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    E-3 Seaman

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  1. I am wondering what the proper procedure is for revoking my vso's poa and representing my claim myself. I contacted my regional VA office in reference to the matter and they informed me that I needed to fill out a form 21-22 and fax it in to the office. I noticed that form 21-22 is the power of attorney form for adding a vso which I do not want to do. I looked at the form 21-22a (for adding an individual) but think it would be silly to fill out a form to give poa to myself. I really don't want the VSO that I am currently involved with to have access to my records. I understand from doing a few searches on this subject that it may be a difficult procedure, but I did not see anywhere that actually stated a procedure to accomplish this. Thanks for any help in the matter.
  2. Thanks for the replies! I figure the doctor probably copy and pasted the wrong CFS opinion for the Medical Opinion Summary because he filled out the DBQ questions stating that I was unable to work due to CFS etc... Do you think that I should try and contact the Doctor to make him aware of this or should I go through my VSO? Fwiw, I filed for Gulf War related issues, Chronic Fatigue, Joint and Muscle Pain and Skin Problems. I have not received a diagnosis for any of these issues prior to the C&P exam.
  3. Hi All, I recently went for my C&P exam and would like your opinions on what percentage of rating I may receive. The C&P was completed by a VA Doctor at a VA Facility. I know it is long, but I would appreciate any input. Thanks in advance. Name of patient/Veteran: 1. Medical record review ------------------------ [X] Other, describe: VBMS, CPRS, Civilian Records 2. Medical history ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: Skin Diseases c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided e. Hearing loss, tinnitus and ear: No answer provided f. Sinus, nose, throat, dental and oral: No answer provided g. Breast: No answer provided h. Respiratory: No answer provided i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: The following conditions have been reported Joints and extremities: Ankle, Shoulder and Arm Miscellaneous musculoskeletal: Fibromyalgia n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: Chronic Fatigue Syndrome r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [ ] Yes [X] No 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- No answer provided **************************************************************************** Skin Diseases 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: [X] 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 [ ] Other: 1. Diagnosis: ------------- Does the Veteran now have or has he/she ever had a skin condition? [X] Yes [ ] No [X] Tumors and neoplasms of the skin, including malignant melanoma Diagnosis: Squamous cell cancer left hand [X] Other skin condition Other diagnosis #1: Epidermal inclusion cyst Date of diagnosis: July 2013 and Aug 2014 Other diagnosis #2: Dyshidrosis Date of diagnosis: 1992 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's skin conditions (brief summary): Exposed to oil well fire soot during deployment. Unemployed since 2010. Onset 1992 of skin papules with itching in hands and forearms lastin 24-48 hours occuring singly and not in clusters. Patient pops lesion with return of clear fluid. No evaluation or treatment sought. Squamous cell cancer left hand with excision June 2013. Epidermal inclusion cyst excision mid back and left anterior ankle July 2013. Excision of intradermal melanocytic nevus left posterior scalp and epidermal inclusion cyst right posterior shoulder in Aug 2014. b. Do any of the Veteran's skin conditions cause scarring or disfigurement of the head, face or neck? [ ] Yes [X] No c. Does the Veteran have any benign or malignant skin neoplasms (including malignant melanoma)? [X] Yes [ ] No d. Does the Veteran have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma)? [ ] Yes [X] No 3. Treatment ------------ a. Has the Veteran been treated with oral or topical medications in the past 12 months for any skin condition? [ ] Yes [X] No b. Has the Veteran had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders? [ ] Yes [X] No 4. Debilitating and non-debilitating episodes --------------------------------------------- a. Has the Veteran had any debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis? [ ] Yes [X] No b. Has the Veteran had any non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months? No response provided. 5. Physical exam a. Indicate the Veteran's visible skin conditions; indicate the approximate total body area and approximate total EXPOSED body area (face, neck and hands) affected on current examination (check all that apply): [X] The Veteran does not have any of the above listed visible skin conditions 6. Specific Skin Conditions --------------------------- Indicate the Veteran's specific skin conditions and complete all applicable subsequent questions (check all that apply): [X] Veteran does not have any of the specific skin conditions listed above 7. 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? [X] Yes [ ] No If yes, complete the following: b. Is the neoplasm [ ] Benign [X] Malignant c. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases? [X] Yes [ ] No; watchful waiting [X] Surgery If checked, describe: excision of SCC dorsal aspect of left hand Date(s) of surgery: 7-8-13 d. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? [ ] Yes [X] No e. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: No response provided. 8. Other pertinent physical findings, complications, conditions, signs and/or symptoms 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 9. Functional impact -------------------- Do any of the Veteran's skin conditions impact his or her ability to work? [ ] Yes [X] No 10. Remarks, if any: -------------------- No remarks provided. **************************************************************************** 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] Military service treatment records [X] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records MEDICAL OPINION SUMMARY ----------------------- Exposed to oil well firesoot during deployment. Unemployed since 2010. 1. Fibromyalgia. The patient met the diagnostic criteria for fibromyalgia. Onset was gradual per patient upon return from his deployment. He became increasingly aware in 1999 and sought treatment in 2004-2006 time frame. He is on multiple medications for pain control. It is at least as likely as not that the fibromyalgia was related to SW Asia deployment 2. Chronic Fatigue Syndrome (CFS). The patient did not meet the diagnostic criteria for CFS. It is not likely that Fatigue was related to CFS or that it was incurred during his deployment in SW Asia 3. It is not likely that the squamous cell carcinoma of the left hand and epidermal inclusion cysts were related to his service in the military or to his deployment in SW Asia. 4. It is as least as likely as not that the tendinitis in the ankles and the degenerative joint disease of the AC joints in the shoulders were related to the deployment in SW Asia as the gradual onset occurred after his deployment in SW Asia although the patient did not seek treatment until later when he became increasingly debilitated RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Is the disability pattern of fatigue, joint pain, muscle pain and skin diseases related to a specific exposure event during servuice in SW Asia b. Indicate type of exam for which opinion has been requested: Skin disaease, Shoulder, Ankle, Fibromyalgia and Chronic Fatigue Syndrome TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL EVIDENCE ] I have reviewed the conflicting medical evidence and am providing the following opinion: See below Fibromyalgia 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] Military service treatment records [X] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Fibromyalgia 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: Exposed to oil well fire soot during deployment. Unemployed since 2010. Muscle and tendon pain x 1999 gradually increasing in severity 2004-2006 time frame. Pain noted over left forearm biceps thighs ankles back. Pain present more than 24 hours after exertion lasting up to one week before resolution. Pt wakes up with discomfort but increasing activity leads to increased pain from muscles. b. Is continuous medication required for control of fibromyalgia symptoms? [ ] Yes [X] No c. Is the Veteran currently undergoing treatment for this condition? [X] Yes [ ] No If yes, describe: Trigger point injections, gabapentin 300 mg twice daily, naproxen 250 mg twice daily, hydrocodone 10 mg / acetaminophen 325 mg four times daily d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [ ] Yes [X] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia? [X] Yes [ ] No a. Findings, signs and symptoms (check all that apply): [X] Widespread musculoskeletal pain [X] Fatigue [X] Sleep disturbances [X] Anxiety b. Frequency of fibromyalgia symptoms (check all that apply): [X] Constant or nearly constant c. Does the Veteran have tender points (trigger points) for pain present? [X] Yes [ ] No [X] Low cervical region: at anterior aspect of the interspaces between transverse processes of C5-C7 If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Second rib: at second costochondral junction If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Occiput: at suboccipital muscle insertion If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Trapezius muscle: midpoint of upper border If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Supraspinatus muscle: above medial border of the scapular spine If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Lateral epicondyle: 2 cm distal to lateral epicondyle If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Gluteal: at upper outer quadrant of buttocks If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Greater trochanter: posterior to greater trochanteric prominence If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Knee: medial joint line If checked, indicate side: [ ] Right [ ] Left [X] Both 4. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): Tenderness over bilateral achilles tendons and over left deltoid ligament left ankle 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact --------------------- Does the Veteran's fibromyalgia impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of the Veteran's fibromyalgia, providing one or more examples: Patient was on workmens compensation 2006-2008 due to left ankle pain on ambulation. He had an exploratory laparascopic surgery in 2007 without a conclusive cause of his left ankle pain. In 2012 he had similar pain on his right ankle lasting one week in duration. This occurred while climbing a hill and supporting most of his weight on his right ankle. 7. Remarks, if any: ------------------- No remarks provided. **************************************************************************** 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 reviewed? [ ] Yes [X] No If no, check all records reviewed: [X] Military service treatment records [X] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records 1. Diagnosis ------------ Does the Veteran now have or has/she ever been diagnosed with chronic fatigue syndrome? [ ] Yes [X] No 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's chronic fatigue syndrome: Exposed to oil well fire soot during deployment. Unemployed since 2010. Patient claims fatigue on arising in the morning. Fatigue worsens during the day. If patient exerts himself he will experience increased fatigue and muscle pain which can persist > 24 hours and may last up to one week. b. Is continuous medication required for control of chronic fatigue syndrome? [ ] Yes [X] No If yes, are the Veteran's symptoms controlled by continuous medication? [ ] Yes [ ] No c. Have other clinical conditions that may produce similar symptoms been excluded by history, physical examination and/or laboratory tests to the extent possible? [X] Yes [ ] No d. Did the Veteran have an acute onset of chronic fatigue syndrome? [ ] Yes [X] No e. Has debilitating fatigue reduced daily activity level to less than 50% of pre-illness level? [X] Yes [ ] No If yes, specify length of time daily activity level has been reduced to less than 50% of pre-illness level: [ ] Less than 6 months [X] 6 months or longer 3. Findings, signs and symptoms ------------------------------- a. Does the Veteran now have or has the Veteran had any findings, signs and symptoms attributable to chronic fatigue syndrome? [X] Yes [ ] No If yes, check all that apply: [X] Debilitating fatigue [X] Generalized muscle aches or weakness [X] Fatigue lasting 24 hours or longer after exercise b. Does the Veteran now have or has the Veteran had any cognitive impairment attributable to chronic fatigue syndrome? [ ] Yes [X] No c. Specify frequency of symptoms: [X] Symptoms are nearly constant d. Do the Veteran's symptoms due to chronic fatigue syndrome restrict routine daily activities as compared to the pre-illness level? [X] Yes [ ] No If yes, specify % of restriction (check all that apply): [X] Symptoms restrict routine daily activities to 50% to 75% of the pre-illness level e. Do the Veteran's symptoms due to chronic fatigue syndrome result in periods of incapacitation? [ ] Yes [X] No 4. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms of chronic fatigue syndrome? [ ] Yes [X] No 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact -------------------- Does the Veteran's chronic fatigue syndrome impact his or her ability to work? [X] Yes [ ] No 7. Remarks, if any: ------------------- No remarks provided. Ankle Conditions Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: ------------------------------------------------------------------------------ [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination a. Evidence review ------------------ Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] 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) [ ] Other: [ ] No records were reviewed b. Was pertinent information from collateral sources reviewed? [X] Yes [ ] No If yes, describe: Orthopedic surgeon workmens comp notes 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: ankle b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Deltoid ligament sprain (chronic/recurrent) Side affected: [ ] Right [X] Left [ ] Both [X] Tendonitis (achilles/peroneal/posterior tibial) Side affected: [ ] Right [ ] Left [X] Both Date of diagnosis: Right 2012 Date of diagnosis: Left 2006 c. Comments (if any): No response provided 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's ankle condition (brief summary): exposure to oil well fire soot. Onset of left ankle pain with pain level 10/10 at onset in 2006. He underwent exploratory laparoscopic surgery in 2007 without a conclusive diagnosis after multiple attempts to treat pain. Pain was worse on ambulation. He was on workmens compensation from 2006 to 2008. In 2012 he experienced the same pain over the right ankle which had a duration of one week of pain with pain level 10/10. Pt unable to walk more than 1/8 mile and unable to stand for more than 20 minutes. He is unable to climb ladders which was part of his duties as a building maintenance worker. b. Does the Veteran report flare-ups of the ankle? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: see above c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: see above 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right ankle ----------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 10 degrees Plantar Flexion (0-45): 0 to 45 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender achilles tendon Is there objective evidence of crepitus? [ ] Yes [X] No Left ankle ---------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 10 degrees Plantar Flexion (0-45): 0 to 45 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender achilles tendon and left deltoid ligament Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right ankle ----------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No Left ankle ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right ankle ----------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion? [X] Yes [ ] No Dorsiflexion (0-20): 0 to 5 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion? [X] Yes [ ] No Dorsiflexion (0-20): 0 to 5 degrees Plantar Flexion (0-45): 0 to 45 degrees d. Flare-ups Right ankle ----------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms or range of motion? [X] Yes [ ] No Dorsiflexion (0-20): 0 to 5 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion? [X] Yes [ ] No Dorsiflexion (0-20): 0 to 5 degrees Plantar Flexion (0-45): 0 to 45 degrees e. Additional factors contributing to disability Right ankle ----------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Disturbance of locomotion, Interference with standing Please describe: see above history Left ankle ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Disturbance of locomotion, Interference with standing Please describe: see above history 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if Veteran has ankylosis of the ankle a. Indicate severity of ankylosis and side affected (check all that apply): Right side: Left side: [ ] In plantar flexion [ ] In plantar flexion [ ] In dorsiflexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an inversion deformity [ ] With an eversion deformity [ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing position [ ] In poor weight-bearing position [ ] In poor weight-bearing position [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No Left ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No 7. Additional comments ---------------------- Does the Veteran now have or has he or she ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below: [X] Achilles tendonitis or achilles tendon rupture Indicate side affected: [ ] Right [ ] Left [X] Both Describe current symptoms: tender achilles tendons bilat limiting dorsiflexion 8. Surgical procedures ---------------------- Indicate any surgical procedures that the Veteran has had performed and provide the additional information as requested (check all that apply): Right side: No response provided Left side: [X] Arthroscopic or other ankle surgery Type of surgery: Exploratory lapraroscopic surgery of left ankle Date of surgery: Dec 2007 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? [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: left anterior ankle Measurements: length 2 cm X width 0.5 cm c. Comments, if any: No response provided 10. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 11. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's ankle condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 12. Diagnostic testing ---------------------- a. Have imaging studies of the ankle been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 13. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: Patient has limited walking up to 1/8 mile. Further walking will cause increased diffuse muscular pain that will last up to one week. 14. Remarks, if any ------------------- No response provided Shoulder and Arm Conditions Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination a. Evidence review Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [X] 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) [ ] Other: [ ] No records were reviewed b. Was pertinent information from collateral sources reviewed? [X] Yes [ ] No If yes, describe: Orthopedic surgeon workmens comp notes 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: Shoulder pain b. Select diagnoses associated with the claimed condition(s) (check all that apply): [X] Acromioclavicular joint osteoarthritis c. Comments, if any: No response provided d. Was an opinion requested about this condition? [X] Yes [ ] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's shoulder or arm condition (brief summary): exposed to oil well fire soot. Unemployed since 2010. Right hand dominant with onset left > right shoulder pain x 2013. Patient has difficulty on reaching overhead repetitively. Unable to throw baseballs footballs basketballs. Unable to carry more than 5 pounds for more than 20 minutes. b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous c. Does the Veteran report flare-ups of the shoulder or arm? [ ] Yes [X] No d. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: see above 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Right Shoulder -------------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 180): 0 to 180 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Abduction Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No Is there objective evidence of crepitus? [ ] Yes [X] No Left Shoulder ------------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 180): 0 to 150 degrees Abduction (0 to 180): 0 to 135 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Abduction Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right Shoulder -------------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: Pain, Fatigue, Weakness ROM after three repetitions: Flexion (0 to 180): 0 to 155 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees Left Shoulder ------------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: Pain, Fatigue, Weakness ROM after three repetitions: Flexion (0 to 180): 0 to 150 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees c. Repeated use over time Right Shoulder -------------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion: [X] Yes [ ] No Flexion (0 to 180): 0 to 150 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees Left Shoulder ------------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion: [X] Yes [ ] No Flexion (0 to 180): 0 to 150 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees d. Flare-ups: No response provided e. Additional factors contributing to disability Right Shoulder -------------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left Shoulder ------------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of scapulohumeral (glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus move as one piece). a. Indicate severity of ankylosis and side affected (check all that apply): Right side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis) [ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis) [ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis) [X] No ankylosis Left side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis) [ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis) [ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis) [X] No ankylosis b. Comments, if any: No response provided 6. Rotator cuff conditions -------------------------- Is rotator cuff condition suspected? Right Shoulder: [ ] Yes [X] No Left Shoulder: [ ] Yes [X] No 7. Shoulder instability, dislocation or labral pathology a. Is shoulder instability, dislocation or labral pathology suspected? [ ] Yes [X] No 8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint conditions ------------------------------------------------------------------------------ a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition suspected? [X] Yes [ ] No If yes, complete questions 8b, 8d and 8e below: b. Does the Veteran have an AC joint condition or any other impairment of the clavicle or scapula? [X] Yes [ ] No If yes, indicate severity and side affected, and answer 8c below: [X] Other, describe: degenerative disease ac joint left shoulder [ ] Right [X] Left [ ] Both c. Does the clavicle or scapula condition affect range of motion of the shoulder (glenohumeral) joint? [ ] Yes [X] No d. Is there tenderness on palpation of the AC joint? [X] Yes [ ] No If yes, indicate side: [ ] Right [ ] Left [X] Both e. Cross-body adduction test (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A If positive, side affected: [ ] Right [ ] Left [X] Both 9. Conditions or impairments of the humerus ------------------------------------------- a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus? [ ] Yes [X] No b. Does the Veteran have malunion of the humerus with moderate or marked deformity? [ ] Yes [X] No c. Does the humerus condition affect range of motion of the shoulder (glenohumeral) joint? No response provided d. Comments, if any: No response provided 10. Surgical procedures ----------------------- No response provided 11. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 12. Assistive devices --------------------- a. Does the Veteran use any assistive devices? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 13. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's shoulder and/or arm conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 14. Diagnostic testing ---------------------- a. Have imaging studies of the shoulder been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate shoulder: [ ] Right [X] Left [ ] Both b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: Xray with left AC joint degenerative disease. 15. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's shoulder conditions providing one or more examples: See history 16. Remarks, if any: -------------------- No remarks provided
  4. For you guys and gals with muscle / joint pain. Do you find yourself having to stay sedentary in order to keep your pain levels down? The doctors want me to exercise and I try to explain to them the situation that I am in and they appear to be clueless. Also, are any of you guys experiencing something like I am. I can pick up my chihuahua which weighs about 7pds and cradle him in my left arm for about 15-20mins while I am outside talking to my neighbor across the street. When I put him down my arm muscles are sore, but the following day (and 3-4 days after that) my arm will be in so much pain that my arm feels like it is broken. I told a VA doctor about this and his reply was "Don't pick up your dog" Anyways, while I experience pain no matter what my activity level is, I noticed something strange about my situation. I began paying attention to my severe pain events and everyday aches and pains that are consistent with this illness and have determined the following: If I exercise (ride my bicycle) or do work (turn a screwdriver) I end up with that normal burn pain that one would normally feel from normally working out or working. What I find different is that the pain last 3-4 times longer than what I remember that it should. Either way, I do not get debilitating pain from from such activity eventhough I do experience what I would consider normal pain levels, maybe slightly higher than what I would remember, but nothing that puts me out of service. On the other hand, if I strain continuosly like holding my dog or standing on an incline for any period of time. My pain level goes to a 10 or beyond and I am out of service. I loose the use of my arm, leg, ankle or whatever muscle I am straining at the time. A perfect example is when I have sex. If I am on my knees with my toes pointing down to the bed, about half way through, I can't enjoy it anymore due to pain levels and if I try to walk, I am in severe pain and have to use a walker. It takes me about 3-4 days just to recover from sex. I had a friend come visit me and we walked up a hill for about an hour looking for arrowheads. I had to come down due to ankle pain and for the next week, I was in a wheel chair due to not being able to put any pressure on my foot due to the severe pain levels from straining my ankle muscles/tendons to remain level on the incline of the hill. Just wondering if any of you guys have noticed that the pain symptoms are worse when your muscles are strained for long periods vs. normal muscle movement.
  5. Moth balls work pretty good at repelling snakes. I am located south of San Antonio and have to deal with my fair share of snakes, scorpions, tarantulas (like apocalyptic amounts), javelina, cougars etc... hope you get your dd214 squared away.
  6. Hi john999! No, I did not seek treatment from the VA or from outside sources except for the accute stomach pain that I believe ended up being my gall bladder which has now been removed and from which I have been relieved from all of the intense accute pain. As far as all of my other issues, I found myself in the beginning not bothered enough by the symptoms to bother with seeking treatment, I had finished college, was making really great money with awesome benefits and basically rode that situation to where the wheels fell off and my body couldn't take anymore. For what it is worth, I have been complaining to my VA Dr's since 2013 and it really seems they are not interested with dealing with GW1 issues or that they are simply not prepaired to do so. I don't nessescarilly blame the VA Dr's, I have questioned all of my outside Dr's, surgeons and orthopedics as well and it seems like none of them have a clue to the issues that I am dealing with and want to relate it to some other condition. That is the problem, I think, is that the symptoms mimic a ton of other conditions and I think that the Dr's egos prevent them from making an diagnosis because they are afraid of looking bad if a wrong diagnosis is given. Luckily for me, they have finally put me into pain management and now I am receiving pain medication for my back which also alleviates the pain from my muscle / joint issues so at least I am not suffering like I have been over the past ten years.
  7. I will try to be as quick as possible, I served on active duty onboard ship from 1986-1989. I injured my lower back on a work detail in early 1987. The docs really didn't do too much for me except give me some tylenol or aspirin as they had the attitude that I was bothering them. They did log the incident in my file however. I have been going to the VA for treatment and after a recent MRI, it shows that I have DDD, a bulging / torn disk and facet joint issues. I suffer a great deal of pain and have sciatica that runs down to my left ankle about 90-95% of the time on rare occasions, it travels down to my right ankle as well. Once my pain level goes above a 5 I am usually on a walker and once it gets up to about an 8 I am in a wheel chair. In addition to this, I was recalled to active service for GW1 I got to breath the black snow like the rest of you that were there and also got several shots while enroute to the sandbox that I have no idea what they were. The only one that I knew for sure was, that they gave me my third ever small pox vaccine. About a month after returning home, I noticed that I just didn't feel like myself, like my batteries were only charging up to 99% or like if I had 1% of my soul taken away from me. I started immeadiately with accute stomach pains and diarrhea. I then started noticing every year that my internal battery so to speak was taking less and less of a charge and that I was starting to experience more and more intense joint and muscular pain as well as the back pain and sciatica. In addition to this I started breaking out with skin rashes and bumps. I am the kind of guy who never goes to the doctor unless I was dying and even then I would wait till my stomach pains were so bad I would just go to the ER for treatment. From 1991 to 2014 I probably went to the ER at least a dozen times because of the stomach pains and they would just give me pains meds and send me home. I can't begin to tell you how many nights that I have spent curled up in the fetal position on my shower floor with hot water running over me for relief. I developed a large cancer tumor on my left hand in mid 2013 and due to not working anymore because of my physical condition, I had to go to the VA for treatment. I filed for VA disability in June 2013 and I also signed up for the Gulf War Registry at the same time. My claim was denied in May 2014 because they could not locate my medical records. A week or so after receiving the denial my elderly mother fell and broke her neck in two places. I became her primary care giver and at this time I had already had my tumor removed from my hand and My VA doctor had finally ordered me to have a sonogram on my gall bladder. Finally in late December 2014 I had my gall bladder removed with two 3cm black stones inside of it, one blocking my bile duct. The surgeon told me they had been there a long while. I located my medical records in storage and turned them over to my VSO this mid May and asked the VA to reopen my claim. I am claiming lower back pain, hearing loss, tinnitus, joint/muscle pain, chronic fatigue and irritable bowel. Since reopening my claim, I have already went to a C&P for my lower back and for my digestion / stomach issues. During the stomach issue questioning from the C&P Dr., she asked me if the VA had done any testing as far as this was concerned and I told her no, I just told her all of the issues I was having currently, that my gall bladder had been removed and that I was no longer experiencing accute stomach pain but still had diarrhea for the last 24yrs as well as gas and indigestion issues. I gave her copies of my MRI report of my back and since I was in quite a bit of pain that day, she did not ask me to do much bending or movement. A few days later I went to my C&P for my hearing loss / tinnitus. The Dr. told me I had substantial high frequency hearing loss and that I needed hearing aids for each ear. I went on the benefits site and it showed that the claim was in the gathering of evidence phase and that they were not asking for any paperwork from me, but they were requesting paperwork from someone other than myself and that they had a dedline of 6/28 to get it in. I rechecked the site on 6/29 and it showed that the 1st item had been accepted and number 2-5 were showing no longer required and it had been moved up to preparation for decision status. I find this weird, because while I have complained about these issues and am suffering depression and anxiety from these issues, my VA doctor hasn't diagnosed me with anything for the chronic fatigue, muscle/joint pains or stomach issues or skin issues for that matter. We just haven't time to work through them yet. When I came in for treatment in June 2013 they diagnosed me with type two diabetes and the cancer and began treating that. Then they started my gall bladder issues and just recently began focusing on my back issues. I also recently had an eye infection treated. So I was really figuring that they would want me to have a C&P for these issues that the VA Doctor has not had time to get to yet. As of yet, I still haven't been called in for my GW1 screening yet eventhough I turned my paperwork in in June 2013. My wife had went into the Va reps office with me in February of this year and she still had my paperwork in her desk drawer. She told me that they did not have anyone available to do the screenings. I talked to her a month ago a she said that they had just started doing burn pit veterans at this time so hopefully I will be called in soon. Sorry to be so long winded and scattered brained but I would appreciate your opinions on the matter. Thanks
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