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Found 19 results

  1. Here is my C& P Exam results for Fibromyalgia, Chronic Bronchitis & Chronic Sinusitis: I put in a new claim for chronic fatigue/malaise. I put in for an increase based upon increased shortness of breath for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War) currently rated at 0%. I put in new claims for chronic sinusitis (related to: Environmental Hazard in Gulf War) (New), chronic bronchitis (related to: Environmental Hazard in Gulf War) (New). What does all this mean as far as service connection/possible percentages? I am currently rated at 90% total: 70 % for eye condition bilateral CRVO (related to: Environmental Hazard in Gulf War), macular edema secondary to Bilateral CRVO (related to: Environmental Hazard in Gulf War); 50 % for post traumatic stress disorder (Non-Combat) with unspecified depressive disorder;10% for tinnitus; and 0% for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War). Two other new claims were not addressed at this C & P exam. Dont know why???? Trying to get to 100% combined disability. Any feedback would be appreciated. Sorry for long post. Did not know how to hide info, if in an attachment. Feel free to move this post, if in wrong section. LOCAL TITLE: C&P MD NOTE STANDARD TITLE: PHYSICIAN NOTE DATE OF NOTE: MAR 07, 2018@12:30 ENTRY DATE: MAR 07, 2018@14:02:03 AUTHOR: XXXXXXXXXXX EXP COSIGNER: URGENCY: STATUS: COMPLETED Gulf War General Medical Examination Disability Benefits Questionnaire * Internal VA or DoD Use Only* Name of patient/Veteran: XXXXXXXXXXXXXXXXXX 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 2. Medical History ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 38 of 139 c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided e. Hearing loss, tinnitus and ear: No answer provided f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx g. Breast: No answer provided h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep apnea) i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: No answer provided n. Endocrine: No answer provided o. Neurologic: Fibromyalgia p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [ ] Yes [X] No 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 39 of 139 [ ] Yes [X] No 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [X] Yes [ ] No If yes, describe the impact of each additional sign and/or symptom that impacts his or her ability to work, providing one or more examples: See individual DBQS 7. Remarks, if any: ------------------- No answer provided **************************************************************************** Fibromyalgia Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 40 of 139 Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Fibromyalgia ICD code: M79.7 Date of diagnosis: 1991 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: He reports of generalized and wide spread musculoskeletal pain with weakness, stiffness, chronic tiredness as well fatigue, multiple joints and body pain including lower back, mid back, upper back in between scapula, neck area, both hip, both pelvis, both thigh area, both knee joints, both ankle area, both shoulder, both wrists, both elbow area as well as both foot and hand area, while he was while he was in Gulf countries in 1991. His condition has been getting worse since then. He also reports of difficulty to fall in sleep and maintain sleep. He reports of headaches, and frequency of headaches 2 to 3 times in a month and it lasts for 8 to 12 hours. He reports of band like sensation of his head during headaches. b. Is continuous medication required for control of fibromyalgia symptoms? [X] Yes [ ] No If yes, list only those medications required for the Veteran's fibromyalgia condition: OTC Aleeve PRN c. Is the Veteran currently undergoing treatment for this condition? [ ] Yes [X] No d. Are the Veteran's fibromyalgia symptoms refractory to therapy? XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 41 of 139 [ ] Yes [X] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia? [X] Yes [ ] No a. Findings, signs and symptoms (check all that apply): [X] Widespread musculoskeletal pain [X] Stiffness [X] Muscle weakness If checked, describe: See my history part [X] Fatigue [X] Sleep disturbances [X] Paresthesias [X] Headache [X] Depression [X] Anxiety b. Frequency of fibromyalgia symptoms (check all that apply): [X] Episodic with exacerbations [X] Present more than one-third of the time c. Does the Veteran have tender points (trigger points) for pain present? [X] Yes [ ] No [X] All bilaterally 4. 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 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No XXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 42 of 139 6. Functional impact --------------------- Does the Veteran&apos ;s fibromyalgia impact his or her ability to work? [ ] Yes [X] No 7. Remarks, if any: ------------------- Fibromyalgia: I reviewed his STR and he had no issue regarding his fibromyalgia condition before deployment. As per history from the Veteran, he developed all the signs and symptoms of fibromyalgia symptoms while he was in Gulf countries. As per CPRS, his CBC, BMP, LFT, UA and chest x-ray were negative. His HIV test, and hep C and hep B and ESR were negative. So his Fibromyalgia condition is at least as likely as not an undiagnosed illness due VA statutes and regulations provide for service connecting certain chronic disability patterns based on exposure to environmental hazards experienced during military service in Southwest Asia. The environmental hazards may have included: exposure to smoke and particles from oil well fires; exposure to pesticides and insecticides; exposure to indigenous infectious diseases; exposure to solvent and fuel fumes; ingestion of pyridostigmine bromides tablets, as a nerve gas antidote; the combined effect of multiple vaccines administered upon deployment; and inhalation of ultra fine-grain san particles. In addition, there may have been exposure to smoke and particles from military installation "burn pit" fires that incinerated a wide range of toxic waste materials. Fibromyalgia is recognized as an undiagnosed illness. VA recognizes this is one of the presumptive diseases related to GULF War Exposure. Therefore, it does not need medical opinion. **************************************************************************** Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 43 of 139 Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS SECTION I: DIAGNOSES -------------------- Does the Veteran now have or has he/she ever been diagnosed with a respiratory condition? (This is the condition the Veteran is claiming or for which an exam has been requested): Yes [X] Chronic bronchitis ICD code: J42 Date of diagnosis: SC SECTION II: MEDICAL HISTORY --------------------------- Describe the history (including onset and course) of the Veteran's respiratory condition (brief summary): The Veteran reports that he developed chronic cough and shortness of breath due to due to exposure to toxic fumes due to burn pit and other inorganic and organic environmental hazardous exposure while he was in Gulf countries in 1991 and his condition has been getting worse . Does the Veteran's respiratory condition require the use of oral or parenteral corticosteroid medications? No Does the Veteran's respiratory condition require the use of inhaled medications? Yes Check all that apply: [X] Inhalational bronchodilator therapy Indicate frequency: Daily Does the Veteran's respiratory condition require the use of oral bronchodilators? No XXXXXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 44 of 139 Does the Veteran's respiratory condition require the use of antibiotics? No response provided Does the Veteran require outpatient oxygen therapy for his or her respiratory condition? No SECTION III: Pulmonary conditions --------------------------------- Does the Veteran have any of the following pulmonary conditions? No Other pertinent physical findings, scars, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? No 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? No Comments, if any: No response provided SECTION IV: Diagnostic testing ------------------------------ Have imaging studies or procedures been performed? Yes Has pulmonary function testing (PFT) been performed? Yes Do PFT results reported below accurately reflect the Veteran's current pulmonary function? No PFT results Date: 09/02/2016 Pre-bronchodilator: Post-bronchodilator, if indicated: FVC: 89% predicted FVC: 89% predicted FEV-1: 89% predicted FEV-1: 90% predicted FEV-1/FVC: 82% FEV-1/FVC: 104% DLCO: 122% predicted Which test result most accurately reflects the Veteran's level of disability (based on the condition that is being evaluated for this report)? FEV-1% predicted Does the Veteran have multiple respiratory conditions? No Has exercise capacity testing been performed? No XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 45 of 139 Are there any other significant diagnostic test findings and/or results? No SECTION V: Functional impact and remarks ---------------------------------------- 1. Functional impact -------------------- Does the Veteran's respiratory condition impact his or her ability to work? No 2. Remarks, if any: ------------------- Chronic bronchitis: As per history from the Veteran, the developed chronic cough and shortness of breath due to due to exposure to toxic fumes due to burn pit and other inorganic and organic environmental hazardous exposure while he was in Gulf. So, his condition is at least as likely as not a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology due to VA statutes and regulations provide for service connecting certain chronic disability patterns based on exposure to environmental hazards experienced during military service in Southwest Asia. The environmental hazards may have included: exposure to smoke and particles from oil well fires; exposure to pesticides and insecticides; exposure to indigenous infectious diseases; exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide tablets, as a nerve gas antidote; the combined effect of multiple vaccines administered upon deployment; and inhalation of ultra fine-grain sand particles. In addition, there may have been exposure to smoke and particles from military installation "burn pit" fires that incinerated a wide range of toxic waste materials. Chronic bronchitis is a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. VA recognizes this is one of the presumptive diseases related to GULF War Exposure. Therefore, it does not need medical opinion. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 46 of 139 Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXXXXXXXXXXXXXX Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes[ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS SECTION I: Diagnosis: --------------------- Does the Veteran now have or has he/she ever been diagnosed with a sinus, nose, throat, larynx, or pharynx condition? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Chronic sinusitis ICD code: J32 Date of diagnosis: 1991 SECTION II: Medical history --------------------------- The Veteran reports that he developed sinus congestion, runny nose due to exposure to toxic fumes due to burn pit and other inorganic and organic environmental hazardous exposure while he was in Gulf countries back in 1991. His condition has been getting worse. SECTION III: Nose, throat, larynx or pharynx conditions ------------------------------------------------------- Does the Veteran have any of the following nose, throat, larynx or pharynx conditions? XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 47 of 139 [X] Yes [ ] No [X] Sinusitis 1. Sinusitis ------------ a. Indicate the sinuses/type of sinusitis currently affected by the Veteran's chronic sinusitis (check all that apply): [ ] None [X] Maxillary [X] Frontal [X] Ethmoid [ ] Sphenoid [ ] Pansinusitis b. Does the Veteran currently have any findings, signs or symptoms attributable to chronic sinusitis? [X] Yes [ ] No If yes, check all that apply: [ ] Chronic sinusitis detected only by imaging studies (see Diagnostic testing section) [X] Episodes of sinusitis [ ] Near constant sinusitis If checked, describe frequency: [X] Headaches [X] Pain of affected sinus [X] Tenderness of affected sinus [X] Purulent discharge [ ] Crusting [ ] Other For all checked conditions, describe: c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months? [ ] Yes [X] No If yes, provide the total number of non-incapacitating episodes over the past 12 months: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or more d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months? [ ] Yes [X] No NOTE: For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician. If yes, provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12 XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 48 of 139 months: [ ] 1 [ ] 2 [ ] 3 or more e. Has the Veteran had sinus surgery? [ ] Yes [X] No If yes, specify type of surgery: [ ] Radical (open sinus surgery) [ ] Endoscopic [ ] Other: Type of procedure, sinuses operated on and side(s): Date(s) of surgery (if repeated sinus surgery, provide all dates of surgery): If Veteran has had radical sinus surgery, did chronic osteomyelitis follow the surgery? [ ] Yes [ ] No f. Has the Veteran had repeated sinus-related surgical procedures performed? [ ] Yes[X] No 6. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the Diagnosis Section above? [ ] Yes[X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes[X] No c. Comments, if any: No answer provided d. Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages?: No answer provided e. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala?: No answer provided f. Does the Veteran have loss of part of the nose or other scars causing other obvious disfigurement?: No answer provided SECTION IV: Diagnostic testing ------------------------------ a. Have imaging studies of the sinuses or other areas been performed? [ ] Yes[X] No XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 49 of 139 b. Has endoscopy been performed?: No c. Has the Veteran had a biopsy of the larynx or pharynx?: No d. Has the Veteran had pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis? No answer provided e. Are there any other significant diagnostic test findings and/or results? No answer provided SECTION V: Functional impact and remarks ---------------------------------------- 1. Functional impact -------------------- Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact his or her ability to work? [ ] Yes [X] No 2. Remarks, if any: ------------------- Chronic sinusitis : As per history from the Veteran, he developed sinus congestion, runny nose due to exposure to toxic fumes due to burn pit and other inorganic and organic environmental hazardous exposure. So, his condition is at least as likely as not a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology due to VA statutes and regulations provide for service connecting certain chronic disability patterns based on exposure to environmental hazards experienced during military service in Southwest Asia. The environmental hazards may have included: exposure to smoke and particles from oil well fires; exposure to pesticides and insecticides; exposure to indigenous infectious diseases; exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide tablets, as a nerve gas antidote; the combined effect of multiple vaccines administered upon deployment; and inhalation of ultra fine-grain sand particles. In addition, there may have been exposure to smoke and particles from military installation "burn pit" fires that incinerated a wide range of toxic waste materials. Chronic sinusitis is a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. VA recognizes this is one of the presumptive diseases related to GULF War Exposure. Therefore, it does not need medical opinion. ***************************************************************** XXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 50 of 139 The Veteran has no question and concern about my examination. He understands me well. /es/ XXXXXXXXXXXX MD Signed: 03/07/2018 14:02
  2. DAV told me there is no expediting claims anymore even for Vietnam Vets. Only terminally ill vets, homeless, or going to be homeless are expedited, so it took DAV 5 months to get my claim into the system because they trashed it the first time because they are a corrupt organization. Mr. Edwards in St. Louis for DAV got Mr Stephen Kelly his 12 years of retro pay in one week without even filing a claim, the way I read it. Dan Knabe For DAV got Mike Franko’s claim “Expedited” after he had been denied once already, also got him service Connected, got his retro pay, and got him a job with DAV as well. There was no mention of homelessness, or illness besides ptsd and knee injury. Mr Kelly was just before me and Mr Franks was just after me and none of us fit the requirements except Mr Kelly and myself were Vietnam vets, and Mr. Kelly and Franko were Gulf War Vets, as best as I remember. I was permanently damaged by something affecting my entire internal body and skin(AO), and records hidden all my life. Edwards and Knabe got their clients records, scoured through them, and completed and closed the claim in one week. The VA is still withholding my records, I have used a VSO (now VFW) for the last four years, and still waiting. VFW told me it would be at least 3 or 4 years before the BVA gets to mine. Minimum 3 to 4 years, and I probably won’t even exist by then. This sounds like picking and choosing who is expedited, which is nepotism or being prejudiced against my claim. I filed in 1983 because the Army lied about my records in 1972 or I would have filed then. Total manipulation to keep me from Justice per Exemption 5 of FOIA. Any recourse? Is a malpractice suit the only recourse, unless they make it right with this last attempt? Thank you! victor ray
  3. I filed my first claim and recently received va decision. 10% awarded for tinnitus, sleep apnea denied, wrist tenosynovitis denied, and hearing loss denied. I have county VSO but I know they are very busy and want to put paperwork in good order before I file the NOD with them. I was only given audio exam from VA but no other exam. I retired from the Air National Guard and have twenty years of service. The service history is convoluted but I have all the records involved 3 DD214's (Active Duty Army and Air Force), Title 10 orders for (Air Guard), and NGB22 (Air Guard and Army Guard). My career was Infantry to start and Flightline Avionics for the latter part. I have my Air Force medical records. What I don't have is my Army medical records covering Active Duty Army (including initial entrance exam) and Army National Guard. Somehow Army records never crossed over into the Air Force but I located (after many requests) the records in MO and have requested 8 months ago. The recently confirmed that received the request but said it would be about 2 more months...I was not able to provide any Army medial records with my initial claim. I have request my C-file last week by fax and certified mail so hopefully I will receive soon. Just wondering what else I should be doing while I wait for those records to show up. Sleep apnea: The denial letter stating the sleep study date was wrong, I had it 10 years previous to the date they mentioned. So I figure I would point that out first thing. Also believe I will have evidence in Army medical records to back up the claim but there is the waiting game. Wrist Tenosynovitis: For this I have complaints on webHA and civilian medical records but it was aggravated by fall from helicopter. Stupidly I did not file an incident report, wrist hurt but also was embarrassed and just want to "shrug it off". I did have witness and maybe I could get lay statements....but this was also preexisting condition, but also aggravated by regular flightline work. Hearing Loss: I was told that I that I have left ear hearing loss but i didn't show service connection. I remember being told by Army medical on exam that I had hearing loss related to gunfire and that "I would want to keep these records.". I was very young at the time and was ignored it but now those are the records in MO that I am waiting on. I was also recently diagnosed with severe and recurring depression and prescribed medication and have long history of diagnosed sleep disorder and medication. I don't know weather to purse these as separate claims or as part of sleep apnea, which are symptoms. I do qualify for both gulf war exam and burn pit registry exam due to Kuwait deployment I and am wondering what the difference between those two are and if they are worth pursuing? I had throat surgery for diverticulum and diagnosed with barretts esophagus that could be related as well as forest fires in Idaho (Army) as well as fires during LA riots (Army Guard) and breathed in massive amounts of dust driving personal carrier in Mohave desert during 4 Ft. Irwin rotations. Once all my C-file and Army medical records show up I was considering going to the Ellis Clinic for exam and report to file with NOD...I figure I could fly out and pay for exam less than $1000 and was wondering if anybody else thought it was worth it? Sorry, that is a lot info to throw out there but I'm trying to figure my way through this claim process and would just appreciate any advice form the community. Thanks!
  4. Hi, I filed for gulf war conditions not really talking to the DAV or other organizations. They have denied all my conditions which have been diagnosed by VA as well which was as early as 2012. Two questions I wanted to ask was : 1. Whether I should file NOD for these conditions? 2. Will I be able to apply for these conditions not using assumed gulf war conditions as they have been diagnosed and not an unexplained illness or condition? Adjustment Disorder with Mixed Anxiety and Depressed Mood I was diagnosed with this condition in 2016 Mental Disorder Diagnosis #1: Adjustment Disorder with Mixed Anxiety and Depressed Mood ICD code: 309.28(F43.23) There are few others where I was diagnosed with Allergic rhinitis (Icd-9-cm 477.9) in 2012. Diagnosis: Tinea versicolor ICD code: B36.0 Date of diagnosis: 2010 I was also treated for it on 2005 but I didn't follow up. Basically VA is saying that I do not have any service connection. Please advise how I should proceed with this. Thank you
  5. Does anyone know a doctor who does IMO letters for Fibromyalgia. I have a diagnosis of Fibromyalgia from a Rheumatologist from Scott & White, Chronic Pain Syndrome and Myofacial Pain from the VA. The C&P clearly went my way except the nurse practitioner who did the C&P stated I had a diagnosis but it does not seem related to Active Duty Service by review of SMR's. So it is going to be hard to pass this under Gulf War presumptive illnesses. Any Help in this matter will be appreciated.
  6. I had this C& P done on the 16th. From start to finish was 1hr and 45 mins. the doctor hardly touched me and looked mostly at her computer. the statement about me having flat feet going into boot camp. I am not sure how she came to that because I didn't tell her that. Any feedback or suggestions would be helpful. I have my PTSD C& P on the 26th. Thank You! Gulf War General Medical Examination Disability Benefits Questionnaire * Internal VA or DoD Use Only* 1. Medical record review ------------------------ [X] Other, describe: VBMS 2. Medical history ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided CONFIDENTIAL Page 5 of 43 e. Hearing loss, tinnitus and ear: Hearing Loss and Tinnitus f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx g. Breast: No answer provided h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep apnea) i. Cardiovascular: No answer provided j. Digestive and abdominal wall: Intestinal Conditions (other than Surgical and Infectious) k. Kidney and urinary tract: No answer provided l. Reproductive: Gynecological Conditions m. Musculoskeletal: The following conditions have been reported Joints and extremities: Ankle Feet: Flatfeet n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: PTSD (Initial or Review) q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [ ] Yes [X] No 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- CONFIDENTIAL Page 6 of 43 Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [ ] Yes [X] No 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- E-file reviewed including buddy statement. Veteran does have fatigue and trouble sleeping that should be further examined with PTSD exam by mental health examiner for insomnia. Veteran reports she had a cold and URi multiple times while in service. She was given an inhaler and was told she hadd possible exercise induced asthma but it only seemd to flare up during change in seasons and was related to more of her sinuses and rhinitis. See rhinitis and sinusitis exam for more information on her "respiratory" complaint. **************************************************************************** Intestinal Conditions (other than surgical or infectious), including irritable bowel syndrome, Crohn's disease, ulcerative colitis and diverticulitis Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No CONFIDENTIAL Page 7 of 43 ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with an intestinal condition (other than surgical or infectious)? [X] Yes [ ] No [X] Irritable bowel syndrome ICD code: K58.0 Date of diagnosis: 2004 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary): Veteran reports constipation started while in boot camp in 2004. The diarrhea started while in Iraq in 2009. It alternated dairrhea and constipation. She saw a GI doctor in 2009 and she took Miralax and another medication for ulcers. She tested negative for h. pylori and ova and aprasites and those were negative. She avoided food triggers and alternated between culcolax and miralax and imdoium. Symptoms continue to the present day. She was also given zofran for nausea. b. Is continuous medication required for control of the Veteran's intestinal condition? [X] Yes [ ] No If yes, list only those medications required for the intestinal condition: miralax imodium probiotics c. Has the Veteran had surgical treatment for an intestinal condition? CONFIDENTIAL Page 8 of 43 [ ] Yes [X] No 3. Signs and symptoms --------------------- Does the Veteran have any signs or symptoms attributable to any non-surgical non-infectious intestinal conditions? [X] Yes [ ] No If yes, check all that apply: [X] Alternating diarrhea and constipation If checked, describe: alternating diarrhea and constipation but it varies. Usually at all 2-3 days of diarrhea followed by almost a week of not going [X] Abdominal distension If checked, describe: swollen abdomen, appears 2-3 months pregnant usually. Cramping and gurgling in the stomac [X] Nausea If checked, describe: feels sick to stomach [X] Vomiting If checked, describe: takes zofran [X] Other, describe: passes out and sweats sometimes and has sharp pains ont he left side of abdomen 4. Symptom episodes, attacks and exacerbations ---------------------------------------------- Does the Veteran have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition? [X] Yes [ ] No If yes, indicate severity and frequency: (check all that apply) [X] Episodes of bowel disturbance with abdominal distress If checked, indicate frequency: [ ] Occasional episodes [X] Frequent episodes CONFIDENTIAL Page 9 of 43 [ ] More or less constant abdominal distress 5. Weight loss -------------- Does the Veteran have weight loss attributable to an intestinal condition (other than surgical or infectious condition)? [ ] Yes [X] No 6. Malnutrition, complications and other general health effects --------------------------------------------------------------- Does the Veteran have malnutrition, serious complications or other general health effects attributable to the intestinal condition? [ ] Yes [X] No 7. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 8. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: 9. Diagnostic testing --------------------- a. Has laboratory testing been performed? [ ] Yes [X] No b. Have imaging studies or diagnostic procedures been performed and are the results available? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 10. Functional impact --------------------- Does the Veteran's intestinal condition impact his or her ability to CONFIDENTIAL Page 10 of 43 work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's intestinal conditions, providing one or more examples: frequent bathroom breaks 11. Remarks, if any: -------------------- E-file reviewed. Veteran's IBS is a diagnosable chronic multisymptom illness with a partially explained etiology that is at least as likely as not related to an exposure event in Southwest Asia as symptoms did not start until she was in Iraq. **************************************************************************** Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes[ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS SECTION I: Diagnosis: CONFIDENTIAL Page 11 of 43 --------------------- Does the Veteran now have or has he/she ever been diagnosed with a sinus, nose, throat, larynx, or pharynx condition? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Chronic sinusitis ICD code: J32.9 Date of diagnosis: 2004 [X] Allergic rhinitis ICD code: 477.9 Date of diagnosis: 2004 SECTION II: Medical history --------------------------- Veteran reports she had drainage and a head cold with stuffiness and she was treated with sudafed and tessalon perles. She had been coughing and had a sore throat and the congestion was in her chest so at night she would have a hard time breathing and had a hard time breathing when running. She was given an inhaler and nasal spray and allergy meds which helped. She had questionable exericse induced asthma, btu she notes it was only when she had a cold or sinus infection that she had the breathing problems. The allergies and rhinitws continue to the prfesent day. She gets URI at least 3 times througout the year. SECTION III: Nose, throat, larynx or pharynx conditions ------------------------------------------------------- Does the Veteran have any of the following nose, throat, larynx or pharynx conditions? [X] Yes [ ] No [X] Sinusitis [X] Rhinitis 1. Sinusitis ------------ a. Indicate the sinuses/type of sinusitis currently affected by the Veteran's chronic sinusitis (check all that apply): [ ] None [X] Maxillary [ ] Frontal [ ] Ethmoid [ ] Sphenoid [ ] Pansinusitis b. Does the Veteran currently have any findings, signs or symptoms attributable to chronic sinusitis? [X] Yes [ ] No If yes, check all that apply: [ ] Chronic sinusitis detected only by imaging studies (see Diagnostic testing section) [X] Episodes of sinusitis [ ] Near constant sinusitis If checked, describe frequency: CONFIDENTIAL Page 12 of 43 [X] Headaches [X] Pain of affected sinus [X] Tenderness of affected sinus [X] Purulent discharge [ ] Crusting [ ] Other For all checked conditions, describe: c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months? [X] Yes [ ] No If yes, provide the total number of non-incapacitating episodes over the past 12 months: [ ] 1 [ ] 2 [X] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or more d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months? [ ] Yes [X] No NOTE: For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician. If yes, provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12 months: [ ] 1 [ ] 2 [ ] 3 or more e. Has the Veteran had sinus surgery? [ ] Yes [X] No If yes, specify type of surgery: [ ] Radical (open sinus surgery) [ ] Endoscopic [ ] Other: Type of procedure, sinuses operated on and side(s): Date(s) of surgery (if repeated sinus surgery, provide all dates of surgery): If Veteran has had radical sinus surgery, did chronic osteomyelitis follow the surgery? [ ] Yes [ ] No f. Has the Veteran had repeated sinus-related surgical procedures performed? [ ] Yes[X] No 2. Rhinitis ----------- CONFIDENTIAL Page 13 of 43 a. Is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis? [ ] Yes [X] No b. Is there complete obstruction on the left side due to rhinitis? [ ] Yes [X] No c. Is there complete obstruction on the right side due to rhinitis? [X] Yes [ ] No d. Is there permanent hypertrophy of the nasal turbinates? [X] Yes [ ] No e. Are there nasal polyps? [ ] Yes [X] No f. Does the Veteran have any of the following granulomatous conditions? [ ] Yes [X] No If yes, check all that apply: [ ] Granulomatous rhinitis [ ] Rhinoscleroma [ ] Wegener's granulomatosis [ ] Lethal midline granuloma [ ] Other granulomatous infection, describe: 6. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the Diagnosis Section above? [ ] Yes[X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes[X] No c. Comments, if any: No answer provided d. Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages? [ ] Yes[X] No e. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala? [ ] Yes[X] No f. Does the Veteran have loss of part of the nose or other scars causing CONFIDENTIAL Page 14 of 43 other obvious disfigurement? [ ] Yes[X] No SECTION IV: Diagnostic testing ------------------------------ a. Have imaging studies of the sinuses or other areas been performed? [ ] Yes[X] No b. Has endoscopy been performed?: No c. Has the Veteran had a biopsy of the larynx or pharynx?: No d. Has the Veteran had pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis?: No e. Are there any other significant diagnostic test findings and/or results? No answer provided SECTION V: Functional impact and remarks ---------------------------------------- 1. Functional impact -------------------- Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact his or her ability to work? [ ] Yes [X] No 2. Remarks, if any: ------------------- E-file reviewed. Veteran's rhinits and sinusitis is a diagnosable chronic multisymptom illness with a partially explained etiology that is at least as likely as not related to an exposure event in Southwest Asia as symptoms did not start until she was in Iraq and she was exposed to noxious fumes and dust storms which negatively impact the sinuses and cause chronic inflammation. **************************************************************************** Ankle Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? CONFIDENTIAL Page 15 of 43 [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: ankle strain b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Other (specify): Other diagnosis: ankle strain ICD Code: 845 Side affected: Both Date of diagnosis: Right:2004 Date of diagnosis: Left:2004 ******************************************************************** c. Comments (if any): No response provided 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's ankle condition (brief summary): Veteran reports she rolled her ankles while in boot camp a few times and had shin splints and she has had ongoing ankle pain since. She did physical therapy before which helped. The pain contineus to the present day. b. Does the Veteran report flare-ups of the ankle? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or CONFIDENTIAL Page 16 of 43 her own words: ankles give out on her at times. Dull and achy pain. Swells by the end off the day. c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: has to take breaks or sit after prolonged standing 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right ankle ----------- [X] All Normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender over lateral mallelolus Is there objective evidence of crepitus? [ ] Yes [X] No Left ankle ---------- [X] All Normal [ ] Abnormal or outside of normal range CONFIDENTIAL Page 17 of 43 [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender over lateral mallelolus Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right ankle ----------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: Pain, Lack of enduance ROM after 3 repetitions: Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: CONFIDENTIAL Page 18 of 43 Pain, Lack of endurance ROM after 3 repetitions: Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees c. Repeated use over time Right ankle ----------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle [ ] No ---------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees d. Flare-ups Right ankle ----------- Is the examination being conducted during a flare-up? [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation [X] Yes [ ] No CONFIDENTIAL Page 19 of 43 Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms or range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the examination being conducted during a flare-up? [ ] No [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees e. Additional factors contributing to disability Right ankle [ ] No ----------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing Left ankle ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength CONFIDENTIAL Page 20 of 43 Right ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes Left ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes b. Does the Veteran have muscle atrophy? [ ] Yes c. Comments, if any: No response provided [X] No [X] No [X] No 5. Ankylosis ------------ Complete this section if Veteran has ankylosis of the ankle a. Indicate severity of ankylosis and side affected (check all that apply): Right side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing position [ ] In poor weight-bearing position [ ] In poor weight-bearing position [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Is ankle instability or dislocation suspected? [X] No ankylosis [ ] No [X] Yes If yes, complete the following: Anterior Drawer Test Is there laxity compared Left side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity CONFIDENTIAL Page 21 of 43 with opposite side? [ ] Yes [X] No [ ] Unable to test Talar Tilt Test Is there laxity compared with opposite side? Left ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No [X] Yes If yes, complete the following: Anterior Drawer Test Is there laxity compared with opposite side? Talar Tilt Test Is there laxity compared with opposite side? [ ] Yes [ ] Yes [ ] Unable to test [ ] No [X] No [X] No 7. Additional comments ---------------------- Does the Veteran now have or has he or she ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below: [X] Shin splints (medial tibial stress syndrome) Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of ankle? [X] Yes (If "yes", complete ROM section of ankle on this DBQ) [ ] No Does this condition affect ROM of knee? [ ] Yes (If "yes", complete VA Form 21-0960M-9 Knee and Lower Leg Conditions) [X] No Describe current symptoms: pain in the shins with prolonged standding or walking [X] Achilles tendonitis or achilles tendon rupture Indicate side affected: [ ] Right [ ] Left [X] Both CONFIDENTIAL Page 22 of 43 Describe current symptoms: pain in the backs of the ankles shooting up the back of the shins 8. Surgical procedures ---------------------- No response provided 9. Other pertinent physical findings, complications conditions, signs, symptoms and scars ------------------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 10. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 11. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's ankle condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 12. Diagnostic testing ---------------------- CONFIDENTIAL Page 23 of 43 a. Have imaging studies of the ankle been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 13. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: limits standing and walking prolonged, has to take frequent breaks or sit down 14. Remarks, if any ------------------- E-file reviewed. Veteran's ankle sprain is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms are related to sprain not to an exposure event. **************************************************************************** Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review CONFIDENTIAL Page 24 of 43 ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: pes planus b. Select diagnoses associated with the claimed condition(s): [X] Flat foot (pes planus) ICD code: 728.71 Side affected: Both Date of diagnosis: Right: 2003 Date of diagnosis: Left: 2003 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [X] Yes [ ] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's foot condition (brief summary): Pes planus was noted on enlistment exam. She did not have pain in her eet when she first enlisted but the pain int he feet started in boot camp. She was treated with motrin and insoles which did not help. She contiues to have the foot pain now if she stands on them prolonged. She still takes motrin adn she soaks them and uses topical rubs. b. Does the Veteran report pain of the foot being evaluated on this DBQ? [X] Yes [ ] No CONFIDENTIAL Page 25 of 43 If yes, document the Veteran's description of pain in his or her own words: aching and cramping and sore c. Does the Veteran report that flare-ups impact the function of the foot? [X] Yes [ ] No If yes, document the Veteran's description of flare-ups in his or her own words: limtis prolonged standing and walking d. Does the Veteran report having any functional loss or functional impairment of the foot being evaluated on this DBQ (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: limits weight bearing 3. Flatfoot (pes planus) ------------------------ a. Does the Veteran have pain on use of the feet? [X] Yes If yes, indicate side affected: [ ] Right [ ] Left [X] Both If yes, is the pain accentuated on use? [X] Yes [ ] No [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both b. Does the Veteran have pain on manipulation of the feet? [X] Yes If yes, indicate side affected: [ ] Right [ ] Left [X] Both If yes, is the pain accentuated on manipulation? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both c. Is there indication of swelling on use? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both d. Does the Veteran have characteristic callouses? [ ] Yes [X] No e. Effects of use of arch supports, built-up shoes or orthotics: Tried But Remains Symptomatic ----------------------------- [ ] No Device Side Not Relieved: CONFIDENTIAL Page 26 of 43 [X] Arch Supports [ ] Right [ ] Left [X] Both f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the tenderness improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A g. Does the Veteran have decreased longitudinal arch height of one or both feet on weight-bearing? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both h. Is there objective evidence of marked deformity of one or both feet (pronation, abduction etc.)? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both i. Is there marked pronation of one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the condition improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A j. For one or both feet, does the weight-bearing line fall over or medial to the great toe? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both k. Is there a lower extremity deformity other than pes planus, causing alteration of the weight-bearing line? [ ] Yes [X] No l. Does the Veteran have "inward" bowing of the Achilles tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both m. Does the Veteran have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet? [X] Yes [ ] No CONFIDENTIAL Page 27 of 43 If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the marked inward displacement and severe spasm of the Achilles tendon improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A n. Comments: No comments provided 4. Morton's neuroma (Morton's disease) and metatarsalgia -------------------------------------------------------- No response provided 5. Hammer toe ------------- No response provided 6. Hallux valgus ---------------- No response provided 7. Hallux rigidus ----------------- No response provided 8. Acquired pes cavus (clawfoot) -------------------------------- No response provided 9. Malunion or nonunion of tarsal or metatarsal bones ----------------------------------------------------- No response provided 10. Foot injuries and other conditions -------------------------------------- No response provided 11. Surgical procedures ----------------------- No response provided 12. Pain -------- RIGHT FOOT: Is there pain on physical exam? [X] Yes [ ] No If yes, (there is pain on physical exam), does the pain contribute to CONFIDENTIAL Page 28 of 43 functional loss? [X] Yes [ ] No (Further description of limitations requested in Section XIII below.) LEFT FOOT: Is there pain on physical exam? [X] Yes [ ] No If yes, (there is pain on physical exam), does the pain contribute to functional loss? [X] Yes [ ] No (Further description of limitations requested in Section XIII below.) 13. Functional loss and limitation of motion -------------------------------------------- a. Contributing factors of disability (check all that apply and indicate side affected): [X] Pain on movement Side affected: [ ] Right [ ] Left [X] Both [X] Pain on weight-bearing Side affected: [ ] Right [ ] Left [X] Both [X] Swelling Side affected: [ ] Right [ ] Left [X] Both [X] Disturbance of locomotion Side affected: [ ] Right [ ] Left [X] Both [X] Interference with standing Side affected: [ ] Right [ ] Left [X] Both [X] Lack of endurance Side affected: [ ] Right [ ] Left [X] Both Contributing factors of disability associated with limitation of motion: b. Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [X] Yes [ ] No If yes, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) please CONFIDENTIAL Page 29 of 43 describe the functional loss: limits weight bearing LEFT FOOT: [X] Yes [ ] No If yes, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) please describe the functional loss: limite weight bearing c. Is there any other functional loss during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [ ] Yes [X] No LEFT FOOT: [ ] Yes [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No c. Comments: No comments provided 15. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 16. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's foot 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 CONFIDENTIAL Page 30 of 43 upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 17. Diagnostic testing ---------------------- a. Have imaging studies of the foot been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition: No response provided 18. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: limits prologned walking andd standing 19. Remarks, if any: -------------------- E-file reviewed. Veteran's pes planus is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as pes planus was present on entrance exam and symptoms started in boot camp before any exposure event in Southwest Asia. **************************************************************************** CONFIDENTIAL Page 31 of 43 Gynecological Conditions Disability Benefits Questionnaire Name of patient/Vetera Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has she ever had a gynecological condition? Yes Diagnosis #1: Vaginitis ICD code: 616.1 Date of diagnosis: 2004 2. Medical history ------------------ Describe the history (including cause, onset and course) of each of the Veteran's gynecological conditions: Veteran was sexually assaulted in boot camp and the vaginits started after that incident. She was treated for the vaginits. She has reoccurring BV now and gets it after her cycle. She also reports she gets a yeast infection before her cycle each month. 3. Symptoms ----------- Does the Veteran currently have symptoms related to a gynecological condition, including any diseases, injuries or adhesions of the female reproductive organs? Yes CONFIDENTIAL Page 32 of 43 If yes, indicate current symptoms, including frequency and severity of pain, if any: (check all that apply) [X] Mild pain: Intermittent pain [X] Other signs and/or symptoms describe and indicate condition(s) causing them: vaginal discharge and odor and itching caused by candidiasis and bacteria 4. Treatment ------------ a. Has the Veteran had treatment for symptoms/findings for any diseases, injuries and/or adhesions of the reproductive organs? Yes If yes, specify condition(s), organ(s) affected, and treatment: treated with diflucan and flagyl Date of treatment: recurrent b. Does the Veteran currently require treatment or medications [for symptoms?] related to reproductive tract conditions? Yes If yes, list current treatment/medications and the reproductive organ condition(s) being treated: ongoing diflucan and flagyl treatments when infections occur c. If yes, indicate effectiveness of treatment in controlling symptoms: [X] Symptoms do not require continuous treatment for the following organ/condition: [X] Conditions of the vulva [X] Conditions of the vagina 5. Conditions of the vulva -------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vulva (to include vulvovaginitis)? Yes If yes, describe: vulvovaginitis causes itching and burning of the vulva. Treated with diflucan 6. Conditions of the vagina --------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vagina? Yes If yes, describe: vaginitis (candida and BV0 treated with diflucan and flagyl 7. Conditions of the cervix --------------------------- Has the Veteran been diagnosed with any diseases, injuries, adhesions or CONFIDENTIAL Page 33 of 43 other conditions of the cervix? No 8. Conditions of the uterus --------------------------- a. Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the uterus? No b. Has the Veteran had a hysterectomy? No c. Does the Veteran have uterine prolapse? No d. Does the Veteran have uterine fibroids, enlargement of the uterus and/or displacement of the uterus? No e. Has the Veteran been diagnosed with any other diseases, injuries, adhesions or other conditions of the uterus? No 9. Conditions of the Fallopian tubes ------------------------------------ Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the Fallopian tubes (to include pelvic inflammatory disease)? No 10. Conditions of the ovaries ----------------------------- a. Has the Veteran undergone menopause? No b. Has the Veteran undergone partial or complete oophorectomy? No c. Does the Veteran have evidence of complete atrophy of 1 or both ovaries? No d. Has the Veteran been diagnosed with any other diseases, injuries, adhesions and/or other conditions of the ovaries? Yes If yes, describe: had ovarian cysts when she was younger but none recently 11. Incontinence ---------------- Does the Veteran have urinary incontinence/leakage? Yes If yes, is the urinary incontinence/leakage due to a gynecologic condition? Yes If yes, condition causing it: stress incontinence If yes, check all that apply: [X] Does not require/does not use absorbent material [X] Stress incontinence CONFIDENTIAL Page 34 of 43 12. Fistulae ------------ a. Does the Veteran have a rectovaginal fistula? No b. Does the Veteran have a urethrovaginal fistula? None 13. Endometriosis ----------------- Has the Veteran been diagnosed with endometriosis? No 14. Complications and residuals of pregnancy or other gynecologic procedures ---------------------------------------------------------------------------- a. Has the Veteran had any surgical complications of pregnancy? No b. Has the Veteran had any other complications resulting from obstetrical or gynecologic conditions or procedures? No 15. Tumors and neoplasms ------------------------ a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? No b. Is the neoplasm No response provided. c. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? No response provided. d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: No response provided. 16. 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? 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? No c. Comments, if any: CONFIDENTIAL Page 35 of 43 No response provided. 17. Diagnostic testing ---------------------- a. Has the Veteran had laparoscopy? No b. Has the Veteran been diagnosed with anemia? No c. Has the Veteran had any other diagnostic testing and if so, are there significant findings and/or results? No 18. Functional impact --------------------- Does the Veteran's gynecological condition(s) impact her ability to work? No 19. Remarks, if any: -------------------- E-file reviewed. Veteran's vaginitis is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms are from bacteria overgrowth and not related to exposure events. **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review CONFIDENTIAL Page 36 of 43 --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: knee dislocation b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Recurrent patellar dislocation Side affected: [ ] Right [X] Left [ ] Both ICD Code: 836 Date of diagnosis: Left 2010 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Veteran denies any spoecific injury while in service. She reports left knee started dislocation after military service. She treats it with wearing a brace and ice and heat. b. Does the Veteran report flare-ups of the knee and/or lower leg? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: locks up and a shooting pain c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: limits standing and bending down and lifting CONFIDENTIAL Page 37 of 43 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Left Knee --------- [X] All normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Extension Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): ttp behind knee Is there objective evidence of crepitus? [ ] Yes b. Observed repetitive use [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Left Knee --------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: CONFIDENTIAL Page 38 of 43 Pain, Lack of endurance Able to describe in terms of range of motion: [X] Yes Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees d. Flare-ups Left Knee --------- Is the exam being conducted during a flare-up? [X] Yes [ ] No [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion: [X] Yes Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees e. Additional factors contributing to disability [ ] No Left Knee --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Rate Strength: 5/5 Left Knee: Flexion: Extension: Is there a reduction in muscle strength? b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5/5 [ ] Yes [X] No CONFIDENTIAL Page 39 of 43 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Left: [ ] None [X] Slight [ ] Moderate b. Is there a history of lateral instability? Left: [X] None [ ] Slight [ ] Moderate c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform [ ] Severe [ ] Severe If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section CONFIDENTIAL Page 40 of 43 below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: No response provided 7. Additional conditions ------------------------ a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below. [X] "Shin splints" (medial tibial stress syndrome) Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of knee? [ ] Yes [X] No Does this condition affect ROM of ankle? [X] Yes [ ] No (If yes, complete VA form 21-0960M-2 Ankle Conditions to document ROM of ankle.) Describe current symptoms: pain in shins with prolonged walking or standing CONFIDENTIAL Page 41 of 43 b. Comments, if any: No response provided 8. Meniscal conditions ---------------------- a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided 9. Surgical procedures ---------------------- No response provided 10. 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? [X] Yes [ ] No If yes, describe (brief summary): popping noted with flexion and extension testing b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: ----------------- [X] Brace(s) Frequency of use: ----------------- [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: CONFIDENTIAL Page 42 of 43 No response provided 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), 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., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 14. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: limits bending, lifting, standing and walking 15. Remarks, if any: -------------------- E-file reviewed. Veteran does have recurrent knee dislocation that is a is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms did not start until after military service and she had no documented injury in Iraq and exposure would not cause these symptoms.
  7. Hi folks, I'm going in tomorrow for the Gulf War exam, but not as part of a C&P claim. Does anyone know what I can expect, should I bring any records, are there DBQs or other documentation that I can review prior? The Environmental Coordinator from the VA has been absolutely no help and just to get the Coordinator to respond to weeks of phone call and emails I had to contact the Public Affairs office at the hospital. Appreciate the assistance.
  8. Has anyone ever filed a claim for weight loss without etiology? I have been going through lots of medical issues for the past several years. but as of late I have been loosing weight and the doctors can not explain why. I was weighing 179 and now I go back and fourth from 135 to 145. I lost the weight in about three months and have not been able to be able to gain it back in the past year. I complained to my doctor about a year ago when the problem started and the first thing she said was quote "You have PTSD and Major Depression are you taking your medications". I got mad and requested a new doctor at the VA. The first thing he did was look and see I complained about blood in my stool and ordered a colonoscopy. The results were a little abnormal with a few extra pileups but not uncommon at my age of 50. He also did a Major blood work up on me with nothing showing up. I was recommended to a dietitian at that point. His conclusion was weight loss without etiology. I'm not a large man. I'm only 5'8 and at 135 to 145 I am weak and look as if I have cancer or something. Any thoughts on what's going on or anyone else gone through this?
  9. Hi, long time user but first time question asker... I just started using the ebenefits online page. I put in a claim in 2008 for gastroesophageal reflux disease, or GERD, which was denied. Under the "Rated Disabilities" section, It has the GERD listed, with the decision as "Not Service Connected". In the column next to it titled "Related To", it has an explanation of "Environmental Hazard in Gulf War". I'm not an expert by any means, but if my GERD is related to an environmental hazard in the Gulf War shouldn't I be compensated for it? Any suggestions on how to proceed?
  10. Does anyone know if fibromyalgia can be a cause or associated with occipital neuralgia? I didn't know I had occipital neuralgia I just thought it was migraine headaches or tension headaches. I started receiving acupuncture and have some post stuck in my ears to block pain, anxiety, nightmares and so forth. Have been on multiple medications throughout the years with little success. Now I have ventured down the road with acupuncture and have been scheduled for Botox. I was planning on filing a claim for migraines/headaches related to fibromyalgia but now after reading the notes from my last two treatments I question the validity of my claim and if the two would be symptomatic of each other. Fibromyalgia and Occipital neuralgia. The headache is a headache either way you look at it but could or could not be related. Anyone have any experience in this area or know of the two to have a comparison that might substantiate the claim?
  11. Looks like we were right all along! http://www.disabledveterans.org/2015/03/30/former-va-chief-of-staff-linked-to-gulf-war-scandal/?inf_contact_key=d88fc72cae9ad59f9bca50441e7b05349dd2addd62f053fd3ee1b6294730caed
  12. I need some assistance on filing a claim for Migraine Headaches. I don't have any record of headaches while in service but I had them and had it noted during my out-processing physical. After getting out I signed up at the VA and begun treatment for them. I am on Topamax twice a day and sumatriptin at the onset of the headache. Here is what I would like to know. I have Fibromyalgia and receive 40% for it. I was told to keep a log of the headaches. For the last month I have done so and can say that when my Fibro is acting up I have some of my more intense headaches. But I also have headaches when my Fibro is not acting up. Should I file my migraine headaches as a secondary issue to my Fibromyalgia? or Under the Claims for Gulf War Illness a presumptive diagnosed condition under section cfr 38. 3.317? This way I would be filing with a diagnosis and I would state they are a result of my service while actively serving in South West Asia. The illness then would not have to be shown in service records but have manifested and be debilitating at least 10%. The window for filing under the GWI presumptive illnesses with or without a diagnosis is open until Dec 2016. Anyone have advise on this?
  13. I need some help. I file a claim for PTSD and was awarded 50%. But the C & P showed I should have been higher. The Beck Anxiety Index score was 56 severe Depression Inventory II was 49 severe Global Assessment of Functioning was 41 serious symptoms I don't want to put the whole C & P on here but I have some issues and they were noted. I didn't have help with the claim so everything else I claimed was denied. I didn't think the rating was fair and was looking at the possibility of it being 70% (but oh well) The VA's reviewers stated although the GAF score stated a 70%-100% It wasn't warranted because I didn't have enough anger issues or my panic attacks wasn't continuous and I didn't show signs of family problems. I am constantly in a panic state and my first wife left me due to anger issues after returning from the gulf. Since then I had been having a lot of issues relating to my health. Especially chronic pain all over, headaches, lot's of mental issues. I often think I see apparition's of three dead burnt bodies coming at me. I went through group counseling for over a year and had an individual counselor for a while. My psychiatrist felt I was suicidal and placed me on the Suicide Watch List. Back in late 2013 I was hurting so bad and emotionally distraught, I thought these same three burnt up bodies were coming for me so I decided at that point I couldn't stand it any longer. I tried to commit SUICIDE. I took a hands full of medication I thought would put me out. As a result I ended up in the mental ward at the VA for 4 days. After It wasn't a month after I was released I sliced my wrist trying to kill myself for the second time. I was referred to mental health and after the first appointment I haven't went back. I feel as if I can't trust them. All the psychiatric doctors at the VA seen my conditions were getting worse but they did nothing for me. Hell they gave me more pills to stop the pain and depression, anxiety and so forth. But they stopped the psychosis pill that help me stop seeing apparitions. They just sat back and let me try and kill myself. My wife found I could do a Notice of Disagreement so she filled it out and I sent it in. What should I do now and HOW? BTW my wife locks up all the medications in the house and gives me them as prescribed to ensure I take them and not try all at once.
  14. I have been diagnosed with Chronic Fatigue Syndrome and have been receiving treatment unsuccessfully. I filed a claim under the Gulf War Illness as a presumptive illness under 38 CFR 3.317. But now since the VA has me listed with Insomnia and sleep pattern disturbances they want me to go to a sleep study. I am worried if I am diagnosed with Sleep Apnea would that ruin my case for CFS. I ask this because a diagnoses of Sleep apnea could be considered the reason for none refreshing sleep. Is there anyone who has been in this situation or is there anyone who could give me good information on this. Thanks vets. Crazy Larry.
  15. Well I don't know where to go with this. Seems I have more issues. I went for my sleep study the other day. First off I was terrified and was uncomfortable. I often have a hard time going to sleep or if I go to sleep I wake up continuously. Being scared I wouldn't sleep or just to take the edge off I had a couple drinks. Two to be exact. That wasn't the problem. After taking all my meds I fell asleep but while asleep I became entangled in the cords and started having a violent dream. I was awaken by security trying to hold me down and then given some type of shot that knocked me out. I then woke up again in another hospital in the mental ward. I was released that evening but was still drugged up from my medications and the tranquilizer they shot me with. The police stopped by my house to check up on me just to see if I was ok. He said he had been dispatched on a health and welfare to my location a couple times but this time he was visiting on his own for he was the office who transported me. I don't know if my study was completed or if there will be another since the VA outsourced this study. What is left now? I clearly don't know what to do.
  16. I need some HELP. First off I am already 70%. PTSD 50% Fibromyalgia 40% Tinnitus 10% I do not know how to file my claim and need guidance. I do not want my conditions to be lumped together as one. Ok here is what I have medical diagnosis for and being treated for since getting out of the service 15 years ago. I show the diarrhea in my military records but not the migraines or chronic fatigue. But I did file a claim for migraines immediately when I left the military and also started receiving treatment from the VA for the headaches/migraines. The claim was denied. lol. go figure. 1. IBS. Being treated with medications Simeticone and one more I can't remember. 2. Migraines. Being treated with Topamax and Sumatriptan. 3. Chronic Fatigue Syndrome - I was just diagnosed with this overlapping my fibromyalgia last week by a doctor who is not associated with the VA. The doctor is a specialist in Rheumatology. I know these are all under the CMI (chronic multi illness)conditions of the Gulf War and would be a considered a diagnosed condition instead of a presumptive condition. But would the VA try lumping them together or overlapping them? How do I file them? Should I file them individually and wait for them to come back or all at once? So who want's to help here.
  17. I am trying to decide how to file a claim and need assistance. I have not had a sleep study because I have not wanted to be given a diagnosis. I have read on different forums that since my sleeping problems was not documented while in service except on my out processing physical then I should file my difficulty sleeping as a presumptive illness caused by or due to service in the gulf war. The VA has been giving me sleeping pills since 2003 and has records of my complaints of not being able to stay asleep more than a couple hours at a time. Then waking just as tired. First, should I accept one of the appointments they have scheduled me for to check me for sleep apnea? Second, if I am diagnosed with sleep apnea would that hurt my claim under sleep disturbance. Any help would be greatly appreciated. I haven't a clue on this one.
  18. This is from my Gulf War C&P Exam. Any thoughts on possible rating are appreciated. I didn't feel as if the doctor was as thorough as he should have been, as he asked very few follow up questions and seemed in a hurry to get me out of there. He checked off "occasional" even though I told him this is an every day thing. Intestinal Conditions (other than surgical or infectious), including irritable bowel syndrome, Crohn's disease, ulcerative colitis and diverticulitis Disability Benefits Questionnaire Name of patient/Veteran: XXXX Indicate method used to obtain medical information to complete this document: [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: CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with an intestinal condition (other than surgical or infectious)? [X] Yes [ ] No [X] Irritable bowel syndrome ICD code: 564.1 Date of diagnosis: 9/6/13 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary): The veteran stated that he always has diarrhea since gulf war;at times he becomes constipated if occasional bubble comes he may have 4-5 loose stools a day. No history of colonoscopy. No history of gallbladder disease or surgery no loss of weight he had hemorrhoids he takes Pepto-Bismol and Imodium. b. Is continuous medication required for control of the Veteran's intestinal condition? [X] Yes [ ] No If yes, list only those medications required for the intestinal condition: imodium,peptobismol c. Has the Veteran had surgical treatment for an intestinal condition? [ ] Yes [X] No 3. Signs and symptoms --------------------- Does the Veteran have any signs or symptoms attributable to any non-surgical non-infectious intestinal conditions? [X] Yes [ ] No If yes, check all that apply: [X] Diarrhea If checked, describe: as above [X] Abdominal distension If checked, describe: occasionally 4. Symptom episodes, attacks and exacerbations ---------------------------------------------- Does the Veteran have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition? [X] Yes [ ] No If yes, indicate severity and frequency: (check all that apply) [X] Episodes of bowel disturbance with abdominal distress If checked, indicate frequency: [X] Occasional episodes [ ] Frequent episodes [ ] More or less constant abdominal distress 5. Weight loss -------------- Does the Veteran have weight loss attributable to an intestinal condition (other than surgical or infectious condition)? [ ] Yes [X] No 6. Malnutrition, complications and other general health effects --------------------------------------------------------------- Does the Veteran have malnutrition, serious complications or other general health effects attributable to the intestinal condition? [ ] Yes [X] No 7. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 8. 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 9. Diagnostic testing --------------------- a. Has laboratory testing been performed? [X] Yes [ ] No [X] CBC (if anemia due to any intestinal condition is suspected or present) Date of test: 1/1/13 Hemoglobin: 15.9 Hematocrit: 46 White blood cell count: 5.6 Platelets: 126 b. Have imaging studies or diagnostic procedures been performed and are the results available? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 10. Functional impact --------------------- Does the Veteran's intestinal condition impact his or her ability to work? [ ] Yes [X] No 11. Remarks, if any: -------------------- The veterans irritable bowel syndrome is a diagnosable but medically un-explained chronic gastrointestinal and multisystem disease of unknown etiology.
  19. I talked with my DAV service rep today about sending a support letter in to identify that although I have a diagnosis from a doctor for Fibromyalgia, it is still a Gulf War Illness. I read that Persian Gulf Illness could be presumptive illnesses either undiagnosed or diagnosed. The diagnosed could be Chronic Fatigue Syndrome, Fibromyalgia, IDS. Is this true and should I hold off for the decision or send a letter in now? If I send a letter how do I reference the correct information.
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