bojack Posted August 12, 2014 Share Posted August 12, 2014 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. Link to comment Share on other sites More sharing options...
0 bojack Posted August 20, 2014 Author Share Posted August 20, 2014 Preparation for notification starting this morning Link to comment Share on other sites More sharing options...
0 NavyWife Posted August 20, 2014 Share Posted August 20, 2014 (edited) 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. Try this today... Edited August 20, 2014 by NavyWife Link to comment Share on other sites More sharing options...
0 bojack Posted August 20, 2014 Author Share Posted August 20, 2014 Thanks navywife I will be checking it everyday from now on, probably once in the morning, noon, and night. Hoping for best.... Cpap machine is helping me out a lot Link to comment Share on other sites More sharing options...
0 bojack Posted August 20, 2014 Author Share Posted August 20, 2014 Mine still has none Link to comment Share on other sites More sharing options...
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