Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–79

CLINICAL VIGNETTES

Medical Impairment
(Problem Area 6)
6–80 Mastering the Kennedy Axis V

Kennedy Axis V—Medical Impairment (Problem Area 6)

100 Superior medical health; physical exam and laboratory tests are normal, including no significant weight
problem; illnesses never seem to affect him/her; few if any problems with even common medical problems (e.g.,
colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to medical
problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a
multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms.
90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more
than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical
problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor
visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally
needs over-the-counter medication.
80 If medical problems are present, they are transient and cause minimal impairment in
social, occupational, or school functioning; somewhat more than average missing of work or school due to
medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a
prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to
organic problems.
70 Mild medical problems which may cause some difficulty in social, occupational, or school
functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from
work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing
despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or
symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia;
epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a
year; takes prescription medication on a daily basis.
60 Moderate difficulty in social, occupational, or school functioning due to medical problems;
missing no more than about 1 month a year from work or school due to medical problems (e.g., moderate asthma,
moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia secondary to
polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia, mild angina
on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po medications (e.g.,
injections, blood levels, nebulizer, physical therapy); needs bladder bag.
50 Serious impairment in social, occupational, or school functioning due to medical problems;
serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing
aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment is needed for
mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a car.
40 Major impairment in several areas (such as work or school or family relations) because of medical
problems; missing about 2 months a year or more from work or school due to medical problems; medical problems
result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses,
hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.
30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical
problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as
metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart,
lung, kidney, liver); on dialysis for kidney failure.
20 Major medical problems confine him/her to bed all of the time and intensive, continuous
medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic
cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart,
lung, kidney, liver); quadriplegic.
10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support
would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma.
NR Not rated
 Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–81

Medical Impairment
NAME: Abbott, George
AGE: 35
Pt. has no acute or chronic medical problems. He is slightly overweight. He exercises sporadically. He has no
more than average difficulty with common medical problems, which he treats with over-the-counter
medications. He occasionally misses work due to medical problems.

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Ratings

Medical Impairment = 90
1) PSY = 100 2) SOC = 90 3) VIO = 90 4) ADL = 90 5) SAb = 80 6) MED = 90 7) ANC = 90
GAF Eq = 95
Dangerousness Level = 80

Explanation of Medical Impairment Rating

No acute or chronic medical problems = 90 or better

Slightly overweight = 90
Exercises sporadically (mildly negative factor)
No more than average difficulty with common medical problems = 90
Occasionally takes over-the-counter medications = 90
Occasionally misses work due to medical problems = 90
6–82 Mastering the Kennedy Axis V

Medical Impairment
NAME: Butler, Eleanor
AGE: 47
Pt. has mild cerebral palsy with left-sided weakness. The cerebral palsy is associated with a mildly to
moderately distorted posture and moderate difficulty walking. Over many years, the cerebral palsy has led to
degenerative back disease with associated moderate, chronic back pain. The cerebral palsy is also associated
with some difficulty swallowing, and the patient has experienced a couple of choking episodes. This has
made it necessary for the pt. to be on a chopped diet. She has a history of hypertension; however, it is well
controlled without medication.

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Ratings

Medical Impairment = 60
1) PSY = 40 2) SOC = 50 3) VIO = 60 4) ADL = 50 5) SAb = 80 6) MED = 60 7) ANC = 70
GAF Eq = 50
Dangerousness Level = 55

Explanation of Medical Impairment Rating

Mild cerebral palsy = 60

Moderate difficulty walking = 60
Moderate chronic back pain = 60
Some difficulty swallowing = 70
History of hypertension = 85
 Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–83

Medical Impairment
NAME: Cross, Anthony
AGE: 24
Pt. has no acute medical problems. Pt. has mild hyperlipidemia. Mild diabetes (treated with daily oral
hypoglycemic medication). Mild obesity. He has frequent gastrointestinal upset (treated fairly well with over-
the-counter antacids).

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Ratings

Medical Impairment = 70
1) PSY = 45 2) SOC = 60 3) VIO = 50 4) ADL = 80 5) SAb = 95 6) MED = 70 7) ANC = 80
GAF Eq = 60
Dangerousness Level = 50

Explanation of Medical Impairment Rating

No acute medical problems = 90 or better

Mild hyperlipidemia = 90
Mild diabetes (treated with oral hypoglycemic medication) = 70
Mild obesity = 90
Frequent gastrointestinal upset (fairly well treated with over-the-counter antacids) = 85
6–84 Mastering the Kennedy Axis V

Medical Impairment
NAME: Davis, Richard
AGE: 45
Pt. has no acute medical problems. Last year, he had a positive PPD (tuberculosis skin test). He had no
symptoms of lung disease and his chest X ray was negative. He was given prophylactic treatment with INH
(isoniazid) and vitamin B6 for 6 months.

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Ratings

Medical Impairment = 80
1) PSY = 20 2) SOC = 35 3) VIO = 50 4) ADL = 25 5) SAb = 80 6) MED = 80 7) ANC = 70
GAF Eq = 35
Dangerousness Level = 35

Explanation of Medical Impairment Rating

No acute medical problems = 90 or better

Positive PPD last year. No evidence of active disease and prophylactic treatment given = 80 or better
 Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–85

Medical Impairment
NAME: Griffin, Paul
AGE: 30
Pt. is being treated with a thyroid supplement for his mild hypothyroidism. Pt. had a head injury during an
auto accident 3 years ago; however, there is no indication that he has any residual brain damage.
Electroencephalogram (asleep and awake) was normal. Pt. has mild to moderate acne. Pt. is mildly obese.
Pt. has no known drug allergies.

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Ratings

Medical Impairment = 70
1) PSY = 40 2) SOC = 50 3) VIO = 40 4) ADL = 55 5) SAb = 30 6) MED = 70 7) ANC = 50
GAF Eq = 45
Dangerousness Level = 30

Explanation of Medical Impairment Rating

Mild hypothyroidism = 70 or better

History of head injury noted with no known damage (no effect on rating)
Mild to moderate acne = 85
Mildly obese = 80
No known drug allergies noted (no effect on rating)
6–86 Mastering the Kennedy Axis V

Medical Impairment
NAME: Hope, Allen
AGE: 56
Pt. is medically stable; however, he is wheelchair-bound due to left hemiparesis and osteoarthritis. He has
moderate dysphagia, which requires monitoring during meals. Pt. is moderately obese with moderate
hyperlipidemia. Moderate hypothyroidism (treated with daily thyroid replacement). Moderate COPD
secondary to smoking.

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Ratings

Medical Impairment = 35
1) PSY = 50 2) SOC = 45 3) VIO = 55 4) ADL = 50 5) SAb = 65 6) MED = 35 7) ANC = 70
GAF Eq = 50
Dangerousness Level = 55

Explanation of Medical Impairment Rating

Medically stable = 90 or better

Wheelchair bound due to hemiparesis and osteoarthritis = 30
Moderate dysphagia; requires monitoring during meals = 60
Moderately obese = 75
Moderate hyperlipidemia = 75
Moderate hypothyroidism = 60
Moderate COPD secondary to smoking = 60
 Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–87

Medical Impairment
NAME: Palmer, John
AGE: 44
Pt. has no significant medical problems except tardive dyskinesia. The tardive dyskinesia was manifested by
mild to moderate irregular movements of his tongue. These included occasionally involuntarily sticking his
tongue out of his mouth. Pt. denied being bothered by the tardive dyskinesia. Pt. was switched to Clozaril,
and the tardive dyskinesia disappeared after a few months.

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Ratings

Medical Impairment = 80
1) PSY = 40 2) SOC = 50 3) VIO = 70 4) ADL = 50 5) SAb = 50 6) MED = 80 7) ANC = 70
GAF Eq = 55
Dangerousness Level = 50

Explanation of Medical Impairment Rating

No significant medical problems = 90 or better

Mild tardive dyskinesia, in remission = 80
Not bothered by the tardive dyskinesia (this is a positive factor)
6–88 Mastering the Kennedy Axis V

Medical Impairment
NAME: Powers, Jennifer
AGE: 35
Pt. is in excellent health. She has no acute or chronic medical problems. She is in the normal weight range
for her height. She exercises on a regular basis. She is not on medication except a daily multivitamin. She
almost never misses work due to medical problems.

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Ratings

Medical Impairment = 100

1) PSY = 90 2) SOC = 100 3) VIO = 100 4) ADL = 100 5) SAb = 100 6) MED = 100 7) ANC = 100
GAF Eq = 100
Dangerousness Level = 90

Explanation of Medical Impairment Rating

In excellent health = 100

No acute or chronic medical problems = 90 or better
Normal weight (this is a positive factor)
Exercises on a regular basis (this is a positive factor)
No medication is required for any illness (this is a positive factor)
Almost never misses work due to medical problems = 90 or better
 Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–89

Medical Impairment
NAME: Sawyer, Barbara
AGE: 42
Pt. has had insulin-dependent diabetes mellitus for the last 5 years. Her diabetes is severe and very brittle; her
blood sugars often range from 200 to 450 mg/dL during a single day. Due to the extreme variations in her
blood sugar and poor compliance with her medication and diet, she requires supervision with her treatments
at least twice daily, as well as ongoing monitoring to ensure that her diabetes is not dangerously out of
control. Pt. had a head injury in 1970 that resulted in a hairline fracture. The fracture healed with no
subsequent problems. Pt. is sensitive to Haldol.

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Ratings

Medical Impairment = 50
1) PSY = 50 2) SOC = 80 3) VIO = 50 4) ADL = 60 5) SAb = 80 6) MED = 50 7) ANC = 80
GAF Eq = 60
Dangerousness Level = 50

Explanation of Medical Impairment Rating

Severe diabetes mellitus (requiring two to three injections every day) with continuing poor control = 50
Requires supervision with her treatments at least twice daily (this is a negative factor)
Requires ongoing monitoring to ensure that her diabetes is not dangerously out of control = 50
(more than routine daily monitoring)
Head injury in 1970 is noted (no effect on the rating)
Sensitivity to Haldol is noted (no effect on the rating)
6–90 Mastering the Kennedy Axis V

Medical Impairment
NAME: Sellers, Mark
AGE: 63
Pt. has temporal lobe epilepsy, which is well controlled with medication. Pt. is felt to be a mild dysphagia
risk. He is considered to be a high risk for falls due to his unsteady gait. Sometimes he has problems with skin
integrity (pressure sores) because he is frequently confined to a Geri Chair.

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Ratings

Medical Impairment = 40
1) PSY = 30 2) SOC = 45 3) VIO = 40 4) ADL = 30 5) SAb = 85 6) MED = 40 7) ANC = 80
GAF Eq = 35
Dangerousness Level = 40

Explanation of Medical Impairment Rating

Well-controlled temporal lobe epilepsy = 70

Mild dysphagia risk = 70
High risk for falls due to unsteady gait with need to frequently be in a Geri Chair = 40
Occasional skin integrity problems = 60 or better
 Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–91

Medical Impairment
NAME: Stewart, Helen
AGE: 58
Pt. is terminally ill with metastatic breast cancer that has spread to her liver. She has lost nearly 50 pounds.
She is having problems with liver failure, and her heart is also showing signs of failing. She is confined to her
bed and on continuous IV treatment, including potent narcotics to control her pain. Recently she was
transferred out of the hospital back to her home with her family. Hospice nurses come in twice daily to
monitor her medications and progress.

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Ratings

Medical Impairment = 20
1) PSY = 70 2) SOC = 90 3) VIO = 70 4) ADL = 90 5) SAb = 100 6) MED = 20 7) ANC = 90
GAF Eq = 80
Dangerousness Level = 35

Explanation of Medical Impairment Rating

Late stages of a terminal illness = 20 or worse

Liver failure and heart showing signs of failing = 20 or worse
Confined to bed with continuous IV treatment, including narcotics = 30 or worse
Qualified for hospice care as a terminally ill person = 30 or worse
6–92 Mastering the Kennedy Axis V

Medical Impairment
NAME: White, Janet
AGE: 43
Overall, pt.’s health is fairly good. She had a gastric resection about 10 years ago because of a peptic ulcer.
She has no residual problems, except for heartburn that is relieved by occasional prn antacid. She is mildly
obese; however, she exercises on a regular basis. Recently she started on a diet. She is edentulous.

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Ratings

Medical Impairment = 85
1) PSY = 75 2) SOC = 70 3) VIO = 90 4) ADL = 85 5) SAb = 80 6) MED = 85 7) ANC = 65
GAF Eq = 80
Dangerousness Level = 65

Explanation of Medical Impairment Rating

Overall fairly good health = 80 or better

Gastric resection 10 years ago, uses occasional prn antacid = 85
Mildly obese; however, exercises regularly = 85
Edentulous = 90
 Scoring Clinical Vignettes (Self-Examination)—Medical Impairment 6–93

Medical Impairment
NAME: Woods, Gilbert
AGE: 28
Pt. has no acute or chronic medical problems. He is not significantly overweight. He does not exercise or take
any active steps to take care of his health.

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Ratings

Medical Impairment = 90
1) PSY = 20 2) SOC = 35 3) VIO = 35 4) ADL = 30 5) SAb = 90 6) MED = 90 7) ANC = 70
GAF Eq = 30
Dangerousness Level = 35

Explanation of Medical Impairment Rating

No acute or chronic medical problems = 90 or better

Not significantly overweight (this is a positive factor)
Not doing anything to actively take care of his health (this is a negative factor)
Notes