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  1. Question in regards to exam. right ear is at least as likely as not(50% probability or greater) left ear is less likely as not. The pure tone is 24.00000 in right 16.00000 in left speech Discrimination is 94% right 92% left Tininnis is at least as likely as not(50% probability or greater) MOS was flight deck mechanic and slept under flight deck 1976-1978. any thoughts on outcome? Thanks in advance.
  2. I was due for the 5 year check up C&P exam late last year and never got anything in the mail for it. They don't forget do they? Are the C&P exams backlogged due to the pandemic? It's not hurting my benefits but I'm wondering when they're going to call me back in.
  3. I was pleasantly shocked that my exam was set up a week after submitting my paperwork request. My service rep requested a increase for my flat feet issues and secondary issues due to my 30 percent rated feet. I have pulled up the rating guidelines and I have medical records from my podiatrist. Wish they could skip these exams as the medical records lists everything. bilateral pain, went the $450 custom inserts and tried for 2 years. No relief. Developed heal spurs and that’s very painful, my Achilles feels like I might snap any day. I tore my calf muscle on top of that due to the way I walk. Some days my Achilles are so tight i can’t leave the house. Based off the one rating chart I should be at 50 percent. My question is can I expect secondary conditions - heal spurs which i never had before, Achilles’ tendonitis as they are very tight and tearing my leg muscle which took 6 months to heal but I still have issues with my ankles. I read 10 percent for heel spurs but Is it 10 per foot? My podiatrist keeps trying new methods. Sleeping with a brace, buy more inserts, need mri because she suspects I have a hairline fracture in one foot. It adds up to lots of money and hoping this gets rated to the max. I feel like the podiatrist just wants to make more money. I don’t see this improving.
  4. All, Another new one for me. Just got the call from "LHI Care" (?). All my previous exams have been done at the VA hospital. The good. They are scheduling the C&P thirty minutes from my home. The place doing the exam is the same place where I had my rehab for my plantar fasciitis a few years back. The bad. I have never done a contracted exam before (so at least I will know what you Veterans are always talking about). The ugly. I am schedule for lower back, spine, shoulder/arm, esophagus and hiatal hernia. This place had no doctors, just physical therapists, so not too comfortable on the Barrett's Esophagus/Hiatal Hernia part of the exam... I took a quick search of LHI in Hadit, and see they look like a 50/50 satisfaction rating, LOL. Any suggestions are appreciated, Hamslice I will be studying the associated DBQ's before hand, and taking copies of my medical records with.
  5. I just had my PTSD C&P exam/evaluation and have a few AAR points and questions. This exam was for an increase to an existing rating. My LHI paperwork said "Appointment length up to: 90 minutes or more *exam length varies based on evidence that presents itself during the examination." My appointment took less than an hour and this includes the time I spent to fill out the following questionnaires: PCL-5 with Criterion A, Roche Inventory and Beck Anxiety Inventory. This was 5 pages of questionnaire that probably took me 10-12 minutes to complete. I took pictures of what I filled out so I have a record. The actual exam where the examiner asked me questions felt like it was 40-50 minutes. I felt the examination was rushed because as I was elaborating on something the examiner would cut me off and tell me that she had to move on to the next thing. At the end as I was answering I question she cut me off and she told me that's all the time we have. Also toward the end she said 'I think you need medication'. I don't take anti-depression meds and explained to her why. Is this something an evaluator should be recommending? Has anyone else felt rushed? Why didn't she use 90 minutes or more and just cut me off? She was clearly authorized to use as much time as she needed based on what evidence was presented. She also asked me about my alcohol consumption? Is this appropriate to ask? After I explained how and when I consume alcohol she says 'so you binge drink'. Should I document all this to LHI? Will LHI send me her evaluation if I request it? Thanks
  6. Sorry if this is a dumb question but I got a call from a VA rep today scheduling me for an exam in relation to my claim I recently filed. All my past exams have been done at a private doctor. Does the VA actually do C&P exams also?
  7. What is advisable to do following the receipt of this letter of proposed reduction in disability rates? After 3 1/2 years and just visiting an outside, C&P doctor, (QTC Medical), I received a letter from the VA to reduce my 100% temporary disability. 3 1/2 years ago I underwent a radical prostatectomy, (surgery removing all they could find of prostate cancer). A week after visiting this outside doctor that the VA ordered, came this reduction letter. When I read the conditions under which the VA can reduce a disability it reads as follows: 1. The VA must determine whether there has been an actual change in the disability since the last rating decision. Prior to surgery my PSA reading reached a high of 5.6 and for the last 3 1/2 years there has been only the very slightest of changes varying from >0.10 and <0.10 and nothing more or less than these numbers and symbols on myhealthevet. 2. The VA must determine whether there has been an actual change in the disability since the last rating decision Again, only the slightest changes, as above, have occurred since my surgery 3. The VA must outline the time period during which the condition is said to have materially improved I cannot find in their letter any specific range of time for improvement. Directly below is their letter in full without actual dollar amounts: We have enclosed a copy of our rating decision for your review. It provides a detailed explanation about our proposal, the reason for it, and the evidence considered. We have reviewed medical records concerning your service-connected conditions and noted some improvement in your Malignant growth of genitourinary system. Based on this evidence,we are preparing to reduce your prior evaluation of its overall disabling effect. The combined evaluation for all of your service-connected disabilities will drop from 100% to 50%. This proposed action does not affect your entitlement to treatment for service-connected conditions. We propose to reduce your monthly rate of compensation from $$$$ to $$. We have reviewed medical records concerning your service-connected disabilities and noted some improvement. We propose to reduce our evaluations of the disabling effects for conditions as follows Malignant growth of genitourinary system 100% 40% Please keep in mind I have a 5" scar, which was re-measured at this outside C&P exam, ED and incontinence at 5-6 Depends daily and the same number of bathroom visits nightly. What's my next step? If I've missed anything just ask please
  8. Scene setter - Retired Navy vet who left service with 40% SC in 1981 - Degenerative joint disease - cervical spine 30%, Hypertension with mild renal insufficiency 10%, sinusitis 10%, bilateral hearing loss 0%. At this moment the individual is in a nursing home with severe dementia (does not always recognize his wife), has COVID19 (asymptomatic) and has diagnosed severe kidney insufficiency moderate to severe. I found out he had VA disability and after 2 months finally got the wife to ask the VA for what his disabilities are. She has POA for him in all matters. How do we get him evaluated for a possible increase on his kidney problem. I am having them submit a ITF immediately - then we need to file on kidney and back issues. Submit statements from the doctors and submit copies of their medical records I understand. I am not sure he could handle a C&P. Are there other options? He is located on the Mississippi Coast.
  9. I’m currently rated at 50% for ptsd and anxiety. This C&P exam is for a ratings increase, insomnia, drug abuse disorder, and IU 1. Diagnosis a. Does the veteran now have or has he ever been diagnosed with a mental disorder? [x]yes icd code: f43.8 if the the veteran currently has one or more mental disorders that conform to dsm-5 criteria, provide all diagnoses: #1 other specified trauma and stressor related disorder. Icd code f43.8 #2 cannabis use disorder, moderate icd code f12.12 2. differentiation of symptoms a. Does the veteran have more than one mental disorder diagnosed? [x]yes b. Is it possible to differentiate what symptoms are attributable to each diagnosis? [x]no Which of the following best summarizes the veterans level of occupational and social impairment with regards to all mental diagnoses? [x] occupational and social impairment with reduced reliability and productivity b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [x]no 3. symptoms For VA rating purposes, check all symptoms that actively apply to the veteran’s diagnosis: [x] anxiety [x]panic attacks more than once a week [x]chronic sleep impairment [x]difficulty in establishing and maintaining effective work and social relationships [x]Difficulty in adapting to stressful circumstances, including work or a work like setting There is much more to the file I left out somethings that I didn’t think were as important in order to save time. If needed I can answer questions or enter whatever else is needed. I know the VA doesn’t think like we do and any opinions given are just that but would still be greatly appreciated . Thanks in advance for any and all reply’s
  10. Welp, Just found out they closed my claim. Surprise surprise, nothing changed EXCEPT they reduced my GERD from 60% down to 10%! WHY and What the?! So apparently that random C&P without my knowledge played a significant part. So my questions are the following: 1. Should I reopen my claims or file an appeal? 2. How do I go about getting ALL of my C&P claim notes, especially whatever was said from this C&P without my knowledge? 3. Should I even attempt to ask for the much qualified for increase on other areas of my body, that have gotten worse, or fight this last round of let downs? I try to explain to everyone when you retire or get out and become a veteran, your own company (the VA) treat you like used tissue. Nobody has any use for used tissue...tossed to the side.
  11. Hey Everyone, I wanted to post here to get some advice. I went to my latest C&P this past Friday May 17th, 2019 for an increase to my original condition of Lumbosacral strain as well as secondary NSAID induced GERD because of taking NSAIDS for years of treating the pain from my back and legs. Here are the issues that I had and am wondering should I submit an additional document to my claim to let the RO know of my concerns before they make a decision or should I wait for decision and then go for higher-level, supplemental, appeal road. Examiner did not use Goniometer to measure ROM on my back (indicated that I was up to 70 degrees and 20 degrees on everything else) Examiner noted pain during ROM testing but did not indicate at what point in ROM that the pain started so that the accurate ROM could be determined Examiner did not fully review my records as indicated by: they did not note spinal stenosis as a diagnosis which is clearly indicated on my MRI results they indicated that they did a straight leg test with negative results when in fact they never did that test. I never layed down. they indicated that I had not sought treatment for my back since 2017 which is completely false. I have documented treatment records at the VA beginning back in Nov 2018 through this month. they referenced a 2 year old MRI result instead of my MRI from 2 weeks ago they indicated that I was taking pain medication for non-service-connected conditions (neck/knees) which are actually service connected conditions in my file. they didn't record my specific statements about flare-ups and the functional impact saying that I didn't report any at all. Any thoughts would be greatly appreciated. Thanks in advance.
  12. 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! Thanks! mhv_Xxxxxxxx_.pdf
  13. During my military separation physical, I told the doctor that I had a injured left shoulder from weightlifting on the ship out to sea. It was the first and only time I mentioned it because I didn't want to be a burden at the time. That was back in May 2008. Since this time, I have always had pain in that shoulder that would come and go. But, fast forward to 2017 and my left shoulder has been in non-stop pain limiting me from doing many things people take for granted. During 2017 & 2018, I went to a pain doctor on three separate occasions for a steroid injection which helps temporarily and had an MRI to confirm my injury. My question is, with this information do you think I would be successful in filing a shoulder injury claim or not? I'm not sure if there are time limitations for this sort of thing, but I cannot raise my left arm above my shoulder without intense pain. Thanks for your thoughts, opinions, and help in advance. I appreciate all of you!
  14. I have been rated 80% with TDIU since 2013. I recently attended my 5 year re-evaluation for PTSD. My exam results showed up on Myhealthyvet today, but I shouldn't get a decision until June or July according to VA.gov. I just wanted to know what you guys thought my rating "MAY" be based on this C&P. Of course, my PTSD and MDD are firing at max speed right now worrying about it. My concern is the part where the Dr says "Moderately Severe" PTSD and depression. I have heard stories about the raters pulling small words like that out and using them for a reason to reduce benefits. Thank you in advance for your time and responses. cp1.pdf cp2.pdf cp3.pdf cp4.pdf cp5.pdf cp6.pdf cp7.pdf cp8.pdf cp9.pdf cp10.pdf
  15. I am thinking 20, 20, 20. Anyone see anything else? 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 [X] Other (please identify other evidence reviewed): JOINT L 1. Diagnosis ----------- Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [X] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: LUMBAR DDD Date of diagnosis: 2015 BY MRI Diagnosis #2: THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION Date of diagnosis: SERVICE CONNECTED Diagnosis #3: BILATERAL RADICULOPATHY Date of diagnosis: 2018 2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): THE VETERAN IS A 42 YO MALE WHO SERVED IN THE MARINE CORP FROM 1995 TO 1999, THE MARINE CORP RESERVE FROM 1999 - 2001, AND THE NATIONAL GUARD FROM 2001 TO 2003 AND AGAIN FROM 2016 TO PRESENT DAY WITH DEPLOYMENT TO AFRICA FROM 2017 TO 2018. HE IS HERE FOR A CURRENT LEVEL OF DISABILITY EXAM FOR THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION. HE REPORTS SINCE HIS LAST COMP AND PEN EVALUATION AROUND 2013 HE HAS WORSENING PAIN WITH ONSET OF RADICULOPATHY IN BOTH LEGS. HIS PAIN LEVEL RANGE IS FROM A 5-9/10 WITH A THROBBING CHARACTER HAVING OVERLYING SHARP JABS. HE IS STIFF AFTER SITTINIG AND IN THE MORNING. HIS MORNING STIFFNESS WILL LAST 1-2 HOURS. HE STATES IN REGARDS TO HIS RADICULOPATHY HIS LEFT IS WORSE THAN HIS RIGHT AND EXTEND TO HIS FEET BILATERALLY. HE PREVIOUS TREATMENT INCLUDES PHYSICAL THERAPY, CHIROPRACTIC CARE. HE DENIES ANY SURGERY. HE JUST ANOTHER ROUND OF PHYSICAL THERAPY. 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: HIS PAIN WILL ELEVATE TO A 9/10 TWICE A WEEK LASTING A FEW HOURS TRIGGERED BY OVERACTIVITY. HE WILL REST AND USE PAIN CONTROL. 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. HE REPORTS HE DIFFICULTY WALKING FOR LONG DISTANCES, CANNOT SIT IN A HARD CHAIR, HAS PROBLEM SOCIAL FUNCTION ACTIVITIES AND PLYAING WITH HIS CHILDREN. HE CANNOT LIFT OVER 15 POUNDS OR STAND MORE THAN 30 MINTUES. HE HAS PROBLEMS WITH ANY MOVEMENT THAT REQUIRES BENDING, LIKE PUTTING ON HIS SHOES. HE HAS DIFFICULTY CONCENTRATING WHEN HIS PAIN ELEVATES. HE HAS DIFFICULTY DRIVING OVER AN HOUR. 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 35 degrees Extension (0 to 30): 0 to 10 degrees Right Lateral Flexion (0 to 30): 0 to 15 degrees Left Lateral Flexion (0 to 30): 0 to 15 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: HE WOULD NOT BE ABLE TO RETREIVE AN ITEM FROM THE FLOOR Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, 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 joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): TENDERNESS OVER THE LUMBAR VERTEBRAE, PARASPINOUS MUSCLES, BILATERAL SI JOINTS AND BILATERAL SCIATIC NERVES. 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: HE HAS NOT USED HIS BACK REPEATEDLY. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: HE WAS NOT HAVING A FLARE. 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: Less movement than normal due to ankylosis, adhesions, etc., Disturbance of locomotion, Interference with sitting, Interference with standing, Other (please describe) Please describe additional contributing factors of disability: INTERFERENCE WITH LIFTING. 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: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam ------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 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: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy --------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Numbness Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 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? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] 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? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ---------------- [X] Brace(s) [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: BACK BRACE FOR SUPPORT 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? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): For Official Use Only Click image to open viewer Priority: MRI LUMBAR SPINE WO CONTRAST Proc Ord: MRI LUMBAR SPINE WWO CONTRAST Exm Date: NOV 07, 2015@11:21 Req Phys: Pat Loc: DAL PACT CL10-I2NURSE (Req'g L Img Loc: MRI Service: Unknown (Case 7346 COMPLETE) MRI LUMBAR SPINE WO CONTRAST (MRI Detailed) CPT:72148 Reason for Study: low back pain chronic Clinical History: as above Report Status: Verified Date Reported: NOV 07, 2015 Date Verified: NOV 07, 2015 Verifier E-Sig:/ES/LENA A OMAR, M.D. Report: MRI Lumbar Spine without contrast dated 11/7/2015 Clinical History: 38-year-old male with history of low back pain chronic Comparison: Radiograph 8/28/2015 Technique: Sagittal and axial T1 and T2, as well as axial PD sequences were obtained of the lumbar spine. Findings: Vertebral body height, alignment, and marrow signal are preserved throughout the lumbar spine. There is either focal fat or hemangioma in the L1 vertebral body. Vertebral bodies are unremarkable. The conus terminates at L1-L2. There is no significant canal or neural foraminal stenosis. No areas of abnormal signal within the cord are seen. There is a tiny central disc protrusion at L5-S1 without any significant narrowing of the thecal sac or neural foramen. Small amount of fluid is present in the facet joints in the lumbar spine. Visualized paraspinal soft tissues are unremarkable. Impression: 1. Essentially unremarkable MRI of the lumbar spine except for a tiny central disc protrusion at L5-S1 without any significant narrowing of the thecal sac or neural foramen. Primary Diagnostic Code: ABNORMAL /LAO 16. Functional impact -------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: THE VETERAN WORKS AS AN ACCOUNTANT. HE SITS FOR LONG PERIODS AT WORK WHICH ELEVATES HIS BACK PAIN AND DECREASES HIS CONCENTRATION AND WORK CAPACITY. HE WOULD NOT BE ABLE TO WORK A PHYSICALLY DEMANDING JOB REQUIRING PROLONGED WALKING, STANDING OR REPEATED HEAVY LIFTING. HE ALSO WOULD REQUIRE THE ABILITY TO MOVE FROM SITTING TO STANDING POSTIONS WITH A SEDENTARY JOB SUCH AS THE ONE HIS IS CURRENTLY WORKING. 17. Remarks, if any: ------------------- 1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) YES 2. Is there evidence of pain when the joint is used in non-weight bearing? (Yes/No/Cannot be performed or is not medically appropriate) YES 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? NA If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. PASSIVE AND ACTIVE RANGE OF MOTION ARE THE SAME. ***************************************************************************** ********** THE VETERAN HAS A SERVICE CONNECTION FOR THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION. THIS IS A CHRIOPRACTIC DIAGNOSIS \: "segmental dysfunction, a motion theory concept that states that two articulating joint surfaces cannot interact optimally if they are misaligned. Basis of vertebral subluxation and theory of illness. SYNONUMS FOR SEGMENTAL DYSFUNCTION OF THE LUMBAR SPINE ARE: LOW BACK PAIN, LUMBAGO, LUMBALGIA. GIVEN THE SERVICE CONNECTED DIAGNOSIS IS BROAD BASED AND GENERAL BY DEFINITION, THE VETERANS CONFIRMED DIAGNOSIS OF LUBMAR DDD WITH COMPLICATIONS OF BILATERAL LEG RADICULOPATHY WOULD BE INCLUDING AND THEREFORE ALSO SERVICE CONNECTED. OF NOTE THE VETERAN COMPLAINED OF BACK PAIN, PAIN IN ARMS, LEGA NAD JOINTS DURING HIS DEPLOYMENT IN 2017 TO 2018 WHICH MORE THAN LIKELY WAS DUE TO HIS LUMBAR DDD WITH RADICULOPATHY.
  16. Newbie! So i had 3 C&P exams on Janurary 18th, back to back. General, audiology, and mental health. Yesterday I went to get copies of each one and my general wasn't available. After a few different phone calls I am being told that the doctor hasn't finished the notes of the exam and it is still being drafted. Mean while my exams for the other 2 have already been recieved. Tell me is this normal? The guy I spoke to was extremely rude and informed me that I was well aware that this process takes months or years, sure maybe the entire process from start to finish but months to type up the report from the exam? I asked if it may be due to needing more supporting exams and he flat out said no, but otherwise couldn't tell me why it wasn't finished. My claim was filed within a year of my separation date if that information even matters.
  17. 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.
  18. Hi everyone, So I thought I would see if I can get an answer on this. So I got out in October 2011 and had a C&P Exam 5 days later where I got denied on a SC Condition. I reopened the case last year in July, denied again because of no new evidence. This year, reopen the case again, no new evidence but given a c&p exam and was rated at 10% on it. Now, should the effective date be from my original C&P Exam where I got denied, or from 2017?
  19. Hi all; Long time reader/lurker during which I have received loads of good info! I thought i would ask a question of my own. I am going through a claim for IBS (3rd time), I am considered a Gulf War Veteran and I am trying to claim it under presumptive condition since it has already been diagnosed by the local VA hospital here in Virginia. Following my C&P exam, the VA wants some documentation about Gulf War Illness which I will provide, but I have noticed I have a mysterious second C&P scheduled at the local VA hospital? So far, I have not received any formal information in the mail. Also I see on e benefits that a new request has showed up which states: Request 3 Due Date: Not available Status: No Longer Needed Exam Request - [Contention] What does Exam Request - [Contention] most likely mean in this context? Thanks in advance, Croz...
  20. Hi, This afternoon I have my C&P exam for PTSD secondary to MST, with a contracted provider. I found out Friday evening after work. Fed Ex had delivered the paperwork earlier, but I didn't get a chance to see it until I got home from work. To say that I am nervous would be the understatement of the year. I am desperately trying to hold myself together. My digestive system is all out of whack. I did spend an hour on the phone last night with a wonderful person from a non VSO group. She is a Marine and has trauma history, so that made the connection pretty easy. She gave me a lot of good tips, if I could only remember them when it's crunch time. One of my biggest fears is that this will be just like my previous mental health C&P...where that examiner, a VA employee, when straight for the jugular and ignored my heaps of physical evidence. I don't know why I am even doing this. I fully expect to get more of the same....nothing. If I do get granted SC, the shock of that may well kill me...because that goes against the grain of what the VA has given me over the years....tons of grief and denials. Anyway, just wanted to write this down as some kind of therapy... No body has to read it, or respond. I'm not here anyway.........
  21. Hello. I went for my fibromyalgia C&P exam and just got the results from myhealthvet. It looks like it was several DBQ's including my back now. Can someone explain these results. I only see one error which is my pain is refractory to medicine. They have my pain is constant but then state NO to the refractory to medicine question. But anyways what do you guys think. IT IS LONG. Sorry. Attached & pasted MHV Fibro.docx CONFIDENTIAL Page 4 of 31 VA Notes Source: VA Last Updated: 30 Jan 2017 @ 1321 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Date/Time: 18 Jan 2017 @ 0800 Note Title: C&P GENERAL MEDICAL - AMIE/CAPRI Location: Fayetteville NC VAMC Signed By: Co-signed By: Date/Time Signed: 25 Jan 2017 @ 1740 Note LOCAL TITLE: C&P GENERAL MEDICAL - AMIE/CAPRI STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 18, 2017@08:00 ENTRY DATE: JAN 25, 2017@17:40:38 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Gulf War General Medical Examination Disability Benefits Questionnaire * Internal VA or DoD Use Only* Name of patient/Veteran: 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 CONFIDENTIAL Page 5 of 31 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 2. Medical History ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided e. Hearing loss, tinnitus and ear: No answer provided f. Sinus, nose, throat, dental and oral: No answer provided g. Breast: No answer provided h. Respiratory: No answer provided i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: The following conditions have been reported Spine: Back (Thoracolumbar Spine) Conditions Miscellaneous musculoskeletal: Fibromyalgia CONFIDENTIAL Page 6 of 31 n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [X] Yes [ ] No Diagnosis #1: Fibromyalgia ICD code: M79.7 Date of diagnosis: approx. 2007 Name of Questionnaire: DBQ Neuro Fibromyalgia 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [ ] Yes [X] No 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- CONFIDENTIAL Page 7 of 31 The E-VBMs, CPRS, JlV, Veteran's history and documents carried in by the patient were all reviewed and carefully considered during this exam. Diagnosis: 1. Fibromyalgia, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. ************************************************************************** The examination was initiated and completed by provider Debra Barton FNP, and administratively reviewed and closed by clinical lead Dr. June Roberts. **************************************************************************** Fibromyalgia 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 [X] Other (please identify other evidence reviewed): JLV CONFIDENTIAL Page 8 of 31 Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Fibromyalgia ICD code: M79.7 Date of diagnosis: approx. 2007 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: The Veteran has a history of active military service in the United States Army highest rank E5 and a Admits to service in Iraq 6/18/04-5/28/05. He presents for Gulf War Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire. He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness). Veteran reports he has had diffuse pain throughout his "joints" and CONFIDENTIAL Page 9 of 31 other locations since he got out of the military. He has had X-rays of the wrist, ankle, knees and back to evaluate for degenerative an inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia. b. Is continuous medication required for control of fibr omyalgia symptoms? [X] Yes [ ] No If yes, list only those medications required for the Veteran's fibromyalgia condition: Gabapentin c. Is the Veteran currently undergoing treatment for this condition? [X] Yes [ ] No If yes, describe: He has been advised on a exercise program and search into a biofeedback program. d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [ ] Yes [X] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia? [X] Yes [ ] No a. Findings, signs and symptoms (check all that apply): [X] Widespread musculoskeletal pain [X] Stiffness [X] Sleep disturbances [X] Paresthesias [X] Headache [X] Depression For all checked conditions, describe: Veteran has had a sleep study and has milds OSA, sleep efficiency was 70%. He has headaches bitemporal that may be associated with his sinus issues. He has parathesias when he tries to sleep. He has been diagnosed with PTSD. b. Frequency of fibromyalgia symptoms (check all that apply): [X] Constant or nearly constant CONFIDENTIAL Page 10 of 31 [X] Often precipitated by environmental or emotional stress or overexertion If checked, describe: Overexertion and extreme cold will exacerbate his symptoms. c. Does the Veteran have tender points (trigger points) for pain present? [X] Yes [ ] No [X] All bilaterally [X] Low cervical region: at anterior aspect of the interspaces between transverse processes of C5-C7 If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Second rib: at second costochondral junction If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Occiput: at suboccipital muscle insertion If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Trapezius muscle: midpoint of upper border If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Supraspinatus muscle: above medial border of the scapular spine If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Lateral epicondyle: 2 cm distal to lateral epicondyle If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Gluteal: at upper outer quadrant of buttocks If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Greater trochanter: posterior to greater trochanteric prominence If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Knee: medial joint line If checked, indicate side: [ ] Right [ ] Left [X] Both 4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars CONFIDENTIAL Page 11 of 31 ----------------------------------------------------------------------- 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 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact --------------------- Does the Veteran's fibromyalgia impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of the Veteran's fibromyalgia, providing one or more examples: Veteran is not able to climb stairs, descend stairs or bend (squat) repeatedly and has to ask others to cover those tasks for him. He is not able to do repetitive task or he starts hurting and has to stop. The Veteran is unable to participate in heavy physical prolonged labor. The Fibromyalgia does not preclude participation in sedentary employment. 7. Remarks, if any: ------------------- The examination was initiated and completed by provider DEBRA BARTON AND REVIEWED BY DESL LEAD AND CLOSED. **************************************************************************** Non-degenerative Arthritis (including inflammatory, autoimmune crystalline and infectious arthritis) and dysbaric osteonecrosis 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 CONFIDENTIAL Page 12 of 31 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 [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: chronic multi-symptom illness(pain throughout his body) b. Select diagnoses associated with the claimed condition(s): No response provided CONFIDENTIAL Page 13 of 31 c. Comments (if any): Diagnosis Degenerative Disc Disease Lumbar Spine L5/S1 date of diagnosis 6/6/2016 ICD 10 M43.06 d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's inflammatory, autoimmune, crystalline or infectious arthritis or Dysbaric Osteonecrosis. (brief summary) The Veteran has a history of active military service in the United States Army highest rank E5 Admits to service in Iraq 6/18/04-5/28/05. He presents for a Gulf War Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire. He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness). Veteran reports he has had diffuse pain throughout his "joints" and other locations since he got out of the military. He has had X-rays of the wrist, ankle, knees and back to evaluate for degenerative an inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia. Review of the radiographs of the wrist, ankle, and knees showed no osseus abnormality. The lumbar spine showe mild L5-S1 disc disease. b. Does the Veteran require continuous use of medication for the arthritis condition? [ ] Yes [X] No c. Has the Veteran lost weight due to arthritis condition? [ ] Yes [X] No d. Does the Veteran have anemia due to the arthritis condition? [ ] Yes [X] No 3. Joint Involvement -------------------- a. Does the Veteran have pain (with or without joint movement) attributable to this arthritis condition? [X] Yes [ ] No If yes, indicate affected joints [ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint CONFIDENTIAL Page 14 of 31 For all checked joints, describe involvement: Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He started complaining of low back pain and pain in some of his other joints. In 2007 he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC. b. Does the Veteran have any limitation of joint movement attributable to the arthritis condition? [X] Yes [ ] No If yes, indicate affected joints [ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint For all checked joints describe limitation of movement: The Veteran has problems with back flexion, extension, RL bending and LL bending. c. Does the Veteran have any joint deformities attributable to the arthritis condition? [ ] Yes [X] No d. Comments No response provided 4. Systemic involvement other than joints ----------------------------------------- a. Does the Veteran have any involvement of any systems, other than joints, attributable to this arthritis condition? [ ] Yes [X] No b. Comments: No response provided 5. Incapacitating and non-incapacitating exacerbations ------------------------------------------------------ a. Due to the arthritis condition, does the Veteran have exacerbations which are not incapacitating? [ ] Yes [X] No b. Due to the arthritis condition, does the Veteran have exacerbations which are incapacitating? [X] Yes [ ] No If yes, indicate frequency of incapacitating exacerbations per year (on average): [ ] 0 [ ] 1 [X] 2 [ ] 3 [ ] 4 or more Indicate the total duration of incapacitation over the past 12 months: [X] < 1 week [ ] 1 week to < 2 weeks [ ] 2 weeks to < 4 weeks [ ] 4 weeks to < 6 weeks [ ] 6 weeks or more Date of most recent incapacitating exacerbation: approx. 11/2016 CONFIDENTIAL Page 15 of 31 Duration of most recent incapacitating exacerbation: less than one day Describe incapacitating exacerbation: Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10 on a 0-10 scale. c. Is the Veteran's arthritis manifested by constitutional manifestations associated with active joint involvement which are totally incapacitating? [ ] Yes [X] No d. Is the Veteran's arthritis manifested by weight loss and anemia productive of severe impairment of health? [ ] Yes [X] No e. Is the Veteran's arthritis manifested by severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods? [ ] Yes [X] No f. Is the Veteran's arthritis manifested by symptoms combinations productive of definite impairment of health objectively supported by examination findings? [ ] Yes [X] No g. Comments: No response provided 6. 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 7. 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 CONFIDENTIAL Page 16 of 31 8. Remaining effective function of the extremities -------------------------------------------------- Due to the Veteran's arthritis 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 9. Diagnostic testing --------------------- a. Have imaging studies been performed and are the results available? [X] Yes [ ] No [X] X-ray Area(s) imaged: Lumbar spine Date: 6/6/2016 Results: L5-S1 degenerative disc diseae b. Have laboratory studies been performed? [X] Yes [ ] No If yes, check all that apply: [X] Erythrocyte sedimentation rate (ESR) Date of test: 6/2/16 Results: 3 [X] C-reactive protein Date of test: 6/2/16 Results: < 2.9 [X] Rheumatoid factor (RF) Date of test: 9/19/13 Results: <10 [X] CBC Date of test: 6/2/16 Hemoglobin: 14.5 Hematocrit: 41.2 White blood cell count: 5.69 Platelets: 243 [X] Other, specify: CCP IgG Ab Date of test: 6/2/16 Results: <16 c. Has the Veteran had a joint aspiration or synovial fluid analysis? [ ] Yes [X] No d. Has the Veteran had a biopsy (e.g., skin, nerve, fat, rectum, kidney)? [ ] Yes [X] No CONFIDENTIAL Page 17 of 31 e. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No f. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: Report: Lumbosacral spine Clinical data: pain Comparison: none. Findings: Alignment: Normal. Vertebral bodies: Normal. Intervertebral disc spaces: Mild narrowing L5-S1. Facet Joints: Normal. Soft Tissues: Normal. Other: Impression: 1. Mild L5-S1 disc disease. Veteran has Degenerative disc disease, not a Rheumatic disease. The Veteran has palpable spasms of the lumbar spine which correlates to the degenerative changes on the lumbar spine x-ray. 10. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(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: Veteran is unable to lift more than 30 lbs. He can't sit or stand for extended periods of time. He is unable to participate in prolonge heavy physical labor. The diagnosed lumbar spine condition does not preclude participation in sedentary employment. 11. Remarks, if any: -------------------- Veteran has degenerative arthritic conditions and Fibromyalgia; not inflammatory arthritic conditions. **************************************************************************** Back (Thoracolumbar Spine) Conditions CONFIDENTIAL Page 18 of 31 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 [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia CONFIDENTIAL Page 19 of 31 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Degenerative disc disease L5-S1 ICD code: M43.06 Date of diagnosis: 6/6/2016 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He started complaining of low back pain and pain in some of his other joints. In 2007 he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC. There he was evaluated and diagnosed with fibromyalgia and degenerative joint/disc disease of the low back and it was opined that it was related to his service experience. However, the Veteran does not recall the diagnosis or any follow-up. He has complained of the low back pain and chronic polyarthralgias since enrolling at the FVAMC in September of 2013. 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: Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10 CONFIDENTIAL Page 20 of 31 on a 0-10 scale. 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. He does not lift over 30 pounds. He does not play sports or enjoy things with his children as his back will act up. He is unable to ride in a car for a long period of time without his back flaring up. 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 70 degrees Extension (0 to 30): 0 to 25 degrees Right Lateral Flexion (0 to 30): 0 to 25 degrees Left Lateral Flexion (0 to 30): 0 to 25 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 25 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: Veteran is unable to lift more than 30 lbs. 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, Extension, Right Lateral Flexion, Left Lateral Flexion Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Veteran has spasm in the lumbosacral area that is tender. CONFIDENTIAL Page 21 of 31 b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is 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. [ ] 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? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance ability over Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Pain and or endurance are limiting the Veteran's functional without repeated use over time. Based on the clinical exam today and the Veteran's statements it is plausible to concur that time he would be more limited. I am not able to determine actual degrees of decreased ROM however. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No CONFIDENTIAL Page 22 of 31 If the examination is not being conducted during a flare-up: [X] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Weakness, Lack of endurance Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Pain, weakness and or endurance are limiting the Veteran's functional ability without being in a flare-up. Based on the clinical exam today and the Veteran's statements it is plausible to concur that during a flare-up he would be more limited. I am not able to determine actual degrees of decreased ROM however. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [ ] 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: Musle spasm present in the lumbosacral paraspinals related to the way the Veteran hols his back. Guarding: [ ] 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: Guarding of the lower back that results in muscle spasm. CONFIDENTIAL Page 23 of 31 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 Please describe additional contributing factors of disability: Veteran is not able to sit or stand for extended periods of time without experiencing more pain and spasms. 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 CONFIDENTIAL Page 24 of 31 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 CONFIDENTIAL Page 25 of 31 ---------------------------------- 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 CONFIDENTIAL Page 26 of 31 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] 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: Veteran is unable to lift more than 30 lbs. He can't sit or stand for extended periods of time. He can otherwise perform his job duties. 17. Remarks, if any: -------------------- There was a thorough review of E-BVMs, CPRS and JLV as well as a focused history from the Veteran regarding his Southwest Asia Service. The Veteran claimed an unexplained chronic multi-symptom illness of pain throughout his body which included low back pain. The low back bain is diagnosed as 1. Degenerative Arthritis of the Spine. M43.06. It is a disease with a clear and specific etiology and diagnosis that is separate from the Fibromyalgia. The Degenerative Arthritis of The Spine is at least as likely as not (50 % probability) that it is related to the Veteran's Military Service. Rationale: The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by a Rehab specialist who opined the back problems were related to his military service. The Veteran did have negative x-rays at that time, however in June of 2016 his X-ray is indicating degenerative changes of the lumbar spine. The Veteran reports job duty changes while CONFIDENTIAL Page 27 of 31 serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: 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 [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. CONFIDENTIAL Page 28 of 31 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: DBQ General Medical Gulf War: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. Please examine and evaluate this Veteran with Southwest Asia service for any chronic disability pattern. Please review the claims file as part of your evaluation and state that it was reviewed. The Veteran has claimed a disability pattern related to Medically unexplained chronic multi-symptom illness (pain throughout his body). Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (1) an undiagnosed illness; or (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, then no medical opinion or rationale is required as these conditions are presumed to be caused by service in the Southwest Asia theater of operations. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a CONFIDENTIAL Page 29 of 31 medical opinion, with supporting rational, as to whether it is "at least as likely as not" that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) review of the record is NOT restricted to the evidence listed below. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Tab D (Federal treatment record in VBMS): VETERAN PROVIDED HIS COPY OF TREATMENT FROM THE VA dated 12/04/2016 Tab B (Veteran's statement in VBMS): Veteran provided statement on how his pain is reflected throughout his entire body. dated 12/04/2016 Tab A (DD Form 214 in VBMS): DD 214, Iraqi Campaign Medal noted dated 12/04/2016 Tab C (Federal treatment record in VBMS): CAPRI MEDICAL FROM THE DURHAM, FAYETTEVILLE, AND WILKES-BARRE VAMC dated 12/16/2016 Please direct any questions regarding this request to: Mike Theriot 8810 Rio San Diego Dr San Diego, CA 92108 Phone number: 6194005515 Email: mike.theriot@va.gov b. Indicate type of exam for which opinion has been requested: DBQ FIBRO 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: The Veteran was diagnosed with Fibromyalgia in approximately 2007 after serving in SWA in 6/18/04-5/28/05. He underwent an extensive evaluation and inflammatory/other rheumatological disorders were ruled out. He meets the diagnostic criteria for fibromyalgia. It is not an undiagnosed illness. It is not a disease with a clear and specific etiology. However, it CONFIDENTIAL Page 30 of 31 is a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. I am unable to state with any degree of certainty which environmental hazards could have caused the disease. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Contention: medically unexplained chronic multisymptom illness ( pain through out his body) b. Indicate type of exam for which opinion has been requested: DBQ ARTH/BACK 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: The contention of medically unexplained chronic multisymptom illness ( pain through out his body) diagnosed as degenerative arthritis of the lumbar spine(also see fibromyalgia template). The diagnosis of djd lumbar spine is not an undiagnosed illness, and is not a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, and did not result from exposure to environmental hazard due to service in SWA. The degerative arthritis of the lumbar spine has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of helicopters. All of which could put increased stress on the lumbar spine, and many of the exercises are carried out with rucks on you back. Thus opined as above. ************************************************************************* Contention: Lumbar Spine Condition due to active military service. Medical Opinion: It is as least as likely as not a 50/50% probability that the Veteran claimed medically unexplained chronic multisymptom illness ( pain through out his body), diagnosed as degenerative disc disease lumbar spine was incurred in or resulted from active military service. Rationale: The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by CONFIDENTIAL Page 31 of 31 a Rehab specialist who opined the back problems were related to his military service. The Veteran reports job duty changes while serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details. The degerative arthritis of the lumbar spine has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of helicopters. All of which could put increased stress on the lumbar spine, and many of the exercises are carried out with rucks on you back. Thus opined as above. THIS DOCUMENT WAS ORIGINALLY INITIATED BY: BARTON,DEBRA A /es/ June L ROBERTS MD Signed: 01/25/2017 17:40 END OF MY HEALTHEVET PERSONAL INFORMATION REPORT
  22. Sort of Long I joined the United States Marine Corps Reserve in July of 1986, and received an honorable discharge in July of 1994. For approximately 45 days in early October of 1986 until late November of 1986, I was stationed at Camp Lejeune, NC with the Warehouse Unit (3051) for training (ACDUTRA). Several years after my separation from service in approximately 1993, I really began to experience the effects of consuming the contaminated water at Camp Lejeune. My mood changed drastically and I began to have major panic attacks. At one point in 1995 I was even taken by ambulance to the hospital for shortness of breath and the fear that I was having a massive heart attack. During this same year, I was formally diagnosed with suffering from Bipolar Disorder and Manic Depression. The strange thing about it is that I have never suffered from any psychological issues prior to my service at Camp Lejeune and do not have a family history of any psychiatric disorders. Over the next nineteen years, I took medication and occasional psychotherapy for my psychiatric condition. In spite of this my condition never really improved to the point that I felt normal. Since approximately 1992, I have had literally dozens of jobs. This is true, because my psychiatric condition makes it nearly impossible to hold down a job for any considerable amount of time. I have real trouble concentrating and focusing on things for long periods of time. Due to my educational background, I have been afforded some really good and high paying jobs like the Social Security Administration and school teaching. However, because of my lack of ability to focus, I am unable to sustain meaningful employment for more than a few months at a time. The stress of the workload and my inability to handle authority make it very difficult to remain on any job for very long; as a result, I ultimately quit. I reason that I can do better working alone and for myself and that I’ll earn a lot more working for myself, but that never seems to manifest either. I would say that most of my family members and close friends believe that there is seriously something wrong with me. I have been out of work for a year and a half and drive for Uber from time to time to earn money for gas and auto insurance. I prefer to spend most of my time alone and have pretty much cut off all contact with friends. I no longer have good health insurance like I did when I was married. Since it is difficult for me to maintain employment, I don’t have regular insurance coverage. As a result, I have not the taken much needed psychiatric medication for approximately four years. Consequently, my alcohol consumption has increased greatly and I weigh more than I ever have in my life. In my heart of hearts, I truly believe that my condition is the direct result of my exposure to the contaminated water that I consumed while at Camp Lejeune, NC. According to the EPA, the levels of PCE, TCE and other chemicals at Camp Lejeune were at least 1000 times higher than normal. Apparently the Marine Corps was aware of this situation and did nothing to correct it. Hundreds of thousands of Marines and their families have been victimized by this situation. In 2012, President Obama signed into law the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012 (P.L. 112-154), which guarantees those veterans who served at Camp Lejeune from 1953 to 1987 for a minimum of 30 days and suffer from any of fifteen identified conditions, free treatment through the VA. I content that I suffer from Neurobehavioral Effects, which is one of the identified conditions. Depression falls within the realm of Neurobehavioral Effects. Perhaps there is a “light at the end of this long tunnel,” because, a Veterans Law Judge, in his appeal letter stated that my service record confirms that I was stationed at Camp Lejeune for training, which falls within the range of subjects identified as potentially exposed to VOCs during my service and that my VA treatment record shows that I have a history of depression and that I have received treatment from the VA for such. Aside from this I also show a history of being treated for years by outside psychiatrist. As a result, I will be afforded the elusive P&C examination as part of my case; I am finally going to receive the due process that I deserve. I keep getting denied! What would you do?
  23. Hello Fellow Vets, I'll try to make this a quick an easy read. I joined the Navy in July 2008 and served 5 years of continuous duty. By the time I was out I had several issues that were not present at my join date and eventually filed a claim for my benefits. Upon departure from the Navy, I filed a claim and was denied benefits for headaches, depression, a left knee and right knee condition. When I received my decision packet, it stated that these conditions could be granted a rating if found service connection. When I met with the DAV representative, he stated that if I could have my primary care doctor write a letter and say the conditions were service connected I would be able to have it reconsidered. So my Primary Care Doctor who is a medical doctor, reviewed my medical record and she drafted a nexus letter that supported my claim (with proper language *more than likely service connected) for all the conditions I listed above (and others I will have to go back and file for at a later date). In addition, she diagnosed my headaches as being migraines as opposed to just headaches ( after I gave her the symptoms I had been experiencing). I submitted this letter in June of 2016. In September 2016 my claim went to preparation for decision and then was kicked back and the VA requested a C&P exam. This exam was conducted by a Nurse Practitioner. She opined that my headaches were due to elevated levels of estrogen and that I was cleared from physical therapy in August 2012 so neither condition was service connected. As I result I dug through my medical record and found evidence of reports of "severe and unusual headaches" on documents that were dated as early as October 2008 before I was ever on birth control. And reports of me complaining of knee pain after I was cleared from physical therapy in the year 2013. Though I found proof that I had been reporting these issues and nothing was being done about it, I also questioned how a science assumption could be made in this matter. If indeed I was suffering from elevated estrogen levels, shouldn't the NP have conducted some sort of blood work? It was not done....EVER. So my question today is Do you think that the opinion of the NP will out weigh the opinion of my MD ( who is also an employee of the VAMC in Atlanta, GA? Thanks For your time!
  24. In recently received my C&P exam and here is a summary of the results. What do you believe my raiting would be? This was done using the DSM 5 standards.The examiner found that you do have a diagnosis of PTSD that meets the DSM V criteria. He also opined that your PTSD was at least as likely as not incurred in or caused by the claimed in service stressor event. It was also noted that your primary diagnosis is bi-polar Veterans Diagnosis: Depressed mood Anxiety Suspiciousness Chronic Sleep Impairment mild memory loss, such as forgetting names, directions or recent events disturbsncea in motivation and mood difficulty in adapting to stressful circumstances including work or work-settings suicidal ideation impaired impulse control, such as unprovoked irritability with periods of violence i do well when I work and worry if I get 100% if I cannot continue my contracting for the military which would really hurt my kids support and make things more stressful. Though I have difficulty working when things get bad, Is it possible to be 100% without unemployability? just would like some feedback and opinions Sincerelrey Just Some POG
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