Mike_S

I'm looking for the same answer but I'm P&T getting 100% for TDIU 70% rating for disabilities. I think the P&T could mean permanent and temporary. They could easily get pissed and change it. There are claims I should appeal and I have a few months left for that and a NOD. I am preparing everything while I decide. I think ASKNOD would probably tell me to file everything.

Gastone Have you seen another connection between SA and CAD? IM please, I don't want to hijack. To add to this discussion. My ED was secondary to CAD but at 0% but SMC was added because of it. I was surprised.

A seminar would be a great idea. It took me a year to understand what was needed for a hopefully successful claim and some group training would have sped things up. I'm glad I did it my way. The DAV had quickly filled out some forms for me in less than an hour and wanted to submit them right away. I hit the pause button to try and understand the process better. Looking back at what they did I would have gotten 10% with all other claims rejected because the forms don't make it easy to show secondary conditions. I got 100% connecting the dots myself. VSO's should have classes to help us do it ourselves if we wish.

How did you get something for malignant melanoma? I submitted that in a DBQ just thinking it may become presumptive or secondary to something I already have.

Maybe the Veterans Choice program can help you. https://www.hnfs.com/content/hnfs/home/va/home/provider/veterans-choice-program.html

What was found and how did they find it or test for it? Of course, I agree to do anything you can that is invasive outside the VA. Stress tests and echo are fine IMO.

Thank you all, Went in todayfor the exam. It was just an hour and she said it was preliminary and there could be more. It was in fact enough time for her to get some of the general information which they already know and I'm sure is really to see your demeanor, how you dress and groom yourself, eye contact and we just need to size you up stuff. She was really attractive and was pleasant to talk to. I hope I didn't stare at her boobs to much. <- I almost never use those emoti-things. I don't know if it went well or not but that part is over for now. She did bring up SA but I didn't push it. I'll keep you all posted.

I am only some percent PTSD and as much as they all have scammed us with a great big xxxx you for your service, I will do my best to leave them with the crap we all deal with. Beyond that, this is the future. We know who you are, where you live and the members of your family. I'm tired of being spit on.

And, you took the time to write an excellent book that helped me with my claim in addition to this site and some of Chris Attigs ebooks and claim workshop.

I'm going to bring copies of sworn statements from friends that describe how I am. I submitted these with my claim and I want to make sure the Dr. has them and KNOWS that I submitted them. Who knows? Hope for the best and expect the worst, remove round from chamber.

Why so little time? Is this exam just to blow me off and say they found nothing? Department of Veterans Affairs Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations III.Recommended Time Allotment for Completing Examination Initial PTSD compensation and pension evaluations typically require about three hours, but complex cases may demand additional time. Follow-up evaluations usually require an hour to an hour and a half.

You will also need a sleep study to show you have sleep apnea.

I just filed a FDC last November. I am still waiting of a C&P for PTSD. I know I will get the AO presumptive for IHD. You can see I have a long list of things I feel are secondary to IHD and I learned a lesson. File a claim for things you feel are service connected or get screwed for not claiming them and lose $$$ for not doing so. My IHD was documented by the VA from about 2001. I had my heart surgery (CABG) in 2006 but the VA never mentioned it when it became presumptive taking needed money from my pocket. I found out by accident when I had an AO exam. I thought I had volunteered to be part of a database that would help other vets in the future. I never had any thoughts of compensation because I never thought there was anything to be compensated for. I filed for Sleep Apnea because I never had sleep issues and did not snore before my heart surgery. I documented this and presented with my claim sworn statements from people that were with me before, during and after my CABG. I was overweight before and after the surgery. The VA looks at being overweight as THE cause of SA and will always use it to reject a claim. All overweight people do hot have SA, 70% of people with SA are overweight. That does not make weight THE CAUSE of SA. I submitted - http://www.journalsleep.org/ViewAbstract.aspx?pid=25806 and https://grants.nih.gov/grants/guide/notice-files/NOT-OD-09-082.html I don't know if the rater will even look at the documents but they have them with my claim. I am 68 years old so I get what I get from SS at the reduced rate. Maybe I should argue for the full rate.

The VA did prescribe Nifedipine as one of the BP meds I am currently taking. My Hypertension is very hard to control and my VA Cardiologist referred me to the PharmD to better control it. We tried many BP meds for nearly a year and finally had some success. The C&P cardiologist also denied the connection for Hypertension and AO but I submitted my claim and included these articles. We occasionally sprayed AO from our Huey. http://www.ncbi.nlm.nih.gov/pubmed/17006952 http://www.publichealth.va.gov/docs/agentorange/reviews/newsletter-winter2012.pdf Page 6 Edema - I used diagnostic code 7121. I don't have varicose veins. Should yield the same result. I asked for at least a 40% disability but it could also be 60%. Edema has been documented in my medical records frequently since my CABG. Do you think a rater will look at all of my records or take the easy way out using the C&P exam?

Thank you Berta I'm still waiting to see if the rater will see it that way. I think the C&P doc shit canned rhe Edema when he stated the cause of the Edema was the BP med Nifedipine which I have been taking for less than two years even though the problem started with my heart surgery 10 years ago. That and the scars will be part of a NOD which I understand can take 3 years or an appeal which will take longer. I don't think I will be around long enough for either to happen. I have only had the one C&P so far and it has taken me nearly to make the connection with my brain issues and the CABG. The VA did not help with any of it. The only way I could find to claim it was with the TDIU. I have no weakness in my extremities from the stroke, just cognitive issues. I don't get SSDI, I took SS at age 62 at a lower rate just to have some income. Is there something else I should apply for from SS?

I just had a C&P for a number of issues related to IHD and am amazed at the ways they find to reject claims. Like scarring, measure all of the scars on my chest and leg (to harvest veins) and don't include all of them in the notes. Edema in the leg from the vein harvest has been a problem since the surgery but cite the likely cause is a new BP med that I've taken for less than 2 years. A brain injury secondary to IHD. Bypass surgery caused an injury possibly through a stroke that really affected my life. Learning about it and then trying to connect it to IHD has been the problem. Most likely than not is the term he used and I hope it helps my TDIU claim. How would this brain injury be considered, would it be rated like a TBI? I'm attaching the results. Sorry, the notes are long. ***Note: Your health care team may not have all of the information from your Personal Health Record unless you share it with them. Contact your health care team if you have questions about your health information.*** Key: Double dashes (--) mean there is no information to display. Name: Date of Birth: 24 Oct 1947 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 01 Mar 2016 @ 1730 File Name: mhv__20160301_1730.txt Date Range Selected: 17 Feb 2015 to 17 Feb 2016 Data Types Selected: My HealtheVet Account Summary VA Notes --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 06 Oct 2010 Authentication Facility ID: 546 Authentication Facility Name: Miami FL VAMC VA Treating Facility Type -------------------- ------ Miami FL VAMC na Great Lakes Healthcare System na VBA BRLS na VBA CORP na ENROLLMENT SYSTEM REENGINEERING na DEPARTMENT OF DEFENSE DEERS na AUSTIN MHV na ST. LOUIS MO VAMC-JC DIVISION na ------------------------------- VA NOTES -------------------------------- Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: 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) [X] Civilian medical records [X] Other: VBMS, VIRTUAL VA MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Direct service connection Does the Veteran have a diagnosis of (a) ISCHEMIC HEART DISEASE that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) due to Agent Orange exposure in Vietnam during service? b. Indicate type of exam for which opinion has been requested: ISCHEMIC HEART DISEASE 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: Veteran did service militarily in Vietnam, where he was probably exposed to Agent Orange. On 2/05/2006 was admitted with an acute MI to a local hospital leading to a Quadruple CABG on 2/08/2006. Therefore he has a diagnosis of (a) ISCHEMIC HEART DISEASE that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) due to Agent Orange exposure in Vietnam during service. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's EDEMA at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: EDEMA 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: Veteran's bilateral leg edema is clinically due to a combination of venous/lymphatic insufficiency of both lower extremities plus the continuous use of moderate doses of the antihypertensive Nifedipine, which is a drug that causes leg edema in a significantly large number of patients. The bilateral leg edema is definitely not due to (decompensated) IHD as Veteran is definitely not in heart failure. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's HYPERTENSION SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: HYPERTENSION 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: Hypertension in this Veteran preceded the development of IHD for years. Therefore, Hypertension is not secondary to IHD. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's SCARRING SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: SCARRING TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: The residual scars in the midsternum and in the left leg are the results of the open heart surgery and of the veins obtained to do the venous-arterial grafts respectively. Such procedures were required in view of Veteran's critical Ischemic Heart Disease. Hence, technically, the scars are proximately the result of Veteran's Ischemic Heart Disease. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's E. D. SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: E.D. TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: Erectile Dysfunction is often a disease of vascular origin. The penile endothelial bed is considered a specialized extension of the peripheral vascular system, responding similarly to various stimuli in order to maintain homeostasis, playing a particular regulatory role in the modulation of vascular smooth muscle (VSM) tone which is crucial for normal erectile function. The small diameter of the cavernosal penile arteries plus the high content of endothelium and VSM may make the penile vascular bed a sensitive indicator of systemic vascular disease. Thus, the penis is a vascular organ that is sensitive to changes in oxidative stress and systemic Nitrogen Oxide (NO) levels. It is also sensitive to local modifications in the vasculature, making the penis an organ supposed to precede vascular systemic alterations. Therefore, ED has a higher incidence in patients with Ischemic Heart Disease, a disease which it often precedes but at times also follows. Therefore, Veteran's E. D. is at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE as a reflection of the affliction of the arteries by atherosclerosis. Besides, ED is also considered to frequently occur in Hypogonadism, but the evidence of this latter was obviated years later (IHD in 2003 vs Hypogonadism in 2010). Nevertheless, Hypogonadism has also contributed to the ED after the initial onset of this latter due predominantly to atherosclerosis. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's BRAIN INJURY SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: BRAIN INJURY TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: From the Neurologic standpoint, Veteran's intellectual and motor function was fundamentally normal and completely preserved before the CABG. Shortly after being discharged post-CABG, he started to experience significant intellectual changes. Eventual Neuropsychological Testing showed apparent "deficits in verbal memory retrieval, ideational fluency, visuocontruction, and graphomotor skills" w/ mild cerebral impairment noted, which was non-specific. However, he never had any motor impairment other than very mild unstable gait with imbalance on physical activities and occasional lightheadedness, symptoms that had their onset some time after the initial intellectual ones. It is well known that one of the complications of Open Heart Surgery during the extracorporeal circulation pump, is the occurrence of strokes, either embolic or due to central (brain) circulatory obstruction. Taking into consideration the timing of the events, it is most likely than not that this Veteran's left occipital brain infarction was technically proximately due to IHD as a result of the CABG that was required to improve his coronary artery circulation. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's GERD SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: GERD 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: Some people might theorize that GERD might be secondary to IHD citing published articles that have not undergone critical appraisal as part of the evidence-based medicine. Regarding GERD, there is no peer-reviewed evidence in the scientific medical literature that it could be due, either directly or secondarily, to IHD. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's SLEEP APNEA SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: SLEEP APNEA 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: Some people might theorize that SLEEP APNEA might be secondary to IHD citing published articles that have not undergone critical appraisal as part of the evidence-based medicine. The arguable proposition that lack of physical activity due to IHD might make the patients gain weight and, thus, precipitate or aggravate the Sleep Apnea has been presented, but this theoretical argument lacks firm substrate. Such argument would try to push onto trying to establish a connection or to force a theoretical justification to make the IHD in some way be related to the Sleep Apnea. The current peer-reviewed medical literature overview of sleep apnea states that the most important risk factors for obstructive sleep apnea (OSA) are advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. Regarding SLEEP APNEA, there is no scientific evidence in the medical litearature that it could be due, either directly or secondarily, to IHD. ************************************************************************* **************************************************************************** Hypertension Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with hypertension or isolated systolic hypertension based on the following criteria: [X] Yes [ ] No [X] Hypertension ICD code: 38341003 Date of diagnosis: 1995 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hypertension condition (brief summary): 68 y/o male Veteran with Hx of Hypertension requesting secondary service connection due to Ischemic Heart Disease. Veteran has had History of Hypertension since at least the mid 90's according to him and was being medically treated while living in Chicago with oral antihypertensive therapy. Over the years he required adjustments of his oral antihypertensive therapy. His BP still fluctuates. No actual Hx to suggest classical angina, syncope, LV Failure, TIA or palpitations. b. Does the Veteran's treatment plan include taking continuous medication for hypertension or isolated systolic hypertension? [X] Yes [ ] No If yes, list only those medications used for the diagnosed conditions: Carvedilol, Nifedipine, Hydralazine c. Was the Veteran's initial diagnosis of hypertension or isolated systolic hypertension confirmed by blood pressure (BP) readings taken 2 or more times on at least 3 different days? [ ] Yes [ ] No [X] Unknown d. Does the Veteran have a history of a diastolic BP elevation to predominantly 100 or more? [ ] Yes [X] No 3. Current blood pressure readings ---------------------------------- Systolic Diastolic Blood pressure reading 1: 148 / 70 Date: 2/17/2016 Blood pressure reading 2: 145 / 70 Date: 2/17/2016 Blood pressure reading 3: 145 / 70 Date: 2/17/2016 Average Blood Pressure Reading: 146 / 70 4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 5. Functional impact -------------------- Does the Veteran's hypertension or isolated systolic hypertension impact his or her ability to work? [ ] Yes [X] No 6. Remarks, if any ------------------ VETERAN'S HYPERTENSION CONDITION WOULD BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING, SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING, PULLING. HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS-- see under CNS--) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF REST AND POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY 2 HOURS. HE DOES HAVE REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO THE ABOVE MENTIONED RECOVERY PERIODS. **************************************************************************** Heart Conditions: (Including Ischemic & Non-ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a heart condition? [X] Yes [ ] No [X] Acute, subacute, or old myocardial infarction ICD code: 1755008 Date of diagnosis: 2/05/2006 [X] Coronary artery disease ICD code: 233817007Date of diagnosis: 2003 [X] Coronary Artery Bypass Graft ICD code: 399261000Date of diagnosis: 2/08/2006 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's heart condition(s) (brief summary): 68 y/o male, a non diabetic with Hx of previous cigarette smoking of 1 1/2 PPD (QUIT 2/05/2006), Hx of Hypertension and Dyslipidemia. He is a Vietnam Veteran with Hx of Ischemic Heart Disease, S/P Quadruple CABG on 2/08/2006 who is asking for direct service connection in account of Agent Orange exposure while in Vietnam. He moved from Chicago to Florida in 1998 and requested medical service in the VA where he was initially seen on March 10/2001. At that time a Hx of chest pain was elicited as having had its onset three years prior, reason for which Veteran had already had a Stress Test in Chicago and it did not show ischemia. In 2003 his chest pain kept recurring and he was submitted to a Nuclear Stress Test at the Miami VA on 11/20/2003 and it demonstrated moderate ischemia of the distal anterior wall. He was advised a Cardiac Cath but he declined and he claims that he never had it done until his episode of severe chest pain on February 5, 2006 when he was admitted to North Ridge Hospital with a diagnosis of an acute subendocardial infarction, leading to a diagnostic cardiac cath and then followed by the Quadruple CABG on 2/08/2006. He claims that after his CABG in 2006 he has not had any kind of chest pain. However, he has had exertional tiredness, exertional dyspnea and leg edema, reason for which he has been submitted to additional cardiovascular diagnostic studies, including Nuclear Stress Tests in 2014 and 2015 and both times the Stress Tests have been negative for ischemia. Goes to the Gym three times a week and walks slow on the treadmill for about 5 minutes and lifts some weight. Gets dyspnea to more than mild-to-moderate exertion although his physical activities are limited in account of getting tired and developing headaches. He develops shortness of breath after walking short distances, doing light yard work or washing the car and frequently needs to sit down to rest. However, he does not have an actual Hx to suggest classical angina, syncope, LV Failure, TIA or palpitations. Uses pressure stockings for his leg edema. b. Do any of the Veteran's heart conditions qualify within the generally accepted medical definition of ischemic heart disease (IHD)? [X] Yes [ ] No If yes, list the conditions that qualify: Severe Coronary artery obstruction c. Provide the etiology, if known, of each of the Veteran's heart conditions, including the relationship/causality to other heart conditions, particularly the relationship/causality to the Veteran's IHD conditions, if any: Heart condition #1: Provide etiology ATEHROSCLEROSIS OF THE CORONARY ARTERIES d. Is continuous medication required for control of the Veteran's heart condition? [X] Yes [ ] No If yes, list medications required for the Veteran's heart condition (include name of medication and heart condition it is used for, such as atenolol for myocardial infarction or atrial fibrillation): Baby Aspirin, Carvedilol, Nifedipine, Hydralazine, Atorvastatin 3. Myocardial infarction (MI) ----------------------------- Has the Veteran had a myocardial infarction (MI)? [ ] Yes [X] No 4. Congestive Heart Failure (CHF) --------------------------------- Has the Veteran had congestive heart failure (CHF)? [ ] Yes [X] No 5. Arrhythmia ------------- Has the Veteran had a cardiac arrhythmia? [X] Yes [ ] No Type of arrhythmia (check all that apply): [X] Other cardiac arrhythmia, specify: Frequent Ventricular Premature Beats If checked, indicate frequency: [ ] Constant [X] Intermittent (paroxysmal) If intermittent, indicate number of episodes in the past 12 months: [ ] 0 [X] 1-3 [ ] More than 4 Indicate how these episodes were documented (check all that apply) [X] Holter 6. Heart valve conditions ------------------------- Has the Veteran had a heart valve condition? [ ] Yes [X] No 7. Infectious heart conditions ------------------------------ Has the Veteran had any infectious cardiac conditions, including active valvular infection (including rheumatic heart disease), endocarditis, pericarditis or syphilitic heart disease? [ ] Yes [X] No 8. Pericardial adhesions ------------------------ Has the Veteran had pericardial adhesions? [ ] Yes [X] No 9. Procedures ------------- Has the Veteran had any non-surgical or surgical procedures for the treatment of a heart condition? [X] Yes [ ] No If yes, indicate the non-surgical or surgical procedures the Veteran has had for the treatment of heart conditions (check all that apply): [X] Coronary artery bypass surgery Indicate date of admission for treatment and treatment facility: FEBRUARY 08, 2006 NORTH RIDGE HOSPITAL, OAKLAND PARK, FL Indicate the condition that resulted in the need for this procedure/treatment: SEVERE CORONARY ARTERY OBSTRUCTION WITH ANGINA PECTORIS 10. Hospitalizations -------------------- Has the Veteran had any other hospitalizations for the treatment of heart conditions (other than for non-surgical and surgical procedures described above)? [ ] Yes [X] No 11. Physical exam ----------------- a. Heart rate: 79 b. Rhythm: [X] Regular [ ] Irregular c. Point of maximal impact: [ ] Not palpable [ ] 4th intercostal space [X] 5th intercostal space [ ] Other, specify: d. Heart sounds: [X] Normal [ ] Abnormal, specify: e. Jugular-venous distension: [ ] Yes [X] No f. Auscultation of the lungs: [X] Clear [ ] Bibasilar rales [ ] Other, describe: g. Peripheral pulses: Dorsalis pedis: [X] Normal [ ] Diminished [ ] Absent Posterior tibial: [X] Normal [ ] Diminished [ ] Absent h. Peripheral edema: Right lower extremity: [ ] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [X] 4+ Left lower extremity: [ ] None [ ] Trace [ ] 1+ [ ] 2+ [X] 3+ [ ] 4+ i. Blood pressure: 146/70 12. 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? [X] Yes [ ] No If yes, are any of these scars painful or unstable, have a total area equal to or greater than 39 square cm (6 square inches), or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.) [ ] Yes [X] No If no, provide location and measurements of scar in centimeters. Location: #1 MIDSTERNAL longitudianl Measurements: length 17.0cm X width 0.6cm c. Comments, if any: #2 Left proximal thigh medially: length 8.5 cm x width 0.6 cm #3 Left distal thigh medially: length 11.3 cm x width 0.9 cm #4 #3 Left proximal leg medially: length 5.3 cm x width 0.7 cm 13. Diagnostic Testing ---------------------- a. Is there evidence of cardiac hypertrophy? [ ] Yes [X] No b. Is there evidence of cardiac dilatation? [ ] Yes [X] No c. Diagnostic tests Indicate all testing completed; provide only most recent results which reflect the Veteran's current functional status (check all that apply): [X] EKG Date of EKG: 1/25/2016 Result: [X] Other, describe: Sinus rhythm with Premature atrial complexes with Aberrant conduction. RSR' or QR pattern in V1 suggests right ventricular conduction delay. Borderline ECG. [X] Chest x-ray Date of CXR: 4/11/2013 Result: [X] Normal [ ] Abnormal, describe: [X] Echocardiogram Date of echocardiogram: 10/11/2012 Left ventricular ejection fraction (LVEF): 50-55 % Wall motion: [ ] Normal [X] Abnormal, describe: Regional wall motion abnormalities can not be excluded due to limited visualization of endocardial borders. Wall thickness: [X] Normal [ ] Abnormal, describe: [X] Holter monitor Date of Holter monitor: 1/28/2016 Result: [ ] Normal [X] Abnormal, describe: PREDOMINANT RHYTHM: Sinus rhythm Slowest rhythm recorded: 65 /min: Sinus rhythm Fastest rhythm recorded: Rate: 128/min. Sinus tachycardia PERTINENT FINDINGS: Ventricular ectopic beats: Isolated: 1527 Begeminal cycles: 0 Couplets: 5 NSVT: 0 Runs: 0 Supraventricular ectopic beats: Isolated: 27 Begeminal cycles: 0 Couplets: 1 SVT: 0 Runs: 0 Bradyarrhythmia recorded: Pauses, longest pause 1 A-V block: No Patient recorded symptoms: Patient recorded symptoms - No COMMENTS: 24 hour Holter monitoring done Predominant rhythm was sinus rhythm Frequent PVCs as described above Occasional PACs [X] Coronary artery angiogram Date of angiogram: 2/06/2006 Result: [ ] Normal [X] Abnormal, describe: Severe Triple Vessels Coronary Artery Disease. Normal size left ventricular chamber with apical hypokinesis and mildly reduced left ventricular ejection fraction of 40% to 45%. 14. METs Testing ---------------- Indicate all testing completed; provide only most recent results which reflect the Veteran's current functional status (check all that apply): a. [X] Exercise stress test Date of most recent exercise stress test: 1/25/2016 Results: Negative for ischemai METs level the Veteran performed, if provided: 6.4 Did the test show ischemia? [ ] Yes [X] No b. If an exercise stress test was not performed, provide reason: No response provided. c. [X] Interview-based METs test Date of interview-based METs test: 2/17/2016 Symptoms during activity: The METs level checked below reflects the lowest activity level at which the Veteran reports any of the following symptoms attributable to a cardiac condition (check all symptoms that the Veteran reports at the indicated METs level of activity): [X] Dyspnea [X] Fatigue Results of interview-based METs test METs level on most recent interview-based METs test: [X] (>3-5 METs) This METs level has been found to be consistent with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph) d. Has the Veteran had both an exercise stress test and an interview-based METs test? [X] Yes [ ] No If yes, indicate which results most accurately reflect the Veteran's current cardiac functional level: [X] Exercise stress test [ ] Interview-based METs test [ ] N/A e. Is the METs level limitation provided above due solely to the heart condition(s) that the Veteran is claiming in the Diagnosis Section? [ ] Yes [X] No If no, complete Section 14f. f. What is the estimated METs level due solely to the cardiac condition(s) listed above? (If this is different than METs reported above because of co-morbid conditions, provide METs level and Rationale below.) METs level METs level on most recent interview-based METs test: [X] The limitation in METs level is due to multiple medical conditions including the heart condition(s); it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition Rationale: Veteran has lightheadedness and becomes unstable when walking more than shorter distances, thus preventing him from walking adequately on a treadmill as his walking is slow. The last available Echo was done on 10/11/2012 and reported a LVEF of 50-55% but the most recent Nuclear Stress Test done on 1/25/2016 reported a calculated LVEF of 56% which more accurately reflects the veteran's current cardiac functional level. g. Comments, if any: No response provided. 15. Functional impact --------------------- Does the Veteran's heart condition(s) impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's heart conditions, providing one or more examples: VETERAN'S HEART'S CONDITION WOULD BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING, SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING, PULLING. HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS-- see under CNS--) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF REST AND POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY 2 HOURS. HE DOES HAVE REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW RELATIVELY COMPLEX INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO THE ABOVE MENTIONED RECOVERY PERIODS. 16. Remarks, if any ------------------- Veteran's bilateral leg edema is clinically due to a combination of venous/lymphatic insufficiency of both lower extremities plus the continuouds use of moderate doses of the antihypertensive Nifedipine. The bilateral leg edeme is definitely not due to heart failure presently. **************************************************************************** Scars/Disfigurement Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran have one or more scars anywhere on the body, or disfigurement of the head, face, or neck? Yes Diagnosis #1: SCARS POST-CABG ICD code: 275322007 Date of diagnosis: FEBRUARY, 2006 Does the Veteran have any scars on the trunk or extremities (regions other than the head, face or neck): Yes Does the Veteran have any scars or disfigurement of the head, face or neck: No SECTION I: Scars of the trunk and extremities ---------------------------------------------- 1. Medical history ------------------ Describe the history (including cause/origin and course) of the Veteran's scar(s) of the trunk or extremities, (brief summary): 68 y/o male Veteran with a midsternal scar due to a previous CABG on 2/08/2006 as well as a left leg scar from the veins obtained to do the venous grafts to the coronary arteries. He is requesting secondary service connection as due to Ischemic Heart Disease. His linear scars are not painful but they are unstable -keloid-. Are any of the scars of the trunk or extremities painful: No Are any of the scars of the trunk or extremities unstable, with frequent loss of covering of skin over the scar: Yes Number of unstable scars: 4 Description of the loss of covering of skin over the scar: #1 Mid sternal scar longitudinal #2 Left proximal thigh medially #3 Left distal thigh medially #4 Left proximal leg medially Are any of the scars BOTH painful and unstable: No Are any of the scars of the trunk or extremities due to burns: No 2. Physical exam for scars on the trunk and extremities ------------------------------------------------------- 2-1. Details of scar findings for the trunk and extremities Right upper extremity: Not affected Left upper extremity: Not affected Right lower extremity: Not affected Left lower extremity: Affected Location of scars on left lower extremity and number them: #1 Left proximal thigh medially #2 Left distal thigh medially #3 Left proximal leg medially Types of scars and provide measurements: Linear Length of each linear scar: Scar #1:8.5 x 0.6 cm Scar #2:11.3 x 0.9 cm Scar #3:5.3 x 0.7 cm Anterior trunk: Affected Location of scars on anterior trunk and number them: #1 Mid sternum, longitudinal Types of scars and provide measurements: Linear Length of each linear scar: Scar #1:17.0 x 0.6 cm Posterior trunk: Not affected 2-2. Summary of nonlinear scar areas for the trunk and extremities ------------------------------------------------------------------ Superficial non-linear scars: None Deep non-linear scars: None SECTION II: Scars or other disfigurement of the head, face, or neck: No response provided --------------------------------------------------------------------- SECTION III: Miscellaneous --------------------------- 1. Limitation of function/other conditions ------------------------------------------ Do any of the scars (regardless of location) or disfigurement of the head, face, or neck result in limitation of function? No Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms (such as muscle or nerve damage) associated with any scar (regardless of location) or disfigurement of the head, face, or neck? No 2. Color photographs -------------------- Color photographs for any scars or disfiguring conditions of the head, face, or neck: Photographs not indicated 3. Functional impact -------------------- Does the Veteran's scar(s) (regardless of location) or disfigurement of the head, face, or neck impact his or her ability to work? No 4. Remarks, if any: ------------------- VETERAN'S SCARS CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING REPEATED BENDING, TWISTING AND LIFTING AS THE SCARS ARE NOT PAINFUL. FOR SUCH REASONS THEY WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Esophageal Conditions (Including gastroesophageal reflux disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Diagnosis --------- Does the Veteran now have or has he/she ever been diagnosed with an esophageal condition? Yes Gastroesophageal reflux disease (GERD) ICD code: 235595009 Date of diagnosis: 1995 Medical history --------------- Description of the history (including onset and course) of the Veteran's esophageal conditions: 68 y/o male Veteran with Hx of GERD for which he is requesting secondary service connection due to Ischemic Heart Disease. He started having symptoms of reflux in the 90's before he moved to Florida from Chicago in 1998. He states that he used to carry tums in his pocket "all the time" to get relief of his reflux symptomatology. While still in Chicago, he had an Upper Endoscopy privately but he does not remember the results other than he did not have an ulcer. However, over the years, the reflux got worse and has had the need to take medications regularly, specifically Omeprazole daily. If he does not take it regularly, his reflux gets worse. Once he keeps taking it daily, he rarely has reflux or any other symptoms. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition? Yes Medications used for the diagnosed condition: Omeprazole Signs and symptoms ------------------ Does the Veteran have any of the following signs or symptoms due to any esophageal conditions (including GERD)? Yes Sign and Symptoms: Reflux Esophageal stricture, spasm and diverticula ------------------------------------------- Does the Veteran have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus? No Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------------- Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? No Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? No Diagnostic Testing ------------------ Have diagnostic imaging studies or other diagnostic procedures been performed? No Has laboratory testing been performed? Yes CBC Date of test: 12/01/2015 Hemoglobin: 16.0 Hematocrit: 47.9 White blood cell count: 6.3 Platelets: 245 Are there any other significant diagnostic test findings and/or results? No Functional impact ----------------- Do any of the Veteran's esophageal conditions impact on his or her ability to work? No Remarks, if any: ---------------- VETERAN'S GERD CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING PROLONGED SITTING, REPEATED BENDING, TWISTING AND LIFTING AS THE GERD IS UNDER ADEQUATE CONTROL WITH HIS MEDICATION. FOR SUCH REASONS GERD WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Sleep Apnea Disability Benefits Questionnaire Name of patient/Veteran: 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 [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) [X] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: VBMS, VIRTUAL VA 1. Diagnosis ------------ Does the Veteran have or has he/she ever had sleep apnea? [X] Yes [ ] No [X] Obstructive ICD code: 73430006 Date of diagnosis: 6/15/2012 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's sleep disorder condition (brief summary): 68 y/o male Veteran with Hx of Obstructive Sleep Apnea requesting secondary service connection due to Ischemic Heart Disease. Veteran claims that he was told the first time that he was a heavy snorer by a friend (he has been divorced since the early '90s) with whom he shared a hotel room around 2007. He has been chronically tired during daytime with daytime hypersomnolence. Then he was eventually requested to have Sleep Study done on 6/15/2012 at the Miami VA confirming the presence of Sleep Apnea. Was initiated on CPAP and his symptomatology has significantly improved. However, because of his residual cognitive impairment after the stroke, he knew about the existence of the drug Modafinil and asked to be prescribed with it and it has helped some regarding his cognitive impairment more than anything else, besides the additional help to his cognitive function by the CPAP. b. Is continuous medication required for control of a sleep disorder condition? [X] Yes [ ] No If yes, list only those medications required for the Veteran's sleep disorder condition: MODAFINIL c. Does the veteran require the use of a breathing assistance device? [ ] Yes [X] 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: 6/15/2012 Facility where sleep study performed, if known: MIAMI VAMC Results: Severe obstructive sleep apnea hypopnea syndrome relieved by nasal CPAP @ 9.0 cm H20 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: ------------------- PROVIDED THAT VETERAN USES THE CPAP REGULARLY, HIS SLEEP APNEA CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING SIMPLE INTELLECTUAL TASKS. FOR SUCH REASON SLEEP APNEA WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. **************************************************************************** Central Nervous System and Neuromuscular Diseases (except Traumatic Brain Injury, Amyotrophic Lateral Sclerosis, Parkinson's Disease, Multiple Sclerosis, Headaches, TMJ Conditions, Epilepsy, Narcolepsy, Peripheral Neuropathy, Sleep Apnea, Cranial Nerve Disorders, Fibromyalgia, and Chronic Fatigue Syndrome) Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records [X] Other: VBMS, VIRTUAL VA 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a central nervous system (CNS) condition? [X] Yes [ ] No [X] Vascular diseases ICD code: 275526006 Date of diagnosis: 2006 [X] Thrombosis, TIA or cerebral infarction [X] Cerebral arteriosclerosis 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's central nervous conditions (brief summary): 68 y/o male Veteran with Hx of a brain injury due to a stroke and Veteran is requesting it as secondarily service connected due to Ischemic Heart Disease. Veteran had the CABG on 2/08/2006 and was discharged on 2/13/2006 from North Ridge Hospital, in Oakland Park, Florida. Within the next few days post-discharge he started noticing that was impossible for him to keep his previous abilities on doing computer programming and mathematic analyses (he is a Phsyics and Mathematics Major and with Master of Physics providing data to different clients, whom he lost due to his inability to keep working) as he used to do before. Brain MRI revealed that Veteran had had a stroke. Neuropsychological testing showed apparent "deficits in vebral memory retrieval, ideational fluency, visuocontruction, and graphomotor skills" w/ mild cerebral impairment noted, which was non-specific. However, he never had any motor impairment other than very mild unstable gait with imbalance on physical activities and occasional lightheadedness, symptoms that still recur. He has never taken any medication post-stroke other than his Baby Aspirin and his regular blood pressure medications. At times he also develops headaches if he exercises more than usual and needs to stop his activities with resolution of the headache. b. Does the Veteran's central nervous system condition require continuous medication for control? [ ] Yes [X] No c. Does the Veteran have an infectious condition? [ ] Yes [X] No If yes, is it active? [ ] Yes [ ] No d. Dominant hand [X] Right [ ] Left [ ] Ambidextrous 3. Conditions, signs and symptoms --------------------------------- a. Does the Veteran have any muscle weakness in the upper and/or lower extremities? [ ] Yes [X] No b. Does the Veteran have any pharynx and/or larynx and/or swallowing conditions? [ ] Yes [X] No c. Does the Veteran have any respiratory conditions (such as rigidity of the diaphragm, chest wall or laryngeal muscles)? [ ] Yes [X] No d. Does the Veteran have sleep disturbances? [X] Yes [ ] No If yes, check all that apply: [X] Sleep apnea requiring the use of breathing assistance device such as continuous positive airway pressure (CPAP) machine e. Does the Veteran have any bowel functional impairment? [ ] Yes [X] No f. Does the Veteran have voiding dysfunction causing urine leakage? [X] Yes [ ] No If yes, please check one: [X] Does not require/does not use absorbent material g. Does the Veteran have voiding dysfunction causing signs and/or symptoms of urinary frequency? [X] Yes [ ] No If yes, check all that apply: [X] Daytime voiding interval between 1 and 2 hours [X] Nighttime awakening to void 2 times h. Does the Veteran have voiding dysfunction causing findings, signs and/or symptoms of obstructed voiding? [X] Yes [ ] No If yes, check all signs and symptoms that apply: [X] Hesitancy If checked, is hesitancy marked? [ ] Yes [X] No [X] Slow or weak stream If checked, is stream markedly slow or weak? [ ] Yes [X] No [X] Decreased force of stream If checked, is force of stream markedly decreased? [ ] Yes [X] No i. Does the Veteran have voiding dysfunction requiring the use of an appliance? [ ] Yes [X] No j. Does the Veteran have a history of recurrent symptomatic urinary tract infections? [ ] Yes [X] No k. Does the Veteran (if male) have erectile dysfunction? [X] Yes [ ] No If yes, is the erectile dysfunction as likely as not (at least a 50% probability) attributable to a CNS disease (including treatment or residuals of treatment)? [ ] Yes [X] No If no, provide the etiology of the erectile dysfunction: Low testosterone level (on Testosterone replacement twice a month) If no, is the Veteran able to achieve an erection (with medication) sufficient for penetration and ejaculation? [X] Yes [ ] No 4. Neurologic exam ------------------ a. Speech [X] Normal [ ] Abnormal b. Gait [ ] Normal [X] Abnormal, describe: Mildly unstable gait when/if Veteran walks fast or longer distances due predominantly to residual lightheadedness post-stroke. The gait is fundamentally stable otherwise. c. Strength Rate strength according to the following scale: 0/5 No muscle movement 1/5 Visible muscle movement, but no joint movement 2/5 No movement against gravity 3/5 No movement against resistance 4/5 Less than normal strength 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 Grip: 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 Pinch (thumb to index finger): 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 Knee 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 Ankle plantar 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 Ankle dorsiflexion: 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 d. Deep tendon reflexes (DTRs) Rate reflexes according to the following scale: 0 Absent 1+ Decreased 2+ Normal 3+ Increased without clonus 4+ Increased 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+ Knee: Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ e. Does the Veteran have muscle atrophy attributable to a CNS condition? [ ] Yes [X] No f. Summary of muscle weakness in the upper and/or lower extremities attributable to a CNS condition (check all that apply): Right upper extremity muscle weakness: [X] None Left upper extremity muscle weakness: [X] None Right lower extremity muscle weakness: [X] None Left lower extremity muscle weakness: [X] None 5. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 6. 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 related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 7. Mental health manifestations due to CNS condition or its treatment --------------------------------------------------------------------- a. Does the Veteran have depression, cognitive impairment or dementia, or any other mental health conditions attributable to a CNS disease and/or its treatment? [ ] Yes [X] No 8. Differentiation of Symptoms or Neurologic Effects ---------------------------------------------------- Are you able to differentiate what portion of the symptomatology or neurologic effects above are caused by each diagnosis? [ ] Yes [X] No 9. 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 10. Remaining effective function of the extremities --------------------------------------------------- Due to a CNS 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., 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 11. Diagnostic testing ---------------------- a. Have imaging studies been performed? [X] Yes [ ] No If yes, provide most recent results, if available: HEAD CT WITH & W/O CONTRAST 11/25/2014: Findings: There is a large old left occipital infarction. Brain volume is otherwise normal. There is no abnormal parenchymal density elsewhere in the brain. There is no mass, mass effect, hydrocephalus or abnormal extra-axial fluid collection. There is no abnormal enhancement. The dural venous sinuses enhance normally. There is moderate atherosclerotic calcification of the cavernous internal carotid arteries and trace atherosclerotic calcification of the intradural vertebral arteries. The included paranasal sinuses and mastoid air cells are clear. There is no skull fracture or suspicious osseous lesion. Impression: 1. Old left occipital infarction. 2. No mass, hydrocephalus or enhancing lesion. b. Have PFTs been performed? [ ] Yes [X] No c. If PFTs have been performed, is the flow-volume loop compatible with upper airway obstruction? [ ] Yes [ ] No d. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 12. Functional impact --------------------- Do the Veteran's central nervous system disorders impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's central nervous system disorder condition(s), providing one or more examples: VETERAN'S POST-STROKE CONDITION WOULD BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING, SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING, PULLING AND THOSE ACTIVITIES RELATED TO MORE THAN SIMPLE INTELLECTUAL CONCENTRATION. His Neuropsychologic Testing identified "deficits in vebral memory retrieval, ideational fluency, visuocontruction, and graphomotor skills" w/ mild cerebral impairment noted, which was non-specific. HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING OR ADDITIONAL LIMITING MEDICAL CONDITIONS) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF PHYSICAL AND MENTAL REST AND POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY HOUR. HE DOES HAVE REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO THE ABOVE MENTIONED RECOVERY PERIODS. 13. Remarks, if any: -------------------- No remarks provided. **************************************************************************** Male Reproductive System Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he ever been diagnosed with any conditions of the male reproductive system? [X] Yes [ ] No [X] Erectile dysfunction ICD code: 397803000 Date of diagnosis: 2006 [X] Other male reproductive system condition (specify diagnosis, providing only diagnoses that pertain to male reproductive system.) Other diagnosis #1: HYPOGONADISM ICD code: 48130008 Date of diagnosis: 12/16/2010 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's male reproductive organ condition(s) (brief summary): 68 y/o male Veteran with Hx of Erectile Dysfunction (ED) and requesting secondary service connection due to Ischemic Heart Disease. He claims that he developed ED after the Open Heart Surgery (CABG) and has required the use of medication (Sildenafil) which has helped him some. However, in 2012 he was also found with very low testosterone level and has been on chronic replacement injection replacement therapy (patches and creams did not work) twice a month with initial improvement and not much afterwards. However, he claims that the testosterone has helped him to stay more alert. He claims that with the use of Viagra he has been able to have enough erection to be capable of acceptable penetration. He is being followed by both the VA Urologist as well as the private Urologist. The latter sees him at least every 3 months. He had the last digital prostate exam around 3 months ago and was told that his prostate was "mildly" enlarged but no other urologic-related abnormalities. b. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition? [X] Yes [ ] No List medications taken for the diagnosed condition: Testosterone Injections c. Has the Veteran had an orchiectomy? [ ] Yes [X] No d. Is there any renal dysfunction due to condition? [ ] Yes [X] No 3. Voiding dysfunction ---------------------- Does the Veteran have a voiding dysfunction? [X] Yes [ ] No If yes, complete the following sections: a. Etiology of voiding dysfunction: Unknown but BPH has been presumed as the cause b. Does the voiding dysfunction cause urine leakage? [X] Yes [ ] No Indicate severity (check one): [X] Does not require the wearing of absorbent material [ ] Requires absorbent material which must be changed less than 2 times per day [ ] Requires absorbent material which must be changed 2 to 4 times per day [ ] Requires absorbent material which must be changed more than 4 times per day [ ] Other, describe: c. Does the voiding dysfunction require the use of an appliance? [ ] Yes [X] No d. Does the voiding dysfunction cause increased urinary frequency? [X] Yes [ ] No If yes, check all that apply: [ ] Daytime voiding interval between 2 and 3 hours [X] Daytime voiding interval between 1 and 2 hours [ ] Daytime voiding interval less than 1 hour [X] Nighttime awakening to void 2 times [ ] Nighttime awakening to void 3 to 4 times [ ] Nighttime awakening to void 5 or more times e. Does the voiding dysfunction cause signs or symptoms of obstructed voiding? [X] Yes [ ] No If yes, check all that apply: [X] Hesitancy If checked, is hesitancy marked? [ ] Yes [X] No [X] Slow stream If checked, is stream markedly slow? [ ] Yes [X] No [X] Weak stream If checked, is stream markedly weak? [ ] Yes [X] No [X] Decreased force of stream If checked, is force of stream markedly decreased? [ ] Yes [X] No f. Are there any other obstructive symptoms? [ ] Yes [X] No 4. Erectile dysfunction ----------------------- Does the Veteran have erectile dysfunction? [X] Yes [ ] No If yes, complete the following section: a. Etiology of erectile dysfunction: ATHEROSCLEROSIS (as occurs with IHD) and HYPOGONADISM b. If the Veteran has erectile dysfunction, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? [X] Yes [ ] No If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable: Initially due ATHEROSCLEROSIS (as occurs with IHD) and aventually maintained/worsened by HYPOGONADISM c. If the Veteran has erectile dysfunction, is he able to achieve an erection sufficient for penetration and ejaculation without medication? [ ] Yes [X] No If no, has the Veteran used medications for treatment of his erectile dysfunction? [X] Yes [ ] No If yes, is the Veteran able to achieve an erection sufficient for penetration and ejaculation with medication? [X] Yes [ ] No 5. Retrograde ejaculation ------------------------- Does the Veteran have retrograde ejaculation? [ ] Yes [X] No 6. Male reproductive organ infections ------------------------------------- Does the Veteran have a history of chronic epididymitis, epididymo-orchitis or prostatitis? [ ] Yes [X] No 7. Physical exam ---------------- a. Penis [ ] Normal [ ] Not examined per Veteran's request [X] Not examined per Veteran's request; Veteran reports normal anatomy with no penile deformity or abnormality [ ] Not examined; penis exam not relevant to condition [ ] Abnormal b. Testes [ ] Normal [ ] Not examined per Veteran's request [X] Not examined per Veteran's request; Veteran reports normal anatomy with no testicular deformity or abnormality [ ] Not examined; testicular exam not relevant to condition [ ] Abnormal c. Epididymis [ ] Normal [ ] Not examined per Veteran's request [X] Not examined per Veteran's request; Veteran reports normal anatomy of epididymis with no deformity or abnormality [ ] Not examined; epididymis exam not relevant to condition [ ] Abnormal d. Prostate [ ] Normal [X] Not examined per Veteran's request [ ] Not examined; prostate exam not relevant to condition [ ] Abnormal 8. Tumors and neoplasms ----------------------- Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 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. Diagnostic testing ---------------------- a. Has a testicular biopsy been performed? [ ] Yes [X] No b. Have any other imaging studies, diagnostic procedures or laboratory testing been performed and are the results available? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): TESTOSTERONE 12/16/2010 122 ng/dL Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL Eval: MALE >50 YEARS 193-740 ng/dL ========================================= TESTOSTERONE 3/18/2011 84 ng/dL Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL Eval: MALE >50 YEARS 193-740 ng/dL ======================================== TESTOSTERONE 12/01/2015 53 ng/dL Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL Eval: MALE >50 YEARS 193-740 ng/dL ======================================== TOTAL PSA 8/11/2015 3.59 ng/mL 0.00 - 4.00 ======================================== 11. Functional impact --------------------- Does the Veteran's male reproductive system condition(s), including neoplasms, if any, impact his ability to work? [ ] Yes [X] No 12. Remarks, if any: -------------------- VETERAN'S ERECTILE DYSFUNCTION (ED) CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING PROLONGED SITTING, REPEATED BENDING, TWISTING AND LIFTING. GERD WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. /es/ J. F. Perez-Rivas, MD Physician, Pembroke Pines OPC Signed: 02/17/2016 16:11

That yellow brick road did finally lead to connections with PTSD and I'm sure there are others. I'm trying to connect mine with IHD which incuded bypass surgery and a related stroke/brain injury. The C&P Cardiologist did connect them as more likely than not but did not connect the SA. I am overweight but that does not necessarily cause SA but it is the reason most convenient for them to use to deny. I submitted with my claim, Lay testimony (sworn) from several people that knew me before, during and after my cardiac event. They state I did not snore, have sleep issues or low energy before the MI but I did right after and ever since. None of this stuff fits neatly on a VA form but need to be presented. I hope the raters look at this stuff and consider it. At least it information WAS present in the claim for a NOD or an appeal.

So I'm not the only one. Did they diagnose a stroke at the same time? My stroke was never diagnosed until I had an MRI done at my expense for something else the VA would not do or continued to drag its feet. I had a Neuropsych exam that really opened my eyes and I could put my finger on the problem. It was recommended in those notes that I see a Neurologist but nobody ever followed through. I only saw this when I requested my medical records and saw it for the first time.

I've never used that many acronyms in my life but I wanted the subject to be descriptive. C&P exam Cardiologist stated ihe injury/stroke more likely than not caused by or during MI or stroke. It has taken 10 years to put it all together and the VA was not of much help. I didn't know why I could no longer write computer programs or do any math (my job). In addition to all of the IHD secondary connections I could make, I also filed for TDIU. How can this injury be rated, like a TBI? Your best guess is fine because this does not fit in any of the boxes the VA wants filled out. More likely than not was a better start than I expected. The Cardiologist stated I could not do a physical job but I COULD do a desk job. I had a desk job and I needed my brain to do it. Thank you for any thoughts about this.

I was given some percentage preference just for being a vet. There were 3 openings and 2 vets were hired. My time in the service was included as part of my time on the job so I had one month of paid leave my first year on the job + sick leave (could be used hourly as need for DR. visits) + holidays. About 2 months off per year. No wonder there is a claims backlog.

Andyman I hope that didn't stress you, it's not that kind of test and it did me a lot of good. There is none of the shrink stuff but more like getting data for how your brain is functioning like memory, motor skills and basically was enjoyable to do. Just reading or listening to a very short story and then being asked to repeat what I remembered was a big problem for me. I thought I could do it but I couldn't do any of it. I was trying to understand why I could no longer write computer programs or do any math and now it was obvious. No short term memory which keeps me from doing simple things like calculate a tip. Relevent here so I must add, I have a degree in Physics. This is a good exam so please relax.

I found the testing very interesting and it answered questions I didn't even know to ask. I've had cognitive issues ever since I had bypass surgery 10 years ago and this testing pointed to answers that not only helped me understand what is wrong but may now help with my claim. When we went over the results I was asked "when did I have the stroke?". What stroke I asked. I have a brain injury that is not a TBI but has the same effect. I don't know how that gets rated but now at least I know why I can no longer write computer programs or do any math. The test can give you a ton of information that you may point to in a claim. I enjoyed the test, 8 hours.

The examiner is a Cardiologist so that part is good. The two screwups are the denial for edema which he believes is caused by one of my BP meds Nifedopine which I've only taken for two years. I have had the edema since my bypass surgery and it is caused by the harvesting of veins in my leg for parts. The scarring is from the same proceedure plus the chest incision.He only measured 3 scars on my leg. There are four scars on my leg. He missed one and that one is the missing 10 cm/sq needed for a 10% rating. Is there any way to get this corrected before the RO rates this, or am I stuck waiting 2 or 3 years for a NOD or CUE? For those claims and all of the othersI have used sworn lay testimony, scholarly medical articles and my medical records to try to make my point. That was all done using Chris Attigs ebooks and claims workbook. Asknods book was also very helpful in many other ways, as was this and many other forums.

I just had a C&P for a number of issues related to IHD and am amazed at the ways they find to reject claims. I will discuss those in another post and bring up the most important one in this post. A brain injury secondary to IHD. Bypass surgery caused an injury possibly through a stroke that really affected my life. Learning about and then trying to connect it to IHD has been the problem. Most likely than not is the term he used and I hope it helps my TDIU claim I'm attaching the results. ***Note: Your health care team may not have all of the information from your Personal Health Record unless you share it with them. Contact your health care team if you have questions about your health information.*** Key: Double dashes (--) mean there is no information to display. Name: Date of Birth: 24 Oct 1947 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 01 Mar 2016 @ 1730 File Name: mhv__20160301_1730.txt Date Range Selected: 17 Feb 2015 to 17 Feb 2016 Data Types Selected: My HealtheVet Account Summary VA Notes --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 06 Oct 2010 Authentication Facility ID: 546 Authentication Facility Name: Miami FL VAMC VA Treating Facility Type -------------------- ------ Miami FL VAMC na Great Lakes Healthcare System na VBA BRLS na VBA CORP na ENROLLMENT SYSTEM REENGINEERING na DEPARTMENT OF DEFENSE DEERS na AUSTIN MHV na ST. LOUIS MO VAMC-JC DIVISION na ------------------------------- VA NOTES -------------------------------- Source: VA Last Updated: 01 Mar 2016 @ 1648 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: 17 Feb 2016 @ 1000 Note Title: C&P EXAM Location: Miami FL VAMC Signed By: PEREZ-RIVAS,JOSE F Co-signed By: PEREZ-RIVAS,JOSE F Date/Time Signed: 17 Feb 2016 @ 1611 ------------------------------------------------------------------------- LOCAL TITLE: C&P EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: FEB 17, 2016@10:00 ENTRY DATE: FEB 17, 2016@16:11:47 AUTHOR: PEREZ-RIVAS,JOSE F EXP COSIGNER: URGENCY: STATUS: COMPLETED Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: 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) [X] Civilian medical records [X] Other: VBMS, VIRTUAL VA MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Direct service connection Does the Veteran have a diagnosis of (a) ISCHEMIC HEART DISEASE that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) due to Agent Orange exposure in Vietnam during service? b. Indicate type of exam for which opinion has been requested: ISCHEMIC HEART DISEASE 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: Veteran did service militarily in Vietnam, where he was probably exposed to Agent Orange. On 2/05/2006 was admitted with an acute MI to a local hospital leading to a Quadruple CABG on 2/08/2006. Therefore he has a diagnosis of (a) ISCHEMIC HEART DISEASE that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) due to Agent Orange exposure in Vietnam during service. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's EDEMA at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: EDEMA 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: Veteran's bilateral leg edema is clinically due to a combination of venous/lymphatic insufficiency of both lower extremities plus the continuous use of moderate doses of the antihypertensive Nifedipine, which is a drug that causes leg edema in a significantly large number of patients. The bilateral leg edema is definitely not due to (decompensated) IHD as Veteran is definitely not in heart failure. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's HYPERTENSION SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: HYPERTENSION 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: Hypertension in this Veteran preceded the development of IHD for years. Therefore, Hypertension is not secondary to IHD. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's SCARRING SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: SCARRING TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: The residual scars in the midsternum and in the left leg are the results of the open heart surgery and of the veins obtained to do the venous-arterial grafts respectively. Such procedures were required in view of Veteran's critical Ischemic Heart Disease. Hence, technically, the scars are proximately the result of Veteran's Ischemic Heart Disease. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's E. D. SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: E.D. TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: Erectile Dysfunction is often a disease of vascular origin. The penile endothelial bed is considered a specialized extension of the peripheral vascular system, responding similarly to various stimuli in order to maintain homeostasis, playing a particular regulatory role in the modulation of vascular smooth muscle (VSM) tone which is crucial for normal erectile function. The small diameter of the cavernosal penile arteries plus the high content of endothelium and VSM may make the penile vascular bed a sensitive indicator of systemic vascular disease. Thus, the penis is a vascular organ that is sensitive to changes in oxidative stress and systemic Nitrogen Oxide (NO) levels. It is also sensitive to local modifications in the vasculature, making the penis an organ supposed to precede vascular systemic alterations. Therefore, ED has a higher incidence in patients with Ischemic Heart Disease, a disease which it often precedes but at times also follows. Therefore, Veteran's E. D. is at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE as a reflection of the affliction of the arteries by atherosclerosis. Besides, ED is also considered to frequently occur in Hypogonadism, but the evidence of this latter was obviated years later (IHD in 2003 vs Hypogonadism in 2010). Nevertheless, Hypogonadism has also contributed to the ED after the initial onset of this latter due predominantly to atherosclerosis. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's BRAIN INJURY SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: BRAIN INJURY TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: From the Neurologic standpoint, Veteran's intellectual and motor function was fundamentally normal and completely preserved before the CABG. Shortly after being discharged post-CABG, he started to experience significant intellectual changes. Eventual Neuropsychological Testing showed apparent "deficits in verbal memory retrieval, ideational fluency, visuocontruction, and graphomotor skills" w/ mild cerebral impairment noted, which was non-specific. However, he never had any motor impairment other than very mild unstable gait with imbalance on physical activities and occasional lightheadedness, symptoms that had their onset some time after the initial intellectual ones. It is well known that one of the complications of Open Heart Surgery during the extracorporeal circulation pump, is the occurrence of strokes, either embolic or due to central (brain) circulatory obstruction. Taking into consideration the timing of the events, it is most likely than not that this Veteran's left occipital brain infarction was technically proximately due to IHD as a result of the CABG that was required to improve his coronary artery circulation. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's GERD SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: GERD 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: Some people might theorize that GERD might be secondary to IHD citing published articles that have not undergone critical appraisal as part of the evidence-based medicine. Regarding GERD, there is no peer-reviewed evidence in the scientific medical literature that it could be due, either directly or secondarily, to IHD. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary Service Connection. Is the Veteran's SLEEP APNEA SECONDARY TO IHD at least as likely as not (50 percent or greater probability) proximately due to or the result of ISCHEMIC HEART DISEASE? b. Indicate type of exam for which opinion has been requested: SLEEP APNEA 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: Some people might theorize that SLEEP APNEA might be secondary to IHD citing published articles that have not undergone critical appraisal as part of the evidence-based medicine. The arguable proposition that lack of physical activity due to IHD might make the patients gain weight and, thus, precipitate or aggravate the Sleep Apnea has been presented, but this theoretical argument lacks firm substrate. Such argument would try to push onto trying to establish a connection or to force a theoretical justification to make the IHD in some way be related to the Sleep Apnea. The current peer-reviewed medical literature overview of sleep apnea states that the most important risk factors for obstructive sleep apnea (OSA) are advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. Regarding SLEEP APNEA, there is no scientific evidence in the medical litearature that it could be due, either directly or secondarily, to IHD. ************************************************************************* **************************************************************************** Hypertension Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with hypertension or isolated systolic hypertension based on the following criteria: [X] Yes [ ] No [X] Hypertension ICD code: 38341003 Date of diagnosis: 1995 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hypertension condition (brief summary): 68 y/o male Veteran with Hx of Hypertension requesting secondary service connection due to Ischemic Heart Disease. Veteran has had History of Hypertension since at least the mid 90's according to him and was being medically treated while living in Chicago with oral antihypertensive therapy. Over the years he required adjustments of his oral antihypertensive therapy. His BP still fluctuates. No actual Hx to suggest classical angina, syncope, LV Failure, TIA or palpitations. b. Does the Veteran's treatment plan include taking continuous medication for hypertension or isolated systolic hypertension? [X] Yes [ ] No If yes, list only those medications used for the diagnosed conditions: Carvedilol, Nifedipine, Hydralazine c. Was the Veteran's initial diagnosis of hypertension or isolated systolic hypertension confirmed by blood pressure (BP) readings taken 2 or more times on at least 3 different days? [ ] Yes [ ] No [X] Unknown d. Does the Veteran have a history of a diastolic BP elevation to predominantly 100 or more? [ ] Yes [X] No 3. Current blood pressure readings ---------------------------------- Systolic Diastolic Blood pressure reading 1: 148 / 70 Date: 2/17/2016 Blood pressure reading 2: 145 / 70 Date: 2/17/2016 Blood pressure reading 3: 145 / 70 Date: 2/17/2016 Average Blood Pressure Reading: 146 / 70 4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 5. Functional impact -------------------- Does the Veteran's hypertension or isolated systolic hypertension impact his or her ability to work? [ ] Yes [X] No 6. Remarks, if any ------------------ VETERAN'S HYPERTENSION CONDITION WOULD BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING, SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING, PULLING. HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS-- see under CNS--) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF REST AND POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY 2 HOURS. HE DOES HAVE REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO THE ABOVE MENTIONED RECOVERY PERIODS. **************************************************************************** Heart Conditions: (Including Ischemic & Non-ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a heart condition? [X] Yes [ ] No [X] Acute, subacute, or old myocardial infarction ICD code: 1755008 Date of diagnosis: 2/05/2006 [X] Coronary artery disease ICD code: 233817007Date of diagnosis: 2003 [X] Coronary Artery Bypass Graft ICD code: 399261000Date of diagnosis: 2/08/2006 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's heart condition(s) (brief summary): 68 y/o male, a non diabetic with Hx of previous cigarette smoking of 1 1/2 PPD (QUIT 2/05/2006), Hx of Hypertension and Dyslipidemia. He is a Vietnam Veteran with Hx of Ischemic Heart Disease, S/P Quadruple CABG on 2/08/2006 who is asking for direct service connection in account of Agent Orange exposure while in Vietnam. He moved from Chicago to Florida in 1998 and requested medical service in the VA where he was initially seen on March 10/2001. At that time a Hx of chest pain was elicited as having had its onset three years prior, reason for which Veteran had already had a Stress Test in Chicago and it did not show ischemia. In 2003 his chest pain kept recurring and he was submitted to a Nuclear Stress Test at the Miami VA on 11/20/2003 and it demonstrated moderate ischemia of the distal anterior wall. He was advised a Cardiac Cath but he declined and he claims that he never had it done until his episode of severe chest pain on February 5, 2006 when he was admitted to North Ridge Hospital with a diagnosis of an acute subendocardial infarction, leading to a diagnostic cardiac cath and then followed by the Quadruple CABG on 2/08/2006. He claims that after his CABG in 2006 he has not had any kind of chest pain. However, he has had exertional tiredness, exertional dyspnea and leg edema, reason for which he has been submitted to additional cardiovascular diagnostic studies, including Nuclear Stress Tests in 2014 and 2015 and both times the Stress Tests have been negative for ischemia. Goes to the Gym three times a week and walks slow on the treadmill for about 5 minutes and lifts some weight. Gets dyspnea to more than mild-to-moderate exertion although his physical activities are limited in account of getting tired and developing headaches. He develops shortness of breath after walking short distances, doing light yard work or washing the car and frequently needs to sit down to rest. However, he does not have an actual Hx to suggest classical angina, syncope, LV Failure, TIA or palpitations. Uses pressure stockings for his leg edema. b. Do any of the Veteran's heart conditions qualify within the generally accepted medical definition of ischemic heart disease (IHD)? [X] Yes [ ] No If yes, list the conditions that qualify: Severe Coronary artery obstruction c. Provide the etiology, if known, of each of the Veteran's heart conditions, including the relationship/causality to other heart conditions, particularly the relationship/causality to the Veteran's IHD conditions, if any: Heart condition #1: Provide etiology ATEHROSCLEROSIS OF THE CORONARY ARTERIES d. Is continuous medication required for control of the Veteran's heart condition? [X] Yes [ ] No If yes, list medications required for the Veteran's heart condition (include name of medication and heart condition it is used for, such as atenolol for myocardial infarction or atrial fibrillation): Baby Aspirin, Carvedilol, Nifedipine, Hydralazine, Atorvastatin 3. Myocardial infarction (MI) ----------------------------- Has the Veteran had a myocardial infarction (MI)? [ ] Yes [X] No 4. Congestive Heart Failure (CHF) --------------------------------- Has the Veteran had congestive heart failure (CHF)? [ ] Yes [X] No 5. Arrhythmia ------------- Has the Veteran had a cardiac arrhythmia? [X] Yes [ ] No Type of arrhythmia (check all that apply): [X] Other cardiac arrhythmia, specify: Frequent Ventricular Premature Beats If checked, indicate frequency: [ ] Constant [X] Intermittent (paroxysmal) If intermittent, indicate number of episodes in the past 12 months: [ ] 0 [X] 1-3 [ ] More than 4 Indicate how these episodes were documented (check all that apply) [X] Holter 6. Heart valve conditions ------------------------- Has the Veteran had a heart valve condition? [ ] Yes [X] No 7. Infectious heart conditions ------------------------------ Has the Veteran had any infectious cardiac conditions, including active valvular infection (including rheumatic heart disease), endocarditis, pericarditis or syphilitic heart disease? [ ] Yes [X] No 8. Pericardial adhesions ------------------------ Has the Veteran had pericardial adhesions? [ ] Yes [X] No 9. Procedures ------------- Has the Veteran had any non-surgical or surgical procedures for the treatment of a heart condition? [X] Yes [ ] No If yes, indicate the non-surgical or surgical procedures the Veteran has had for the treatment of heart conditions (check all that apply): [X] Coronary artery bypass surgery Indicate date of admission for treatment and treatment facility: FEBRUARY 08, 2006 NORTH RIDGE HOSPITAL, OAKLAND PARK, FL Indicate the condition that resulted in the need for this procedure/treatment: SEVERE CORONARY ARTERY OBSTRUCTION WITH ANGINA PECTORIS 10. Hospitalizations -------------------- Has the Veteran had any other hospitalizations for the treatment of heart conditions (other than for non-surgical and surgical procedures described above)? [ ] Yes [X] No 11. Physical exam ----------------- a. Heart rate: 79 b. Rhythm: [X] Regular [ ] Irregular c. Point of maximal impact: [ ] Not palpable [ ] 4th intercostal space [X] 5th intercostal space [ ] Other, specify: d. Heart sounds: [X] Normal [ ] Abnormal, specify: e. Jugular-venous distension: [ ] Yes [X] No f. Auscultation of the lungs: [X] Clear [ ] Bibasilar rales [ ] Other, describe: g. Peripheral pulses: Dorsalis pedis: [X] Normal [ ] Diminished [ ] Absent Posterior tibial: [X] Normal [ ] Diminished [ ] Absent h. Peripheral edema: Right lower extremity: [ ] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [X] 4+ Left lower extremity: [ ] None [ ] Trace [ ] 1+ [ ] 2+ [X] 3+ [ ] 4+ i. Blood pressure: 146/70 12. 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? [X] Yes [ ] No If yes, are any of these scars painful or unstable, have a total area equal to or greater than 39 square cm (6 square inches), or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.) [ ] Yes [X] No If no, provide location and measurements of scar in centimeters. Location: #1 MIDSTERNAL longitudianl Measurements: length 17.0cm X width 0.6cm c. Comments, if any: #2 Left proximal thigh medially: length 8.5 cm x width 0.6 cm #3 Left distal thigh medially: length 11.3 cm x width 0.9 cm #4 #3 Left proximal leg medially: length 5.3 cm x width 0.7 cm 13. Diagnostic Testing ---------------------- a. Is there evidence of cardiac hypertrophy? [ ] Yes [X] No b. Is there evidence of cardiac dilatation? [ ] Yes [X] No c. Diagnostic tests Indicate all testing completed; provide only most recent results which reflect the Veteran's current functional status (check all that apply): [X] EKG Date of EKG: 1/25/2016 Result: [X] Other, describe: Sinus rhythm with Premature atrial complexes with Aberrant conduction. RSR' or QR pattern in V1 suggests right ventricular conduction delay. Borderline ECG. [X] Chest x-ray Date of CXR: 4/11/2013 Result: [X] Normal [ ] Abnormal, describe: [X] Echocardiogram Date of echocardiogram: 10/11/2012 Left ventricular ejection fraction (LVEF): 50-55 % Wall motion: [ ] Normal [X] Abnormal, describe: Regional wall motion abnormalities can not be excluded due to limited visualization of endocardial borders. Wall thickness: [X] Normal [ ] Abnormal, describe: [X] Holter monitor Date of Holter monitor: 1/28/2016 Result: [ ] Normal [X] Abnormal, describe: PREDOMINANT RHYTHM: Sinus rhythm Slowest rhythm recorded: 65 /min: Sinus rhythm Fastest rhythm recorded: Rate: 128/min. Sinus tachycardia PERTINENT FINDINGS: Ventricular ectopic beats: Isolated: 1527 Begeminal cycles: 0 Couplets: 5 NSVT: 0 Runs: 0 Supraventricular ectopic beats: Isolated: 27 Begeminal cycles: 0 Couplets: 1 SVT: 0 Runs: 0 Bradyarrhythmia recorded: Pauses, longest pause 1 A-V block: No Patient recorded symptoms: Patient recorded symptoms - No COMMENTS: 24 hour Holter monitoring done Predominant rhythm was sinus rhythm Frequent PVCs as described above Occasional PACs [X] Coronary artery angiogram Date of angiogram: 2/06/2006 Result: [ ] Normal [X] Abnormal, describe: Severe Triple Vessels Coronary Artery Disease. Normal size left ventricular chamber with apical hypokinesis and mildly reduced left ventricular ejection fraction of 40% to 45%. 14. METs Testing ---------------- Indicate all testing completed; provide only most recent results which reflect the Veteran's current functional status (check all that apply): a. [X] Exercise stress test Date of most recent exercise stress test: 1/25/2016 Results: Negative for ischemai METs level the Veteran performed, if provided: 6.4 Did the test show ischemia? [ ] Yes [X] No b. If an exercise stress test was not performed, provide reason: No response provided. c. [X] Interview-based METs test Date of interview-based METs test: 2/17/2016 Symptoms during activity: The METs level checked below reflects the lowest activity level at which the Veteran reports any of the following symptoms attributable to a cardiac condition (check all symptoms that the Veteran reports at the indicated METs level of activity): [X] Dyspnea [X] Fatigue Results of interview-based METs test METs level on most recent interview-based METs test: [X] (>3-5 METs) This METs level has been found to be consistent with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph) d. Has the Veteran had both an exercise stress test and an interview-based METs test? [X] Yes [ ] No If yes, indicate which results most accurately reflect the Veteran's current cardiac functional level: [X] Exercise stress test [ ] Interview-based METs test [ ] N/A e. Is the METs level limitation provided above due solely to the heart condition(s) that the Veteran is claiming in the Diagnosis Section? [ ] Yes [X] No If no, complete Section 14f. f. What is the estimated METs level due solely to the cardiac condition(s) listed above? (If this is different than METs reported above because of co-morbid conditions, provide METs level and Rationale below.) METs level METs level on most recent interview-based METs test: [X] The limitation in METs level is due to multiple medical conditions including the heart condition(s); it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition Rationale: Veteran has lightheadedness and becomes unstable when walking more than shorter distances, thus preventing him from walking adequately on a treadmill as his walking is slow. The last available Echo was done on 10/11/2012 and reported a LVEF of 50-55% but the most recent Nuclear Stress Test done on 1/25/2016 reported a calculated LVEF of 56% which more accurately reflects the veteran's current cardiac functional level. g. Comments, if any: No response provided. 15. Functional impact --------------------- Does the Veteran's heart condition(s) impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's heart conditions, providing one or more examples: VETERAN'S HEART'S CONDITION WOULD BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING, SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING, PULLING. HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS-- see under CNS--) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF REST AND POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY 2 HOURS. HE DOES HAVE REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW RELATIVELY COMPLEX INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO THE ABOVE MENTIONED RECOVERY PERIODS. 16. Remarks, if any ------------------- Veteran's bilateral leg edema is clinically due to a combination of venous/lymphatic insufficiency of both lower extremities plus the continuouds use of moderate doses of the antihypertensive Nifedipine. The bilateral leg edeme is definitely not due to heart failure presently. **************************************************************************** Scars/Disfigurement Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran have one or more scars anywhere on the body, or disfigurement of the head, face, or neck? Yes Diagnosis #1: SCARS POST-CABG ICD code: 275322007 Date of diagnosis: FEBRUARY, 2006 Does the Veteran have any scars on the trunk or extremities (regions other than the head, face or neck): Yes Does the Veteran have any scars or disfigurement of the head, face or neck: No SECTION I: Scars of the trunk and extremities ---------------------------------------------- 1. Medical history ------------------ Describe the history (including cause/origin and course) of the Veteran's scar(s) of the trunk or extremities, (brief summary): 68 y/o male Veteran with a midsternal scar due to a previous CABG on 2/08/2006 as well as a left leg scar from the veins obtained to do the venous grafts to the coronary arteries. He is requesting secondary service connection as due to Ischemic Heart Disease. His linear scars are not painful but they are unstable -keloid-. Are any of the scars of the trunk or extremities painful: No Are any of the scars of the trunk or extremities unstable, with frequent loss of covering of skin over the scar: Yes Number of unstable scars: 4 Description of the loss of covering of skin over the scar: #1 Mid sternal scar longitudinal #2 Left proximal thigh medially #3 Left distal thigh medially #4 Left proximal leg medially Are any of the scars BOTH painful and unstable: No Are any of the scars of the trunk or extremities due to burns: No 2. Physical exam for scars on the trunk and extremities ------------------------------------------------------- 2-1. Details of scar findings for the trunk and extremities Right upper extremity: Not affected Left upper extremity: Not affected Right lower extremity: Not affected Left lower extremity: Affected Location of scars on left lower extremity and number them: #1 Left proximal thigh medially #2 Left distal thigh medially #3 Left proximal leg medially Types of scars and provide measurements: Linear Length of each linear scar: Scar #1:8.5 x 0.6 cm Scar #2:11.3 x 0.9 cm Scar #3:5.3 x 0.7 cm Anterior trunk: Affected Location of scars on anterior trunk and number them: #1 Mid sternum, longitudinal Types of scars and provide measurements: Linear Length of each linear scar: Scar #1:17.0 x 0.6 cm Posterior trunk: Not affected 2-2. Summary of nonlinear scar areas for the trunk and extremities ------------------------------------------------------------------ Superficial non-linear scars: None Deep non-linear scars: None SECTION II: Scars or other disfigurement of the head, face, or neck: No response provided --------------------------------------------------------------------- SECTION III: Miscellaneous --------------------------- 1. Limitation of function/other conditions ------------------------------------------ Do any of the scars (regardless of location) or disfigurement of the head, face, or neck result in limitation of function? No Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms (such as muscle or nerve damage) associated with any scar (regardless of location) or disfigurement of the head, face, or neck? No 2. Color photographs -------------------- Color photographs for any scars or disfiguring conditions of the head, face, or neck: Photographs not indicated 3. Functional impact -------------------- Does the Veteran's scar(s) (regardless of location) or disfigurement of the head, face, or neck impact his or her ability to work? No 4. Remarks, if any: ------------------- VETERAN'S SCARS CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING REPEATED BENDING, TWISTING AND LIFTING AS THE SCARS ARE NOT PAINFUL. FOR SUCH REASONS THEY WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Esophageal Conditions (Including gastroesophageal reflux disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Diagnosis --------- Does the Veteran now have or has he/she ever been diagnosed with an esophageal condition? Yes Gastroesophageal reflux disease (GERD) ICD code: 235595009 Date of diagnosis: 1995 Medical history --------------- Description of the history (including onset and course) of the Veteran's esophageal conditions: 68 y/o male Veteran with Hx of GERD for which he is requesting secondary service connection due to Ischemic Heart Disease. He started having symptoms of reflux in the 90's before he moved to Florida from Chicago in 1998. He states that he used to carry tums in his pocket "all the time" to get relief of his reflux symptomatology. While still in Chicago, he had an Upper Endoscopy privately but he does not remember the results other than he did not have an ulcer. However, over the years, the reflux got worse and has had the need to take medications regularly, specifically Omeprazole daily. If he does not take it regularly, his reflux gets worse. Once he keeps taking it daily, he rarely has reflux or any other symptoms. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition? Yes Medications used for the diagnosed condition: Omeprazole Signs and symptoms ------------------ Does the Veteran have any of the following signs or symptoms due to any esophageal conditions (including GERD)? Yes Sign and Symptoms: Reflux Esophageal stricture, spasm and diverticula ------------------------------------------- Does the Veteran have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus? No Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------------- Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? No Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? No Diagnostic Testing ------------------ Have diagnostic imaging studies or other diagnostic procedures been performed? No Has laboratory testing been performed? Yes CBC Date of test: 12/01/2015 Hemoglobin: 16.0 Hematocrit: 47.9 White blood cell count: 6.3 Platelets: 245 Are there any other significant diagnostic test findings and/or results? No Functional impact ----------------- Do any of the Veteran's esophageal conditions impact on his or her ability to work? No Remarks, if any: ---------------- VETERAN'S GERD CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING PROLONGED SITTING, REPEATED BENDING, TWISTING AND LIFTING AS THE GERD IS UNDER ADEQUATE CONTROL WITH HIS MEDICATION. FOR SUCH REASONS GERD WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Sleep Apnea Disability Benefits Questionnaire Name of patient/Veteran: 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 [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) [X] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: VBMS, VIRTUAL VA 1. Diagnosis ------------ Does the Veteran have or has he/she ever had sleep apnea? [X] Yes [ ] No [X] Obstructive ICD code: 73430006 Date of diagnosis: 6/15/2012 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's sleep disorder condition (brief summary): 68 y/o male Veteran with Hx of Obstructive Sleep Apnea requesting secondary service connection due to Ischemic Heart Disease. Veteran claims that he was told the first time that he was a heavy snorer by a friend (he has been divorced since the early '90s) with whom he shared a hotel room around 2007. He has been chronically tired during daytime with daytime hypersomnolence. Then he was eventually requested to have Sleep Study done on 6/15/2012 at the Miami VA confirming the presence of Sleep Apnea. Was initiated on CPAP and his symptomatology has significantly improved. However, because of his residual cognitive impairment after the stroke, he knew about the existence of the drug Modafinil and asked to be prescribed with it and it has helped some regarding his cognitive impairment more than anything else, besides the additional help to his cognitive function by the CPAP. b. Is continuous medication required for control of a sleep disorder condition? [X] Yes [ ] No If yes, list only those medications required for the Veteran's sleep disorder condition: MODAFINIL c. Does the veteran require the use of a breathing assistance device? [ ] Yes [X] 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: 6/15/2012 Facility where sleep study performed, if known: MIAMI VAMC Results: Severe obstructive sleep apnea hypopnea syndrome relieved by nasal CPAP @ 9.0 cm H20 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: ------------------- PROVIDED THAT VETERAN USES THE CPAP REGULARLY, HIS SLEEP APNEA CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING SIMPLE INTELLECTUAL TASKS. FOR SUCH REASON SLEEP APNEA WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. **************************************************************************** Central Nervous System and Neuromuscular Diseases (except Traumatic Brain Injury, Amyotrophic Lateral Sclerosis, Parkinson's Disease, Multiple Sclerosis, Headaches, TMJ Conditions, Epilepsy, Narcolepsy, Peripheral Neuropathy, Sleep Apnea, Cranial Nerve Disorders, Fibromyalgia, and Chronic Fatigue Syndrome) Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records [X] Other: VBMS, VIRTUAL VA 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a central nervous system (CNS) condition? [X] Yes [ ] No [X] Vascular diseases ICD code: 275526006 Date of diagnosis: 2006 [X] Thrombosis, TIA or cerebral infarction [X] Cerebral arteriosclerosis 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's central nervous conditions (brief summary): 68 y/o male Veteran with Hx of a brain injury due to a stroke and Veteran is requesting it as secondarily service connected due to Ischemic Heart Disease. Veteran had the CABG on 2/08/2006 and was discharged on 2/13/2006 from North Ridge Hospital, in Oakland Park, Florida. Within the next few days post-discharge he started noticing that was impossible for him to keep his previous abilities on doing computer programming and mathematic analyses (he is a Phsyics and Mathematics Major and with Master of Physics providing data to different clients, whom he lost due to his inability to keep working) as he used to do before. Brain MRI revealed that Veteran had had a stroke. Neuropsychological testing showed apparent "deficits in vebral memory retrieval, ideational fluency, visuocontruction, and graphomotor skills" w/ mild cerebral impairment noted, which was non-specific. However, he never had any motor impairment other than very mild unstable gait with imbalance on physical activities and occasional lightheadedness, symptoms that still recur. He has never taken any medication post-stroke other than his Baby Aspirin and his regular blood pressure medications. At times he also develops headaches if he exercises more than usual and needs to stop his activities with resolution of the headache. b. Does the Veteran's central nervous system condition require continuous medication for control? [ ] Yes [X] No c. Does the Veteran have an infectious condition? [ ] Yes [X] No If yes, is it active? [ ] Yes [ ] No d. Dominant hand [X] Right [ ] Left [ ] Ambidextrous 3. Conditions, signs and symptoms --------------------------------- a. Does the Veteran have any muscle weakness in the upper and/or lower extremities? [ ] Yes [X] No b. Does the Veteran have any pharynx and/or larynx and/or swallowing conditions? [ ] Yes [X] No c. Does the Veteran have any respiratory conditions (such as rigidity of the diaphragm, chest wall or laryngeal muscles)? [ ] Yes [X] No d. Does the Veteran have sleep disturbances? [X] Yes [ ] No If yes, check all that apply: [X] Sleep apnea requiring the use of breathing assistance device such as continuous positive airway pressure (CPAP) machine e. Does the Veteran have any bowel functional impairment? [ ] Yes [X] No f. Does the Veteran have voiding dysfunction causing urine leakage? [X] Yes [ ] No If yes, please check one: [X] Does not require/does not use absorbent material g. Does the Veteran have voiding dysfunction causing signs and/or symptoms of urinary frequency? [X] Yes [ ] No If yes, check all that apply: [X] Daytime voiding interval between 1 and 2 hours [X] Nighttime awakening to void 2 times h. Does the Veteran have voiding dysfunction causing findings, signs and/or symptoms of obstructed voiding? [X] Yes [ ] No If yes, check all signs and symptoms that apply: [X] Hesitancy If checked, is hesitancy marked? [ ] Yes [X] No [X] Slow or weak stream If checked, is stream markedly slow or weak? [ ] Yes [X] No [X] Decreased force of stream If checked, is force of stream markedly decreased? [ ] Yes [X] No i. Does the Veteran have voiding dysfunction requiring the use of an appliance? [ ] Yes [X] No j. Does the Veteran have a history of recurrent symptomatic urinary tract infections? [ ] Yes [X] No k. Does the Veteran (if male) have erectile dysfunction? [X] Yes [ ] No If yes, is the erectile dysfunction as likely as not (at least a 50% probability) attributable to a CNS disease (including treatment or residuals of treatment)? [ ] Yes [X] No If no, provide the etiology of the erectile dysfunction: Low testosterone level (on Testosterone replacement twice a month) If no, is the Veteran able to achieve an erection (with medication) sufficient for penetration and ejaculation? [X] Yes [ ] No 4. Neurologic exam ------------------ a. Speech [X] Normal [ ] Abnormal b. Gait [ ] Normal [X] Abnormal, describe: Mildly unstable gait when/if Veteran walks fast or longer distances due predominantly to residual lightheadedness post-stroke. The gait is fundamentally stable otherwise. c. Strength Rate strength according to the following scale: 0/5 No muscle movement 1/5 Visible muscle movement, but no joint movement 2/5 No movement against gravity 3/5 No movement against resistance 4/5 Less than normal strength 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 Grip: 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 Pinch (thumb to index finger): 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 Knee 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 Ankle plantar 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 Ankle dorsiflexion: 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 d. Deep tendon reflexes (DTRs) Rate reflexes according to the following scale: 0 Absent 1+ Decreased 2+ Normal 3+ Increased without clonus 4+ Increased 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+ Knee: Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right:[ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ e. Does the Veteran have muscle atrophy attributable to a CNS condition? [ ] Yes [X] No f. Summary of muscle weakness in the upper and/or lower extremities attributable to a CNS condition (check all that apply): Right upper extremity muscle weakness: [X] None Left upper extremity muscle weakness: [X] None Right lower extremity muscle weakness: [X] None Left lower extremity muscle weakness: [X] None 5. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 6. 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 related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 7. Mental health manifestations due to CNS condition or its treatment --------------------------------------------------------------------- a. Does the Veteran have depression, cognitive impairment or dementia, or any other mental health conditions attributable to a CNS disease and/or its treatment? [ ] Yes [X] No 8. Differentiation of Symptoms or Neurologic Effects ---------------------------------------------------- Are you able to differentiate what portion of the symptomatology or neurologic effects above are caused by each diagnosis? [ ] Yes [X] No 9. 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 10. Remaining effective function of the extremities --------------------------------------------------- Due to a CNS 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., 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 11. Diagnostic testing ---------------------- a. Have imaging studies been performed? [X] Yes [ ] No If yes, provide most recent results, if available: HEAD CT WITH & W/O CONTRAST 11/25/2014: Findings: There is a large old left occipital infarction. Brain volume is otherwise normal. There is no abnormal parenchymal density elsewhere in the brain. There is no mass, mass effect, hydrocephalus or abnormal extra-axial fluid collection. There is no abnormal enhancement. The dural venous sinuses enhance normally. There is moderate atherosclerotic calcification of the cavernous internal carotid arteries and trace atherosclerotic calcification of the intradural vertebral arteries. The included paranasal sinuses and mastoid air cells are clear. There is no skull fracture or suspicious osseous lesion. Impression: 1. Old left occipital infarction. 2. No mass, hydrocephalus or enhancing lesion. b. Have PFTs been performed? [ ] Yes [X] No c. If PFTs have been performed, is the flow-volume loop compatible with upper airway obstruction? [ ] Yes [ ] No d. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 12. Functional impact --------------------- Do the Veteran's central nervous system disorders impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's central nervous system disorder condition(s), providing one or more examples: VETERAN'S POST-STROKE CONDITION WOULD BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING, SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING, PULLING AND THOSE ACTIVITIES RELATED TO MORE THAN SIMPLE INTELLECTUAL CONCENTRATION. His Neuropsychologic Testing identified "deficits in vebral memory retrieval, ideational fluency, visuocontruction, and graphomotor skills" w/ mild cerebral impairment noted, which was non-specific. HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING OR ADDITIONAL LIMITING MEDICAL CONDITIONS) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF PHYSICAL AND MENTAL REST AND POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY HOUR. HE DOES HAVE REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO THE ABOVE MENTIONED RECOVERY PERIODS. 13. Remarks, if any: -------------------- No remarks provided. **************************************************************************** Male Reproductive System Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he ever been diagnosed with any conditions of the male reproductive system? [X] Yes [ ] No [X] Erectile dysfunction ICD code: 397803000 Date of diagnosis: 2006 [X] Other male reproductive system condition (specify diagnosis, providing only diagnoses that pertain to male reproductive system.) Other diagnosis #1: HYPOGONADISM ICD code: 48130008 Date of diagnosis: 12/16/2010 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's male reproductive organ condition(s) (brief summary): 68 y/o male Veteran with Hx of Erectile Dysfunction (ED) and requesting secondary service connection due to Ischemic Heart Disease. He claims that he developed ED after the Open Heart Surgery (CABG) and has required the use of medication (Sildenafil) which has helped him some. However, in 2012 he was also found with very low testosterone level and has been on chronic replacement injection replacement therapy (patches and creams did not work) twice a month with initial improvement and not much afterwards. However, he claims that the testosterone has helped him to stay more alert. He claims that with the use of Viagra he has been able to have enough erection to be capable of acceptable penetration. He is being followed by both the VA Urologist as well as the private Urologist. The latter sees him at least every 3 months. He had the last digital prostate exam around 3 months ago and was told that his prostate was "mildly" enlarged but no other urologic-related abnormalities. b. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition? [X] Yes [ ] No List medications taken for the diagnosed condition: Testosterone Injections c. Has the Veteran had an orchiectomy? [ ] Yes [X] No d. Is there any renal dysfunction due to condition? [ ] Yes [X] No 3. Voiding dysfunction ---------------------- Does the Veteran have a voiding dysfunction? [X] Yes [ ] No If yes, complete the following sections: a. Etiology of voiding dysfunction: Unknown but BPH has been presumed as the cause b. Does the voiding dysfunction cause urine leakage? [X] Yes [ ] No Indicate severity (check one): [X] Does not require the wearing of absorbent material [ ] Requires absorbent material which must be changed less than 2 times per day [ ] Requires absorbent material which must be changed 2 to 4 times per day [ ] Requires absorbent material which must be changed more than 4 times per day [ ] Other, describe: c. Does the voiding dysfunction require the use of an appliance? [ ] Yes [X] No d. Does the voiding dysfunction cause increased urinary frequency? [X] Yes [ ] No If yes, check all that apply: [ ] Daytime voiding interval between 2 and 3 hours [X] Daytime voiding interval between 1 and 2 hours [ ] Daytime voiding interval less than 1 hour [X] Nighttime awakening to void 2 times [ ] Nighttime awakening to void 3 to 4 times [ ] Nighttime awakening to void 5 or more times e. Does the voiding dysfunction cause signs or symptoms of obstructed voiding? [X] Yes [ ] No If yes, check all that apply: [X] Hesitancy If checked, is hesitancy marked? [ ] Yes [X] No [X] Slow stream If checked, is stream markedly slow? [ ] Yes [X] No [X] Weak stream If checked, is stream markedly weak? [ ] Yes [X] No [X] Decreased force of stream If checked, is force of stream markedly decreased? [ ] Yes [X] No f. Are there any other obstructive symptoms? [ ] Yes [X] No 4. Erectile dysfunction ----------------------- Does the Veteran have erectile dysfunction? [X] Yes [ ] No If yes, complete the following section: a. Etiology of erectile dysfunction: ATHEROSCLEROSIS (as occurs with IHD) and HYPOGONADISM b. If the Veteran has erectile dysfunction, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? [X] Yes [ ] No If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable: Initially due ATHEROSCLEROSIS (as occurs with IHD) and aventually maintained/worsened by HYPOGONADISM c. If the Veteran has erectile dysfunction, is he able to achieve an erection sufficient for penetration and ejaculation without medication? [ ] Yes [X] No If no, has the Veteran used medications for treatment of his erectile dysfunction? [X] Yes [ ] No If yes, is the Veteran able to achieve an erection sufficient for penetration and ejaculation with medication? [X] Yes [ ] No 5. Retrograde ejaculation ------------------------- Does the Veteran have retrograde ejaculation? [ ] Yes [X] No 6. Male reproductive organ infections ------------------------------------- Does the Veteran have a history of chronic epididymitis, epididymo-orchitis or prostatitis? [ ] Yes [X] No 7. Physical exam ---------------- a. Penis [ ] Normal [ ] Not examined per Veteran's request [X] Not examined per Veteran's request; Veteran reports normal anatomy with no penile deformity or abnormality [ ] Not examined; penis exam not relevant to condition [ ] Abnormal b. Testes [ ] Normal [ ] Not examined per Veteran's request [X] Not examined per Veteran's request; Veteran reports normal anatomy with no testicular deformity or abnormality [ ] Not examined; testicular exam not relevant to condition [ ] Abnormal c. Epididymis [ ] Normal [ ] Not examined per Veteran's request [X] Not examined per Veteran's request; Veteran reports normal anatomy of epididymis with no deformity or abnormality [ ] Not examined; epididymis exam not relevant to condition [ ] Abnormal d. Prostate [ ] Normal [X] Not examined per Veteran's request [ ] Not examined; prostate exam not relevant to condition [ ] Abnormal 8. Tumors and neoplasms ----------------------- Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 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. Diagnostic testing ---------------------- a. Has a testicular biopsy been performed? [ ] Yes [X] No b. Have any other imaging studies, diagnostic procedures or laboratory testing been performed and are the results available? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): TESTOSTERONE 12/16/2010 122 ng/dL Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL Eval: MALE >50 YEARS 193-740 ng/dL ========================================= TESTOSTERONE 3/18/2011 84 ng/dL Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL Eval: MALE >50 YEARS 193-740 ng/dL ======================================== TESTOSTERONE 12/01/2015 53 ng/dL Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL Eval: MALE >50 YEARS 193-740 ng/dL ======================================== TOTAL PSA 8/11/2015 3.59 ng/mL 0.00 - 4.00 ======================================== 11. Functional impact --------------------- Does the Veteran's male reproductive system condition(s), including neoplasms, if any, impact his ability to work? [ ] Yes [X] No 12. Remarks, if any: -------------------- VETERAN'S ERECTILE DYSFUNCTION (ED) CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING PROLONGED SITTING, REPEATED BENDING, TWISTING AND LIFTING. GERD WOULD NOT PRECLUDE HIM ON OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS. /es/ J. F. Perez-Rivas, MD Physician, Pembroke Pines OPC Signed: 02/17/2016 16:11

I'm learning from this and see my future. I think you are prepared and have the evidence that points to the mistakes. Say only what you must to point out the errors. If they ask questions just answer as briefly as you can because the enemy looks for any opening. I think you are ready. We are all behind you.