lucaswlandon Posted November 23, 2013 Share Posted November 23, 2013 SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 2. Current Diagnoses -------------------- a. Diagnosis #1: PTSD ICD code: 309.81 Indicate the Axis category: [X] Axis I [ ] Axis II Diagnosis #2: Major Depressive Disorder, recurrent, severe, without psychotic fearures ICD code: 296.33 Indicate the Axis category: [X] Axis I [ ] Axis II Diagnosis #3: Alcohol Abuse ICD code: 305.00 Indicate the Axis category: [X] Axis I [ ] Axis II b. Axis III - medical diagnoses (to include TBI): GERD c. Axis IV - Psychosocial and Environmental Problems (describe, if any): Combat in Iraq d. Axis V - Current global assessment of functioning (GAF) score: 60 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: The symptoms of these disorders overlap and any attempt to separate then would be mere speculation. 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 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 Page 17 of 33 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: The symptoms of these disorders overlap and any attempt to separate them would be mere speculation. 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 ------------------ a. Records reviewed (check all that apply): [X] Claims folder (C-file): [ ] Yes [X] No If no, provide reason C-file was not reviewed: VBMS b. Was pertinent information from collateral sources reviewed? No response provided. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): He was born and raised in Columbus, Ohio. He had two parents, one older brother and two younger sisters. He graduated from high school in 2000. He joined the National Guard in 2001. He deployed to Iraq on December 7, 2003 and served in Iraq from 18 of 33 02/-08/04 until 02/02/05. He received the Combat Action Badge for direct involve- ment with the enemy on 04/19/04. He got an honorable discharge in 2009. He got married on 11/20/2010 and has two daughters and one son. He sleeps i n a different room because he has to have the TV on to sleep. He stays in a small dark room with the TV on. b. Relevant Occupational and Educational history (pre-military, military, and post-military): He worked for did father in high school painting and wallpaper. He was a radio operator for a medical unit in the service. He worked for Grant Hospital for 5 years as a dispacher, Med Flight for 3 months, for his father-in-law for a year sandblasting, and back at Grant Hospital and is has been accused of creating a hostile work environment. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): He was treataed with Zoloft in 1998-1999 for a period of 6 months following the break-up with a girlfriend. He reported depression with insomnia in May 2004. In October, 2004, he reported suicidal thoughts. He reported a suicide attempt (Tylenol and Alcohol) in 2006 following service and was hospitalized for 2-3 days at Mt. Carmel East in Columbus, Ohio. He went home for a day and was then hospitalized at Riverside Methodist Hospital in Columbus, Ohio, for 3 days. He has been seen at the Dayton VAMC for the last year in the PTSD program. He saw Dr. Moon who has him on Celexa-40mg daily, Vistaril-10mg tid as needed for anxiety and Ambien-10mg/qhs. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): No legal issues Page 19 of 33 e. Relevant Substance abuse history (pre-military, military, and post-military): He reported that he used to drink 6 beers at night in order to go to sleep. No DUI's. He now drinks socially and his last drink was 2 days ago (2 beers) at a Veteran's Day party. f. Sentinel Event(s) (other than stressors): No response provided. g. Other, if any: No response provided. 3. Stressors ------------ a. Stressor #1: On 04/19/2004, I was assigned to Charlie Company, 118 Area Support Medical BAttalion, and came into direct involvement with the emeny 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 b. Stressor #2: On 11/13/2004, I was assigned to the Company and we got mortared and Sgt. Catelina Dima was killed 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 4. PTSD Diagnostic Criteria --------------------------- a. Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, referred to as Criteria A-F, are from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Criterion A: The Veteran has been exposed to a traumatic event where both of the following were present: Page 20 of 33 [X] The Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. [X] The Veteran's response involved intense fear, helplessness or horror. Criterion B: The traumatic event is persistently reexperienced in 1 or more of the following ways: [X] Recurrent and distressing recollections of the event, including images, thoughts or perceptions [X] Recurrent distressing dreams of the event [X] Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event [X] Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following: [X] Efforts to avoid thoughts, feelings or conversations associated with the trauma [X] Efforts to avoid activities, places or people that arouse recollections of the trauma [X] Markedly diminished interest or participation in significant activities [X] Feeling of detachment or estrangement from others [X] Restricted range of affect (e.g., unable to have loving feelings) Criterion D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or more of the following: [X] Difficulty falling or staying asleep [X] Irritability or outbursts of anger [X] Difficulty concentrating [X] Hypervigilance [X] Exaggerated startle response Criterion E: [X] The duration of the symptoms described above in Criteria B, C and D is more than 1 month. Criterion F: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. b. Which stressor(s) contributed to the Veterans PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2 5. Symptoms Page 21 of 33 ----------- For VA rating purposes, check all symptoms that apply to the Veterans 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] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Flattened affect 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: Decreased appetite, energy level, interest in sex, concentration, he snaps at his wife and kids. He reported his depression as an 8-9 on a 0-10 scale where 0 is no depression and 10 is suicidal. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, if any ------------------ The Veteran meets DSM-IV-TR and DSM-5 criteria for PTSD related to his in-service experiences. His Major Depressive Disorder is related to his PTSD and depressive symptoms in service were early manifestations of the current disorder. Link to comment Share on other sites More sharing options...
Berta Posted November 23, 2013 Share Posted November 23, 2013 With the CAB , OEF service, and this VA diagnosis of PTSD you should certainly expect a SC award,in my opinion. The Veteran meets DSM-IV-TR and DSM-5 criteria for PTSD related to his " His Major Depressive Disorder is related to his PTSD and depressive symptoms in service were early manifestations of the current disorder." How soon after your discharge did you file this claim? Reason I ask might not apply to you here......... but it pays to mention from time to time....... Awards on claims filed within one year after discharge, use the day after the discharge as the EED (earliest effective date) for the retro. Link to comment Share on other sites More sharing options...
lucaswlandon Posted November 24, 2013 Author Share Posted November 24, 2013 what is SC award? no i was discharged in 2007 with 2 years of irr. so 2009 completely out. thanks for the reply Link to comment Share on other sites More sharing options...
stillhere Posted November 24, 2013 Share Posted November 24, 2013 SC= service connection Stillhere Link to comment Share on other sites More sharing options...
HadIt.com Elder john999 Posted November 24, 2013 HadIt.com Elder Share Posted November 24, 2013 It sounds like a 30% rating to me since doctor describes your ptsd as mild. Once you get the SC for PTSD you can hire IME/IMO doctor to show your ptsd is not based on mild symptoms. Link to comment Share on other sites More sharing options...
lucaswlandon Posted November 26, 2013 Author Share Posted November 26, 2013 i just found out that i have a 50% rating in the pending desicion approval stage. Link to comment Share on other sites More sharing options...
Navy04 Posted November 26, 2013 Share Posted November 26, 2013 Great news bud Link to comment Share on other sites More sharing options...
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