Results Of My Mental Health Exam

[vern2]

Attached are results of a Menatal health exam for contentions that I did not even claim, anxiety and depression. I am not sure what all this means, perhaps some of the more experienced can explain what this means. I tried to uplaod as an attachment (Word 10 document but would not allow it.)

1. Diagnosis

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a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes [ ] No

If the Veteran currently has one or more mental disorders that conform to

DSM-IV criteria, provide all diagnoses:

Diagnosis #1: Adjustment Disorder With Mixed Anxiety and Depressed Mood

ICD code: 309.28

Indicate the Axis category: [X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): Per VA policy, the

undersigned does not have the necessary credentials to speak diagnostically with

regard to TBI.

c. Axis IV - Psychosocial and Environmental Problems (describe, if any):

Problems with primary support group

d. Axis V - Current global assessment of functioning (GAF) score: 70

2. Differentiation of symptoms

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a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

b. Is it possible to differentiate what symptom(s) is/are attributable to each

diagnosis?

[ ] Yes [ ] No [X] Not applicable (N/A)

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

Comments, if any: Per VA policy, the undersigned does not have the necessary

credentials to speak diagnostically with regard to TBI.

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)

[ ] No mental disorder diagnosis

[ ] A mental condition has been formally diagnosed, but symptoms are not

severe enough either to interfere with occupational and social

functioning or to require continuous medication

[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

[ ] Occupational and social impairment with occasional decrease in work

efficiency and intermittent periods of inability to perform occupational

tasks, although generally functioning satisfactorily, with normal routine

behavior, self-care and conversation

[ ] Occupational and social impairment with reduced reliability and

productivity

[ ] Occupational and social impairment with deficiencies in most areas, such

as work, school, family relations, judgment, thinking and/or mood

[ ] Total occupational and social impairment

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?

Per VA policy, the undersigned does not have the necessary credentials to

speak diagnostically with regard to TBI.

SECTION II:

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Clinical Findings:

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1. Evidence review

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If any records (evidence) were reviewed, please list here: C-file. VA medical

records.

2. History

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NOTE: Initial examinations require pre-military, military, and post-military

history. If this is a review examination only indicate any relevant

history since prior exam.

a. Relevant Social/Marital/Family history (pre-military, military, and postmilitary):

"I've been married for going on 34 years - it could be going a lot

better - my wife says I'm angry and depressed and having issues, which

started in the last year since my health went downhill - I had heart surgery this May,

and I suffer from erectile dysfunction, which doesn't make me feel very good

and is depressing; I have one adult daughter from a previous marriage - when I got

divorced from my previous wife, I didn't see or talk to my daughter for the

next 14 years because I moved away, and then I figured they didn't want me in

Their lives; I get along great with the people I know outside of family."

b. Relevant Occupational and Educational history (pre-military, military, and

post-military): "I took an early retirement due to my health in December of

2011 - before that I worked full-time as a community readiness specialist in

civil service for 14 years and retired because I was having heart problems and

had gotten up to 279 pounds - it was a struggle to get through a day."

c. Relevant Mental Health history, to include prescribed medications and family

mental health (pre-military, military, and post-military): "I'm seeing

a Social Worker who has diagnosed me with Adjustment Disorder With Mixed Anxiety and

Depressed Mood, and I'm prescribed Prozac."

d. Relevant Legal and Behavioral history (pre-military, military, and postmilitary):

Denied and not found in available records.

e. Relevant Substance abuse history (pre-military, military, and post-military):

Denied and not found in available records.

f. Sentinel Event(s) (other than stressors): Denied and not found in available

records.

g. Other, if any: Mental Status: Alert and fully oriented. Speech normal in

rate, tone, and syntax. Thought content and process unremarkable. Mood

presented as euthymic with full and reactive affect. No observable

responsiveness to internal stimuli. Hallucinations and delusions denied.

Suicidal and homicidal ideation, intent, and planning denied. No observable

impairment in attention, concentration, or memory.

Results of the Montreal Cognitive Assessment were consistent with very mild

cognitive impairment (a total score of 25).

3. Symptoms

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For VA rating purposes, check all symptoms that apply to the Veteran's

diagnoses:

[X] Depressed mood

[X] Anxiety

[ ] Suspiciousness

[ ] Panic attacks that occur weekly or less often

[ ] Panic attacks more than once a week

[ ] Near-continuous panic or depression affecting the ability to function

independently, appropriately and effectively

[ ] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent events

[ ] Impairment of short- and long-term memory, for example, retention of only

highly learned material, while forgetting to complete tasks

[ ] Memory loss for names of close relatives, own occupation, or own name

[ ] Flattened affect

[ ] Circumstantial, circumlocutory or stereotyped speech

[ ] Speech intermittently illogical, obscure, or irrelevant

[ ] Difficulty in understanding complex commands

[ ] Impaired judgment

[ ] Impaired abstract thinking

[ ] Gross impairment in thought processes or communication

[ ] Disturbances of motivation and mood

[ ] Difficulty in establishing and maintaining effective work and social

relationships

[ ] Difficulty in adapting to stressful circumstances, including work or a

worklike setting

[ ] Inability to establish and maintain effective relationships

[ ] Suicidal ideation

[ ] Obsessional rituals which interfere with routine activities

[ ] Impaired impulse control, such as unprovoked irritability with periods of

violence

[ ] Spatial disorientation

[ ] Persistent delusions or hallucinations

[ ] Grossly inappropriate behavior

[ ] Persistent danger of hurting self or others

[ ] Neglect of personal appearance and hygiene

[ ] Intermittent inability to perform activities of daily living, including

maintenance of minimal personal hygiene

[ ] Disorientation to time or place

4. Other symptoms

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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, if any:

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The diagnoses above, if any, are based on DSM-IV diagnostic criteria.

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the

Veteran's application.

I am not disputing any of this-Yet! I want to see where the VA is trying to go with this exam. Mental Health issues are recent, manily anxiety and depression over declining health.

[MRRRR5]

My opinion only, this looks to be in the 10 to 30% range for rating.

[Berta]

Question:

The C & P asks about TBI

"Comments, if any: Per VA policy, the undersigned does not have the necessary

credentials to speak diagnostically with regard to TBI."

Was your claim for TBI?

[vern2]

Question:

The C & P asks about TBI

"Comments, if any: Per VA policy, the undersigned does not have the necessary

credentials to speak diagnostically with regard to TBI."

Was your claim for TBI?

No, I did not eve file for any mental issues, this is something VA added after they started finally working my claim after 14 months.

[Berta]

Gee, that is odd.......... then again

"this is something VA added after they started finally working my claim after 14 months."

The long waits and frustrations of the claims process would give anyone mental health issues in my opinion!

Seriously, what was your initial claim for?

[vern2]

Increase to existing claim for htn, and secondary for heart disease, ED, sleep apnea and reopen rhinitis claim. My review of the exam results reveals 10% for minor impairment for MH issues, and I agree, dealing with VA is enough to cause anyone stress and anxiety.

[JoeyAnderson]

The RO will often ask for a MH exam if you claim insomnia, since it is a symptom of many MH disorders. Usually it's good for the vet b/c MH disorders are rated separately, so if you have one you didn't know you had, as in your case, you can end up with a possible bump up in your total percentage (depending on how the 'VA math' works out).

I'd give 2:1 odds it'll be 10%.

Joey