Sidney56 Posted October 16, 2010 Share Posted October 16, 2010 (edited) 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 October 16, 2010 by Sidney56 Link to comment Share on other sites More sharing options...
Moderator pacmanx1 Posted October 17, 2010 Moderator Share Posted October 17, 2010 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. Link to comment Share on other sites More sharing options...
Berta Posted October 17, 2010 Share Posted October 17, 2010 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. Link to comment Share on other sites More sharing options...
Sidney56 Posted October 17, 2010 Author Share Posted October 17, 2010 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. Link to comment Share on other sites More sharing options...
HadIt.com Elder LarryJ Posted October 18, 2010 HadIt.com Elder Share Posted October 18, 2010 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. Link to comment Share on other sites More sharing options...
Sidney56 Posted October 18, 2010 Author Share Posted October 18, 2010 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. Link to comment Share on other sites More sharing options...
HadIt.com Elder john999 Posted October 18, 2010 HadIt.com Elder Share Posted October 18, 2010 If you are having hallucinations you belong in the hospital. No question about 100%. The VA has a responsibility to protect you. Link to comment Share on other sites More sharing options...
Question
Sidney56
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:
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 Sidney56Link to comment
Share on other sites
Top Posters For This Question
5
2
1
1
Popular Days
Oct 18
6
Oct 17
3
Oct 16
1
Top Posters For This Question
Sidney56 5 posts
john999 2 posts
Berta 1 post
pacmanx1 1 post
Popular Days
Oct 18 2010
6 posts
Oct 17 2010
3 posts
Oct 16 2010
1 post
9 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now