I just want to start by saying that when I initially went over them I was really depressed but I know that they jacked up so here goes. It only took maybe 2 wks to get the results from the VA, while my claim is in decision phase.
This is for an initial claim.
I had 35 xrays done in total my first exam
Cervical Spine:
Four-view series of the cervical spine demonstrates cervical straightening without subluxation. No evidenof fracture. Oblique images are somewhat limited, but no definite bony neuroforaminal narrowing. I feel that the suggested narrowing on these images is due to some rotation and not due to significant arthropathy, as there is no significant degnenerative change noted on the frontal and leteral views.
Impression:
Cervical straightening and loss of lordosis. This could be simply due to positioning of the patient, although muscular or ligamentous strain cannot be exluded. I see no fracture or significant degenerative process.
Thoracic Spine:
Multiple views of the thoracic spine show good alignment throughout with disc spaces preserved and vertebral body height maintained.
Impression:
Negative throacic spine
There is a small linear radiodense body overlying approximately the level of T2 just to the left of midline of unclear significance, likely reflecting artifact, but correlate clinicallly.
Lumbosacral Spine:
Multiple views of the lumbosacral spine show good alignment throughout the lumbar spine with disc spaces preserved and verteral body height maintained. The SI joints are unremarkable.
Impression:
Negative lumbar spine
For everything else left shoulder right shoulder knees ankles feet, it all says the same thing multiple views no fracture or abnormality and impressions are negative
DBQ Questionnaires (this is where I really got depressed)
Does the Veteran now have or has she ever been diagnosed witha thoracolumbar spine(back) condition?
The Doctor marked no
The same with shoulder/ arm condition.
When he actually saw me he didn't have my medical records and he hardly did any ROM except for my shoulders and arms, while he was doing ROM my entire left arm and shoulder went numb.
When I was in service I saw a physical therapist for both my shoulder and back. I saw a chiropractor for my lower back due to the narrowing. In 09 I was diagnosed with a herniated disc.
He marked no or negative or normal in all of the sections. The straight leg raising test he marked negative but I never did a test. I stood for him or sat in the chair. The last time I had to lift my leg it didn't go more than 45 degrees.
He did write again the thoracic xrays shows a small linear raiodense body at T2, likely reflecting artifact. follow up with pcp prn. In 2008 I think during an MRI my lower back my doctor caught this and sent me for an MRI of my whole spine I have a cyst he sent me to a neurosurgeon who said it would do more damage than good to remove it and it didn't look bad to him. That was the end of that.
For does it impact my ability to work he marked no. What a joke. I had every temporary possible in service for my lower back no lifting no bending no pushing no pulling.
On the Nerves DBQ he marked no for not having sciatica. It was the first thing I told him about that I was diagnosed with in 2007 a month after I got to my perm party station. He did ask me to bend forward and I stopped where the pain started so I didn't bend very far. No other test were done
He didn't look at my back or have me remove any clothing or my shoes. He wrote his notes on what seemed to be a torn scrap piece of paper.
The only conditions marked yes for in the Questionnaires are neck, elbow, knee and lower leg.
In service I was seen for neck strain once or twice but I thought it was due to my shoulder pain that developed soon after my left ulnar nerve started to pop out
On the General Medical- Compensation Disability Benefits Questionnaire under musculoskeletal condition he marked yes for neck, elbow and forarm, knee and lower leg
On the bottom of the report it says Unconfirmed Interpretation MD should review
On the chest x-ray it says no abnormal findings
----
Mental Disorder Questionnaire
Does the Veteran now have or has she ever been dianosed with a mental disorder? Yes
Diagnosis#1 Adjustment Disorder with Depressed Mood
ICD code: 309.0
Axis I
Comments: Disrupted relationship with her sister, decsreased social engagements, occasional nightmares about "death" mild dysphoria, initation and middle insomnia ( some of which is attributable to her infant son's night time risings), and pain in back, shoulders, and neck are among symptoms the claimant reported.
Psychosocial and Enviornmental Problems: Unemployed; financial stress
GAF score: 65
Is it possible to differntiat what symptons is are attributable to each diagnosis? Not Applicable
Occupational and social imparment she marked
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication.
Clinical Findings
Medical records from march 2010 NMC Portsmouth Ft Lee VA showed the claimant was evaluated for physical health conditions. No psychiatric condition was noted. However, Medical records February 2010 from Kenner AHC notes in the problem list the claimant had adjustment disorder with anxiety and depressed mood, however, no mental health records was available detailing the contact.
( The Doctor told me she had the last three months of my medical records.I stopped seeing my therapist in March 2010, I had seen her since Nov 2007.)
Claimant admitted a family history of mental illness (Grandmother, mother, sister and aunt.)
I had a hard time remembering dates for her like when I left the military and when I was treated. for symptoms she only marked depressed mood (she didn't mark memory loss. Now I'm sure she would have if I told her I was experiencing memory loss, however at the time I couldn't remember to tell her lol)
She marked yes for capable of managing my own finances
Remarks: The claimant's symptoms appear to be related to pain but are also likely a function of the circumstatnces of being unemployed and the mother of an infant and a toddler. medical records do not show the claimant has been diagnosed with a chronic pain condition, but noted (as she was observed to have) breast hypertropy, which could be contributing to back pain. As such, her current condition is diagnosed as an Adjustment Disorder with Depressed Mood.
END OF REPORT
This evaluator was very vocal about my pain when I told her how I was treated in the military by the doctors when I tried to make the connection to them with my large chest and upper back pain. She also told me that I should not keep my emotions and feelings and thoughts bottled up because of what might happen when I brake or snap. (The Doctor that treated me at Ft Lee, she used to tell me the same thing)
Okay my questions:
Can someone tell me what a rating for spinal lordosis might be? Can someone tell me exactly what it is if known? I have done some research today but still I'm not exactly sure.
For my lumbarsacroal spine can someone tell me what SI joints are unremarkable means? I tried to look it up but couldn't find a definiate answer.
Now I knew from the get go after my exam that I would have an issue for one because the doctors didn't have my medical records. Also, no MRI was done, no real ROM was done. After reading the results I was left confused and depressed as to why the Doctor would mark no for so many things that we discussed. As they say the proof is in the pudding, and I have seen many doctors that have said I have back problems and shoulder problems and sciatica. What depressed me more, was I worked so hard to get my husband to believe that my pain was not in my head. When he head me say my xrays came back negative he went back to telling me that I was making the pain up and it was all mental. Sigh. I have never felt so helpless or hopeless. I had already been having a bad day. I called the VA this morning so I could make an appt to see Doctor and the lady told me I had to fill out an application and wait to see if I was approved. I felt like I should run my head into the wall. When I opened that envelope and went through it, it was insult to injury for me.
As far as my mental exam, there was a lot I couldn't tell her because I was never going to see her again, so I didn't feel comfortable talking to her about what I was going through. An error in my part I'm sure, but once I get a good therapist I can talk to I will bare my soul.
I mentioned being treated for my back and such but the examiner failed to anotate anything about my conditions we went over. How likely is it that whoever is rating my claim will go by these results over my medical records which show my treatment for the conditions I claimed?
I'm going to head to the VA I hope this friday or next to fill out the application and try to talk to someone I really need to start seeing a therapist again. Any advice would be great as far as the next step, I know I have to wait for a decision to be made, however I don't think anything will favorable or perhaps I will have deffered conditions.
Another thing, theres nothing saying least as likely or likely as least in the exam report anywhere. I know that's the language that the VA looks for. Will not having any of that in their affect the outcome of their decision on my claim?
I know it was a long read but I could write forever to try to keep negative thoughts from entering my mind.
Question
j92mike
I just want to start by saying that when I initially went over them I was really depressed but I know that they jacked up so here goes. It only took maybe 2 wks to get the results from the VA, while my claim is in decision phase.
This is for an initial claim.
I had 35 xrays done in total my first exam
Cervical Spine:
Four-view series of the cervical spine demonstrates cervical straightening without subluxation. No evidenof fracture. Oblique images are somewhat limited, but no definite bony neuroforaminal narrowing. I feel that the suggested narrowing on these images is due to some rotation and not due to significant arthropathy, as there is no significant degnenerative change noted on the frontal and leteral views.
Impression:
Cervical straightening and loss of lordosis. This could be simply due to positioning of the patient, although muscular or ligamentous strain cannot be exluded. I see no fracture or significant degenerative process.
Thoracic Spine:
Multiple views of the thoracic spine show good alignment throughout with disc spaces preserved and vertebral body height maintained.
Impression:
Negative throacic spine
There is a small linear radiodense body overlying approximately the level of T2 just to the left of midline of unclear significance, likely reflecting artifact, but correlate clinicallly.
Lumbosacral Spine:
Multiple views of the lumbosacral spine show good alignment throughout the lumbar spine with disc spaces preserved and verteral body height maintained. The SI joints are unremarkable.
Impression:
Negative lumbar spine
For everything else left shoulder right shoulder knees ankles feet, it all says the same thing multiple views no fracture or abnormality and impressions are negative
DBQ Questionnaires (this is where I really got depressed)
Does the Veteran now have or has she ever been diagnosed witha thoracolumbar spine(back) condition?
The Doctor marked no
The same with shoulder/ arm condition.
When he actually saw me he didn't have my medical records and he hardly did any ROM except for my shoulders and arms, while he was doing ROM my entire left arm and shoulder went numb.
When I was in service I saw a physical therapist for both my shoulder and back. I saw a chiropractor for my lower back due to the narrowing. In 09 I was diagnosed with a herniated disc.
He marked no or negative or normal in all of the sections. The straight leg raising test he marked negative but I never did a test. I stood for him or sat in the chair. The last time I had to lift my leg it didn't go more than 45 degrees.
He did write again the thoracic xrays shows a small linear raiodense body at T2, likely reflecting artifact. follow up with pcp prn. In 2008 I think during an MRI my lower back my doctor caught this and sent me for an MRI of my whole spine I have a cyst he sent me to a neurosurgeon who said it would do more damage than good to remove it and it didn't look bad to him. That was the end of that.
For does it impact my ability to work he marked no. What a joke. I had every temporary possible in service for my lower back no lifting no bending no pushing no pulling.
On the Nerves DBQ he marked no for not having sciatica. It was the first thing I told him about that I was diagnosed with in 2007 a month after I got to my perm party station. He did ask me to bend forward and I stopped where the pain started so I didn't bend very far. No other test were done
He didn't look at my back or have me remove any clothing or my shoes. He wrote his notes on what seemed to be a torn scrap piece of paper.
The only conditions marked yes for in the Questionnaires are neck, elbow, knee and lower leg.
In service I was seen for neck strain once or twice but I thought it was due to my shoulder pain that developed soon after my left ulnar nerve started to pop out
On the General Medical- Compensation Disability Benefits Questionnaire under musculoskeletal condition he marked yes for neck, elbow and forarm, knee and lower leg
----
I have an Abnormal Spirometry Report
Test interpretation: Unconfirmed Report
Pre: FVC= 1.78L FEV1=1.10L FEV1%=61.8% 1.10/1.78 FEV1/FVC
Severe obstruction. Moderately servere restriction
Post: FVC= 1.4L (-19.5%); FEV1= 0.8L (-25.4%); FEV1%= 57.3% (-7.2%)
Very severe obstruction. Severe restriction
On the bottom of the report it says Unconfirmed Interpretation MD should review
On the chest x-ray it says no abnormal findings
----
Mental Disorder Questionnaire
Does the Veteran now have or has she ever been dianosed with a mental disorder? Yes
Diagnosis#1 Adjustment Disorder with Depressed Mood
ICD code: 309.0
Axis I
Comments: Disrupted relationship with her sister, decsreased social engagements, occasional nightmares about "death" mild dysphoria, initation and middle insomnia ( some of which is attributable to her infant son's night time risings), and pain in back, shoulders, and neck are among symptoms the claimant reported.
Psychosocial and Enviornmental Problems: Unemployed; financial stress
GAF score: 65
Is it possible to differntiat what symptons is are attributable to each diagnosis? Not Applicable
Occupational and social imparment she marked
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication.
Clinical Findings
Medical records from march 2010 NMC Portsmouth Ft Lee VA showed the claimant was evaluated for physical health conditions. No psychiatric condition was noted. However, Medical records February 2010 from Kenner AHC notes in the problem list the claimant had adjustment disorder with anxiety and depressed mood, however, no mental health records was available detailing the contact.
( The Doctor told me she had the last three months of my medical records.I stopped seeing my therapist in March 2010, I had seen her since Nov 2007.)
Claimant admitted a family history of mental illness (Grandmother, mother, sister and aunt.)
I had a hard time remembering dates for her like when I left the military and when I was treated. for symptoms she only marked depressed mood (she didn't mark memory loss. Now I'm sure she would have if I told her I was experiencing memory loss, however at the time I couldn't remember to tell her lol)
She marked yes for capable of managing my own finances
Remarks: The claimant's symptoms appear to be related to pain but are also likely a function of the circumstatnces of being unemployed and the mother of an infant and a toddler. medical records do not show the claimant has been diagnosed with a chronic pain condition, but noted (as she was observed to have) breast hypertropy, which could be contributing to back pain. As such, her current condition is diagnosed as an Adjustment Disorder with Depressed Mood.
END OF REPORT
This evaluator was very vocal about my pain when I told her how I was treated in the military by the doctors when I tried to make the connection to them with my large chest and upper back pain. She also told me that I should not keep my emotions and feelings and thoughts bottled up because of what might happen when I brake or snap. (The Doctor that treated me at Ft Lee, she used to tell me the same thing)
Okay my questions:
Can someone tell me what a rating for spinal lordosis might be? Can someone tell me exactly what it is if known? I have done some research today but still I'm not exactly sure.
For my lumbarsacroal spine can someone tell me what SI joints are unremarkable means? I tried to look it up but couldn't find a definiate answer.
Now I knew from the get go after my exam that I would have an issue for one because the doctors didn't have my medical records. Also, no MRI was done, no real ROM was done. After reading the results I was left confused and depressed as to why the Doctor would mark no for so many things that we discussed. As they say the proof is in the pudding, and I have seen many doctors that have said I have back problems and shoulder problems and sciatica. What depressed me more, was I worked so hard to get my husband to believe that my pain was not in my head. When he head me say my xrays came back negative he went back to telling me that I was making the pain up and it was all mental. Sigh. I have never felt so helpless or hopeless. I had already been having a bad day. I called the VA this morning so I could make an appt to see Doctor and the lady told me I had to fill out an application and wait to see if I was approved. I felt like I should run my head into the wall. When I opened that envelope and went through it, it was insult to injury for me.
As far as my mental exam, there was a lot I couldn't tell her because I was never going to see her again, so I didn't feel comfortable talking to her about what I was going through. An error in my part I'm sure, but once I get a good therapist I can talk to I will bare my soul.
I mentioned being treated for my back and such but the examiner failed to anotate anything about my conditions we went over. How likely is it that whoever is rating my claim will go by these results over my medical records which show my treatment for the conditions I claimed?
I'm going to head to the VA I hope this friday or next to fill out the application and try to talk to someone I really need to start seeing a therapist again. Any advice would be great as far as the next step, I know I have to wait for a decision to be made, however I don't think anything will favorable or perhaps I will have deffered conditions.
Another thing, theres nothing saying least as likely or likely as least in the exam report anywhere. I know that's the language that the VA looks for. Will not having any of that in their affect the outcome of their decision on my claim?
I know it was a long read but I could write forever to try to keep negative thoughts from entering my mind.
Thanks yall,
Natalie
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