mekon1971

Retro in the bank, haven't received the big brown envelope yet.

Logged on to ebennies yesterday morning to see if anything had moved (wasn't expecting it) but was suprised to see "pending notification" so I got very antsy! Around 4 p.m. it moved to complete, and I wanted to see what I got, so I checked the letters - 80% - I did a little dance, spun around, then checked my application that I had locked in and it updated to show 70% PTSD and 30% Hypothyroidism. I updated my dependents and filed that - it was approved within 30 minutes, then I filed a new claim for secondaries on some things that were denied - waiting on the notice before I do a NOD on the rest. Oh, and this happened on my wife's birthday, so I printed out the letter and put it on her pillow - when she went in the bedroom to get changed after work, I suddenly heard a "Thank You, Jesus" and she came running out for a hug! It's nice to finally have some validation.

Congratulations!

Congratulations!

Congratulations!

Congratulations!

Congratulations!

Congratulations!

My regional office is Waco, TX and file was transferred to Lincoln, NE and both were at "preparation for decision" then the Waco part changed to "Gathering of Evidence" then when I looked deeper it said "Lincoln RO Local Opinion" with a 2 month deadline. What is this?

Congratulations!

Congrats on the win - keep up the fight!

Congrats!

This is the emergency room record, showing the neck and ear injury, not sure how you can injure your ear without injuring your head, seeing as how they are attached. This is the record the doctor is quoting from my c-file - notice how he left out the part about ear injury and c-spine injury. It even says it is a limited exam! ER Dcmnt.pdf

What was the break-down?

Harley, No, not a RVN era vet. Most of those exams were from a 2-day visit to the C&P clinic. And like you pointed out, most are clearly documented in SMR's but a few are related to G/W or are probably secondary to documented contentions. If there was an opinion, I put it on here, if there was not, I didn't. I only included checked portions of the DBQ's, if an area had nothing marked in it, I skipped over it to save on my typing. P.S. Thank you for the time you are/have spent on my DBQ's - while I wait, it's nice to know what I need to try to get Nexus letters, buddy letters, etc. for.

meghhp0405, My C&P's HTN readings (on medication) are: 3. Current blood pressure readings 1. 160/100 7-31-12 2. 180/100 7-31-12 3. 155/102 7-31-12 Hope you're still fighting the good fight, killemall! You should have that with documentation.

Army 1989 - 1997 Desert Storm Vet Not currently service connected. Claim filed 10/14/2011 How I see my claims working out: Hypothyroidism 60 or 100 Obesity Secondary to Hypothyroidism 0 PTSD 50 or 70 Sleep Apnea 50 DMII 20 Thorocolumbar 10 or 20 Shoulder 20 HTN 10 GERD 10 Hiatal Hernia 10 Liver 10 IBS 10 Arthritis 10 Voiding 0 Eczema 0 SMC-K and possible SMC-S The weird ones - these came up because of my Gulf War Exam and SMR review by the examiner Vision - 20? Tinnitus - 10? CFS - 10? Fibromyalgia - 10? TBI - 10? Honest evaluation is what I want - I don't need or want smoke and mirrors.

My PTSD C&P is on here, everyone is saying 70% on it.

I was really surprised with the test results, so was my wife! According to my SMR's, my 4000 was at: Left: 1994 (15) 1994 (10) 1996 (10) Right: 1994 (00) 1994 (00) 1996 (05). So there has been some marginal loss, even if it still falls within 'normal' limits. My concern is more about the future than about today, even a 0% SC would be better than a denial. And as far as the tinitus, as you can see by my TBI C&P (another post) that looks like it will be a fight, if anything comes of it. The better chance will be to have it as a residual to the otitis in my SMR's (but I have not yet seen anything in my file RE: request for MO on the Otitis/Tinitus link) Tinitus can also be linked to Thyroid Disorders so it will be interesting to see how that part pans out.

1. Diagnosis: TBI? NO 2. Medical Record review: C-File Other: Emergency care and treatment (10/4/1993) 22 yo wm hx of fall while playing football with injury to his left shoulder, neg LOC. DX contussion + abrassion to left shoulder 3. Medical history The veteran states during his military service in the Army, he was playing football when he injured his head, low back, and his left shoulder. He was tackled adn he was knocked out for about 30 min. He was stransferred to teh hospital. He said that his first memory was woke up in the field. He had x-rays on his back and his shoulder. Since then, he has been complaining recurrent low back pain due to suspected pinch nerve and osteoarthritis. He has been seen or ER at VAMC because of his back. He also recalled that he had Physical Therapy during his Army time. He also recalled that during his Desert Storm, he was hit in the head but had no LOC. He denies any other accident or trauma over his head, back, or his shoulder. From his head trauma, he still having cognitive problem and memory issues. From his left shoulder, he is having pop all the time, some weakness and LOM. He is having a constant 4/10 on pain intensity but its depend on activities. Sometimes is a zero but sometime is an 8/10. From his low back, he is having a constant back pain about 4/10 on pain intensity. His worse pain is a 10/10 on pain intensity once a year. He is on Naproxen with fair response. SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI 1. Memory, attention, concentration, executive functions <X> A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items) , attention, concentratin, or executive functions, but without objective evidence on testing. 2. Judgement: NORMAL 3. Social Interaction <X> Social interaction is occasionally inappropriate Remarks: He prefers to be alone 4. Orientation: <X> Always oriented to person, time, place, and situation 5. Motor activity <X> Motor activity is normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function) 6. Visual spatial orientation <X> Mildly impaired: Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS 7. Subjective symptoms. NONE 8. Neurobehavioral effects <X> One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. Remaks: He is having anger problem and easily irritable. 9. Communication. <X> Able to communicate by spoken and written language and to comprehend spoken and written language. 10. Consciousness NORMAL Section III Additional residuals, other findings, diagnostic testing, functional impact and remarks 1. Residual? 2. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms a. Scars? NO b. Other pertinent physical findings, complications, conditions, signs and/or symptoms? YES Describe: General the veteran is alert, active and oriented x3. It's adequately dressed and normal hygiene. Head - normal size and shape wwithout evidence of trauma Eyes - pupils equally round and reactive to light, extrocular movements are normal. Viual field and acuity are within normal limits. Ears - grossly normal in auditory acuity Neurological exam Cranial nerves exams (I to XII) within normal limits Gait - tandem gain (normal), walking on heels and toes (abnormal). 3. Diagnostic testing a. Has neuropsychological testing been performed? YES If yes, provide date: 7/25/2012 Results: MoCA test 27/30 normal exam. Low score on copy the cube (0/1) and language (1/3) more likely related to PTSD problem. Not a cognitive problem. 5. Remarks, if any C-file was reviewed. No evidence of traumatic brain injury. No residual of traumatic brain injury.

1. Diagnosis Does the Veteran now have or has he/she ever had a shoulder adn/or arm condition? YES Diagnosis #1: left shoulder AC chronic sprain <X> Left 2. Medical History a. Same as Back b. Dominant hand: RIGHT 4. Initial range of motion (ROM) measurements a. Right shoulder flextion ends: 180 pain: no objective evidence of painful motion b. Right shoulder abduction: ends: 180 pain: 180 c. Left shoulder flexion: ends: 150 pain: 150 d. Left shoulder abduction: ends: 180 pain: No objective evidence of painful motion 5. ROM measurements after repetitive use testing b. Right shouldter post test ROM flexion ends: 180 abduction ends: 180 c. Left shoulder post test ROM flexion ends: 150 abduction ends: 180 7. Pain or palpation a. Does the Veteran have localized tenderness or pain on palpation of joints/soft tissue/biceps tendo of either shoulder? YES, LEFT 8. Muscle strength testing: Shoulder forward flexion: LEFT 4/5 12. History of specific test for clavicle, scapula, acromoclaviclar (AC) joint, and sternoclavicular joint condtions b. Is tehre tenderness on palpation of the AC joint? YES c. Cross-body adduction test (passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular jint pathology.) POSITIVE, RIGHT 18. Diagnostic Testing: a. Have imaging studies of the shoulder been performed and are the results available? YES b. Are there any other significant diagnostic test findings and/or results? YES If yes, provide type of procedure, date and results Clinical history: 40 wm w/ multiple arthralgias on PG exam. r/o occult dz. thanks. Report Status: Verified Date reported Nov 18, 2011 Report: Left shoulder Impression: No fracture or dislocation. No calcification at the attachment of the supraspinatus tendon. The acromioclavicular and the glenohumeral joints appear normal. 17. Functional impact YES, He is on SSDI because of Mental and physical condition 18. Remarks, if any: C-file was reviewed. Emergency care and treatment (10/4/1993) 22 yo wm hx of fall while playing football today with injury to his left shoulder, neg LOC. DX contussion + abbrassion to left shoulder. Left shoulder x rays (Oct 4, 1993) the tip of the clavicle appeared to be slightly superior in relation to the acromion process which raises the possibility of some AC separation. In addition, on one of the projections a faint lucent line is seen at the tip of the clavicle and the possibility of a hairline fracture at this site cannot be entirely excluded.

1. Diagnosis: Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? YES If yes, provide only diagnoses that pertain to thoracolumbar spine (back) conditions: Diagnosis #1: Low back strain and degenerative disc disease Date of Diagnosis: UNKNOWN 2. Medical history: The veteran stated during his military service in the Army, he was playing football when he injured his head, low back, and his left shoulder. He was tackled and he was knocked out for about 30 min. He was transferred to the hospital. He said that his first memory was woke up in the field. He had x-rays on his back and his shoulder. Since then, he has been complaining recurrent low back pain due to suspected pinch nerve and osteoarthritis. He has been seen or ER at VAMC because of his back. He also recalled that he had Physical Therapy during his Army time. He also recalled that during his Desert Storm, he was hit in the head but had no LOC. He denies any other accident or trauma, he still having cognitive problem and memory issues. From his left shoulder, he is having pop all the time, some weakness and LOM. He is having a constant 4/10 on pain intensity but its depend on activities. Sometimes is a zero but sometimes is an 8/10. From his lower back, he is having a constant back pain about 4/10 on pain intensity. His worse pain is a 10/10 on pain intensity once a year. He is on Naproxen with fair response. 4. Initial range of motion (ROM) measurement: a. forward flexion ends: 60 Select where objective evidence of painful motion begins: 40 b. Select where extension ends: 15 Select where objective evidence of painful motion begins: 10 c. Select here right lateral flexion ends: 20 Select where objective evidence of painful motion begins: 20 d. Select where left lateral flexion ends: 20 Select where objective evidence of painful motion begins: 20 e. Select where right lateral rotation ends: 20 Select where objective evidence of painful motion begins: 20 f. Select where left lateral rotation ends: 30 Select where objective evidence of painful motion begins: <X) No objective evidence of painful motion 5. ROM measurment after repetitive use testing a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? YES b. post test forward flexion ends: 60 c. post test extension ends: 15 d. post test right lateral flexion ends: 20 e. post test left lateral flexion ends: 20 f. post test right latereral rotation ends: 20 g. post test left lateral rotation ends: 30 or greater 6. Functional loss and additional limitation in ROM b. Does the Veteran h ave any funtional loss and/or functional impairment of the thoracolumbar spine (back)? YES c. If the Veteran has a functional loss, functional impairment and/or additional limitations of ROM of the thoracolumbar spine (back) after repetitive use, indicate the contributing factors of disability below: <X> Pain on movement 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait) a. Does the Veteran have localized tenderness or pain to palpation for joints and/or soft tissue of teh thoracolumbar spine (back)? YES If yes, describe: thoracolumbar paraspinal muscle b. Does the Veteran have guarding ofr muscle spasm of the thoracolumbar spine (back)? YES If yes, is it severe enough to result in: <X> Guarding and/or muscle spasm is present, but do not result in abnormal gait or spinal countour 10. Sensory exam Foot/toes (L5): Right and left Decreased 14. Intervertebral disc syndrome (IVDS) and incapacitating episodes a. Does the Veteran have IVDS of the thoracolumbar spine? YES b. If yes, has the veteran had any incapacitating episodes over past 12 months? NO 18. Diagnostic testing a. Have imaging studies of the thoracolumbar spine been performed and are the results available? YES If yes, is arthritis documented? YES c. Are there any other significant diagnostic test findings and/or results? YES If yes, provide type of test or procedure, date and results (brief summary): Report status: Verified Date Reported: Nov 10, 2011 Date Verified: Nov10, 2011 Impression: Frontal and Lateral Lumbar Spine 11/9/2011: No comparison lumbar spine. Preserved lumbar column alignment, vertebral body heights and disc spaces. Multilevel anterior osteophytic lipping. Normal sacroiliac joints. Posterior fusion anomaly at lumbosacral transition. Nonobstructive bowel gas pattern. Indeterminate renal outlines. No opacities to suggest biliary, pancreatic, or urinary tract stones. 19. Function Impact YES, He is on SSDI due to Mental and Physical condition. 20. Remarks, if any: C-File was reviewed. No evidence of back injury during service.

NO C-FILE <X> hearing loss and/or tinnitus (audiologist, performing current exam) 1. Objective findings: 1. Puretone thresholds in decibels (air conduction): RIGHT EAR LEFT EAR 500 10 5 1000 10 5 2000 10 10 3000 15 20 4000 20 25 6000 20 15 8000 10 15 Average 14 15 c. Validity of puretone test results <X> Test results are valid for rating purposes. 2. Diagnosis Right Ear <X> Normal Hearing Left Ear <X> Normal Hearing 3. Evidence Review <X> No records were reviewed 6. Remarks, if any Claims folder not available for review at the time of evaluation. Hearing is within normal limits for both ears. Veteran reported dates of active duty from 1989 to 1997. He reported military noise exposure to artillery and equipment. No occupational or recreational noise exposure was reported. SECTION 2 TINNITUS 1. Medical History Does the Veteran report recurrent tinnitus? YES Date and cicumstances of onset of tinnitus: Veteran reports tinnitus in the right ear only "for as long as I can remember, from Desert Storm." 2. Evidence Review: <X> No records were reviewed 3. Etiology of tinnitus <X> Cannot provide a medical opinion regarding the etiology of the Veteran's tinnitus without resorting to speculation. Reason: Claims folder was not available for review, however hearing thresholds are within normal limits for both ears which would indicate tinnitus is not caused by military acoustic trauma. 5. Remarks, if any: Veteran reported he had several ear invections while in the military when he was younger and is unsure if tinnitus is because of that. Veteran also reported he has had traumatic brain injury. 08/27/212 ADDENDUM Claims folder has been received by Audiology clinic and reviewed. Veteran currently has hearing within normal limits for both ears. Audiograms found in service medical records from enlistment in 1988 and others from 1994 and 1996 show hearing within normal limits for both ears with no standard threshold shift. Veteran reports history of several ear infections while in the military when he was younger. Reports of otitis media and otitis externa were found in service medical records. Veteran reported during the audiological evaluation that he was unsure if tinnitus was due to that. Veteran also has history of traumatic brain injury. An opinion is requested regarding tinnitus according to the 2507. After review of service medical records, personal interview and audiometric testing, it is the opiniion of this examiner that veteran's tinnitus is less likely as not a result of noise exposure during military service as veteran has hearing within normal limits now and during service. No complaints of tinnitus were found in service medical records. opinions regarding other possible causes for tinnitus, including history of: Otitis media, otitis externa, and traumatic brain injury, should be deferred to the appropriate medical specialty.

This was in my records, but I was unaware of it till I got a copy of my records. Medical Opinion 1, Disability Benefits Questionaire 1. Definitions 2. Restatement of requested opinion: a. insert requested opinion from general remarks: Are there sleep disturbances or neuropsychological conditions consistent with undiagnosed illness or unexplained chronic multi-system illness related to service in the Middle East? 3. Evidence review Was the Veteran's VA claims file reviewed? YES 4. Medical opinion for direct service connection b. <X> The claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rationale in section c. c. Rationale: The Veteran was evaluated on 7/25/12 and a service connected diagnosis of PTSD was made at that time. That diagnosis along with his resolving alcohol dependence account for his psychiatric symptoms. He had no memory complaints, and only mild attention complaints consistent with those observed in PTSD (and are in fact a criteria of PTSD). His sleep complains are consistent with and explained by PTSD and sleep apnea. He did report mild anergia and amotivation, but these are best accounted for as secondary to PTSD and sleep apnea. There is no evidence of unexplained psychiatric illness or symptoms. //signed Staff Psychologist 12/12/2012

Review of Medical Records C-file review was requested by VARO but not available. Medical Record review was requested by VARO but not available. C-File Was: Requested by VARO but not available Medical Records were: Requested by VARO but not available Medical History: Symptom(s): Generalzed weakness, migratory joint pains, sleep disturbance, inability to concentrate, forgetfulness Frequency of Generalized weakness: Frequent Migratory Joint Pains: Frequent Sleep Disturbance: Frequent Inability to concentrate: Frequent Forgetfulness: Frequent Physical Exam: Vital Signs Temperature: Normal Pulse: 76 bpm Respiratory Rate: 24 Blood Pressure: 160/100 Weight: 310 - pounds Weight Change: Gain is there evidence of pharyngitis? YES Is there cervical lymphadenopathy? No Is there axillary lymphadenopath? No TESTS Where the results of all tests included in the exam report? NO Diagnosis: Employment History Usual Occupation: On SS since 2009 because of PTSD Is the Veteran currently employed? No Retired? No Is the veteran unemployed but not retired? Yes Duration of Current Unemployment: 2009 Reasons given for Unemployment: PTSD Has the criterion of new onset of debilitating fatigue that is severe enough to reduce or impair average daily activity below 50 percent of the patient's preillness activity level for a period of 6 months been met? NO Has the criterion that other clinical conditions that may produce similar symptoms have been excluded by thorough evaluation, based on history, physical examination, and appropriate laboratory tests been met? No Have at least 6 of 10 Chronic Fatigue Syndrom diagnostic criteria been met? NO Was a medical opinion requested? No