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Found 34 results

  1. Retired in 2013 with 40% rating. 20-cervical strain, 10-knee injury, 10-degenerative arthritis. couple of questions, I am considering a sleep study for osa. I snore a lot and it disturbs my sleep. If I am diagnosed with osa, how difficult is it to connect to service. Is it worth my time to try. also, I suffer from lower back pain, loss of work, and some physical therapy. I've already been rated at 20 percent. How would I go about increasing my %, and is it worth my time. What's the success rate with the va after 4 years of retirement Thanks in advance for any help.
  2. Looking at the results in my file from the C&P. Does this look favorable? I know the degree of anything awarded goes off other particulars ect. RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Is Veteran's sleep disturbance secondary to his stress related disorder? b. Indicate type of exam for which opinion has been requested: psychological TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not ( 50% or greater probability) proximately due to or the result of the Veteran's service connected condition. ******************************** Intestinal Conditions (other than surgical or infectious), including irritable bowel syndrome, Crohn's disease, ulcerative colitis and diverticulitis Disability Benefits Questionnaire 11. Remarks, if any: -------------------- GULF WAR STATEMENT: In reviewing electronic files in VBMS and CPRS in conjunction with today's examination, the Veteran has a diagnosable, but medically unexplained illness of unknown etiology. * The disability pattern most closely correlates with a diagnosed illness of unknown etiology. * He indicates he has intermittent episodes of diarrhea/constipation/bloating and pain. * It is my medical opinion that this condition at least as likely as not (50 percent or greater probability) qualifies as a presumptive condition from service in SouthWesttAsia per website http://www.publichealth.va.gov/exposures/gulfwar/medically- unexplained-il lness. *************************** RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CURRENT DIAGNOSIS OF OBSTRUCTIVE SLEEP APNEA AT LEAST AS LIKELY AS NOT 950 PERCENT OR GREATER PROBABILITY) RELATED TO OR INCURRED DURING HIS MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: OSA 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. ******************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S ERECTILE DYSFUNCTION AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) PROXIMATELY DUE TO OR RELATED TO THE MEDICATION (PROZAC) USED TO TREAT HIS SERVICE CONNECTED MENTAL HEALTH CONDITION? b. Indicate type of exam for which opinion has been requested: ED TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. *************************************** RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CURRENT DIAGNOSIS OF SPERMATOCELE AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) RELATED TO THE TESTICULAR PAIN DURING ACTIVE MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: SPERMATOCELE 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. ***************************************** RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CURRENT DIAGNOSIS OF PATELLOFEMORAL SYNDROME RIGHT KNEE AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) INCURRED IN OR RELATED TO HIS RIGHT KNEE PFS DURING ACTIVE MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: PATELLOFEMORAL PAIN SYNDROME RIGHT KNEE 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. ******************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CHRONIC CERVICAL STRAIN AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) DUE TO OR THE RESULT OF HIS MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: CHRONIC CERVICAL STRAIN. 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. ********************************************** 4. Erectile dysfunction ----------------------- Does the Veteran have erectile dysfunction? [X] Yes [ ] No If yes, complete the following section: a. Etiology of erectile dysfunction: prozac (medication used to treat service connected mental health condition) b. If the Veteran has erectile dysfunction, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? [X] Yes [ ] No If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable:prozac (treatment for service connected mental health condition) ***************************************** GULF WAR STATEMENT: In reviewing electronic files in VBMS and CPRS in conjunction with today's examination, the Veteran has a diagnosable condition (GERD), but medically unexplained illness of unknown etiology. The condition GERD is at least as likely than not (50 percent or greater probability) related to his military service in Southwest Asia. ********************************************
  3. Looking at the results in my file from the C&P. Does this look favorable? I know the degree of anything awarded goes off other particulars ect. RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Is Veteran's sleep disturbance secondary to his stress related disorder? b. Indicate type of exam for which opinion has been requested: psychological TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not ( 50% or greater probability) proximately due to or the result of the Veteran's service connected condition. ******************************** Intestinal Conditions (other than surgical or infectious), including irritable bowel syndrome, Crohn's disease, ulcerative colitis and diverticulitis Disability Benefits Questionnaire 11. Remarks, if any: -------------------- GULF WAR STATEMENT: In reviewing electronic files in VBMS and CPRS in conjunction with today's examination, the Veteran has a diagnosable, but medically unexplained illness of unknown etiology. * The disability pattern most closely correlates with a diagnosed illness of unknown etiology. * He indicates he has intermittent episodes of diarrhea/constipation/bloating and pain. * It is my medical opinion that this condition at least as likely as not (50 percent or greater probability) qualifies as a presumptive condition from service in SouthWesttAsia per website http://www.publichealth.va.gov/exposures/gulfwar/medically- unexplained-il lness. *************************** RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CURRENT DIAGNOSIS OF OBSTRUCTIVE SLEEP APNEA AT LEAST AS LIKELY AS NOT 950 PERCENT OR GREATER PROBABILITY) RELATED TO OR INCURRED DURING HIS MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: OSA 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. ******************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S ERECTILE DYSFUNCTION AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) PROXIMATELY DUE TO OR RELATED TO THE MEDICATION (PROZAC) USED TO TREAT HIS SERVICE CONNECTED MENTAL HEALTH CONDITION? b. Indicate type of exam for which opinion has been requested: ED TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. *************************************** RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CURRENT DIAGNOSIS OF SPERMATOCELE AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) RELATED TO THE TESTICULAR PAIN DURING ACTIVE MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: SPERMATOCELE 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. ***************************************** RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CURRENT DIAGNOSIS OF PATELLOFEMORAL SYNDROME RIGHT KNEE AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) INCURRED IN OR RELATED TO HIS RIGHT KNEE PFS DURING ACTIVE MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: PATELLOFEMORAL PAIN SYNDROME RIGHT KNEE 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. ******************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: IS THE VETERAN'S CHRONIC CERVICAL STRAIN AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) DUE TO OR THE RESULT OF HIS MILITARY SERVICE? b. Indicate type of exam for which opinion has been requested: CHRONIC CERVICAL STRAIN. 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. ********************************************** 4. Erectile dysfunction ----------------------- Does the Veteran have erectile dysfunction? [X] Yes [ ] No If yes, complete the following section: a. Etiology of erectile dysfunction: prozac (medication used to treat service connected mental health condition) b. If the Veteran has erectile dysfunction, is it as likely as not (at least a 50% probability) attributable to one of the diagnoses in Section 1, including residuals of treatment for this diagnosis? [X] Yes [ ] No If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable:prozac (treatment for service connected mental health condition) ***************************************** GULF WAR STATEMENT: In reviewing electronic files in VBMS and CPRS in conjunction with today's examination, the Veteran has a diagnosable condition (GERD), but medically unexplained illness of unknown etiology. The condition GERD is at least as likely than not (50 percent or greater probability) related to his military service in Southwest Asia. ********************************************
  4. Just got off the phone with the VSO at the VA he found what the problem was holding up my decision and told me to expect my package within 10 days and gave me a IRIS number. However I am very concerned with what he told me. The letter he read said, A combined evaluation of 100% plus entitlements to benefits at the 100% rate due to individual unemployability has been assigned as a result of the following actions, Entitlement to individual unemployability is granted effective July 11, 2015 to March 8, 2016. Migraines 30% increased to 50% PTSD 50% (no change) Sleep Apnea 50% (no change) Services connected Radiculopathy left upper 20% Services connected Radiculopathy left upper 20% Degenerative joint Disease 10% increases to 20% Cervical strain 10% (no change) Tinnitus 10% (no change) He also told me there was no mention of 100% disability after March 8, 2016, could this be possible? I did the VA math and was more than 95% what am I missing? Will I have to go through the appeal process now after all this time to prove it all over again? Or am I over thinking this and just need to wait till I get my package from the VA, maybe the 100% rating is hid within the 8 pages...Thoughts?..so stressed...Help me brothers....sisters.
  5. Going through ebenefits today to submit a claim for my neck I came to the page with all the ratings. I am rated for my lower back and have never had any secondary condition for it. Today I see 1. Cervical strain 2. Neck strain 3. Multilevel degenerative disc disease 4. Disc osteophyte complex 5. Facet Syndrome I have always had neck problems and have what I think is more than enough records while on active duty to prove it started only after I was in the military. It is documented when I enrolled into the VA but it never was something that stopped me from anything. Until last year it got a lot worse. And by the fall of last year I was having a lot of problems with my neck causing me pain, keeping me in bed, not being able to dress myself, couldn't drive etc. After a new xray from the VA in SEPT 2015 it had a few indication there might be some problems going on. At the end of the year I had a few days in a row where the pain worsened dramatically each day until I eventually couldn't move. Any movement caused pain. My wife took me to the VA ED in a different city than where I am normally treated and they gave me some stuff for the pain and to relax me. My wife wanted them to do a MRI but they couldn't they said since I was not at my assigned VA. Called PCP the next day for a MRI and 3 months later the VA had me seen. The problem was better the day of the MRI than it was 3 months prior in the ED but I still had lots of discomfort. In between all this I established care with a private PCP 2 days after leaving the VA ED they had seen me and given me some injections and referred me to physical therapy. He also prescribed some medications. Fast forward to today and I am planning on making a claim after I have all my notes compiled to make it a less bumpy adventure with the VA and pretty much everything found in the MRI is now listed as a secondary to my service connected lower back. Should I still file a new claim for my neck and list all the secondary's they have under my lower back rating? And should my rating percentage for my back have been looked at for possibly increasing it now that these secondary problems are added? or is this a way for the VA to rate the neck problems without having to compensate for another service connected disability. The original rating is unchanged after all these secondary's are added into it. If so, is it better to have my lower back rating increased? Or to have a separate rating for my neck? And if it stays as a secondary condition under my lower back, can I still pursue treatment for it through the VA or will they consider treating my lower back since my neck is now secondary to that? (which blows my mind.) At this point I have stopped going any further with the filing the claim. I have it started so it doesn't expire for a year. Just want to make sure I a m making the best choices.
  6. What type of rating would you receive for a cervical strain of the lower back?
  7. I had a previous claim and was rated at 90%. I tried using the VA calculator and adding my disabilities but I continuously came up with the low 80 percentile. I've read a little about Bilateral factor's but I still came up with a lower percentage. Is there any way I could find out which disabilities I have are considered bilateral? I'm concerned I will later be contacted by the VA and informed I was given the incorrect rating all along. I've tried to contact them and even spoke with a rep and discussed my calculations. He advised I should request a recount. Here are my disabilities and ratings patello-femoral syndrome, right knee 10% tinnitus 10% right shoulder chronic sprain (claimed as right shoulder impingement with pain) 10% patello-femoral syndrome, left knee 10% status post left shoulder SLAP tear repair and residual strain 20% scars, left shoulder, status post surgery (painful) 20% complications from nerve block, left shoulder girdle 40% traumatic deviated nasal septum (claimed as nasal fracture with restricted airway) 10% chronic lumbar strain (claimed as LB strain with LOS) 10% chronic cervical strain (claimed as C-spine bulging disc with LOM and pain) 10% I have a few rated at 0% but I don't see how it would change my rating. If anyone could help me calculate this correctly or advise which is considered "bilateral" it would be greatly appreciated. Thank you
  8. Good day to all, Here are some specifics to gain a better understanding...... FDC took effect and was awarded 70% around late March. I was prior AD Air force and seperated 08. I joined the AF reserve in 2011. The issues on my FDC that I was denied for 1) cervical and upper back pain 2) bilateral numbness pain and tingling left and right arm. These issues originated while reporting for annual tour at my reserve unit while on Active Duty title 10 orders 2011. I had a pretty bad motor vehicle accident. Hit the median and blew a tire..went airborne like the Dukes of Hazard and lost control, spun out and jumped the median sideways landing upside down on the opposite traffic lane and flipping upright. I have the AD for training orders, the ER visit btw, treatment and diagnosis of cervical strain/whiplash, mishap report from my unit, service treatment records at the base urgent care and later physical therapy for cervicalgia symptoms. No LOD was ever given to me only intiated which is one of the issues I have. I have that letter as well. I am no longer in the reserves either. I also have private physician records just recently of X-ray and MRI that shows evidence of worsening conditions which are 4 cervical disc bulges. A Neurologist that I have been seeing conducted an EMG exam that shows evidence of bilateral radiculopathy/neuropathy. In the award letter the VA stated the evidence used to determine the claim, came from only Active Duty STR's. Also the contentions were denied in their words (No link was found to military service) I was a newbie and was completely naive about the whole claim process. I should have sent them my STR's from the reserves.... I went to my VSO organization and met with a counselor, talked to him explaining all the new evidence I had and what next steps take. He asked me if had an LOD then tells me that without the LOD the evidence doesn't mean anything. That they wont even look at it and it would be a waste of time to submit it....Is this true? I am submitting all of it, with a statement of support 4138 and requesting a reconsideration to SC for these denied contentions.....because in essence they did not have it. Please if anyone has any thoughts it would be greatly appreciated. Still a newbie but so grateful for the members here and their knowledge. Thank you for all that you do to research and the information that empowers us. I will keep you posted. God bless, All-American Airman
  9. These are the results from my C and P Exam I had on Saturday. Any ideas, I was sent back to the local VARO, from a Remand, and this is the C and P Examination requested by the Veterans Law Judge. I'm assuming I will just get denied again from the way this is reading, any thoughts or ideas will be appreciated. I was praying for secondary or aggravation disability because my neck problems are real!! Here goes my exam..... Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination 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: VA TREATMENT RECORDS VISTA WEB VBMS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: BASED ON THEW EVALUATION OF THE VETERAN AND THE REVIEW OF THE MEDICAL HISTORY, THE EXAMINER MUST EXPRESS AN OPINION AS TO WHETHER IT AS AT LEAST AS LIKELY AS NOT THAT THE VETERAN HAS ANY CURRENT CERVICAL SPINE DISABILITY THAT IS DUE TO THE MARCH 2001 MVA OR ANY OTHER INCIDENT OF SERVICE. THIS INCLUDES WHETHER THE VETERAN'S CURRENT NECK DISABILITY HAD IT'S ONSET DURING SRVICE AND /OR WHETHER IT IS LIKELY OR NOT THAT THE VETERAN'S CURRENT DEGENERATIVE ARTHRITIS OF THE CERVICAL SPINE/ IVD SYNDROME IS A PROGRESSION OF THE VETERAN'S REPORTS THAT HIS NECK PAIN BEGAN AT E TIME OF THE MARCH 2001 MVA. b. Indicate type of exam for which opinion has been requested: CERVICAL SPINE 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: ALL OF THIS VETERAN'S STRs AS WELL AS VA TREATMENT RECORDS WERE REVIEWED. UNFORTUNATELY, STRs ARE SILENT FOR A COMPLAINT OF NECK PAIN IN SERVICE BY THIS VETERAN. IT WAS NOT UNTIL A PROGRESS NOTE WRITTEN BY ATTENDING PHYSICIAN IN ATLANTA VA IS NECK PAIN MENTIONED. PROGRESS NOTE 8/2/2006: "6 MONTHS OF NECK PAIN". XRAYS PERFORMED AT THAT TIME WERE READ AS NORMAL CONFIDENTIAL Page 32 of 161 REASON FOR XRAY NOTED IN XRAY REQUEST: "2 WEEKS OF NECK PAIN" THE ETIOLOGY OF THIS VETERAN'S CURRENT CONDITION CANNOT BE DETERMINED IN A COMPENSATION AND PENSION EXAM. REGARDING STATEMENT OF DR SCHEID 12/26/07 STATING VETERAN'S CONDITION IS "SERVICE CONNECTED", THIS IS STRICTLY HIS OPINION WITHOUT BASIS, SINCE HIS PROGRESS NOTE OF 8/26/06 STATES: VETERAN COMPLAINS OF NECK PAIN OF SIX MONTHS DURATION. IT IS NOT UNCOMMON FOR A PCP TO TAKE A VETERAN'S DESCRIPTION OF AN INJURY OR ILNESS AND USE THE TERMS "SERVICE CONNECTED" WITHOUT IT ACTUALLY BEING SERVICE CONNECTED. AS TO DR GUTIERREZ NOTE AT HINES VA DATED 2/2011: NOTE STATES: "1.Continues with this SC condition. On robaxin and tramadol/naproxen. Seems all issue started after MVA when he was in the service. More likely than not that this is sequelae of injury. I referred him to appeal decision by C&P Board since they have access to all files and records." AGAIN,THIS IS A CASE OF A PCP USING THE TERM "SERVICE CONNECTED" WHEN IN FACT THE CONDITION IS NOT YET SERVICE CONNECTED. DR GUTIERREZ ALSO NOTES THAT C&P HAS ACCESS TO ALL FILES AND RECORDS AND IMPLIED THAT HE, HIMSELF, DOES NOT.HENCE,THEY WERE NOT REVIEWED BY HIM. VETERAN WAS SEPERATED FROM SERVICE IN JULY 2001 AND MADE NO MENTION UNTIL AUGUST 2006 OVER 5 YEARS LATER OF ANY NECK PAIN. THERE IS NO NEXUS FOR SERVICE CONNECTION IN THIS EXAMINER'S OPINION. WHICH IS THE SAME OPINION REACHED ON PREVIOUS OCCASIONS REGARDING VETERAN'S NECK COMPLAINTS. ************************************************************************* /es/ JOANNE H PA LATKO PA-C ORTHO Signed: 01/10/2015 12:30 Date/Time: 10 Jan 2015 @ 0900 Note Title: C&P ORTHO SPINE Location: EDWARD J. HINES JR. HOSPITAL Signed By: LATKO,JOANNE H PA CONFIDENTIAL Page 33 of 161 Co-signed By: LATKO,JOANNE H PA Date/Time Signed: 10 Jan 2015 @ 1227 Note LOCAL TITLE: C&P ORTHO SPINE STANDARD TITLE: ORTHOPEDIC SURGERY C & P EXAMINATION CONSULT DATE OF NOTE: JAN 10, 2015@09:00 ENTRY DATE: JAN 10, 2015@12:27:44 AUTHOR: LATKO,JOANNE H PA EXP COSIGNER: URGENCY: STATUS: COMPLETED Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [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: VISTA WEB ATLANTA VA TREATMENT RECORDS HINES VA TREATMENT RECORDS VBMS CONFIDENTIAL Page 34 of 161 If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No [ ] Ankylosing spondylitis [ ] Cervical strain [ ] Degenerative arthritis of the spine [X] Intervertebral disc syndrome [ ] Segmental instability [ ] Spinal fusion [X] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture [X] Other Diagnosis Diagnosis #1: CHRONIC CERVICAL STRAIN Date of diagnosis: 2012 Diagnosis #2: NECK PAIN PER VA TREATMENT RECORDS Date of diagnosis: 8/2/2006 Diagnosis #3: SPINAL STENOSIS Date of diagnosis: 2012 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's cervical spine (neck) condition (brief summary): VETERAN GIVES HISTORY OF BEING INVOLVRD IN A MOTOR VEHICLE ACCIDENT IN MARCH OF 2001 JUST PRIOR TO BEING DISCHARGED. HE WAS TAKEN TO THE ED AND TREATED FOR BACK PAIN. VETERAN STATES HE NEVER SPECIFICALLY SAID THAT HIS NECK HURT, CONSIDERING EVERYTHING TO BE HIS "BACK". VETERAN STATES NECK CONFIDENTIAL Page 35 of 161 PAIN BECAME BOTHERSOME ABOUT 1-2 YEARS AFTER SEPERATION WITH PAIN AND STIFFNESS. HE NOTED DIFFICULTY GETTING OUT OF BED AND RAISING HIS OFF OF THE PILLOW. CURRENTLY VETERAN IS BEING TRATED AT HINES VA FOR NECK AND BACK PAIN. HE WAS SEEN RECENTLY IN HINES ED FOR HIS NECK BECAUSE HIS HOME MEDICATIONS WERE NOT HOLDING HIM. HE HAS TAKEN A LEAVE OF ABSENCE FROM HIS CUSTOMER SERVICE POSITION ABOUT 65 MOS AGO AND DOEWS NOT ANTICIPATE RETURNING TO WORK. VETERAN FEELS THAT HIS NECK CONDITION WAS EXACERBATED BY HIS WORK AS A COOK IN SERVICE, LIFTING HEAVY POTS AND PANS. VETERAN DESCRIBES OCCASIONAL "ELECTRICAL SHORT" TYPE OF PAIN. HE ALSO NOTES NUMBNESS AND TINGLING DOWN HIS RIGHT ARM WITH TINGLING IN HIS RIGHT THUMB, ALING WITH SHOOTING PAIN WITH SPASM IN HIS NECK. VETERAN SELT TREATS WITH ICE PACKS AND OTHER MODALITIES TO INCREASE HIS COMFORT LEVEL. b. Dominant hand: [ ] Right [X] Left [ ] Ambidextrous c. Does the Veteran report that flare-ups impact the function of the cervical spine (neck)? [ ] Yes [X] No 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: VETERAN NOTES THAT AT TIMES HIS NECK PAIN IS SEVERE ENOUGH TO PREVENT HIM FROM COOKING. HE LIVES CLOSE BY TO HIS SSISTER AND HER FAMILY AND AT THESE TIMES THEY ARE ABLE TO ASSIST HIM. 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 20 degrees Extension (0-45): 0 to 20 degrees Right Lateral Flexion (0-45): 0 to 20 degrees Left Lateral Flexion (0-45): 0 to 20 degrees Right Lateral Rotation (0-80): 0 to 50 degrees Left Lateral Rotation (0-80): 0 to 60 degrees CONFIDENTIAL Page 36 of 161 If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: DIFFICULTY DRIVING AN AUTO AS HE HAS DIFFICULTY TURNING HIS NECK TO SEE BEHIND AND ALONG SIDE OF HIM. Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Forward flexion, Extension, Right lateral flexion, Left lateral flexion, Right lateral rotation, Left lateral rotation Is there evidence of pain with weight bearing? [ ] Yes [X] 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): SPINAL AND PARASPINAL TENDERNESS ON PALPATION WORSE IN RIGHT PARASPINAL RE b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [ ] Yes [X] No If no, please provide reason: TOO PAINFUL 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 cond ucted immediately after repetitive use over time: [ ] The examination supports the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination contradicts the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [X] The examination neither supports nor contradicts the Veteran?s statements describing functional loss with repetitive use over time. CONFIDENTIAL Page 37 of 161 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: UNABLE TO PERFORM REPETITIVE MOTION TESTING TODAY d. Flare-ups Is the examination being conducted during a flare-up? [ ] Yes [X] No If no, does the Veteran report flare-ups? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination supports the Veteran?s statements describing functional loss during flare-ups. [ ] The examination contradicts the Veteran?s statements describing functional loss during flare-ups. Please explain. [X] The examination neither supports nor contradicts 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: VETERAN DOES NOT DESCRIBE FLARE UPS e. Guarding and muscle spasm Does the Veteran have localized tenderness, guarding, or muscle spasm of the cervical spine? [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: 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: Guarding [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour CONFIDENTIAL Page 38 of 161 [ ] 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: Less movement than normal due to ankylosis, adhesions, etc., Weakened movement due to muscle or peripheral nerve injury, etc. Please describe: LESS MOVEMENT/SLOW MOVEMENT DUE TO PAIN 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: [ ] 5/5 [X] 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 CONFIDENTIAL Page 39 of 161 -------------- 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: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Hand/fingers (C6-8): Right: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate location and severity of symptoms (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] CONFIDENTIAL Page 40 of 161 Severe Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] 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) No response provided. d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 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? [X] Yes [ ] No b. If yes to question 10a 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 11. Assistive devices --------------------- CONFIDENTIAL Page 41 of 161 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] Cane(s) [ ] Occasional [X] Regular [ ] Constant [X] Walker [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: USES CANE/WALKER FOR STABILITY 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 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.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. 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 14. Diagnostic testing ---------------------- a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No b. Does the Veteran have a vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No CONFIDENTIAL Page 42 of 161 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): EMG CERVICAL 2/13/11 Conclusion: There is electrophysiologic evidence of right ulnar neuropathy at the elbow based on the nerve conduction study alone. Given the limited nature of the study (without EMG examination), unable to futher localize. MRI CERVICAL SPINE 12/2014 Impression: Straightening of the usual cervical lordosis with very mild kyphosis at C4-5 level. C4-5: Central disc protrusion indents cord with moderate central stenosis. C5-6: R paramedian and central extrusion with downward extension indents cord with mild to moderate central stenosis. No abnormal enhancement in cervical or thoracic central spinal canal. T7-8:R paramedian disc protrusion and L paramedian small disc extrusion with mild central stenosis. XRAY CERVICAL SPINE 2006: NORMAL 15. Functional impact ---------------------- Does the Veteran's cervical spine (neck) condition impact on his or her ability to work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's cervical spine CONFIDENTIAL Page 43 of 161 (neck) conditions, providing one or more examples: MANUAL LABOR WOULD BE DIFFICULT FOR THIS VETERAN 16. Remarks, if any: -------------------- VA FORM 21-2705 REQUESTED DBQ BACK, HOWEVER BODY OF REQUEST NOTES CERVICAL SPINE CONDITION. DBQ CHANGED TO NECK (CERVICAL SPINE) Signed By: MELENDY,KAREN L
  10. I had a sit down with a neurologist to review my MRI about my neck problem and what he said sort of shocked me. Currently 20% rated for "cervical strain" awarded back in 09. (They never did the MRI). The imaging revealed degenerative disc disease with 2 herniated discs which are pinching a nerve which makes my left arm basically useless. Bone spurs too. Except the nerve thing, same symptoms I've always had since injury so I'm thinking the VA misdiagnosed me. I just sort of dealt with it but after 2 months of pain meds I had enough. Debating on asking for an increase but not sure how to go about it. Any suggestions would be greatly appreciated. Thanks again.
  11. I recently had a C&P exam for my cervical degeneration and bilateral nerve damage. I am currently SC'd for 20% cervical strain. I had IMO diagnosis and MRI results which confirmed these contentions + 2 herniations. I picked up my exam copy and was shocked to see the examiner did not recommend service connection. She totally dismissed the possibility and instead reported it was more probable do to old age. (I am 40). I am really surprised. She asked me what my MOS was and I told her I was a grunt. She asked me when I initially injured it (cervical strain) and I told her my chin was stuck to my shoulder for three weeks after I took a stumble down a cliff with a 130 pound ruck on my back. I have been struggling with this for the past 7 years. I just assumed it was a bad strain until I started feeling bad pain in my arms. I'm so upset, frustrated. I thought this claim would be a no brainer but It just goes to show ya.
  12. In September I contacted a Veteran Attorney firm. They filed every service connection I had for increase plus 2 new contentions (IBS & Spinal conditions). I had my C&P exam last Saturday and I think it went extremely well. I had medical diagnosis from a private GI specialist for the IBS and a private Neurosurgeon diagnosis with MRI confirming DDD of the cervical spine with damage to my nerve root causing radiation into my upper extremities. The lawyers can't officially represent my claim until I receive denial and didn't want me to submit any evidence since if my claim is approved out of the gate they can't legally get paid. Well I did anyway and I have a good feeling about it. The examiner seemed to confirm all my contentions and she was very thorough (the exam took about 2 hours). She mentioned I had the spine of an 80 year old and at the end, encouraged me to walk away from my job. She even tested me for old injuries that I had long forgot that she found in my C- file, so I feel pretty confident about it all. The only thing of concern is that although I'm already rated for cervical strain, and I never got a private nexus for the DDD. I remember her saying however that I must have had DDD for a very long time because of the stage it's at and because I'm still very young. Hopefully she will put it all together for me. I guess I'll just have to wait until I request a copy later next week. I'll keep everyone informed when I do considering the semi unique way I went about this. Thanks for your time.
  13. Just want to post my exams to see what you guys and gal think, these exams were from Friday Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Name of patient/Veteran: 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 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Major Depressive Disorder with Anxious Distress ICD code: 296.32 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): n/a 2. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ] Not shown in records reviewed 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 reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[ ] No[X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ a. Medical record review: Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: previous exam, decision narrative b. Was pertinent information from collateral sources reviewed? [ ] Yes[X] No MENTAL STATUS: Appearance: casually dressed, adequately groomed Activity: normal, no psychomotor agitation or retardation Attitude: pleasant, polite, cooperative Speech: fluent, coherent Mood: depressed Affect: worried, mood congruent Perception: no hallucinations Thought flow: logical, goal directed Thought content: no delusions Thoughts of harm: no suicidal/homicidal ideation Level of consciousness: alert Oriented: to all spheres Attention: fair Current Suicide Risk Factors: _X____ Does not have thoughts of suicide or self harm at this time _X____ Does not express feelings of hopelessness or helplessness at this time Current Suicide Assessment: _X____ Low: Patient judged NOT to be at significant risk for self-harm d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Denied e. Relevant Substance abuse history (pre-military, military, and post-military): Denied f. Other, if any: 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] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Disturbances of motivation and mood Behavioral observations: worried 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [X] Yes[ ] No If yes, describe: reduced concentration, restlessness, irritability, fatigue 5. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 6. Remarks (including any testing results), if any: --------------------------------------------------- On August 4, 2014, VA published an interim final rule, RIN 2900-A096 - Mental Disorders and Definition of Psychosis for Certain VA Purposes to update regulations in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The publication of this interim final rule indicates that a diagnosis of a mental disorder must conform to the standards set in the DSM-5. As of August 28, 2014 all examinations must be conducted utilizing DSM-5. Examiners no longer need to comment on DSM-IV diagnostic criteria if DSM-5 diagnostic criteria is not met. The GAF score is not used in DSM-5. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination 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: VHA medical records MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Is the Veteran's recurrent major depression a continuation of the complaint/note in service? b. Indicate type of exam for which opinion has been requested: DBQ Mental Disorder 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: Veteran's current symptoms are the same symptoms noted while in the service. His symptoms are ongoing and are considered a continuation of the same disorder. ************************************************************************* ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Sep 2014 @ 1300 Note Title: COMPENSATION AND PENSION EXAMINATION Location: MARTINSBURG VAMC Signed By: CANETE,LUCILA Z Co-signed By: CANETE,LUCILA Z Date/Time Signed: 19 Sep 2014 @ 1600 ------------------------------------------------------------------------- LOCAL TITLE: COMPENSATION AND PENSION EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: SEP 19, 2014@13:00 ENTRY DATE: SEP 19, 2014@16:00:13 AUTHOR: CANETE,LUCILA Z EXP COSIGNER: URGENCY: STATUS: COMPLETED Fibromyalgia Disability Benefits Questionnaire Name of patient/Veteran: 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 efile; VAMC 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 Date of diagnosis: 2005 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: 33 years old USAirforce veteran from 2000 to 2006, is here for a C&P evaluation on his current condition of fibromylagia. In 2003, he started coming unexplained fatigue which described coming with similar symptoms when one suffers from flu-like symptoms when one developes generalized muscle soreness, insides of both legs, thighs, shoulder and neck areas and medial side of both arms and achiness of both hands (described it as fatigue feeling). When he would wear the body armour, he feels that his entire body feels sore and touch of the armor which is heavy makes him feel the soreness. More noticeable over the medical surfaces of the thighs. During his active service he worked with Nuclear Program at Minot, Airforce Base, North Dakota he is on strict monitoring due to the sensitivity concern of the program. (Perosonal Reliability Program). Around the same year 2003 the Base physician and several times 2003-2004. He was tried on Amytriptylline 25 mg po hs which helped X 2 months only to return back to his initial symptoms. 6 months before he left the USAirforce, he had sleep study done which confirmed sleep apnea which he wears CPAP to date. It seemed to help his drowsiness during the daytime but it has not affected his sensation of muscle soreness. He had a medical board but was honorably discharged. He was recommended not eligible to re-enlist and or serve the remaining 2 years of inactive reserve. He has been coming here at Martinsburg VA since 2012 for scheduled Compensation & Pension Evaluation. He has been placed on Sertraline for depression which did not help his body pain. It has been discontinued and not on any medications. He sees the Pain Mgmt for his neck complaints and have an appointment for PT regarding the rest of his body pains. Reviewed vbms STRS efile: 11/10/2005: Routine Physical Examination Note on his active problem list: Mylagias/Myositis (Non-specified) Multiple progress notes/Behavioral Clinic: Mild Depression 2003/ Major Depression 2005/ Involutional Melancholia 2005. Medications: Amitriptylline 25 mg po qd (prescribed to problems with Depression) No specific mention that this was given for fibromyalgia. 1/25/2005 Progress notes: Mentioned that member was seen prior for fibromyalgia which responded well to Elavil a hs. Mention about implication for his work statys (PRP) using Elavil. There as a discussion with Dr. Higgins who mentioned that the medication causes no limiting side effects, and is not being used for anti-depressant purposes, that this case does not automatically require PRP suspension. Memorandum from XXXXwritten by TODD P Huhn, CAPT, USAF, MC XXXXXhas been seen for symptoms consistent with fibromylgia, a condition of chronic muscle pain. He responded very well to medication for this which he takes at night. This is not being used as an anti-depressant medication. After conferring with the AFSPC PRP medical consultant, Lt. Col Higgins, we concurred that Sra XXX was medically cleared to take this medication and maintain his PRP clearance. Routine H&P by an outpatient primary care provider at Martinsburg VA 7/18/2014: LOCAL TITLE: PHYSICIAN, PRIMARY CARE/OUTPATIENT CLINIC STANDARD TITLE: PRIMARY CARE PHYSICIAN NOTE DATE OF NOTE: JUL 18, 2014@08:59 ENTRY DATE: JUL 18, 2014@09:01:34 AUTHOR: VU,PETER D EXP COSIGNER: URGENCY: STATUS: COMPLETED CHIEF COMPLAINT: chronic neck strain w/ headache PRESENT ILLNESS: said he has chronic neck strain and occasional tension headache w/o any trauma or injury. pt said he needs clearance to participate in walk for wellness at home. pt gained some wt w/ BMI >35. Today,PT denies any SI or HI,fever,chills,sob,cp, productive cough, n/v,abdominal pain,vision problems, weakness, dizziness,headache, change of bm,orthopnea, palpitation,syncope, LOC, urinary or stool incontinence, hematuria or hematochezia. PAST HISTORY: Active problems - Computerized Problem List is the source for the following: 1. Recurrent major depression (SNOMED CT 66344007) 09/30/13 ASGHAR,ALI 2. Nonallopathic lesions of rib cage 3. Pain in Thoracic Spine 05/09/13 NEFF,SHAWN M 4. Somat Dysfunc Thorac Reg 05/09/13 NEFF,SHAWN M 5. Somat Dysfunc Cervic Reg 04/09/13 NEFF,SHAWN M 6. Cervicalgia 04/09/13 NEFF,SHAWN M 7. Headache 8. Hyperlipidemia 01/24/13 VU,PETER D 9. SUBJECTIVE TINNITUS 01/23/13 SHALLIS,JULIE B 10. Depression 01/18/13 VU,PETER D 11. GERD 01/18/13 VU,PETER D 12. Anxiety 01/18/13 VU,PETER D 13. Cholelithiasis 01/18/13 VU,PETER D 14. Hx of tobacco user in remission 01/18/13 VU,PETER D 15. OSA on c-pap 01/18/13 VU,PETER D 16. Hx of tinnitus 01/18/13 VU,PETER D 17. Irritable Bowel Syndrome PHYSICAL EXAM: GENERAL: ambulatory, awake, alert, oriented x3,nad, pleasant,obese young man. HEENT: PERRLA. Clear oropharynx and tympanic membrane. no sinus tenderness. no cervical adenopathy. NECK: No bruits or stiffness. Good ROM w/o difficulty but mild discomfort on rotation and moderate trapezius muscle stiffness on palpation. CHEST: Chest normal shape and symmetrical.No masses,tenderness or other abnormalities LUNGS: Clear, no crackles, wheezing, or rhonchi. HEART: RSR, no murmurs, no gallop ABDOMEN: obese. Soft, non tender, positive bowel sounds, liver and spleen are not palpable. No rebound tenderness to palpation. BACK: No cva tenderness or point tenderness.slr negative. EXTREMITIES: No edema. Good ROM w/o pain or difficulty. Good muscle strength and tone plus well developed muscle. nl sensation and good radial pulse and capillary refill. NEUROLOGICAL: Cranial nerve intact, no focal deficit, ambulatory w/o difficulty. ASSESSMENT: - Hx of chronic neck strain: discussed and full explaination about his condition and booklet about neck given w/ instruction for home exercise. increase flexeril to 10mg qhs prn w/advise of side effects and continue heating pad alternate w/icepack. pt already was tx by PT, chiropractor and pain school in past. pt said he does not want to be on pain medication. pt had xray of neck in past was negative. -hx of IBS: Discussed and tx w/ bentyl 10mg bid and metamucil and f/u GI as directed. -hx GERD: on prilosec -hx Depression/anxiety: stable and denies any SI or HI. f/u w/ MHC as directed. -hx of OSA:stable on C-pap b. Is continuous medication required for control of fibromyalgia symptoms? [ ] Yes [X] No c. Is the Veteran currently undergoing treatment for this condition? [ ] Yes [X] No d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [X] Yes [ ] 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] Fatigue [X] Sleep disturbances [X] Headache [X] Depression [X] Irritable bowel symptoms For all checked conditions, describe: Musculoskeletal symtpoms: 1) constant sensation of 'muscle fatigue/sore'on both anterior thighs, skin feels sore over the medial portion of both thighs, localized sensitivity(soreness) over the specific medial portion of both arms, bilateral scapular muscles and back of his neck. 2) Feels tired even if he has not done anything but can still do his routines both at home and at work. 3) He feels no motivation, problems with concentration, crying for no reasons, feels anxiety and hx/o bouts of panic attack and chest pain while in the active service. Diagnosed with Depression while in the active service and was not placed on medication because he wants to continue working with Nuclear Program. Taking a anti-depressants will disqualify him from that program. He was evaluated by a psychologist. He was receiving regular psychological therapy while in the active service. He is currently seen by psychologist here at Martinsburg VA and received Cognitive Therapy and currently on the HOPE Program (Group Therapy). No medications for depression given to date. 4) Hx/o IBS and is service connected for IBS. Takes Dicyclomine BID. He said his current meds seem to help him. b. Frequency of fibromyalgia symptoms (check all that apply): [X] Constant or nearly constant c. Does the Veteran have tender points (trigger points) for pain present? [ ] Yes [X] No 4. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- 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 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? [ ] Yes [X] No 7. Remarks, if any: ------------------- He now works both patroling and now in the office. He has so far able to carry on his duties as a security officer. Physical examination today revealed: (-) direct tenderness on palpation over the occipital, supraspinatus, sternal, knees. He points to overall sensation of soreness on his neck area, and localized sensitivity on the bilateral thigh muscles and linear medial thigh bilaterally and medial areas on both arms. Strength 5/5 all throughout. Sensory are all WNL both upper and lower extremeties. **************************************************************************** Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims 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 efile; VAMC If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No Cervical Spine Common Diagnoses: [ ] Ankylosing spondylitis [X] Cervical strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Cervical Strain (Cervicalgia) ICD code: 847.0 Date of diagnosis: 2002-2003 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's cervical spine (neck) condition (brief summary): 33 years old USAirforce veteran from 2000 to 2006, is here for a C&P evaluation on his neck condition. In 2002-2003, he start noticing when he works out his posterior neck feels sore. He said he has problems wearing the ballistic helmet. He feels localized soreness on the back of his head and also localized sensation of soreness over the parietal portion of his head. He was referred while in the active service to PT. In 10/25/2004. MRI of his neck was carried out which showed very minor disc bulge C5-C6 and C6-C7 levels, not felt to be of significance. Stretching exercises while in PT helped. But sit-ups and turning it wrong and bending it a lot seems to accentuate the neck soreness. He described his constant low level soreness 2-3/10. It feels tight most of the time. He has upcoming schedule for PT related to the neck but also to his complaints of his wholebody pain. 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the cervical spine (neck)? [ ] Yes [X] No 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Select where forward flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater b. Select where extension ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater c. Select where right lateral flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater d. Select where left lateral flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater e. Select where right lateral rotation ends (normal endpoint is 80 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [X] 70 [ ] 75 [ ] 80 or greater Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater f. Select where left lateral rotation ends (normal endpoint is 80 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [X] 80 or greater Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater g. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a cervical spine (neck) condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------- a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Select where post-test forward flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater c. Select where post-test extension ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater d. Select where post-test right lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater e. Select where post-test left lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater f. Select where post-test right lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [X] 70 [ ] 75 [ ] 80 or greater g. Select where post-test left lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [X] 75 [ ] 80 or greater 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the cervical spine &
  14. LOCAL TITLE: C&P EXAMINATION 16255 STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: AUG 18, 2014@10:00 ENTRY DATE: AUG 20, 2014@11:38:48 AUTHOR: URGENCY: STATUS: COMPLETED Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: none If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No Cervical Spine Common Diagnoses: [ ] Ankylosing spondylitis [ ] Cervical strain [X] Degenerative arthritis of the spine [X] Intervertebral disc syndrome [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: degenerative arthritis ICD code: 721.10 Date of diagnosis: 2014 Diagnosis #2: IVDS ICD code: 353.2 Date of diagnosis: 2014 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's cervical spine (neck) condition (brief summary): veteran had sustained a vehicle accident while on orders 5 months before he deployed in Iraq ,it was a rollover accident. he was stationed in Wisconsin and he believe he had normal cervical spine X-ray they were reporetd normal, without a fracture and it's only during deployment in 2- 3 2010 that he complained of bad neck pain and numbness in hands in Monterey VA in 2014 they had X-rays of his shoulders and was told that his issues were coming from his neck , he had neck arthritis ; he was sent to TMC while in Iraq and complaining of his neck and was told that neck was ok to continue his duties and he did current symptoms are constant 6/10 pain , and if turns his neck shoots to a 8/10 and disrupts his sleep. Re his MOS he was in transportation with lots of driving heavy truck and as well a s lifting daily about 35- 50 Lb daily plus all they usual weight they had to carry on ther back 3. Flare-ups ------------ 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: takes hot shower and OTC medication , gets a massage from his wife 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Select where forward flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater b. Select where extension ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater c. Select where right lateral flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater d. Select where left lateral flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater e. Select where right lateral rotation ends (normal endpoint is 80 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater f. Select where left lateral rotation ends (normal endpoint is 80 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater g. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a cervical spine (neck) condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------- a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Select where post-test forward flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater c. Select where post-test extension ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater d. Select where post-test right lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater e. Select where post-test left lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater f. Select where post-test right lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater g. Select where post-test left lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the cervical spine (neck) following repetitive-use testing? [ ] Yes [X] No b. Does the Veteran have any functional loss and/or functional impairment of the cervical spine (neck)? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the cervical spine (neck) after repetitive use, indicate the contributing factors of disability below: [X] Less movement than normal [X] Pain on movement 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait) ---------------------------------------------------------------------------- a. Does the Veteran have localized tenderness or pain to palpation for joints/soft tissue of the cervical spine (neck)? [X] Yes [ ] No b. Does the Veteran have muscle spasm of the cervical spine resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No c. Does the Veteran have muscle spasms of the cervical spine not resulting in abnormal gait or abnormal spinal countour? [X] Yes [ ] No d. Does the Veteran have guarding of the cervical spine resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No e. Does the Veteran have guarding of the cervical spine not resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No 8. 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 9. 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+ 10. 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 (C6-8): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 11. Radiculopathy ------------------ Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate location and severity of symptoms (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] 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 C5/C6 nerve roots (upper radicular group) [X] Involvement of C7 nerve roots (middle radicular group) d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 12. Ankylosis ------------- Is there ankylosis of the spine? [ ] Yes [X] No 13. 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 14. Intervertebral disc syndrome (IVDS) and incapacitating episodes ------------------------------------------------------------------- a. Does the Veteran have IVDS of the cervical spine? [X] Yes [ ] No b. If yes, has the Veteran had any incapacitating episodes over the past 12 months due to IVDS? [ ] Yes [X] No 15. 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 16. 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 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.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 17. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. 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 b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? [ ] Yes [X] No 18. Diagnostic testing ---------------------- a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No b. Does the Veteran have a 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): MRI CERVICAL SPINE W/O CONTRAST Exm Date: MAY 23, 2014@18:42 Impression: 1. Moderate degenerative changes in the cervical spine predominantly at C5-6 and C6-7 with moderate canal stenosis at C5-6 and mild canal stenosis at C6/7. 2. Areas of moderate to severe neural foraminal narrowing at these 2 levels. 3. Image quality slightly degraded by patient motion artifact on multiple sequences. 19. Functional impact ---------------------- Does the Veteran's cervical spine (neck) condition impact on his or her ability to work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's cervical spine (neck) conditions, providing one or more examples: has to get someone else to do the heavy duties at work and he is on profile with no lifting , unable to wear body armor or anything that will place more pressure on his neck no pull up 20. REMARKS ----------- a. Remarks, if any: No comments provided. b. Mitchell criteria: 1. Whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Answer: yes, pain would significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time 2. Describe any such additional limitation due to pain, weakness, fatigability or incoordination, and if feasible, this opinion should be expressed in terms of the degrees of additional ROM loss due to "pain on use or during flare-ups" Answer Pain could limit his range of motion at the extreme ends of the ROM, but I am unable to speculate precisely how much limitation of ROM he would experience during a flareup, It is not possible without resorting to mere speculation to estimate either loss of ROM or describe loss of function because there is no conceptual or empirical basis for making such a determination w/o directly observing function under these conditions. **************************************************************************** Shoulder and Arm Conditions Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: none If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a shoulder and/or arm condition? [X] Yes [ ] No Diagnosis #1: sprain ICD code: 840.9 Date of diagnosis: 2014 Side affected: [ ] Right [ ] Left [X] Both 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's shoulder and/or arm condition (brief summary): he has had issues with his shoulders since AD when he was doing work working a lot above his shoulders during AD when deployed in 2009 ; he was told that X-rays were normal; had some PT but not much help symptoms got worse during his MVA and are now chronic , FU caused by any job he will do using his hands elevated above his shoulders and when he drives b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the shoulder and/or arm? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: stops his activities 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Right shoulder flexion Select where flexion ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [X] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 b. Right shoulder abduction Select where abduction ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 c. Left shoulder flexion Select where flexion ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [X] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 d. Left shoulder abduction Select where abduction ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [X] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 e. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a shoulder or arm condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------ a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Right shoulder post-test ROM Select where flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [X] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where abduction ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 c. Left shoulder post-test ROM Select where flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [X] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where abduction ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [X] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the shoulder and arm following repetitive-use testing? [X] Yes [ ] No b. Does the Veteran have any functional loss and/or functional impairment of the shoulder and arm? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the shoulder and arm after repetitive use, indicate the contributing factors of disability below (check all that apply and indicate side affected): [X] Less movement than normal [ ] Right [ ] Left [X] Both [X] Pain on movement [ ] Right [ ] Left [X] Both 7. Pain (pain on palpation) --------------------------- a. Does the Veteran have localized tenderness or pain on palpation of joints/soft tissue/biceps tendon of either shoulder? [X] Yes [ ] No If yes, shoulder affected: [ ] Right [ ] Left [X] Both b. Does the Veteran have guarding of either shoulder? [ ] Yes [X] No 8. Muscle strength testing -------------------------- 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 BENJAMIN, CHRISTIAN TELEFORD CONFIDENTIAL Page 53 of 77 Shoulder 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 [ ] 0/5Shoulder forward 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 9. Ankylosis ------------ Does the Veteran have ankylosis of the glenohumeral articulation (shoulder joint)? [ ] Yes [X] No 10. Specific tests for rotator cuff conditions ---------------------------------------------- a. Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation indicates a positive test; may signify rotator cuff tendinopathy or tear.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A If positive, side affected: [ ] Right [ ] Left [X] Both b. Empty-can test (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner. Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A c. External rotation/Infraspinatus strength test (Patient holds arm at side with elbow flexed 90 degrees. Patient externally rotates against resistance. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A If positive, side affected: [ ] Right [ ] Left [X] Both d. Lift-off subscapularis test (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may indicate subscapularis tendinopathy or tear.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A If positive, side affected: [ ] Right [ ] Left [X] Both 11. History and specific tests for instability/dislocation/labral pathology --------------------------------------------------------------------------- a. Is there a history of mechanical symptoms (clicking, catching, etc.)? [X] Yes [ ] No If yes, side affected: [ ] Right [ ] Left [X] Both b. Is there a history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint? [ ] Yes [X] No c. Crank apprehension and relocation test (With patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of instability with further external rotation may indicate shoulder instability.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 12. History and specific tests for clavicle, scapula, acromioclavicular (AC) joint, and sternoclavicular joint conditions ---------------------------------------------------------------------------- a. Does the Veteran have an AC joint condition or any other impairment of the clavicle or scapula? [ ] Yes [X] No b. Is there tenderness on palpation of the AC joint? [ ] Yes [X] No c. Cross-body adduction test (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 13. Joint replacement and/or other surgical procedures ------------------------------------------------------ a. Has the Veteran had a total shoulder joint replacement? [ ] Yes [X] No b. Has the Veteran had arthroscopic or other shoulder surgery? [ ] Yes [X] No c. Does the Veteran have any residual signs and/or symptoms due to arthroscopic or other shoulder surgery? [ ] Yes [X] No 14. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. 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 b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): OTHER ROM'S IN DEGREES RSHOULDER INTERNAL ROTATION 80 pain at 40 EXTERNAL ROTATION 65 pain at 65 L SHOULDER INTERNAL ROTATION 70 pain at 20 EXTERNAL ROTATION 70 pain at 30 15. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's shoulder and/or arm conditions, 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) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 16. Diagnostic Testing ---------------------- a. Have imaging studies of the shoulder been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): SHOULDER, RIGHT COMPLETE (RAD Detailed) CPT:73030 Proc Modifiers : RIGHT Reason for Study: check for DJD thanks Clinical History: Report Status: Verified Date Reported: AUG 18, 2014 Date Verified: AUG 18, 2014 Verifier E-Sig: Report: Comparison: None Impression: 3 view right shoulder show no fracture, dislocation nor bony destructive change. Normal acromio-clavicular joint . Normal subacromial joint space . Normal glenohumeral joint space . Primary Diagnostic Code: NORMAL COMPLETE) SHOULDER, LEFT COMPLETE (RAD Detailed) CPT:73030 Proc Modifiers : LEFT Reason for Study: check for DJD thanks Clinical History: Report Status: Verified Date Reported: AUG 18, 2014 Date Verified: AUG 18, 2014 Verifier E-Sig: Report: Comparison: None Impression: 3 view left shoulder show no fracture, dislocation nor bony destructive change. Normal acromio-clavicular joint . Normal subacromial joint space . Normal glenohumeral joint space . Primary Diagnostic Code: NORMAL 17. Functional impact --------------------- Does the Veteran's shoulder condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's shoulder conditions providing one or more examples: issues with occupatio requiring lifting overhead or repeetitive working overhead 18. REMARKS ----------- a. Remarks, if any: No comments provided. b. Mitchell criteria: 1. Whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Answer: yes, pain would significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time 2. Describe any such additional limitation due to pain, weakness, fatigability or incoordination, and if feasible, this opinion should be expressed in terms of the degrees of additional ROM loss due to "pain on use or during flare-ups" Answer Pain could limit his range of motion at the extreme ends of the ROM, but I am unable to speculate precisely how much limitation of ROM he would experience during a flareup, It is not possible without resorting to mere speculation to estimate either loss of ROM or describe loss of function because there is no conceptual or empirical basis for making such a determination w/o directly observing function under these conditions **************************************************************************** Sleep Apnea Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: none If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran have or has he/she ever had sleep apnea? [X] Yes [ ] No [X] Obstructive ICD code: 780.57 Date of diagnosis: 05/2011 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's sleep disorder condition (brief summary): C/O sleep issues since he was deployed to Iraq in 2010 and he was Dx with OSA in 2011 ; he was initially on CPAP but he has touble with wearing it , especially since the nightmares form his PTSD disrupt his sleep all together he does not sleep for longer than 6 hours/ night , wearing the machine only 2- 3 hours at time and was Rx BIPAP insteat by cleep clinic in palo alto b. Is continuous medication required for control of a sleep disorder condition? [ ] Yes [X] No c. Does the veteran require the use of a breathing assistance device? [X] Yes [ ] No d. Does the Veteran require the use of a continuous positive airway pressure (CPAP) machine? [X] Yes [ ] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to sleep apnea? [X] Yes [ ] No If yes, check all that apply: [X] Persistent daytime hypersomnolence 4. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. 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 b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 5. Diagnostic testing --------------------- a. Has a sleep study been performed? [X] Yes [ ] No If yes, does the Veteran have documented sleep disorder breathing? [X] Yes [ ] No Date of sleep study: 5/25/2011 Facility where sleep study performed, if known: anville Il VA Results: osa as per VA Dx , SEVERE , AHI 72 AVERAGE O2 SAT 91 % AND LOWEST 68 % b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact -------------------- Does the Veteran's sleep apnea impact his or her ability to work? [ ] Yes [X] No 7. Remarks, if any: ------------------- ALREADY dX WITH osa SINCE 2011 AND ON CPAP THEN CURRENTLY BIPAP 5/25/11 PSN Dx severe OSA **************************************************************************** Medical Opinion Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [ ] 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. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination 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: none MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Priority processing GWOT. Please expedite. Over One Year Old Claim Date of claim: 05/24/2013 Days pending: 439 Veteran has a power of attorney. Please send a courtesy copy of the exam notice letter to CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS The Veteran will need to report for the following exam(s): DBQ MUSC Neck (cervical spine) DBQ MUSC Shoulder and arm DBQ PSYCH Initial PTSD DBQ RESP Sleep apnea ____________________________________________________________________________ _________ " **************************************************************************** ********* DBQ MUSC Neck (cervical spine): MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION : Direct service connection Does the Veteran have a diagnosis of (a)neck condition that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) long term wear of ACH and poor road conditions while serving in Iraq? Rationale must be provided in the appropriate section. **************************************************************************** ********* 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: REVIEW OF VISTA WEB 3/20/09 SHOWS EVIDENCE OF THE ROLL OVER ACCIDENT; C SPINE X-RAY WERE TAKEN AT THE TIME WITH EVIDENCE OF MILD DDD AS WELL AS EVIDENCE OF WHIPLASH INJURY AS TYPICAL REPORTED FINDINGS WHICH IS A RISK FACTOR FOR CHRONIC NECK ISSUES AND DJD/ DDD WITH RADICULOPATHY ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: DBQ MUSC Shoulder and arm: MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION : Direct service connection Does the Veteran have a diagnosis of (a)bilateral conditions that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) long term wear of ACH and poor road conditions while serving in Iraq? Rationale must be provided in the appropriate section. **************************************************************************** ********* b. Indicate type of exam for which opinion has been requested: SHOULDERS 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: HAS HAD PER VISTA WEB ROLL OVER ACCIDENT IN 2009 AS WELL AS COMPLAINS OF HIS BILATERAL SHOULDERS IN 5 2010 AS XRAYS WERE TAKEN AS WELL AS 2011, AS EVIDENCE OF CHRONIC BILATERAL SHOULDERS ISSUES ; CONDITION IN VIEW OF THE ACCIDENT WAS AT LEAST AS LIKELY AS NOT CONTRIBUTED AS ETIOLOGY BY THIS MAJOR ROLL OVER ACCIDENT ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: DBQ RESP Sleep apnea: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. A sleep study is not of record. Please conduct a sleep study as part of your exam. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection. OPINION REQUESTED: Secondary Service Connection. Is the Veteran's sleep apnea at least as likely as not (50 percent or greater probability) proximately due to or the result of PTSD/Depression? Rationale must be provided in the appropriate section. b. Indicate type of exam for which opinion has been requested: SLEEP TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] b. The condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: THERE IS NO EVIDENCE THAT PTSD CAUSES OSA;ETIOLOGY OF OSA IS USUALLY CAUSED BY UPPER AIRWAYS CONDITIONS , NOT DEPRESSION NOR PTSD. PLEASE SEE ALSO MH OPINION IF QUESTION ASKED ALSO TO MH PROVIDER ************************************************************************* Attached the following: Sleep Apnea secondary to PTSD The veteran further claims that his sleep condition is secondary to, but separate from, PTSD. Supporting this contention are studies done by Brooke Army Hospital and Walter Reed Army Hospital. In the Brooke Army Hospital report, entitled Sleep Disordered Breathing in Combat Veterans with PTSD, researchers concluded that "data show that more than 70% of those active-duty members who carry a diagnosis of PTSD are at risk for the diagnosis of obstructive sleep apnea". In the Walter Reed Hospital report, entitled Prevalence of Sleep Disorders among Soldiers with Combat Related Posttraumatic Stress Disorder, researchers concluded that "sleep complaints were almost universal among soldiers with PTSD. The majority were diagnosed with insomnia and/or obstructive sleep apnea". In a BVA decision involving the Hartford, Connecticut VA regional office (Docket#10-25 465) entitlement to service connection for obstructive sleep apnea as secondary to PTSD was granted with 'Reasons and Bases for Findings and Conclusions' based upon the studies cited above. c. Rationale: THERE IS NO EVIDENCE THAT PTSD CAUSES OSA; ETIOLOGY OF OSA IS USUALLY CAUSED BY UPPER AIRWAYS CONDITIONS, NOT DEPRESSION NOR PTSD. Contrary to the opinion of, Cxxxxx F Cxxxxx, MD, the above shows connection of obstructive sleep apnea to PTSD. ******************************************************************************************************************************************** 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's Cervical spine (neck) condition (brief summary): Veteran had sustained a vehicle accident while on orders 5 months before He deployed in Iraq, it was a rollover accident. He was stationed in Wisconsin and he believe he had normal cervical spine X-ray They were reported normal, without a fracture and it's only during Deployment in 2- 3 2010 that he complained of bad neck pain and numbness In hands in Monterey VA in 2014 they had X-rays of his shoulders and was told that His issues were coming from his neck, he had neck arthritis; he was sent To TMC while in Iraq and complaining of his neck and was told that neck Was ok to continue his duties and he did Current symptoms are constant 6/10 pain, and if turns his neck shoots to a 8/10 and disrupts his sleep. All ROM of the cervical neck pain started at (0). Was asked to report when pain increased, as per her report current symptoms are a constant 6/10 pain
  15. Hi everyone. Just thinking out loud about what I should do next. I was just awarded 70% for 1 MH contention and am considering 3 different routes to take. 1) they deleted my TBI rating % citing "pyramiding " which left me 2 points short of 95. I am considering filing a notice of disagreement for increase. I will be hiring an attorney to do this. 2) Filing new contentions. I am 20% SC for cervical strain but now it's become arthritic and has given me serious nerve damage issues that I will need surgery for. 3) do both at the same time. Any suggestions would be great!
  16. Ok. So I received my C an P exam results back. They put major depression: occupational and social impairment with reduced reliability and productivity. Mild memory loss...Flattened effect...impaired judgment Impaired abstract thinking Disturbances of motivation and mood....difficulty in establishing and maintaining effective work and social relationships Difficulty in adapting to stressful circumstances Inability to establish and maintain effective relationships Right knee osteoarthritis and severe bilateral knee chondromalacia 50 forward flexion and pain Left knee 100 forward flexion no pain Lumbar strain...less movement than normal... Forward flexion 75 Cervical strain...less movement than normal Left lateral rotation 55...pain on movement And abnormal lymphatic was marked on line 25....not really sure what that's about.
  17. I was service connected 20% for cervical strain (neck). back in 09. About 6 months ago, I re-injured it working in my yard and its been absolutly horrible. I now have pain and numbess wrapping around my back, into my shoulder, down my arm and elbow and into my hand. I spoke to my doctor and he said it has become "degentrative" and the pain and numbness I have experiencing is nerve damage. My question is do I claim and increase or has this become a completely different condition/s all together? Any advice would be helpful. God bless.
  18. Well I dont know where to start. Its hard for me not to use irrational words as its so freaking hard to contain myself. Today I logged in to ebenefits and the "Open Claims" was unavailable. I then looked down in the completed section and saw that my claim which I started June 2012 was closed out as of today 9/30/13 and I couldnt beleive my eyes. I immediately went over to create my benefits summary and said a little prayer before it loaded and sure enough there it was !!!! 100% !!!! My head felt like it was going to explode, its really hard to describe. 16 months !!! I then saw the link for commisary letter and Deers enrollment and that gave me the hint of the P&T. I originally filed my claim in JUNE 2012 out of Manhattan RO for IU for Bipolar Disorder II & Increase for Cervical Strain (Neck) and Bilateral Shoulder Tears. I was rated at 80% at the time. I hope Im not jumping the gun because Im basing all of this excitement out of my results from ebenifits as I have not received my Big Brown Envelope yet. I moved from New York to Ca in August 2012 but my claim wasnt transferred to the Los Angeles RO until July 2013. From the time I submitted everything back in June 2012 things moved very fast but came to a halt around Nov.2012 then got stuck at "Preparing for Decision". In August 2013 it jumped back to Collecting Dust, and I was called in for 2 More C&P Exams, one of which resulted in my car being towed !!! which I wont get into. As far as I know, I will now be eligible for base/commisary priveleges. Still waiting for the results of my PDBR (Physical Disability Board of Review) Results which was filed around the same time as my increase. This is my first post on this site but I have literally been on here 3-5 times a week the past year and I although none of you know me, I feel like I know alot of you. Thank you all for the knowlege and support I owe you all a round of drinks ! ! ! Now Im just crossing my fingers that this government shutdown doesnt interfere with my first payment as Im tapped out from borrowing funds from family and friends. God Bless 100% P&T - 9/30/13 SSDI 2006 PDBR - pending
  19. I have never posted before, but I have read probably every post posted within the last four years. Below is a synopsis of filing my initial claim for benefits after leaving Active Duty. VA Disability rating at 60% combined for: Degenerative Disc Disease L3-L4 - 40% Cervical Strain - 20% Right Knee post Meniscus Surgery - 10% Tinnitus - 10% Migraines - 0% Right Shoulder - Torn Rotator Cuff- 0% I appointed DAV to file the claim on my behalf. At times it was frustrating, but in the end I felt they represented my interest well. Timeline: Active Duty Army 2006-2012, OIF 07-09 and OIF 10-11, Filed initial claim 25 March 2013, moved to gathering evidence 15 June, Submitted IRIS inquiry on 20 December 2013 asking about status of claim, Received response to IRIS on 30 December 2013, Claim moved from Gathering Evidence to Complete between 1 January and 3January, Received Retroactive Pay via Direct Deposit on 6 January. I wanted to say Thank you to all the dedicated posters on Hadit.com, I truely feel that your expertise helped me compile a very solid claim.
  20. Recently I filed a claim for: Claim Received: 03/06/2013 Claim Type: Compensation Claim Closed: 02/01/2014 Contentions: Thoracic strain with lumbar facet arthropathy L5-S1 (Increase), cervical strain (claimed as tendonitis of neck) (Increase), PTSD- personal trauma w/anxiety d/o and panic attacks (New), Pinfueculitis, bilateral eye (New), VBMS (New), Right ankle, stable joint, aterior talodibulat chronic strain (Increase) My files are routed through the Houston Regional Office. During the QTC exam the Doctor only filled out the questioner and gave me an x-ray of my neck and back, no physical exam was conducted on either. My back was changed to thoracic strain with lumbar facet arthropathy, L5-S1 with IVDS and radiculopathy and my neck is still listed as a cervical strain and I was denied for increase and still I am rated at 10% for both ratings and the Doctor for the QTC verbally told me that both conditions has gotten worse in his medical opinion but as I stated no physical exam, range of motion or anything was conducted, just the questioner and an x-ray which I already had when I was previously awarded 10% for both service connected injuries, where a range of motion was conducted during those two exams. On my claim I also claimed two new conditions one for pinguecula in both eyes and PTSD and did not have a C&P for either. Both of those claims were also denied. I had a separate C&P exam conducted by QTC for the Right ankle, stable joint, aterior talodibulat chronic strain (Increase) and the Doctor for this exam was pretty confused and asking my rudely why I thought my condition had gotten worse and what was worse about it when I had already filled out the questioner provided by QTC for this exam which he had in front of him. My ankle recently rolled on me prior to the exam so during the exam it was swollen and he kept asking me why was my leg shaking when trying to do the range of motion test, and was I nervous which was causing my leg to shake. I told the examiner that I was in pain and trying my best to do the resistance test. This claim as well was denied so I was denied for all 5 claims. Both QTC exams one for the neck and back and the other for my right ankle were all conducted in the same QTC facility. So what should I do next? Should I file an appeal, reopen the case and see my Primary Care Physician and have him conduct a C&P exam for my neck and back? My neck is the main concern where I always have to pop it to relive the tension.
  21. Just went to another rating exam yesterday. This time I had an actually doctor, not a practitioner. I have a few questions. My case is quite complicated. In 96 when I retired from the service, I submitted documentation of all the injuries regarding my spine including an helicopter accident which also caused whip lash. The VA rated me at 0% and never used the gonimetor to measure neck movement. Same thing happened in 2010. Continued rating for 0% for cervical strain. July, I had surgery on the spine. Diagnosed with degenerative disk disease, cervical radiculopathy & cervical spinal stenosis. The doctor did the correct measurement of movement of my spine while sitting. I was barely abe to move next either direction due to pain. Then they wanted me to lay down on bed to do the same, however I told them I required a pillow as I can't lay down due to continued severe neck pain with out support. Same very little movement. He also measure my scar as well. Would I get rated for Syndrome Based on Incapacitating Episodes): With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease Unfavorable ankylosis of the entire spine ............................................ 100 Unfavorable ankylosis of the entire thoracolumbar spine Syndrome Based on Incapacitating Episodes): With or without symptoms such as pain (whther or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease Unfavorable ankylosis of the entire spine ............................................ 100 Unfavorable ankylosis of the entire thoracolumbar spine HE asked on a scale from 1-10 on pain, I told him a 9. Also he asked where else, I told him the shoulders & hands plus severe head aches. I think you get a rating for the surgery scar as well. And he did read the neurological report that said I had neuropathy entire body and carpal tunnel. I was confined home to bed rest for 3 months prior to surgery, and 3 months of convalescent after surgery. Any idea how this rating might go.I just barely was able to slightly move my neck, so not sure if it will be rated as fixed or with a 40-60% rating. Thank you.
  22. Hey there and thanks in advance for your time. My main question is how much weight is given to comments? The Checkmarked Impairment would indicate up to 50% - but the comments seem to read more like 70%. Would appreciate your thoughts on where you think this might land. Sorry for it being so long, stripped out as much as I could. SECTION I: a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [x ] Yes [ ] No Diagnosis #1: Major Depression, single episode, moderate to severe ICD code: 296.22 Indicate the Axis category: [x ] Axis I [ ] Axis II Comments, if any:The veteran's Major Depression is more likely than not secondary to her musculoskeletal condition and chronic pain from her service connected lumbarsacral/cervical strain and knee condition. She has had worsening of her pain conditions over time to the point that it has significantly interfered with her ability to care for her own needs and participate in activities which she previously enjoyed. This eventually led to depression. Clinical records clearly indicate that her depression is felt to be due to her medical conditions and chronic pain. There is a clear association between the severity of her depression and the severity of her pain and physical limitations. b. Axis III - medical diagnoses: ACTIVE PROBLEM Low back strain Arthritis of spine Degeneration of intervertebral disc Arthritis of knee Chondromalacia of patella Derangement of meniscus Premature beats (SNOMED CT 29717002) Paresthesia (SNOMED CT 91019004) Paresthesia of foot (SNOMED CT 309087008) Chronic constipation (SNOMED CT 236069009) Esophagitis (SNOMED CT 16761005) Neck pain (SNOMED CT 81680005) Rectal hemorrhage (SNOMED CT 12063002) Nausea (SNOMED CT 422587007) Lumbar disc prolapse with radiculopathy (SNOMED CT 202735001) Major Depressive, Single Episode Chronic Low Back Pain (ICD-9-CM 724.2) Bursitis/Tendonitis Stomatitis, Aphthous * (ICD-9-CM 528.2) Rosacea * (ICD-9-CM 695.3) Migraine with Aura, without mention of intractable Migraine without mention of Syncope * (ICD-9-CM 780.2) Other specified cardiac dysrhythmias Graves' Disease * (ICD-9-CM 242.00) Endometriosis * (ICD-9-CM 617.9/617.0) Pain in joint involving lower leg (ICD-9-CM 719.46) c. Axis IV - Psychosocial and Environmental Problems (describe, if any): unemployment; chronic mental health symptoms, chronic pain, financial concerns, limited social supports; numerous medical conditions d. Axis V - Current global assessment of functioning (GAF) score: 52 mconsistent with recent GAF (52 on 10-25-13) Comments, if any: Veteran has moderate to serious difficulty with depression and anxiety; she has intermittent passive suicidal ideation; she has poor motivation and chronic problems with energy/concentration/focus/distractibility/interest /hoplessness/helplessness. She is social withdrawn and periodically does not leave her house for extended periods at a time. She becomes frustrated over her need for her husband to act as a caretaker. She is unable to attend to a number of ADLs, but is not neglectful of hygiene or appearance. She has frequent anxiety attacks but no panic attacks or violence. No impulsivity. She has withdrawn from activities that she previously enjoyed and frequently avoids family and friends. She has lost a number of friends due to social withdrawal. She endorses irritability and poor frustration tolerance. 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? [x ] Occupational and social impairment with reduced reliability and productivity c. Relevant Mental Health history MENTAL HEALTH HISTORY: No h/o mental health treatment in childhood, adolescence or during the military. SMR are negative for mental health treatment. She reports being resistant to mental health treatment and having a long history of aversion to psychotropic medications. She was therefore very resistant to referral to mental health services. She first participating in behavioral health medicine at the VA in 2012 where she got limited treatment for chronic headaches. She was referred to mental health after having a "breakdown". She was first seen in November 2012 at which time she was diagnosed with major depression. Clinical records endorse her depression as being due to her chronic pain from her service-connected conditions. She has a history of being a very strong and independent woman who has great difficulty dealing with being dependent on others for basic care. This has greatly added to her depression over time. She is seen every 2-3 months for medication management and weekly to biweekly for individual therapy. On her current medication of Remeron 15 mg q.h.s. and temazepam 22.5 mg q.h.s. There is no history of inpatient psychiatric admissions, substance abuse treatment\problems or suicide attempts. 4 months ago she endorsed passive suicidal ideation. She continues to endorse chronic difficulties with hopelessness, helplessness, worthlessness, and guilt. She has chronic difficulties with "need for control", excessive worry, racing thoughts, feeling like a burden, social withdrawal, irritability, poor frustration tolerance and emotional detachment. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): No history of DUIs, arrest or time in jail. She is at risk for foreclosure due to losing her source of income. She continues to endorse social withdrawal, emotional detachment, irritability and poor frustration tolerance. There is no history of assault or violence. e. Relevant Substance abuse history (pre-military, military, and post-military): ETOH: Never problematic; she thinks a glass of wine per month. Drugs: Never. Smoking: In her teens 3. Symptoms ----------- For VA purposes, check all symptoms that apply to the Veteran's diagnoses: [x ] Depressed mood [x ] Anxiety [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 ] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [x ] Flattened affect [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 [x ] Inability to establish and maintain effective relationships 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [x ] Yes [ ] No If yes, describe:social withdrawl; frequent hopelessness/helplessness; chronic problems with energy/concentration/focus; ruminating thoughts; excessive worry; her need for control; social withdrawal; emotional attachment; frequent sense of worthlessness and guilt; black and white thinking 5. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [x ] Yes [ ] No 6. Remarks, if any: ------------------- The following gives added information reading the Veteran's employability for both sedentary and physical employment based on her mental health symptoms. Veteran is considered fully capable of managing funds in her own best interest. Her ability to understand and follow instructions is considered mildly impaired. Her ability to retain instructions as well as sustain concentration to perform simple tasks is considered markedly impaired. Her ability to sustain concentration to task persistence and pace is considered markedly impaired. Her ability to respond appropriately to coworkers, supervisors, or the general public is considered moderately to markedly impaired. Her ability to respond appropriately to changes in the work setting is considered markedly impaired. Her ability to accept supervision is considered mildly impaired. Her ability to accept criticism is considered mildly impaired. Her ability to be flexible in the work setting is considered markedly impaired. Her ability to work in groups is considered moderately impaired. Her ability for impulse control in the work setting is considered moderately impaired. The veteran has poor stress tolerance and is easily overwhelmed and exhausted. For example, she was very exhausted by the end of her to our assessment.
  23. I have read a ton of stuff here on hadit. What is most important about this topic is I have read about how people are locked in at the 10 year mark and 20 year mark. Well attached with this topic is the true answer, thanks to JBasser for pointing me in the right direction. There is a 5 year PROTECTION and I have YET to read a 10 year PROTECTION in this regulation. This attachment is the REAL DEAL and it needs to be added to hadit some how some way for others to be able to find it. I have highlighted many important aspects of the 5 year protection rule and the process of the Reduction of Ratings.... I will let everybody know that that ONE C&P Exam CANNOT be a basis for a REDUCTION. By this regulation the VA must look at the OVERALL HISTORY. So, in my case the VA wants to reduce my ratings of Cervical Spine and Lowback. On the decision letter they are basing this ONLY on the C&P Exam. Sorry but this is ILLEGAL and they CANNOT proceed in doing this. They are changing my true diagnostic of Cervical Strain to Cervical DDD and Lumbar Strain to Lumbar DDD. Most people don't know the DC they put on these letters are not the real DC, a lot of times. Example: The my original DC on the Decision Letter in 1996 showed "Cervical Spine Pain" but the VA computers actually show "Cervical Strain", see the difference. So, just by this alone it shows that my issues are actually getting WORSE not better. History actually shows that just 4 years ago I didn't have these problems like I to currently have and I am not just talking about the radiculopathy. I am talking about waking up every morning and it taking me 3 hours to get out of bed because my neck and back are in a lot of pain, it didn't show me taking 3200mg of Gabapentin and 300 of Tramadol per day, it doesn't show that I was getting treated for radiculopathy in my arms and legs, ALL like it is today. Again OVERALL HISTORY..... So, the VA MUST look at the OVERALL HISTORY of the medical issues at hand and NOT just on one C&P Exam. BTW all my previous C&P exams I have had from 2010 to now, actually 3 of them for my neck and back, didn't show anything getting BETTER.... Now let me tell you this true story that happened today. I was on the phone with JBasser and he swore up and down that there is a 5 year rule. So, after I left of delivering my NOD and Request for Hearing letters I decided to drop in over at the State of Florida Veterans Service Office. I talked with an officer there and I asked him about the 10 year rule ( I said 10 because that is what I have heard) about being locked on on ratings. His reply was "You are locked in at 20 years for ratings and 10 years for service connection." I come home and actually found the regulation online. So, this will tell you that some of these VSOs don't know much of nothing and are worse than the VA raters themselve....Oh, but he did say if I can get Dr. Bash to do a DBQ on my neck and back that should be sufficient. Well I am going to hopefully get them done by Dr. Bash whenever I fly up there and I am going to use it at the hearing. But most importantly I will have my copy of 38 CFR 5.10 "Proceedings To Reduce A Rating" This policy might be on here but I can't find it.... Document deleted at request of admin...
  24. Jus looking for some insight. I have a congressmans office involved a few month ago. My claim has been in reno. I filed for neck strain back in 1996 but was denied. I didnt appeal so it was final. I know me cervical strain is a result of the gunshot injury in 1991. The va stated there was no correlation between the injury and neck issue. I was diagnosed with osteoarthritis in 2003 by the va. Its rather interesting the Va grants service connection for bullet fragments in scalp and concussion and amnesia but at 0% for scar. I have uneven bridging on the left side of my head which the va doc never examined. Most of all i believe that i hope to get my dd214 corrected and receieve the purple heart. its been a long time. I have two medical opinions verifying the injury now and a statement from my corpsman. I am going to pursue this and hope to get it rated back to 1991. Whats funny is i didnt remember what happened after i got shot. Took me 15 yrs to recall the close range shot in an enemy bunker. Plus the va has only my service treatment records up until aug 1990. I got out in April 1991. How can they deny me when there are no medical records after aug 1990. Any advice would be appreciated.
  25. I have my Video Conference hearing on Tuesday 11/13 at Bay Pines, so I will fill all in on how the proceedings go. One of the issues I have on appeal is headaches and I got a letter from my doctor that states: His headaches have a significant vascular component, although they are not classic migraine. He also gives history of at least 2 motor vehicle accidents where he sustained severe cervical strain and possible concussion. In my opinion his vascular headaches are being driven by his suboccipital neuritis by way of trauma. Both of my auto accidents were while I was on active duty and I am hoping this is enough of a nexus for the VA to service connect me for my headaches secondary to my cervical spine condition. What do the experts on hadit think???
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