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OffGridGrunt

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About OffGridGrunt

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    E-3 Seaman

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  • Service Connected Disability
    60%
  • Branch of Service
    USMC
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    Buddhism, dog training, prepping

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  1. Not sure if I'm answering all of what you're asking but a general timeline will maybe help put things into some context... exit service in 2004, file for PTSD - don't show up for C&P (idiot I know). Even with no-show based on STRs alone I got SC @ a whopping 10% 2009 I am pushed to file an increase by friends for PTSD - AGAIN I don't show up for C&P. Even though I was a no-show I get increased to 30% between 2009 I finally start seeing the VA (instead of civilian doctors) because I lost my civ coverage. I show up and right out of the gate I get a very biased social worked who tells me straight to face that I don't have PTSD and she won't even bother giving me "the test" (I know now she was referring to the PCl of which I've taken a million now). nevertheless this BAD social worked pushed the agenda of getting me diagnosed bi-polar. 2012 I file a claim for increase in PTSD - I SHOW UP!!! they tell me all my problems are because I'm bi-polar and that my PTSD isn't service connected (despite the fact I'd been SC for 8 years by that point with 1 increase during that time but hey that's the VA right?). I was in too rough shape to fight this via appeal or whatnot. I just let it go. 2015 divorce and several other factors has me crash land into a VA dom facility. 8 of the 10 months I was there (outside the obligatory substance abuse stuff in the beginning) was exclusively TRAUMA therapy. 2 of Those 8 months was in an actual inpatient PTSD program. After 10 months of inpatient care, not a single mention of bi-polar, mania or any of the other horseshit that made it's way into my record once upon a time. 10 months in a near lockdown facility that produced about ~700 entries into my medical record - not a single mention of bi-polar. 2015 After almost a year at this facility I apply again for an increase in PTSD (still only at 30%), records as thick as a phone book - ALL pointing to PTSD. Despite all of this overwhelming evidence the examiner I had looked right passed it and pulled out the bi-polar diagnosis code from 5 or 6 years back in my charts and put ALL my symptoms on that. Since that time I put in for a reconsideration (not a NOD > appeal). I had a NEW C&P for PTSD on the 21st of October during which my examiner was amazing, empathetic and treated me like I was who I was saying I was and not some piece of crap leech just trying to scam the system for a check (the feeling I generally get every other time) I got all the informal assurances from the examiner that I mentioned before. I mentioned to the examiner my frustration because going the PTSD program they set my official diagnosis date as 2015. She laughed and said it's in your STRs that you were originally diagnosed in 2003 while on active duty. She then went on to explain how it's obvious to her that my PTSD is my primary and only mental health issue and that it is absolutely service connected. The problem is that when I go to access my records via myhealthevet, my PTSD note is marked confidential. The DBQ/C&P I had for my foot the day before is there no problems but all information about my PTSD exam has been removed and been replaced with the word CONFIDENTIAL in big bold letters. None of my mental health providers can access it either. I'm told the only way to get a copy of the exam is to do a FOIA request to the regional office. I like many other vets share a bit of a distrust for the VA and I must admit that make the one document that for me is a "silver bullet" and making it unaccessible by anyone or anything short of a FOIA request. I've been fighting this for over a decade. I'm just ready for it to be over. I really don't have anymore energy for it. If this C&P doesn't do it I'm just going to walk away.
  2. So I'm resurrecting this old thread in hopes that my new situation/information could shed some more light on things, but of course I'm also hoping for advice/direction/hope (any and all appreciated even if I don't take/accept it!). The overall situation of things has changed quite a bit. I filed for a re-evaluation (within the time period) rather than filing a NOD and an appeal. I did a DBQ/C&P for my foot one day, and another C&P the next (relevance of the foot DBQ will become obvious shortly). This was my 4th C&P for PTSD (of which I've been service connected for since 2004 - I didn't show up for initial C&P when I exited service so service connection, and a rating of 10% was established exclusively from my STRs; since then each subsiquent C&P has concluded my PTSD is NOT service connected (!@#$, !@#$, @#$% etc etc) so they've refused all requests for increase since 2009 ( I was bumped from 10% to 30% in 2009). I've had significant troubles with C&Ps in the past due to my claims getting derailed by a couple minority, outlier diagnoses (bi-polar and drug abuse) which stay in my records despite the fact they are not part of my active DX. My requests for an increase have been denied and any/all my problems have been attributed to the minority of medical opinions (in my record) vs the majority. Despite going through 4 months of inpatient (Domiciliary) trauma care, followed by two months of inpatient (actual inpatient) PTSD programming; despite all this my claim was AGAIN put off on some inactive, irrelivent bi-polar, a DX that during a 10 months stay of domiciliary/inpatient care was never mentioned once. All the above frustrations aside I just recently had another C&P on the basis of re-evaluation rather than a NoD and appeal. The examiner was extremely empathetic and sympathetic to my situation. Normally going through a PTSD C&P is enough to rattle my cage right down to the bones but I ended up walking out of the office feeling like it was a therapy session rather than interrogation. The examiner gave credibility to all my claims, feelings and situation. She very clearly walked me through how she saw that my (active, not disputed in any way) diagnosis of PTSD was absolutely service connected. In addition to all this awesomeness, as we stand to leave her office she says stops me before we leave and says to me, "I'm not supposed to say this but I want you to know that I'm not going to say that any of your issues have to do with Bi-Polar or drug use. You're clearly not Bi-Polar and any drug use (I only use cannabis for which I have a prescription) is obviously a secondary symptom to your PTSD." I made it about 10 steps down the hall before the gravity of everything she just said hit me, and the anxiety/relief dump almost had me pass out in the hall. We actually had to stop into an office to take a break so I could get my BP right so I could walk out of the place. Anyhow.. Fast forward about 2 to 3 weeks now and I'm finding myself just as anxious as ever. The reason for this, and where my questions (if there even is one) lies. I'm very active on e-benefits and also myhealthyvet. I regularly check the notes my care providers put in my record. I was very excited to see the notes from my C&P as quite honestly I was/am literally terrified I imagined it all and I'm just going to have the carpet pulled out from underneath me again by the VA. (the question/important part) So my C&P/DBQ (I'm already SC for PTSD) is completely removed from my blue-button access. The entry itself has the normal date/Dr name stuff at the top, but in the section where there would be notes, all that is there is there word "CONFIDENTIAL". The DBQ/C&P from the day before for my foot/toe is totally visible, as is every other record (about 4 or 5 thousand pages worth of records). So in short, from about 12 or so years of medical records, the only one they've deemed "confidential" was the one where my examiner specifically told me she was going to SC me and "get me taken care of". I'd appreciate any thoughts you all might have on this. I've been talked off the edge and have come to realize/understand that the reason it's confidential is because it's probably one hell of a bee in their bonnet and they don't want to release it until they've addressed it. Nevertheless I'd appreciate any advice from those more experienced and wiser than myself when it comes to this sort of thing. In addition I have a side question in regards to all of this. I've called the main info line to get status info on my claim and they are saying to expect a possible decision around April. I'm curious that due to the fact I am registered in the VA's system as homeless (hardship case) if a 4 month wait for a decision, with my final C&P almost 3 weeks ago now, is realistic or is it likely/possible I could see a decision much sooner than April? The reason I ask is that I have a divorce/custody issue coming up in February and having a decision before then would go a long way to making me look less like a useless piece of crap and more of a viable provider and secure place/person for my children to visit. Anyhow. Thanks for anyone who took the time to read the details and extra thanks for anyone who might be able to give me some advice/direction/hope based on what I've told you. Blessings to you all, Happy Marine Corps birthday (today) and Veteran's Day (tomorrow)... Enjoy your weekend! OGG
  3. Thanks for the info Andy. I had kind of assumed that would be the case. I too am learning a lot on this site. I really wish I had done a lot more research before filing this claim. I'm definitely getting there though. The first thing I need to do is get my case back into the evidence gathering stage. This time I know how to properly back up my case (thanks in no small part to this site and it's community). I feel so much more confident armed with the knowledge I've gained from here and all the follow up research it's lead me too. Now I need to get a copy of my c-file so I can see what all I have claimed in the past and then start re-claiming all I can. Thanks for your comments, OGG
  4. Okay so recently I was looking at my unchanging claims status and noticed the "Decide My Claim" button. I called my VSO (the DAV) and asked about the button and if I could/should push it. My VSO told me that since all the DBQs were in there was no reason not to - so I did. I now believe this was a big mistake. I had initiated "decide my claim" option prior to looking at the DBQs that were in my medical record. One of my DBQs was not what I had expected it to be and now I'd really like to put in new/more documentation as it seems that the only evidence to be considered for my claim is the DBQ/C&P which was guided by out dated and inaccurate information. The first question/issue I need to tackle is whether or not I can open my claim back up for evidence, and if I can how do I initiate this process. I am far less concerned about causing my claim to take longer to be decided as I am with it being the most complete and fully developed as I can. I am definitely feeling like I walked into this thoroughly unprepared and misguided as to what a fully developed claim really is; I'm learning though. I am wondering/hoping there is some way for me to build a body of evidence to address and suppliment some troubles I see on the horizon after reading my DBQ - specifically in regards to my claim for a PTSD increase. In addition to adding specific treatment records that very clearly support my claim, I'm wondering if I am able to submit as evidence some sort of Statement of Case letter. I've come to realize that when I initiated this claims process I was very naive and had no idea what a fully developed claim was. I'm hoping that I can rectify this situation before my claim goes to some sort of decision. Any direction and/or assistance in turning this around and reopening things so that I can correct my mistakes would be very much appreciated. Thanks in advance for any input or direction you may have, OGG ------ Addendum ---------- So after some significant research online I seemed to have found many of the answers I was looking for. The first thing I've found is that I've been doing a horrible job representing myself and I have been doing a significant injustice to the claims I've submitted over the years. It is now so very clear why I've struggled so much getting even the most modest rating for issues that I should have had service connected years ago. I was simply saying "hey check me for this" and letting the VA do the rest. I had no concept of forming my own case and gathering my own evidence to support my claims. This is exactly why I've been stuck at a rating of 30% for PTSD when I should have easily rated 70% or higher. I now see why claims that should have been no problem and easily proved amounted to nothing and ended in denial after denial. I finally get it. I know what I have to do on my end of things and I now see that it is MY responsibility to insure that a proper accounting of all the facts takes place. I really feel like a dunce but at the same time relieved. Now I simply need to figure out how to bring my current claim back into the gathering evidence phase so that I can do the work that I now realize I need to do. I'm actually lucky because I really enjoy doing this type of thing, I just never realized that I was in fact the one who was supposed to be doing it!
  5. Oh I know the VA is entirely capable of giving me the shaft on the initial decision. They may even have a laugh at my expense and deny my appeal. It is my general experience however that when it comes down to getting a lawyer this is just the kind of regulatory verbiage they like to use to run the establishment through the ringer. Basically I'm saying that i may not be the guy to make this work for me but i believe that when it comes time I'll be able to find someone who can. Again i may be overdosing on optimism but nevertheless I feel a whole lot better for finding this.
  6. Well I think I've found something that is likely to be helpful in the event that I have to end up appealing a decision that comes out of this DBQ or it will give me a foundation on which to put together the evidence that seems to be getting overlooked. I found this gem just a few minutes ago: This can be found in CFM 3.304 (1) If the evidence establishes a diagnosis of posttraumatic stress disorder during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. I believe this can help me a lot as I was in fact diagnosed while I was in the marine corps. Anyone feel free to burst my bubble but I feel that this should essentially nullify the examiner's statement that she doesn't believe my PTSD was the result of my military service. It seems as though the responsibility is on her to prove otherwise. Thanks in advance for any input someone might want to share about this OGG
  7. Berta, I kind of ended up glossing over this comment my first time through as i ended up going over to the comment you made in my other thread. Let me see if i understand what you're saying. Whenever I officially get SCd for this most recent claim i made in October I will be back payed to that time (it will actually be June as that's when i submitted my intent to file). I kind of assumed that would be a given. However to get a retroactive date effective to my original claim in 2004, I would have to file a CUE. How difficult is it to file a cue? Are they any more difficult to win or is it generally like any other claim; as long as the evidence backs it up you should be fine. I guess what I'm wondering is do they come under a higher level of scrutiny or is it basically the same thing just a different process? also I'm wondering about the implied/potential secondary condition. While I realize I'm likely overdosing on wishful thinking, if the evidence supports the fact that I've had this problem since I was in the military is there any possibility of getting that retroactively connected too? I realize the answer is most likely no to that but now I'm wondering if I didn't apply for sciatica problems when I got out. The truth is my sciatica nerve issues gave me twice the hell that my back did: I'd actually be surprised if I didn't file for something. Thanks again for your input and help I do appreciate it. PS, I replied to the comments you made in the other thread. I'd appreciate your thoughts on my ideas to address the issues you brought up. OGG
  8. Berta thanks so much for chiming in on my current conundrum. I'm not entirely sure what the addendum was about. There was no additional exam, the C&P was actually on the 27th of October. Why I wasn't signed until the 30th, and then again 4 days later with that rather crushing addendum I really couldn't say. I understand your concerns. Her statement at the end is rather damning. As far as whether or not she had all the treatment records I can't say. On the face of it I feel like she must. Anything within the last year as far as treatment records go is here in Texas and I can't imagine she'd miss it as it's her "home" system. That being said all the records that she brought up in her DBQ were all from when I was living in Virginia which is at least two years ago or more. ----------- So actually I went back through her DBQ and found one item cited from my time here at the domiciliary. It was a single note by my case manager that simply broke down when I got to the domiciliary, what I was diagnosed with, when I graduated from the substance abuse program, to the trauma program and then the PTSD program. Other than that she doesn't reference anything else from the last year. I'm not entirely sure what to do at this point. I have a few options but none of them are particularly ideal. I can either cross my fingers and see how the rater sees things and hope that the rater spends a little more time digging down in my treatment, the diagnosis and opinions of all my mental health team here and any of the other treasure trove of supporting documentation you'd likely to find if you simply spent a little bit of time. My other options seems to be to bite the bullet and reopen the claim with more evidence. I'll likely prepare an evidence packet myself and send it in for consideration. The downside of this is that I'm literally leaving for Michigan today so it may make things sticky for me if they decide they'd like to do another C&P or something like that. The last option is very much similar to the last however it will take more time. The issue I've had ever since I started attempting to work on an increase for my PTSD is that my "trauma" has essentially just been my word. That being said there is actual documentation that can back up my story but I need to obtain my military medical record which I understand can be a waiting game all of it's own. I know the proof is there and I know I can find it. If I get a reduction I will be appealing it promptly and come well armed with documentation they can't deny. As far as the examiner stating that she didn't believe I was capable of managing my funds I'm not particularly concerned about that. The incidents that she sited were from about 7 years ago. While I may have difficulty expressing myself in the heat of the moment given a pen and some paper I'm pretty confident in my ability to argue her opinion. Not only was it a significant time ago, a significant amount of things have changed for me over the last year. I'm an entirely different person than the one she's describing in the DBQ and I really don't think I'll have a hard time proving that if and when the case may be. On the up side of things I'm getting SC'd for 2 new issues, SC'd for one secondary issue and an increase for an issue that I'm already sc'd for. I have faith one way or another, and eventually things will work themselves out. Thanks again for your comments, OGG
  9. I filed a claim sometime in early October for an increase of my PTSD, a foot injury, as well as put in for 2 new conditions and one secondary condition. While I am largely very happy with how the claims for my physical disabilities has gone (my examiner told me within the first 5 minutes he was going to connect me for all the new stuff and that I rated an increase for the foot issue - after that I just had to actually do the C&P! My PTSD exam and resulting DBQ however were not nearly as smooth as my other C&P's had gone. Honestly I was actually kind of shocked when I finally got around to pulling it off myhealthevet and reading it. A big reason I was so surprised is that as far as "evidence" goes I've been piling it up over the last year. To get to how this all went down I have to run it back a little bit and explain my situation. I ran into a rough time around February of last year...... So I had my big sob story all typed up and then chickened out. Sufficed to say that I lost everything. Not only did I lose my wife and kids, I lost the dream property we had worked so hard to get to. I just walked away from it, I couldn't bring myself to walk back into the cabin. I literally just left everything I'd worked for the last 6 years of my life at 9,000 feet on the side of a mountain and just walked away. Sufficed to say I crashed and burned really hard. For about 3 weeks I spent every waking moment doing everything I could to make the pain go away, up to and including multiple attempts at OD'ing. I finally was able to get my wits together, did some searching online and ended up in a VA domiciliary program in Texas. While I've never identified myself as a drug addict, I definitely needed some help getting the wheels back on so the first thing I did was enroll myself in a 45 day substance abuse program. After that I was able to put in 3 1/2 months of inpatient trauma treatment, followed by 2 months of inpatient PTSD treatment. It's been about 9 months but I'm glad I did it, I honestly don't think I would have made it through to the New Year if I hadn't come here. Anyhow, after 9 months of inpatient therapy which included almost 6 months of trauma/PTSD treatment, daily group meetings, twice weekly counselor/psychologist one on ones, and intensive medication programs to help me through everything, I kinda thought I had a decent chance of getting an increase from 30%. I've tried for increases in the past but I haven't been the most consistent person over the years. I have a hard time following through on treatment and in addition to that due to having a non-combat trauma I haven't had a very easy time getting the VA to accept my diagnosis, at least on the disability side. The treatment side has no issue with it. Anyhow, like I said I had hope because in the past I had been told that I wasn't getting increases in my rating because I wasn't following through on treatment and because of that it made it difficult for me to build much of a case. Everything was simply my word as to how things were, or how I was getting by, but I didn't have anyone respectable to back me up about the things that I was going through and the troubles I have. So this leads me to my most recent C&P/DBQ. I've cut out a decent amount of personal information and trauma narrative stuff, but the meat and potatoes should be in there for anyone that's familiar with these things. I've been service connected since 2004 and my trauma is most definitely legitimate. I really hope there's a possible sunny side to all of this. I've done a massive amount of googling over the last few days and I've seen posts where people say that just because the examiner says one thing doesn't mean that's the direction the rater is going to go with things. I'm really discouraged right now. I've had a very contentious relationship with the VA for a long time. I have a very hard time trusting the VA anymore. I've had some very bad caregivers who were telling me one thing to my face while shredding me in their notes after I'd left (We have access to those you know....) One LCSW in particular went out of here way to push a personality disorder diagnosis on me, essentially getting the diagnosis put in my chart by filling up my psychiatrist with a lot of crap; all the while telling me how much she was trying to help me. Now here I am again. I feel like I'm really getting the short end of the stick by the VA and in particular this examiner, after I did have a pretty awesome doctor for my physical C&Ps and lord knows I'm not the first one to get the un-greased by the wonderful VA. That being said I'm just frustrated because I've really put in so much effort into my recovery and treatment. I'm working the DBT, mindfulness and challenging beliefs far more than I'm comfortable with, but I'm doing it. Anyhow I went from erasing my sob story to writing a whole new one. Thanks for taking the time to read through this and pass on any info/experience/ideas you might have. Thanks in advance, OGG The following is an excerpt from another thread I started about a DBQ for my back that ended up digressing a little. I figured there's no reason to type it all out again new so I just copy and pasted the "important" parts. Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire SECTION I: --------------------- 1. Diagnostic Summary -------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses: ------------------- Mental Disorder Diagnosis #1: PTSD Mental Disorder Diagnosis #2: Cannabis Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #3: Alcohol Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #4: Inhalant Use Disorder, In Early Remission, In a Controlled Environment Alright I'm definitely not proud of the huffing. All I can say is that my life had fallen to pieces. My wife took my kids and left me while I was getting the car fixed overnight. She filed false abuse charges against me to keep me from the kids. I'm no saint but I never abused my wife or my kids. Up until this moment I hadn't had a drink in 5 years... I just smoked pot - which I was prescribed. Also I think this would be a good time to put what my actual working diagnosis list for a little bit of contrast. This list was pulled straight off my myhealthevet file and reflects 9 months of inpatient treatment. I can't help but feel like this lady was snowballing me. Yes there's some overlap. What's the difference between PTSD and Chronic PTSD? I don't know. Why do I have 2 types of insomnia DX'd? I don't know that either. #1)Chronic post-traumatic stress disorder (SCT 313182004) #2)Posttraumatic stress disorder (SCT47505003) #3) Anxiety (SCT 48694002) - symptom of PTSD #3) Depressive disorder (SCT 35489007) - symptom of PTSD #4) Insomnia (SCT 193462001) - symptom of PTSD #5) Psychophysiologic insomnia (SCT 425832009) - symptom of PTSD #6) Cannabis dependence (SCT 85005007) #7) Alcohol dependence (SCT 66590003) 3. Differentiation of symptoms ----------------------------- a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes[ ] NO b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes[ ] No[ ] Not applicable (N/A) I have a problem with this part. Just how is she going differentiate between my various diagnosis which all are attributed to the PTSD? (besides the substance abuse issues) 4. Occupational and social impairment ------------------------------------ a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. I have a problem with this as well. I haven't been able to work in 6 years. I've tried but it always ends up being a failed attempt. I usually end up getting myself too worked up about social situations, get too depressed to get out of bed, get fired for being late because I have serious sleep problems which sometimes lead me to not being able to wake up for my alarm, etc etc. In addition I barely go out. Hell I went out of my way to move 10 miles from the closest power poll 9,000' above sea level just to find myself some peace. I can't handle large groups, I psych myself out when I'm out at night, I see danger and trouble everywhere. Anyhow back to getting smeared. b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [X] Yes[ ] No[ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Symptoms of PTSD and substance use contribute to social and occupational impairment. However, symptoms of PTSD have not increased in severity since the veteran's last C&P exam in 2013. A quick side note A: I've been in a treatment facility for almost a year now, I'm pretty sure my "substance abuse" isn't contributing to my issues. I smoked cannabis medicinally and I don't even drink. Why do I smoke pot because it helps with my PTSD as well as a laundry list of other issues. That being said I've been "clean" for a year now. So... now that she's basically said I barely have PTSD, and my troubles are simply because I'm a drug addict, let's get on to the next section. 3. PTSD Diagnostic Criteria -------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).d [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is NOT attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. That last one is my favorite! Not only does she say that my disturbances are NOT attributable to substances be it medication or drugs nor are they attributed to another medical condition. She also manages to manages to assess me with 20 out of 24 possible sub-criteria or disturbances in the diagnosis of PTSD. I'm sure I'm reading into this wrong and I can't look at things like this but that certainly feels like more than 30% disabling. I dunno. 4. Symptoms ---------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events 6. Other symptoms ---------------- In this section she just goes about telling whatever version of my life story she could piece together from old treatment records. Spends a lot of time on the fact that I smoke pot, that I didn't have a relationship with my father and various other fun facts that do a lot to distract you from the lack of a cohesive narrative or making any of what she wrote mean anything as far as the DBQ goes. She doesn't list a single "other symptom" like the line below talks about. She just kinda makes me out to be a flaky loser. Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No....... 7. Competency ------------ Is the Veteran capable of managing his or her financial affairs? [ ] Yes[X] No At this point she pulls out some more fun facts from my medical record. She says that "I frequently go on spending sprees", and brings up how when I was 25 and got my first backpay check and I blew it on fun stuff like a car, and a computer and whatnot (I was single going to university at the time). What this cluck of a woman doesn't see in her precious computer is that other than my time here at the VA facility I'd been able to support my wife and two kids on my 50% SC. Trust me there's no spending sprees going on there. 8. Remarks, (including any testing results) if any: -------------------------------------------------- Psychological Testing: A test of response bias specifically related to PTSD symptoms was administered to the veteran during this examination to assess the credibility of his self report. The name of this measure is withheld in this report in order to protect the integrity of the test. This test was specifically standardized on a sample of veterans applying for financial remuneration for a claim of disability resulting from PTSD. The veteran's score on this test was below the established cutoff, indicating that his performance was consistent with individuals responding in a valid manner. As such, he did not appear to be intentionally exaggerating signs and symptoms of PTSD or attempting to appear worse off that he actually is. Ahh what a finish eh? I think she should spend less time worrying about my credibility and a little more about hers. Well, last but not least let's hear her final word on the subject: Signed: 10/30/2015 13:35 11/03/2015 ADDENDUM STATUS: COMPLETED PTSD is less likely than not a result of military duties. /es/ Her Name Goes Here, PSYCHOLOGIST Signed: 11/03/2015 15:22 So yeah that's essentially where I'm at. I'm just hoping that whoever rates my PTSD takes what she says with a grain of salt and also takes time to look at the 1200 pages of treatment records I've added to my medical record in the last year as well as the weakly psychologist appointments, 20 page typed trauma narrative, the countless notes that were put in on my behalf. I hope they also see the weekly PCL-5s averaging between 65 and 72, the by weekly CAPs averaging around 66, the PHQ9 score of 23, the gad-7 score of 20 - All of which were administered by a Doctor or LCSW. Yah I've got this one too; World Health Organization Disability Assessment Schedule 2.0 Cognition: 75 Mobility: 12 Self-care: 70 Getting along: 83 Life activities (household): 100 Life activities (work/school): 85 Participation: 79 Summary: 70 *Range is 0 to 100 where 0 indicates no disability and 100 means full disability I realize I'm probably putting too much hope into all of this. I know that the disability tests and rating exams probably don't amount to anything as far as determining anything with the VA. If the particular examiner is up on their stuff they might know the significance of the WHODAS 2.0 or put stock in the CAPs screening but really they don't have to look at them at all. Hopefully at the very least I can use all I've put together to apply for SSDI. If you've gotten this far thank you so much for reading my rant and hopefully pulling out the important bits from what I did post of my DBQ. Hopefully I haven't over edited it but I just didn't think what she wrote was particularly applicable to the questions that the DBQ was asking and I generally feel she was just trying to prove out whatever she had come to believe based on small glimpses of my medical record. I really wish I had been afforded the opportunity to address some of the conclusions she was making about me and the picture she was painting.
  10. That great advice I really appreciate it. I agree about just letting this claim go through. I know it's not a good way to live but I have a lot riding on this Claim. In addition to getting SC'd for this lower back condition, I'm also getting SC'd for testicular issues secondary to chronic kidney stones. In addition I'm getting an increase for an issue with my foot. (I'll be posting all these C&Ps over the next few days). Lastly I have an increase for PTSD in the works. I'm currently SC'd at 30% for PTSD. That being said I've just finished 3 months of inpatient substance abuse, 3 months of inpatient trauma therapy, and 2 months of inpatient PTSD program. I am really hoping that that gets me some traction with the rater as the examiner absolutely shredded me in my C&P. Honestly that DBQ is truly a masterpiece of contradiction and incompetency. She says that my ptsd hasn't gotten worse, that I don't rate an increase and that my ptsd symptoms are just issues with substance abuse and MDD. Meanwhile she attributes all but 2 of the 24 DSM-5 PTSD criteria to.... My PTSD. Oh I just gotta show ya lol! Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire SECTION I: --------------------- 1. Diagnostic Summary -------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses: ------------------- Mental Disorder Diagnosis #1: PTSD Mental Disorder Diagnosis #2: Cannabis Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #3: Alcohol Use Disorder, In Early Remission, In a Controlled Environment Mental Disorder Diagnosis #4: Inhalant Use Disorder, In Early Remission, In a Controlled Environment Alright I'm definitely not proud of the huffing. All I can say is that my life had fallen to pieces. My wife took my kids and left me while I was getting the car fixed overnight. She filed false abuse charges against me to keep me from the kids. I'm no saint but I never abused my wife or my kids. Up until this moment I hadn't had a drink in 5 years... Just smoked pot. Also I think this would be a good time to put what my actual working diagnosis list for a little bit of contrast. This list was pulled straight off my myhealthevet file and reflects 9 months of inpatient treatment. I can't help but feel like this lady was snowballing me. #1)Chronic post-traumatic stress disorder (SCT 313182004) #2)Posttraumatic stress disorder (SCT47505003) #3) Anxiety (SCT 48694002) - symptom of PTSD #3) Depressive disorder (SCT 35489007) - symptom of PTSD #4) Insomnia (SCT 193462001) - symptom of PTSD #5) Psychophysiologic insomnia (SCT 425832009) - symptom of PTSD #6) Cannabis dependence (SCT 85005007) #7) Alcohol dependence (SCT 66590003) 3. Differentiation of symptoms ----------------------------- a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes[ ] NO b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes[ ] No[ ] Not applicable (N/A) 4. Occupational and social impairment ------------------------------------ a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [X] Yes[ ] No[ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Symptoms of PTSD and substance use contribute to social and occupational impairment. However, symptoms of PTSD have not increased in severity since the veteran's last C&P exam in 2013. A quick side note A: I've been in a treatment facility for almost a year now, I'm pretty sure my "substance abuse" isn't contributing to my issues, and B: I smoke pot. I don't even drink. Why do I smoke pot because it helps with my PTSD as well as a laundry list of other issues. In addition to that I had a prescription for it. That being said I've been "clean" for a year now. So... now that she's basically said I barely have PTSD, let's get on to the next section. 3. PTSD Diagnostic Criteria -------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical ggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. That last one is my favorite! There are a few more gems to go though. 6. Other symptoms ---------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No....... 8. Remarks, (including any testing results) if any: -------------------------------------------------- Psychological Testing: A test of response bias specifically related to PTSD symptoms was administered to the veteran during this examination to assess the credibility of his self report. The name of this measure is withheld in this report in order to protect the integrity of the test. This test was specifically standardized on a sample of veterans applying for financial remuneration for a claim of disability resulting from PTSD. The veteran's score on this test was below the established cutoff, indicating that his performance was consistent with individuals responding in a valid manner. As such, he did not appear to be intentionally exaggerating signs and symptoms of PTSD or attempting to appear worse off that he actually is. Ahh what a finish eh? I think she should spend less time worrying about my credibility and a little more about hers. I'm hoping that whoever rates my PTSD takes what she says with a grain of salt and also takes time to look at the 1200 pages of treatment records I've added to my medical record in the last year as well as thehe weakly psychologist appointments, 20 page typed trauma narrative, the countless notes that were put in on my behalf. I hope they also see the weekly PCL-5s averaging between 65 and 72, the by weekly CAPs averaging around 66, the PHQ9 score of 23, the gad-7 score of 20. If they don't take all that into consideration I guess I'll have plenty to throw at 'em when it comes time for an appeal. World Health Organization Disability Assessment Schedule 2.0 Cognition: 75 Mobility: 12 Self-care: 70 Getting along: 83 Life activities (household): 100 Life activities (work/school): 85 Participation: 79 Summary: 70
  11. Ya after pouring through all my medical records and doing massive amounts of googling the CFR I was pretty sure I was on to something in regards to the neuropathy. I'm a day away from moving across the country so not really sure where that's going to leave me as far as trying to continue my claim. Unfortunately my VSO told me to go ahead and hit the "decide my claim now" option on ebenefits. So I'm going from Texas to Michigan. I'm not sure how that will work. Can I even reopen the claim to add more stuff onto it like the secondary neuropathy issues? Do I try and get my claim moved up to Michigan mid stream or do I leave it in Texas and try and pull the strings from up North? This is my fourth claim and somehow I always manage to foul them up one way or the other. I felt pretty good about the whole thing, especially after my C&P Doc basically told me he's going to SC me and/or increase me for everything I claimed. Now I'm feeling like I screwed up.
  12. I recently finished a series of C&Ps for various conditions and I was hoping to get some input on just what exactly it all means - I was wondering what if any kind of rating might I be looking at? Is there a possibility for getting back pay? What can I do (possibly in an appeal) to do more to strengthen my case? At this point my case should be done with the gathering evidence phase (I can't check because ebenefits is being weird). All C&P's are done and everything that needed to be turned in is (I hope). The first C&P/DBQ I'd like assistance with is my claim for "Lower Back Condition". Originally I had claimed "chronic lower back pain" only to later find out that really isn't a thing and thus I was denied. When I went in for this most recent exam the reviewing doctor first went to my C-File and saw that I had claimed "chronic lower back pain" back in 2004. He then went into my military treatment record and found considerable amounts of treatment records for several issues in my lumbar spine and beyond. "They should have connected you back in 2004" he said to me. Sufficed to say that his positive first impressions put me a little more at ease with the C&P (which normally turns me into an anxious, nervous wreck). I've now gained access to the DBQ and would like any information that you well informed folks could provide. I've cut it down as much as I thought I could. If a question is missing and/or option is missing assume it wasn't checked. All non-pertinent information I cut out and did some heavy editing as far as formatting goes. Here it is: Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire 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? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VA medical records. 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: LS strain, chronic, with LLE radiculopathy Date of diagnosis: 2000s 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): During military service, the Veteran did develop chronic left lower back pain with radiation down the left buttock to the calf. On 6/10/2003, an MRI of the LS spine was performed with the following findings: Broad based posterior/central disc bulging at L4-5 without associated neural impingement. After service discharge in 2004, the Veteran continued with intermittent lower back and LLE problems. Repeat lumbar MRi in 2009 was read as normal. Currently he continues with chronic daily left lower back pain with LLE weakness and paresthesias. He is taking Ibuprofen and has a TENS unit as needed. He deniesbowel/bladder/sexual dysfunction related to his lower back. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: Increased pain and stiffness c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (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. Stiffness/LLE radiculopathy 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [X] Abnormal or outside of normal range Forward Flexion (0 to 90): 0 to 75 degrees Extension (0 to 30): 0 to 20 degrees Right Lateral Flexion (0 to 30): 0 to 30 degrees Left Lateral Flexion (0 to 30): 0 to 30 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes (please explain) [X] No Description of pain (select best response): Pain noted on exam on rest/non-movement If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): There is localized tenderness over the bilateral paralumbar muscles and the left SI joint and left sciatic notch. b. Observed repetitive use: 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 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 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? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not currently flared up. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not currently flared up. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [X] Not resulting in abnormal gait or abnormal spinal contour Provide description and/or etiology: Left lower back muscle spasm is noted today. Localized tenderness: [X] Not resulting in abnormal gait or abnormal spinal contour Guarding: [X] None f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: [X] None 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus 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+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [X] Left [ ] Both d. Indicate severity of radiculopathy and side affected: Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 10. Other neurologic abnormalities ---------------------------------- [ ] Yes [X] No 12. Assistive devices --------------------- [ ] Yes [X] No 13. Remaining effective function of the extremities --------------------------------------------------- [X] No 14. 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? [X] Yes [ ] No If yes, describe (brief summary): Vital signs are stable; Lungs are clear; Heart is without m/g/r; Abdomen is soft, and without masses or organomegaly or tenderness; Genitalia are normal, no hernias or testicular lesions, the testicles and epididymii are tender to touch bilaterally; 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 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [ ] Yes [X] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): Repeat lumbar MRI has been ordered and is currently pending; when completed and reported, I will review it and add any additional comments as indicated. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: The Veteran's current lower back condition would limit his ability to perform repetitive heavy lifting, pushing or pulling. 17. Remarks, if any: -------------------- The Veteran is claiming service connection for a lower back condition. Opinion: It is as least as likely as not that the Veteran's current lower back condition is proximately due to or caused by military service. Rationale: The C file was reviewed. The STRs do document a two year history in 2002 of chronic lower back pain with LLE radiculopathy. This is also noted on separation exam in 2004. I was able to elicit the same symptoms ongoing today, as well as to confirm this on phyiscal examination. Repeat lumbar MRI has been ordered since the last study was in 2009; when completed and reported, I will review it and add any additional comments as indicated. Thus, the service connection is substantiated. 12/23/2015 ADDENDUM STATUS: COMPLETED The Veteran underwent a lumbar MRI on 12/21/2015 with the following findings: L3-4: Mild facet arthrosis with minimal posterior disc bulge L4-5: Mild facet arthrosis with minimal posterior disc bulge L5-S1: Mild facet arthrosis with minonal posterior disc bulge ------END------- Any help interpreting this would be greatly appreciated. The "service connection is substantiated" is pretty straight forward. I'm curious whether or not I have a chance at getting the SC backdated to my original claim. It seems to me (a total non expert) that the evidence is there to support it. I am also curious about whether or not I can refute some of the conclusions that this doctor came to. While an awesome C&P doctor a back expert he is not. Since the writing of the C&P I had a chiropractor evaluation who found several more things than this doctor did. I'm curious if any of it will be enough to make a 10% difference when the rating comes down. In addition I am curious if within my C&P as well as the most recent chiro consult if there isn't evidence for a possible future claim for nerve pain in my lower body. "Many times spinal conditions have other conditions that contribute to the severity of the spinal condition. For example, many spine conditions also cause radiculopathy. These secondary conditions can sometimes be independently ratable." In my C&P I believe I meet all these conditions. I am diagnosed with lumbosacral strain - chronic, as well as Lower Left Extremity radiculopathy. In addition the C&P also diagnosed me with LLE weakness and paresthesias. The following is a list of conditions that the Chiropractor diagnosed me with just 8 days after the C&P doctor finalized his report. ----------Chiropractic Evaluation-------------- LOCAL TITLE: PM&R CHIROPRACTOR CONSULT RESULT STANDARD TITLE: PHYSICAL MEDICINE REHAB CONSULT DATE OF NOTE: DEC 31, 2015@11:04 Midback pain: medial scapula, left worse than right Quality: Burning (small area "about the size of a dime") Radiating: Patient Denies 0-10: 9/10 Timing: Intermittent Worse: working in a "hunched" or bent over position. Better: Standing up /stretching Low Back Pain: Thoraco-lumbar and lower L4-5-S1. Quality: Dull/Ache/sometimes sharp/Throbbing Radiating: buttock/thigh and foot ("tasered"), left worse than right 0-10: 6-7/10 Timing: Intermittent Worse: Standing/coughing while bent over Better: changing positions/activities Trunk ROM: Flexion:Mod dec Pain:Severe Extension:Mild dec Pain:No pain Rotation:Mild dec Pain:No pain Lateral Flexion:Mild dec Pain:No pain Muscle Atrophy: No Seated SLR: Positive L Supine SLR: Positive R (low back pain) Hip hyperextension test: Positive R Kemps test: Negative R L Spinous Process Tenderness: T3-7, L2,3, Right SI Myofascial Tenderness: Bilateral Rhomboids, Thoraco-lumbar paraspinals bilaterally. Lumbar MRI 12/21/2015 Impression: 1. Mild facet arthrosis and minimal disc bulges of the lower lumbar spine without thecal sac or neuroforaminal stenosis. Oswestry Disability Index Questionnaire Section 1 -- Pain Intensity: 2. The pain is moderate at the moment. Section 2 -- Personal Care (Washing, Dressing, etc.): 2. It is painful to look after myself and I am slow and careful. Section 3 -- Lifting: 2. Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed e.g. on a table. Section 4 -- Walking: 1. Pain prevents me walking more than 1 mile. Section 5 -- Sitting: 3. Pain prevents me from sitting more than one-half hour. Section 6 -- Standing: 2. Pain prevents me from standing for more than 1 hour. Section 7 -- Sleeping: 2. Because of pain, I have less than 6 hours sleep. Section 8 -- Sex Life (if applicable): N/A Section 9 -- Social Life: 3. Pain has restricted my social life, and I do not go out very often. Section 10 -- Traveling: 2. Pain is bad but I manage journeys over two hours. DISABILITY INDEX SCORE: 38% Segmental Dysfunction: L3LP, RPIN, RAI_Sacrum, T3LP, T5LP Assessment: 1. Lumbar: Segmental dysfunction 2. Lumbar: strain 3. Pelvic: Segmental dysfunction 4. Sacrum: Segmental Dysfunction 5. Thoracic: Segmental dysfunction Alright. If you've made it this far thanks for taking the time to read this massive wall of text. If you have some information or experience to offer let me thank you in advance!
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