Hello, I was hoping that someone could look over these notes and give me a guess on what my rating might be for depression/anxiety. Thanks
‐‐‐‐‐‐‐‐‐‐‐‐
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
disorder(s)?
[X] Yes[ ] No
ICD code: 309.28
If the Veteran currently has one or more mental disorders that conform to
DSM‐5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Adjustment Disorder with mixed Anxiety and
Depressed Mood
ICD code: 309.28
Comments, if any:
This is a IDES examination.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): none
2. 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
3. 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 with reduced reliability and
productivity
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 diagnosed4/23/2015 My HealtheVet
about:blank 6/101
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. 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?
[X] Yes[ ] No
If yes, list any records that were reviewed but were not included in
the Veteran's VA claims file:
No answer provided
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):
Service member grew up in NY, an only child. His
parents are alive. He does not know his biological father. He has a
good
relationship with his stepfather but does not talk to his mother.
SM did well in high school. He was on the honor role and was on the
track team. he had male friends and had girlfriends.
SM is in his third marriage. His first marriage lasted 2 months and his
current marriage is in its second year. He has two children from his
second marriage (7 and 8), but his children live with their mother.
They rent a house. Veteran is still active duty (since 1999) as a
NCOIC.
b. Relevant Occupational and Educational history (pre‐military, military,
and
post‐military):
SM enlisted in the USAF shortly after high school, and he has been on
active duty since 1999. His highest rank has been TSgt, which it is
now.
He did not see combat "I was in a plane far above the Middle East." He
received the "usual medals and awards." There were no disciplinary
actions.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre‐military, military, and post‐military):
SM first went for help for anxiety in the fall of 2014. He was treated
with Atarax for anxiety and panic. He reports having panic attacks a
few
times a week. Zoloft and Welbutrin were added for treatment on
depression. He states Zoloft had a good effet of his mood but that the
Welbutrin did not. There were some ED side effects with this regimen.
In
addition to his medications, SM receives gets cognitive therapy, "the
same thing I gave to the Airmen as their RTA." He is still under active
treatment in the AF.
He describes his anxiety as panic as well. "I am extremely tense and
nervous in crowds, I don't like to leave the house or go out to eat. I
worry about my wife and kids and my health. I don't like to fly
anymore."
"My depression is much worse than my anxiety. I take pain meds and all
day feel sad." He states he gets 3‐4 hours of sleep a night. He reports
some anorexia, irritability and anger. He has problems with attention
and concentration." He has no suicidal ideation. He has had no change
in
libido but "We haven't had sex in months."
He reports insomnia starting in 2010. He has trouble falling asleep and
staying asleep. This may be a primary insomnia because it does not
coincide with the onset of depression and anxiety. Ambien helps with
this.
d. Relevant Legal and Behavioral history (pre‐military, military, and
post‐military):
none
e. Relevant Substance abuse history (pre‐military, military, and
post‐military):
none
f. Other, if any:
No response provided.
3. Symptoms
‐‐‐‐‐‐‐‐‐‐‐
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Difficulty in understanding complex commands
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
4. Other symptoms
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes[X] No
5. Competency
‐‐‐‐‐‐‐‐‐‐‐‐‐
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
6. Remarks (including any testing results), if any:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
No remarks provided.
‐‐‐‐‐‐‐‐‐‐‐‐
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
disorder(s)?
[X] Yes[ ] No
ICD code: 309.28
If the Veteran currently has one or more mental disorders that conform to
DSM‐5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Adjustment Disorder with mixed Anxiety and
Depressed Mood
ICD code: 309.28
Comments, if any:
This is a IDES examination.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): none
2. 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
3. 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 with reduced reliability and
productivity
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 diagnosed4/23/2015 My HealtheVet
about:blank 6/101
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. 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?
[X] Yes[ ] No
If yes, list any records that were reviewed but were not included in
the Veteran's VA claims file:
No answer provided
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):
Service member grew up in NY, an only child. His
parents are alive. He does not know his biological father. He has a
good
relationship with his stepfather but does not talk to his mother.
SM did well in high school. He was on the honor role and was on the
track team. he had male friends and had girlfriends.
SM is in his third marriage. His first marriage lasted 2 months and his
current marriage is in its second year. He has two children from his
second marriage (7 and 8), but his children live with their mother.
They rent a house. Veteran is still active duty (since 1999) as a
NCOIC.
b. Relevant Occupational and Educational history (pre‐military, military,
and
post‐military):
SM enlisted in the USAF shortly after high school, and he has been on
active duty since 1999. His highest rank has been TSgt, which it is
now.
He did not see combat "I was in a plane far above the Middle East." He
received the "usual medals and awards." There were no disciplinary
actions.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre‐military, military, and post‐military):
SM first went for help for anxiety in the fall of 2014. He was treated
with Atarax for anxiety and panic. He reports having panic attacks a
few
times a week. Zoloft and Welbutrin were added for treatment on
depression. He states Zoloft had a good effet of his mood but that the
Welbutrin did not. There were some ED side effects with this regimen.
In
addition to his medications, SM receives gets cognitive therapy, "the
same thing I gave to the Airmen as their RTA." He is still under active
treatment in the AF.
He describes his anxiety as panic as well. "I am extremely tense and
nervous in crowds, I don't like to leave the house or go out to eat. I
worry about my wife and kids and my health. I don't like to fly
anymore."
"My depression is much worse than my anxiety. I take pain meds and all
day feel sad." He states he gets 3‐4 hours of sleep a night. He reports
some anorexia, irritability and anger. He has problems with attention
and concentration." He has no suicidal ideation. He has had no change
in
libido but "We haven't had sex in months."
He reports insomnia starting in 2010. He has trouble falling asleep and
staying asleep. This may be a primary insomnia because it does not
coincide with the onset of depression and anxiety. Ambien helps with
this.
d. Relevant Legal and Behavioral history (pre‐military, military, and
post‐military):
none
e. Relevant Substance abuse history (pre‐military, military, and
post‐military):
none
f. Other, if any:
No response provided.
3. Symptoms
‐‐‐‐‐‐‐‐‐‐‐
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Difficulty in understanding complex commands
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
4. Other symptoms
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes[X] No
5. Competency
‐‐‐‐‐‐‐‐‐‐‐‐‐
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
6. Remarks (including any testing results), if any:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
No remarks provided.
