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Received C&p Results......

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Sidney56

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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If you are having hallucinations you belong in the hospital. No question about 100%. The VA has a responsibility to protect you.

Were you referring to something on the C&P results John? My wife told the examiner that she would not consider hospitalization

again, because they only kept me sedated the whole period.

Are you saying that if I'm put back on the ward, that there is no question on 100%?

I read somewhere here on the board that if they find you incompetent and in need of a fiduciary, it will only prolong

the final decision due to the fact that they have to do a field examination. On the C&P results, it stated that "no

in-home assessment was needed". I think that Berta stated in one of her post that if retro pay was involved, they tend to

drag their feet on appointing a fiduciary.

One question that I do have is, how did the VARO send me a copy of the C&P exam if all my records are at

the AMC? When I first requested a copy of the exam, I was told that they did not have my records and would

have to get them from Washington. I responded back through IRIS that I did not need a copy and would wait

for a decision, because 800# told me that it would stop the process until they retrieved the records, made a

copy and sent them back to AMC. I hope this is not what has happened!!

Edited by Sidney56
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Sid

I was saying if you are having hallucinations then you are probably having psychotic episodes. Your judgement is impaired. I think with your GAF and those symptoms the VA needs to get your meds corrected. The best way to do this is to be in the hospital. I do think that with that C&P exam you should be 100% schedular,but it is the rater that makes the call. The VA should not let you out as long as you are having hallucinations. This can be treated. Do you hear voices and see things that are not there? If you respond to these hallucinations it could be dangerous to yourself or others because you are not responsible. However, if something were to happen while you were psychotic the police would throw you in jail. The police don't care if you are crazy or what happens to you if you are in a psychotic state. If you are in the hospital with psychotic symptoms the VA will sedate you until they get your symptoms under control.

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Thanks John for your reply and concern. I do appreciate what you have said and I am trying to control my situation

with the new meds that my psych Doc has put me on. Speaking with guys like you make dealing with these issues that I have

a little more bearable because I know that there are some caring souls still left in the world. I do have

some good days, but the C&P Doc seems to have come to the conclusion that I'm unable to do anything.

I just hope that this fiduciary process does not have me waiting another year just to hear something.

Sid

I was saying if you are having hallucinations then you are probably having psychotic episodes. Your judgement is impaired. I think with your GAF and those symptoms the VA needs to get your meds corrected. The best way to do this is to be in the hospital. I do think that with that C&P exam you should be 100% schedular,but it is the rater that makes the call. The VA should not let you out as long as you are having hallucinations. This can be treated. Do you hear voices and see things that are not there? If you respond to these hallucinations it could be dangerous to yourself or others because you are not responsible. However, if something were to happen while you were psychotic the police would throw you in jail. The police don't care if you are crazy or what happens to you if you are in a psychotic state. If you are in the hospital with psychotic symptoms the VA will sedate you until they get your symptoms under control.

Edited by Sidney56
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