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megajunk

Seaman
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About megajunk

  • Rank
    E-3 Seaman
  • Birthday 12/29/1964

Profile Information

  • Military Rank
    SSgt
  • Location
    Georgia

Previous Fields

  • Service Connected Disability
    10%
  • Branch of Service
    USAF
  1. I recently received a phone call from the VA to schedule a C&P for my foot pain. Scheduled for tomorrow morning.
  2. I just called the 800-827-1000 number and was told: He does not see anywhere in the claim (526 Form) which I signed 2/15/2000, and was submitted on 3/2/2000 where the claim was closed, denied, adjudicated or rated in any way. It looks like it just 'dropped through the cracks'. He said there was an annotation of "Correction of Local Quality Error" and that was as "still open". The claim still shows they are waiting for other info from a private doctor, but that they had in fact received that info on 2/1/2019, so it is waiting to be processed and reviewed. No, this was at a private doctor. I was told they had records going back to the 80s, and the were counseled that could destroy everything over 10 years old, and they did it. She told me she had a record of my appointments, but nothing about what the appointments were for, etc. I had two appointments. Only one of which I showed up for. I will contact my regional office and request a copy of my c-file. Again, thanks everyone for your help, and your service!
  3. As far as other documents related to the back pain claim, I have nothing. I did not even remember making this "claim", exactly. As I was out processing from the AF, I am sure someone at the hospital asked me about medical problems, and I told them I had back and foot pain. I do not know if there was a claim filed at that time, or not. I never thought about it again, until I got a letter asking about it, which only happened because I wanted to see about getting hearing aids, and that led to all of this. So, I guess there must have been a claim filed, but I did not even realize it. So, no, I never made any appeal, as I didn't know if (and still don't) if it was denied, or what. Regarding my condition from 2000 to 2018, as I said (and she recorded) 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): -- relates -- "I had to change really heavy parts in the bottom load of the air craft while I was in the military. They had these monorails but they didn't always work so we had to pick them up a lot of times. I can remember having back pain and having physical therapy in the Air Force and having to go to traction but that's all I can remember about what they did. Since then I have always had back pain, upper and lower back. I have pain all the time, especially if I try to stand up for ten or more minutes. I can try to lean against something and put pressure and that seems to help. At night when I am sleeping it will wake me up with pain and I have to roll out of bed and walk around for a minute. I have just been living with the pain." Not sure if the above has any merit, or not. The VA has never asked me for more information about my back, only the C&P. They wanted all sorts of info on the foot pain, however. I did see a doctor about my back sometime around 2006. I called them to get records, but they told me they'd already destroyed them all. Thanks! I appreciate your help!
  4. I recently (October 2018) made my first claim and was examined and rated @ 10% for Tinnitus. Immediately afterwards, I received a letter from the VA stating that they had made an appointment for me for back pain that was from a claim in March of 2000. (I left the USAF in January, 2000). This is the result of that C&P exam. I was also sent a letter about foot pain that I had claimed in 2000. I ended up filling out more paperwork to explain condition, and sending in medical records from private doctors. I believe that they combined the foot pain, and the back pain into one claim. I cannot see anything on eBenefits regarding the status these claims since they are so old (that's what they told me). I am also soliciting opinions as to what the effective date for these claims would be. Please let me know what you think regarding this DBQ from a C&P exam: Thank you VERY much! ************************************************************************* LOCAL TITLE: COMPENSATION & PENSION EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: DEC 21, 2018@09:30 ENTRY DATE: DEC 21, 2018@16:02:11 URGENCY: STATUS: COMPLETED Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Xxxxxxxx XXXX Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: No response provided. Diagnosis #1: THORACOLUMBAR STRAIN. ICD code: 48532005 Date of diagnosis: Uncertain 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): -- relates -- "I had to change really heavy parts in the bottom load of the air craft while I was in the military. They had these monorails but they didn't always work so we had to pick them up a lot of times. I can remember having back pain and having physical therapy in the Air Force and having to go to traction but that's all I can remember about what they did. Since then I have always had back pain, upper and lower back. I have pain all the time, especially if I try to stand up for ten or more minutes. I can try to lean against something and put pressure and that seems to help. At night when I am sleeping it will wake me up with pain and I have to roll out of bed and walk around for a minute. I have just been living with the pain." 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: see History 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. see History 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 60 degrees Extension (0 to 30): 0 to 30 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 but does not result in/cause functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [ ] Yes [X] No 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: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [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: Exam was not conducted under stated condition d. Flare-ups Is the exam being conducted during a flare-up? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: No change in ROM e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [ ] Yes [X] No 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: Interference with sitting, Interference with standing 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: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 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: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] Yes [X] No 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [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? [ ] 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 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [ ] 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? [ ] Yes [X] No 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: unable to do strenuous activities 17. Remarks, if any: -------------------- -- "Correia" -- Is there evidence of pain on passive ROM testing? No -- Is there evidence of pain when the joint is used in non-weight bearing? No -- If yes, is the opposing joint undamaged? **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Xxxxxxxx XXXX 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 MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: -- Does the Veteran have a diagnosis of (a) back pain 1995 that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) motor vehicle accident and complaints of back pain during service? b. Indicate type of exam for which opinion has been requested: Back TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: -- C-file review: -- no date on note; c/o right upper back pain x 10 days; dx MS strain, right upper back/shoulder; tx provided -- 04/10/1996 c/o severe back pain x two weeks; dx recurrent musculoskeletal pain -- 05/03/1995 s/p MVA; activated airbag; dx negative exam, no injuries noted, minor MS aches -- 05/01/1995 c/o right upper back pain x 10 days; dx MS strain right upper back/shoulder' tx provided -- condition was first noted in the military as documented; noted condition is still present during C&P Exam ************************************************************************* Thanks!
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