Ok Guys copy and pasting my C&P exam results. The examiner got some of my statments a little wrong such as how often I see the doc and how often I take Corticosteroids. I see my doc every couple months, I take corticosteroids as needed up to 3 or 4 times a year. I am currently on Montelukastat for Wheezing, Symbicort, and Albuterol daily. What exactly does my exam mean and he said I had oversizded lungs from playing the Alto and Baratone Sax from 6th till 11th grade. I am confused to say the least. I am currently at 60% but have other issues, PTSD related to MST, Fibro, CFS, Hysterectomy related to Cervical Dysplasia, Bowel adhesions, Scar tissue, Pain, etc etc. I can copy and past the list the VA put together or my claims person has put down I only filed for a couple things and then log into my ebenfits and they had added a ton of stuff.
Here is my C&P Exam for the Asthma only, they did not even address my other claims,
Date/Time: 03 Apr 2014 @ 1300
Note Title: C&P EXAM
Location: WM JENNINGS BRYAN DORN VETERANS AFFAIRS MEDICAL CENTER
Signed By: MCWILLIAMS,WILLIAM
Co-signed By: MCWILLIAMS,WILLIAM
Date/Time Signed: 03 Apr 2014 @ 1312
Note
LOCAL TITLE: C&P EXAM
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: APR 03, 2014@13:00 ENTRY DATE: APR 03, 2014@13:12:03
AUTHOR: MCWILLIAMS,WILLIAM EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Respiratory Conditions
(Other Than Tuberculosis and Sleep Apnea)
Disability Benefits Questionnaire
Name of patient/Veteran: Jessica Phillips-Breznican
Indicate method used to obtain medical information to complete this
document:
In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed: No
Check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment
records)
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
PHILLIPS-BREZNICAN, JESSICA LUC CONFIDENTIAL Page 8 of 180
which an exam has been requested): Yes
[X] Asthma
Date of diagnosis: 1999
SECTION II: MEDICAL HISTORY
----------------------------
Describe the history (including onset and course) of the Veteran's
respiratory condition (brief summary): Pt was driving to PT and had acute
episode of CP/SOB. Was diagnosed w/ asthma. No h/o childhood asthma. Now on
multiple meds for asthma and needs steriod bursts when exacerbations get
bad.
Last one was 2 months ago. She has SOB when walking up stairs or around in
stores.
Does the Veteran's respiratory condition require the use of oral or
parenteral corticosteroid medications: Yes
[X] Requires intermittent courses or bursts of systemic (oral or
parenteral) corticosteroids
Indicate number of courses or bursts in past 12 months: 4 or more
Does the Veteran's respiratory condition require the use of inhaled
medications: Yes
Check all that apply:
[X] Inhalational bronchodilator therapy
Indicate frequency: Daily
[X] Inhalational anti-inflammatory medication
Indicate frequency: Daily
Does the Veteran's respiratory condition require the use of oral
bronchodilators: Yes
Indicate frequency: Daily
Does the Veteran's respiratory condition require the use of antibiotics:
No
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: Yes
Check all that apply:
[X] Asthma
Asthma
------
Has the Veteran had any asthma attacks with episodes of respiratory failure
in the past 12 months? Yes
Indicate average number of asthma attacks with episodes of respiratory
failure per week in past 12 months: 4 or more
PHILLIPS-BREZNICAN, JESSICA LUC CONFIDENTIAL Page 9 of 180
Has the Veteran had any physician visits for required care of exacerbations?
Yes
Description of frequency and severity of exacerbations: monthly. severe
enough to get prednisone "every couple of months."
Indicate frequency of physician visits for required care of exacerbations
over past 12 months: At least monthly
Other pertinent physical findings, scars, 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
SECTION IV: Diagnostic testing
------------------------------
Have imaging studies or procedures been performed? Yes
[X] Chest x-ray
Date: 6/13
Results: normal
Has pulmonary function testing (PFT) been performed? Yes
Do PFT results reported below accurately reflect the Veteran's
current
pulmonary function? Yes
PFT results
Date: 1/14
Pre-bronchodilator: Post-bronchodilator, if indicated:
FVC: 102.3% predicted FVC: 122.6% predicted
FEV-1: 89.1% predicted FEV-1: 118.3% predicted
FEV-1/FVC: 74% FEV-1/FVC: 82%
DLCO: % predicted DLCO: % 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/FVC
If diffusion capacity of the lung for carbon monoxide by the single breath
method (DLCO) testing has not been completed, provide reason: Not indicated
in Veteran's particular case
Does the Veteran have multiple respiratory conditions? No
Has exercise capacity testing been performed? No
Are there any other significant diagnostic test findings and/or results? No
PHILLIPS-BREZNICAN, JESSICA LUC CONFIDENTIAL Page 10 of 180
SECTION V: Functional impact and remarks
----------------------------------------
1. Functional impact
--------------------
Does the Veteran's respiratory condition impact his or her ability to
work?
Yes
Describe impact of each of the Veteran's respiratory conditions,
providing
one or more examples: She has severe SOB w/ minimal activity. Has been
umemployed since Nov, 2013
/es/ WILLIAM MCWILLIAMS
RESIDENT PHYSICIAN
Signed: 04/03/2014 13:12
Then this is what they put down for all my "claims" on ebenefits:
Contentions: VBMS (New), musculoskeletal pain-fibromyalgia, chronic fatigue syndrome, myofacial pain (New), post traumatic stress disorder (Reopen), allergies (Reopen), Asthma, bronchial (Increase), unemployability (New), gynecological issues (Reopen), cervical dysplasia and hysterectomy (previously considered as cervical dysplasia, status post abdominal hysterectomy) (Reopen), bowel adhesions (previously considered as status post enterolysis, bowel adhesions) (Reopen), laparoscopy to repair female parts (previously considered as status post laparoscopy with lysis of adhesions and claimed (Reopen), right ovarian cyst (Reopen), irritable bowel syndrome (New), frequent severe headaches (New), dizziness or fainting spells (New), Sinusitis, allergic rhino (New), shortness of breath (Increase), pain or pressure in chest (New), trouble sleeping (New), depression or excessive worry (New), easily fatigability (New), anorexia associated with PTSD (New), traumatic abortion (New)
Below is what has been posted by them under my claims section:
Next Steps:
We will review all available evidence and make a decision on your claim upon receipt of all requested information as outlined in the headings, "What Do We Still Need from You?" and "What Have We Done?".
Several factors will determine the duration of the "Development" phase, including:
type of claim filed
number of disabilities you claim
complexity of your disability(ies), and
availability of evidence needed to decide your claim.
Additional Details
Your Designated Power of Attorney
DISABLED AMERICAN VETERANS
Regional Office of Jurisdiction:
Columbia
Send Documentation To
Department of Veterans Affairs Regional Office
Columbia Regional Office
6437 Garners Ferry Road
Columbia, SC 29209
Ask your last employer to complete and return the enclosed VA Form 21-4192, Request for Employment Information.
Date Requested: 03/07/2014 Due Date:04/06/2014
On your application, you indicated that you received treatment from .
Complete and return an enclosed VA Form 21-4142, Authorization and Consent to Release Information, for each health care provider so that we can obtain treatment information. You may want to obtain and send us the information yourself.
Date Requested: 04/03/2014 Due Date:05/03/2014
What Do We Still Need From Others?
This is a list of all items that have been requested from 3rd parties.
Items
From
Date Requested
Due Date
Follow-Up Dates
Employer (21-4192)
US ARMY MEPS
03/07/2014
04/06/2014
Employer (21-4192)
Cherokee County Alcohol & Drug
03/07/2014
04/06/2014
Employer (21-4192)
Staffmasters
03/07/2014
04/06/2014
Medical evidence from private provider
Bluestone Psychiatric Group
04/03/2014
04/18/2014
04/03/2014
Medical evidence from private provider
04/03/2014
04/18/2014
04/03/2014
Medical evidence from private provider
Womack Army Hospital
04/03/2014
04/18/2014
04/03/2014
Medical evidence from private provider
Gateway Medical Associates
04/03/2014
04/18/2014
04/03/2014
What We Have Received (solicited)
This is a list of all items that have been received from either the Veteran or a 3rd party. Please be advised that it may take up to 21 days to receive, process, and annotate in our system any information that you mail to one of our Regional Offices. Don't see an item listed? Check our "Unsolicited Items" page to see if it was received by VA.
Items
Date Requested
Date Received
03/18/2014
04/03/2014
We have requested copies of your disability medical records from Social Security. It may take several months to receive a response.
03/07/2014
03/18/2014
You were previously denied service connection for laparoscopy with lysis of adhesions with chronic pelvic pain and pelvid adhesion disease, right ovarian cyst, bowel adhesions, cervical dysplasia and hysterectomy, allergic rhinitis. You were notified of the decision on June 29, 2005. The appeal period for that decision has expired and the decision is now final. In order for us to reopen your claim, we need new and material evidence. Your claim was previously denied because there is no objective medical evidence to show that the current disability incurred in service or is a result or your militaryservice. Service connection for was denied on a direct basis. Therefore, the evidence you submit must be new and relate to this fact.
03/07/2014
03/12/2014
You were previously denied service connection for posttraumatic stress disorder (PTSD). You were notified of the decision on . The appeal period for that decision has expired and the decision is now final. In order for us to reopen your claim, we need new and material evidence. Your claim was previously denied because . Therefore, the evidence you submit must be new and relate to this fact. If your PTSD is caused by a fear associated with hostile military or terrorist activity, you must provide evidence or a statement to support your claim.
02/06/2014
03/07/2014
You were previously denied service connection for right ovarian cyst, status post laproscopy pelvic adhesions, cervical dysplasia, status post abdominal hysterectomy, allergic rhinitus. You were notified of the decision on date of previous denial. The appeal period for that decision has expired and the decision is now final. In order for us to reopen your claim, we need new and material evidence. Your claim was previously denied because there is no objective medical evidence to show that the current disability incurred in service or is a result or your military service. Service connection for was denied on a direct basis. Therefore, the evidence you submit must be new and relate to this fact.
02/06/2014
03/07/2014
What We Have Never Received from You (solicited)
This is a list of items that have never been received from you and that have been closed.
Items
Date Requested
Date Closed
SSA records unavailable /request from Veteran
03/18/2014
04/03/2014
Request for Outpatient Treatment Records
02/06/2014
02/25/2014
DBQ RESP Respiratory conditions
02/06/2014
02/25/2014
So, short of me attaching my complete medical records I do have a VA diagnosis of PTSD, Anxiety, Depression, Asthma, and myofacial muscle pain....the female problems were found out after I was medically discharged from the ARMY and I was never informed. I just found this out about 8 months ago, if I had known I may have been able to avoid having my uterus and cervix removed. I also have in my medical records documentation of the cyst on my right ovary. Can anyone at all please please point me in some sort of direction my DAV rep has not called me or anything in regards to all this since we filed my claim last August. I am unemployed esentailly homeless and back living with my mother with two teen boys, and down to my last straw/shred of sanity.
Question
JessBreznican
Ok Guys copy and pasting my C&P exam results. The examiner got some of my statments a little wrong such as how often I see the doc and how often I take Corticosteroids. I see my doc every couple months, I take corticosteroids as needed up to 3 or 4 times a year. I am currently on Montelukastat for Wheezing, Symbicort, and Albuterol daily. What exactly does my exam mean and he said I had oversizded lungs from playing the Alto and Baratone Sax from 6th till 11th grade. I am confused to say the least. I am currently at 60% but have other issues, PTSD related to MST, Fibro, CFS, Hysterectomy related to Cervical Dysplasia, Bowel adhesions, Scar tissue, Pain, etc etc. I can copy and past the list the VA put together or my claims person has put down I only filed for a couple things and then log into my ebenfits and they had added a ton of stuff.
Here is my C&P Exam for the Asthma only, they did not even address my other claims,
Date/Time: 03 Apr 2014 @ 1300
Note Title: C&P EXAM
Location: WM JENNINGS BRYAN DORN VETERANS AFFAIRS MEDICAL CENTER
Signed By: MCWILLIAMS,WILLIAM
Co-signed By: MCWILLIAMS,WILLIAM
Date/Time Signed: 03 Apr 2014 @ 1312
Note
LOCAL TITLE: C&P EXAM
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: APR 03, 2014@13:00 ENTRY DATE: APR 03, 2014@13:12:03
AUTHOR: MCWILLIAMS,WILLIAM EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Respiratory Conditions
(Other Than Tuberculosis and Sleep Apnea)
Disability Benefits Questionnaire
Name of patient/Veteran: Jessica Phillips-Breznican
Indicate method used to obtain medical information to complete this
document:
In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed: No
Check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment
records)
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
PHILLIPS-BREZNICAN, JESSICA LUC CONFIDENTIAL Page 8 of 180
which an exam has been requested): Yes
[X] Asthma
Date of diagnosis: 1999
SECTION II: MEDICAL HISTORY
----------------------------
Describe the history (including onset and course) of the Veteran's
respiratory condition (brief summary): Pt was driving to PT and had acute
episode of CP/SOB. Was diagnosed w/ asthma. No h/o childhood asthma. Now on
multiple meds for asthma and needs steriod bursts when exacerbations get
bad.
Last one was 2 months ago. She has SOB when walking up stairs or around in
stores.
Does the Veteran's respiratory condition require the use of oral or
parenteral corticosteroid medications: Yes
[X] Requires intermittent courses or bursts of systemic (oral or
parenteral) corticosteroids
Indicate number of courses or bursts in past 12 months: 4 or more
Does the Veteran's respiratory condition require the use of inhaled
medications: Yes
Check all that apply:
[X] Inhalational bronchodilator therapy
Indicate frequency: Daily
[X] Inhalational anti-inflammatory medication
Indicate frequency: Daily
Does the Veteran's respiratory condition require the use of oral
bronchodilators: Yes
Indicate frequency: Daily
Does the Veteran's respiratory condition require the use of antibiotics:
No
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: Yes
Check all that apply:
[X] Asthma
Asthma
------
Has the Veteran had any asthma attacks with episodes of respiratory failure
in the past 12 months? Yes
Indicate average number of asthma attacks with episodes of respiratory
failure per week in past 12 months: 4 or more
PHILLIPS-BREZNICAN, JESSICA LUC CONFIDENTIAL Page 9 of 180
Has the Veteran had any physician visits for required care of exacerbations?
Yes
Description of frequency and severity of exacerbations: monthly. severe
enough to get prednisone "every couple of months."
Indicate frequency of physician visits for required care of exacerbations
over past 12 months: At least monthly
Other pertinent physical findings, scars, 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
SECTION IV: Diagnostic testing
------------------------------
Have imaging studies or procedures been performed? Yes
[X] Chest x-ray
Date: 6/13
Results: normal
Has pulmonary function testing (PFT) been performed? Yes
Do PFT results reported below accurately reflect the Veteran's
current
pulmonary function? Yes
PFT results
Date: 1/14
Pre-bronchodilator: Post-bronchodilator, if indicated:
FVC: 102.3% predicted FVC: 122.6% predicted
FEV-1: 89.1% predicted FEV-1: 118.3% predicted
FEV-1/FVC: 74% FEV-1/FVC: 82%
DLCO: % predicted DLCO: % 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/FVC
If diffusion capacity of the lung for carbon monoxide by the single breath
method (DLCO) testing has not been completed, provide reason: Not indicated
in Veteran's particular case
Does the Veteran have multiple respiratory conditions? No
Has exercise capacity testing been performed? No
Are there any other significant diagnostic test findings and/or results? No
PHILLIPS-BREZNICAN, JESSICA LUC CONFIDENTIAL Page 10 of 180
SECTION V: Functional impact and remarks
----------------------------------------
1. Functional impact
--------------------
Does the Veteran's respiratory condition impact his or her ability to
work?
Yes
Describe impact of each of the Veteran's respiratory conditions,
providing
one or more examples: She has severe SOB w/ minimal activity. Has been
umemployed since Nov, 2013
/es/ WILLIAM MCWILLIAMS
RESIDENT PHYSICIAN
Signed: 04/03/2014 13:12
Then this is what they put down for all my "claims" on ebenefits:
Details of Your ClaimClaim Received: 08/16/2013
Claim Type: Compensation
Estimated Claim Completion Date: 10/03/2014 to 03/27/2015
Contentions: VBMS (New), musculoskeletal pain-fibromyalgia, chronic fatigue syndrome, myofacial pain (New), post traumatic stress disorder (Reopen), allergies (Reopen), Asthma, bronchial (Increase), unemployability (New), gynecological issues (Reopen), cervical dysplasia and hysterectomy (previously considered as cervical dysplasia, status post abdominal hysterectomy) (Reopen), bowel adhesions (previously considered as status post enterolysis, bowel adhesions) (Reopen), laparoscopy to repair female parts (previously considered as status post laparoscopy with lysis of adhesions and claimed (Reopen), right ovarian cyst (Reopen), irritable bowel syndrome (New), frequent severe headaches (New), dizziness or fainting spells (New), Sinusitis, allergic rhino (New), shortness of breath (Increase), pain or pressure in chest (New), trouble sleeping (New), depression or excessive worry (New), easily fatigability (New), anorexia associated with PTSD (New), traumatic abortion (New)
Below is what has been posted by them under my claims section:
We will review all available evidence and make a decision on your claim upon receipt of all requested information as outlined in the headings, "What Do We Still Need from You?" and "What Have We Done?".
Several factors will determine the duration of the "Development" phase, including:
DISABLED AMERICAN VETERANS
Columbia
Department of Veterans Affairs Regional Office
Columbia Regional Office
6437 Garners Ferry Road
Columbia, SC 29209
-
Date Requested: 03/07/2014
-
Date Requested: 04/03/2014
What Do We Still Need From Others?Ask your last employer to complete and return the enclosed VA Form 21-4192, Request for Employment Information.
Due Date: 04/06/2014
On your application, you indicated that you received treatment from .
Complete and return an enclosed VA Form 21-4142, Authorization and Consent to Release Information, for each health care provider so that we can obtain treatment information. You may want to obtain and send us the information yourself.
Due Date: 05/03/2014
This is a list of all items that have been requested from 3rd parties.
This is a list of all items that have been received from either the Veteran or a 3rd party. Please be advised that it may take up to 21 days to receive, process, and annotate in our system any information that you mail to one of our Regional Offices. Don't see an item listed? Check our "Unsolicited Items" page to see if it was received by VA.
This is a list of items that have never been received from you and that have been closed.
Items Date Requested Date Closed SSA records unavailable /request from Veteran 03/18/2014 04/03/2014 Request for Outpatient Treatment Records 02/06/2014 02/25/2014 DBQ RESP Respiratory conditions 02/06/2014 02/25/2014So, short of me attaching my complete medical records I do have a VA diagnosis of PTSD, Anxiety, Depression, Asthma, and myofacial muscle pain....the female problems were found out after I was medically discharged from the ARMY and I was never informed. I just found this out about 8 months ago, if I had known I may have been able to avoid having my uterus and cervix removed. I also have in my medical records documentation of the cyst on my right ovary. Can anyone at all please please point me in some sort of direction my DAV rep has not called me or anything in regards to all this since we filed my claim last August. I am unemployed esentailly homeless and back living with my mother with two teen boys, and down to my last straw/shred of sanity.
Thanks Jessica
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