mtbrad82

Hello everyone I'm looking for input on a recent exam I had. I am already service connected for billateral shoulders and ankles at 0% and already submitted a favorable DBQ which led to another exam. She really made me feel uncomfortable Ankle Conditions Disability Benefits Questionnaire Name of patient/Veteran: JOHN DOE ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: ------------------------------------------------------------------------------ [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth JOHN DOE CONFIDENTIAL Page 4 of 26 [X] In-person examination a. Evidence 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) [ ] Other: [ ] No records were reviewed b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: BILATERAL ANKLE SPRAIN b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Lateral collateral ligament sprain (chronic/recurrent) Side affected: [ ] Right [ ] Left [X] Both ICD Code: 844.0 Date of diagnosis: Right 2001 Date of diagnosis: Left 2001 [X] Deltoid ligament sprain (chronic/recurrent) Side affected: [ ] Right [ ] Left [X] Both ICD Code: 845.0 Date of diagnosis: Right 2001 Date of diagnosis: Left 2001 JOHN DOE CONFIDENTIAL Page 5 of 26 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): VET HAS INTERMITTENT PAIN. VET TAKES PAIN MEDICATIONS WITH SOME RELIEF. VET ALSO USES AN ANKLE BRACE. VET DOES NOT DO MUCH PHYSICAL ACTIVITY. 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 her own words: "I AM NOT ABLE TO DO ANYTHING BUT SIT AROUND AND ICE IT" 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: "NOT ABLE TO PARTICIPATE IN ANY SPORTS ACTIVITY" "I WOULDN'T BE ABLE TO DO A PHYSICAL JOB" 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): No pain noted on exam Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No JOHN DOE CONFIDENTIAL Page 6 of 26 Is there objective evidence of crepitus? [ ] Yes [X] No Left 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): No pain noted on exam Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right 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? [ ] Yes [X] No 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? [ ] Yes [X] No 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? JOHN DOE CONFIDENTIAL Page 7 of 26 [ ] Yes [X] No [ ] Unable to say w/o mere speculation Left 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? [ ] Yes [X] No [ ] Unable to say w/o mere speculation d. Flare-ups Right ankle ----------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain Able to describe in terms or range of motion? [ ] Yes [X] No If no, please describe: AS PER VET'S STATEMENT Left ankle ---------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. JOHN DOE CONFIDENTIAL Page 8 of 26 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 Able to describe in terms of range of motion? [ ] Yes [X] No If no, please describe: AS PER VET'S STATEMENT e. Additional factors contributing to disability Right ankle ----------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: 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: 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 Right ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No JOHN DOE CONFIDENTIAL Page 9 of 26 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 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: Left side: [ ] In plantar flexion [ ] In plantar flexion [ ] In dorsiflexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an inversion deformity [ ] With an eversion 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 [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No Left ankle Is ankle instability or dislocation suspected? [ ] Yes [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 JOHN DOE CONFIDENTIAL Page 10 of 26 Does this condition affect ROM of ankle? [ ] Yes (If "yes", complete ROM section of ankle on this DBQ) [X] 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: VET DOES NOT HAVE ANY CURRENT SYMPTOMS SECONDARY TO SHIN SPLINTS. VET IS ALSO NOT PHYSICALLY ACTIVE AS PER HIS HISTORY 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? [X] Yes [ ] No If yes, identify assistive devices used (check all that apply and indicate frequency): [ ] Wheelchair Frequency of use: [ ] Occasional [ ] Regular [ ] Constant [X] Brace(s) Frequency of use: [X] Occasional [ ] Regular [ ] Constant [ ] Crutches Frequency of use: [ ] Occasional [ ] Regular [ ] Constant JOHN DOE CONFIDENTIAL Page 11 of 26 [ ] Cane(s) Frequency of use: [ ] Occasional [ ] Regular [ ] Constant [ ] Walker Frequency of use: [ ] Occasional [ ] Regular [ ] Constant [ ] Other: Frequency of use: [ ] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: BILATERAL ANKLE CONDITION 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 ---------------------- 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 JOHN DOE CONFIDENTIAL Page 12 of 26 If yes, describe the functional impact of each condition, providing one or more examples: AVOIDS PHYSICAL ACTIVITY 14. Remarks, if any ------------------- No response provided **************************************************************************** Shoulder and Arm Conditions Disability Benefits Questionnaire Name of patient/Veteran: JOHN DOE ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination a. Evidence 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 JOHN DOE CONFIDENTIAL Page 13 of 26 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) [ ] Other: [ ] No records were reviewed b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: BILATERAL SHOULDER STRAIN b. Select diagnoses associated with the claimed condition(s) (check all that apply): [X] Shoulder strain Side affected: [ ] Right [ ] Left [X] Both ICD Code: 840.9 Date of diagnosis: Right 2005 Date of diagnosis: Left 2005 c. Comments, if any: No response provided d. Was an opinion requested about this condition? [X] Yes [ ] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's shoulder or arm condition (brief summary): VET HAS INTERMITTENT PAIN IN BILATERAL SHOULDERS. HE TAKES PAIN MEDICATIONS TRAMADOL AND IBUPROFEN WHICH HELPS. VET IS ABLE TO DO LIFTING AND CARRYING UPTO 20 LBS. VET ALSO STATES THAT HE WAS COACHING HIS CHILD'S BASEBALL TEAM FROM FEBRUARY TO APRIL OF 2015. HE STOPPED DUE TO SHOULDER PAIN. JOHN DOE CONFIDENTIAL Page 14 of 26 b. Dominant hand: [ ] Right [X] Left [ ] Ambidextrous c. Does the Veteran report flare-ups of the shoulder or arm? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: "I AM NOT ABLE TO DO ANYTHING" "IT CONSTANTLY BOTHERS ME NO MATTER WHAT MOVEMENT I DO" d. 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: "I AM NOT ABLE TO COACH FOR MY KIDS BASEBALL TEAM" 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Right Shoulder -------------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 180): 0 to 90 degrees Abduction (0 to 180): 0 to 90 degrees External rotation (0 to 90): 0 to 30 degrees Internal rotation (0 to 90): 0 to 90 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: HAS DIFFICULTY RAISING ARM ABOVE HIS SHOULDER ON TODAY'S EXAM 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, Abduction, External rotation JOHN DOE CONFIDENTIAL Page 15 of 26 Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No Left Shoulder ------------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 180): 0 to 90 degrees Abduction (0 to 180): 0 to 90 degrees External rotation (0 to 90): 0 to 30 degrees Internal rotation (0 to 90): 0 to 90 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: HAS DIFFICULTY RAISING ARM ABOVE HIS SHOULDER ON TODAY'S EXAM 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, Abduction, External rotation Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right Shoulder -------------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Shoulder JOHN DOE CONFIDENTIAL Page 16 of 26 ------------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right Shoulder -------------- 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 Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: AS PER VET'S STATMENT Left Shoulder ------------- 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 Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: AS PER VET'S STATEMENT d. Flare-ups Right Shoulder -------------- Is the exam being conducted during a flare-up? [ ] Yes [X] No JOHN DOE CONFIDENTIAL Page 17 of 26 If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: AS PER VET'S STATEMENT Left Shoulder ------------- Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: AS PER VET'S STATEMENT JOHN DOE CONFIDENTIAL Page 18 of 26 e. Additional factors contributing to disability Right Shoulder -------------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Less movement than normal due to ankylosis, adhesions, etc. Please describe additional contributing factors of disability: VET HAS GUARDING OF THE RIGHT SHOULDER WHEN DOING ROM MOVEMENTS Left Shoulder ------------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Less movement than normal due to ankylosis, adhesions, etc., Weakened movement due to muscle or peripheral nerve injury, etc. Please describe additional contributing factors of disability: VET HAS GUARDING OF THE LEFT SHOULDER WHEN DOING ROM MOVEMENTS 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Shoulder: Rate Strength: Forward flexion: 4/5 Abduction: 4/5 Is there a reduction in muscle strength? [X] Yes [ ] No If yes, is the reduction entirely due to the claimed condition in the Diagnosis Section? [X] Yes [ ] No Left Shoulder: Rate Strength: Forward flexion: 4/5 Abduction: 4/5 Is there a reduction in muscle strength? [X] Yes [ ] No If yes, is the reduction entirely due to the claimed condition in the Diagnosis Section? [X] Yes [ ] No JOHN DOE CONFIDENTIAL Page 19 of 26 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of scapulohumeral (glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus move as one piece). a. Indicate severity of ankylosis and side affected (check all that apply): Right side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis) [ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis) [ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis) [X] No ankylosis Left side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis) [ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis) [ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis) [X] No ankylosis b. Comments, if any: No response provided 6. Rotator cuff conditions -------------------------- Is rotator cuff condition suspected? Right Shoulder: [X] Yes [ ] No If "Yes" complete the following: Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation indicates a positive test; may signify rotator cuff tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A JOHN DOE CONFIDENTIAL Page 20 of 26 Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner. Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A External Rotation/ Infraspinatus Strength Test (Patient holds arms at side with elbow flexed 90 degrees. Patient externally rotates against resistance. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A Lift-off Subscapularis Test (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may indicate subscapularis tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A Left Shoulder: [X] Yes [ ] No If "Yes" complete the following: Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation indicates a positive test; may signify rotator cuff tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner. Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A External Rotation/ Infraspinatus Strength Test (Patient holds arms at side with elbow flexed 90 degrees. Patient externally rotates against resistance. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A Lift-off Subscapularis Test (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may indicate subscapularis tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 7. Shoulder instability, dislocation or labral pathology -------------------------------------------------------- a. Is shoulder instability, dislocation or labral pathology suspected? JOHN DOE CONFIDENTIAL Page 21 of 26 [ ] Yes [X] No 8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint conditions ------------------------------------------------------------------------------ a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition suspected? [ ] Yes [X] No 9. Conditions or impairments of the humerus ------------------------------------------- a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus? [ ] Yes [X] No b. Does the Veteran have malunion of the humerus with moderate or marked deformity? [ ] Yes [X] No c. Does the humerus condition affect range of motion of the shoulder (glenohumeral) joint? No response provided d. Comments, if any: No response provided 10. Surgical procedures ----------------------- No response provided 11. 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 JOHN DOE CONFIDENTIAL Page 22 of 26 12. Assistive devices --------------------- a. Does the Veteran use any assistive devices? [ ] 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 13. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's shoulder and/or arm conditions, 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 14. Diagnostic testing ---------------------- a. Have imaging studies of the shoulder 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 15. 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 impact of each of the Veteran's shoulder conditions providing one or more examples: HAS DIFFICULTY WITH OVERHEAD ACTIVITY AND LIFTING AND CARRYING OVER 20 LBS. JOHN DOE CONFIDENTIAL Page 23 of 26 16. Remarks, if any: -------------------- No remarks provided **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: JOHN DOE Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? No If no, check all records reviewed: [X] Veterans Health Administration medical records (VA treatment records) MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: REVIEW OF CONFLICTING EVIDENCE OF BILATERAL SHOULDER CONDITION JOHN DOE CONFIDENTIAL Page 24 of 26 b. Indicate type of exam for which opinion has been requested: SHOULDER TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL EVIDENCE ] I have reviewed the conflicting medical evidence and am providing the following opinion: 3. AS PER TODAY'S EXAM, THE ROM OF BILATERAL SHOULDERS WAS SIMILAR TO THE ROM OF C AND P EXAM DONE ON 5-28-2015. 4. THERE WAS NO NOTED DECREASE IN THE ROM AFTER REPETITIVE TESTING. 5. TODAY'S EXAM SHOWED MILD WEAKNESS BUT THERE WAS NO PAIN OR TENDERNESS ON PALPATION OF THE BILATERAL SHOULDERS. VET COMPLAINED OF PAIN ONLY WHEN TRYING TO RAISE THE ARM ABOVE HIS SHOULDERS BILATERALLY 6. SOME OF THE ADDITIONAL LOSS IS SUBJECTIVE BUT I DO AGREE THAT THERE WAS LESS MOVEMENT THAN NORMAL AND WEAKENED MOVEMENT ON TODAY'S EXAM. 10. VET DID NOT GIVE A HISTORY OF RECURRENT DISLOCATION ON TODAY'S EXAM. UPON QUESTIONING THE VET, HE HAS NOT BEEN EVALUATED FOR ANY SHOULDER CONDITION SINCE LEAVING THE MILITARY. ON REVIEWING THE VA CLINICAL NOTES, VET WAS SEEN SEVERAL TIMES BY ORTHOPEDICS BUT DID NOT GET EVALUATED FOR A SHOULDER CONDITION. 11. MY EXAMINATION TODAY DID NOT DEMONSTRATE ANY TENDERNESS ON PALPATION OF THE AC JOINT. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: REVIEW OF CONFLICTING EVIDENCE FOR BILATERAL ANKLE CONDITION b. Indicate type of exam for which opinion has been requested: ANKLE TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL EVIDENCE ] I have reviewed the conflicting medical evidence and am providing the following opinion: 3. TODAY'S ROM EXAM OF BILATERAL ANKLES WAS NORMAL. 4. REPETITIVE TESTING OF THE BILATERAL ANKLES ROM DID NOT SHOW ANY CHANGES IN ROM 5. TODAY'S EXAM DID NOT SHOW ANY SWELLING OR TENDERNESS ON PALPATION OF THE BILATERAL ANKLES. 6. VET COMPLAINED OF DIMINISHED ABILITY TO DO PHYSICAL ACTIVITY WITH THE BILATERAL ANKLES. NO WEAKENED MOVEMENT OR PAIN ON MOVEMENT WAS NOTED ON JOHN DOE CONFIDENTIAL Page 25 of 26 TODAY'S OBJECTIVE EXAM. 9. BILATERAL JOINT INSTABILITY IS NOT SUSPECTED ON TODAY'S EXAM 10. VET COMPLAINED OF SHIN SPLINTS ON TODAY'S EXAM. NO TENDERNESS OF THE BILATERAL LOWER EXTREMITIES WERE NOTED ON TODAY'S EXAM. VET IS ALSO NOT PHYSICALLY ACTIVE AS PER HISTORY. I REVIEWED VET'S CORRESPONDENCE DATED 10-16-2014 FOR SHOULDER AND ANKLE. WHEN QUESTIONING THE VET WITH REGARDS TO TREATMENT RECEIVED FOR HIS ANKLES AND SHOULDER AFTER LEAVING ACTIVE MILITARY SERVICE, VET INDICATED THAT HE HAD NOT SOUGHT MEDICAL ATTENTION FOR IT NOR DID ANY WORKUP SUCH AS X-RAYS WERE DONE FOR HIS ANKLES AND SHOULDER. HE DID SEE ORTHOPEDIC IN 2015 FOR HIS KNEE. HE WAS EVALUATED BY PCP IN 2014/2015 AND NO MENTION OF A BILATERAL SHOULDER OR BILATERAL ANKLE CONDITION WAS NOTED ON HIS PROBLEM LISTS. IT IS SPECULATION ON MY PART BUT I WOULD HAVE TO CONSIDER THAT HIS CURRENT SYMPTOMS OF BILATERAL SHOULDER AND ANKLE PAIN MAY NOT BE RELATED TO ACTIVE MILITARY SERVICE. HE DOES GIVE HISTORY OF COACHING HIS CHILD'S BASEBALL TEAM FOR A FEW MONTHS AFTER LEAVING ACTIVE MILITARY SERVICE. HE HAS NOT SOUGHT MEDICAL ATTENTION FOR BILATERAL SHOULDERS AND ANKLES AFTER LEAVING ACTIVE MILITARY SERVICE. PLEASE NOTE THAT VET'S ATTITUDE ON TODAY'S EXAM WAS COMBATIVE/ANGRY *************************************************************************

Thanks Mike, any opinion on rating?

I had a c&p last week and was just wanting some input if possible LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: SECTION I: 1. Diagnostic Summary ---------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire: Current Diagnoses ------------------- a. Mental Disorder Diagnosis #1: Major Depressive Disorder, Recurrent,Moderate Mental Disorder Diagnosis #2: Other Specified Trauma and Stressor-related Disorder Comments, if any: Veteran does not currently meet the full criteria for PTSD. Veteran meets part of the criteria for PTSD largely due to his dysphoria symptoms (i.e. emotional numbing, and interpersonal detachment), sleep issues, irritability, and issues with concentration. Additionally, Veteran's stressor has not been conceded on the 2507. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Please see Medical Records 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? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Veteran reports experiencing symptoms of both anxiety due to the trauma and depression, which are similar in characteristics such as irritability, issues with sleep, and difficulty concentrating. Symptoms of both disorders can be exacerbated by one another also. 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 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 [X] No [ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The assessment of functioning indicates the veteran's overall level of functioning, which is affected by his symptoms of each disorder. The level of impairment the veteran is experiencing from his symptoms of anxiety due to trauma cannot be separated from the level of impairment the veteran is experiencing from his symptoms of depression. 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 TBISECTION 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: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [X] Military separation examination [X] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: Records in CPRS and VistaWeb reviewed b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History --------- a. Relevant Social/Marital/Family history (pre-military, military, not listing c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Veteran denied any history of mental health treatment prior to enlisting into the service. Report of Medical History, dated, 06-05-2013, noted that Veteran experienced anxiety, depression, insomnia, panic attacks, and weight loss while in service. Veteran stated that he did receive mental health treatment while in service, starting in 2012 until his discharge in 2013. Veteran stated that he was hospitalized once in June 2013, at xxxxxxx in xxxxx, because of suicidal ideation. STRs indicate the following mental health treatment: 06-03-2013: Treatment with xxxxxxxx and diagnosed with Depression 06-12-2013: Treatment at xxxxxxxxx Center ER and diagnosed with Moderate Depression; Admitted into the facilty and discharged on 06-14-2013; diagnosed with Major Depressive Disorder, Recurrent, Moderate, with GAF=55 09-04-2013; Problem list noting Depression, Insomnia, Psychiatric Diagnosis on Axis I, and Adjustment Disorder with Depressed Mood Post-Deployment Assessments: 05-11-2010: Reported that health was "somewhat better now than before deployment;" denied any exposure to blasts/explosions, vehicle accidents, falls, or other events; denied expsoure to dead bodies; did not feel in great danger; denied any PTSD symptoms; reported that he did discharge his weapon and had direct combat 08-30-2010: No reported Mental Health Issues; no reported exposure to traumatic events and no reported PTSD symptoms Veteran's records indicate that he has received the following mental health treatment since his discharge from the service: 01-31-2014: Treatment with Dr.xxxxxxxx and diagnosed with Major Depressive Disorder, Recurrent, mild to moderate 04-10-2014: Treatment with Dr. Xxxxxxxx and diagnosed with Depressive Disorder NOS 04-23-2014: Treatment with xxxxxxx, SW and diagnosed with Depression, Anxiety, and Explosive Anger; last seen 07-02-2014 04-28-2014: Attendance to one Anger Management Class, led by xxxxxxxxx, HC 07-25-2014: Treatment with Dr. Xxxxxxx and diagnosed with Psychosis NOS and Rule Out of PTSD Veteran is currently prescribed the following psychiatric medication: Mirtazapine, Risperidone, and Escitalopram. Veteran stated that the medication has been effective, but "I still have times that I can't control so that's why I try to distance myself from people." Currently, Veteran is currently experiencing symptoms of depression, including sadness, reporting "I'm never happy." Veteran also indicated that he social withdraws/isolates, loss of interest in activties, lack of motivation, increased fatigue, forgetfulness/easily distracted, irritated easily, feelings of hopelessness, feelings of helpless, significant weight loss of 50 lbs in a 2 month timeframe after the death of his maternal grandmother, and issues with sleep. Veteran stated that he was diagnosed with sleep apnea and received sleep apnea machine while in service. Veteran stated that he sleeps about 3-4 hours a night, and reported that he experiences issues with maintaining sleep. Veteran stated that his sleep is disrupted because of his physical pain, specifically pain in his knees, and because of thinking of things. Veteran reported that he experiences nightmares about "my days in Iraq." Veteran stated that he experiences the nightmares about 3-4 times a month. Veteran stated that he hears voices at night, through his dreams. Veteran stated that the voices are those of his deceased grandmother and other soldiers that he served with. Veteran stated that he hears the voices about 1-2 times a month. Veteran stated that his wife informed him that he will "atlk in my sleep about the deployments." Veteran stated that he startles easily and stated that his recollections of Iraq will be triggered by "sudden, loud sounds." Veteran stated that he will respond with anxiety, increased heart rate, and nervousness. Veteran stated that this will occur about 1-2 times a "if month. Veteran stated that he currently resides in a gated community and stated that he decided to live in this area for safety reasons. Veteran stated that he is hypervigilant, double-checking doors and locks and closets. Veteran stated that he will check these things I'm gone for an extended period of time. I have to make suI'm still safe." Veteran stated that he talks to other military friends about his service experiences. Veteran stated that he "hated the military for a while," around the time of his grandmother's death. Veteran stated that he does not "feel like the military was there for me." Veteran also reported that he would not recommend to others to join the military. Veteran reported that he does not socialize with others, because of the quick angry outbursts. Veteran stated that when he becomes angry, he will be consumed with the anger. Veteran stated that he thinks that the anger occurs on its own, and though he attempts to control it, Veteran thinks his angry outburst and mood are unpredictable. Veteran stated that he becomes angry "whenever a situation don't go my way." Veteran stated that when he becomes angry at times, he will experience "hot and cold sweats" and tension in his body. Veteran recalled the angry that he felt when he was asked to contact his unit to extend his stay to attend his grandmother's funeral. Veteran stated that he "shouldn't had to do that." Veteran stated that he felt "alone" during this time and felt that others were not supportive or concerned about the mental health issues that the Veteran was coping with at the time, such as the significant weight loss and sadness. Veteran became tearful when discussing this during the exam. Veteran denied any current thoughts of suicide and/or homicide. Veteran stated that he has the phone numbers of the Crisis Hotline. Veteran stated that he started to experience mental health issues after his second deployment. Veteran reported that his anger has been "building" since 2011 and worsened after the death of his grandmother. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran reported that he is currently involved in a foreclosure. Veteran did not report any history of bankruptcy. Veteran reported that following November 2013: Charged and arrested with Possession of Marijuana; released on bond; Veteran stated that he was not convicted with this charge January 2014: Charged and arrested for xxxxx and xxxxx against his wife; Charged were dropped in April 2014; Veteran stated that he was not convicted with this charge e. Relevant Substance abuse history (pre-military, military, and post-military): Alcohol: 1st tried at age 18; Veteran stated that he "very rarely" consumes alcohol Cigarettes: 1st tried at age 19; denied any current use; Veteran stated that he only smoked cigarettes in Iraq, during this first deployment Marijuana: 1st tried at age 18; Veteran stated that he consumes marijuana daily; Veteran stated that it "helps me cope." Other Illicit Drugs: denied any history of use f. Other, if any: Death of not listed 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: Exposure in Iraq, specifically during second deployment 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 militar 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). riterion 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: No response provided. 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). 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 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 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 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 5. 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] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships [X] Impaired impulse control, such as unprovoked irritability with periods of violence 6. Behavioral Observations ------------------------- Veteran is an African-American male, of average height and weight. Veteran's appearance/grooming was appropriate. Veteran demonstrated tense motor activity and was guarded initially during the exam. Rapport was slowly established. Veteran's speech was at a normal rate and volume was was low. His attention/concentration were intact. Veteran maintained appropriate eye contact during the exam. Affect was retricted and mood was anger and depressed. Veteran demonstrated average to above average intellectual functioning. Veteran's thought processes were linear and he did not display any perceptional issues/psychotic features. Veteran did not report any current thoughts of suicide or homicide. 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 -------------------------------------- Veteran was aware of the reason for the evaluation. Veteran's stressor has not been conceded on the 2507. Veteran's completion of the Post-deployment Assessment did not indicate any exposure to blasts/explosions, exposure to dead bodies, losing consciousness, or experiencing PTSD symptoms. However, on the Memorandum Statement submitted by the Veteran, he noted that he "passed out for five to ten minutes from a mortar explosion that blew up equipment in our Combat camp." Additionally, it appears that Veteran's mental health symptoms are in large part due to the death of his maternal grandmother and the military's handling of the Veteran's attendance to her funeral and his grief reaction to the situation at the time. Stressors: Veteran stated that he was exposed to the "smell of death,"smell of burning bodies," "seeing dead bodies every few blocks," and incoming mortar fire. Veteran stated that he learned of fellow soldiers deaths during deployment. Veteran stated that he was directly exposed to combat. Veteran stated that while on his way to Qatar, he witnessed an Iraqi with an RPG. Veteran stated that the RPG "went by right in front of the truck" that the Veteran was in. Veteran stated that he witnessed vehicles being "blown up right in front of me." NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's