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UPDATE AGAIN***UPDATE on RFE for my husband
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AirForceVetsWife
The claim is complete. They've mailed our packet.
on SC disabilities list on ebenefits it used to say Major Depressive Disorder and now it says "Major Depression (Previously diagnosed as Major Depressive Disorder)" Is that a bad sign? or are they calling MDD Major depression now? Everything I've read it says Major depression IS major depressive disorder.
Now I'm worried that this is a reduction thing.
This is what the American Psychiatric Association says:
Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.
Depression symptoms can vary from mild to severe and can include:
Symptoms must last at least two weeks for a diagnosis of depression.
I think I'm just getting myself super hyped up
Ok, I really think I'm just worrying myself for nothing because it says MDD is also known as Major Depression
Ok, sorry you all...I just wanted to be sure to update you all. I got his C&P this morning.
I was feeling good about it because the social/work impairment that was checked was the same as his first C&P back in 2013 when he was initially rated at 70%. Well, looking at the ratings...the one that was checked then and now is under 50%....so now I'm confused.
The biggest thing I see, is at the end of the new exam, the doctor put "His current mental health status is the progression of his major depressive disorder" So that doesn't show that he's better
But, here's the C&P with personal info redacted
Mental Disorders
(other than PTSD and Eating Disorders)
Disability Benefits Questionnaire
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
SECTION I:
----------
1. Diagnosis
------------
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-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: MAJOR DEPRESSION
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): HTN, HX OF TACHYCARDIA, HX OF
RIGHT SHOULDER SURGERY.
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 occupational and social impairment, is it possible to
differentiate which impairment is caused by each mental disorder?
[ ] Yes [ ] No [X] Not Applicable (N/A)
c. If a diagnosis of TBI exists, is it possible to differentiate which
occupational and social impairment indicated above is caused by the TBI?
[ ] Yes [ ] No [X] Not Applicable (N/A)
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder
[X] CPRS
[X] Other (please identify other evidence reviewed):
PRIOR CXP EXAMS.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
, WAS DRIVEN HERE BY HIS WIFE AS HE
DOES NOT DRIVE MUCH ON HIGH WAY.HE IS MARRIED SINCE 2008, ONLY
MARRIAGE,HAS 2 DAUGHTERS.THIS VET WAS AIR FROCE VET,SERVED FROM 2007 TO
2012.DURING HIS CARRIER, HE WAS STATE SIDE,NOT IN ANY WAR ZONE. HIS
MOTHER AND SISTER LIVE LOCALLY.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
SINCE DC FROM AIR FORCE, HE HAD 5 JOBS,HIS LONGEST JOB WAS FOR TRACTOR
SUPPLY FOR 3 YRS. SINCE LAST ONE YR, HE IS WORKING FOR LOWES FULL
TIME.
HE WAS NEVER FIRED FROM ANY JOB, WENT FOT BETTER PAYING JOB.MANY OF HIS
JOBS WERE SEASONAL JOBS.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
HE IS CURRENTLY NOT IN ANY MH CARE.HE DID RECEIVE MH CARE WHILE IN AIR
FORCE.HE HAS PROBLEMS WITH SLEEP, DIFFICULTY FALLING A SLEEP, WAKING UP
AND SOME TIME DIFFICULTY FALLING A SLEEP. DAY TIME HE FFELS TIRED. HE
ISOLATES HIM SELF FROM OTHERS.IN THE PAST HE USED TO ENJOY OUT DOOR BUT
NOT ANY MORE, LOST INTEREST.WHEN HE IS DEPRESSED, HE STAYS BY HIM SELF
AND AVOIDS OTHERS.HE DOES NOT LIKE TO BE OUT AWAY FROM HOME, HE FEELS
INSECURED AND BECAUSE OF THIS HE FEELS ANGRY AT HIM SELF.AT WORK HE
TRIES TO PUT SHOW THAT HE IS FEELING GOOD BUT IN REALITY, HE DOES NOT
FEEL GGOD. IF HE HEARS CRYING BABY, HE WANTS TO GO HOME AND BE WITH HIS
KIDS.AT HOME HE DOES NOT LIKE TO INTERACT WITH HIS WIFE AND KIDS BUT
BEING AT HOME HE FEELS VERY SECURED.OFF AND ON HE FEELS WORTHLESS, AND
AT WORK HE FEELS THAT HE IS GOING TO GET FIRED AND THAT MAKE HIS JOB
HARDER TO DO.
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:
NA
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] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or
a
worklike setting
4. Behavioral observations
--------------------------
ALERT,ORIENTEDX3,COOPERATIVE,POOR EYE CONTACT. AFFECT IS CONSTRICTED,
DYSPHORIC MOOD. RATE OF SPEECH NORMAL, GOAL DIRECTED. NO AH/VH OR ANY OTHER
PERCEPTUAL DISTURBANCES. NOT SUICIDAL OR HOMICIDAL. NO COGNITIVE DEFICIT.
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Yes [X] No
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
---------------------------------------------------
THIS VET CONTINUES TO EXPERIENCED SXS OF DEPRESSION SUCH AS INSOMNIA, LACK
OF
ENERGY, LACK OF INTEREST, ANHEDONIA, WORTHLESS, SOCIAL ISOLATION. THESE HAS
AFFECTED HIS JOB BUT SOME HOW HE COULD KEEP THE JOB, WITH UNDERSTANDING THAT
HE HAS TO SUPPORT HIS FAMILY.
HIS CURRENT MENTAL HEALTH STATUS IS THE PROGRESSION OF HIS MAJOR DEPRESSIVE
STATE.
/es/ PRAMOD A SHAH, MD
Signed: 05/10/2019 10:45
This was his first one in 2013
------------
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: Major Depressive Disorder
ICD code: 000
Indicate the Axis category:
[X] Axis I [ ] Axis II
b. Axis III - medical diagnoses (to include TBI): Hypertension,,Tachycardia
ICD code: 000
c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
Moderate - financial
d. Axis V - Current global assessment of functioning (GAF) score: 55 - 60
2. Differentiation of symptoms
------------------------------
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?
No response provided.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes[X] No[ ] Not shown in records reviewed
d. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
No response provided.
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 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
------------------
If any records (evidence) were reviewed, please list here:
VBMS, CPRS
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Veteran denies family history of mental illness.He is married with 2
children (2,1 year old) in Paris,Tn. Due to his depressive symptoms
they are having domestic issues.He tends to isolate a great deal.He
has
very few activities he does that he enjoys to do.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The Veteran graduated from High School. he served in the Air Force
from
7/24/2007 - 3/27/2012. He was not in combat.He was honorably
discharged
at E4 rank.Since discharge he has been working in the receiving
department of a tractor supply company in Paris,Tn. The Veteran's
productivity and reliability have been decreasing both at work and at
home.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
He denies pre - military mental problems. His depressive symptoms
gradually came in while in the service. By Christmas 2011 he notice
fatigue, sadness, poor concentration.His depression increased over the
next many months.His depressive symptoms are manifested by feelings
sad
most of the day, ahedonia,difficulty sleeping, fatigue, poor self
esteem, decreased libido and difficulty concentrating.He sought help
for these symptoms by Nov.2011 while in the service. The first
documentation I could find was in his problem list from his VBMS note
on 11/16/2011.Because of cardiac problems he says he was not started
on
antidepressant medication.He felt it was very stressful in the
military
not to be able to do mechanic work in service because of his right
should problems. He felt this stress was a possible trigger for his
depression.He says he did see a counselor while in the service. Since
discharge he has continued to have symptoms of depression. He is not
getting mental health treatment nor dis he on any psychotropic
medication.There is a mention of ADHD in his record but at the present
time he feels this is not an issue for him. He is not hyperactive.
His
concentration difficulty appears more related to his general
depression
at the present time. He denies manic - like episodes.
Mental Status Evaluation today.
General appearance is WNL.
Veteran showed no unusual gestures or grimaces.
Affect was flat.
The veteran is oriented in all 3 spheres.
General information WNL.
Recent and remote memory intact.
Number sense WNL including subtracting serial sevens.
Veteran denied auditory and visual hallucinations and/or delusions.
Veteran denied wanting to harm or kill himself or others.The Veteran
denied suicidal or homicidal ideation or intent.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
None.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
He denies illegal drug use and rarely has an alcoholic
beverage.Veteran
denies any previous alcohol or drug treatment.
f. Sentinel Event(s) (other than stressors):
No response provided.
g. Other, if any:
No response provided.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that 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] Flattened affect
[X] Difficulty in understanding complex commands
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or
a
worklike setting
[X] Inability to establish and maintain effective relationships
4. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders
that are not listed above?
[ ] Y
es[X] No
5. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
6. Remarks, if any:
-------------------
The criteria contained in DSM-1V are being used until the time of
transition to DSM-V.I suggested the Veteran seek Mental Health treatment
for his Depression symptoms.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: Reed, Jeremy Scott
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
a. Was the Veteran's VA claims file reviewed? Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
VBMS, CPRS.
MEDICAL OPINION SUMMARY
-----------------------
So great...they checked less boxes this time...this really doesn't look good...
Edited by AirForceVetsWifeLink to comment
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