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Ptsd C&p Results Any Opinions?


92Y/3533

Question

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.

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  • HadIt.com Elder

Welcome to Hadit.

Estimating VA MH ratings is tricky because you might assume one percentage and the VA does something else. In my personal, non-expert opinion, I agree with your estimation of 10%-30%. Having the diagnosis confirmed by the C&P doc does help. Keep in mind the VA likes to grant the minimal 10%, but you could always appeal if you disagree.

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Vync, is on the money bud. With the Docs statement of the Occupational Impairment, I feel you will be definitely granted 10-30%. God Bless and good luck

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