New Evidence Ime, Opinion

[lu12]

Psychiatric, Medical report of the evaluations and treatment of

NAME

SSN

October 31, 2007

Identification:

One is a male patient of 39 years, neighbor and resident of the municipality of Aguadilla, divorced, father of two children, catholic, with schooling of two years of university, comes of a brotherhood of three and is the eldest one, at present does not work. This patient already receives social security and Veterans Administration of benefits.

The affectation history of this patient arises while being active in the military service where he suffers a physical accident in one of his knees and in disc's as a result of this they are herniated in the lumbar area; since then and although in treatment he did not show improvement. Eventually he was licensed because a medical discharge physical disability?. Being out of military service he underwent treatment to improve his physical illness. From the veterans health administration V.H.A. file there is evidence of psychological complaints type to which they did not lend attention nor service and it was not until he was out of military service that he started the psychiatric treatment, in the private and V.H.A. Facilities. At present he continues making both types of treatment. What is the test demonstrating: in the first place, a human being is compound of a mind and a body, and when one is affected, the other is affected; to say that the knee and back disorders and disabilities did not affect of some form the mind is to think that the body does not have a mind; it is necessary to think that a young man that has pain, limitations and performance frustrations will affect their mental state and of that he complained, but although he did , they took it superficially as if nothing. It is true that later in 1997 he had an accident that overwhelm and aggravated the mental part, but that does discard that the mental condition existed. If the 1989 and 1990 veteran's files are seen, he complained of anxiety and psychiatric problems which were not treated nor taken in consideration by V.H.A. If we take in consideration as I mentioned before that the mind and body are a single organization: How is it possible to explain that a young person with an ill knee and herniated lumbar area disc's does not have the probability of mental affectation? The answer is that that is impossible; the benefit of the doubt should be given to the veteran's.

Continuation: name…

S.S. #

Page 2

Clinical Psychiatric profile and other complaints:

• Anxiety
  
• Depressive
  
• Poor sexual life
  
• Doesn't concentrate
  
• Pain in different parts
  
• Insomnia
  
• Low tolerance level
  
• Slow motor skills
  
• Doesn't desire to do things
  
• Frustrated
  
• Anxiety eating
  
• Sees colored clouds
  
• Afraid of people
  
• Tense
  
• Nothing gives pleasure
  
• Lack of energy
  
• Insecure
  
• Rage
  
  Mental Exam:
  
  
  • Appearance: Male of 39 years, chronological age that he represents; belongs to the Hispanic ethnic group. Measures 5'9" and weighs 200 pounds; has a higher BMI than average. The grooming is basic. At simple sight there are no congenital defects; limps occasionally while walking. Has goatee mustache type. No tics, mannerisms nor stereotypes.
    
  • Verbal tone: Tone is audible and articulation is clear.
    
  • Psycho motor behavior: Established visual contact and verbal acceptance.
    
  • Affection: Is adequate as expressed.
    
  • Mood: Serious, sad, depressive, preoccupied, frustrated.
    
  • Perceptions: None.
    
    Continuation: name…
    
    S.S. #
    
    Page 3
    
    
    • Process of thoughts: Coherent, relevant and directed to a goal.
      
    • Contents of the expressed: See clinical profile.
      
    • Judgment: Poor
      
    • Introversion: Accepted illness and seek help.
      
    • Intellectual level: Acceptable to his schooling
      
    • Psychotic material: None available.
      
    • Suicide ideas: None present.
      
    • Cognitive Process:
      

    a) Attention: Low, Story of good Joseph, Did 3.

    :) Concentration: Low, Subtract 7 of 100, Did 3.

    c) Memories: Remote, recent and immediate: Low

    d) Orientation: Oriented in person, space and time.

    e) Similarity Test: Did 3.

    f) Contraries Test: Did 3.

    g) Abstracts Tests: Did 3.

    h) Proverbs Tests: Did 3.

    [*]Illusions: None present.

    [*]Referential ideas: None.

    [*]Paranoid ideas: None present

    [*]General functional capacity: Poor.

    [*]Labor capacity: Poor.

    [*]Social activities: Doesn't assist.

    [*]Family activities: Doesn't assist.

    [*]Labor prognostic: Poor.

    Continuation: name…

    S.S. #

    Page 4

    [*]Habits of use of illegal substances: None.

    [*]History of use of habit forming substances or medications: None.

    [*]History of panic: None.

    [*]Tolerance level: Low.

    [*]Social judgment: Reduced.

    [*]Capacity to execute a task: None existent.

    [*]Smoking habits: None.

    [*]Alcohol habits: None

    [*]Summons History: None.

    [*]Pending law suits: none

    [*]History of repeating Academic Grade: None.

    [*]History of changes of religion: None.

    [*]History of changes of political party: None

    [*]History of sex change: None.

    [*]Goal existence: None. Not short, not medium, nor long term.

    [*]Receives benefits from insurance or money by another concept at present: Yes. Which? Social Security and V. A.

    [*]Plan of death planned by:

    Homicide: No

    Suicide: No

    [*]Patient conduct at:

    a) Neighborhood: Not active.

    B) Community: Not active.

    Continuation: name…

    S.S. #

    Page 5

    c) Family scope: Tense

    d) Town: Not active.

    e) Country: Not active.

    [*]Relations with spouse: Tense

    [*]Relations with children: Bad

    [*]Relations with parents: good.

    [*]Relations with grandparents: None.

    [*]Existence or none of malingering: No

    Diagnostic: DSM IV

    Axis I) Major chronic depression and anxiety due to chronic physical medical conditions.

    Axis II) Deferred

    Axis III) Herniated Disk C-2 -C-3, L4-5, L5-S1, Radioculopathy U/Es C-2 C-3, C3-C4 Radioculopathy L-4, L-5, S-1, S-4, L-4, L-5, HNP L/Es, L4-5, L-5, S-1. Spine DDD, DJD, Osteoarthritis in both knees, Chondromalacy in left knee, DJD.

    Axis IV) Physical, labor and emotional disability.

    Axis V) 50

    Comments:

    Patient is in psychotherapy and antidepressants and his prognosis is poor. There is no doubt that there is casual relation between his physical disabilities and conditions and mental behavior. Patient, SMR, VHA, Private Medical records were reviewed.

    lu12

    This what I got for AMC & BVA. Veteran's must comply with VA & CFR regulations. This MATERIAL EVIDENCE DECLINE was not accepted by the PSYCHIATRIC Examiner at my Dec 2007 C&P examination.

    GB

    LU12

Edited January 17, 2008 by lu12

[Pete53]

That is a powerful IME who wrote it?

[Berta]

I suggest you delete the SSA # immediately-

Veteran- what type of doctor was this-

I am a little turned off by the way he wrote this up-as it could out VA on the defensive-

there is a complete topic here as to the criteria for an IMO- which should be followed to the letter-it is under the search feature link up top

[Berta]

"Patient is in psychotherapy and antidepressants and his prognosis is poor. There is no doubt that there is casual relation between his physical disabilities and conditions and mental behavior. Patient, SMR, VHA, Private Medical records were reviewed."

There must be a full medical rationale for that statement and also a full nexus statement referencing specifics in the SMRs.

Did he give a Curriculum Vitae or at least state his medical specialty and what expertise he has to opine on your disabilites?

[lu12]

"Patient is in psychotherapy and antidepressants and his prognosis is poor. There is no doubt that there is casual relation between his physical disabilities and conditions and mental behavior. Patient, SMR, VHA, Private Medical records were reviewed."

There must be a full medical rationale for that statement and also a full nexus statement referencing specifics in the SMRs.

Did he give a Curriculum Vitae or at least state his medical specialty and what expertise he has to opine on your disabilites?

Good day Berta,

what you mean is that this is not good enough?

Diplomat & scholastic forensic license. Milwaukee, WI

Diplomat & scholastic, license psychiatrist. Milwaukee, WI

lu12

Edited January 17, 2008 by lu12

[lu12]

I suggest you delete the SSA # immediately-

Veteran- what type of doctor was this-

I am a little turned off by the way he wrote this up-as it could out VA on the defensive-

there is a complete topic here as to the criteria for an IMO- which should be followed to the letter-it is under the search feature link up top

Berta, I think I took care of the SS#.

He is a Psychiatric.

So you do think, that this statement, Dx. and opinion are not clear enough?

The affectation history of this patient arises while being active in the military service where he suffers a physical accident in one of his knees and in disc's as a result of this they are herniated in the lumbar area; since then and although in treatment he did not show improvement. Eventually he was licensed because a medical discharge physical disability?. Being out of military service he underwent treatment to improve his physical illness. From the veterans health administration V.H.A. file there is evidence of psychological complaints type to which they did not lend attention nor service and it was not until he was out of military service that he started the psychiatric treatment, in the private and V.H.A. Facilities. At present he continues making both types of treatment. What is the test demonstrating: in the first place, a human being is compound of a mind and a body, and when one is affected, the other is affected; to say that the knee and back disorders and disabilities did not affect of some form the mind is to think that the body does not have a mind; it is necessary to think that a young man that has pain, limitations and performance frustrations will affect their mental state and of that he complained, but although he did , they took it superficially as if nothing. It is true that later in 1997 he had an accident that overwhelm and aggravated the mental part, but that does discard that the mental condition existed. If the 1989 and 1990 veteran's files are seen, he complained of anxiety and psychiatric problems which were not treated nor taken in consideration by V.H.A. If we take in consideration as I mentioned before that the mind and body are a single organization: How is it possible to explain that a young person with an ill knee and herniated lumbar area disc's does not have the probability of mental affectation? The answer is that that is impossible; the benefit of the doubt should be given to the veteran's.

Clinical Psychiatric profile and other complaints:

• Anxiety
  
• Depressive
  
• Poor sexual life
  
• Doesn't concentrate
  
• Pain in different parts
  
• Insomnia
  
• Low tolerance level
  
• Slow motor skills
  
• Doesn't desire to do things
  
• Frustrated
  
• Anxiety eating
  
• Sees colored clouds
  
• Afraid of people
  
• Tense
  
• Nothing gives pleasure
  
• Lack of energy
  
• Insecure
  
• Rage
  

Axis I) Major chronic depression and anxiety due to chronic physical medical conditions.

Axis II) Deferred

Axis III) Herniated Disk C-2 -C-3, L4-5, L5-S1, Radioculopathy U/Es C-2 C-3, C3-C4 Radioculopathy L-4, L-5, S-1, S-4, L-4, L-5, HNP L/Es, L4-5, L-5, S-1. Spine DDD, DJD, Osteoarthritis in both knees, Chondromalacy in left knee, DJD.

Axis IV) Physical, labor and emotional disability.

Axis V) 50

Comments:

Patient is in psychotherapy and antidepressants and his prognosis is poor. There is no doubt that there is casual relation between his physical disabilities and conditions and mental behavior. Patient, SMR, VHA, Private Medical records were reviewed.

then dont understand???

lu12

[Berta]

"Diplomat & scholastic forensic license. Milwaukee, WI

Diplomat & scholastic, license psychiatrist"

Impressive background-please

dont allow me to discourage you- this is a detailed IMO-

but I always see the landmines and sure want to point them out-before VA does-

If you paid real money for this I am sure he could alter it to comply with the medical rationale statement and the nexus-

But by all means submit this to the VA-

they would have to provide medical rationale to knock it down anyhow-

He is completely correct here:

"How is it possible to explain that a young person with an ill knee and herniated lumbar area disc's does not have the probability of mental affectation? The answer is that that is impossible; the benefit of the doubt should be given to the veteran's"

And he makes a strong statement-

but just remember- when the VA weighs the evidence for Benefit of doubt-they are the ones who own the scale-

Send this in -by all means-

I have read the rationale why so many IMos get rejected by VA that I must honestly tell you what I thought when I read it-

My opinion does not matter LU- it is the opinion of the VA that matters-

by all means send this in- unless he would alter it a bit first-regardless send it to the VA

BY the Way- is your SSA award for the same conditions in your SC claim?

Did VA get your SSA records?