oldtimer88

Thanks Berta and Broncovet, My VA scheduled MRI is December 19, 2016. That puts me outside the 1 year window to file a NOD. And yes, facial spasms/migraine botox injections being covered by VA Health Choice. But my claim for the spasms denied. But, the Health choice was just recently approved. So will that be considered new evidence or material?

Thanks Gastone, No I have never been told life threatening, limited vision is quite possible. I think that is the issue with VA this condition has never been called this, in my research it seems to be rated under Blepharospasm is a condition where the eye twitches uncontrollably. It is rated under code 8103, convulsive tic. Now the VA doctor has requested a MRI be done and says in his notes the MRI is related to service connection condition, but VA keeps saying they are not related so maybe this will help as well. After this MRI, he is referring me to a Neurologist with VA. Appointment in December, I am going to submit NOD now.

Ok Experts help me out, I think this exam was not focused on my complaints. I have already been rated 10% bilateral for shin splints (which was only approved when NOD filed and X-rays showed degenarative (sp) arthiritis in both ankles and knees. So i filed a claim for Exertional Compartment syndrome as NEW claim and lower leg pain as secondary to EXTERIONAL COMPARTMENT. My exam was suppose to be focused on lower leg pain and knee pain. This is the exam, don't match with ALL complaints. So does this sound like a denial for new or increase, because they already rated me for shin splints? Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: Exertional compartment syndrome as related to "shin splints" b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Shin splints (including tibia and/or fibula stress fracture and/or exertional compartment syndrome) Side affected: [ ] Right [ ] Left [X] Both ICD Code: M79.A29 Date of diagnosis: Right SC Date of diagnosis: Left SC c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): The Veteran began having bilateral leg pain while in basic training with boot camp. She was diagnosed with "shin splints." She continues to have bilateral lower leg pain, now when walking for prolonged distances. She has some swelling of the knees with prolonged walking, statest that the knees become painful and and the lower legs are stiff and tight. She uses Capsaicin for comfort as well as Motrin. There is no locking or giving way of the knees. She walks presently with an antalgic gait, after coming from the parking lot. The right lower extremity is worse than the left. b. Does the Veteran report flare-ups of the knee and/or lower leg? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: "My knees hurt, they're stiff, they throb. c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: "Can't walk long distances. My knees hurt walking from the parking lot." 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Right Knee ---------- [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 115 degrees Extension (140 to 0): 115 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [ ] Yes (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No Left Knee --------- [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 115 degrees Extension (140 to 0): 115 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [ ] Yes (please explain) [X] No Description of pain (select best response): No pain noted on exam Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right Knee ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right Knee ---------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not witnessed Left Knee --------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with rep eated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not witnessed d. Flare-ups Right Knee ---------- Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: As the veteran is not actively experiencing a flare-up at the time of the examination, and the examination is being conducted within a limited time frame, I am unable to determine if pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time. Owing to the same causes, I am also unable to describe any such additional limitation that might be due to pain, weakness, fatigability or incoordination that might occur. Left Knee --------- Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: As the veteran is not actively experiencing a flare-up at the time of the examination, and the examination is being conducted within a limited time frame, I am unable to determine if pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time. Owing to the same causes, I am also unable to describe any such additional limitation that might be due to pain, weakness, fatigability or incoordination that might occur. e. Additional factors contributing to disability Right Knee ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Other (please describe) Please describe additional contributing factors of disability: Difficulty maneuvering stairs and climbing ladders. Swelling of the knees with prolonged walking. Left Knee --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Other (please describe) Please describe additional contributing factors of disability: Difficulty maneuvering stairs and climbing ladders. Swelling of the knees with prolonged walking. 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Knee: Rate Strength: Flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Knee: Rate Strength: Flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe b. Is there a history of lateral instability? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe c. Is there a history of recurrent effusion? [X] Yes [ ] No If yes, describe: Veteran reports swelling of the knees with prolonged walking. d. Performance of joint stability testing Right Knee Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: No response provided 7. Additional conditions ------------------------ a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below. [X] Chronic exertional compartment syndrome Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of ankle? [ ] Yes [X] No Describe current symptoms: stiffness, tightness b. Comments, if any: No response provided 8. Meniscal conditions ---------------------- a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No For all checked boxes above, describe: No response provided 9. Surgical procedures ---------------------- No response provided 10. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ----------------- [X] Other: OTC compression sleeve [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: Veteran wears a compression sleeve occasionally when planning to walk for long distances. 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate knee: [ ] Right [ ] Left [X] Both b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 14. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: Difficulty walking for prolonged distances. Unable to run. Difficulty maneuvering stairs. 15. Remarks, if any: -------------------- Letter dated 22 May 2002 from W. Clark Jernigan, MD, Piedmont Orthopaedics, Greenville, SC, states that Veteran had "exertional compartment syndrome, often diagnosed as 'shin splints.'" ********************************************************************* The Veteran's knee pain is not due to, not related to, not secondary to the exertional compartment syndrome which, as stated by the above orthopaedist, is the same as "shin splints." The exertional compartment syndrome is with the lower leg. The Veteran's current exertional compartment syndrome has not progressed. She is now having knee pain, which, as stated above, is not related to, not due to, not secondary to her SC exertional compartment syndrome or "shin splints," (as called by Dr. Jernigan as one in the same). ********************************************************************* X-Rays, 9/23/2016, knees bilaterally: Mild degenerative changes. Age, according to medical literature, continues to be one of the highest risk factors for developing degenerative joint disease. Obesity is also one of the highest risk factors. The Veteran's mild degenerative changes of the knees are at least as likely as not the result of these two high risk factors.

No broncovet the headache diary wasn't listed as evidence.My c&P exam was on July 14th and I had appt with VA doctor on and turned the diary in on July 22nd. How do I order my c-file? I have a full copy of my 17 years of medical records from active duty and national guard. So I dont know how to order a c-file. Thank you and everyone for helping me to work this out. I have started on my letter to submit. When I am done, can I send it to your inbox for suggestions?

I included all the days that I had to take or leave early that on my headache diary that I gave to my VA doctor last month. I was told today that it was sent to VAMC to be scanned in. So I am sure they can go and look at it and use it for consideration since it was submitted outside of the evidence window that they used to make the decision (Oct 2014 to March 2015). I have to use sick time or vacation time to cover time lost. We are only given 16 hours per YEAR for sick time. We get 1 day in April and 1 day in October. Since April 2015 I have used 8 days vacation and my 1 sick day with being off for headaches or leaving early.

yes, the doctor made note of it inin the exam well. Anxiety medicine has been changed and dosage increased in the last 6 months. I currently take 2 blod pressure medicines. b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any 56 conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): HTN,Anxiety

Thank J! I know you experts know how to handle with with less stress. So do I need to give up or am I just dumb! Should the examiner have hand written this in the remarks? Because the question only ask Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [X] Yes [ ]. I have made an appointment with a private neurologist and I am going to the local VA office to see what they say i need to do next.

I'm at a lost, don't know what else to give them. Indicate location of typical head pain [X] Both sides of head 4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [X] Yes [ ] No b. Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [X] Yes [ ] No 5. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any 56 conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): HTN,Anxiety 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: Slows her prodoctivity. 8. Remarks, if any: ------------------- PE: BP-136/75 -HEENT-normocephlaic,EOME,PERLA,no facial drops or tongue deviations,cranial nerves II/XII gorssly normal. -Neck-Supple, no JVD or carotid bruits.

I'm at a lost, don't know what else to give them. Indicate location of typical head pain [X] Both sides of head 4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [X] Yes [ ] No b. Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [X] Yes [ ] No 5. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any 56 conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): HTN,Anxiety 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: Slows her prodoctivity. 8. Remarks, if any: ------------------- PE: BP-136/75 -HEENT-normocephlaic,EOME,P

Thanks broncovet, it states evidence used as folows: VAMC treatment records from October 2014 thru March 2015. VA Headaches Examination on July 14, 2015, which was the C & P exam for increase. Yes, it acknowledges all the criteria but doctor also he stated this in the remarks --------- PE: BP-136/75 -HEENT-normocephlaic,EOME,PERLA,no facial drops or tongue deviations,cranial nerves II/XII gorssly normal. -Neck-Supple, no JVD or carotid bruits. Current level of headache and migrain severity:- moderate to sever based on subjective reporting by patient. So do I need to mention the July visit which included the headache diary that should now be on file in the DRo review?

Good Morning Navy04, I got the letter yesterday. See below: Denial for increase on migraines state: * Charateristics prostating attacks occurring on an average once a month over last several months. * A higher evaluation of 50% is not warranted for migraine unless the evidence shows very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. I'm lost on this one because the c & p exam says all of this and on top of that I had to turn in a Headache diary to the VA doctor for the last 4 months because he wanted to see the frequency and pain level as well. I had reported at the end of last year that the headaches were coming more frequent and getting worse and I knew the twitching was a contributing to that. That was from March to July. I gave it to VA doctor in July. They increased my dosage of medicine in October. In July he added another medicine to take as well. That would be the only new evidence I would have to send on this one. Denial for the eye disease, hemifacial spasms/blepharopasm, other facial nerve disorder" Evidence does not show that the eye disease , etc is not related to the service connected condition of headaches, nor is there any evidence of this disability during military service. Service connection for eye disease, etc is denied since this condition neither occurred in nor was cause by service. The VA medical opinion found no link between your diagnosed medical condition and military service. I'm lost on this one because I have researched these things to find out where and how the start and there is medical evidence to link hemifacial spasms and migraines. Also, I thought secondary were conditions that were aggravated or caused by sevice connected. The headaches causes worse twitching and vice versa. With all the crazy conditions and illnesses coming from soldiers that were stationed at FT McClellan, how can they say these strange things are not coming from there. We did have to eat the food, drink and bath in the water, play in the mud and sleep on the ground. I am so digusted, I want to do a reconsideration, NOD, Appeal or whatever I need to do for both. So I need help. Did I use the wrong terminology on the conditions? thank you for taking the time to listen and help. You were the ony expert to advise me.

Hey Navyo4, claim closed on 8/13/15, looks like both were denied. It states on enebefits that decision sent, appeal process blah, blah, blah. No letter generated. What next?

Thank you Vync, hemifacial spasms are twitching of the eyes and face. I was told yesterday that my claim and exam were sent to the VA hospital for a medical opinion. Which is confusing because I thought that was the reason for the exam. I am currently at 30% for headaches/migraines. Seems like they trying to find a way to deny something. I have plenty of research material and my private doctor's statement saying the spasms are caused by headaches and can contribute to the severity of a headache. I was also told it takes 30-60 days to get those medical opinions back and this was common for secondary issues. Go figure!!!

I had my exam on July 14, I was told today that it has been sent to VA hospital for medical opinion. I thought the examiner was the medical opinion.

Hello Eveyone, here is a copy of my C & P exam for increase on migraines. I also filed a FDC for the hemifacial spasms that can be caused by migraines and aggravate migraines as well. tell me what you guys think. The examiner add HTN and anxiety in his remarks. Why?? Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: vbms If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a headache condition? [X] Yes [ ] No [X] Migraine including migraine variants ICD code: 784.0 Date of diagnosis: 2009 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): CO- "patient not aware when headache and migrains strated but got got worst in basic training, also in Germany after she delivered her daughter with migrains". \ Frequency of headache and migrains-18 per month. Prostrating attack frequency-5 per month. Work:- Computer private sector-full time for past three years. b. Does the Veteran's treatment plan include taking medication for the diagnosed condition? [X] Yes [ ] No If yes, describe treatment (list only those medications used for the diagnosed condition): Meloxicam.Sumatriptan. 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pain on both sides of the head [X] Other, describe: sharp b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain) [X] Yes [ ] No [X] Nausea [X] Vomiting [X] Sensitivity to sound [X] Other, describe: dizzy,eye twitches,concentration problems . c. Indicate duration of typical head pain [X] 1-2 days d. Indicate location of typical head pain [X] Both sides of head 4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [X] Yes [ No b. Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [X] Yes [ ] No 5. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [X] Yes [ ] If yes, describe (brief summary): HTN,Anxiety 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: Slows her prodoctivity. 8. Remarks, if any: ------------------- PE: BP-136/75 -HEENT-normocephlaic,EOME,PERLA,no facial drops or tongue deviations,cranial nerves II/XII gorssly normal. -Neck-Supple, no JVD or carotid bruits. Current level of headache and migrain severity:- moderate to sever based on subjective reporting by patient.