DEPARTMENT OF VETERANS ATFAIRS

VA Health Care Center

7300 South Raeford Road
Fayetteville, NC 28304

June 7,2018

To r,vhom it may concern:

Mr. James Elder (DOB 912211959) has a history of chronic abdominal wound dehiscence from
multiple abdominal hemia revisions, causing smatl frequent bowel obstructions and
hospitalizations. Itdr. Elder has undergone several swgeries and hospital admissions since last
November. It has been determined by the surgeon &at Mr. Elder's abdomen must stay open and
wrappedlcontained with plastic wrap (no stitcheslstaples). Hence veteran has very limited mobility
and difficulty with day to day activities. As a result, he requires moderate-total assistance with his
ADLs from his spouss and a nurse 7 days a week.

If you have any questions or concerns,please feel free to contact my clinic at l-9fi-475-6196 or
910'475-6220; or leave a message via the call center at 910-488 -ZQA ext. 7816.

Sincerely,
(./, l;
{ rb /-,/ n
) L/g
Safi Sobhy Soliman, MD
 DEPARTMENT OF VETERANS ATFAIRS
VA Health Care Center
7300 South Raeford Road
Fayetteville, NC ?8304

June 7, 2018

To whom it may concem:

Mr. James Elder (DOB 912211959) has a history of chronic abdominal wound dehiscence from
multiple abdominal hernia revisions, causing small frequeat bowel obstructions and
hospitalizatiors. Mr. Elder has undergone several surgeries and hospital admissions since last
November. It has been determined by the surgeon that N{r. Elder's abdomen must stay open and
wrappedlcontained with plastic wrap (no stitches/staples). Hence veteran has very limited mobility
and difficulty with day to day activities. As a result, he requires moderate-total assistance with his
ADLs from his spouse and a rulrse 7 days a week.

If you have any questions or concerns,please feel free to contact my clinic at 1-910-475-6196 or
9t0-475-6220; or leave a message via the call center at 910-488 -212A ext. 7816.

Sincerely,

f/,Wfr
Safi Sobhy Soliman, MD
 0MB Contr0l No. 2900-0721
ResDondent Burden; 30 rninutes
Expiration Date: 5-ll -1018

EXAil''NAT'ON FOR HOUSEEOUND STATUS OR PERMANENT

NEED FOR REGULAR AID AND ATTENDANCE
7HffiME - MIDDC NAtue - unsr NAME oF vETERAN @EoFCLAIMANT TO VETERAN

James E1der self

James Elder
AE. CLAIIANNTS SOCIAL SECURITY NUMBER 5. CLAIM NUMBER
h vergnlr.r's soctAL SECURITY NUMBER
256-15-1365 2s6-i5-1365 N/A
6, 7. HOMEADDRESS
DATE OF EXAMINATION
7312 Shilling Law Circle; FayeLtevitle NC 283L4
5/3/2018
g. NNTIT AruO EODRESS OF HOSPITAL

I vrs fi NA 1f"Yes"'t:auPlete ltens 8B and 9)

Fr,rlsg nran cAREFULLY (connncdto rhi hcu-or

qucsrion of *hcthcrthc craimant is housc'oound
[t1h3,itx,1fi]:",,:fJi,#x":iffi;-,]::":,,*^r,:f::c^:"p:T,":,.,o thc
mcmar impairment' that toss or
extc,rt that djscasc or injury produces phlsicar or
HT":jj:[ S:illii:f:l;f"'*:*,',"F,Y'J"'$;1X3['#ffiJ:i:".tT#Ttohc *i"ti bt kc"p him'rhcrself oidinanly clcan and
rhc abirity: ro dress and ,fi,i#. i;; hi-^li,.ii"n
io t"i}," tif n'rur";
coordiiration or cnfccbrcmenr atrccrs "nJra
nrescntablc.
t*,liUf -L^r-:rr^-
hc/srre is
rcnccthowwcn hc/she arnburates,where he/shc gocs, andwhat
,*:*n:X".".:1T.T,:1i;,Tl:t[iJiffi'3ffi1i:3'#f."i-::$i',$hshourd
ablc to do during a
ffiisneeclstoet1ualetorhelerelo!,ossistancedescribedinquestions20thtough34)
psychosis;chronic pain;GBRD;osa o''"'d"pffi;-;j;;;;;l-::fii:Xl::l:::;li"'*t";PrsD;DJD;
anoominar. warr dehiscence; rliverticurosis;
PrsD
:"i;;;;-;:;;;;;-;;;nic I :::l
13. HEIGHT
118. SEX 12. WEIGHT
FEET:6 INCHES: 1
male ACTUAL: LBS. 2 2 9 ESTIMATED: LBS. -
15, GAIT
14. NUTRITION
soft foods steady
low fat, low salL, low cholesterol, ACTtVtTIES/FUNCTIONS?
@ED
pl5i ; pain ; ps ychos i s; *o'lnd dthi / t"q
Lt2/11 "ttn"t
MBER OF HOURS IN BED

From I PM to g AM: N/A From I AM to I PM: N/A

(! l "No," provide explonation)
@IHERSELF?

EIYES ENo with set uP

ABLE To PREPARE owN MEALS? (!f "No"'proxide

,ffilMANT
IYES ENo d/t parn; surgical slte to
DOES rHE CLATMANT Neeo
etptanation)
abdomen; unable to stand long
:=:;;;i;;ffitro orHrn
rEil5il6To HvnrtrNtr NFFt-rs? tlt
HYGTENE NEEDS? \" 't'rt'tid: attnttiit',rii
rtt \t;.',.!tt;d.' dlllLtti
as-EGilNEE ril eArHrNG AnO

ElYESnNomod_totafassistd/tpainandrecentsurgeries/abdominafwound
248. CORRECTED VISION
etplanation)
,ffis rHE CCMANT LEGALLY BLIND? (!f "Yes," pro+'ide

ffiG H3ME 6ARE? |lJ "Yes"'ptovide erplanation)

26. DOES THE CmtfrllAN-r nfOffif ftteOtCAflON MANAGEMENT? Ql"l'es"'protitle explonation)

EYES nNo with assistance from spouse

RS? ($ P xtvide exPlarat i on )
IVIAUEOE HISIHER OWN FINANCIAL AFFAI
" No
27. DOES THE CLAIIUAI\IT NNTETTEIE]IiilJ5 "'

El YES nNo wj-th assistance from spouse

VA FORM 2 -2680. JUN
MAY 2015 21-2680 WHICH WILL NOT BE USED.
 28. POSTURE AND GENERAL A.'EARANCE (Auach a separaie sheet of paper il.additir;;;;;"
Veteran appears clean and neat/ with good pallor. Shaved.
appropriately. Good posture. Ambulat.ory wlthout devj-ce Alert and oriented Dressed
or asslst.ance.

29.DEScRlBERESTRlcTloNSoFEACHUPPERExTREMirywrgPARTlcULARREFER
ro rHE fiiios or r,rniiriiii;;;;;';";;;-;,oeetorpaperiradditionatspa,e
I??1T::::"rll:,:Ty:-ilrl"ENo
stif fness and weakness (rires easily),. unable .o uuf"orr"Tr:;;::;;::;3I"'Il."ru^
is needed)

assist-ance with needs of nature; Iimited requires

ROM,. able to feed hlmself .

30.DESCR1BERESTRlCTIoNSoFEAcHLowERExTREMlTYWlTHPARTlcULAa
orHER INTERFERENCE'
rr rNorCniio, coMMENr sPEcnrcaliv oi.i wErGHr BEARTNG,
li$ffilu*=toR BALANcE AND pRopuLsroN oF EACH LowER
Unable to stand or walk for long periods of time d/t
recent surgeries; teqs tire easlly.

31. DESCFIBE RESTRICTION OF THE SPINE, TNUNX NHO NCCK

Decreased RoM to neck and back r,/t arthritis;lj-mited.
abdominal wound being left open,. pain r/L arthrlt.is
RoM d/t recent surgieries and
and surgery.

32, SET FORTH ALL OTHER PATHOLOGY IN.

Bi?ilSSS,".pff="*!#r?A rrpT,:lgT^-,fflT;**llr*i_"i-_:X*ryiifl.iry.+"_fry9tM .ELF_.ARE, AMBULATE oR TRAVEL BEyoNDTHE
Hosernurzeo, sivot io rHE wARD oR clrl,iaie-nea] "o$#E"il""?'{;''fiir'btril'HE3|"HJirt"Tr"3iB[lt-.
B[E!'3[3,i:fi#i&i,ffi
D/t recent surg'eries veteran has some difficulty with qettinq
experiences chronic pain. He requires moderate-'lotal assistancearounci, tires eas1ly and
r!,ith ADL..

33- DESCRIBE HOW OFTEN PER DAY OR W

prsD,. recenr surseri_es, pain, and poor
:::::::-:"::l:-::11":,dlr
transport memory. r^life and son
veteran any time needed.

efecliveness in terms ofdistance thot can be travle.l, j2 (lfso, specrly and describe
x in ltem aboveS

EJYEs
(f "rES," gi\.e dishwe) (CheLk
L_-lNo appltuable-boxorsp""itriii,iir.t
Ej IBLOCK IboroBLocKS nlMILE
35A. PRINTED NAME OF EXAM|N|NG ptySCrAtr 358. S,9NaTUBE ATqTITLE OF eX,qrrlrr,rrXE pXffi 35C. DATE SIGNED
Safi. Soliman 6 / 9 /2018
36A. NAME AND AODRESS OF MEDICAL FAEiUTY-
7300 South Raeford Rd. 368. TELEPHONE NUMBER OF
(lnclude Araa Cocle)
Eayetteville, NC 28304
+1 (910) 4BB_212A
PRIvACYACTNoTICE:TheVAwitlnotdisc1oseiriformationcol1ected*,r,i"

i:llJi# El,'"f,'H',-,11.i#li,[:x1"d:;i,tully,altpiutt"i]i:h.,*:lx:,]:i"i::*:l,I?g i! !t: v4 svstcm orrccord s.5BvA2r22/28. compcnsarion,

(ssNi,;;;;;i;"f".*urirn ;s i,and-.iili.;;fi;;#;rc rcquircd
Giving us vour Social Sccuritu Nutnbcr
to.proviic thcir SSN undcr Tirre 18. u.S.c. 570i(cx r). Thc vA

as wcri u.6'.oriJi;il;.iounr.i,,.a
8ffifi::*:lT[',1'JtilriJ;ti:1il[,'l"ft:X"Yl^?lii( to trre un'itlo Stiic. uy ui.tu" oryour participation-in any bcncnr

RESPoNDENT BURDEN: weaeed this infornration to determinc your

eligibility for aid and attendance or houscbound benefits. Title 3g, united states code l52 r (d)

numbcr is dispiavcd' you are not requircd ro ."tponJ io i

oMB Intcmct pate at hlil):'rrElLrkinfo-€o;;i-s-hliJd;lirBa.\iaiq. rf
"oil."tioi Ir;;;i;d.'yr".ir'l"rr
i;i;;;;i;;
iit-n-i. ,"uru", i. not di.!iuy.a. viii-otde .orrrol numbcrs
can bc rocarcd on thc
suggcstions about this form. r-s00-827-i0d0 to gcr infomrarion on whcre ro scnd comr.c*rs or

VA FORM 21.2680, MAY 2015