comp exam for a ptsd claim that I filed in March of 2014. I got my results today on MyHealtheVet, and have no idea what to make of it. Mainly i'm concerned because it says that my claim file wasn't reviewed, and I'm worry that may cause it to be inadequate. I'm also concerned because I've only recently started treatment at my VA clinic (the day I went in was actually the day two of my brothers were killed in afghanistan), and I'm worried that since I don't have a long record of treatment since getting out, that the VA may try and deny me. If anyone could make heads or tails of this, it'd be much appreciated I've been stressing this for months now and now that i'm so close to being done I'm ready to pull out my hair. If it helps, I am an infantryman with a CIB. Apologize in advance for the wall of text, tried to delete out irrelevant (and personal) info. 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 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: 309.81 Comments, if any: Is at least as likely as not caused by or the result of fear of hostile military or terrorist activity. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): See claims file. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No 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 veterans occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood 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 (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 [ ] 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) Veteran 1 [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 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: Combat deployment to Afghanistan 2011-12 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 Criteria 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 Criteria 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 violation, 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). 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, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [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] Panic attacks more than once a week [X] Chronic sleep impairment [X] Flattened affect [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 [X] Suicidal ideation 6. Behavioral Observations -------------------------- No response provided 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 -------------------------------------------------- This veteran served a combat deployment of approximately 11 months in Afghanistan from 2011 to 2012. During that time, he was in frequent fire fights and witnessed numerous deaths including the deaths of friends of his. He also witnessed the deaths of Afghanis including an Afghan policeman with whom they worked and become friends who was killed as they were clearing a building. Vet has had anniversary reactions to the deaths of 2 friends that occurred on August 14, 2011. After his unit went back to Germany in May 2012, veteran had chronic sleep impairment and did seek treatment. He made 1 suicide attempt August of 2012 when he almost hung himself, though he interrupted the act before he completed it. He was diagnosed at some time in Landstuhl RMC with adjustment disorder. He was seen at the Denver VAMC August 14, 2014, anniversary of the deaths of his friends and has been diagnosed with PTSD. I do concur with that diagnosis. Please refer to the DBQ for complete list of current symptoms. All diagnoses considered in the course of this exam condition are based upon criteria in DSM-5. The veteran is able to maintain activities of daily living including personal hygiene. He has not experienced significant trauma since discharge. There have not been remissions during the past year. Symptoms are continuous. He does not have problems with drug and alcohol abuse. There is not inappropriate behavior. He is in treatment but has just initiated it and it is too early to determine how he will respond. He has been prescribed Fluoxetine. Thought processes and communication are not impaired. Social functioning is impaired as described. Employment is impacted due to psychological issues as described. The veteran has had significant difficulty interacting with the public and was terminated from a position earlier this year. He is currently enrolled in school but is having difficulty completing his assignments. The veteran describes post military stressors from tension in his primary romantic relationship as a result of his symptoms and estrangement from his family. Other than diagnoses listed no other mental conditions were found. The veteran is competent to handle VA funds.
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