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chiefhouse00

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  1. Greetings Here are the C&Ps for headaches and neck stiffness claims. Both of these aliments are service-connected. Please review and let me know your opinion and recommendations. Thanks LOCAL TITLE: MEDICAL C&P REPORT STANDARD TITLE: INTERNAL MEDICINE C & P EXAMINATION CONSULT DATE OF NOTE: FEB 11 ENTRY DATE: FEB 11, 2015 URGENCY: STATUS: COMPLETED Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: (Me) Indicate method used to obtain medical information to complete this document: [X] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. Evidence review --------------- Was the Veteran's VA claims file reviewed? Yes If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: C-file reviewed in VBMS and virtual VA. CPRS. MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Please provide the following clarification: Veteran is claiming headaches. He complained of frontal headaches in service. His VA treatment records note of headaches/tension headaches. Please provide an opinion as to whether it is at least as likely as not that the veteran's current headache diagnosis was incurred in or caused by his complaints of frontal headaches during military service. Please provide a rationale. POTENTIALLY RELEVANT EVIDENCE: STRs - frontal headaches (tabbed) VA treatment records - headaches/tension headaches b. Indicate type of exam for which opinion has been requested: Medical Opinion Only TYPE OF MEDICAL OPINION PROVIDED: [MEDICAL OPINION FOR DIRECT SERVICE CONNECTION] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: Veteran with claim of service connection for headaches. Based on the veteran's current VHA treatment records, veteran with tension headaches. Current diagnosis of tension headaches is consistent with veteran's known neck pain from cervical degenerative disc disease which can be a common trigger of tension headaches. Current diagnosis of tension headaches is also consistent with the description of the headaches by the veteran in CPRS VHA Primary Care Outpatient Note dated 10/30/13, described as "... having pain to neck, with tension which climbs to the back of his neck and onto his scalp." Although veteran with a remote history of frontal headaches in his service medical records (STR 12/11/69 and 10/5/71), based on the description/location of these headaches in service, these frontal headaches in service are NOT consistent with tension headaches and therefore are unrelated to the veteran's current diagnosis of tension headaches. In addition, there is no objective evidence of continuity between the veteran's current tension headaches and military service. Therefore the veteran's claimed headaches with a current diagnosis of tension headaches is less likely than not incurred in or caused by the claimed in-service injury, event or illness. ========================================================================= Date/Time: 03 Feb 2015 Note Title: MEDICAL C&P REPORT Date/Time Signed: 03 Feb 2015 ------------------------------------------------------------------------- Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: (ME) 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: VBMS/CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No [X] Other Diagnosis Diagnosis #1: CERVICAL DEGENERATIVE DISEASE ICD code: 722.4 Date of diagnosis: 2004 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's cervical spine (neck) condition (brief summary): VETERAN IS HERE FOR CLAIM OF NECK STIFFNESS DUE TO SC HEPATITIS C. THIS WAS DIAGNOSED IN RECORDS AS CERVICAL DEGENERATIVE DISEASE RIGHT HANDED MILITARY: Air Force 8/1969-8/1999 WORK: COMPUTER LOGITICIAN VETERAN STATE: ONSET: 1985 PLAYING BASKETBALL AND KNOCKED DOWN AND WENT TO ER. INITIAL C&P (2000) EXAM WAS IN DETROIT. TOLD THAT HAD BULGING DISC IN CERVICAL REGION. WORSENED IN 2013 WHEN FELL DOWN THE STEPS 6-8 STEPS AND HIT BACK OF HEAD AGAINST WALL HAD BEEN PLACED ON NEW MEDICATION WHICH WAS SUPPOSED TO BE TAKEN AT NIGHT FOR PROSTATE. SEEN AT TAMC. STILL WITH PROBLEMS WITH NECK. GIVEN BRACE NO THERAPY. PAIN: CONSTANT "SHARP/DULL" 6/10 FLARES: 9/10 TRIGGERS: UNKNOWN BUT THINKS MAYBE STRESS, OR POSITIONAL. POSSIBLY SITTING TOO LONG SO GETS UP WALK AROUND EVERY 20 -30 MIN. FREQ OF FLARES: 3 TIME/WEEKS TREATMENT: TRIES TO RELAX. BAYER ASA WITHOUT SIDE EFFECTS DURAION: 1 HOUR LOCATION: RIGHT WORSE THAN LEFT BRACE WORN 5/22/70 neck still pain check xray 5/22/70 cervical xray no sig agn 5/27/70 eval neck cspin neg, still painful 6/12/96 eval stiff neck dx cervical strain/sprain 2/1/00 rating neck stiffness denied 6/3/01 er eval neck pain dx wryneck 6/18/01 gi eval 16 week eval peg/ribavarin went to er for neck pain june 3, dx with muscle spasm and given nsaids, felxeril dx ms pain in neck 7/11/01 gi eval peg/ribavarin previous neckpain/muscle spasm resolved. 7/29/04 mri cerical disc c3-4. 8/13/04 neuro eval left ulnar dist pain. mri disc c3-4. dx ulnar compression 2/22/06 va eval notes dx djd cervical and lumbar 8/18/06 eval neck pain. l sided neck pain x 1 day. dx cervicalgia 3/14/07 neuro eval neck and back pain f/u posterior neck pain. no dx given 2/29/08 va initial no mention of neck pain 4/3/12 er eval syncope hurt head, neck back dx syncope 4/3/12 ct cervical degen dz. 4/4/12 neck and back pain noted 5/4/12 er eval for ha and fver. notes neck stiffness and sub acute ha x 1 mo after fall. dx fever, ha, uri, htn 5/30/12 neuro eval note neck and back pain 1/18/13 va eval syncope. out for 2 min with neck pain. wear neck brace 1/19/13 mri neck deeggn 9/3/13 vae neck degen spine not incurred in service. 11/4/13 neck pain and ha since accident in may 2012. taking neurontin and fioricet. known oa of the cervical spine dx cervicalgia, va eval neck pain/ha since 2003 injured in 1970 1/6/14 neck pain since 1970. b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous c. Does the Veteran report that flare-ups impact the function of the cervical spine (neck)? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: SEE ABOVE d. Does the Veteran report having any functional loss or functional impairment of the cervical spine (neck) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: SEE ABOVE 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0-45): 0 to 25 degrees Extension (0-45): 0 to 10 degrees Right Lateral Flexion (0-45): 0 to 25 degrees Left Lateral Flexion (0-45): 0 to 25 degrees Right Lateral Rotation (0-80): 0 to 30 degrees Left Lateral Rotation (0-80): 0 to 25 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 examination, which ROM exhibited pain (select all that apply)? Forward flexion, Extension, Right lateral flexion, Left lateral flexion, Right lateral rotation, Left lateral rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine (neck)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): TENDERNESS TO PALPATION OF MUSCLES OF NECK 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 supports 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 [X] No [ ] Unable to say w/o mere speculation d. Flare-ups Is the examination being conducted during a flare-up? [ ] Yes [X] No If no, does the Veteran report flare-ups? [X] Yes [ ] No Frequency: SEE ABOVE Severity: SEE ABOVE Duration: SEE ABOVE If the examination is not being conducted during a flare- up: [X] The examination supports the Veteran’s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [X] No [ ] Unable to say w/o mere speculation e. Guarding and muscle spasm Does the Veteran have localized tenderness, guarding, or muscle spasm of the cervical spine? [X] Yes [ ] No Muscle spasm [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Localized tenderness [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: SEE ABOVE Guarding [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: 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 Please describe: SEE ABOVE 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 Elbow 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 Elbow 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 Wrist 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 Wrist 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 Finger 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 Finger Abduction 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 Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatomes) testing: Shoulder area (C5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Hand/fingers (C6- Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 8. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 9. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities related to a cervical spine (neck) condition (such as bowel or bladder problems due to cervical myelopathy)? [ ] Yes [X] No 10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest a. Does the Veteran have IVDS of the cervical spine? [ ] Yes [X] No 11. 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? [X] Yes [ ] No Assistive Device: Frequency of use: ----------------- ----------------- [X] Brace(s) [ ] Occasional [ ] Regular [X] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: BRACE WORN FOR NECK 12. Remaining effective function of the extremities ---------------------------------------------------- Due to a cervical spine (neck) condition, is there functional impairment of an extremity such that no effective function remains other
  2. Greetings I've attached a copy of my recent VA Rating Decision that I received a couple weeks ago. I was very upset with the rating decision (but have calm down a little) and would like you to take a look at it and provide comments and recommendations. I was so mad about the ratings that I requested my earlier post "Stun" be removed but after realizing that all of you are there to help, ask that it be reinstated. So, thanks for listening. Best Regards Chiefhouse My VA Rating Decision 2015.pdf
  3. Greetings Hadit Administrator I was a little hasty in my actions and would like to reactivate this thread, if at all possibe so I and others can continue receiving advice and providing inputs on this issue. Thanks for your consideration. Best Regards Chiefhouse
  4. Greetings I feel your pain. After my recent C&P examination (Feb 2015) for a stiff neck claim, that same C&P doctor was instructed by the RO to ask me a few questions about a previous C&P Exam that I had Nov 2014, concerning my claim for "Restriction of Activities." The reason for these additional questions was because the RO had concerns about the results of that C&P exam (Nov 2014), in which I was granted Restriction of Activities. Well, that C&P exam (Nov 2014) decision didn't go well with the RO and the C&P doctor (Feb 2015) who conducted the follow-up questions. As a result, this C&P doctor non-concurred and requested that the RO disallow the Restriction of Activities which resulted in a denial of the claim. How can that happen when one C&P doctor disagrees with the other and the RO sides with the last C&P doctor. I plan to submit a NOD. Best Regards Chiefhouse
  5. Greetings Hadit Administrator Please remove my tread from Hadit, Com. Thanks for your inputs. Best Regards Chiefhouse
  6. Greetings A retired AF friend was recently diagnosed with Stage IV Prostate Cancer. He never went to Vietnam and spent most of his career in Europe, DC, and PACAF (Hickam). Can he submit a claim for Prostate Career? Best Regards Chiefhouse
  7. Greetings The RO used the following last minute C&P DBQ's to deny my claims for Restriction of Activities, Neck Stiffness, and Headaches vice assessment frommy VA Doctor (for the last 8 years) and C&P examination conducted Nov 2014. Also, the RO discredited my ER visit records and didn't reference any DBQ's to deny my Depression claim. I will provide the RO Decision Letter on my next post. LOCAL TITLE: MEDICAL C&P REPORT STANDARD TITLE: INTERNAL MEDICINE C & P EXAMINATION CONSULT DATE OF NOTE: FEB 11 ENTRY DATE: FEB 11, 2015 URGENCY: STATUS: COMPLETED Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: (Me) Indicate method used to obtain medical information to complete this document: [X] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. Evidence review --------------- Was the Veteran's VA claims file reviewed? Yes If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: C-file reviewed in VBMS and virtual VA. CPRS. MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Please provide the following clarification: Veteran is claiming headaches. He complained of frontal headaches in service. His VA treatment records note of headaches/tension headaches. Please provide an opinion as to whether it is at least as likely as not that the veteran's current headache diagnosis was incurred in or caused by his complaints of frontal headaches during military service. Please provide a rationale. POTENTIALLY RELEVANT EVIDENCE: STRs - frontal headaches (tabbed) VA treatment records - headaches/tension headaches b. Indicate type of exam for which opinion has been requested: Medical Opinion Only TYPE OF MEDICAL OPINION PROVIDED: [MEDICAL OPINION FOR DIRECT SERVICE CONNECTION] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: Veteran with claim of service connection for headaches. Based on the veteran's current VHA treatment records, veteran with tension headaches. Current diagnosis of tension headaches is consistent with veteran's known neck pain from cervical degenerative disc disease which can be a common trigger of tension headaches. Current diagnosis of tension headaches is also consistent with the description of the headaches by the veteran in CPRS VHA Primary Care Outpatient Note dated 10/30/13, described as "... having pain to neck, with tension which climbs to the back of his neck and onto his scalp." Although veteran with a remote history of frontal headaches in his service medical records (STR 12/11/69 and 10/5/71), based on the description/location of these headaches in service, these frontal headaches in service are NOT consistent with tension headaches and therefore are unrelated to the veteran's current diagnosis of tension headaches. In addition, there is no objective evidence of continuity between the veteran's current tension headaches and military service. Therefore the veteran's claimed headaches with a current diagnosis of tension headaches is less likely than not incurred in or caused by the claimed in-service injury, event or illness. ========================================================================= Date/Time: 03 Feb 2015 Note Title: MEDICAL C&P REPORT Date/Time Signed: 03 Feb 2015 ------------------------------------------------------------------------- Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: (ME) 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: VBMS/CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No [X] Other Diagnosis Diagnosis #1: CERVICAL DEGENERATIVE DISEASE ICD code: 722.4 Date of diagnosis: 2004 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's cervical spine (neck) condition (brief summary): VETERAN IS HERE FOR CLAIM OF NECK STIFFNESS DUE TO SC HEPATITIS C. THIS WAS DIAGNOSED IN RECORDS AS CERVICAL DEGENERATIVE DISEASE RIGHT HANDED MILITARY: Air Force 8/1969-8/1999 WORK: COMPUTER LOGITICIAN VETERAN STATE: ONSET: 1985 PLAYING BASKETBALL AND KNOCKED DOWN AND WENT TO ER. INITIAL C&P (2000) EXAM WAS IN DETROIT. TOLD THAT HAD BULGING DISC IN CERVICAL REGION. WORSENED IN 2013 WHEN FELL DOWN THE STEPS 6-8 STEPS AND HIT BACK OF HEAD AGAINST WALL HAD BEEN PLACED ON NEW MEDICATION WHICH WAS SUPPOSED TO BE TAKEN AT NIGHT FOR PROSTATE. SEEN AT TAMC. STILL WITH PROBLEMS WITH NECK. GIVEN BRACE NO THERAPY. PAIN: CONSTANT "SHARP/DULL" 6/10 FLARES: 9/10 TRIGGERS: UNKNOWN BUT THINKS MAYBE STRESS, OR POSITIONAL. POSSIBLY SITTING TOO LONG SO GETS UP WALK AROUND EVERY 20 -30 MIN. FREQ OF FLARES: 3 TIME/WEEKS TREATMENT: TRIES TO RELAX. BAYER ASA WITHOUT SIDE EFFECTS DURAION: 1 HOUR LOCATION: RIGHT WORSE THAN LEFT BRACE WORN 5/22/70 neck still pain check xray 5/22/70 cervical xray no sig agn 5/27/70 eval neck cspin neg, still painful 6/12/96 eval stiff neck dx cervical strain/sprain 2/1/00 rating neck stiffness denied 6/3/01 er eval neck pain dx wryneck 6/18/01 gi eval 16 week eval peg/ribavarin went to er for neck pain june 3, dx with muscle spasm and given nsaids, felxeril dx ms pain in neck 7/11/01 gi eval peg/ribavarin previous neckpain/muscle spasm resolved. 7/29/04 mri cerical disc c3-4. 8/13/04 neuro eval left ulnar dist pain. mri disc c3-4. dx ulnar compression 2/22/06 va eval notes dx djd cervical and lumbar 8/18/06 eval neck pain. l sided neck pain x 1 day. dx cervicalgia 3/14/07 neuro eval neck and back pain f/u posterior neck pain. no dx given 2/29/08 va initial no mention of neck pain 4/3/12 er eval syncope hurt head, neck back dx syncope 4/3/12 ct cervical degen dz. 4/4/12 neck and back pain noted 5/4/12 er eval for ha and fver. notes neck stiffness and sub acute ha x 1 mo after fall. dx fever, ha, uri, htn 5/30/12 neuro eval note neck and back pain 1/18/13 va eval syncope. out for 2 min with neck pain. wear neck brace 1/19/13 mri neck deeggn 9/3/13 vae neck degen spine not incurred in service. 11/4/13 neck pain and ha since accident in may 2012. taking neurontin and fioricet. known oa of the cervical spine dx cervicalgia, va eval neck pain/ha since 2003 injured in 1970 1/6/14 neck pain since 1970. b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous c. Does the Veteran report that flare-ups impact the function of the cervical spine (neck)? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: SEE ABOVE d. Does the Veteran report having any functional loss or functional impairment of the cervical spine (neck) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: SEE ABOVE 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0-45): 0 to 25 degrees Extension (0-45): 0 to 10 degrees Right Lateral Flexion (0-45): 0 to 25 degrees Left Lateral Flexion (0-45): 0 to 25 degrees Right Lateral Rotation (0-80): 0 to 30 degrees Left Lateral Rotation (0-80): 0 to 25 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 examination, which ROM exhibited pain (select all that apply)? Forward flexion, Extension, Right lateral flexion, Left lateral flexion, Right lateral rotation, Left lateral rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine (neck)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): TENDERNESS TO PALPATION OF MUSCLES OF NECK 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 supports 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 [X] No [ ] Unable to say w/o mere speculation d. Flare-ups Is the examination being conducted during a flare-up? [ ] Yes [X] No If no, does the Veteran report flare-ups? [X] Yes [ ] No Frequency: SEE ABOVE Severity: SEE ABOVE Duration: SEE ABOVE If the examination is not being conducted during a flare- up: [X] The examination supports the Veteran’s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [X] No [ ] Unable to say w/o mere speculation e. Guarding and muscle spasm Does the Veteran have localized tenderness, guarding, or muscle spasm of the cervical spine? [X] Yes [ ] No Muscle spasm [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Localized tenderness [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: SEE ABOVE Guarding [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: 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 Please describe: SEE ABOVE 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 Elbow 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 Elbow 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 Wrist 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 Wrist 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 Finger 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 Finger Abduction 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 Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatomes) testing: Shoulder area (C5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Hand/fingers (C6- Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 8. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 9. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities related to a cervical spine (neck) condition (such as bowel or bladder problems due to cervical myelopathy)? [ ] Yes [X] No 10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest a. Does the Veteran have IVDS of the cervical spine? [ ] Yes [X] No 11. 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? [X] Yes [ ] No Assistive Device: Frequency of use: ----------------- ----------------- [X] Brace(s) [ ] Occasional [ ] Regular [X] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: BRACE WORN FOR NECK 12. Remaining effective function of the extremities ---------------------------------------------------- Due to a cervical spine (neck) condition, is there functional impairment of an extremity such that no effective function remains other
  8. Greetings As I suspected my claims were denied again by the VA here in Hawaii. Once I get over this shock and gather my thoughts, I will provide more details on what occurred. I provided my military service medical records, VA medical records and current medical records, and the RO totally dismissed those legal documents. I have nothing to hide and only want fairness, and that didn't happen. I would like the Sec of the VA to have the VA IG take a hard look at this VA facility because things here are not right. My VA doctors and C&P examiner confirmed my diabetes and depression condition but the RO had two other C&P doctors (within the last two weeks) disagree with their assessments of my medical condition. So, yes, I'm in disbelief with this outcome but very determine to have this whole process reviewed. Best Regards Chiefhouse
  9. Greetings I checked eBenefits and saw that my NOD with six contentions closed on 26 Feb but no change in VA rating letter. Is there a delay in updating the VA Rating Letter? I should get the VA Decision Letter soon. I was hoping for an increase but it don't look that way. More to follow... v/r Chiefhouse
  10. Greetings I've calmed down a little since my last post and what I saw on eBenefits today. When I opened eBenefits this morning and to my surprised I notice that I was scheduled for a C&P appointment today. I immediately called the I-800 number and was first told that it looks like I missed the appointment. He further researched the problem and said that it was a General DBQ with another doctor concerning my contentions (he couldn't tell me which one) but I was not required for be present. Well, I certainly learned something new today. This shocker C&P was scheduled before 0700 hrs and completed at noon. When this is all over I will let everyone know the outcome. Very interesting. More to follow... Best Regards Chiefhouse
  11. Greetings I haven't got an official rating deciding yet but I would like to ask this question as I stress awaiting the final rating decision. Can an RO disallow a recommendation from my VA Doctor and C&P examining doctor to rate me with Restriction of Activities for my uncontrolled DMII condition? I might be jumping the gun on this but I had a very recent C&P for my neck and headaches, and this C&P doctor ask me additional questions about my Restriction of Activities and number of times I was hospitalized. And in her C&P report for my neck/headaches, she added the section for DMII and marked the block that I should not be rated for Restriction of Activities. Can this be done? So can anybody give me some feedback on this issue? Best Regards Chiefhouse
  12. Greetings My appeal case is currently with a Veterans Law Judge for appropriate action. It changed to Level 4 on 5 Jan 2015. How long do you think it will be before I hear something? Best Regards Chiefhouse
  13. Greetings carlie Thanks for responding to my last post...I was hoping the wait time would be a little sooner since it closed on 19 Nov 2014. I haven't received a docket number for the first BVA case yet, so that one may take a year or more. I've come this far and plan on riding this horse to the finish line. I will keep everyone posted and as always, thanks for your sound advice. Best Regards Chiefhouse
  14. Greetings Any idea how long it will take to get rating decisions from the BVA on my second case recently completed? Best Regards Chiefhouse
  15. Greetings Here's an update of my cases: Case #1: Your case has been received at BVA and is currently being processed by administrative personnel and will be assigned to a Veterans Law Judge. Please note that, by law, BVA considers appeals in the order in which they are entered on the docket. Your docket number is based on the date of your appeal to BVA, and this number reserves your place in the line of cases to be decided by BVA. Because BVA receives tens of thousands of appeals per year, you may have to wait some time before a Veterans Law Judge issues a decision on your appeal. Thank you in advance for your patience. Administrative Case Processing (2) 04/14/2009 - Local VA Office Decision - RO 03/08/2010 - Notice of Disagreement (NOD) - RO 03/25/2010 - Appeal Pending - RO 03/14/2011 - Statement of the Case (SOC) - RO 05/11/2011 - Substantive Appeal (Form 9) - RO 02/24/2014 - Supplemental Statement(s) of the Case (SSOC) - RO 05/22/2014 - Certification of Appeal - RO 11/19/2014 - Received by BVA 11/19/2014 - Administrative Case Processing - BVA Case# 2: Decision & Claims File Dispatch: This indicates that BVA mailed the decision to you (and your representative, if any) and transferred your case to another location. Please refer to your Appeal Detail screen for further information about the specific location of your case. 07/12/2011 - Local VA Office Decision - RO 08/12/2011 - Notice of Disagreement (NOD) - RO 11/04/2011 - Appeal Pending - RO 10/07/2013 - Statement of the Case (SOC) - RO 12/02/2013 - Substantive Appeal (Form 9) - RO 02/24/2014 - Supplemental Statement(s) of the Case (SSOC) - RO 05/22/2014 - Certification of Appeal - RO 11/19/2014 - Decision & Claims File Dispatch - BVA Best Regards Chiefhouse
  16. Greetings Good idea...I will call the BVA Ombudsman's Office and ask when will the recorded hearing be transcribed be sent to me. I know this can take some time but it don't seem like any moment is taking place. Best Regards Chiefhouse
  17. Greetings Still waiting for anything...something but haven't heard a word from the BVA since my traveling board hearing on 16 Sep 2014. Best Regards Chiefhouse
  18. Greetings I have been waiting since 2009 to finally get this opportunity to meet a BVA Traveling Board Judge. The DAV represented me and help me prepare for the board. I believed all of my contentions are solid and will be rated higher but you never know what the outcome will be...I’m hoping for the best results. Our session lasted about 40 minutes and was recorded. I'm currently rated at 90% and have enough solid service-connected evidence to get higher rating. In regards to one of my contentions, I'm rated at 20% for Diabetes and hope to get that increased to at least 60%. I provided a doctor's note for regulation of activities and medical records of four consecutive years of hospital stays for diabetic complications. That should take my over 100%. Best Regards Chiefhouse
  19. Greetings How long does it normally take to get results from a traveling board judge? I meet a BVA Traveling Board on 16 Sep 2014. I haven't heard anything yet. Best Regards Chiefhouse
  20. Greetings Still trying to understand how I was rated with diabetes mellitus type II instead of diabetes mellitus type I. This is how the VA rated me, "Service connection for diabetes mellitus type II as secondary to the service-connected disability of hepatitis C. We have granted service connection for diabetes mellitus related to the service-connected disability of hepatitis C. VA examiner opined that your diabetes mellitus is at least as likely as not caused by your service-connected Hepatitis C due to islet cell destruction after treatment with Ribavirin and Interferon for Hepatitis C. The examiner noted difficulty controlling your diabetes with large and multiple doses of insulin suggesting islet cell dysfunction rather than the usual gradual pancreatic insufficiency." As mentioned earlier, I want to file a claim for an increase due to DM Type 1 because of issues with ketoacidosis and hypoglycemic. and three ER stays (2012, 2013, and Feb 2014) but I can't under diabetes mellitus type II. I'm I making to such out of this...can DC 7913 Diabetes Mellitus be used for DM Type ll and Type I? If so, I will try to relax a little. Best Regards Chiefhouse
  21. Greetings Berta You made a very good point of maybe connecting my DM Type 1 increase request to my service-connect Hep C instead of DM Type ll, which I'm 20% service-connected for both. I will wait for the BVA judge review/decision on my current increase request for regulation of activities and hospitalization for episodes of ketoacidosis and hypoglycemic reactions which I was hospitalize for in 2012, 2013, and 2014. Best Regards Chiefhouse
  22. Greetings Berta I'm service connected for Hep C and failed three treatment sessions over an eight year period. My first treatment started before retiring from the military. I'm currently rated 20 percent for Hep C. Best Regards Chiefhouse
  23. Berta and All I was diagnosed by the C&P Examiner as having DM Type 1 but the VA service connected me for DM Type 2. I want to file a claim for an increase due to DM Type 1 because of issues with ketoacidosis or hypoglycemic. Sorry to repeat what I mentioned earlier but I'm not clear on this particular process. I was told that my claim should be submitted as Type 2 versus Type 1. This is driving me crazy...I might already be there. Best Regards Chiefhouse
  24. Greetings C&P statement, "VETERAN WAS DIAGNOSED WITH DIABETES MELLITUS IN 2006. THE DIABETES MELLITUS HAS BEEN DIFFICULT TO CONTROL WITH LARGE DOSES OF INSULIN. THERE HAVE BEEN NOTED DEVELOPMENT OF TYPE I DM DUE TO ISLET CELL DESTRUCTION AFTER TREATMENT WITH RIBAVARIN AND PEGALATED INTERFERON WHICH THE VETERAN DID RECEIVE. NOTEWORTHY THAT THE VETERAN'S DIABETES HAS BEEN VERY DIFFICULT TO CONTROL WITH LARGER AND MULTIPLE DOSES OF INSULIN SUGGESTING ISLET CELL DYSFUNCTION. THEREFORE VETERAN'S DIABETES MAY HAVE EVOLVED FROM SOME DAMAGE TO THE ISLET CELLS RATHER THAN THE USUAL ETIOLOGY ASSOCIATED WITH GRADUAL PANCREATIC INSUFFICIENCY. THEREFORE IT IS AT LEAST LIKELY AS NOT THAT VETERAN'S DIABETES WAS DUE TO TREATMENT INCLUDING THE USE OF INTERFERON FOR HEPATITIS C." The VA rated me 20% for DM Type 2 but now I have symptoms of DM Type 1. I put in for an increase for regulation of activities and hospitalization for episodes of ketoacidosis and hypoglycemic reactions requiring one hospitalization in 2012,2013, and 2014. Can I claim this as Type 1 or Type 2? Or does it matter? Best Regards Chiefhouse
  25. Berta Right on target...great advice. I'm a little nervous but I got to get my act together. My wife and DAV will be there to support me. I will have my material organized and give it my best shot. Best Regards Chiefhouse
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