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.
Question
92Y/3533
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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Vync
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%
Vync
92Y, Congratulations! Kimmy, One way is to contact the Release of Information office at your husband's VAMC. He needs to fill out a release form and sign it. They might be able to print it right
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