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New Evidence Ime, Opinion

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lu12

Question

Psychiatric, Medical report of the evaluations and treatment of

NAME

SSN

October 31, 2007

Identification:

One is a male patient of 39 years, neighbor and resident of the municipality of Aguadilla, divorced, father of two children, catholic, with schooling of two years of university, comes of a brotherhood of three and is the eldest one, at present does not work. This patient already receives social security and Veterans Administration of benefits.

The affectation history of this patient arises while being active in the military service where he suffers a physical accident in one of his knees and in disc's as a result of this they are herniated in the lumbar area; since then and although in treatment he did not show improvement. Eventually he was licensed because a medical discharge physical disability?. Being out of military service he underwent treatment to improve his physical illness. From the veterans health administration V.H.A. file there is evidence of psychological complaints type to which they did not lend attention nor service and it was not until he was out of military service that he started the psychiatric treatment, in the private and V.H.A. Facilities. At present he continues making both types of treatment. What is the test demonstrating: in the first place, a human being is compound of a mind and a body, and when one is affected, the other is affected; to say that the knee and back disorders and disabilities did not affect of some form the mind is to think that the body does not have a mind; it is necessary to think that a young man that has pain, limitations and performance frustrations will affect their mental state and of that he complained, but although he did , they took it superficially as if nothing. It is true that later in 1997 he had an accident that overwhelm and aggravated the mental part, but that does discard that the mental condition existed. If the 1989 and 1990 veteran's files are seen, he complained of anxiety and psychiatric problems which were not treated nor taken in consideration by V.H.A. If we take in consideration as I mentioned before that the mind and body are a single organization: How is it possible to explain that a young person with an ill knee and herniated lumbar area disc's does not have the probability of mental affectation? The answer is that that is impossible; the benefit of the doubt should be given to the veteran's.

Continuation: name…

S.S. #

Page 2

Clinical Psychiatric profile and other complaints:

  • Anxiety
  • Depressive
  • Poor sexual life
  • Doesn't concentrate
  • Pain in different parts
  • Insomnia
  • Low tolerance level
  • Slow motor skills
  • Doesn't desire to do things
  • Frustrated
  • Anxiety eating
  • Sees colored clouds
  • Afraid of people
  • Tense
  • Nothing gives pleasure
  • Lack of energy
  • Insecure
  • Rage

    Mental Exam:

    • Appearance: Male of 39 years, chronological age that he represents; belongs to the Hispanic ethnic group. Measures 5'9" and weighs 200 pounds; has a higher BMI than average. The grooming is basic. At simple sight there are no congenital defects; limps occasionally while walking. Has goatee mustache type. No tics, mannerisms nor stereotypes.
    • Verbal tone: Tone is audible and articulation is clear.
    • Psycho motor behavior: Established visual contact and verbal acceptance.
    • Affection: Is adequate as expressed.
    • Mood: Serious, sad, depressive, preoccupied, frustrated.
    • Perceptions: None.

      Continuation: name…

      S.S. #

      Page 3

      • Process of thoughts: Coherent, relevant and directed to a goal.
      • Contents of the expressed: See clinical profile.
      • Judgment: Poor
      • Introversion: Accepted illness and seek help.
      • Intellectual level: Acceptable to his schooling
      • Psychotic material: None available.
      • Suicide ideas: None present.
      • Cognitive Process:

      a) Attention: Low, Story of good Joseph, Did 3.

      :) Concentration: Low, Subtract 7 of 100, Did 3.

      c) Memories: Remote, recent and immediate: Low

      d) Orientation: Oriented in person, space and time.

      e) Similarity Test: Did 3.

      f) Contraries Test: Did 3.

      g) Abstracts Tests: Did 3.

      h) Proverbs Tests: Did 3.

      [*]Illusions: None present.

      [*]Referential ideas: None.

      [*]Paranoid ideas: None present

      [*]General functional capacity: Poor.

      [*]Labor capacity: Poor.

      [*]Social activities: Doesn't assist.

      [*]Family activities: Doesn't assist.

      [*]Labor prognostic: Poor.

      Continuation: name…

      S.S. #

      Page 4

      [*]Habits of use of illegal substances: None.

      [*]History of use of habit forming substances or medications: None.

      [*]History of panic: None.

      [*]Tolerance level: Low.

      [*]Social judgment: Reduced.

      [*]Capacity to execute a task: None existent.

      [*]Smoking habits: None.

      [*]Alcohol habits: None

      [*]Summons History: None.

      [*]Pending law suits: none

      [*]History of repeating Academic Grade: None.

      [*]History of changes of religion: None.

      [*]History of changes of political party: None

      [*]History of sex change: None.

      [*]Goal existence: None. Not short, not medium, nor long term.

      [*]Receives benefits from insurance or money by another concept at present: Yes. Which? Social Security and V. A.

      [*]Plan of death planned by:

      Homicide: No

      Suicide: No

      [*]Patient conduct at:

      a) Neighborhood: Not active.

      B) Community: Not active.

      Continuation: name…

      S.S. #

      Page 5

      c) Family scope: Tense

      d) Town: Not active.

      e) Country: Not active.

      [*]Relations with spouse: Tense

      [*]Relations with children: Bad

      [*]Relations with parents: good.

      [*]Relations with grandparents: None.

      [*]Existence or none of malingering: No

      Diagnostic: DSM IV

      Axis I) Major chronic depression and anxiety due to chronic physical medical conditions.

      Axis II) Deferred

      Axis III) Herniated Disk C-2 -C-3, L4-5, L5-S1, Radioculopathy U/Es C-2 C-3, C3-C4 Radioculopathy L-4, L-5, S-1, S-4, L-4, L-5, HNP L/Es, L4-5, L-5, S-1. Spine DDD, DJD, Osteoarthritis in both knees, Chondromalacy in left knee, DJD.

      Axis IV) Physical, labor and emotional disability.

      Axis V) 50

      Comments:

      Patient is in psychotherapy and antidepressants and his prognosis is poor. There is no doubt that there is casual relation between his physical disabilities and conditions and mental behavior. Patient, SMR, VHA, Private Medical records were reviewed.

      lu12

      This what I got for AMC & BVA. Veteran's must comply with VA & CFR regulations. This MATERIAL EVIDENCE DECLINE was not accepted by the PSYCHIATRIC Examiner at my Dec 2007 C&P examination.

      GB

      LU12

Edited by lu12
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  • HadIt.com Elder

If you paid real money for this I am sure he could alter it to comply with the medical rationale statement and the nexus-

Berta.

Boy, when I saw Dr. Crowley, he was to the point. He would only state what the medical records supported.

He stayed with the facts only. Medical evidence.

Are we saying Dr. Crowley's credentials will be questioned, because I had to pay someone to tell the truth of my claims file for the last 40 some years.

One doctor can sit in her padded cushion and change my medical records, to dis-qualify me and then me spend the rest of my life trying to knock down her lies.

If all of her gargbage was actually in the records, I am confident the first doctor at the VAMC would have spotted the same information.

Strange how this doctor can spend 45 minutes with me and come up with a diagnosis, for which I have never been treated for in 44 years.

Am I reading this post correctly.

Always Appreciate.

Betty

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  • HadIt.com Elder

Betty:

I have never seen the VA question a licensed Doctor's opinion nor their credentials. However, they will oftentimes find a sneaky way to get around a solid opinion but that is the VA isn't it.

Veterans deserve real choice for their health care.

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"Diplomat & scholastic forensic license. Milwaukee, WI

Diplomat & scholastic, license psychiatrist"

Impressive background-please

dont allow me to discourage you- this is a detailed IMO-

but I always see the landmines and sure want to point them out-before VA does-

If you paid real money for this I am sure he could alter it to comply with the medical rationale statement and the nexus-

But by all means submit this to the VA-

they would have to provide medical rationale to knock it down anyhow-

He is completely correct here:

"How is it possible to explain that a young person with an ill knee and herniated lumbar area disc's does not have the probability of mental affectation? The answer is that that is impossible; the benefit of the doubt should be given to the veteran's"

And he makes a strong statement-

but just remember- when the VA weighs the evidence for Benefit of doubt-they are the ones who own the scale-

Send this in -by all means-

I have read the rationale why so many IMos get rejected by VA that I must honestly tell you what I thought when I read it-

My opinion does not matter LU- it is the opinion of the VA that matters-

by all means send this in- unless he would alter it a bit first-regardless send it to the VA

BY the Way- is your SSA award for the same conditions in your SC claim?

Did VA get your SSA records?

Berta I'm getting lost here real fast. I'm ok your last statement, but what I dont understand it is about the medcial rational and the nexus, I believe it is in this report.

Would you be a bit more specific about those land mines that you make reference off, and how should I addressed those with the PSY.

Also and yes the VA got my SSA award letter and both are due to my lumbar and R. knee. I first got my s-c only for the lumbar 60% and for the R. knee at a 30% and in Oct 2007 another 30% for my GI Condition.

About my cervical condition it is also included with the SSA that is way I'm trying to get s-c for my cervical and my TMJ.

LU12

lu12

Edited by lu12
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  • HadIt.com Elder
Betty:

I have never seen the VA question a licensed Doctor's opinion nor their credentials. However, they will oftentimes find a sneaky way to get around a solid opinion but that is the VA isn't it.

Pete,

From what I am reading, looks like I may be headed to the courts.

I can say, when this is over, there may be one less doc at the VAMC

or she will have a mark on her license.

I won't continue to sit still while she continues to lie.

I have already sent to the Judge the Copy of the Nov. 16, 2007

examination that never took place.

He can check his computer and find the computer has been wiped clean

of that examination.

As Dr. Crowley said, I need to get me a lawyer. I may have to get one

sooner than I expected.

Betty

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  • HadIt.com Elder

If it was me I would sic the OIG on her ass

That is cheaper than getting a lawyer

Edited by Pete53

Veterans deserve real choice for their health care.

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  • HadIt.com Elder
If it was me I would sic the OIG on her ass

That is cheaper than getting a lawyer

Pete,

I am going to give the Judge time to try to make this right and if he doesn't to court we will go and then the higher court can do something with her.

This Judge knows that Dr. Crowley is sitting in his office with both copies of that addumdum.

I made sure he knew and sent copies by Senator Warners' office, so they would make it to the file.

Thanks,

Betty

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