Now Waiting Game For Me?

[bojack]

This veteran's C&P exam was recently completed by MSLA, under the

national DEM contract. Please refer to the C&P exam, which has been emailed in a PDF

format to the initiating Regional Office.

I just finished all my C&P exams 2 weeks ago.

More TBI follow up....

CC/HPI: h/o TBI. In 2005 fell 2 stories when stairway collapsed, loc unknown

duration. Was awoken and helped up by colleague. Was evaluated in field and then

sent back out. In 2007 fell 2+ stories from ladder of guard tower more than 2

stories, loc (unknown duration) and woke up on ground. Was evaluated in field

then sent back out.

**reports extreme light and glare sensitivity indoors and outdoors. Reports the

new sunglasses he got do not help him enough. LEE 4/11/14 VA LB.

**reports much difficulty with near work, especially reading. Reports letters

float on page, int diplopia, blur, headache and at times nausea when attempting

to read for long periods of time

INCOMING OCULAR HISTORY: photophobia

FAMILY OCULAR HISTORY:

(-) Glaucoma

(-) Blindness

(-) Age Related Macular Degeneration

OCULAR MEDICATIONS: none

INCOMING SYSTEMIC/PSYCHOLOGICAL HISTORY:

Computerized Problem List is the source for the following:

1. Laceration NEC (ICD-9-CM E928.9) 10/05/11 HECHANOVA,DEM

2. Headache 02/06/14 LEE,SE-YOUNG

3. Tinnitus 02/06/14 LEE,SE-YOUNG

4. Neck pain 02/06/14 LEE,SE-YOUNG

5. Chronic low back pain 02/06/14 LEE,SE-YOUNG

6. Foot pain 02/06/14 LEE,SE-YOUNG

7. Knee pain 02/06/14 LEE,SE-YOUNG

8. Insomnia 02/06/14 LEE,SE-YOUNG

9. Chronic rhinitis 02/06/14 LEE,SE-YOUNG

10. Traumatic brain injury with brief loss of 03/05/14 HAGER,GILBERT

P

consciousness

11. Other Signs and Symptoms Involving Cognition 03/05/14 HAGER,GILBERT

P

12. Posttraumatic stress disorder (SNOMED CT 05/29/14 HAGER,GILBERT

P

47505003)

13. Pain in joint involving shoulder region 05/29/14 HAGER,GILBERT

P

14. MDD, Recurrent, Moderate 07/17/14 WANGEN,KERRY

E

SYSTEMIC MEDICATIONS:

Active Outpatient Medications (including Supplies):

CONFIDENTIAL Page 25 of 205 Active Outpatient Medications Status

=========================================================================

1) CETIRIZINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE

DAILY FOR ALLERGY

2) FLUNISOLIDE 0.025% 200D NASAL INH SPRAY INHALE 2 ACTIVE

SPRAYS IN EACH NOSTRIL TWICE A DAY FOR NASAL

ALLERGY

3) MIRTAZAPINE 15MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE

BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT

CONSULTING YOUR PROVIDER.

4) PAROXETINE HCL 40MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE

BEDTIME FOR MOOD. DO NOT STOP MEDICATION WITHOUT

CONSULTING YOUR PROVIDER. ** NOTE DOSE INCREASE **

.

5) PRAZOSIN HCL 2MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE

BEDTIME FOR 7 DAYS, THEN TAKE TWO CAPSULES AT

BEDTIME FOR 7 DAYS, THEN TAKE THREE CAPSULES AT

BEDTIME ** MUST CONTACT/SEE VA PROVIDER FOR REFILL

**

6) TOPIRAMATE 25MG TAB TAKE ONE TABLET BY MOUTH TWICE A ACTIVE

DAY FOR 4 WEEKS, THEN TAKE TWO TABLETS TWICE A DAY

AVOID DEHYDRATION

7) TRAZODONE HCL 100MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE

BEDTIME

ALLERGIES:

Patient has answered NKA

INCIDENT HISTORY:

Presumed/confirmed traumatic brain injury/acquired brain injury due to: series

of head traumas

When did the incident occur (OEF, OIF, OND, other): 2007

Type of TBI injury (blast, penetrating, intraocular, etc): blunt force and blast

induced

Any ocular or periocular injury to the eyes: N

History of treatment for traumatic brain injury (VA facility, Dept. of

Defense or elsewhere): evaluated in field but sent out shortly after

PRIOR VISUAL HISTORY:

1. When was your last eye examination? 4/11/14, VA LB (no DFE yet)

2. Do you wear glasses or contacts? N

3. How old is your most recent eyeglasses or contact lens prescription?

4. Any history of lazy eye/amblyopia, eye turn, patching, or vision therapy? N

5. Any history of face turn or head tilt? N

6. Any history of eye surgery/injury? N

7. Did you use personal protective eye wear in the service? Y

CONFIDENTIAL Page 26 of 205URGENT VISUAL CONDITIONS (if sudden):

(-) Flashes

(+) Floaters

(+) Missing part of visual field/restricted field of vision: sometimes

(+) Bumping into objects/walls while moving: sometimes

(-) Covering/closing one eye

(-) Decreased night vision

(-) Curtain/shade over vision

(-) Inability to completely close eyes

(-) Double vision

(-) Wandering eye

(+) Pain in or around the eyes- associated with light

(-) Pain with movement of eyes

VISUAL SYMPTOMS (PRE/POST ABI)

1. Blurred vision at distance (with glasses if rx'ed): N

2. Blurred vision at near (with glasses if rx'ed): Y

3. Pulling or tugging of eyes: Y

4. Face or head turn: N

5. Covering/closing an eye: N

6. Photosensitivity

When indoors: Y

When outdoors: Y

Glare from indoor OR outdoor surfaces: Y

Light adapted: N

7. Decreased night vision: Y

8. Do you have dry eye symptoms: N

9. Headache or browache associated with vision: Y

10. Bothered by movement in spatial world: Y

11. Bothered by noises in environment: Y

12. Dizziness or balance problems Y, postural changes

When riding in moving vehicle:

Walking down a hall or aisle in store:

Concentration at near:

Walking in crowd:

Approaching busy intersections:

13. Do you seem to neglect/not notice objects, people, doorways to one side

or the other when walking or moving in wheelchair? Is it to the right or left?

Comment further. N

14. Do you notice postural shifts when standing and/or walking? Y

READING SYMPTOMS (WITH GLASSES):

1. Fatigue while reading: Y

2. Strain while reading: Y

3. Skip or lose place while reading:

4. Have difficulty finding next line:

5. Note doubling of words: Y

6. Words float off page: Y

7. Transient blur while reading: Y

8. Unable to sustain near work/reading: Y

9. Blur in distance after reading: N

CONFIDENTIAL Page 27 of 20510. Difficulty shifting focus from near to far/far to near: N

11. Browache/headache associated with reading: Y

12. Poor reading comprehension: N

13. Easily distracted/decreased attention span: Y

14. Poor concentration: Y

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

LENSOMETRY:

CURRENT SPECTACLES

OD: pl sph

OS: pl sph

COMMENTS: sunglasses, amber tint?, from last exam (says they do not help enough

to block out the sun)

VISUAL ACUITY (cc/primary gaze): Snellen

OD: 20/20

OS: 20/20

OU: 20/20

NVA (cc) OU: 20/20

ENTRANCE TESTING

Cover test: ortho at D, 4 XP at near

EOMs: Full range of motion (-)pain/diplopia

Confrontation VF: (peripheral, simultaneous)

Fixation: un/steady

OD: Full to finger counting

OS: Full to finger counting

PUPILS: ERRL, (-) APD

_____________________________________________________________________

REFRACTIVE DATA

Subjective Refraction:

OD: pl sph

OS: pl sph

Binocular balance:

OD: pl sph

OS: pl sph

TRIAL FRAME/FINAL RX:

OD: pl sph 20/20

OS: pl sph 20/20

BINOCULAR VA: 20/20

____________________________________________

_________________________

OCULOMOTOR, VESTIBULAR, ACCOMODATIVE, VERGENCE ASSESSMENT

CONFIDENTIAL Page 28 of 205Step Vergences

Distance Base In: x/4/1

Distance Base Out: x/4/1

Near Base In: x/6/2

Near Base Out: x/4/1

**patient very sensitive to testing and tiring towards end of exam

Accommodation Testing

Method Used:

(X)Push Up

( )Pull Away

( )Minus Lens

( )Fused Cross Cyl (FCC)

OD: 25 cm (4D)

OS: 25 cm (4D)

Near point of convergence (break/recovery): 13cm/20 cm

Facility Testing

Method Used:

+/-1.00 Flippers

OU: difficulty clearing minus, 5 cpm (very slow)

RECOMMENDED GLASSES: leader wrap sunglasses (dark tinted) and near reading

glasses with 0.5 BI prism OD and OS, grey tint 1 and AR coat

_____________________________________________________________________________

GENERAL HEALTH ASSESSMENT

SLIT LAMP FINDINGS:

Lids & Lashes: clear OU

Conjunctiva: white & quiet OU

Cornea: clear OU

Angles: open OU

Ant Chamber: deep & quiet OU

Iris findings: flat, avascular OU

Lens: clear OU (undilated)

INTRAOCULAR PRESSURE (mmHg)

( )GAT (x)Tonopen @ 9:40am

OD: 11

OS: 11

OPHTHALMOSCOPY FINDINGS

(X)UNDILATED

( )DILATED WITH 1% T AND 2.5% PE OU-PT ED ON SIDE EFFECTS

C/D Ratios:

OD: 0.20

OS: 0.20

Optic Nerve Head Evaluation:

PARK, JU EUN CONFIDENTIAL Page 29 of 205 OD: (-) pallor with distinct margins, pink & healthy rim tissue

OS: (-) pallor with distinct margins, pink & healthy rim tissue

***patient defers dilation today due to light sensitivity. Will bring someone to

drive him at next appointment for DFE.

Assessment:

1. H/o traumatic brain injury

- photophobia and glare sensitivity

- convergence insufficiency and accommodative insufficiency

2. Essential emmetropia OU

Plan:

Order separate sunglasses and near work glasses. Near work glasses to have

0.5 base in prism in each eye, with grey tint 1 and anti-reflective coat.

Sunglasses to be leader with wrap and dark tint.

***Return in 1 month for dilation and check on progress with glasses

Final Rx:

OD: pl sph

OS: pl sph

See consult for glasses information

_____________________________________________________________________

Assessment and plan reviewed and approved by Staff Attending

Disclaimer: Because the acuities and fields in this evaluation were taken

using special techniques and lighting NOT contained in the VA Physician Guide

Disability Evaluation Examination, they cannot be used for rating purposes.

[NavyWife]

Wow, that's really fast! I hope you get a good rating!

[bojack]

Thank you, most of my records are from VA treatment and service records. I do have few treatments from my private doctors, but most of my treatments came from VA hospital. Also, they received all my C&P results 08/06/214. I just hope they dont ask for more evidence since I do not have more to give or offer.

[NavyWife]

Once they make a decision, you can go on Ebenefits under "Download VA letters". click on any of those links and see if your percentage has changed.

[bojack]

Thank you

I am so nervous right now, but I know they cant deny my ptsd and tbi for sure

[bojack]

VA sleep clinic juat gave me cpap machine today for my sleep apnea, but c&p examier thinks I don't have sleep apnea.

[THOMAS89031]

Bojack, you should apply for Social Security Disability. With all the meds you are on, and your medical records, I would think it would go thru without a hitch. jmho. As for sleeping with a gun, I can't remember how many years it took me to not sleep with one. But in todays society, it might be a good idea to start again!! (tongue in cheek) I decided to sleep with a can of wasp spray and a butane lighter on my nightstand. It make a terrific flamethrower!! Good Luck and Semper Fi !!!