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Found 104 results

  1. So as some of you may know, I filed a claim on 12/12/16 it was a reopen for depression/bipolar. and a new claim for tinnitus. It went to prep for decision in about 2-3 weeks with no C&P Exam. So Im a bit scared because this has never happened before. For the reopen, Ive sent in a ton of new and material evidence. But I just scared that the claim was denied for whatever reason. Although the va has paperwork on my mental health issues/treatment both in and out of service my claim was initially declined because i missed the appt back in 2011. So my question is this. Should i just let my current claim go and just hope for the best. Or would it be smarter or even possible for me to claim depression/bipolar as secondary to my already SC'd disabilities for which I am at 80%? I've done it all on my own up to this point, this final hurdle seems o be the most difficult and confusing. All help is welcomed - Thanks.
  2. I was hoping that someone can tell me how and where I can read the notes from my C&P or any of my notes from my Dr.'s appointments. Thanks in advance.
  3. This is what my examiner put for functional level I was happy about it but it true. How might this effect my claim for TDIU or IU? I am 90 right now. 4. Functional impact Do any of the Veteran’s residual conditions attributable to a traumatic brain injury impact his or her ability to work? [X] Yes [] No If yes, describe impact of each of the Veteran’s residual conditions attributable to a traumatic brain injury, providing one or more examples: (1) Trauma effects on Veteran's Memory seem to create one of his most significant impairments. Work on aircraft, where the lives of pilots & passengers are at risk, and much of the tasks are quite technical, seems particularly inappropriate for an individual with his apparent level of cognitive impairment. (2) In most employments, relationships & cooperation with coworkers & customers are important. The Veteran's emotional impairments would seem to be a liability. (3) What he interprets as chronic headache, may be a response to cognitive impairment. An employer would be prudent who asks himself whether this Veteran with his impairments is the individual who should be working on aircraft engines. The Veteran's Physician requested from the employer a modification of his work schedule because of concerns about circadian rhythms in the Veteran. That request was nixed because granting it would in the employer's view, it would be a violation of the collectible bargaining agreement with the Union. However, the Veteran's positives with respect to employment were well stated by him when he said to this examiner, "I'm as strong as an O
  4. back in 2011 I filed for a plethora of disabilities that i received during my time in the air force as a load master. I was given an 80% rating. One of the claims was for depression an ptsd. However, I missed that c&p appt (i forget everything) and i obviously was not given a rating. However, I was sent a letter that says: "You were denied service connection for depression/anxiety/stress because you did not report for the scheduled exam in order to determine if the current disability began on active duty and to obtain sufficient information for evaluation of the disability. Although there is a record of treatment in service for anxiety/depression/stress, no permanent residual or chronic subject to service connection is shown by the service medical records or demonstrated by evidence following the service." Now this was sent to me in 2011. Since then ive received a ton of treatment but ive also have had some unfortunate events happen as a result of the depression, anxiety, anger etc (jail, a stint at the mental health clinic, even a broken hand twice on two separate occasions on 2 separate faces, and few more incidents. i am working so hard on controlling my frustrations with the world and i am taking my meds and getting counseling - i hate living like this because i physically cant control it. And i was never like that prior to 06' my join date). so my question is what exactly does that quote from the va mean? does it mean that they recognize i was treated for depression during active duty but due to me missing the appointment, they need more information? And if i were to file a claim for depression and ptsd - and i were to receive the 80% I need in order to be rated 100%, how would the back pay work? Would the date go bak to my initial 2011 date? Or would they back pay me from the current date of filing? Sorry for the long post - thanks for the help. Also am i correct in saying that they would only be paying the difference between the 80% pay and the 100% pay right??
  5. I filed a claim sometime in early October for an increase of my PTSD, a foot injury, as well as put in for 2 new conditions and one secondary condition. While I am largely very happy with how the claims for my physical disabilities has gone (my examiner told me within the first 5 minutes he was going to connect me for all the new stuff and that I rated an increase for the foot issue - after that I just had to actually do the C&P! My PTSD exam and resulting DBQ however were not nearly as smooth as my other C&P's had gone. Honestly I was actually kind of shocked when I finally got around to pulling it off myhealthevet and reading it. A big reason I was so surprised is that as far as "evidence" goes I've been piling it up over the last year. To get to how this all went down I have to run it back a little bit and explain my situation. I ran into a rough time around February of last year...... So I had my big sob story all typed up and then chickened out. Sufficed to say that I lost everything. Not only did I lose my wife and kids, I lost the dream property we had worked so hard to get to. I just walked away from it, I couldn't bring myself to walk back into the cabin. I literally just left everything I'd worked for the last 6 years of my life at 9,000 feet on the side of a mountain and just walked away. Sufficed to say I crashed and burned really hard. For about 3 weeks I spent every waking moment doing everything I could to make the pain go away, up to and including multiple attempts at OD'ing. I finally was able to get my wits together, did some searching online and ended up in a VA domiciliary program in Texas. While I've never identified myself as a drug addict, I definitely needed some help getting the wheels back on so the first thing I did was enroll myself in a 45 day substance abuse program. After that I was able to put in 3 1/2 months of inpatient trauma treatment, followed by 2 months of inpatient PTSD treatment. It's been about 9 months but I'm glad I did it, I honestly don't think I would have made it through to the New Year if I hadn't come here. Anyhow, after 9 months of inpatient therapy which included almost 6 months of trauma/PTSD treatment, daily group meetings, twice weekly counselor/psychologist one on ones, and intensive medication programs to help me through everything, I kinda thought I had a decent chance of getting an increase from 30%. I've tried for increases in the past but I haven't been the most consistent person over the years. I have a hard time following through on treatment and in addition to that due to having a non-combat trauma I haven't had a very easy time getting the VA to accept my diagnosis, at least on the disability side. The treatment side has no issue with it. Anyhow, like I said I had hope because in the past I had been told that I wasn't getting increases in my rating because I wasn't following through on treatment and because of that it made it difficult for me to build much of a case. Everything was simply my word as to how things were, or how I was getting by, but I didn't have anyone respectable to back me up about the things that I was going through and the troubles I have. So this leads me to my most recent C&P/DBQ. I've cut out a decent amount of personal information and trauma narrative stuff, but the meat and potatoes should be in there for anyone that's familiar with these things. I've been service connected since 2004 and my trauma is most definitely legitimate. I really hope there's a possible sunny side to all of this. I've done a massive amount of googling over the last few days and I've seen posts where people say that just because the examiner says one thing doesn't mean that's the direction the rater is going to go with things. I'm really discouraged right now. I've had a very contentious relationship with the VA for a long time. I have a very hard time trusting the VA anymore. I've had some very bad caregivers who were telling me one thing to my face while shredding me in their notes after I'd left (We have access to those you know....) One LCSW in particular went out of here way to push a personality disorder diagnosis on me, essentially getting the diagnosis put in my chart by filling up my psychiatrist with a lot of crap; all the while telling me how much she was trying to help me. Now here I am again. I feel like I'm really getting the short end of the stick by the VA and in particular this examiner, after I did have a pretty awesome doctor for my physical C&Ps and lord knows I'm not the first one to get the un-greased by the wonderful VA. That being said I'm just frustrated because I've really put in so much effort into my recovery and treatment. I'm working the DBT, mindfulness and challenging beliefs far more than I'm comfortable with, but I'm doing it. Anyhow I went from erasing my sob story to writing a whole new one. Thanks for taking the time to read through this and pass on any info/experience/ideas you might have. Thanks in advance, OGG The following is an excerpt from another thread I started about a DBQ for my back that ended up digressing a little. I figured there's no reason to type it all out again new so I just copy and pasted the "important" parts. Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire SECTION I: --------------------- 1. Diagnostic Summary -------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses: ------------------- Mental Disorder Diagnosis #1: PTSD Mental Disorder Diagnosis #2: Cannabis Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #3: Alcohol Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #4: Inhalant Use Disorder, In Early Remission, In a Controlled Environment Alright I'm definitely not proud of the huffing. All I can say is that my life had fallen to pieces. My wife took my kids and left me while I was getting the car fixed overnight. She filed false abuse charges against me to keep me from the kids. I'm no saint but I never abused my wife or my kids. Up until this moment I hadn't had a drink in 5 years... I just smoked pot - which I was prescribed. Also I think this would be a good time to put what my actual working diagnosis list for a little bit of contrast. This list was pulled straight off my myhealthevet file and reflects 9 months of inpatient treatment. I can't help but feel like this lady was snowballing me. Yes there's some overlap. What's the difference between PTSD and Chronic PTSD? I don't know. Why do I have 2 types of insomnia DX'd? I don't know that either. #1)Chronic post-traumatic stress disorder (SCT 313182004) #2)Posttraumatic stress disorder (SCT47505003) #3) Anxiety (SCT 48694002) - symptom of PTSD #3) Depressive disorder (SCT 35489007) - symptom of PTSD #4) Insomnia (SCT 193462001) - symptom of PTSD #5) Psychophysiologic insomnia (SCT 425832009) - symptom of PTSD #6) Cannabis dependence (SCT 85005007) #7) Alcohol dependence (SCT 66590003) 3. Differentiation of symptoms ----------------------------- a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes[ ] NO b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes[ ] No[ ] Not applicable (N/A) I have a problem with this part. Just how is she going differentiate between my various diagnosis which all are attributed to the PTSD? (besides the substance abuse issues) 4. Occupational and social impairment ------------------------------------ a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. I have a problem with this as well. I haven't been able to work in 6 years. I've tried but it always ends up being a failed attempt. I usually end up getting myself too worked up about social situations, get too depressed to get out of bed, get fired for being late because I have serious sleep problems which sometimes lead me to not being able to wake up for my alarm, etc etc. In addition I barely go out. Hell I went out of my way to move 10 miles from the closest power poll 9,000' above sea level just to find myself some peace. I can't handle large groups, I psych myself out when I'm out at night, I see danger and trouble everywhere. Anyhow back to getting smeared. b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [X] Yes[ ] No[ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Symptoms of PTSD and substance use contribute to social and occupational impairment. However, symptoms of PTSD have not increased in severity since the veteran's last C&P exam in 2013. A quick side note A: I've been in a treatment facility for almost a year now, I'm pretty sure my "substance abuse" isn't contributing to my issues. I smoked cannabis medicinally and I don't even drink. Why do I smoke pot because it helps with my PTSD as well as a laundry list of other issues. That being said I've been "clean" for a year now. So... now that she's basically said I barely have PTSD, and my troubles are simply because I'm a drug addict, let's get on to the next section. 3. PTSD Diagnostic Criteria -------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).d [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is NOT attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. That last one is my favorite! Not only does she say that my disturbances are NOT attributable to substances be it medication or drugs nor are they attributed to another medical condition. She also manages to manages to assess me with 20 out of 24 possible sub-criteria or disturbances in the diagnosis of PTSD. I'm sure I'm reading into this wrong and I can't look at things like this but that certainly feels like more than 30% disabling. I dunno. 4. Symptoms ---------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events 6. Other symptoms ---------------- In this section she just goes about telling whatever version of my life story she could piece together from old treatment records. Spends a lot of time on the fact that I smoke pot, that I didn't have a relationship with my father and various other fun facts that do a lot to distract you from the lack of a cohesive narrative or making any of what she wrote mean anything as far as the DBQ goes. She doesn't list a single "other symptom" like the line below talks about. She just kinda makes me out to be a flaky loser. Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No....... 7. Competency ------------ Is the Veteran capable of managing his or her financial affairs? [ ] Yes[X] No At this point she pulls out some more fun facts from my medical record. She says that "I frequently go on spending sprees", and brings up how when I was 25 and got my first backpay check and I blew it on fun stuff like a car, and a computer and whatnot (I was single going to university at the time). What this cluck of a woman doesn't see in her precious computer is that other than my time here at the VA facility I'd been able to support my wife and two kids on my 50% SC. Trust me there's no spending sprees going on there. 8. Remarks, (including any testing results) if any: -------------------------------------------------- Psychological Testing: A test of response bias specifically related to PTSD symptoms was administered to the veteran during this examination to assess the credibility of his self report. The name of this measure is withheld in this report in order to protect the integrity of the test. This test was specifically standardized on a sample of veterans applying for financial remuneration for a claim of disability resulting from PTSD. The veteran's score on this test was below the established cutoff, indicating that his performance was consistent with individuals responding in a valid manner. As such, he did not appear to be intentionally exaggerating signs and symptoms of PTSD or attempting to appear worse off that he actually is. Ahh what a finish eh? I think she should spend less time worrying about my credibility and a little more about hers. Well, last but not least let's hear her final word on the subject: Signed: 10/30/2015 13:35 11/03/2015 ADDENDUM STATUS: COMPLETED PTSD is less likely than not a result of military duties. /es/ Her Name Goes Here, PSYCHOLOGIST Signed: 11/03/2015 15:22 So yeah that's essentially where I'm at. I'm just hoping that whoever rates my PTSD takes what she says with a grain of salt and also takes time to look at the 1200 pages of treatment records I've added to my medical record in the last year as well as the weakly psychologist appointments, 20 page typed trauma narrative, the countless notes that were put in on my behalf. I hope they also see the weekly PCL-5s averaging between 65 and 72, the by weekly CAPs averaging around 66, the PHQ9 score of 23, the gad-7 score of 20 - All of which were administered by a Doctor or LCSW. Yah I've got this one too; World Health Organization Disability Assessment Schedule 2.0 Cognition: 75 Mobility: 12 Self-care: 70 Getting along: 83 Life activities (household): 100 Life activities (work/school): 85 Participation: 79 Summary: 70 *Range is 0 to 100 where 0 indicates no disability and 100 means full disability I realize I'm probably putting too much hope into all of this. I know that the disability tests and rating exams probably don't amount to anything as far as determining anything with the VA. If the particular examiner is up on their stuff they might know the significance of the WHODAS 2.0 or put stock in the CAPs screening but really they don't have to look at them at all. Hopefully at the very least I can use all I've put together to apply for SSDI. If you've gotten this far thank you so much for reading my rant and hopefully pulling out the important bits from what I did post of my DBQ. Hopefully I haven't over edited it but I just didn't think what she wrote was particularly applicable to the questions that the DBQ was asking and I generally feel she was just trying to prove out whatever she had come to believe based on small glimpses of my medical record. I really wish I had been afforded the opportunity to address some of the conclusions she was making about me and the picture she was painting.
  6. C&P(Compensation and Pension)Exams Sub-post, Mental Health/PTSD Exams (means you'll see a Psychologist or MH "Expert") Most of us here on Hadit.com LOVE to see C&P's. it is practically a GUARANTEE that we never see exams that are exactly the same. i believe the reason most of us look at these things is to help you all ease your own tensions, waiting for the Results of a C&P is no where near as intense as waiting for the Rating decision based of said exams. when you all come here, asking us to look, we do it for you, and us, because we are all still fighting as well. we learn, from your flaws and chaotic whirlpool of hope and despair, but we try to calm that storm for you. it's really rather sad that only us Veteran Civilians can give as much support and attention unlike those programs that claim to be lookin out for us. if Hadit.com was where ALL Veterans came to get the help they needed i believe our Veteran Community as a whole would be a lot better,but that isn't the case, so we make do with what we have. and what do we have you ask? Each other, that's it. just to the left and right of each one of us is someone still fighting a horrible system that seems not only to benefit, but THRIVE on denying a majority of us the Compensation's we've been guaranteed by Law. So, what's the point of this little post you may ask? well, look at it this way, those of us here, those of us who fight, not just for ourselves, but for each other, we have limited time. we DO have to fight our own cases as well, and we have to garner enough Information as we can.....so i despise when people waste my phukin time. and even more, i despise how they waste my fellow Shield brethren's time, it seriously feels to me as those who waste our time, literally waste moments of our Life. you know, that highly limited thing that we have so little of. Why am i posting this in the C&P Forum you may ask? Because, it is HERE, where it is the SIMPLEST to weed out the Scum.....those who would manipulate and twist all that WE do, for their own gains. How is it so simple you may be asking yourselves? well, lets take a look see at what exactly a C&P exam actually IS. and no i don't mean the fancy VA tracking numbers and Military-ish style jargon. i mean, what as LAYPEOPLE we must understand it as. Compensation and Pension- The underlined really only deals with us Vets here on Hadit.com, it's for those of us, who were broken, but since we signed a Contract, held up our Right Hand, and Swore an Oath, we are COMPENSATED for Damages that are based on a wonky azz math system that pretty much guarantees that you'll be Compensated, no matter how Slight or All Encompassing your injuries are. Mental Health Exams are ALWAYS conducted by MH professionals, personally, i wouldn't accept anything less than a PhD holding Psychologist, they actually get their Doctorates in Diagnosing Mental Health Disorders. most of us have been to them, SEVERAL times, always poking, prodding, asking questions that we deem unnecessary, and lots of times the Exams themselves seem to be rather scatterbrained. what one Doc does in St. Louis Mo is not even close to the tests ran by old Doc in Seattle Wa.....why is this? who knows? but the general theory of ALL MH medical evaluations is the same. they're not Medical Exams, they are FORENSIC Exams. which means, that PhD Doc ain't your buddy, he's a COP. they need to shock you, destabilize you, rile you up and see what is REALLY in there, if you're such a GOOD faker that you can fool a well trained Doc, then that is in and of itself another form of Psychosis, you all wonder why sooooo few cases of Fraud cause the termination of Compensation Benefits? because most of these "shifty" Docs are REALLY good at their jobs. even the way you react to how they react tells them many things. there is a common misconception of "buiding to deny" a case or something of that order, but for MH, not quite so. when it comes to MH, the VA HAS to be sure, it HAS to base all their decisions off of the Law, and MH is one area, where i believe we get very very very little Frauding of the system. the VA needs it's own Doc's, because lets face a solid fact, as a Treating Doc your own personal Doc is caught up in your well being and health, a VA Rating Officer has to know that what Information they get is 100% legit. i don't blame them, MH is only Treatable, not Curable. pretty much translates to benefits for life, i.e. Compensation on a Tax Free Check if you come here, and post your C&P Exam, and you think we're gonna sugar coat it and say try harder, you're sadly mistaken. this is my Callout, if you come here, looking to waste my time, and the time of the Veterans who kept me sane, who filled me with Hope, and even more, gave me the Knowledge i needed to win my Claims, i'm gonna shame you into Obscurity. we don't have time for you, if you post a C&P that you even THINK may cause some of us to think you're a liar, you better go find a Lawyer to look at your Shite, because you are NOT welcome here. i will find you, you can't lie to me, if you post your information, as i have done, as i have opened and bared my soul to my fellow Vets, and i see your Cancerous lies, i will call you out, and haunt your Posts. the few Rotten Apples such as yourself have caused a backlash against Broken Veterans on orders of magnitude that are both offensive and onerous in themselves. i would rather see a piece of Shite like you get your benefits, if it meant EVERY Vet who needed them right now got them, but that isn't how our System works, so you ain't gettin Shite from me..... Carry on Shield Siblings....
  7. So on Monday I had my C&P exams for my feet/ankles/toe and scars. I think it went rather well and the doctor was thorough. These C&P exams were ordered on September 8th, 2016 by the DRO in WACO after she over turned the other DRO's decision. She ordered the C&P exams so I could get a proper rating on my contentions. She over turned the DRO's decision due to his egregious errors in my decision that I brought to the attention of Mr. Robert McDonald's office and my local Congressman. After getting the representative from McDonald's office to contact me and then to get the WACO office to contact me, I sit here today awaiting the decision I should have had years ago. I am grateful the new DRO reviewed the decision that the previous DRO made and over turned it. The DRO that made the egregious errors in my decision has apparently done this to other Veterans. I hope they investigate this DRO. I am thankful I did not have to go another 2-4 years to the BVA to appeal a decision due to the egregious errors by one DRO. I am grateful the new DRO assigned saw the egregious error and reversed the decision at the RO level. I did talk to the DRO on Wednesday and she said she received the scar C&P exam but not yet received the Foot/Ankle/Toe C&P exam. She said it shouldn't be too long and then she can rate me. I am so anxious right now!
  8. Greetings all, This is my first post after looking for similar situations. My C&P exam for spine issues was in June and it seemed favorable until an addendum was made this month which turned everything around. They denied my claim for aggravated spine issues and had inaccurate information stating my condition didn't progress until after service. Is the best way to go about this by filing an appeal or by making a new claim for low back pain?
  9. Hi everyone; I have several threads going but i want to get these C&P exams out there in the open. Please look at both C&P exams (Foot Conditions) (Ankle Conditions). Look at the errors done by ONE doctor. The first C&P exam I attached is for Foot Misc. The very first error by the C&P examiner is the fact that he states under #1 Diagnoses Avulsion Fracture 5th Metatarsal - date of diagnoses 6/23/2013. That is WRONG! If you look at the other C&P Exam for Ankles, under #1 Diagnoses he states right 5th metatarsal fracture - date of diagnoses 1993! YES that is right! See where I am going with this???? Let's continue on.... C&P exam for Foot Misc - #2 Medical History - he specifically states Toe condition left toe. The date of the symptoms 1991. #3 Morton's Neuroma - YES left. #15 Functional Impact - YES #16 Remarks - For the claimant's claimed of RIGHT FOOT CONDITION, there is no diagnoses because the claimant does not claim the condition. For the claimant condition LEFT FOOT CONDITION, the diagnosis is already noted in the diagnosis section. For the claimants condition of TOE CONDITION ON LEFT FOOT, the diagnosis is already noted in the diagnosis section. He is obviously mistaken on my right foot condition because it was in my original claim May 2013 but let's continue.... C&P exam for Ankles - #1 Diagnosis - He notes ankle sprain 1993 and he notes right 5th metatarsal fracture 1993 BUT he puts it as LEFT foot! WTF????? Do you see this??? First he has the right fracture on my foot C&P exam with the wrong date, then on this one he has the right fracture but noted on the left foot! #2 Medical History: States my history #17 Functional Impact - YES #18 Remarks - The claimant now has or has had ankle condition. For the claimants claimed condition of RIGHT ANKLE CONDITION, the diagnosis is already noted in the diagnosis section. For the claimant's condition LEFT ANKLE CONDITION, the diagnosis is already noted in the diagnosis section. this doctor has F'd both C&P's up!!! To add to this I get some medical opinion in November 2014 from some doctor who apparently reviewed these C&P exams, my DBQ's submitted on my behalf by my Podiatrist at the time. This is so ridiculous! On top of this, the DRO takes my Nexus letters supposedly into consideration but no rationale? See attached the Nexus LetterNexus letter-redacted .pdf C&P Exam Feet 7-2013_Redacted.pdf C&P Exam Ankles 7-2013_Redacted.pdf
  10. Greetings, This is my first time posting here and I am trying to get a definitive answer on a question I have had on my mind for awhile. I filed a claim with the VA for PTSD and related anxiety and depression 2/13 and am scheduled for a C&P in a week. My symptoms have been gradually getting worse over the years and I finally reached out for help. Not getting too in depth about my personal struggle my background is that I was a USN FMF Hospital Corpsman with a combat rotation in Iraq at a field hospital in 2005. I am not worried about my stressor being conceded, but I DO NOT have a current diagnosis from the VA for PTSD. I was seen on active duty in 2006 for anxiety and prescribed medication however I have not gone to the VA for mental health issues. I am currently being seen at the local Vet Center by a therapist and currently attend a weekly PTSD group. Because my C&P is in a week I do not have time to be seen by a VA Psychologist but could go to the PET clinic for emergency medications and be seen by a Psychiatrist . My question is, do I need a current diagnosis from a VA mental health MD? Will a diagnosis/referral from my Vet Center therapist suffice? I am asking this because, through reading online about this process, I have received two contradictory answers to these questions. I have read that during my C&P the examining VA doctor will assign a diagnosis at that time. Is this accurate? Will the C&P examiner diagnosis PTSD and will that be enough to satisfy the criteria of needing a current PTSD diagnosis? If not, please provide any advise/information that will be useful for me going forward with my claim. Thank you for your help and I appreciate all the advise and stories I have read on these boards, it is nice to know I am not alone. -Sam
  11. Today both my PTSD due to MST and my Major Depression claims were denied. I had my C&P on 12/17/2015. I picked up my exam notes from the records department of my local CBOC where the exam had been held, and just a few minutes later my MST coordinator called to tell me of my denial. I checked e-Benefits and it has already been finalized with notification letter sent. The C&P examiner did several things I find fishy and that I was uncomfortable with during the exam, and then apparently diagnosed me as Borderline Personality Disorder and reported that I don't have PTSD. I had been diagnosed with PTSD by different (civilian)doctors in both 2006 and in 2014. I am very upset by this because in her report, she states that I meet all the criteria, but that she won't count the D and E criteria because she thinks it fits better with a BPD diagnosis. I have no idea how or why she made this determination. She said my symptoms were "long-standing." Well, yes, they were, because the stressor that caused my PTSD occured 17 years ago. This is what her notes said when she denied that I have PTSD. “The Veteran is reporting an alleged sexual assault during her time in the Army that would meet Criterion A and reporting symptoms consistent with criteria B, C, F, G, and H. However, her reported mood symptoms, anxiety, impulsivity, substance use, irritability and angry outbursts, risky behaviors, risky sexual behaviors, and social and occupational are better accounted for by her BPD diagnosis.” “The symptoms she is reporting that would meet PTSD criteria D & E are better accounted for by her BPD diagnosis, appear to be long-standing and more of a characterological nature.” I don't feel comfortable at this time sharing more of her C&P notes. It is still too fresh for me. I am trying to figure out what my next step will be...filing for an appeal or a reconsideration. Any advice or insight would be greatly appreciated.
  12. Hey guys, I'm a long time luker here.... finally decided to make an account.... A little background on me.... 5 years Army Active duty (Supposed to be only 4.... but I got stop lost for 1 year and some change....) 2001-2006 3 deployments to Iraq. I had my C&P late November for my PTSD.... I was rated at 50% SC. I was also rated 10% for Tinnutus.... giving me 55%... for a total of 60% SC rating. I just wanted to seek some opinions from us folks if the 50% rating for PTSD is sufficient.... if not.... what I am looking for recommendations on what to do?.... I also have my first PCP appointment on March..... Here is my PTSD C&P Results.... some info has been deleted (names and such).... Date/Time: xxxx Nov xxxx @ xxxx Note Title: C&P EXAM Location: VA Southrn Nevada Hlthcare Sys Signed By: xxxx Co-signed By: xxxx Date/Time Signed: xxxx ------------------------------------------------------------------------- LOCAL TITLE: C&P EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: NOV xxxx ENTRY DATE: NOV xxxx AUTHOR: xxxx EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: xxxx SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder ICD code: F43.10 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Deferred to physician Comments, if any: Complaints of tinnitus, back pain and headaches with no current medical treatment 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: 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 [X] 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 [X] Other: Separation physical found in STRs in eFolder notes complaints of anxiety around unfamiliar people, a tendency to avoid crowds, and memory disturbance. DD 214 shows Vetean recieved Iraq Campaign Medal. Enlistment physical is negative for mental health complaints. VA electronic records show no contact with VA mental health treating sources. b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): xxxx b. Relevant Occupational and Educational history (pre-military, military, and post-military): xxxx c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Mr. xxxx did not report any history of mental health problems or treatment prior to military service. He stated that he has never received mental health treatment of any kind. He indicated that he filed a claim for a mental health condition because of frequent issues with poor sleep and irritability that have led to family strain. Mr. xxxx identified PTSD stressors related to military service. He indicated that during his third deployment to Iraq he was frequently assigned to recovery missions that involved recovering disabled US military vehicles. He indicated that these vehicles were often contaminated with blood and body matter. He described a particular recovery mission during which the vehicle he was riding in and was hit by an IED at a busy intersection. He stated that the explosion caused him to "black out" that he subsequently "woke up and down the gun Hatch crying, and I wanted to shoot people." He indicated that no other servicemembers were injured during this incident. He also stated that during deployments, especially his second deployment, he was repeatedly exposed to mortar shelling. Mr. xxxx described ongoing PTSD symptoms related to the above stressors. These symptoms were said to include intrusive memories that occur on a weekly basis or more frequently, and that are often triggered by tinnitus the reminds him of IED explosion described above. He stated that he will listen to music in an effort to reduce tinnitus and trauma memories. He estimated that he experiences nightmares of deployment about twice a month. He did not report any clear dissociative flashbacks, but stated that he will sometimes be distracted by intrusive memories of deployment, causing him to "zone out". He acknowledged avoidance of trauma reminders including Middle Eastern people, burning odors, cigarette smoke, busy intersections and news programs about war or terrorism. He reported hypervigilant behaviors such as keeping weapons in his home, adding security features to his home, planning for emergencies, avoiding crowds, always remaining alert to his surroundings, preferring to sit with his back to the wall and near an exit, and always remaining alert to his surroundings. He indicated that he continues to startle easily, and to respond defensively if startled. He described onset of sleep as delayed by anxiety and indicated that mid-stage sleep is variably interrupted with delay returning to sleep. He noted that his wife complains that he is active in his sleep. He indicated that he awakens earlier than he wants to occasionally and denied sleeping excessively. He stated that he typically feels rested on awakening, and estimated that he sleeps 5-6 hours per night. However, he complained of some daytime fatigue and unintentional sleep. He reported irritability that he expresses either verbally or by isolating himself. He noted that he will occasionally slam doors. He denied violent or destructive thoughts or behaviors. He indicated that concentration is poor in that he is easily distracted. He stated that he has lost touch with family members and friends since being deployed. Mr. xxxx reported experiencing occasional, brief depressive episodes during which he feels sad and lonely. He noted that he can feel free from emotional distress at times, for example during and after exercise. He was vague regarding any experience of guilt or self blame. He stated that he cries occasionally, without relief of distress. He indicated that his appetite is good and he estimated that he has gained some 20 pounds in the last year because of reduced activity and occasionally eating for comfort. He reported fair energy, and no manic or hypomanic symptoms were elicited. He denied any history of suicidal ideation or suicide attempt. He stated that he continues to enjoy time with his family, exercising, playing video games and watching movies. Mr. xxxx reported that he worries about his finances, situation and job and that worry can interfere with concentration. Panic, obsessive-compulsive and psychotic symptoms were denied. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): None reported e. Relevant Substance abuse history (pre-military, military, and post-military): None reported f. Other, if any: NA 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: Repeated exposure to blood and body matter while conducting recovery missions in Iraq Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: Being in a vehicle hit by an IED at a busy intersection in Iraq Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: Frequent exposure to mortar shelling in Iraq Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2 [X] Stressor #3 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- Mr. xxxx was casually dressed and groomed with an unremarkable appearance. Posture and eye contact were appropriate and facial expression was mobile. He was well oriented and remained cooperative throughout. Mood was mildly anxious and affect was appropriate to topic. Speech was fluent with rate, volume and intonation consistent with affect. Thought processes were logical and goal-directed and cognition appeared intact based on verbal production. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- Portions of this document were completed using voice recognition software. While it has been proofread, some errors might remain. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. What do you guys think?.... is 50% a fair rating? or did I get low balled.... also if I did get low balled.... what actions do I need to take? Also I recently put in a claim for Sleep Apnea and IBS...... Thanks a lot for reading and any input will be greatly appreciated!
  13. good afternoon all, i am a new member on this, former US army reservist, and currently employed full time. i separated in 2009 but filed my claim in Aug 2015 (i wasnt aware as a reservist of only 6 yrs total enlistment that i could actually apply for anything). my decision finally moved in the Preparation for Decision phase two days ago, 6/21/2016. i have two questions: 1 - how quickly does it go from here?...(im guessing the answer is that there is no answer. everyone's claim is handled differently but has anyone experienced the claim to wrap up rather quickly from here?) 2 - i am trying to determine what sort of rating i may get for my mental health based off my C&P results. anyone with experience please take a look (below) and offer their opinion? thank you kindly for any assistance and response: SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: F 43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: F 43.10 Mental Disorder Diagnosis #2: Unspecified Depressive Disorder ICD code: F32.9 -------------------------------------------------------- 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation ****i know by definition this summary may fall within the 30% rating, but please continue reading below****** a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [X] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] 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: 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: [censored] Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No d. Additional stressors: If additional stressors, describe (list using the above sequential format): Stressor #4 [censored] This stressor meets Criterion A; this stressor is related to the Veteran's fear of hostile military or terrorist activity; this stessor is not related to personal assualt. 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Feelings of detachment or estrangement from others. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Hypervigilance. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Other, please indicate stressor number (i.e., Stressor #4, #5, etc.) as indicated above: Stressor #4 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [this is a 30% symptom] [X] Anxiety [30% symptom] [X] Suspiciousness [30% symptom] [X] Panic attacks more than once a week [this is a 50% symptom] [X] Chronic sleep impairment [30% symptom] [X] Flattened affect [50% symptom] [X] Disturbances of motivation and mood [50% symptom] ****the symptoms listed above fall under both 30% and 50% criteria, so i am uncertain whether they will consider both or make the decision based off the Summary at the begining of the report, which technically defines the 30% rating****** 9. Remarks, (including any testing results) if any -------------------------------------------------- Based on this examination and a review of the records, it is determined that the Veteran meets DSM-5 criteria for PTSD. It is further determined that this diagnosis is at least as likely as not (50/50 probability) a result of the identified in service stressors. The Veteran is also found to meet criteria for Unspecified Depressive Disorder. This diagnosis is determined to be at least as likely as not (50/50 probability) proximately due to or a result of the PTSD. The Veteran gives a credible account of stressors deemed consistent with his MOS, and with service in the identified combat theater. While there are no related service treatment records, post-deployment questionnaires suggest that Veteran was experiencing subjective distress at the time of his redeployment. The claimed anxiety and sleep disturbance are deemed to be symptoms of both of the current diagnoses. this ends my report. thank you again for anyone's response and assistance. [The Silent Warrior of the Army Team]
  14. I am currently rated at 50% for PTSD and just had my C&P exam for an increase. Below is my current C&P results. Also I suffer from Major Depression and Erectile Dysfunction due to my medication. Could these two items be filed as secondary since the examiner did not list them in my C&P exam.Any input would be appreciated on to what my outcome may be. Thank you SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD, moderate to severe, chronic Comments, if any: The trauamtic event was learning that a close friend of his killed two older female civilians. PTSD also causes secondary panic attacks 2-3 times per week. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[ ] No[X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[ ] No[X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No 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) [X] 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: b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: On 11/25/2014, Dr. XXX conducted a C&P Initial Evaluation for PTSD and diagnosed the veteran with PTSD with panic attacks. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Mr. XX is currently married to his wife of 10 years. He describes the quality of his current marriage as, "loving - but my wife puts up with me." He reports his irritability and anger can stress his wife. He adopted his wife's 14 year old daughter. He reports he has no friends of his own, but he reports he is friendly with many of his wife's friends. He tends to avoid crowds and group social activities. He is quite close with his parents. His main hobby is drumming and working on computers. Overall his social support is limited. He reports that the primary effect of his psychiatric symptoms on his social relationships are tension and distance caused by irritability, rage (including yelling, swearing, and very occasional violence towards inanimate objects - like punching a hole in the door), withdrawal, and emotional numbing. b. Relevant Occupational and Educational history: Mr. XXX highest level of education is some college. He served in the Airforce. He is currently employed as a cyber security analyst at XXX a telecommunications company called XXX. He has worked at XXX since 2011. In 2012, he was written up for "going off on a customer." He reports he works from home or calls in sick 4-5 days a month due to feeling stressed. He reports during times of stress he impulsively loses his temper when talking with customers or makes careless mistakes. He is a lead, and he has five other analysists who report to him. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mr. XXX denied history of psychiatric hospitalization, receiving out-patient therapy, receiving any type of psychopharmacological treatment, or prior suicide attempts. He has been referred to a psychiatrist by his PCP but he is not currently engaged in therapy. He receives medication management from his private PCP, and he is currently maintained on a regimen of Zoloft, hydroxyzine, prazosin and diazepam. d. Relevant Legal and Behavioral history: No arrests. Received an article 15 in the military after he learned of the murders. e. Relevant Substance abuse history: No response provided. f. Other, if any: No response provided. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 5. Behavioral Observations: --------------------------- Mr. XXX was casually dressed, and was cooperative throughout the examination. His speech was fluent. His psychomotor behavior was appropriate. His affect was constricted and his mood was anxious. His insight was intact. Thought process was linear, goal directed, and future oriented. No reported hallucinations or delusions. No reported homicidal or suicidal ideation. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- Veteran's PTSD and panic attacks currently cause moderate socio-occupational impairment.
  15. I have been 100% perm and total since 2003, before that i was 70%. I just got an appointment for a C and P exam to reevaluate. WHY! Has anyone ever heard of this? Has anyone ever had one after being perm and total? What is going on?
  16. I am currently rated at 50% for PTSD and just had my C&P exam for an increase. Below is my current C&P results. Any input would be appreciated on to what my outcome may be. Thank you SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD, moderate to severe, chronic Comments, if any: The trauamtic event was learning that a close friend of his killed two older female civilians. PTSD also causes secondary panic attacks 2-3 times per week. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[ ] No[X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[ ] No[X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No 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) [X] 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: b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: On 11/25/2014, Dr. XXX conducted a C&P Initial Evaluation for PTSD and diagnosed the veteran with PTSD with panic attacks. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Mr. XX is currently married to his wife of 10 years. He describes the quality of his current marriage as, "loving - but my wife puts up with me." He reports his irritability and anger can stress his wife. He adopted his wife's 14 year old daughter. He reports he has no friends of his own, but he reports he is friendly with many of his wife's friends. He tends to avoid crowds and group social activities. He is quite close with his parents. His main hobby is drumming and working on computers. Overall his social support is limited. He reports that the primary effect of his psychiatric symptoms on his social relationships are tension and distance caused by irritability, rage (including yelling, swearing, and very occasional violence towards inanimate objects - like punching a hole in the door), withdrawal, and emotional numbing. b. Relevant Occupational and Educational history: Mr. XXX highest level of education is some college. He served in the Airforce. He is currently employed as a cyber security analyst at XXX a telecommunications company called XXX. He has worked at XXX since 2011. In 2012, he was written up for "going off on a customer." He reports he works from home or calls in sick 4-5 days a month due to feeling stressed. He reports during times of stress he impulsively loses his temper when talking with customers or makes careless mistakes. He is a lead, and he has five other analysists who report to him. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mr. XXX denied history of psychiatric hospitalization, receiving out-patient therapy, receiving any type of psychopharmacological treatment, or prior suicide attempts. He has been referred to a psychiatrist by his PCP but he is not currently engaged in therapy. He receives medication management from his private PCP, and he is currently maintained on a regimen of Zoloft, hydroxyzine, prazosin and diazepam. d. Relevant Legal and Behavioral history: No arrests. Received an article 15 in the military after he learned of the murders. e. Relevant Substance abuse history: No response provided. f. Other, if any: No response provided. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 5. Behavioral Observations: --------------------------- Mr. XXX was casually dressed, and was cooperative throughout the examination. His speech was fluent. His psychomotor behavior was appropriate. His affect was constricted and his mood was anxious. His insight was intact. Thought process was linear, goal directed, and future oriented. No reported hallucinations or delusions. No reported homicidal or suicidal ideation. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- Veteran's PTSD and panic attacks currently cause moderate socio-occupational impairment.
  17. I am currently rated at 50% for PTSD and just had my C&P exam for an increase. Below is my current C&P results. Any input would be appreciated on to what my outcome may be. Thank you SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD, moderate to severe, chronic Comments, if any: The trauamtic event was learning that a close friend of his killed two older female civilians. PTSD also causes secondary panic attacks 2-3 times per week. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[ ] No[X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[ ] No[X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No 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) [X] 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: b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: On 11/25/2014, Dr. XXX conducted a C&P Initial Evaluation for PTSD and diagnosed the veteran with PTSD with panic attacks. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Mr. XX is currently married to his wife of 10 years. He describes the quality of his current marriage as, "loving - but my wife puts up with me." He reports his irritability and anger can stress his wife. He adopted his wife's 14 year old daughter. He reports he has no friends of his own, but he reports he is friendly with many of his wife's friends. He tends to avoid crowds and group social activities. He is quite close with his parents. His main hobby is drumming and working on computers. Overall his social support is limited. He reports that the primary effect of his psychiatric symptoms on his social relationships are tension and distance caused by irritability, rage (including yelling, swearing, and very occasional violence towards inanimate objects - like punching a hole in the door), withdrawal, and emotional numbing. b. Relevant Occupational and Educational history: Mr. XXX highest level of education is some college. He served in the Airforce. He is currently employed as a cyber security analyst at XXX a telecommunications company called XXX. He has worked at XXX since 2011. In 2012, he was written up for "going off on a customer." He reports he works from home or calls in sick 4-5 days a month due to feeling stressed. He reports during times of stress he impulsively loses his temper when talking with customers or makes careless mistakes. He is a lead, and he has five other analysists who report to him. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mr. XXX denied history of psychiatric hospitalization, receiving out-patient therapy, receiving any type of psychopharmacological treatment, or prior suicide attempts. He has been referred to a psychiatrist by his PCP but he is not currently engaged in therapy. He receives medication management from his private PCP, and he is currently maintained on a regimen of Zoloft, hydroxyzine, prazosin and diazepam. d. Relevant Legal and Behavioral history: No arrests. Received an article 15 in the military after he learned of the murders. e. Relevant Substance abuse history: No response provided. f. Other, if any: No response provided. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 5. Behavioral Observations: --------------------------- Mr. XXX was casually dressed, and was cooperative throughout the examination. His speech was fluent. His psychomotor behavior was appropriate. His affect was constricted and his mood was anxious. His insight was intact. Thought process was linear, goal directed, and future oriented. No reported hallucinations or delusions. No reported homicidal or suicidal ideation. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- Veteran's PTSD and panic attacks currently cause moderate socio-occupational impairment.
  18. Greetings ladies and gentlemen, I received a 70% rating for PTSD from last years increase when it was at 50%. I've been unemployed for over a year since being fired for several aggressive angry outbursts related to stressors tied to my PTSD. Filed for TDIU May 11th of 2016 and I have a C&P scheduled for June 10th of 2016. What the heck can I expect at a TDIU c&p? I sent in all of my formal write-ups and suspension paperwork from my previous employer as well as buddy statements from coworkers who witnessed my behavior and how my work performance was affected due to PTSD. I have tried multiple times to have HR from my previous employer fill out the VA-form requesting employment info but they have not cooperated with me. Won't return calls or emails. Even sent them the form but nothing gets back to me. I fear that will hurt me and also be I'm clean shaven and well dressed (I'm ocd about my appearance by it seems as if it's the only thing I can control). I stay home taking care of my daughter but she goes to daycare a couple times a week to give me a break. It gets too much at times. Should that be mentioned ? I just thought my claim is moving fast and not sure if that is good or bad 😕 Any thoughts? Thanks for all you do. It is greatly appreciated.
  19. My claim for ervice connection for Irritable Bowel Syndrome (IBS) as a presumptive service connected disability due to my service in the Gulf War per 38 C.F.R §3.317 was denied. Wondering how I can succesfully appeal. VA DENIAL LETTER “ Service connection is not permitted if there is affirmative evidence that the disability was unrelated to military service in the Gulf War. Service connection for unexplained chronic multi symptom illness to include irritable bowel syndrome is denied because evidence established that this disability result from poor diet and fitness. Your service treatment records do not contain complaints, treatment, or diagnosis for this condition. We did not find a link between your medical condition and military service. On examination, the examiner indicated that your stated symptoms do not meet the criteria for a diagnosis for irritable bowel syndrome and are most likely the result of poor dietary and fitness habits.” SERVICE INFORMATION & MEDICAL DIAGNOSIS: I served in Southwest Asia during Operation Iraq Freedom. My unit did participate in ground combat in Iraq. I have been diagnosed with IBS from VA medical doctor. I currently take both RX & non-RX medication for IBS. This information was submitted in my claim but not listed as evidence considered C&P EXAM Examined at VA Loma Linda. Examiner is a physican assistant. Examiner did not ask about fitness or diet patterns. Blue Button says I am unable to view the exam notes.
  20. Hi everyone I am new here, and after reading some of these C&P stories I am pretty upset to say the least. I find myself here because I recently received a letter in the mail stating I had an appointment for a C&P, but the letter does not in any way say what it is for. I logged on to the EBenefits website because I check there once a week, and found my claim completion estimation had been pushed back by between 5-8 months with no information about why. So I went to check out my documents section I than went to generation my summary of benefits and it says my combined service-connected evaluation is 90% and it says my effective date was February 1st of 2016. I never received a packet or any sort of breakdown never received any money, so why do I need to do another C&P if I've done all my documents?
  21. C&P Exam PTSD:MST Eating Disorder.pdf ^^^^^^Well the attached report indicates to me a 10% PTSD rating. I am currently 30% and I do not understand how this happened but I might be in for a reduction. I thought the exam went well. I had a PTSD and Eating Disorder C&P. Regarding the occupational/social impairment she checked the one that resembles 10% and for "b" she marks YES and goes on to say my trauma impacts my occupational/social impairment. Look at the symptoms she notes: Anxiety; Panic Attacks more than once a week; Chronic sleep impairment; difficulty in establishing and maintaining effective work and social relationships She even stated in the exam that I was BDD (Body Dysmorphic Disorder) but her reports indicates while I have BDD characteristics I don't warrant the BDD rating. She states for the VA established diagnosis of SPECIFIED TRAUMA AND STRESSOR RELATED DISORDER, there is NO CHANGE in the diagnosis. At this time the claimant's condition is active. Does this Exam mean I am going to be reduced or would I fall under the below??? 3.344 Stabilization of disability evaluations. (a) Examination reports indicating improvement. Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and Department of Veterans Affairs regulations governing disability compensation and pension. It is essential that the entire record of examinations and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. This applies to treatment of intercurrent diseases and exacerbations, including hospital reports, bedside examinations, examinations by designated physicians, and examinations in the absence of, or without taking full advantage of, laboratory facilities and the cooperation of specialists in related lines. Examinations less full and complete than those on which payments were authorized or continued will not be used as a basis of reduction. Ratings on account of diseases subject to temporary or episodic improvement, e.g., manic depressive or other psychotic reaction, epilepsy, psychoneurotic reaction, arteriosclerotic heart disease, bronchial asthma, gastric or duodenal ulcer, many skin diseases, etc., will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Ratings on account of diseases which become comparatively symptom free (findings absent) after prolonged rest, e.g. residuals of phlebitis, arteriosclerotic heart disease, etc., will not be reduced on examinations reflecting the results of bed rest. Moreover, though material improvement in the physical or mental condition is clearly reflected the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. When syphilis of the central nervous system or alcoholic deterioration is diagnosed following a long prior history of psychosis, psychoneurosis, epilepsy, or the like, it is rarely possible to exclude persistence, in masked form, of the preceding innocently acquired manifestations. Rating boards encountering a change of diagnosis will exercise caution in the determination as to whether a change in diagnosis represents no more than a progression of an earlier diagnosis, an error in prior diagnosis or possibly a disease entity independent of the service-connected disability. When the new diagnosis reflects mental deficiency or personality disorder only, the possibility of only temporary remission of a super-imposed psychiatric disease will be borne in mind. (b) Doubtful cases. If doubt remains, after according due consideration to all the evidence developed by the several items discussed in paragraph (a) of this section, the rating agency will continue the rating in effect, citing the former diagnosis with the new diagnosis in parentheses, and following the appropriate code there will be added the reference “Rating continued pending reexamination ___ months from this date, §3.344.” The rating agency will determine on the basis of the facts in each individual case whether 18, 24 or 30 months will be allowed to elapse before the reexamination will be made. (c) Disabilities which are likely to improve. The provisions of paragraphs (a) and (b) of this section apply to ratings which have continued for long periods at the same level (5 years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. Reexaminations disclosing improvement, physical or mental, in these disabilities will warrant reduction in rating.
  22. Hey guys! Seems like I been away from you guys for a while now, so I knew I needed to login and share some updates with my fellow hadit.com vets! I had my final C&P Exam--Hearing Loss/Tinnitus last Monday April 18th. I checked eBennies last nite 04/285/16, and my claim is now in the Prepped for Decision: New Documents Rcvd--Development letter Sent, so I'm happy to see that its been moving faster than I originally expected or had hoped it would be. After all, I submitted my claims about 73 days ago and my estimated completion time was 06/22/16 to 10/122/2016 and now its 05/22/16 to 06/23/2016!! Sooooo...I been busy with other things to this point and even now and not sure how I shold be feeling when it appears to be moving so fast now. With that being said, I had three exams (TBI Residuals--HA's/PTSD/Tinnitus) and I only seen that my VARO has only recvd or showing 2 of 3 exams in eBennies today when I logged in. So, what does that mean if the PTSD DBQ wasn't shown & the TBI Residuals--Headaches & Tinnitus were, with it being in the PFD stage? Semper Paratus
  23. I had this C& P done on the 16th. From start to finish was 1hr and 45 mins. the doctor hardly touched me and looked mostly at her computer. the statement about me having flat feet going into boot camp. I am not sure how she came to that because I didn't tell her that. Any feedback or suggestions would be helpful. I have my PTSD C& P on the 26th. Thank You! Gulf War General Medical Examination Disability Benefits Questionnaire * Internal VA or DoD Use Only* 1. Medical record review ------------------------ [X] Other, describe: VBMS 2. Medical history ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided CONFIDENTIAL Page 5 of 43 e. Hearing loss, tinnitus and ear: Hearing Loss and Tinnitus f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx g. Breast: No answer provided h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep apnea) i. Cardiovascular: No answer provided j. Digestive and abdominal wall: Intestinal Conditions (other than Surgical and Infectious) k. Kidney and urinary tract: No answer provided l. Reproductive: Gynecological Conditions m. Musculoskeletal: The following conditions have been reported Joints and extremities: Ankle Feet: Flatfeet n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: PTSD (Initial or Review) q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [ ] Yes [X] No 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- CONFIDENTIAL Page 6 of 43 Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [ ] Yes [X] No 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- E-file reviewed including buddy statement. Veteran does have fatigue and trouble sleeping that should be further examined with PTSD exam by mental health examiner for insomnia. Veteran reports she had a cold and URi multiple times while in service. She was given an inhaler and was told she hadd possible exercise induced asthma but it only seemd to flare up during change in seasons and was related to more of her sinuses and rhinitis. See rhinitis and sinusitis exam for more information on her "respiratory" complaint. **************************************************************************** Intestinal Conditions (other than surgical or infectious), including irritable bowel syndrome, Crohn's disease, ulcerative colitis and diverticulitis Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No CONFIDENTIAL Page 7 of 43 ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with an intestinal condition (other than surgical or infectious)? [X] Yes [ ] No [X] Irritable bowel syndrome ICD code: K58.0 Date of diagnosis: 2004 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary): Veteran reports constipation started while in boot camp in 2004. The diarrhea started while in Iraq in 2009. It alternated dairrhea and constipation. She saw a GI doctor in 2009 and she took Miralax and another medication for ulcers. She tested negative for h. pylori and ova and aprasites and those were negative. She avoided food triggers and alternated between culcolax and miralax and imdoium. Symptoms continue to the present day. She was also given zofran for nausea. b. Is continuous medication required for control of the Veteran's intestinal condition? [X] Yes [ ] No If yes, list only those medications required for the intestinal condition: miralax imodium probiotics c. Has the Veteran had surgical treatment for an intestinal condition? CONFIDENTIAL Page 8 of 43 [ ] Yes [X] No 3. Signs and symptoms --------------------- Does the Veteran have any signs or symptoms attributable to any non-surgical non-infectious intestinal conditions? [X] Yes [ ] No If yes, check all that apply: [X] Alternating diarrhea and constipation If checked, describe: alternating diarrhea and constipation but it varies. Usually at all 2-3 days of diarrhea followed by almost a week of not going [X] Abdominal distension If checked, describe: swollen abdomen, appears 2-3 months pregnant usually. Cramping and gurgling in the stomac [X] Nausea If checked, describe: feels sick to stomach [X] Vomiting If checked, describe: takes zofran [X] Other, describe: passes out and sweats sometimes and has sharp pains ont he left side of abdomen 4. Symptom episodes, attacks and exacerbations ---------------------------------------------- Does the Veteran have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition? [X] Yes [ ] No If yes, indicate severity and frequency: (check all that apply) [X] Episodes of bowel disturbance with abdominal distress If checked, indicate frequency: [ ] Occasional episodes [X] Frequent episodes CONFIDENTIAL Page 9 of 43 [ ] More or less constant abdominal distress 5. Weight loss -------------- Does the Veteran have weight loss attributable to an intestinal condition (other than surgical or infectious condition)? [ ] Yes [X] No 6. Malnutrition, complications and other general health effects --------------------------------------------------------------- Does the Veteran have malnutrition, serious complications or other general health effects attributable to the intestinal condition? [ ] Yes [X] No 7. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 8. 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: 9. Diagnostic testing --------------------- a. Has laboratory testing been performed? [ ] Yes [X] No b. Have imaging studies or diagnostic procedures been performed and are the results available? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 10. Functional impact --------------------- Does the Veteran's intestinal condition impact his or her ability to CONFIDENTIAL Page 10 of 43 work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's intestinal conditions, providing one or more examples: frequent bathroom breaks 11. Remarks, if any: -------------------- E-file reviewed. Veteran's IBS is a diagnosable chronic multisymptom illness with a partially explained etiology that is at least as likely as not related to an exposure event in Southwest Asia as symptoms did not start until she was in Iraq. **************************************************************************** Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes[ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS SECTION I: Diagnosis: CONFIDENTIAL Page 11 of 43 --------------------- Does the Veteran now have or has he/she ever been diagnosed with a sinus, nose, throat, larynx, or pharynx condition? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Chronic sinusitis ICD code: J32.9 Date of diagnosis: 2004 [X] Allergic rhinitis ICD code: 477.9 Date of diagnosis: 2004 SECTION II: Medical history --------------------------- Veteran reports she had drainage and a head cold with stuffiness and she was treated with sudafed and tessalon perles. She had been coughing and had a sore throat and the congestion was in her chest so at night she would have a hard time breathing and had a hard time breathing when running. She was given an inhaler and nasal spray and allergy meds which helped. She had questionable exericse induced asthma, btu she notes it was only when she had a cold or sinus infection that she had the breathing problems. The allergies and rhinitws continue to the prfesent day. She gets URI at least 3 times througout the year. SECTION III: Nose, throat, larynx or pharynx conditions ------------------------------------------------------- Does the Veteran have any of the following nose, throat, larynx or pharynx conditions? [X] Yes [ ] No [X] Sinusitis [X] Rhinitis 1. Sinusitis ------------ a. Indicate the sinuses/type of sinusitis currently affected by the Veteran's chronic sinusitis (check all that apply): [ ] None [X] Maxillary [ ] Frontal [ ] Ethmoid [ ] Sphenoid [ ] Pansinusitis b. Does the Veteran currently have any findings, signs or symptoms attributable to chronic sinusitis? [X] Yes [ ] No If yes, check all that apply: [ ] Chronic sinusitis detected only by imaging studies (see Diagnostic testing section) [X] Episodes of sinusitis [ ] Near constant sinusitis If checked, describe frequency: CONFIDENTIAL Page 12 of 43 [X] Headaches [X] Pain of affected sinus [X] Tenderness of affected sinus [X] Purulent discharge [ ] Crusting [ ] Other For all checked conditions, describe: c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months? [X] Yes [ ] No If yes, provide the total number of non-incapacitating episodes over the past 12 months: [ ] 1 [ ] 2 [X] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or more d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months? [ ] Yes [X] No NOTE: For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician. If yes, provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12 months: [ ] 1 [ ] 2 [ ] 3 or more e. Has the Veteran had sinus surgery? [ ] Yes [X] No If yes, specify type of surgery: [ ] Radical (open sinus surgery) [ ] Endoscopic [ ] Other: Type of procedure, sinuses operated on and side(s): Date(s) of surgery (if repeated sinus surgery, provide all dates of surgery): If Veteran has had radical sinus surgery, did chronic osteomyelitis follow the surgery? [ ] Yes [ ] No f. Has the Veteran had repeated sinus-related surgical procedures performed? [ ] Yes[X] No 2. Rhinitis ----------- CONFIDENTIAL Page 13 of 43 a. Is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis? [ ] Yes [X] No b. Is there complete obstruction on the left side due to rhinitis? [ ] Yes [X] No c. Is there complete obstruction on the right side due to rhinitis? [X] Yes [ ] No d. Is there permanent hypertrophy of the nasal turbinates? [X] Yes [ ] No e. Are there nasal polyps? [ ] Yes [X] No f. Does the Veteran have any of the following granulomatous conditions? [ ] Yes [X] No If yes, check all that apply: [ ] Granulomatous rhinitis [ ] Rhinoscleroma [ ] Wegener's granulomatosis [ ] Lethal midline granuloma [ ] Other granulomatous infection, describe: 6. 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 the 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 answer provided d. Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages? [ ] Yes[X] No e. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala? [ ] Yes[X] No f. Does the Veteran have loss of part of the nose or other scars causing CONFIDENTIAL Page 14 of 43 other obvious disfigurement? [ ] Yes[X] No SECTION IV: Diagnostic testing ------------------------------ a. Have imaging studies of the sinuses or other areas been performed? [ ] Yes[X] No b. Has endoscopy been performed?: No c. Has the Veteran had a biopsy of the larynx or pharynx?: No d. Has the Veteran had pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis?: No e. Are there any other significant diagnostic test findings and/or results? No answer provided SECTION V: Functional impact and remarks ---------------------------------------- 1. Functional impact -------------------- Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact his or her ability to work? [ ] Yes [X] No 2. Remarks, if any: ------------------- E-file reviewed. Veteran's rhinits and sinusitis is a diagnosable chronic multisymptom illness with a partially explained etiology that is at least as likely as not related to an exposure event in Southwest Asia as symptoms did not start until she was in Iraq and she was exposed to noxious fumes and dust storms which negatively impact the sinuses and cause chronic inflammation. **************************************************************************** Ankle Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? CONFIDENTIAL Page 15 of 43 [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- 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: ankle strain b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Other (specify): Other diagnosis: ankle strain ICD Code: 845 Side affected: Both Date of diagnosis: Right:2004 Date of diagnosis: Left:2004 ******************************************************************** c. Comments (if any): No response provided 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's ankle condition (brief summary): Veteran reports she rolled her ankles while in boot camp a few times and had shin splints and she has had ongoing ankle pain since. She did physical therapy before which helped. The pain contineus to the present day. b. Does the Veteran report flare-ups of the ankle? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or CONFIDENTIAL Page 16 of 43 her own words: ankles give out on her at times. Dull and achy pain. Swells by the end off the day. c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: has to take breaks or sit after prolonged standing 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right ankle ----------- [X] All Normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar 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? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender over lateral mallelolus Is there objective evidence of crepitus? [ ] Yes [X] No Left ankle ---------- [X] All Normal [ ] Abnormal or outside of normal range CONFIDENTIAL Page 17 of 43 [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar 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? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender over lateral mallelolus Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right ankle ----------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: Pain, Lack of enduance ROM after 3 repetitions: Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: CONFIDENTIAL Page 18 of 43 Pain, Lack of endurance ROM after 3 repetitions: Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees c. Repeated use over time Right ankle ----------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle [ ] No ---------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees d. Flare-ups Right ankle ----------- Is the examination being conducted during a flare-up? [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation [X] Yes [ ] No CONFIDENTIAL Page 19 of 43 Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms or range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the examination being conducted during a flare-up? [ ] No [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees e. Additional factors contributing to disability Right ankle [ ] No ----------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing Left ankle ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing 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 CONFIDENTIAL Page 20 of 43 Right ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes Left ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes b. Does the Veteran have muscle atrophy? [ ] Yes c. Comments, if any: No response provided [X] No [X] No [X] No 5. Ankylosis ------------ Complete this section if Veteran has ankylosis of the ankle a. Indicate severity of ankylosis and side affected (check all that apply): Right side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing position [ ] In poor weight-bearing position [ ] In poor weight-bearing position [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Is ankle instability or dislocation suspected? [X] No ankylosis [ ] No [X] Yes If yes, complete the following: Anterior Drawer Test Is there laxity compared Left side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity CONFIDENTIAL Page 21 of 43 with opposite side? [ ] Yes [X] No [ ] Unable to test Talar Tilt Test Is there laxity compared with opposite side? Left ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No [X] Yes If yes, complete the following: Anterior Drawer Test Is there laxity compared with opposite side? Talar Tilt Test Is there laxity compared with opposite side? [ ] Yes [ ] Yes [ ] Unable to test [ ] No [X] No [X] No 7. Additional comments ---------------------- Does the Veteran now have or has he or she ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below: [X] Shin splints (medial tibial stress syndrome) Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of ankle? [X] Yes (If "yes", complete ROM section of ankle on this DBQ) [ ] No Does this condition affect ROM of knee? [ ] Yes (If "yes", complete VA Form 21-0960M-9 Knee and Lower Leg Conditions) [X] No Describe current symptoms: pain in the shins with prolonged standding or walking [X] Achilles tendonitis or achilles tendon rupture Indicate side affected: [ ] Right [ ] Left [X] Both CONFIDENTIAL Page 22 of 43 Describe current symptoms: pain in the backs of the ankles shooting up the back of the shins 8. Surgical procedures ---------------------- No response provided 9. 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 10. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 11. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's ankle condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while 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 12. Diagnostic testing ---------------------- CONFIDENTIAL Page 23 of 43 a. Have imaging studies of the ankle been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings 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 13. 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: limits standing and walking prolonged, has to take frequent breaks or sit down 14. Remarks, if any ------------------- E-file reviewed. Veteran's ankle sprain is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms are related to sprain not to an exposure event. **************************************************************************** Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review CONFIDENTIAL Page 24 of 43 ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- 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: pes planus b. Select diagnoses associated with the claimed condition(s): [X] Flat foot (pes planus) ICD code: 728.71 Side affected: Both Date of diagnosis: Right: 2003 Date of diagnosis: Left: 2003 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [X] Yes [ ] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's foot condition (brief summary): Pes planus was noted on enlistment exam. She did not have pain in her eet when she first enlisted but the pain int he feet started in boot camp. She was treated with motrin and insoles which did not help. She contiues to have the foot pain now if she stands on them prolonged. She still takes motrin adn she soaks them and uses topical rubs. b. Does the Veteran report pain of the foot being evaluated on this DBQ? [X] Yes [ ] No CONFIDENTIAL Page 25 of 43 If yes, document the Veteran's description of pain in his or her own words: aching and cramping and sore c. Does the Veteran report that flare-ups impact the function of the foot? [X] Yes [ ] No If yes, document the Veteran's description of flare-ups in his or her own words: limtis prolonged standing and walking d. Does the Veteran report having any functional loss or functional impairment of the foot being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: limits weight bearing 3. Flatfoot (pes planus) ------------------------ a. Does the Veteran have pain on use of the feet? [X] Yes If yes, indicate side affected: [ ] Right [ ] Left [X] Both If yes, is the pain accentuated on use? [X] Yes [ ] No [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both b. Does the Veteran have pain on manipulation of the feet? [X] Yes If yes, indicate side affected: [ ] Right [ ] Left [X] Both If yes, is the pain accentuated on manipulation? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both c. Is there indication of swelling on use? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both d. Does the Veteran have characteristic callouses? [ ] Yes [X] No e. Effects of use of arch supports, built-up shoes or orthotics: Tried But Remains Symptomatic ----------------------------- [ ] No Device Side Not Relieved: CONFIDENTIAL Page 26 of 43 [X] Arch Supports [ ] Right [ ] Left [X] Both f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the tenderness improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A g. Does the Veteran have decreased longitudinal arch height of one or both feet on weight-bearing? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both h. Is there objective evidence of marked deformity of one or both feet (pronation, abduction etc.)? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both i. Is there marked pronation of one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the condition improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A j. For one or both feet, does the weight-bearing line fall over or medial to the great toe? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both k. Is there a lower extremity deformity other than pes planus, causing alteration of the weight-bearing line? [ ] Yes [X] No l. Does the Veteran have "inward" bowing of the Achilles tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both m. Does the Veteran have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet? [X] Yes [ ] No CONFIDENTIAL Page 27 of 43 If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the marked inward displacement and severe spasm of the Achilles tendon improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A n. Comments: No comments provided 4. Morton's neuroma (Morton's disease) and metatarsalgia -------------------------------------------------------- No response provided 5. Hammer toe ------------- No response provided 6. Hallux valgus ---------------- No response provided 7. Hallux rigidus ----------------- No response provided 8. Acquired pes cavus (clawfoot) -------------------------------- No response provided 9. Malunion or nonunion of tarsal or metatarsal bones ----------------------------------------------------- No response provided 10. Foot injuries and other conditions -------------------------------------- No response provided 11. Surgical procedures ----------------------- No response provided 12. Pain -------- RIGHT FOOT: Is there pain on physical exam? [X] Yes [ ] No If yes, (there is pain on physical exam), does the pain contribute to CONFIDENTIAL Page 28 of 43 functional loss? [X] Yes [ ] No (Further description of limitations requested in Section XIII below.) LEFT FOOT: Is there pain on physical exam? [X] Yes [ ] No If yes, (there is pain on physical exam), does the pain contribute to functional loss? [X] Yes [ ] No (Further description of limitations requested in Section XIII below.) 13. Functional loss and limitation of motion -------------------------------------------- a. Contributing factors of disability (check all that apply and indicate side affected): [X] Pain on movement Side affected: [ ] Right [ ] Left [X] Both [X] Pain on weight-bearing Side affected: [ ] Right [ ] Left [X] Both [X] Swelling Side affected: [ ] Right [ ] Left [X] Both [X] Disturbance of locomotion Side affected: [ ] Right [ ] Left [X] Both [X] Interference with standing Side affected: [ ] Right [ ] Left [X] Both [X] Lack of endurance Side affected: [ ] Right [ ] Left [X] Both Contributing factors of disability associated with limitation of motion: b. Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [X] Yes [ ] No If yes, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) please CONFIDENTIAL Page 29 of 43 describe the functional loss: limits weight bearing LEFT FOOT: [X] Yes [ ] No If yes, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) please describe the functional loss: limite weight bearing c. Is there any other functional loss during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [ ] Yes [X] No LEFT FOOT: [ ] Yes [X] No 14. 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: No comments provided 15. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 16. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's foot condition, 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 CONFIDENTIAL Page 30 of 43 upper extremity include grasping, manipulation, etc., while 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 17. Diagnostic testing ---------------------- a. Have imaging studies of the foot been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition: No response provided 18. 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: limits prologned walking andd standing 19. Remarks, if any: -------------------- E-file reviewed. Veteran's pes planus is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as pes planus was present on entrance exam and symptoms started in boot camp before any exposure event in Southwest Asia. **************************************************************************** CONFIDENTIAL Page 31 of 43 Gynecological Conditions Disability Benefits Questionnaire Name of patient/Vetera Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has she ever had a gynecological condition? Yes Diagnosis #1: Vaginitis ICD code: 616.1 Date of diagnosis: 2004 2. Medical history ------------------ Describe the history (including cause, onset and course) of each of the Veteran's gynecological conditions: Veteran was sexually assaulted in boot camp and the vaginits started after that incident. She was treated for the vaginits. She has reoccurring BV now and gets it after her cycle. She also reports she gets a yeast infection before her cycle each month. 3. Symptoms ----------- Does the Veteran currently have symptoms related to a gynecological condition, including any diseases, injuries or adhesions of the female reproductive organs? Yes CONFIDENTIAL Page 32 of 43 If yes, indicate current symptoms, including frequency and severity of pain, if any: (check all that apply) [X] Mild pain: Intermittent pain [X] Other signs and/or symptoms describe and indicate condition(s) causing them: vaginal discharge and odor and itching caused by candidiasis and bacteria 4. Treatment ------------ a. Has the Veteran had treatment for symptoms/findings for any diseases, injuries and/or adhesions of the reproductive organs? Yes If yes, specify condition(s), organ(s) affected, and treatment: treated with diflucan and flagyl Date of treatment: recurrent b. Does the Veteran currently require treatment or medications [for symptoms?] related to reproductive tract conditions? Yes If yes, list current treatment/medications and the reproductive organ condition(s) being treated: ongoing diflucan and flagyl treatments when infections occur c. If yes, indicate effectiveness of treatment in controlling symptoms: [X] Symptoms do not require continuous treatment for the following organ/condition: [X] Conditions of the vulva [X] Conditions of the vagina 5. Conditions of the vulva -------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vulva (to include vulvovaginitis)? Yes If yes, describe: vulvovaginitis causes itching and burning of the vulva. Treated with diflucan 6. Conditions of the vagina --------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vagina? Yes If yes, describe: vaginitis (candida and BV0 treated with diflucan and flagyl 7. Conditions of the cervix --------------------------- Has the Veteran been diagnosed with any diseases, injuries, adhesions or CONFIDENTIAL Page 33 of 43 other conditions of the cervix? No 8. Conditions of the uterus --------------------------- a. Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the uterus? No b. Has the Veteran had a hysterectomy? No c. Does the Veteran have uterine prolapse? No d. Does the Veteran have uterine fibroids, enlargement of the uterus and/or displacement of the uterus? No e. Has the Veteran been diagnosed with any other diseases, injuries, adhesions or other conditions of the uterus? No 9. Conditions of the Fallopian tubes ------------------------------------ Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the Fallopian tubes (to include pelvic inflammatory disease)? No 10. Conditions of the ovaries ----------------------------- a. Has the Veteran undergone menopause? No b. Has the Veteran undergone partial or complete oophorectomy? No c. Does the Veteran have evidence of complete atrophy of 1 or both ovaries? No d. Has the Veteran been diagnosed with any other diseases, injuries, adhesions and/or other conditions of the ovaries? Yes If yes, describe: had ovarian cysts when she was younger but none recently 11. Incontinence ---------------- Does the Veteran have urinary incontinence/leakage? Yes If yes, is the urinary incontinence/leakage due to a gynecologic condition? Yes If yes, condition causing it: stress incontinence If yes, check all that apply: [X] Does not require/does not use absorbent material [X] Stress incontinence CONFIDENTIAL Page 34 of 43 12. Fistulae ------------ a. Does the Veteran have a rectovaginal fistula? No b. Does the Veteran have a urethrovaginal fistula? None 13. Endometriosis ----------------- Has the Veteran been diagnosed with endometriosis? No 14. Complications and residuals of pregnancy or other gynecologic procedures ---------------------------------------------------------------------------- a. Has the Veteran had any surgical complications of pregnancy? No b. Has the Veteran had any other complications resulting from obstetrical or gynecologic conditions or procedures? No 15. Tumors and neoplasms ------------------------ a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? No b. Is the neoplasm No response provided. c. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? No response provided. d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: No response provided. 16. 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? 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? No c. Comments, if any: CONFIDENTIAL Page 35 of 43 No response provided. 17. Diagnostic testing ---------------------- a. Has the Veteran had laparoscopy? No b. Has the Veteran been diagnosed with anemia? No c. Has the Veteran had any other diagnostic testing and if so, are there significant findings and/or results? No 18. Functional impact --------------------- Does the Veteran's gynecological condition(s) impact her ability to work? No 19. Remarks, if any: -------------------- E-file reviewed. Veteran's vaginitis is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms are from bacteria overgrowth and not related to exposure events. **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review CONFIDENTIAL Page 36 of 43 --------------- 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: knee dislocation b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Recurrent patellar dislocation Side affected: [ ] Right [X] Left [ ] Both ICD Code: 836 Date of diagnosis: Left 2010 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): Veteran denies any spoecific injury while in service. She reports left knee started dislocation after military service. She treats it with wearing a brace and ice and heat. 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: locks up and a shooting pain 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: limits standing and bending down and lifting CONFIDENTIAL Page 37 of 43 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Left Knee --------- [X] All normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Extension 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? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): ttp behind knee Is there objective evidence of crepitus? [ ] Yes b. Observed repetitive use [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 Left Knee --------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: CONFIDENTIAL Page 38 of 43 Pain, Lack of endurance Able to describe in terms of range of motion: [X] Yes Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees d. Flare-ups Left Knee --------- Is the exam being conducted during a flare-up? [X] Yes [ ] No [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion: [X] Yes Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees e. Additional factors contributing to disability [ ] No Left Knee --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing 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 Rate Strength: 5/5 Left Knee: Flexion: Extension: Is there a reduction in muscle strength? b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5/5 [ ] Yes [X] No CONFIDENTIAL Page 39 of 43 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): 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? Left: [ ] None [X] Slight [ ] Moderate b. Is there a history of lateral instability? Left: [X] None [ ] Slight [ ] Moderate c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform [ ] Severe [ ] Severe If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section CONFIDENTIAL Page 40 of 43 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] "Shin splints" (medial tibial stress syndrome) Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of knee? [ ] Yes [X] No Does this condition affect ROM of ankle? [X] Yes [ ] No (If yes, complete VA form 21-0960M-2 Ankle Conditions to document ROM of ankle.) Describe current symptoms: pain in shins with prolonged walking or standing CONFIDENTIAL Page 41 of 43 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 b. 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? [X] Yes [ ] No If yes, describe (brief summary): popping noted with flexion and extension testing 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: ----------------- [X] Brace(s) Frequency of use: ----------------- [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: CONFIDENTIAL Page 42 of 43 No response provided 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., while 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? [ ] Yes [X] No 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: limits bending, lifting, standing and walking 15. Remarks, if any: -------------------- E-file reviewed. Veteran does have recurrent knee dislocation that is a is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms did not start until after military service and she had no documented injury in Iraq and exposure would not cause these symptoms.
  24. Okay, so this is going to be hard to believe for anyone reading this, and it's fine if you don't because it happened to me and I'm still having hard time believing it. Back in 2014 I got into an argument with a VA dermatology doctor about putting me on Accutaine/ Isotretinoin for Cystic Acne. I showed her that I hadn't finished the treatment as a civilian due to entering the service and the same thing happened upon getting out, but she wouldn't put me on it and claimed no sane doctor would. I went to a civilian dermatologist and she recommended I be put on the treatment on the first visit. Furthermore, the civilian doctor said I would be a "perfect candidate" for the treatment. I brought this back to the VA dermatologist and she was furious. She stuck to her decision, and brought in a fellow dermatologist to back her up, and man she brought in identified himself as a dermatologist and backed her up and that was about it for that situation... Almost two years later, this past March 7th, I had an appointment for a GERD disability claim, and a lower back pain disability claim. The examiner was none other then the dermatologist my psycho dermatologist doctor brought in to back her up. It took me a while to remember where I had seen him before, but halfway through the exam it hit me. However, he didn't recognize me. He also didn't seem to know anything about the human body because when I tried to explain to him that a bad knee day equals a bad lower back day he tried to tell me this did not matter. This was quite shocking and disturbing to hear because my chiropractor has told me that the two issues are connected, and so did my knee surgeon. Then last week I went to pick-up a buddy of mine at the ER due to a really bad sinus infection, and when I went to the front desk to get my friend I see the same guy who was my C&P examiner and who supposedly was a dermatologist treating patients in the ER!! What the hell is going on here? Is this dude even a doctor at all? Has anyone experienced such a thing?
  25. Hello all! I'm in the process of a claim for blood disorders. I'm actually in PFN stage as of yesterday so I've been a little bit nervous! The rating criteria state that if my levels are between 30-70, the rating will be 70% and if levels are between 70-100, the rating will be 30%. Over the past 2 years, my levels fell anywhere between 30-100, and over the past 6 months, my levels were under 70. My question is, will the VA take past levels into consideration or will my rating be based off of what my levels were at the time I had blood tests during my C&P exam?