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Mrdbraggs

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About Mrdbraggs

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  1. LOCAL TITLE: COMP & PEN GENERAL MEDICAL EXAM STANDARDTITLE: C& PEXAMINATIONNOTE AUTHOR: GALLEGOS,HOLLYM EXPCOSIGNER: URGENCY: STATUS: COMPLETED Ankle Conditions Disability Benefits Questionnaire Nameofpatient/Veteran: Braggs,DerickCryer Is this DBQ being completed in conjunction with a VA 21-2507, C&P Ex a m i n a t i o n Request ? [X]Yes []No ACEand 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 (VBMSor Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): Vi st a 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: No response provided b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Lateral collateral ligament sprain (chronic/ recurrent) Side affected: [ ] Right [ ] Left [X] Both [X] Tendonitis(achilles/peroneal/posterior tibial) BRAGGS, DERICK CRYER CONFIDENTIAL Page 46 of 171 Side affected: [ ] Right [ ] Left [X] Both Date of diagnosis: Right 2018 Date of diagnosis: Left 2018 [X] Arthritic conditions [X] Arthritis, degenerative Side affected: [ ] Right [ ] Left [X] Both Date of diagnosis: Right 2018 Date of diagnosis: Left 2018 c . Co m m e n t s ( i f a n y ) : N o r e s p o n s e p r o v i d e d d. Was an opinion requested about this condition (Internal VA only)? [X]Yes []No []N/A 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's ankle condition (brief summary): Veteran reports he strained both ankles repetitively in service. He was seen many times, and right was injured more frequently than left. He participated in physical therapy for both ankles. After separation, he has progressively worsening pain. Walking and standing are limited to 10 minutes. He has not had any treatment on ankles since separation. He has frequent clicking with weight bearing. He occasionally restrains them. 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: They click all the time and seem kind of weak. 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 f u n ct i o n al impairment in his or her own words: Walking and standing are limited to 10 minutes 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right ankle BRAGGS, DERICK CRYER CONFIDENTIAL Page 47 of 171 ----------- [ ] 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 20 degrees If abnormal, does the range of motion itself contribute to a functional loss?[X]Yes,(pleaseexplain) []No If yes, please explain: Walking and standing are limited to 10 minutes 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, Plantar Flexion Isthereevidenceofpainwithweightbearing?[X]Yes []No Is there objective evidence of localized tenderness or pain on palpation of thejointorassociatedsofttissue?[]Yes [X]No Isthereobjectiveevidenceofcrepitus?[]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 15 degrees Plantar Flexion (0-45): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss?[X]Yes,(pleaseexplain) []No If yes, please explain: Walking and standing are limited to 10 minutes 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, Plantar Flexion Isthereevidenceofpainwithweightbearing?[X]Yes []No Is there objective evidence of localized tenderness or pain on palpation of BRAGGS, DERICK CRYER CONFIDENTIAL Page 48 of 171 thejointorassociatedsofttissue?[]Yes [X]No Isthereobjectiveevidenceofcrepitus?[]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: [ ] The examination is medically consistent with the Veterans statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veterans statements describingfunctionallosswithrepetitiveuseovertime. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veterans statements describing functional loss with repetitive use over t ime. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X]Yes []No []Unabletosayw/omerespeculation Select all factors that cause this functional loss: Pain Abletodescribeintermsofrangeofmotion?[]Yes [X]No BRAGGS, DERICK CRYER CONFIDENTIAL Page 49 of 171 If no, please describe: Limitations would be variable based on degree of repetitive use or flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner. 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: [ ] The examination is medically consistent with the Veterans statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent w iththeVeteransstatements describingfunctionallosswithrepetitiveuseovertime. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veterans statements describing functional loss with repetitive use over t ime. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X]Yes []No []Unabletosayw/omerespeculation Select all factors that cause this functional loss: Pain Abletodescribeintermsofrangeofmotion?[]Yes [X]No If no, please describe: Limitations would be variable based on degree of repetitive use or flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner. d. Flare-ups Right ankle ----------- Istheexaminationbeingconductedduringaflare-up? []Yes [X]No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veterans statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veterans statements describingfunctionallossduringflare-ups. Pleaseexplain. [X] The examination is neither medically consistent or inconsistent with the Veterans statements describing functional loss during flare-ups. BRAGGS, DERICK CRYER CONFIDENTIAL Page 50 of 171 Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X]Yes []No []Unabletosayw/omerespeculation Select all factors that cause this functional loss: Pain Abletodescribeintermsorrangeofmotion?[]Yes [X]No If no, please describe: Limitations would be variable based on degree of repetitive use or flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner. Left ankle ---------- Istheexaminationbeingconductedduringaflare-up? []Yes [X]No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veterans statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veterans statements describingfunctionallossduringflare-ups. Pleaseexplain. [X] The examination is neither medically consistent or inconsistent with the Veterans statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X]Yes []No []Unabletosayw/omerespeculation Select all factors that cause this functional loss: Pain Abletodescribeintermsofrangeofmotion?[]Yes [X]No If no, please describe: Limitations would be variable based on degree of repetitive use or flare. Definitive measurements cannot be rendered as are purely speculative without direct observation of examiner. 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: None Left ankle ---------- BRAGGS, DERICK CRYER CONFIDENTIAL Page 51 of 171 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 3/5Activemovement against gravity 4/ 5 Active movement against some resistance 5/5Normalstrength Right ankle: RateStrength: PlantarFlexion: 5/5 Dorsiflexion: 5/ 5 Isthereareductioninmusclestrength?[]Yes [X]No Left ankle: RateStrength: PlantarFlexion: 5/5 Dorsiflexion: 5/ 5 Isthereareductioninmusclestrength?[]Yes [X]No b.DoestheVeteranhavemuscleatrophy?[]Yes [X]No c. Comments, if any: No response provided 5. Ankylosis ------------ Co m p l e t e t h i s s e c t i o n i f V e t e r a n h a s a n k y l o s i s o f t h e a n k l e a. Indicate severity of ankylosis and side affected (check all that apply): Right side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing p o si t i o n [ ] In poor weight-bearing position [ ] In poor weight-bearing p o si t i o n Left side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity BRAGGS, DERICK CRYER CONFIDENTIAL Page 52 of 171 [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Isankleinstabilityor dislocationsuspected? [X]Yes []No If yes, complete the following: Anterior Drawer Test Istherelaxitycompared withoppositeside? Talar Tilt Test Istherelaxitycompared withoppositeside? Left ankle Isankleinstabilityor dislocationsuspected? []Yes [X]No []Unabletotest [X]Yes []No [X]Yes []No If yes, complete the following: Anterior Drawer Test Istherelaxitycompared withoppositeside? Talar Tilt Test Istherelaxitycompared withoppositeside? []Yes [X]No []Unabletotest [X]Yes []No 7. Additional comments ---------------------- Does the Veteran now have or has he or she ever had "shin splints", st r ess fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?[ ] Yes [X] No 8. Surgical procedures ---------------------- No response provided 9. Other pertinent physical findings, complications conditions, signs, sympt oms and scars BRAGGS, DERICK CRYER CONFIDENTIAL Page 53 of 171 ------------------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the DiagnosisSectionabove?[]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 Sectionabove?[]Yes [X]No 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? [X]Yes []No If yes, indicate ankle: [ ] Right [ ] Left [X] Both b. Are there any other significant diagnostic test findings or results? [X]Yes []No If yes, provide type of test or procedure, date and results (brief BRAGGS, DERICK CRYER CONFIDENTIAL Page 54 of 171 summary): Pacemaker Type Yr Manufactured * ( So m e p a c e m a k e r s a r e M R Co n d i t i o n a l ) Does the patient have any RELATIVEcontraindications to MRI? NOHeartvalveType:NOBrainAneurysmClip: Yearimplanted: NO Ca r o t i d a r t e r y v a s c u l a r c l a m p I n f u s i o n p u m p N O M a y b e p r e g n a n t NO Intravascular stents, filtersor coilsNOShunt (spinal or intraventricular) NO Any implant held in place by a magnet NO Any metallic fragments or shrapnel NO Transdermal patch The patient DOESNOT have absolute or relative co n t r ai n d i cat i o n s for the requested MRexamination. Thepatient isnot claustrophobic. EXTENSION or PAGERWHEREYOU CAN BEREACHED IN CASEOF ABNORM ALITY ^@@^ Report Status: Verified 2018 Date Verified: MAY29, 2018 Date Reported: MAY29, Verifier E-Sig:/ ES/ MANU M. BHATTATIRY, MD Re p o r t : DISCUSSION: MRI right ankle Comparison: Plain film series of 4/ 20/ 2018. Clinical History: Right ankle pain. Technique: Multiple spin echo, multiplanar images were obtained without contrast. Bones: No acute fractures, dislocation or osseous lytic lesions. Subtle nonspecific heterogeneous increased marrow signal probably related to degenerative changes versus remote trauma, in the lateral malleolus, in the lateral aspect of the fibula. No BRAGGS, DERICK CRYER CONFIDENTIAL Page 55 of 171 definite osteochondral defects involving the talar dome; subchondral cystic degenerative changes are noted involving the medial aspect of the medial talar dome. Mild degenerative changes of the tibiotalar joint with patchy foci of sclerosis of the apposing articular surfaces. The ankle mortise is preserved; the medial and lateral clear spaces appear intact. No loose bodies are noted within the tibiotalar joint. Tendons: The Achilles tendon appears unremarkable. Mild thickening with heterogeneous signal of the tibialis posterior and flexor digitorum longus tendons consistent with tendinosis. The flexor hallucis longus tendon appears unremarkable. Physiological amount of fluid is noted within the tibialis posterior tendon sheath. Mild to moderate amount of fluid is noted within the flexor hallucis longus tendon sheath consist ent with tenosynovitis; there is probable associated resultant t ar sal tunnel syndrome. Mild diffuse heterogeneous signal with minimal thickening of the peroneal tendons consistent with tendinosis; the peroneal tendon sheath appears unremarkable. The extensor tendonsappear intact. Ligaments: The spring ligament appears intact. The t ibiocalcaneal and tibionavicular ligaments are mildly thickened consistent with chronic strain. Diffuse thickening with heterogeneous signal of the anterior tibiotalar ligament consistent with chronic strain versus partial-thickness tear. Mild diffuse chronic strain of the posterior tibiotalar ligament. Partial thickness interstitial tear of the anterior talofibular ligament. The posterior talofibular ligament appears intact. Diffuse heterogeneous signal of the calcaneofibular ligament consistent with chronic partial thickness tear. The anterior and posterior tibiofibular ligament s appear unremarkable. Within the sinus tarsi, there is heterogeneous increased signal within the cervical and interosseous talocalcaneal ligaments consistent with chronic BRAGGS, DERICK CRYER CONFIDENTIAL Page 56 of 171 st r ai n . Soft Tissues: Physiological amount of fluid is noted within the tibiotalar joint; no evidence for retrocalcaneal bursitis. No soft tissue mass lesions or abnormal fluid collections. No edema is noted within the sinus tarsi. The visualized portions of the plantar aponeurosis appear grossly intact. Impression: 1. No acute osseous abnormalities of the right ankle. Mild degenerativechangesofthetibiotalarjoint. 2.Tendinosis of the tibialis posterior and flexor digitorum longus tendons. Mild to moderate flexor hallucis longus tenosynovitis with probable associated result in tarsal tunnel syndrome. Peroneal t e n d i n o si s noted. 3.Chronicstrainofthetibiocalcaneal/tibionavicular ligamentsandtheposteriortibiotalarligament. 4.Chronic strain versus partial-thickness tear of the anterior t ibiot alar ligament and calcaneofibular ligament. 5. Mild chronic strain of the cervical and interosseous talocalcaneal ligaments within the sinus tarsi. Signed by Manu Bhattatiry on 5/29/2018 3:17 PM CDT Primary Diagnostic Code: ABNORMALITY, ATTN. NEEDED Primary Interpreting Staff: MANU M. BHATTATIRY, MD, RADIOLOGIST (Verifier) /MB BRAGGS, DERICK CRYER CONFIDENTIAL Page 57 of 171 MRI ANKLEWOCONTRAST Exm Date: MAY26, 2018@12:55 Req Phys: PENUKONDA,ISM AIL SUHAIL Pat Loc: FTW PACT TRINITY11 (Req'g Loc) Img Loc: FW THEPRAIRIEMRI Service: Unknown (Case 8053 COMPLETE) MRI ANKLEWO CONTRAST (MRI Det ailed) CPT:73721 Proc Modifiers : LEFT Reason for Study: L ANKLEPAIN Clinical History: Some of the following may be hazardous to the patient's safety or could interfere with the patient's examination. I f c o n t r a i n d i c a t i o n s a r e p r e s e n t t h e M RI s t u d y M U ST b e PRE-APPROVED by a Radiologist. Please answer all questions listed below. Does the patient have any ABSOLUTEcontraindications to MRI? NOMetal in eyesNOInfusion pump NONeurostimulator or bone g r o w t h s t i m u l a t o r N O T i s s u e e x p a n d e r N O Co c h l e a r i m p l a n t N O Pacemaker Type Yr Manufactured * ( So m e p a c e m a k e r s a r e M R Co n d i t i o n a l ) Does the patient have any RELATIVEcontraindications to MRI? NOHeartvalveType:NOBrainAneurysmClip: Yearimplanted: NO Ca r o t i d a r t e r y v a s c u l a r c l a m p I n f u s i o n p u m p N O M a y b e p r e g n a n t NO Intravascular stents, filtersor coilsNOShunt (spinal or intraventricular) NO Any implant held in place by a magnet NO Any metallic fragments or shrapnel NO Transdermal patch The patient DOESNOT have absolute or relative co n t r ai n d i cat i o n s for the requested MRexamination. Thepatient isnot claustrophobic. EXTENSION or PAGERWHEREYOU CAN BEREACHED IN CASEOF BRAGGS, DERICK CRYER CONFIDENTIAL Page 58 of 171 ABNORM ALITY ^@@^ Report Status: Verified 2018 Date Verified: MAY29, 2018 Date Reported: MAY29, Verifier E-Sig:/ ES/ MANU M. BHATTATIRY, MD Re p o r t : DISCUSSION: MRI left ankle Comparison: Plain film seriesof both anklesof 4/20/2018. Clinical History: Left ankle pain Technique: Multiple spin echo, multiplanar images were obtained without contrast. Bones: Bone island noted in the distal fibula. Subtle heterogeneous increased marrow signal in the distal fibular epiphysis laterally with a probable remote avulsion injury to the lateral malleolus. The ankle mortise is preserved. Ost eochondr al defect measuring 4.3 mm with associated subtle marrow edema is noted in the medial talar dome. The ankle mortise is preserved; the medial and lateral clear spaces appear unremarkable. Mild to moderate degenerative changes of the tibiotalar joint with pat chy foci of degenerative sclerosis and subchondral degenerative cystic changes involving the apposing articular surfaces. No loose bodies are noted within the tibiotalar joint space. Tendons: The Achilles tendon appears grossly unremarkable. The tibialis posterior tendon reveals mild diffuse heterogeneous signal consistent with mild tendinosis. The flexor digitorum longus and flexor hallucis longus tendons appear unremarkable. Minimal tibialis posterior tenosynovitis; mild to moderate amount of fluid is noted within the flexor hallucis longus tendon sheat h consistent with tenosynovitis with probable resultant tarsal BRAGGS, DERICK CRYER CONFIDENTIAL Page 59 of 171 tunnel syndrome. Subtle heterogeneous signal involving the peroneal tendons consistent with tendinosis; minimal amount of fluid is noted within the peroneal tendon sheath. The extensor tendons appear unremarkable. Ligaments: Diffuse mild thickening of the spring ligament consistent with chronic strain. Thickening of the t ibiocalcaneal and tibionavicular portions of the deltoid ligament consistent with chronic strain. Thickening with heterogeneous signal of the anterior tibiotalar ligament consistent with partial-thickness tear. The posterior tibiotalar ligament appears unremarkable. Partial-thickness tear of the anterior talofibular ligament. The posterior talofibular ligament appears intact. Diffuse t hickening with heterogeneous signal of the calcaneofibular ligament consistent with chronic strain versus partial-thickness interstitial tear. The anterior and posterior tibiofibular ligaments appear unremarkable. Mild chronic strain of the cervical and interosseous talocalcaneal ligaments within the sinus tarsi. Soft Tissues: Physiological amount of fluid is noted within the tibiotalar joint space; no retrocalcaneal bursitis. The sinus tarsi appears grossly unremarkable. No soft tissue mass lesions or abnormal fluid collections. The visualized portions of the plantar aponeurosis appear grossly intact. Impression: 1 . N o a c u t e o s s e o u s a b n o r m a l i t i e s o f t h e l e f t a n k l e . Su b - c m osteochondral defect with associated subtle marrow edema involving the medial talar dome. Mild to moderate degenerative changes of the tibiotalar joint. 2. Minimal tibialis p o st e r i o r tenosynovitis. Mild to moderate flexor hallucis longus tenosynovitis with probable resultant tarsal tunnel syndrome. Mild peroneal tendinosis. Clinical correlation suggested. 3. Chronic strain of the spring ligament and the BRAGGS, DERICK CRYER CONFIDENTIAL Page 60 of 171 tibiocalcaneal/tibionavicular ligaments. 4. Partial-thickness tear of the anterior tibiotalar ligament and anterior t al o f i b u l ar ligament. Chronic strain versus partial-thickness interstitial tear of the calcaneofibular ligament. 5. Mild chronic strain of theligamentswithinthesinustarsiasnoted. Signed by Manu Bhattatiry on 5/29/2018 1:19 PM CDT Primary Diagnostic Code: ABNORMALITY, ATTN. NEEDED Primary Interpreting Staff: MANU M. BHATTATIRY, MD, RADIOLOGIST (Verifier) /MB c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 13. Functional impact --------------------- Re g a r d l e s s o f t h e V e t e r a n ' s c u r r e n t e m p l o y m e n t s t a t u s , d o t h e condit ion(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: Walking and standing are limited to 10 minutes 14. Remarks, if any ------------------- Pain present with non weight bearing and passive ROM. Active ROM same as passive. **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Nameofpatient/Veteran: Braggs,DerickCryer BRAGGS, DERICK CRYER CONFIDENTIAL Page 92 of 171 passive. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Nameofpatient/Veteran: Braggs,DerickCryer ACEand 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 (VBMSor Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): Vi st a MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Does the Veteran has a diagnosis of left ankle condition that is at least as likely as not incurred in or caused by service? TYPEOFMEDICALOPINIONPROVIDED: [ MEDICALOPINIONFORDIRECTSERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50%or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: STR's and medical records reviewed. 20 Jan 1993 notes a bilateral ankle complaint. 21Aug1992 notes complaint of both ankles and diagnosis of bilateral achilles tenodontis. Enlistment is silent for ankle BRAGGS, DERICK CRYER CONFIDENTIAL Page 93 of 171 conditions. 6Aug1996 notes ankle pain but does not delineate whether one or both. 10Aug1992 notes a complat of left ankle pain for one week. Veteran has had ongoing ankle condition since separation and his MRI supports a chronic condition. Therefore, it is greater than 50%likely it resulted from service. ************************************************************************* /es/ HOLLYM GALLEGOS PA-C Signed: 07/ 11/ 2018 10:50 Date/ Time: 11Jul2018@0900 NoteTitle: COMP& PENGENERALMEDICALEXAM Locat ion: Dallas TX VAMC Signed By: GALLEGOS,HOLLY M Co-signed By: GALLEGOS,HOLLY M D a t e / T i m e Si g n e d : 11Jul2018@1035 Not e LOCAL TITLE: COMP & PEN GENERAL MEDICAL EXAM STANDARDTITLE: C& PEXAMINATIONNOTE DATEOFNOTE: JUL11, 2018@09:00 ENTRYDATE: JUL11, 2018@10:35:48 AUTHOR: GALLEGOS,HOLLYM EXPCOSIGNER: URGENCY: STATUS: COMPLETED Medical Opinion Disability Benefits Questionnaire Nameofpatient/Veteran: Braggs,DerickCryer ACEand 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 (VBMSor Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed):
  2. Mrdbraggs

    TDIU

    This is from the C&P exam for IU. I already receive Social Security and I have a letter from a doctor stating that the Bipolar disorder makes it difficult for me to maintain employment.
  3. CAN SOMEONE HELP ME MAKE SENSE OF THE RESULTS OF MY C&P EXAM FOR IU? LOCAL TITLE: COMP & PEN MENTAL HEALTH/PSYCHOLOGY EXAM STANDARD TITLE: PSYCHOLOGY C & P EXAMINATION CONSULT DATE OF NOTE: SEP 07, 2018@09:00 ENTRY DATE: SEP 10, 2018@13:29:26 AUTHOR: HILBORN,ROBERT S EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Name of patient/Veteran: Derick Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes [ ] No ICD code: Bipolar I Disorder If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Bipolar I Disorder Comments, if any: The Veteran is currently service connected at 70% for Bipolar Disorder. He was not diagnosed with Bipolar Disorder until after service, though he has several markers identified during service, including periods of 3. 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 deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [ ] Yes [ ] No [X] Not Applicable (N/A) 3. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting The veteran verbally consented to the exam and did not express any concerns. The Veteran currently meets DSM-5 criteria for a diagnosis of Bipolar Disorder that is more likely than not caused by or a result of his military service, given obvious markers for Bipolar Disorder during service, and no reported mood symptoms or treatment thereof prior to service. His mood symptoms impact his ability to function effectively. As such, his current level of impairment is best described as, occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and mood.
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