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Rx7mike

Mental Health C&p Any Opinions Appreciated

Question

This is for an appeal of my current VA 60% i was Retired @90% and am on SSDI due to SC issues Thanks for insight

Mental Disorders
(other than PTSD and Eating Disorders)
Disability Benefits Questionnaire

SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
disorder(s)?
[X] Yes[ ] No

If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Bipolar I Disorder, Severe, Most Recent
Episode
Depressed (296.53)

Mental Disorder Diagnosis #2: Panic Disorder, without agoraphobia (300.01)

b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Deferred to medical provider.

Comments, if any:
The examinee reported a number of medical complaints that are beyond
the scope of this referral. Nonetheless, this writer would suggest
that
he be evaluated further by a qualified medical professional to address
such concerns.


2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes

b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[X] Yes

If yes, list which symptoms are attributable to each diagnosis:
The veteran's symptoms of mood instability, impulsivity,
irritability,
and concentration difficulties are related to his diagnosis of
Bipolar
Disorder. His panic attacks are related to his diagnosis of Panic
Disorder.



3. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of
occupational
and social impairment with regards to all mental diagnoses? (Check only
one)

[X] Occupational and social impairment with deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood


b. For the indicated level of occupational and social impairment, is it
possible to differentiate what portion of the occupational and social
impairment indicated above is caused by each mental disorder?
[X] Yes

If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
Based on the veteran's self-report and all available medical records,
the veteran's occupational and social impairment are linked primarily
to his Bipolar Disorder. He denied significant impact of his Panic
Disorder on his occupational and social impairment.



SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence review
------------------

a. Medical record review:
-------------------------
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? Yes
Was the Veteran's VA claims file reviewed? Yes

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

Updated treatment records through Hampton VAMC. The veteran was previously
examined for "Bipolar Disorder" and "Anxiety Disorder." For this reason,
this
writer obtained information since his previous exam, dated in 2011. For
previous history, please refer back to his previous C&P report.

b. Was pertinent information from collateral sources reviewed? No


2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Since 2011, the veteran has reported increased social isolation and
interpersonal conflict in connection with his Bipolar Disorder. The
veteran reported that he has stopped talking to "everyone" except his
wife
and his brother. He reported detachment from family members with whom he
previously had positive relationships. According to the veteran, he
continues to be married and they have three children together. He
described his relationship with his wife as "good, I couldn't hold it
together without her." He noted dependence upon his wife for activities
of
daily living related to reported physical conditions. He reported that
his
Bipolar Disorder has prevented him from watching his children engage in
extracurricular activities, and feels that he is not as supportive as he
should be. He stated that he "can't tolerate" social situations, and
isolates in order to avoid conflict. According to the veteran, his "anger
and violence have gotten out of control." He reported continued physical
aggression since 2011. He estimated involvement in altercations twice per
week. He denied homicidal ideations, but rather impulsive reactions to
stressful situations. His medical record is consistent with this report.



b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The veteran denied steady employment during this review period. He
reported that he attempted to continue working as a mechanic, but due to
a
combination of mental and physical problems, he has experienced an
unsuccessful series of attempts to obtain/maintain employment. He stated
that engages in verbal conflicts with others, and ultimately has lost his
jobs. "They never last long, one didn't event last a week." He stated
that
he has attempted to work in manual labor jobs, but is physically unable
to
do so. He also noted conflicts with customers. He reported that he "tried
the vocational rehabilitation program" and is currently on social
security/disability related to his mental illness.

Regarding the veteran's educational history, he reported that he began
classes at ECPI in February 2013, and was planning to obtain a degree in
Network Security. However, his grade declined shortly after enrolling due
to distractibility and confusion. He reported an altercation with his
academic advisor, resulting in physical aggression. He reported that he
has not been legally charged because his advisor started the conflict. He
reported that after that
situation, he experienced significant confusion
surrounding his class schedule. He was reportedly asked to leave a class,
because he was sitting in the wrong class. When asked for further
details,
the veteran responded that he still does not understand what happened,
and
he did not provide further clarification. However, he stated that he has
been unable to complete his class work, and recently dropped out of
classes.


c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
The veteran reported that since 2011, he has continued with medication
management through the Hampton VAMC (Virginia Beach CBOC). He is
currently
prescribed Lithium, Valium, Ziprazidone, and Diazepam. He reported that
he
has requested individual psychotherapy since 2011, but has not yet
started. He denied any history of psychiatric hospitalizations or
emergency room visits related to his mental health conditions in the
current review period. Record review reveals a significant verbal
altercation with another veteran in the Virginia Beach CBOC waiting room
in October 2013. According to that record, he had experienced significant
stress related to his daughter's health condition at the time, and he was
easily provoked.

The veteran's medical record also indicates a history of panic attacks
and
engaging in "cutting" within the past few weeks as a method of relieving
stress.


d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Since 2011, he has continued to engage in physical fighting. However, he
denied legal charges related to his behavior. He received a speeding
ticket in December 2013, and got into a verbal altercation with the
police
officer. However, he was reportedly not charged for his behavior. "I
don't
know why; I clearly was in the wrong. But I feel like I can't control it.
It comes out of nowhere."



e. Relevant Substance abuse history (pre-military, military, and
post-military):
The veteran denied current use of alcohol or other substances since 2007.
He denied ever having a pattern of problematic or chronic use of
substances. He reported that he uses his medications as prescribed.

3. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veteran's
diagnoses:

[X] Depressed mood
[X] Anxiety
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Flattened affect
[X] Speech intermittently illogical, obscure, or irrelevant
[X] Impaired judgment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or
a
worklike setting
[X] Impaired impulse control, such as unprovoked irritability with
periods
of violence
[X] Grossly inappropriate behavior
[X] Persistent danger of hurting self or others

Behavioral observations:
Please refer to the remarks section below.

5. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[ ] Yes[X] No

If no, explain:
The veteran has reported that he cannot be trusted with finances. In
addition, he reports that his wife is the designated payee for his
social
security check. His prior history of shopping sprees also lends
additional evidence of this assertion. Overall, the symptoms of his mood
disorder would significantly interfere with his ability to appropriately
budget and spend his financial resources. He is at high risk for
misusing
such money, or falling victim to a predator (as he has routinely
displayed impaired judgment during episodes of mania).



6. Remarks (including any testing results), if any:
---------------------------------------------------
The veteran was notified of the limitations inherent in the present
interview. The examinee was made aware that the undersigned was functioning
solely in the role of an assessor, and not as a treatment provider. The
nature of the examination, with respect to the pending claim/request, was
made clear. Further, the limited confidentiality of the present results was
explained, and the veteran understood that the present results would be
shared with individuals attempting to adjudicate his compensation claim.
Additionally, the examinee was informed of this writer's affirmative
responsibility to prevent either the respondent or others from being placed
in danger of harm. Specifically, information related to ongoing elder/child
abuse would be related to an appropriate protective services agency.
Additionally, the veteran was instructed that if it is believed that he is
an
imminent threat to either himself or others, the limits placed upon
confidentiality, as previously explained, will no longer apply. The veteran
demonstrated an understanding of this material and provided verbal consent
to
continue with the scheduled assessment.

Mr. Mallette presented on time and in fair spirits. Rapport with this writer
appeared easily established and social skills were fairly intact. Personal
hygiene was fair. He was alert and aware throughout the present contact. He
was an active participant throughout the evaluation. He was oriented to all
spheres and understood the nature of the present assessment. Speech was
within normal limits for volume and rate. He demonstrated difficulty in
responding to specific questions, as his answers were initially on topic,
but
eventually derailed. However, he demonstrated awareness of this and
unsuccessfully attempted to correct himself.

Cognitive skills presented as grossly intact. He was able to complete
multi-step tasks without noticeable difficulty. The veteran reported "dull"
mood and this is congruent with his nonverbal behaviors, which were
indicative of depression. Performance was within expected limits on all
measures of memory. He was able to remember current and past president's
names, and he was able to recall all three target words after a 10 minute
interval without prompting or assistance. Additional screens of memory
functioning and attention did not suggest the presence of impairment in
memory or concentration. He was able to complete serial number tasks without
difficulty and he was able to correctly spell a 5 letter word forwards and
backwards.

Performance on a digit span type task was below expected limits, as he was
able to accurately recite five digits forward and four backward. Abstract
reasoning skills and general fund of information did not evidence noticeable
impairment. Intellectual dysfunction was not evident, nor suspected. No
symptoms of formal thought disorder were observed or reported. The veteran
also denied symptoms of psychosis, suicidal ideation, or homicidal ideation.


This compensation exam was conducted specifically to assess for the presence


of "Bipolar Disorder, Mixed." The veteran's medical record consisted of
many
diagnoses, including Bipolar Disorder, Bipolar II Disorder, ADHD, Anxiety
Disorder, Panic Disorder, and R/O Borderline Personality Disorder. His
C&P
exam in 2011 reveals a diagnosis of Bipolar Disorder, Mixed, and states that
his anxiety is attributed to his Bipolar Disorder. Most recent medical
documentation indicates Bipolar Disorder and Anxiety Disorder.

Regarding his mood disturbance, the veteran reported a "dull" mood most
days.
However, he reported distinct episodes of mania and depression, with each
lasting anywhere from 2-3 weeks. He reported that during a manic phase, he
achieves approximately 3 hours of sleep per night with adequate energy.
However, when in a depressive phase, "I feel like crap" and "sleep all day."
During his manic phase, he experiences elevated sense of self-esteem,
decreased need for sleep, talkativeness, racing thoughts, distractibility,
increase in goal-directed activity, and involvement in risky behaviors
(including losing up to $3000 within 4 hours of gambling, which caused
financial problems for the family; and increased sex drive with prior sexual
indiscretions, although his current medications provide complications
related
to sex drive). He reported that his spending became such a problem that his
wife has been designated as his payee for Social Security, and she handles
all of the household finances. Regarding depressive symptoms, the veteran
reported episodes of sad mood, markedly diminished interest in previously
enjoyed activities, significant weight fluctuations due to variable
appetite,
hypersomnia, fatigue, concentration difficulties, and psychomotor agitation.
The veteran meets criteria for Bipolar I Disorder, Severe, Most Recent
Episode Depressed. The veteran's reported symptoms are not suggestive of
mixed features, as he describes them as distinct episodes.

The veteran also reported many symptoms of anxiety, including panic attacks
beginning in 2007. He described these as including chest pain, difficulty
breathing, sweating, shaking, abdominal distress, dizziness, chills,
depersonalization, fear of losing control, and fear of dying. He stated that
these panic attacks are usually unexpected. He reported persistent concern
about having another attack. He also reported that when he first notices an
attack beginning, he tries to calm himself down. The veteran reported that
panic attacks occur in multiple settings. However, as a result of panic
attacks on the highway, he has begun to avoid highways when possible. He
reported that he can tolerate highways when his wife is driving, although he
experiences significant tension. Although he reported prior motorcycle
accidents, he denied direct correlation of symptoms to these accidents. He
denied intrusive or other PTSD symptoms related to his accidents. The
veteran's previous C&P report attributed the veteran's anxiety symptoms
to
his Bipolar Disorder. Although Bipolar Disorder with anxious distress
encompasses some feelings of restlessness and fear that something awful may
happen (DSM-5, p. 149), the veteran's reported symptoms are more reflective
of Panic Disorder, without Agoraphobia. He denied additional anxiety
symptoms
that would warrant an additional anxiety diagnosis.

According to the veteran's medical record, prior test results reveal
responses congruent with Antisocial Personality Disorder. However, the
veteran was never diagnosed with Antisocial Personality Disorder. He denied
symptoms of conduct disorder during his childhood, and there is no evidence
of such in his medical record. In addition, he reported feeling remorse for
his actions until recently. "I'm concerned because I've started not to care
anymore. It's like I'm numb and I don't like that." In addition, the DSM-5
states that Antisocial Personality Disorder should not be diagnosed when
antisocial behavior occurs exclusively during the course of a bipolar
disorder (p. 662). The veteran also denied symptoms related to Borderline
Personality Disorder.

The veteran reported that his primary problems are related to his mood
disturbance, particularly his agitation, irritability, and lack of
concentration. He reported that they have contributed to significant
impairment in interpersonal relationships and his ability to obtain and
maintain employment. It is believed that the veteran experiences significant
impairment in judgment, motivation, and mood, resulting in significant
difficulties in occupational and social functioning.

As a mental health professional, I recognize that the determination on this
individuals claim is properly a matter for the VBA and/or the court to
decide. Therefore, the clinical opinions provided in this report in regard
to
these issues are of an advisory nature only. The medical of record in this
case was reviewed and considered in the overall assessment of the veteran.
He
appeared to freely acknowledge prior events and behaviors that may reflect
poorly upon him. As such, the results of the present clinical interview are
considered to be an accurate reflection of his current functioning. I will
be
glad to provide the referral source with any further information, records,
or
testimony that it may require. Please note that all diagnoses reflect DSM 5
criteria.

(In short is there any hope. The VA requested my info from SSDI on the 7th which will show i recieved for SC injuries and that i am unemployable.

My othere C&P for my shoulders she cleared me for seditary work but she didnt take in concideration my MH) Please help

Thank You)

It seems as if she is with me then she falls off the wagon so to speak but then comes back really strong on some points. She requested i need further intensive followup with my provider before i left.

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looks like 70% to me

first dsm 5 I've seen. screw gaf scores and good luck

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as Jesusplay stated, you are looking @70%. with the possibility of automatic U.I. If you don't put in for it as soon as you get your rating. I think you may even get 100% if you are not currently or you cant hold a steady Job.

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70-100% definitely bud. Good luck and keep us posted.

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Now im just looking at a timeline of sorts. i did request IU when i filed NOD but since i didnt have a Disability rating for one high enough the 1800 said its not there. The P&T DR who did my main exam did state that not to worry i was worse than i was a year ago. but in the final notation notated that i could do seditary work without knowing my mental capacity i guess.

looks like 70% to me

first dsm 5 I've seen. screw gaf scores and good luck

jesusplay you refer to first dsm 5 you have seen what does that mean exactly./ Thank you all for your help

as Jesusplay stated, you are looking @70%. with the possibility of automatic U.I. If you don't put in for it as soon as you get your rating. I think you may even get 100% if you are not currently or you cant hold a steady Job.

My RO is straight forward and located in the winston salem office she stated as soon as i get that rating in my hands if its not 100 she said fax it to her and she will hand walk it in so i can get it hopefully fast tracked fingers crossed

I Have been on SSDI since before i was medically retired for medical reasons. i also have 3 other claims rated at 10% each wich looks like i will be increased to 20% min on them as well. The DRO requested a cd from my SSDI and i know i was a pproved for only SC items as i was in the WTU while i was approved a decision on my ssdi was reached in 7 days after a denial.

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its long but here are the other rted issues all currently @ 10% focus on shoulders the C&P requested i see my ortho as soon as possinble

LOCAL TITLE: C&P GENERAL MEDICAL
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JAN 14, 2014@08:00 ENTRY DATE: JAN 14, 2014@15:35:14
AUTHOR: EXP COSIGNER:
URGENCY: SEVERE STATUS: COMPLETED


Scars/Disfigurement
Disability Benefits Questionnaire

Name of patient/Veteran: Mallette,Michael Thomas

Indicate method used to obtain medical information to complete this
document:
In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed: Yes
List any records that were reviewed but were not included in the Veteran's
VA claims file: xt shoulder today


1. Diagnosis
------------
Does the Veteran have one or more scars anywhere on the body, or
disfigurement of the head, face, or neck? Yes
Diagnosis #1: Residual scars from 8 arthroscopies surgeries left shoulder
ICD code: 709.2
Date of diagnosis: 2006/2007/2008 and 2009/2010

Does the Veteran have any scars on the trunk or extremities (regions other
than the head, face or neck): Yes

Does the Veteran have any scars or disfigurement of the head, face or neck:
No

SECTION I: Scars of the trunk and extremities
----------------------------------------------
1. Medical history
------------------
Describe the history (including cause/origin and course) of the Veteran's
scar(s) of the trunk or extremities, (brief summary): veteran had multiple
scars from arthroscopic surgeries to both shoulders
per veteran scars was itchy after surgeries
currently he reports scars not bothers

Are any of the scars of the trunk or extremities painful: No

Are any of the scars of the trunk or extremities unstable, with frequent
loss of covering of skin over the scar: No

Are any of the scars BOTH painful and unstable: No

Are any of the scars of the trunk or extremities due to burns: No

2. Physical exam for scars on the trunk and extremities
-------------------------------------------------------
2-1. Details of scar findings for the trunk and extremities
Right upper extremity: Affected
Location of scars on right upper extremity and number them: shoulder
with
not clear small scars 1 cm x 1 cm
scar not pigmented,not adhered,not keloid,not painful
Types of scars and provide measurements:
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar #1: 1 X 1 cm Scar #2: 1 X 1 cm
Scar #3: 1 X 1 cm

Left upper extremity: Affected
Location of scars on left upper extremity and number them: shoulder with
not clear small scars 1 cm x 1 cm
scar not pigmented,not adhered,not keloid,not painful
Types of scars and provide measurements:
Deep non-linear
Length and width of each deep non-linear scar:
Scar #1: 1 X 1 cm Scar #2: 1 X 1 cm
Scar #3: 1 X 1 cm

Right lower extremity: Not affected

Left lower extremity: Not affected

Anterior trunk: Not affected

Posterior trunk: Not affected

2-2. Summary of nonlinear scar areas for the trunk and extremities
------------------------------------------------------------------
Superficial non-linear scars:
Right upper extremity: Approximate total area: 4 cm2
Left upper extremity: Approximate total area: 4 cm2

Deep non-linear scars: No response provided

SECTION II: Scars or other disfigurement of the head, face, or neck: No
response
provided
---------------------------------------------------------------------

SECTION III: Miscellaneous
---------------------------
1. Limitation of function/other conditions
------------------------------------------
Do any of the scars (regardless of location) or disfigurement of the head,
face, or neck result in limitation of function? No
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs and/or symptoms (such as muscle or nerve damage)
associated with any scar (regardless of location) or disfigurement of the
head, face, or neck? No

2. Color photographs
--------------------
Color photographs for any scars or disfiguring conditions of the head, face,
or neck: Photographs not indicated

3. Functional impact
--------------------
Does the Veteran's scar(s) (regardless of location) or disfigurement of the
head, face, or neck impact his or her ability to work? No

4. Remarks, if any:
-------------------
Veteran reports he served Army from 2005 to 2011 active duty as in mechanic

he also was in Reserve from 3/2000 to 9/2002 also mechanic he worked auto
shop my whole life,working mechanic at age 17-18 (1995-1997)
His working stopped in 2/28/ 2011 after separation from Army and he was
approved SS disability since 2010 due to MH bipolar and anxiety and other
issue
he attended vocational rehab few weeks ago,he used GI bill for school
studying net work security and he had issue with faculty
per veteran Dr Alphonso thinks he cannot work due to anger issue
he is married and had 3 children 10/6 and 3 ,wife is home maker ,it is
hard
to live on VA pension 1200 and SS is 1031 and 200 for each child
he reports problem watching his children due to anxiety children played
each other daughter was pushed by another kid and had a concussion,the
grand father of his neighbor kid yelled at his son and each time seing
him
he had flash back
however veteran denies suicidal/homocidal
he also mentioned about almost lost his house and his wife not listed as
his dependence due to paper work not in place and became tearful
also he said PMD always prescribed pain pill and this caused him
constipation
he tried anger management not working due to group setting "stupid people
say something stupid that anger me ",awaiting Dr Becker individual
counseling
he reports last year he was in program by SS but after receiving paper
from
VAMC he was out of that program and told permanent program and he had
case
review change to 7 yrs
Per veteran he reports he used to have strong will but not anymore
he reports if he can provide to his hammily /kids then he will be be much
happy
he admits anger for little things
also he reports he has 2 friends only and usually had lots of friends
he reports now in order not to take anger out to other he scratches
himself both forearms

NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.


****************************************************************************


Esophageal Conditions
(Including gastroesophageal reflux disease (GERD), hiatal hernia
and other esophageal disorders)
Disability Benefits Questionnaire

Name of patient/Veteran: Mallette,Michael Thomas

Indicate method used to obtain medical information to complete this
document:
In-person examination

Evidence review
---------------
Was the Veteran's VA claims file
reviewed: Yes
List any records that were reviewed but were not included in the Veteran's
VA claims file: xt shoulder today

Diagnosis
---------
Does the Veteran now have or has he/she ever been diagnosed with an
esophageal condition? Yes
GERD ICD code: 530.81 Date of diagnosis: 2006/2007

Medical history
---------------
Description of the history (including onset and course) of the Veteran's
esophageal conditions: Veteran reports in 2006-2007 he had heartburn real
bad
after meal and burning helped with drinking water
he saw Dr in service at Fort Sills and Fort Eustis,prescribed prilosec
prilosec helped sometimes
burping while running for PT
no nausea/vomitting
no abdominal pain
oily food/greasy caused abdominal cramps
no problem swalowing
no weight loss,weight fluctuates
He had gastric emptying scan 8/2011 revealed

Impression:
Markedly delayed gastric emptying.

Primary Diagnostic Code: ABNORMALITY, ATTN. NEEDED

Primary Interpreting Staff:
CHIEF, NUCLEAR MEDICINE (Verifier)
/TKC


Veteran board reviewed mentioned GERD

Does the Veteran's treatment plan include taking continuous medication for
the diagnosed condition: Yes
Medications used for the diagnosed condition: prilosec

Signs and symptoms
------------------
Does the Veteran have any of the following signs or symptoms due to any
esophageal conditions (including GERD)? Yes
Sign and Symptoms:
Pyrosis (heartburn)

Esophageal stricture, spasm and diverticula
-------------------------------------------
Does the Veteran have an esophageal stricture, spasm of esophagus
(cardiospasm or achalasia) , or an acquired diverticulum of the esophagus?
No

Other pertinent physical findings, complications, conditions, signs and/or
symptoms

-----------------------------------------------------------------------------
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

Does the Veteran have any other pertinent physical findings, complications,
conditions, signs and/or symptoms related to any conditions listed in the
Diagnosis section above? No

Diagnostic Testing
------------------
Have diagnostic imaging studies or other diagnostic procedures been
performed? No

Has laboratory testing been performed? Yes
CBC Date of test: july 30/2012
Hemoglobin: 16.4
Hematocrit: 49.6
White blood cell count: 8.5
Platelets: 232,000

Are there any other significant diagnostic test findings and/or results? No

Functional impact
-----------------
Do any of the Veteran's esophageal conditions impact on his or her ability
to
work? No

Remarks, if any: No response provided
-----------------

NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.


****************************************************************************


Shoulder and Arm Conditions
Disability Benefits Questionnaire

Name of patient/Veteran: Mallette,Michael Thomas

Indicate method used to obtain medical information to complete this
document:

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

xt shoulder today

If no, check all records reviewed:

[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:

1. Diagnosis
-------------
Does the Veteran now have or has he/she ever had a shoulder and/or arm
condition?
[X] Yes [ ] No

Diagnosis #1: Left shoulder recurrent dislocations s/p 4
arthroscopic surgeries,not helped
ICD code: 831
Date of diagnosis: 2006
Side affected: [ ] Right [X] Left [ ] Both

Diagnosis #2: right shoulder DJD s/p dislocation and 4 arthroscopic
surgeries
ICD code: 715.91
Date of diagnosis: 2012
Side affected: [X] Right [ ] Left [ ] Both

Diagnosis #3: Left shoulder joint unstable
ICD code: 718.81
Date of diagnosis: 2014
Side affected: [ ] Right [X] Left [ ] Both

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
shoulder and/or arm condition (brief summary):
Veteran reports he had injury to both shoulders
left shoulder injury in 2006 in combat training ,not sure what
happened
but left shoulder went out socket in 2006 and he saw dr in service and
he had MRI in St Mary in Korea in 2006 told inconclusive
Few months later at boxing tournament left shoulder again dislocated
briefly he had left shoulder recurrent dislocations 8-9 time before
surgery in 2007,then in 2007 he 1st arthroscopy surgery at at Fort
Sill Oklahoma by military doctor,and another surgery followed 2
months
later by another surgery same shoulder,same hospital and by different
doctor
These 2 arthroscopy surgeries not fixing problem
left shoulder still dislocated now and then and he cannot raise left
arm above shoulder and 3rd surgery arthroscopy done dec 2007 and 4th
surgery done in 2008 also arthroscopy for arthritis left
shoulder,totaly 4 left shoulder arthroscpic surgeries.

He was dischaged from service/medical retired in 2011 with 80%.

Right shoulder problem also started in 2006 with dislocation while he
stationed in Korea and surgery not done since left shoulder get


treated first and in 2007 at Fort Sill while lifting a dumpster lid
and the wind blew lid back and his r arm "ripped the r shoulder joint
out "and he had dislocation,he saw Dr and had surgery in 2007 followed
by PT .

After that surgery 2007 r shoulder still painful and decreased ROM he
saw Dr at Fort Sills and had second surgery done in 2008 and he was
reclassified to aviation tech,he took training at Fort Eustis in
2008-2009 .

After training 2009 he was deployed to Korea and he was sent back due
to his lithium treatment for bipolar(started 2005) and other physical
limitations of shoulder,he stayed at Fort Eustis from 2009 to 2011
then
finally went to medical board in 2011.

In 2010 he had MRI and told labial tear and saw Orthopedist and had
3rd
arthroscopic surgery to r shoulder this followed by second surgery in
2010 to r shoulder 5 months later



At this time he is seing orthopedist at VAMC both contract orthopedist
Dr Watson and Dr Oppenheimer told not able to help
fee basis granted twice to 2 Private orthpedists outside also recently
in 2013 told not able to help either


Currently both shoulders painful daily 7-8/10 constant
with rainy weather pain was up to 9/10
He is not able to lift and carry anything >5 lbs
problem with driving
no problem with self care except taking bath he has problem with
reaching upper back and hair

He reports he is upset since not able to work or going to
school,vocational rehab was not continued since anxiety and anger

Exam today revealed left shoulder unstable with spontaneous
dislocations when he raised his arm himself
r shoulder also had limitation but not dislocated ROM somewhat better
Internal rotation he had to lower his head to reach back of head
external rotation he cannot reach higher than buttocks

After exam he leans against the wall to put his left shoulder back to
place


LOCAL TITLE: ORTHO-FOLLOW-UP NOTE
STANDARD TITLE: ORTHOPEDIC SURGERY E & M NOTE
DATE OF NOTE: OCT 01, 2012@14:01 ENTRY DATE: OCT 01, 2012@14:01:20

AUTHOR: EXP COSIGNER:

URGENCY: STATUS: COMPLETED


History of both shoulder multiple dislocations.
Multiple surgeries on each. Right still hurts
but does not dislocate. Left still dislocates.
On tramadol now as well as ss disability. Reduces
it himself. Sent to fee base ortho but saw
several and no one would do surgery. At this
point has no had dislocation since August but
pain continues constantly. He would like a
cortisone shot at this for the pain and
realizes it will not relieve the dislocations.
However, subsequently he is noted to have
numerous apparently staph impetigo areas over
the shoulder so no injection is done. Possibly
pain meds or pain clinic evaluation should be
done. Has MRI cds which he may come in to
see Dr. Oppenheim for her further evaluation.
Otherwise advised heat or ice, shoulder brace
and analgesics.

/es/
ORTHOPEDIC SURGEON (CONTRACT)
Signed: 10/01/2012 14:23


SHOULDER 2 OR MORE VIEWS

Exm Date: APR 22, 2011@16:13
Req Phys Pat Loc: HAM DEPLOYMENT
HEALTH
CLINIC (
Img Loc: RADIOLOGY OOS
Service: Unknown



(Case 1240 COMPLETE) SHOULDER 2 OR MORE VIEWS (RAD Detailed)
CPT:73030
Proc Modifiers : LEFT, RIGHT
Reason for Study: Bilateral shoulder pain

Clinical History:
constant pain both shoulders. Hx of recurrent shoulder
dislocations with bilateral surgeries

Report Status: Verified Date Reported: APR 22,
2011
Date Verified: APR 22,
2011
Verifier E-Sig:/ES/H.I.MAHADEVAN M.D.

Report:
Bilateral shoulder:

Multiple views. No prior study.

Impression:
Well-defined small lucencies with slightly sclerotic margins
are
seen in the glenoid on both sides. This finding is likely to be

postsurgical. No significant bony deformity or joint space
narrowing seen. Alignment is normal. No soft tissue
calcifications are noted.

Primary Diagnostic Code: NO ACUTE FINDINGS

Primary Interpreting Staff:
H.I.MAHADEVAN M.D., STAFF RADIOLOGIST (Verifier)
/HIM


CT UPPER EXTREMITY W/O CONT

Exm Date: AUG 02, 2012@08:14
Req Phys: Pat Loc: HAM ORTHOPEDICS
(Req'g Loc)
Img Loc: COMPUTERIZED
TOMOGRAPHY OOS
Service: Unknown



(Case 1049 COMPLETE) CT UPPER EXTREMITY W/O CONT (CT Detailed)
CPT:73200
Proc Modifiers : LEFT
Reason for Study: Left shoulder Pain

Clinical History:
Urgent CT requested by outside consultant. Pt is pre-op. Needs
scan before surgery. Please do within 72 hours

Report Status: Verified Date Reported: AUG 02,
2012
Date Verified: AUG 02,
2012
Verifier E-Sig:/N M.D.

Report:
CT left shoulder:

Axial images are supplemented by coronal and sagittal reformats.

Images are reviewed in soft tissue and bone window settings. The
left glenoid shows multiple lucencies which may be postsurgical
defects and or subchondral cysts. There is mild sclerosis at the
articular margin of the glenoid. There is some narrowing of the
glenohumeral joint inferiorly and osteophyte formation is seen
at
the inferior anterior aspect of the head of the humerus.
Slightly
high position of the head of the humerus noted. No definite
abnormality seen at the acromioclavicular joint. The remainder
of
the bony structures about the left shoulder appear unremarkable.


A couple of small lucencies are seen in the right glenoid also.
The visualized lower neck and upper mediastinum do not show any
definite abnormalities.



Impression:
Postsurgical / degenerative changes in the left glenohumeral
joint. Probable postsurgical defects in the right glenoid.

Electronically Signed By: Mahadevan, Harihara I

Electronically Signed On: 08/02/2012 10:11:09

Primary Diagnostic Code:

Primary Interpreting Staff:
STAFF RADIOLOGIST (Verifier)
/HIM




Today shoulders xr revealed

SHOULDER 2 OR MORE VIEWS

Exm Date: JAN 14, 2014@10:36
Req Phys: DO,TAM Pat Loc: HAM C&P DO
(Req'g
Loc)
Img Loc: RADIOLOGY OOS
Service: Unknown



(Case 344 COMPLETE) SHOULDER 2 OR MORE VIEWS (RAD Detailed)
CPT:73030
Proc Modifiers : BILATERAL EXAM
Reason for Study: for c and p shoulder

Clinical History:

Report Status: Verified Date Reported: JAN 14,
2014
Date Verified: JAN 14,
2014
Verifier E-Sig:/ES/LYNN BERGREN

Report:
Bilateral shoulder series:

Comparison: Bilateral shoulder series 4/22/2011

Findings:

Left shoulder: Frontal views of the left shoulder in internal and

external rotation a coronal oblique view of the left shoulder
demonstrate multiple cystic lesions within the glenoid. No
fracture or dislocation. These have slightly progressed when
compared to the previous examination. An osteophyte projects off
of the humeral head. The visualized portion of the lung is
clear.

Right shoulder: Frontal views of the right shoulder in internal
and external rotation and a coronal oblique view of the right
shoulder demonstrates subchondral bone cysts in the humeral head
glenoid far fewer than on the contralateral side. No evidence of
acute fracture or dislocation. Mild degenerative changes in the
AC joint.



Impression:


1. Subchondral bone cysts in the left greater than right glenoid
which may be secondary to prior surgical intervention or
degenerative changes. 2. Degenerative changes of the right AC
joint.

Electronically Signed By: Bergren, Lynn

Electronically Signed On: 01/14/2014 11:19:20

Primary Diagnostic Code:

Primary Interpreting Staff:
LYNN BERGREN, Staff Radiologist (Verifier)
/LB



Select an imaging exam...

b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous

3. Flare-ups
------------
Does the Veteran report that flare-ups impact the function of the shoulder
and/or arm?
[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in
his or her own words:
flaring up left shoulder with rainy weather same ROM

4. Initial range of motion (ROM) measurements
---------------------------------------------
a. Right shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[X] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

b. Right shoulder abduction

Select where abduction ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [X] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

c. Left shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [X] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

d. Left shoulder abduction

Select where abduction ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135
[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170
[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

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