Need help understanding C&P exam.

[cvsp]

Hi all,

   Been a while since I have been in this forum.  I sort of come and go with getting my troubles with the VA worked out (read: get frustrated with it).  This time around I am working with the DAV on a increase for CFS.  Service records are riddled with mention of all the symptoms, including actual diagnosis for CFS which I hear is rare for the time frame of my service 89-95.  

   Just had another C&P exam this week.  Dr went over and added a lot of stuff over the CFS:.  IBS, Scars, Lower back pain,  EPSTEIN BAR VIRUS and skin rash.  Not sure why all the add-ons, but I assume it cannot hurt?   

   Needless to say the exam was 3 hours, unconformable and made me uneasy.  Of most concern is what was noted on the CFS portion.  I am reading up today to see what all it means and what the possible ratting might be,   I post such here as any advice from the experts would be grateful.  I tried to clean it up as much as possible to shorten the post and remove personal information.  If this is out of line for this forum I apologize in advance. 

Chronic Fatigue Syndrome
 Disability Benefits Questionnaire
 Name of patient/Veteran: xxxxx xxxxxxxxxxxxxxxx

 [X] In-person examination
 Evidence review
 ---------------
 Was the Veteran's VA claims file reviewed?
 [X] Yes [ ] No

 If yes, list any records that were reviewed but were not included in the
 Veteran's VA claims file: ALL ELECTRONIC DATA

 1. Diagnosis
 ------------
 Does the Veteran now have or has/she ever been diagnosed with chronic
fatigue syndrome?
 [X] Yes [ ] No

 [X] Chronic fatigue syndrome
 ICD code: UNKNOWN
 Date of diagnosis: 1991
 2. Medical History
 ------------------
 a. Describe the history (including onset and course) of the Veteran's
chronic fatigue syndrome:
 United States Army veteran who served in the Gulf
 War. army 1989-1995
 He lives alone in a his home in xxxxxxxx. He has a college ed and
 is currently employed . -- Chronic Fatigue Syndrome, AND IBS W DIARRHEA.
 He is not currently taking medication.
 PMH: Low Back Pain (ICD-9-CM 724.2) Hyperlipidemia (ICD-9-CM
272.4) Coin Lesion, Pulmonary (ICD-9-CM 793.1) Stress (ICD-9-CM 308.9)
 Hand Injuries (ICD-9-CM 959.4) Diarrhea, chronic Fatigue Syndrome, Major Depressive Disorder,
 Recurrent, Moderate (DSM-IV 296.32/ICD-9-CM 296.32)

 b. Is continuous medication required for control of chronic fatigue syndrome?
 [ ] Yes [X] No

 If yes, are the Veteran's symptoms controlled by continuous medication?
 [ ] Yes [ ] No

 c. Have other clinical conditions that may produce similar symptoms been
 excluded by history, physical examination and/or laboratory tests to the
 extent possible?
 [X] Yes [ ] No

 d. Did the Veteran have an acute onset of chronic fatigue syndrome?
 [X] Yes [ ] No

 e. Has debilitating fatigue reduced daily activity level to less than 50% of
 pre-illness level?
 [X] Yes [ ] No

 If yes, specify length of time daily activity level has been reduced
to  less than 50% of pre-illness level:
 [ ] Less than 6 months [X] 6 months or longer

 3. Findings, signs and symptoms
 -------------------------------
 a. Does the Veteran now have or has the Veteran had any findings, signs and
 symptoms attributable to chronic fatigue syndrome?
 [X] Yes [ ] No

 If yes, check all that apply:

 [X] Debilitating fatigue

 [X] Generalized muscle aches or weakness

 [X] Fatigue lasting 24 hours or longer after exercise

 [X] Headaches (of a type, severity or pattern that is different from
 headaches in the pre-morbid state)

 [X] Migratory joint pains

 [X] Neuropsychological symptoms

 [X] Sleep disturbance

 b. Does the Veteran now have or has the Veteran had any cognitive impairment
 attributable to chronic fatigue syndrome?
 [X] Yes [ ] No

 If yes, check all that apply:

 [X] Poor attention

 [X] Inability to concentrate

 [X] Forgetfulness

 [X] Confusion

 c. Specify frequency of symptoms:

 [X] Symptoms are nearly constant

 d. Do the Veteran's symptoms due to chronic fatigue syndrome restrict
routine daily activities as compared to the pre-illness level?
 [X] Yes [ ] No

 If yes, specify % of restriction (check all that apply):

 [X] Symptoms are so severe as to restrict routine daily activities
 almost completely

 e. Do the Veteran's symptoms due to chronic fatigue syndrome result in
 periods of incapacitation?
 [ ] Yes [X] No

 4. Other pertinent physical findings, scars, complications, conditions,
signs and/or symptoms

-----------------------------------------------------------------------------
 a. Does the Veteran have any scars (surgical or otherwise) related to any
 conditions or to the treatment of any conditions listed in the Diagnosis
 section above?
 [ ] Yes [X] No

 b. Does the Veteran have any other pertinent physical findings,
 complications, conditions, signs and/or symptoms of chronic fatigue
 syndrome?
 [ ] Yes [X] No

 5. Diagnostic testing
 ---------------------
 Are there any significant diagnostic test findings and/or results?
 [ ] Yes [X] No

 6. Functional impact
 --------------------
 Does the Veteran's chronic fatigue syndrome impact his or her ability
to work?
 [X] Yes [ ] No

 If yes, describe the impact of the Veteran's chronic fatigue
syndrome, providing one or more examples:
 NO RELATIONSHIPS, HAS DIFFICULTY HOLDING DOWN A JOB,

 7. Remarks, if any:
 -------------------
 No remarks provided.
 

 

Thanks in advance for any input, possible guess on rating percent or advice as to what I should be doing to follow up. 

:)