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RMurr

Seaman
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About RMurr

  • Rank
    E-3 Seaman

Profile Information

  • Military Rank
    SSG E6

Previous Fields

  • Service Connected Disability
    none
  • Branch of Service
    Army
  1. Shrek, thanks for the advice. I was going to have my folks wright a letter, they are the only ones I know that has all of the information.
  2. My systems worsened after my deployment to the golf. I told the Dr about that, but there is no note of it in my C&P How do I get that in my record?
  3. I just completed a C&P exam foe IBS. See below. I was wondering why there was no statement from the doctor saying, it was or was not connected to my service. All medical records from my first term of service are missing including hospital records form what I am being told. (Had four different times I was admitted to the Hospital during that time). There is a comment on a reenlistment psychical where I said I had parasites in South America. The C&P Doctor noted that. I also have a question on a bone fracture, but not sure if I should post it here or somewhere else. Thanks for any help that you can provide. Intestinal Conditions (other than surgical or infectious), including irritable bowel syndrome, Crohn's disease, ulcerative colitis and diverticulitis Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidenc e Review ---------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review -------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ----------- Does the Veteran now have or has he/she ever been diagnosed with an intestinal condition (other than surgical or infectious)? [X] Yes [ ] No [X] Irritable bowel syndrome ICD code: K58 Date of diagnosis: per history 1985 2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary): 53 yo Army Veteran states he was in hospital in Panama for 2 months with a presumed parasitic infection (he states it was never identified though he states he was told he had a parasitic infection). Since that time he's have urgency for BMs. It has been unchanged since that time. He has seen doctors over the years and no improvement in symptoms. Current bowel pattern: diarrhea x 2 days (watery stools, 4-5 per day), then 1-2 weeks constipated and cycle repeats. no blood in stool. He states he had another colonoscopy 1 yr ago and had 2 polyps that were benign. These records are not available for review. He is on no meds for his bowels currently. Tried fiber which didn't help, other otc medicines. review of str: records from his hospitalization in Panama/lab results are not available for review. Non of his records from first period of service are found in vbms. At time of his re-entry exam in 1990, he reported "parasites" in 1988. Examiner's notes are difficult to read and it's unclear it this was commented on. b. Is continuous medication required for control of the Veteran's intestinal condition? [ ] Yes [X] No c. Has the Veteran had surgical treatment for an intestinal condition? [ ] Yes [X] No 3. Signs and symptoms -------------------- Does the Veteran have any signs or symptoms attributable to any non-surgical non-infectious intestinal conditions? [X] Yes [ ] No If yes, check all that apply: [X] Alternating diarrhea and constipation If checked, describe: per above [X] Abdominal distensionIf checked, describe: gassy 4. Symptom episodes, attacks and exacerbations --------------------------------------------- Does the Veteran have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition? [X] Yes [ ] No If yes, indicate severity and frequency: (check all that apply) [X] Episodes of bowel disturbance with abdominal distress If checked, indicate frequency: [ ] Occasional episodes [X] Frequent episodes [ ] More or less constant abdominal distress 5. Weight loss ------------- Does the Veteran have weight loss attributable to an intestinal condition (other than surgical or infectious condition)? [ ] Yes [X] No 6. Malnutrition, complications and other general health effects -------------------------------------------------------------- Does the Veteran have malnutrition, serious complications or other general health effects attributable to the intestinal condition? [ ] Yes [X] No 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? [ ] Yes [X] No 8. 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: 9. Diagnostic testing -------------------- a. Has laboratory testing been performed? [ ] Yes [X] No b. Have imaging studies or diagnostic procedures been performed and are the results available? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 10. Functional impact -------------------- Does the Veteran's intestinal condition impact his or her ability to work? [ ] Yes [X] No 11. Remarks, if any: ------------------- This examiner introduced herself to Veteran and ensured that 2 identifiers were correctly answered. Veteran was thanked for their military service. The purpose of this specific exam was reviewed. Veteran was informed that the VBA makes determinations on claims, and that all questions regarding claims should be directed toward the Regional Office. Limitations of confidentiality were reviewed. Veteran agreed to proceed with this examination.
  4. It's been a bit, but they finally gave me a C&P for my TBI. This is what they put in my DBQ. Any thoughts? Thanks in advance for all your help. Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) Disability Benefits Questionnaire * Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ---------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review -------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Evidence Comments: History of concussion noted on C&P examination dated 6/17/1995. Motor vechicle accident in 1986 and hit with wooden board in 1991. Veteran reported headaches in frontal area every 2-3 months throbbing, resolves with aspirin in 45-60 minutes. Also once in a while feels dizzy and dysequilibrium. No c/o memory problem, vertigo. No psychiatric manifestations were described. Report of medical history 1/22/1990 noted head injury 87 in car accident. Statement of medical examination and duty status 10/19/1985 motor vehicle accident on Howard AFB, "was severely injured from striking the windshield with his head." Diagnosed with cervical strain following a motorcycle accident 10/18/1983 Headache Evaluation Dr. 11/29/2017: "these symptoms have been a stable impairment over the intervening years." Veteran reported a short fuse and depressed/anxious mood. Diagnosed postconcussional syndrome, migraine, obstructive sleep apnea, tinnitus, and unspecified anxiety disorder. "cognitive symptoms are a product of his concussion to some degree but I suspect that they are being exacerbated by mood symptoms and fatigue." C&P psych mental disorders 7/31/2018 proffered diagnoses of generalized anxiety disorder and adjustment disorder with mixed disturbance of emotion and conduct. Examiner indicated that Veteran's fatigue, irritability, and difficulty concentrating are overlapping symptoms. SECTION I: Diagnosis and medical history --------------------------------------- If you are making the initial diagnosis of TBI or if you are stating that the claimant does not meet the criteria for a diagnosis of TBI, please indicate your specialty: [X] N/A claimant diagnosed with TBI in-service Date of diagnosis: 10/19/1985 1. Diagnosis ----------- Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Traumatic brain injury (TBI) Date of diagnosis: 10/19/1985 [X] Other diagnosed residuals attributable to TBI, specify: Other diagnosis #1: Migraine headaches Date of diagnosis: 11/29/2017 2. Medical history ----------------- Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): Veteran reported limited independent recollection of the head injury event, stating that he is repeating what was told to him by his ex-wife and other sources of information. He said that when he was stationed in Panama he was in the driver's seat of a stopped car when another car struck it head on. He estimated the date as December 1985. He reported he was taken to a hospital for an unspecified amount of time. He did not receive followj-up treatment. Following his head injury, Veteran reported "having problems." He stated he couldn't sleep and was frequently late to work. He and his wife argued, sometimes escalating physically. He reported receiving 2 Article 15's during this time period and losing rank. Veteran reported decreased interest in previously enjoyed activities following the injury, and believed that these symptoms led to his divorce from his first wife. Veteran stated he sought a psychiatric evaluation but "he told me there was nothing wrong with me." He has not sought psychiatric treatment since. He reported, "I learned to deal with it." Veteran estimated that he had 2-3 other head injuries playing football or bumping into something, but did not lose consciousness. He reported he may have experienced an alteration of consciousness, "Nothing bad that I can remember." Veteran reported cognitive symptoms of memory impairment. He said that his job position changed three years ago after he forgot to perform a task, resulting in great expense for the company. He said he had missed more minor things earlier which were easy to fix. Veteran reported easy irritability, such that he avoids the company of others. He attempts to cope with regular physical exercise. Veteran reported that he has been under the care of a non-VA neurologist for his headache condition for approximately one year. He said that his current medication has reduced the frequency of his headaches from 2-3 times per week to 3 times per month. Side effects of medication include weight gain. Veteran could not identify specific triggers for headache. Duration is up to a day. Location is bifrontal. He reported vomiting with headache 1-2 times per year. Associated symptoms of photo- and phonosensitivity. Medication reduces headache pain but does not alleviate it. Prior to receiving treatment for the headaches, Veteran estimated missing work due to headache 7-8 days per year. Veteran stated he did not experience headache pain prior to the head injury. There is no family history of a headache condition. SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI ---------------------------------------------------------------------------- 1. Memory, attention, concentration, executive functions ------------------------------------------------------- [X] A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing If the veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary): Veteran reported cognitive symptoms of memory impairment. He said that his job position changed three years ago after he forgot to perform a task, resulting in great expense for the company. He said he had missed more minor things earlier which were easy to fix. 2. Judgment ---------- [X] Normal 3. Social interaction ------------------- [X] Social interaction is routinely appropriate 4. Orientation ------------- [X] Always oriented to person, time, place, and situation 5. Motor activity (with intact motor and sensory system) ------------------------------------------------------- [X] Motor activity normal 6. Visual spatial orientation ---------------------------- [X] Normal 7. Subjective symptoms --------------------- [X] Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light 8. Neurobehavioral effects ------------------------- [X] One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them 9. Communication --------------- [X] Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. 10. Consciousness ---------------- [X] Normal SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks ---------------------------------------------------------------------------- 1. Residuals ----------- Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)? [X] Yes [ ] No If yes, check all that apply: [X] Headaches, including Migraine headaches 2. Other pertinent physical findings, scars, 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 3. Diagnostic testing -------------------- a. Has neuropsychological testing been performed? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): Montreal Cognitive Assessment (MOCA) performed 1/22/2019 Visuospatial/Executive: 4/5 Naming: 3/3 Attention: 5/6 Language: 3/3 Abstraction: 2/2 Delayed recall: 3/5 (4/5 with cues) Orientation: 6/6 Total score: 26/30, which is within the normal range 4. Functional impact ------------------- Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's residual conditions attributable to a traumatic brain injury, providing one or more examples: Veteran reported prostrating headaches require bedrest, which preclude economic activity. Veteran reported cognitive and mood symptoms have disrupted his work and relationships, but has been employed with the same company for over 20 years and has been married for 20 years. 5. Remarks, if any: ------------------ Prior to starting the interview, the Veteran was identified via birth date and Social Security number. I thanked the Veteran for serving our country and introduced myself as a neutral examiner. I informed the Veteran of the purpose of the assessment and its non-confidential and non-therapeutic nature. I advised the Veteran regarding the voluntariness of participation and conditions necessitating mandated reporting. I further notified the Veteran that any decision about the claim is solely determined by the Veteran's Benefits Administration, and that any questions following the exam should be directed to the Regional Office. The Veteran expressed an understanding of the advisory and agreed to proceed with the evaluation. All opinions are rendered with a reasonable degree of psychiatric certainty. Veteran sustained an in-service head injury in 1985, resulting in loss of consciousness and hospitalization. Subsequent to the head injury, he reported experiencing headaches, mood, and memory disturbance. Please see headache DBQ. As noted in the 7/31/2018 mental disorders, Veteran has been diagnosed with anxiety disorder and adjustment disorder. The symptoms of fatigue, poor concentration, and irritability also overlap with TBI.
  5. thanks Buck, I will give that a try. the only thing positive that I have learned is that they have 500 pages of documents from the hospital and medical files. Maybe now I will finaly learn what gave me disantary that caused a 2 month hospital stay. All they said to me was parasites. I will give an update once I get the records. thank you guys again for the help.
  6. The exam was done by QTC so I won't be able to get the report till after the decision is made. I also don't think putting in a request for the c&p exam would help since it seams to take forever. I'm just getting a bit uneasy, and driving the wife nuts. I'm pretty sure he is going to say the accident caused it. he made a comment that I was a model soldier until accedent then I got two article 15.
  7. I have been reading this form for about two months now and I’m hoping you may be able to give me some insight. I submitted an application for compensation in January 2018 for injuries I received in a long time ago. Here is a bit of the back ground. When I got out of the service in 1995 I thought I was applying for benefits, turns out it was only the Gulf war registry. I’m not trying to make an excuse for why I didn’t apply earlier, just telling you what happened. I was in a head on car crash in panama, hit by a drunk driver. I was out for 15-30 min, then spent 4 days in the hospital. The Va sent me for a C&P 3 weeks ago for adjustment disorder with anxiety, The DR. is the one who told me I was in the hospital for 4 days. I only knew what my ex-wife told me. After an hour doing the exam the DR. made a call to QTC and was requesting that I have a cognitive exam done, of course they said no, it wasn’t being asked for. 1. Should I be getting another C&P for TBI? I did submit my neurologist reports that said all my condition i.e. short term memory problems, migraines and emotional problems were a direct result of the accident, and I have the LOD report. along with the list of my meds i'm on. 2. Or will they just use what in my file and the C&P and render a decision? I do have a few other items I’m claiming, but I will post them in the correct forum. Thanks for any help you can give.
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