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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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Sidney56

Received C&p Results......

Question

I have an appeal at the AMC for an increase due to mood disorder and filed for IU.

I just received a copy of the exam completed August 16,2010 and want to know what you

guys think about it. I highlighted in RED some of the things that I would like some input on.

Here are the results:

COMPENSATION AND PENSION EXAMINATION

MENTAL DISORDERS (EXCEPT PTSD AND EATING DISORDERS)

.............................................................................

REVIEW OF MEDICAL RECORDS

.............................................................................

C-FILE WAS: Reviewed

MEDICAL RECORDS WERE: Reviewed

MEDICAL HISTORY

................

IS THIS EXAMINATION FOR REVIEW OF AN ALREADY SERVICE-CONNECTED MENTAL DISORDER: Yes

PAST MEDICAL HISTORY

.....................

SIGNIFICANT NON-PSYCHIATRIC ILLNESSES, INJURIES, OR HOSPITALIZATIONS:

Hypertension, Dyslipidemia, Headaches

DATES, CURRENT TREATMENT, AND OTHER SIGNIFICANT DETAILS:

Mr. XXXXXX receives all of his care through the Fayetteville VAMC

TREATMENT

............

WAS THERE OUTPATIENT TREATMENT FOR A MD DISORDER: Yes

DATE(S) FOR OUTPATIENT TREATMENT: every 2-3 months

CONDITION(S) AND LOCATION TREATED: Mood disorder due to a general medical condition (TBI)

HOSPITALIZATION(S)

...................

WERE THERE ONE/MORE HOSPITALIZATIONS FOR A MD DISORDER: Yes

DATES OF HOSPITALIZATIONS: June 2009

CONDITIONS AND LOCATION TREATED:

Fayetteville VAMC inpatient psychiatry

Depressive Disorder NOS, Nicotine Dependence

PRESENT MEDICAL HISTORY

...........................

ARE THERE MEDICAL AN/OR PSYCHIATRIC SYMPTOMS (OTHER THEN PTSD) PRESENT DURING PAST YEAR?: Yes

IS THERE CURRENT TREATMENT FOR A MENTAL DISORDER?: Yes

SUMMARY OF CURRENT TREATMENT FOR A MENTAL DISORDER:

Mr. XXXXX is seen by Dr. XXXX on a quarterly basis. He receives all of his mental health treatment through the Fay, VAMC.

FREQUENCY, SEVERITY, AND DURATION OF NON-PTSD PSYCHIATRIC/MEDICAL SYMPTOMS:

DAILY, severe symptoms of depression

PSYCH EXAM

.................

GENERAL APPEARANCE: Disheveled clothes, other

DESCRIPTION OF ANY OTHER APPEARANCE CHARACTERISTICS:

Mrs. XXXXX apologized for pt's attire, He had on pajamas, She stated, "he has been wearing the same thing for the past 11 days,

every day I ask him to change but he won't, I don't push him."

PSYCHOMOTOR ACTIVITY: Fatigued, Other

DESCRIPTION OF ANY OTHER PSYCHOMOTOR ACTIVITY: no eye contact, stared at the floor

SPEECH: Soft or whispered

ATTITUDE TOWARD EXAMINER: Cooperative

AFFECT: Constricted

MOOD: Dysphoric, Other

DESCRIPTION OF ANY OTHER MOOD: "poor" irritable

ATTENTION: Attention intact

ABLE TO DO SERIAL 7"s?: No

ABLE TO SPELL A WORD FORWARD AND BACKWARD?: No

COMMENTS: 92, 83, 77

world, drold

ORIENTATION:

INTACT TO PERSON: Yes

INTACT TO TIME: No

INTACT TO PLACE: Yes

THOUGHT PROCESS:

Other

DESCRIPTION OF ANY OTHER THOUGHT PROCESS: slow

THOUGHT CONTENT: Poverty of thought, Paranoid ideation

DELUSIONS: None

JUDGMENT: Understands outcome of behavior

INTELLIGENCE: Average

INSIGHT: Patient understands that he/she has a problem.

DOES THE PATIENT HAVE SLEEP IMPAIRMENT?: Yes

TYPE OF HALLUCINATIONS: Auditory, Visual

ARE HALLUCINATIONS PERSISTENT?: Yes

DOES THE PATIENT HAVE INAPPROPRIATE BEHAVIOR?: Yes

INTERPRETS PROVERBS APPROPRIATELY?: No

EXPLANATION OF INAPPROPRIATE INTERPRETATIONS(s): concrete interpretation

DOES THE PATIENT HAVE OBSESSIVE/RITUALISTIC BEHAVIOR?: No

IS THERE PRESENCE OF HOMICIDAL THOUGHTS?: No

IS THERE PRESENCE OF SUICIDAL THOUGHTS?: No

EXTENT OF IMPULSE CONTROL: Fair

EPISODES OF VIOLENCE: Yes

ABILITY TO MAINTAIN MINIMUM PERSONAL HYGIENE?: No

EXAMPLES/COMMENTS: sometimes won't shower for a week

IS THERE PROBLEM WITH ACTIVITIES OF DAILY LIVING?: Yes

HOUSEHOLD CHORES: prevents

TOILETING: None

GROOMING: Severe

SHOPPING: Prevents

SELF-FEEDING: None

BATHING: Severe

DRESSING:/UNDRESSING: None

ENGAGING IN SPORTS/EXERCISE: None

TRAVELING: Prevents

DRIVING: Prevents

OTHER RECREATIONAL ACTIVITIES: Prevents

DESCRIPTION OF OTHER PROBLEM WITH ACTIVITIES OF DAILY LIVING:

He replied "I am not going anywhere" when asked if he showers and changes his clothes daily.

COMMENTS OR ELABORATION OF ANY ITEMS IN THE MSE OR FOR ITEMS NOT COVERED OR OTHER COMMENTS:

He reports that he will see shadows out of the corner of his eye. He reports it "happens more sometimes than others."

He reports that he hears voices that tell him to do things, but is vague. He reported command hallucinations when hospitalized last year.

He is not using alcohol.

MEMORY

.......

REMOTE MEMORY: Normal

RECENT MEMORY: Severely impaired

IMMEDIATE MEMORY: Mildly impaired

EXAMPLE(S) OF MEMORY DISORDER:

recalled elementary school easily

can't remember what he ate yesterday

cat, hat, pencil (recalled 2 out of 3 after 5 minutes)

TESTS

.......

PSYCHOLOGICAL TESTING

........................

NAME(S) OF PSYCHOLOGICAL TESTING CARRIED OUT AND DESCRIPTION OF RESULTS:

BDI-II score =53 (severe)

COMMENT ON VALIDITY OF TEST RESULTS: Valid

WERE RESULTS OF TESTING TAKEN INTO ACCOUNT IN THE EXAMINATION REPORT?: Yes

DIAGNOSIS

...................

MENTAL DISORDER: MENTAL COMPETENCY

DOES THE VETERAN KNOW THE AMOUNT OF THEIR BENEFIT PAYMENT? Yes

DOES THE VETERAN KNOW THE AMOUNT OF MONTHLY BILLS?: No

DOES THE VETERAN PRUDENTLY HANDLE PAYMENTS?: No

DOES THE VETERAN PERSONALLY HANDLE MONEY AND PAYS BILLS?: No

IS THE VETERAN CAPABLE OF MANAGING FINANCIAL AFFAIRS?: No

EXAMPLE(S) TO SUPPORT THIS CONCLUSION: Mr. XXXXX has a general idea of his income. He does not handle the finances

in his family. He is not capable of managing his finances.

IS A SOCIAL WORK ASSESSMENT NECESSARY TO RENDER AN OPINION?: No

MENTAL DISORDER: EMPLOYMENT HISTORY

.......................................

USUAL OCCUPATION: Morgue assistant, paramedic

IS THE VETERAN CURRENTLY EMPLOYED?; No

IS VETERAN RETIRED?: No

IS VETERAN UNEMPLOYED BUT NOT RETIRED?: Yes

DURATION OF CURRENT UNEMPLOYMENT: 2 to 5 years

REASON GIVEN FOR UNEMPLOYMENT: " I can't work on all these medications." His medical record indicates that he

was having trouble things and arguing with people at work.

VETERAN CONTENDS UNEMPLOYMENT IS DUE TO THE MENTAL DISORDER'S EFFECTS: Yes

FACTORS AND OBJECTIVE FINDINGS OR REBUTTAL TO THIS CONTENTION: Chronic irritability and depression as well as auditory/visual

hallucinations would prevent him from functioning satisfactorily in a workplace.

AXIS I: Mood Disorder Due to a General Medical Condition (TBI)

AXIS II: None

AXIS III: Traumatic Brain Injury (TBI) , Dyslipidemia, Hypertension, Headaches

AXIS IV: Severe: requires constant supervision

AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING SCORE: 30 TIME FRAME: Current Functioning

DOES EACH DIAGNOSIS OF MENTAL DISORDER MEET THE DSM-IV DIAGNOSTIC CRITERIA?: Yes

PSYCH SUMMARY

...............

EFFECTS OF MENTAL DISORDER ON OCCUPATIONAL AND SOCIAL FUNCTIONING

..................................................................

IS THERE TOTAL OCCUPATIONAL AND SOCIAL IMPAIRMENT DUE TO MENTAL DISORDER SIGNS AND SYMPTOMS?: Yes

EXAMPLE(S) AND PERTINENT SYMPTOMS, INCLUDING THOSE ALREADY REPORTED:

Mr. XXXXX has significant depressive and psychotic symptoms as well as attention and memory problems despite

compliance with his medication. He would not be able to maintain satisfactory work and interpersonal performance

in any setting. According to his wife, he requires 24 hour supervision due to safety concerns. On two occasions, "he almost

burned the house down" when he used the stove. He has various family members that sit with him when his wife has to work.

He should be considered for Aid and Attendance.

WAS A MEDICAL OPINION REQUESTED?: No

Okay guys, I know that is a long post and I omitted some of the personal behavior content due to the fact that it is tooo disturbing

and embarrassing to divulge.

Edited by Sidney56

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OK, I want you to know that this is my opinion and I could very much be wrong or way off. There is a lot in red so I will try to sum it up for you. VA will probably increase your already service connected mood disorder. Your increase maybe 100% schedular or 70% and award you TDIU and pay you the 100% rate. VA may also request that you have a fiduciary (wife will have control of your VA money). The report says that you were hospitalized for a mood disorder in June 2009; it says that you have severe depression that causes problems with your daily activities and that you cannot be left alone. VA may also consider A & A since you have to have someone with you at all times. I think I covered the most important stuff; you will just have to wait to find out what VA will do. Others may chime in.

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I agree - as long as the TBI is directly due to your service,this should grant TDIU and possibly A & A.

Pete is right about the fiduciary as well.

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Thanks Berta and Pete for your input.

Yea Berta, I was discharged with a diagnosis of TBI. Just waiting for the envelope now and

hoping for the best. I talked with someone on the 800# and she said that it was in review

process as they have all the information that they need. She said I should hear something

before Christmas as they usually rate within 16-27 days. Maybe this fiduciary thing is why

its taking so long. I take everything that I hear from the 800# with a grain of salt.

I have learned to not count my chicks before they hatch with the VA.

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I agree with Berta and Pete.

They have already stated that you will require a fiduciary and that you do not need an "in-home assesment" (can't remember how they worded that, but that is what it boils down to, anyway). So, that part of it shouldn't hold up your award.

If you really want the best "scoop" as far as where you stand and for how long, ditch the #800 and go with the IRIS method of contacting the VA.

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I agree with Berta and Pete.

They have already stated that you will require a fiduciary and that you do not need an "in-home assesment" (can't remember how they worded that, but that is what it boils down to, anyway). So, that part of it shouldn't hold up your award.

If you really want the best "scoop" as far as where you stand and for how long, ditch the #800 and go with the IRIS method of contacting the VA.

Thanks Larry......Could anyone explain how this fiduciary process is done? Also if anyone has Aid and Attendance, exactly what

did you have to do to obtain this service. I don't see any reason my wife couldn't be my aid, if all they are going to do is sit

with me. I don't like people around me that I don't really know. Trust issues that I am dealing with. This is one of the reasons

that I hardly ever leave home. Why should I bring someone into my home, the only safe haven that I have.

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