Researching Passed Claims

[Tomahawk]

Can anyone give me some tips on how to search former VA claims for secondary conditions?

[Tomahawk]

Berta you are amazing. Thank you very much. I will scan the exams when I get home and post them.

[Hoppy]

Berta,

I was also going to suggest that he look for doctors who are named. However, I was going to suggest that he also search the doctors name in the BVA. I did that with Dr. Bash and was amazed what I found. The BVA has declared war on Dr. Bash and tried to discredit him just because he writes so many different opinions about some many different conditions. They even attacked his credentials. I can post the case. However, I did not want to pass along the BVA's attempted assination of a doctor who tries to help veterans.

Edited September 3, 2010 by Hoppy

[Berta]

Yeah=I recall the BVA quoted a VA C & P doctor as saying "that radiologist"- meaning Dr. Bash.

My VARO refused to read his IMOs for my claim even when I had a DRO conference set up between the DRO and my rep when I asked them to CUE themselves in 2005.

The rep claimed he specifically gave the IMOs to the DRO highlighting what they contained. The SSOC however says otherwise so I dont know who was lying.

In any event the BVA awarded me based on my 2 IMOs from Dr. Bash, a freeby IMO from a former VA doctor, and due to my extensive lay evidence.

The fact that Dr. Bash was a NeuroRAdilogist gave him considerable weight with the BVA as my claim involved Neuro matters and MRI findings re diabetes, CAD and CVA,

Plus I had already proved malpractice so those findings too helped him develop the IMOs.

[Tomahawk]

I cant get my scanner to work so Im just going to type them out and post it.

This was the first doctor I see.

Review of medical Files: C-file reviewed.

Medical History:

1.) The patient has chronic left leg pain problem. X-Rays of the left knee are normal. He has an RSD-type problem and that could be causing some of his knee pain. He gets aching, pain, stiffness, weakness, and give way. He has had no surgery.

2.) He is using brace and a cane.

3.) He has been disabled, would be limited to kind of sit down work.

4.) Normal daily activity is difficult.

5.) Range of motion of the knee: From 0 to 110 degrees of flexion.

6.) There is pain throughout the range of motion.

7.) According to DeLuca, repetitive use caused him more pain. No range of motion or other change noted.

8.) No flare-ups noted.

9.) The knee is stable.

10.) An X-ray is normal.

Final Diagnosis: Left knee strain, left leg pain related to reflex sympathetic dystrophy (RSD).

Conclusion: X-Rays of the knee are normal. His knee and leg pain may be more likely than not related to the chronic pain syndrome related to his old surgery on his left foot. This is more likely than not the case.

Review of medical records: C-file reviewed. X-rays show a degenerative disk and a spina bifida.

Medical History:

1.) The patient had the onset of back pain last several years. Found to have some lumbar disk disease. No surgery has been done. There was a concern it might be due to his altered gait. He has soreness and tenderness across his lumbar spine.

2.) He gets some left leg pain and some numbness and tingling with it.

3.) He is using a cane and multiple braces on his lower extremeties.

4.) He has been disabled since March of 2009 and would be limited to strictly sedentary-type work.

5.) Range of motion of the back: He can flex from 0 to 50 degrees, extend from 0 to 10 degrees, left lateral flex 0 to 10 degrees, right lateral flex 0 to and 10 deggrees, left lateral rotate 0 to 10 degrees, right lateral rotate 0 to 10 degrees.

6.) According to DeLuca, repetitive use caused increasing pain. No other change noted.

7.) Flareups occur with heavy use.

8.) He has tenderness and pain throughout range of motion.

9.) Sensorimotor exam: He has RSD-type findings in his left lower extremity, hypersensitivity to touch, and consequently, some give-way weakness in that left lower extremety. Also straight leg raising causes back pain. Right lower extremity, neurologically, is normal.

10.) No incapacitation.

11.) No x-rays needed.

Final diagnosis : Degenerative disk disease, spina bifida, lumbar spine.

Conclusion: Having reviewed the record and examination, any relationship of this to his service, left foot, is purely speculative.

Review of medical records: C-File reviewed.

Medical History:

1.) The patient has postop bunion and claw toes left foot and hammertoes left foot and a bunion right foot. The bunion right foot is not related to the left foot. It is just a bunion. He still has left foot pain and regional pain syndrome related to it. Gets some bunion pain on the right foot.

2.) No surgery done on the right foot.

3.) He wears a brace on the foot, uses a cane to ambulate, and has had surgery on the left foot.

4.) As far as corrective devices, he uses a brace on the left ankle and a cane to ambulate. Therefore he has been disabled.

5.) Examination of the right foot shows bunion. Left foot shows postoperative bunion, hammertoes left foot with hypersensitivity to touch.

6.) There is tenderness over the bunion, generalized ache and pain from his regional pain syndrome, left lower extremity.

7.) He has difficulties, an awkward wide-based gait with standing and walking.

8.) He has some abnormal weightbearing.

9.) Not applicable.

10.) Not applicable.

11.) X-rays not needed.

Final Diagnosis:

1.) Postoperative bunion, hammertoes left foot, with regional pain syndrome.

2.) Bunion, right foot.

Conclusion:

Having reviewed the record the bunion is not related to the left foot. The bunion is just a natural occurring phenomenon on that right foot.

Issue number one he refers to my RSD as "RSD - type" WTF is that? I have a confrimed diagnosis of it from my initial C&P exam where they di triple phase bone scans or some shit. It isnt a pain LIKE RSD it IS RSD.

Problem number two. He reviewed my mediical file huh? Then why is there no mention of the multiple knee sprains and injuries that are IN my service medical record. Or no mention of my lower back strains that are IN my service medical record. Also NO mention of the 2 herniated discs with focal annular tears that I have and receive epidural injections for.

Issue number three how did he get the range of motion degrees? The only thing I was able to do was the forward flexion, which was just barely a forward flexion. Hell I have to squat to pick up my socks and shoes, and almost fall on my face doing that and putting them on.

NO mention of the custom orthotics that I have to have made and wear.

He claims I have post operative surgery for claw and hammer toes. Really? Where was I at when I was diagnosed and operated on for those conditions? Ive never had either of those issues in my life.

As for the right foot bunion, I never claimed that was caused by service connection. I simply stated that over compensating for my left leg issue has put undo stress and pain on my right foot.

Ill post the stomach and sleep apnea in a different post as it was 2 different VA doctors and I dont want to make this too long to read,

[Tomahawk]

Review of medical records: the veteran’s C-file has been reviewed.

Medical history:

The patient is a 33 year old Caucasian male veteran who presents to C&P today for an esophagus and hiatal hernia examination. The veteran is claiming that his recently diagnosed gastroesophageal reflux disease and esophagitus status post funddoplication surgery are due to nonsteroidal anti-inflammatory medications, namely Naprosyn that he was taking for a left foot condition during his active military enlistment. The patient states that he started to develop symptoms of pyrosis during his military enlistment and was medicated with over the counter antacids. Review of the veteran’s C-file sows on his separation exam he had checked indigestion as a symptom. There are no medical reports of symptoms of pyrosis, or indigestion noted in his service medical records. Review of his CPRS electronic charting notes on a consult that was placed, that he started to develop symptoms of GERD between 20002 and 2003. His first endoscopy procedure was completed earlier this year which documented mild esophagitus and further testing diagnosed him with GERD. He had a treatment course of PPIs that he failed, and as recently as May had fundoplication surgery.

Physical examination: He is a 33 year old Caucasian male veteran, alert and oriented x3, in no acute distress. Height 73 inches weight 270 pounds. He appears well nourished. He has no outward signs of anemia. All mucosa is moist and pink. The abdomen is soft. It is obese. It is nontender. No masses, no guarding, no rebound. No signs of bruits.

Diagnostic and clinical test: Review of endoscopic reports confirms mild esophagitis, and other testing confirms GERD, and the veteran is post fundoplication surgery.

Diagnosis: GERD, post operative fundoplication surgery. Form 2507 requested opinion: It is less likely than not that the veteran’s use of NSAIDs from 1998 to 2003 caused his GERD. NSAIDs are not known to cause GERD however the use of them in individuals with known GERD may contribute to the severity. The veteran also has other factors which would contribute to the severity such as his obesity.

First problem with his is my first endoscopy was NOT this year. My only two endoscopies were both last year. One in feb the other in may.

Second problem with this is that he never weighed or measured me. If you are going to quote something in a medical exam shouldn’t you actually to the measuring instead of copying it from over 3 months ago which was the last time I was weighed and measured at the VA.

Thirdly if actually reviewing my diagnostic tests it would show barret’s esophagitus, hiatel hernia, 3 erosions in my throat, as well as GERDs.

Fourth issue While yes I did stop taking NSAIDS in 2003 I was promptly put back on them 4 months later and have continued to be on them. No mention of that?

I could complain about the sleep apnea exam as well, I knew that was a shot in the dark. While I do have sleep issues documented in my SMR, and have a letter from my roommate in the marines that I snored and would wake in panic attacks, I really can’t prove medically that I had, or acquired it while on active duty. But it does piss me off that at the end of the exam he claims it is the fact that I am overweight that I have sleep apnea. Especially considering the main reason I am overweight is my inability to be active, and 80% of the meds they have me on list weight gain as a side effect.

[Hoppy]

Tomahawk

I’m not sure I have a really good understanding of what you’re trying to do. Redirect me if I get off base. I think you have been trying to get service connection for your back. I’m not sure if you had advanced this claim as direct service connection or secondary to your foot condition. Technically, the VA is supposed to consider all etiologies. It appears from the C&P exam that the examiner only addressed the possibility that the back condition is due to the foot condition. The RO might have asked him to perform a specific C&P addressing limited questions.

In the event you are rebutting the determination that the examiner was not correct in establishing the back condition is secondary to the foot condition, attacking his failure to find a connection between the two conditions if successful does not produce evidence of a nexus between the knee condition and the back condition. At best you might get another C&P exam. The record must contain evidence in support of the claim that outweighs the evidence against the claim. Thus, if the VA will not schedule another C&P exam then you need to get an IMO.

The IMO should go into more detail and be stronger than any evidence against the claim. I have seen reports relating foot conditions to back conditions whereby the examiner goes into detail as to the extended length of time between the onset of the foot condition and the onset of the back condition. Thus, showing years of unusual or altered gait. You might want to search the BVA for ‘altered gait” and see if you can find any good cases.

You can point out that they failed to evaluate direct service connection and that the SMR does show a history of back pain. If you provide me with more details of how many times you were treated and how long you reported pain during each episode while on active duty I might be able to give you good insight into how to advance direct service connection. I worked with lawyers and doctors developing evidence for permanent disability settlements for industrial injuries involving back claims prior to the invention of the MRI.

I will try to look at the other claim as time goes on. However I am most familiar with back injuries and mental health issues.