Help with mental health exam

BrkylnNick

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Registered Member
Hi, first off, I’m new to this forum so sorry if I’m posting in the wrong place. I’m currently in Fort Belvoir WTU and have finished my C&P exams with the exception of audiology(they’re super backed up). I’m curious as to if anyone can tell me if they think these C&P exam notes indicate an unfitting condition as well as a possible rating. I have read the rating criteria and the occupational/social impairment section would make one think 10% but my panic attacks being almost everyday and with my other symptoms I think I should be more around 30%. The exam notes follow.

Mental Disorders

(other than PTSD and Eating Disorders) Disability Benefits Questionnaire

Name of patient/Veteran:

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

ICD code: F41.10

If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Panic Disorder ICD code: F41.0

Mental Disorder Diagnosis #2: Adjustment Disorder with Mixed Anxiety and Depressed Mood

ICD code: F43.23

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): see Veteran's medical record for pertinent medical conditions.

2. Differentiation of symptoms

------------------------------

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

VA Health Summary (Continuity of Care Document)

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[X] Yes [ ] No

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

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

If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses

panic attacks are attributed to the Panic Disorder; symptoms of insomnia and attention issues, social isolation can be attributed to either conditions, all other symptoms are attributed to the Adjustment Disorder with Mixed Anxiety and Depressed Mood.

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 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 occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder?

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

If no, provide reason

overlapping symptoms attributes to Veteran's social and occupational impairment.

c. If a diagnosis of TBI exists, is it possible to differentiate which

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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

2. History

----------

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

Veteran was born and raised in New Jersey to an intact union. He has two sisters. Veteran denied history of physical, sexual, and emotional

abuse.

Veteran is single and lives in the barracks. He does not have any children. Socially, "I use to work out a lot but since I got hurt, I can't do it."

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

Educationally, Veteran denied academic and disciplinary problems throughout his educational years. He went to high school and wrestled, box, and played football. "I played every sports." He graduated on

time and worked until he joined the military in 2016."

Veteran joined the US Army in 2016. His MOS is 15Y. Veteran is currently stationed at Fort Belvoir, VA and has been there since May

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2019. Veteran was stationed in Korea. Veteran indicated that a couple of his friends killed themselves when he was in Korea. These friends were not residing in the same facility as Veteran. He also indicated that a friend of his was killed while on leave. Veteran denied combat deployments.

Veteran is currently in the medical board process which was prompted due right shoulder dysfunction.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):

Pre-Military: Veteran denied family and personal history of mental health problems.

Military: Veteran indicate that he has been having trouble falling

asleep. "I'm feeling anxious all the time. I having been having panic attacks for the last couple of years." Veteran indicated that he is

unsure of the triggers to his attacks. He noted that his anxiety

attacks have worsened. During these attacks, he expressed having difficulties breathing becomes sweaty, and has chest tightness and rapid heart race. He stated that these attacks typically last for 30 minutes.

"I usually can't sleep when I have them. I don't enjoy anything that I

use too and don't want to be around people. I get angry easily and a

little bit paranoid." Veteran noted that he does not know what happened in Korea (2017-2019). He indicated that it was stressful in Korea. "It

was everything, work was high tempo, we were doing drills in case of war with N. Korea." Veteran reported to difficulty focusing. He noted that

he has tried to return to school but has not been able to focus. "When

my anxiety gets bad, I don't eat. My weight doesn't really change." Per Veteran, he noticed that these issues emerged after he injured his shoulder in Korea. However, he stated that he has always had sleep problems since he entered service. He noted that he has trouble falling asleep. Veteran also stated that he has nightmares and does not recall the content of his nightmares. Per Veteran, he has been having nightmares for a year.Veteran indicated that he does not like to be around crowds. Veteran indicated that he avoid places or situations where he feels will trigger the panic attacks. He reported to lack of

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trust.

Veteran is currently seeing a social worker and a psychiatrist at Fort Belvoir, VA. He is being treated with Cymbalta, Propanol, and Minipres. Veteran's medical record is indicative of mental health treatment. He has been diagnosed with Adjustment Disorder with Mixed Anxiety and Depressed Mood and Panic Disorder.

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

Veteran denied legal issues.

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

Veteran denied substance abuse.

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] 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 establishing and maintaining effective work and social relationships

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

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4. Behavioral observations

--------------------------

Veteran was cooperative during the examination.

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: ---------------------------------------------------

No remarks provided.

****************************************************************************

Miscellaneous

Disability Benefits Questionnaire

Name of patient/Veteran:

Please use this DBQ to address 1151 requests, or other issues that are not specifically addressed by specific DBQs such as Individual Unemployability (UI).

Mental health - Separation Health Assessment Disability Benefits Questionnaire

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* Internal VA or DoD Use Only*

Was a DD Form 2807-1, Report of Medical History, completed by the Service member and available for review at the time of this examination? [x] Yes [] No [ ] N/A

Any changes to his/her health status since DD 2807-1 completed? [ ] Yes[x] No[] N/A

(Proposed) Date of separation from active service: medical board 1. Medical record review

-------------------------

Was the Veteran's VA claims file reviewed?

[x] Yes [ ] No

2. Medical history (Review of Systems) --------------------------------------

1. Psychiatric: [x] Yes[ ] No

#1. Claimed Conditions: Adjustment Disorder with Mixed Anxiety and Depressed

Mood, insomnia, panic disorder w/shortness of breath, sleep disorder, unspecified.

Onset: History:

Prognosis: Unknown. #2. Claimed Condition: Onset:

History:

Prognosis:

(Please follow format if more claims are being addressed)

PTSD SCREEN PC-PTSD -------------------

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In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:

1. Have had nightmares about it or thought about it when you did

not want to?

[] Yes [x]

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

[] Yes [x] No

3. Were constantly on guard, watchful, or easily startled? [] Yes [x] No

4. Felt numb or detached from others, activities, or your surroundings?

[] Yes [x] No

Depression screen: PHQ2

-----------------------

Over the past two weeks, how often have you been bothered by any

of the following problems?

Little interest or pleasure in doing things.

[] 0 = Not at all [] 1 = Several days [] 2 = More than half the days [x] 3 = Nearly every day

Feeling down, depressed, or hopeless.

[] 0 = Not at all [] 1 = Several days [x] 2 = More than half the

days [x] 3 = Nearly every day

Brief Suicide Risk Assessment: 6

-----------------------------

- (Perform if score positive on Depression or PTSD screens)

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Are you feeling hopeless about the present or future? [] Yes [x] No

Have you had thoughts about taking your life - if yes - when did

you have these thoughts, and do you have a plan to take your life?

[] Yes [x] No

Have you ever had a suicide attempt? [] Yes [x] No

3. Physical Exam -----------------

1. Psychiatric (Specify any personality deviation) [x] Normal [] Abnormal [ ] Not examined

5. Diagnosis:

-------------

#1. Claimed conditions: Adjustment Disorder with Mixed Anxiety and Depressed Mood, insomnia, panic disorder w/shortness of breath, sleep disorder, unspecified.

Diagnosis/Rationale: Veteran symptoms meet the DSM-5 diagnostic criteria Panic Disorder and Adjustment Disorder with Mixed Anxiety and Depressed Mood

#2. Claimed condition: Diagnosis/Rationale:

(for additional Claim/diagnosis, please follow above format)

6. Remarks, if any: -------------------

All additional DBQs found to be necessary completed as appropriate at

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time

of signing this DBQ? [x] Yes[ ] No

/es/ ANGELINA B DICKERSON PSYCHOLOGIST

Signed: 07/26/2019 13:06
 

oddpedestrian

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10-30% I would fight for 30% from the VA not sure if you can get it unfitting.
 

chaplaincharlie

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When your ratings come back you can ask for a VARR. As written, this condition will likely be fitting.
 

BrkylnNick

New Member
Registered Member
Thank you gentlemen, do you think my shoulder condition is unfitting? Grade 3 A/C seperation with pretty bad residuals. Nerve damage and a lot of popping that was even audabile to the examiner during the C&P exam. P3 no gear profile as well as not being able to ruck or have any weight bearing on my right shoulder. No published notes from the C&P exam still and that was two weeks ago! Go figure. Any help is much appreciated
 

BrkylnNick

New Member
Registered Member
When your ratings come back you can ask for a VARR. As written, this condition will likely be fitting.
Thank you gentlemen, do you think my shoulder condition is unfitting? Grade 3 A/C seperation with pretty bad residuals. Nerve damage and a lot of popping that was even audabile to the examiner during the C&P exam. P3 no gear profile as well as not being able to ruck or have any weight bearing on my right shoulder. No published notes from the C&P exam still and that was two weeks ago! Go figure. Any help is much appreciated

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