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  1. Sorry in advance, but this is a long one. History: currently 30% for migraines. Diagnosed with this eye condition through MRI and told it is caused by migraines. Had C&P exam for increase on migraines. then they scheduled this one. I have attached both exam. the first one is for the increase. the second one is for the secondary conditions that I feel are caused by the migraines. This last exam looks like it shot my in the head dead. please tell me you opinion. first exam no medical opinion. second exam states IMP not related. but I have an appointment with the VA opthamologist surgeon later this month. Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: vbms If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a headache condition? [X] Yes [ ] No [X] Migraine including migraine variants ICD code: 784.0 Date of diagnosis: 2009 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): CO- "patient not aware when headache and migrains strated but got got worst in basic training, also in Germany after she delivered her daughter with migrains". Frequency of headache and migrains-18 per month. Prostrating attack frequency-5 per month. Work:- Computer private sector-full time for past three years b. Does the Veteran's treatment plan include taking medication for the diagnosed condition? [X] Yes [ ] No If yes, describe treatment (list only those medications used for the diagnosed condition): Meloxicam.Sumatriptan. 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pain on both sides of the head [X] Other, describe: sharp b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain) [X] Yes [ ] No [X] Nausea [X] Vomiting [X] Sensitivity to sound [X] Other, describe: dizzy,eye twitches,concentration problems c. Indicate duration of typical head pain [X] 1-2 days d. Indicate location of typical head pain [X] Both sides of head 4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [X] Yes [ ] No b. Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [X] Yes [ ] No 5. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any 56 conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): HTN,Anxiety 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: Slows her prodoctivity. 8. Remarks, if any: ------------------- PE: BP-136/75 -HEENT-normocephlaic,EOME,PERLA,no facial drops or tongue deviations,cranial nerves II/XII gorssly normal. -Neck-Supple, no JVD or carotid bruits. Current level of headache and migrain severity:- moderate to sever based on subjective reporting by patient. [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VBMS If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran have a peripheral nerve condition or peripheral neuropathy? [X] Yes [ ] No Diagnosis #1: henifacial spasm Date of diagnosis: 2014 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's peripheral nerve condition (brief summary): 51 Y/O female. Service connected for headaches. Pt was in the National Guard until 2003. Onset of twiching left eye in 2012. The twiching has progressed to a left hemifacial spasm at the present. b. Dominant hand [X] Right [ ] Left [ ] Ambidextrous 3. Symptoms ------ Does the Veteran have any symptoms attributable to any peripheral nerve conditions? [X] Yes [ ] No Constant pain (may be excruciating at times) [X] Other symptoms (describe symptoms, location and severity): Left facial nerve 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Were special tests indicated and performed for median nerve evaluation? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? [X] Yes [ ] No If yes, describe (brief summary): Pt received the first and only Botulin toxin injections March 2015 with an improvement of the spasms of 60%. it was a small dose. 15. Diagnostic testing a. Have EMG studies been performed? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): Normal MRI and CAT of the head reported by the patient 16. Functional impact --------------------- Does the Veteran's peripheral nerve condition and/or peripheral neuropathy impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's peripheral nerve and/or peripheral neuropathy condition(s), providing one or more examples: Data entry on a computer. Spasms distracts her concentration at work. 17. Remarks, if any: -------------------- IMP Left hemifacial Spasms unrelated to her service connected Migraines headaches
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