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ctbenja1015
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Anyone have a clue about shoulders and neck ratings? Will I automatically get rated for radiculopathy in both arms even if I didn't claim it?
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LOCAL TITLE: C&P EXAMINATION 16255
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: AUG 18, 2014@10:00 ENTRY DATE: AUG 20, 2014@11:38:48
AUTHOR:
URGENCY: STATUS: COMPLETED
Neck (Cervical Spine) Conditions
Disability Benefits Questionnaire
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?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
none
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a cervical
spine (neck) condition?
[X] Yes [ ] No
Cervical Spine Common Diagnoses:
[ ] Ankylosing spondylitis
[ ] Cervical strain
[X] Degenerative arthritis of the spine
[X] Intervertebral disc syndrome
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: degenerative arthritis
ICD code: 721.10
Date of diagnosis: 2014
Diagnosis #2: IVDS
ICD code: 353.2
Date of diagnosis: 2014
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
cervical
spine (neck) condition (brief summary):
veteran had sustained a vehicle accident while on orders 5 months before
he deployed in Iraq ,it was a rollover accident. he was stationed in
Wisconsin and he believe he had normal cervical spine X-ray
they were reporetd normal, without a fracture and it's only during
deployment in 2- 3 2010 that he complained of bad neck pain and numbness
in
hands
in Monterey VA in 2014 they had X-rays of his shoulders and was told that
his issues were coming from his neck , he had neck arthritis ; he was sent
to TMC while in Iraq and complaining of his neck and was told that neck
was
ok to continue his duties and he did
current symptoms are constant 6/10 pain , and if turns his neck shoots to
a
8/10 and disrupts his sleep.
Re his MOS he was in transportation with lots of driving heavy truck and
as
well a s lifting daily about 35- 50 Lb daily plus all they usual weight
they had to carry on ther back
3. Flare-ups
------------
Does the Veteran report that flare-ups impact the function of the cervical
spine (neck)?
[X] Yes [ ] No
If yes, document the Veteran's description of the impact of
flare-ups in
his or her own words:
takes hot shower and OTC medication , gets a massage from his wife
4. Initial range of motion (ROM) measurements
---------------------------------------------
a. Select where forward flexion ends (normal endpoint is 45 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater
Select where objective evidence of painful motion begins:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
b. Select where extension ends (normal endpoint is 45 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
c. Select where right lateral flexion ends (normal endpoint is 45 degrees):
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
d. Select where left lateral flexion ends (normal endpoint is 45 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
e. Select where right lateral rotation ends (normal endpoint is 80 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55
[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25
[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55
[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater
f. Select where left lateral rotation ends (normal endpoint is 80 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55
[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25
[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55
[ ]
60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater
g. If ROM does not conform to the normal range of motion identified above
but
is normal for this Veteran (for reasons other than a cervical spine
(neck)
condition, such as age, body habitus, neurologic disease), explain:
No response provided.
5. ROM measurements after repetitive use testing
-------------------------------------------------
a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
[X] Yes [ ] No
b. Select where post-test forward flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater
c. Select where post-test extension ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
d. Select where post-test right lateral flexion ends:
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
e. Select where post-test left lateral flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater
f. Select where post-test right lateral rotation ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55
[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater
g. Select where post-test left lateral rotation ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55
[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater
6. Functional loss and additional limitation in ROM
---------------------------------------------------
a. Does the Veteran have additional limitation in ROM of the cervical spine
(neck) following repetitive-use testing?
[ ] Yes [X] No
b. Does the Veteran have any functional loss and/or functional impairment of
the cervical spine (neck)?
[X] Yes [ ] No
c. If the Veteran has functional loss, functional impairment and/or
additional limitation of ROM of the cervical spine (neck) after
repetitive
use, indicate the contributing factors of disability below:
[X] Less movement than normal
[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/soft tissue of the cervical spine (neck)?
[X] Yes [ ] No
b. Does the Veteran have muscle spasm of the cervical spine resulting in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
c. Does the Veteran have muscle spasms of the cervical spine not resulting
in
abnormal gait or abnormal spinal countour?
[X] Yes [ ] No
d. Does the Veteran have guarding of the cervical spine resulting in
abnormal
gait or abnormal spinal countour?
[ ] Yes [X] No
e. Does the Veteran have guarding of the cervical spine not resulting in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
8. Muscle strength testing
--------------------------
a. 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
Elbow flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Elbow extension
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Finger Flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Finger Abduction
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
9. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Biceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Triceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Brachioradialis:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
10. Sensory exam
----------------
Provide results for sensation to light touch (dermatomes) testing:
Shoulder area (C5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Inner/outer forearm (C6/T1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Hand/fingers (C6-8):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
11. Radiculopathy
------------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[X] Yes [ ] No
a. Indicate location and severity of symptoms (check all that apply):
Constant pain (may be excruciating at times)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ]
Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]
Severe
Intermittent pain (usually dull)
Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ]
Severe
Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ]
Severe
Paresthesias and/or dysesthesias
Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ]
Severe
Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ]
Severe
Numbness
Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ]
Severe
Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ]
Severe
b. Does the Veteran have any other signs or symptoms of radiculopathy?
[ ] Yes [X] No
c. Indicate nerve roots involved: (check all that apply)
[X] Involvement of C5/C6 nerve roots (upper radicular group)
[X] Involvement of C7 nerve roots (middle radicular group)
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
12. Ankylosis
-------------
Is there ankylosis of the spine? [ ] Yes [X] No
13. Other neurologic abnormalities
----------------------------------
Does the Veteran have any other neurologic abnormalities related to a
cervical spine (neck) condition (such as bowel or bladder problems due to
cervical myelopathy)?
[ ] Yes [X] No
14. Intervertebral disc syndrome (IVDS) and incapacitating episodes
-------------------------------------------------------------------
a. Does the Veteran have IVDS of the cervical spine?
[X] Yes [ ] No
b. If yes, has the Veteran had any incapacitating episodes over the past
12 months due to IVDS?
[ ] Yes [X] No
15. 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?
[ ] Yes [X] No
16. Remaining effective function of the extremities
----------------------------------------------------
Due to a cervical spine (neck) 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 upper extremity include grasping, manipulation, etc.; functions of 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. Other pertinent physical findings, complications, conditions, signs
and/or symptoms
-----------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms?
[ ] Yes [X] No
18. Diagnostic testing
----------------------
a. Have imaging studies of the cervical spine been performed and are the
results available?
[X] Yes [ ] No
If yes, is arthritis (degenerative joint disease) documented?
[X] Yes [ ] No
b. Does the Veteran have a vertebral fracture with loss of 50 percent or
more
of height?
[ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
MRI CERVICAL SPINE W/O CONTRAST
Exm Date: MAY 23, 2014@18:42
Impression:
1. Moderate degenerative changes in the cervical spine
predominantly at C5-6 and C6-7 with moderate canal stenosis at
C5-6 and mild canal stenosis at C6/7.
2. Areas of moderate to severe neural foraminal narrowing at
these 2 levels.
3. Image quality slightly degraded by patient motion artifact on
multiple sequences.
19. Functional impact
----------------------
Does the Veteran's cervical spine (neck) condition impact on his or her
ability to work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's cervical spine
(neck) conditions, providing one or more examples:
has to get someone else to do the heavy duties at work and he is on
profile with no lifting , unable to wear body armor or anything that
will place more pressure on his neck no pull up
20. REMARKS
-----------
a. Remarks, if any:
No comments provided.
b. Mitchell criteria:
1. Whether pain, weakness, fatigability, or incoordination could
significantly limit functional ability during flare-ups, or when the
joint is used repeatedly over a period of time.
Answer: yes, pain would significantly limit functional ability during
flare-ups, or when the joint is used repeatedly over a period of time
2. Describe any such additional limitation due to pain, weakness,
fatigability or incoordination, and if feasible, this opinion should be
expressed in terms of the degrees of additional ROM loss due to
"pain on
use or during flare-ups"
Answer
Pain could limit his range of motion at the extreme ends of
the ROM, but I am unable to speculate precisely how much
limitation of
ROM he would experience during a flareup, It is not
possible without resorting to mere speculation to estimate either loss
of
ROM or describe loss of function because there is no conceptual or
empirical basis for making such a determination w/o directly observing
function under these conditions.
****************************************************************************
Shoulder and Arm Conditions
Disability Benefits Questionnaire
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?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
none
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever had a shoulder and/or arm
condition?
[X] Yes [ ] No
Diagnosis #1: sprain
ICD code: 840.9
Date of diagnosis: 2014
Side affected: [ ] Right [ ] Left [X] Both
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
shoulder and/or arm condition (brief summary):
he has had issues with his shoulders since AD when he was doing work
working a lot above his shoulders during AD when deployed in 2009 ; he
was told that X-rays were normal; had some PT but not much help
symptoms got worse during his MVA and are now chronic , FU caused by
any job he will do using his hands elevated above his shoulders and
when he drives
b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous
3. Flare-ups
------------
Does the Veteran report that flare-ups impact the function of the shoulder
and/or arm?
[X] Yes [ ] No
If yes, document the Veteran's description of the impact of
flare-ups in
his or her own words:
stops his activities
4. Initial range of motion (ROM) measurements
---------------------------------------------
a. Right shoulder flexion
Select where flexion ends (normal endpoint is 180 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [X] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
b. Right shoulder abduction
Select where abduction ends (normal endpoint is 180 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
c. Left shoulder flexion
Select where flexion ends (normal endpoint is 180 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [X] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
d. Left shoulder abduction
Select where abduction ends (normal endpoint is 180 degrees):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [X] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
e. If ROM does not conform to the normal range of motion identified above
but
is normal for this Veteran (for reasons other than a shoulder or arm
condition, such as age, body habitus, neurologic disease), explain:
No response provided.
5. ROM measurements after repetitive use testing
------------------------------------------------
a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
[X] Yes [ ] No
b. Right shoulder post-test ROM
Select where flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [X] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
Select where abduction ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
c. Left shoulder post-test ROM
Select where flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [X] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
Select where abduction ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [X] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180
6. Functional loss and additional limitation in ROM
---------------------------------------------------
a. Does the Veteran have additional limitation in ROM of the shoulder and
arm
following repetitive-use testing?
[X] Yes [ ] No
b. Does the Veteran have any functional loss and/or functional impairment of
the shoulder and arm?
[X] Yes [ ] No
c. If the Veteran has functional loss, functional impairment and/or
additional limitation of ROM of the shoulder and arm after repetitive
use,
indicate the contributing factors of disability below (check all that
apply and indicate side affected):
[X] Less movement than normal [ ] Right [ ] Left [X] Both
[X] Pain on movement [ ] Right [ ] Left [X] Both
7. Pain (pain on palpation)
---------------------------
a. Does the Veteran have localized tenderness or pain on palpation of
joints/soft tissue/biceps tendon of either shoulder?
[X] Yes [ ] No
If yes, shoulder affected: [ ] Right [ ] Left [X] Both
b. Does the Veteran have guarding of either shoulder?
[ ] Yes [X] No
8. Muscle strength testing
--------------------------
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
BENJAMIN, CHRISTIAN TELEFORD CONFIDENTIAL Page 53 of 77
Shoulder abduction:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5Shoulder forward flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
9. Ankylosis
------------
Does the Veteran have ankylosis of the glenohumeral articulation (shoulder
joint)?
[ ] Yes [X] No
10. Specific tests for rotator cuff conditions
----------------------------------------------
a. 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.)
[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A
If positive, side affected: [ ] Right [ ] Left [X] Both
b. 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
c. External rotation/Infraspinatus strength test (Patient holds arm 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.)
[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A
If positive, side affected: [ ] Right [ ] Left [X] Both
d. 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.)
[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A
If positive, side affected: [ ] Right [ ] Left [X] Both
11. History and specific tests for instability/dislocation/labral pathology
---------------------------------------------------------------------------
a. Is there a history of mechanical symptoms (clicking, catching, etc.)?
[X] Yes [ ] No
If yes, side affected: [ ] Right [ ] Left [X] Both
b. Is there a history of recurrent dislocation (subluxation) of the
glenohumeral (scapulohumeral) joint?
[ ] Yes [X] No
c. Crank apprehension and relocation test (With patient supine, abduct
patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense
of
instability with further external rotation may indicate shoulder
instability.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
12. History and specific tests for clavicle, scapula, acromioclavicular (AC)
joint, and sternoclavicular joint conditions
----------------------------------------------------------------------------
a. Does the Veteran have an AC joint condition or any other impairment of
the
clavicle or scapula?
[ ] Yes [X] No
b. Is there tenderness on palpation of the AC joint?
[ ] Yes [X] No
c. Cross-body adduction test (Passively adduct arm across the patient's
body
toward the contralateral shoulder. Pain may indicate acromioclavicular
joint pathology.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
13. Joint replacement and/or other surgical procedures
------------------------------------------------------
a. Has the Veteran had a total shoulder joint replacement?
[ ] Yes [X] No
b. Has the Veteran had arthroscopic or other shoulder surgery?
[ ] Yes [X] No
c. Does the Veteran have any residual signs and/or symptoms due to
arthroscopic or other shoulder surgery?
[ ] Yes [X] No
14. Other pertinent physical findings, complications, conditions, signs
and/or symptoms
-----------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
conditions
listed in the Diagnosis section above?
[X] Yes [ ] No
If yes, describe (brief summary):
OTHER ROM'S IN DEGREES
RSHOULDER INTERNAL ROTATION 80 pain at 40 EXTERNAL ROTATION 65
pain at 65
L SHOULDER INTERNAL ROTATION 70 pain at 20 EXTERNAL ROTATION 70
pain at 30
15. 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)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
16. Diagnostic Testing
----------------------
a. Have imaging studies of the shoulder been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
SHOULDER, RIGHT COMPLETE (RAD Detailed) CPT:73030
Proc Modifiers : RIGHT
Reason for Study: check for DJD thanks
Clinical History:
Report Status: Verified Date Reported: AUG 18,
2014
Date Verified: AUG 18,
2014
Verifier E-Sig:
Report:
Comparison: None
Impression:
3 view right shoulder show no fracture, dislocation nor bony
destructive change.
Normal acromio-clavicular joint .
Normal subacromial joint space .
Normal glenohumeral joint space .
Primary Diagnostic Code: NORMAL
COMPLETE) SHOULDER, LEFT COMPLETE (RAD Detailed) CPT:73030
Proc Modifiers : LEFT
Reason for Study: check for DJD thanks
Clinical History:
Report Status: Verified Date Reported: AUG 18,
2014
Date Verified: AUG 18,
2014
Verifier E-Sig:
Report:
Comparison: None
Impression:
3 view left shoulder show no fracture, dislocation nor bony
destructive change.
Normal acromio-clavicular joint .
Normal subacromial joint space .
Normal glenohumeral joint space .
Primary Diagnostic Code: NORMAL
17. Functional impact
---------------------
Does the Veteran's shoulder condition impact his or her ability to
work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's shoulder
conditions
providing one or more examples:
issues with occupatio requiring lifting overhead or repeetitive working
overhead
18. REMARKS
-----------
a. Remarks, if any:
No comments provided.
b. Mitchell criteria:
1. Whether pain, weakness, fatigability, or incoordination could
significantly limit functional ability during flare-ups, or when the
joint is used repeatedly over a period of time.
Answer: yes, pain would significantly limit functional ability during
flare-ups, or when the joint is used repeatedly over a period of time
2. Describe any such additional limitation due to pain, weakness,
fatigability or incoordination, and if feasible, this opinion should be
expressed in terms of the degrees of additional ROM loss due to
"pain on
use or during flare-ups"
Answer
Pain could limit his range of motion at the extreme ends of
the ROM, but I am unable to speculate precisely how much
limitation of
ROM he would experience during a flareup, It is not
possible without resorting to mere speculation to estimate either loss
of
ROM or describe loss of function because there is no conceptual or
empirical basis for making such a determination w/o directly observing
function under these conditions
****************************************************************************
Sleep Apnea
Disability Benefits Questionnaire
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?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
none
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran have or has he/she ever had sleep apnea?
[X] Yes [ ] No
[X] Obstructive
ICD code: 780.57 Date of diagnosis: 05/2011
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
sleep
disorder condition (brief summary):
C/O sleep issues since he was deployed to Iraq in 2010 and he was Dx
with OSA in 2011 ; he was initially on CPAP but he has touble with
wearing it , especially since the nightmares form his PTSD disrupt his
sleep all together he does not sleep for longer than 6 hours/ night ,
wearing the machine only 2- 3 hours at time and was Rx BIPAP insteat
by cleep clinic in palo alto
b. Is continuous medication required for control of a sleep disorder
condition?
[ ] Yes [X] No
c. Does the veteran require the use of a breathing assistance device?
[X] Yes [ ] No
d. Does the Veteran require the use of a continuous positive airway pressure
(CPAP) machine?
[X] Yes [ ] No
3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to sleep apnea?
[X] Yes [ ] No
If yes, check all that apply:
[X] Persistent daytime hypersomnolence
4. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms
-----------------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
conditions
listed in the Diagnosis section above?
[ ] Yes [X] No
5. Diagnostic testing
---------------------
a. Has a sleep study been performed?
[X] Yes [ ] No
If yes, does the Veteran have documented sleep disorder breathing?
[X] Yes [ ] No
Date of sleep study: 5/25/2011
Facility where sleep study performed, if known: anville Il VA
Results:
osa as per VA Dx , SEVERE , AHI 72
AVERAGE O2 SAT 91 % AND LOWEST 68 %
b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
6. Functional impact
--------------------
Does the Veteran's sleep apnea impact his or her ability to work?
[ ] Yes [X] No
7. Remarks, if any:
-------------------
ALREADY dX WITH osa SINCE 2011 AND ON CPAP THEN CURRENTLY BIPAP
5/25/11 PSN
Dx severe OSA
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
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? Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
none
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks:
Priority processing GWOT. Please expedite. Over One Year Old Claim
Date of claim: 05/24/2013
Days pending: 439
Veteran has a power of attorney.
Please send a courtesy copy of the exam notice letter to CALIFORNIA
DEPARTMENT OF VETERANS AFFAIRS
The Veteran will need to report for the following exam(s):
DBQ MUSC Neck (cervical spine)
DBQ MUSC Shoulder and arm
DBQ PSYCH Initial PTSD
DBQ RESP Sleep apnea
____________________________________________________________________________
_________
"
****************************************************************************
*********
DBQ MUSC Neck (cervical spine):
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION : Direct service connection
Does the Veteran have a diagnosis of (a)neck condition that is at least as
likely as not (50 percent or greater probability) incurred in or caused by
(the) long term wear of ACH and poor road conditions while serving in Iraq?
Rationale must be provided in the appropriate section.
****************************************************************************
*********
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: REVIEW OF VISTA WEB 3/20/09 SHOWS EVIDENCE OF THE ROLL OVER
ACCIDENT; C SPINE X-RAY WERE TAKEN AT THE TIME WITH EVIDENCE OF MILD DDD AS
WELL AS EVIDENCE OF WHIPLASH INJURY AS TYPICAL REPORTED FINDINGS WHICH IS A
RISK FACTOR FOR CHRONIC NECK ISSUES AND DJD/ DDD WITH RADICULOPATHY
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks:
DBQ MUSC Shoulder and arm:
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION : Direct service connection
Does the Veteran have a diagnosis of (a)bilateral conditions that is at
least as likely as not (50 percent or greater probability) incurred in or
caused by (the) long term wear of ACH and poor road conditions while serving
in Iraq?
Rationale must be provided in the appropriate section.
****************************************************************************
*********
b. Indicate type of exam for which opinion has been requested: SHOULDERS
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: HAS HAD PER VISTA WEB ROLL OVER ACCIDENT IN 2009 AS WELL AS
COMPLAINS OF HIS BILATERAL SHOULDERS IN 5 2010 AS XRAYS WERE TAKEN AS WELL
AS 2011, AS EVIDENCE OF CHRONIC BILATERAL SHOULDERS ISSUES ; CONDITION IN
VIEW OF THE ACCIDENT WAS AT LEAST AS LIKELY AS NOT CONTRIBUTED AS ETIOLOGY
BY
THIS MAJOR ROLL OVER ACCIDENT
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: DBQ RESP Sleep apnea:
Please review the Veteran's electronic folder in VBMS and state that it
was
reviewed in your report.
A sleep study is not of record. Please conduct a sleep study as part of your
exam.
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.
OPINION REQUESTED: Secondary Service Connection.
Is the Veteran's sleep apnea at least as likely as not (50 percent or
greater probability) proximately due to or the result of PTSD/Depression?
Rationale must be provided in the appropriate section.
b. Indicate type of exam for which opinion has been requested: SLEEP
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE
CONNECTION ]
b. The condition claimed is less likely than not (less than 50%
probability) proximately due to or the result of the Veteran's service
connected condition.
c. Rationale: THERE IS NO EVIDENCE THAT PTSD CAUSES OSA;ETIOLOGY OF OSA IS
USUALLY CAUSED BY UPPER AIRWAYS CONDITIONS , NOT DEPRESSION NOR PTSD.
PLEASE
SEE ALSO MH OPINION IF QUESTION ASKED ALSO TO MH PROVIDER*************************************************************************
Attached the following:
Sleep Apnea secondary to PTSD
The veteran further claims that his sleep condition is secondary to, but separate from, PTSD. Supporting this contention are studies done by Brooke Army Hospital and Walter Reed Army Hospital. In the Brooke Army Hospital report, entitled Sleep Disordered Breathing in Combat Veterans with PTSD, researchers concluded that "data show that more than 70% of those active-duty members who carry a diagnosis of PTSD are at risk for the diagnosis of obstructive sleep apnea". In the Walter Reed Hospital report, entitled Prevalence of Sleep Disorders among Soldiers with Combat Related Posttraumatic Stress Disorder, researchers concluded that "sleep complaints were almost universal among soldiers with PTSD. The majority were diagnosed with insomnia and/or obstructive sleep apnea".In a BVA decision involving the Hartford, Connecticut VA regional office (Docket#10-25 465) entitlement to service connection for obstructive sleep apnea as secondary to PTSD was granted with 'Reasons and Bases for Findings and Conclusions' based upon the studies cited above.
c. Rationale: THERE IS NO EVIDENCE THAT PTSD CAUSES OSA; ETIOLOGY OF OSA IS
USUALLY CAUSED BY UPPER AIRWAYS CONDITIONS, NOT DEPRESSION NOR PTSD.
Contrary to the opinion of, Cxxxxx F Cxxxxx, MD, the above shows connection of obstructive sleep apnea to PTSD.********************************************************************************************************************************************
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
Cervical spine (neck) condition (brief summary):
Veteran had sustained a vehicle accident while on orders 5 months before
He deployed in Iraq, it was a rollover accident. He was stationed in
Wisconsin and he believe he had normal cervical spine X-ray
They were reported normal, without a fracture and it's only during
Deployment in 2- 3 2010 that he complained of bad neck pain and numbness
In hands in Monterey VA in 2014 they had X-rays of his shoulders and was told that
His issues were coming from his neck, he had neck arthritis; he was sent
To TMC while in Iraq and complaining of his neck and was told that neck
Was ok to continue his duties and he didCurrent symptoms are constant 6/10 pain, and if turns his neck shoots to a
8/10 and disrupts his sleep.All ROM of the cervical neck pain started at (0). Was asked to report when pain increased, as per her report current symptoms are a constant 6/10 pain
-
-
-
According to my VSO if you filled the FDC you may get an additional 12 months added to your back pay. Worth looking into if you did.
-
Thanks Georgiapapa, It seemed to put me between 30-50, but as long as they get the service connection in the first round. I don't really expect more than 30 since I am still working full time.
-
Newbie looking for general Idea of compensation: I was thinking 30%, but not sure how the secondary illness' affect it.
VA Notes
Source: VA
Last Updated: 22 Aug 2014 @ 0346
Sorted By: Date/Time (Descending)
VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed
and signed by all required members of your VA health care team. If you have any questions about your
information please visit the FAQs or contact your VA health care team.
Date/Time: 18 Aug 2014 @ 1200
Note Title: C&P MENTAL HEALTH 16257
Location: PALO ALTO HEALTH CARE SYSTEM - PALO ALTO DIVSION
Signed By:
Co-signed By:
Date/Time Signed: 19 Aug 2014 @ 1639
Note
LOCAL TITLE: C&P MENTAL HEALTH 16257
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
DATE OF NOTE: AUG 18, 2014@12:00 ENTRY DATE: AUG 19, 2014@16:39:32
AUTHOR:
EXP COSIGNER:
URGENCY: 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?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: 309.81
Comments, if any:
The veteran's depression and anxiety are considered to be, at least as likely as not, secondary to his PTSD. Mental Disorder Diagnosis #2: Unspecified Depressive Disorder
ICD code: 311
Comments, if any:
Ongoing anxiety for ~ 5 years - anxiety started during
pre-mobilization- served in Iraq -2009-2010. Depression began in
2010.
Mental Disorder Diagnosis #3: Alcohol Use Disorder
ICD code: 303.90
Comments, if any:
Sober for 3 years. At peak drank a 6 pack + 8-10 shots several
times a week. His alcohol abuse was, at least as likely as not,
exacerbated by his PTSD. He states he normally only drank a few
drinks with friends before service.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): See below
ICD code: See below
Comments, if any: "----------------------------- PLL - All
Problems
-----------------------------
13 Problems
ST PROBLEM LAST MOD
PROVIDER
A Generalized Anxiety Disorder (ICD/DSM 300.02)
A Depressive Disorder NEC (ICD-9-CM 311.)
SA Alcohol abuse, in remission (ICD-9-CM 305.03
A Unspecified Sleep Disturbance (ICD-9-CM 780.50)
A Posttraumatic Stress Disorder (ICD/DSM 309.81)
A Other and unspecified hyperlipidemia (ICD-9-CM 04/18/2014272.4)
A Erectile dysfunction associated with type 2 diabetes mellitus (SCT 428007007) (ICD-9-CM250.80/607.84)
A Esophageal Reflux (ICD-9-CM 530.81)
A Cervicalgia (ICD-9-CM 723.1) 04/18/2014
A Lumbago (ICD-9-CM 724.2) 04/18/2014
A Tobacco Use Disorder (ICD-9-CM 305.1) 04/18/2014
A Plantar fascial fibromatosis (ICD-9-CM 728.71) 04/18/2014
A Unspecified Sleep Apnea (ICD-9-CM 780.57) 04/18/2014
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:
Overlapping symptoms and interaction of symptoms prevent
attribution of symptoms to one specific diagnosis. That stated, it
is, at least as likely as not, his depression is secondary to his
PTSD, and his alcohol use was exacerbated by his PTSD.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
Comments, if any:
Denies hx of LOC or coma
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:
Overlapping symptoms and interaction of symptoms prevent
attribution of symptoms to one specific diagnosis. That stated, it
is, at least as likely as not, his depression is secondary to his
PTSD, and his alcohol use was exacerbated by his PTSD.
The veteran is currently employed on a full-time basis as a
maintenance mechanic for the range at Fort Hunter-Liggett.
He is not currently in school.
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
[ ] 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:
VBMS (electronic C-file) was reviewed. Records available in CPRS
were reviewed. The veteran and his wife provided history and
clinical information.
b. Was pertinent information from collateral sources reviewed?
[X] Yes [ ] No
If yes, describe:
The veteran was interviewed with his wife.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
The veteran was born in Penn and grew up in Penn, Albuquerque NM, then
Georgia. He was reared in somewhat chaotic circumstances - parents
divorced when vet was 4 yo - grew up with his stepfather; financial
constraints - 7 children; father was an alcoholic. The veteran had 6
biological siblings + 1 stepbrother. He reports he went through the
12th grade, graduating HS with C academic marks. No college before
service.
The veteran states he had friends. He denies behavioral problems/
arrests. He endorses alcohol abuse occasionally and later drug abuse -
MJ, methamphetamine (30 - 31 yo- episodic). The veteran denies a
history of emotional, physical, and sexual abuse.
The veteran has been married 3 times, to his third wife for ~ 2
years, and has 3 biological + 3 stepchildren - "all grown and out
of
the house". He states he is close to his 3rd wife. The veteran
remarks he occasionally talked with his first wife in rearing the
children. Could not be friends with his second wife. First wife became
a drug addict and left him for a 19 yo. Second wife wanted a divorce
due to his being gone so long, and she had to undergo surgery without
him. The veteran has contact with his children and describes himself
as close to them. He describes close relationships with his siblings
when they are together.
Currently he rents a house on Post where he resides with his wife and
dogs.
The veteran notes that he has friends.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Military History: Enlisted into the Army Reserves at 37 years old. Had
planned to go into service after HS but was in a MVA and ended up
working at a papermill. He was trained as a truck driver, serving in
Iraq as a truck driver between 2009-2010. The veteran did drink
during
service - to excess when he came back. He has served for ~ 8 years to
date from 2006 to Present - currently ETS is an instructor for truck
drivers. He was given an Honorable discharge from Active Duty. The
veteran was exposed to combat. Denies a history of MST.
Education: The veteran notes he did go back for job specific
education
after service attaining no degrees with good academic marks. He did
not obtain any degrees in-service to date.
Occupation: The veteran is currently employed on a full-time basis for
the Department of the Army as a maintenance mechanic for the ranges,
last working Friday. He describes his work performance as fair, his
attendance record as excellent with no missed time from work in the
last 1 year due to mental health problems other than appointments, and
his ability to get along with his supervisors as well and his
coworkers
as "95% of the time well". The veteran is still in service as
a TPU
soldier - actively drilling and doing his Reserve status. He admits to
being fired from Wal-Mart Distribution Center in 2012 due to workplace
violence - "threw a shop rag" after being employed there for 5 years.
He mentions he has held ~ 2 jobs since service. The veteran is not on
State Disability or Social Security Disability. He transferred from
another Army job due to inability to get along with his superiors.
Activities: "Watch TV".
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
The veteran reports a history of family mental health problems
including father was an alcoholic.
The veteran denies pre-military mental health problems. To reiterate,
he does have a history of +/-childhood trauma to which he does not
endorse clinical symptoms -Stepbrother was killed in a MVA - "not
that
close - lived States apart". Stepbrother was killed in a MVA in NJ
-
vet was in Georgia at the time. He denies developmental problems or
learning disabilities.
The veteran states he was treated in-service for mental health or
substance abuse issues - after 2nd wife said she wanted a divorce, vet
went into a depression - OP MHC x 3 months in-service and has been
"treated ever since".
He reports his first mental health treatment was in-service in 2010 at
the Combat Stress Center in Speicher, Tikrit for depression.
Pre-Deployment Health Assessment dated 08/08/2009 (page 15) does
indicate the veteran had sought care or counseling in the year prior
to
deployment. The veteran endorses 1 previous psychiatric
hospitalizations 11/2010 - Iowa City VAH for anxiety, depression, and
PTSD like symptoms. He endorses 1 previous substance abuse program -
Rock Island, Illinois at the VA - Intensive OP Treatment - for
alcohol.
The veteran has been in previous outpatient mental health or
substance abuse treatment. The veteran is currently in outpatient
treatment with the Monterey CBOC
(WITTLIN,BYRON J: CHAPMAN-GOREY,STACI). Previous diagnoses have
included: See above. The veteran is taking psychotropic medication
currently: Paxil, Welbutrin. He does report a history of previous
psychotropic medications. STR's of 7/10/2014 indicate a history
of
"PTSD, Anxiety and depression" and treatment with Welbutrin
and Paxil.
The veteran reports he has not made any previous suicide attempts or
acts of self mutilation. He comments he "did have a self destructive
nature when got back - drinking and driving". The veteran denies a
history of physical violence. Last fight: "Why left otherjob" -
04/2014 - verbal altercation with a supervisor. Last physical fight -
HS. Denies domestic violence - "swings" in his sleep, per
wife. Denies history of anger management classes.
Current MSE is negative for expressed psychotic symptoms or acute
suicidal or homicidal ideation. Last CRRS Mental Health Progress Note: JUL 28, 2014.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
Endorses history of pre-military behavioral or legal problems- DUI -
in 2000 on Superbowl Sunday.
Denies history of military behavioral or legal problems.
Endorses history of post-military behavioral or legal problems -
04/2011 - DUI and reckless driving.
Denies history of being on parole or probation.
Denies current legal problems.
e. Relevant Substance abuse history (pre-military, military, and post-military):
Endorses history of pre-military substance abuse.
Endorses history of military substance abuse - did not drink on Active
Duty.
Endorses history of post-military substance abuse.
Any previous substance abuse-related legal charges: Yes.
Last drink: 04/30/2011.
Last drug use: 2003- Methamphetamines.
f. Other, if any:
No response provided.
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: Shot at, rockets on the base , mortared, 4 convoys hit by
IED's- only once was his company's truck involved - minor
damage
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)
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).
[X] Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings).
[X] Intense or prolonged psychological distress at exposure to
internal
or external cues that symbolize or resemble an aspect of the
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) thatarouse
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.
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
5. Symptoms
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Had my exams today, not sure how it went. The first doctor did ROM for my neck and shoulders, then asked questions about my sleep apnea. I think it went well although I kept having to correct her on events. She told my wife and I that she was having a family issue and would have to take a call and possibly have to leave, not sure if her mind being pre-occupied helped or hurt. The 2nd exam was for PTSD, questions strait off the DBQ, very dull and nonchalant, but already had 3 VA doctors confirm the PTSD, not terribly worried about that one would not expect it to be over 30% since I still work full time. Will post results when I get them. Thanks again.
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Thanks, will try to get a couple before Monday.
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I am going to my C&P exams on Monday 18th of August. I have both the medical and psychiatric exams. I am worried about my Cervical Spine claim. I have a Statement of Medical Examination and Duty Status from my last deployment in 2009-2010. It describes pain in the neck, shoulders and numbness in both hands. I had x-rays and was given anti-inflammatories while deployed. I got back to CONUS in August of 2010 and was sent to physical therapy for 6 weeks but was not able to see a specialist until September of 2011. With no x-ray or MRI I was diagnosed with Arthritis (ICD-9-CM 716.90), Joint Pain, Shoulder (ICD-9-CM 719.41), Paresthesia (ICD-9-CM 782.0) and Spondylosis, Cervical, w/oMyel (ICD-9-CM 721.0). After moving to CA from IL, I was finally sent for x-rays and an MRI. The MRI showed 3 bulging discs, spinal stenosis and Foreman narrowing due to bone spurs. I think they will say it is DDD and the whole normal aging thing, but I had an x-ray 3 months prior to deployment that showed my neck as being clear. I am an 88M and we got thrown all over the place when going through checkpoints at 60 mph, often hitting your ACH on the top of the cab and then bottoming the seat out. I did complain the entire four years about my neck, shoulders and the numbness.
Any thoughts about how hard it will be to convince them it is service related? Or advice going forward?
Neck, Shoulders And Sleep Apnea Exam Results
in Veterans Compensation & Pension Exams
Posted
Thanks Stretch. I actually have a neurologist appointment tomorrow. Trying to send enough information showing the studies that show OSA is second-ary to PTSD.