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diabetes C&p Exam Fatigue Sleep Apnea. New Take On Sa?
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Question
airborne82_11b2p
Just had c&p for pgw issues. I have not read this particular take on sleep apnea? Opinions? It appears VA Dr says at least as likely as not for sleep apnea, chronic fatigue, joint and muscle pain.
1. Medical record review
------------------------
[X] Other, describe: VBMS, VVA, CPRS with remote
2. Medical history
------------------
a. No symptoms, abnormal findings or complaints: No answer provided
b. Skin and scars: No answer provided
c. Hematologic/lymphatic: No answer provided
d. Eye: No answer provided
e. Hearing loss, tinnitus and ear: Hearing Loss and Tinnitus
f. Sinus, nose, throat, dental and oral: No answer provided
g. Breast: No answer provided
h. Respiratory: Sleep Apnea
i. Cardiovascular: No answer provided
j. Digestive and abdominal wall: No answer provided
k. Kidney and urinary tract: No answer provided
l. Reproductive: No answer provided
m. Musculoskeletal: No answer provided
n. Endocrine: No answer provided
o. Neurologic: Headaches (including Migraine Headaches)
p. Psychiatric: No answer provided
q. Infectious disease, immune disorder or nutritional deficiency: No
answer
provided
r. Miscellaneous conditions: No answer provided
3. Diagnosed illnesses with no etiology
---------------------------------------
From the conditions identified and for which Questionnaires were completed,
are there any diagnosed illnesses for which no etiology was established?
[X] Yes [ ] No
Diagnosis #1: Sleep Apnea, both obstructive and central
ICD code: 327.23, 327.27
Date of diagnosis: 9/13/2014
Name of Questionnaire: sleep apnea
Diagnosis #2: Headaches
ICD code: 780.79
Date of diagnosis: 6/11/2014
Name of Questionnaire: Headaches - already submitted and entered into
VBMS
6/17/2014
4. Additional signs and/or symptoms that may represent an "undiagnosed
illness" or "diagnosed medically unexplained chronic multisymptom
illness"
-----------------------------------------------------------------------------
Does the Veteran report any additional signs and/or symptoms not addressed
through completion of DBQs identified in the above sections?
[X] Yes [ ] No
If yes, check all that apply: Fatigue, Muscle pain, Joint pain
For all checked signs and symptoms in this section, provide pertinent
information related to each (e.g. frequency, duration, severity,
precipitating/relieving factors, physical exam, studies): See Veteran's
Statement in support of claim dated 6/11/2014 which describes his chronic
fatigue. His muscle and joint pains are random, never the same joint,
flare
transiently for about 1-2 days on average about once/month. Other than
these
short flares, he has no complaints about his joints or muscles. All this
has
been flaring since 1991. The Veteran is a reliable historian he gave a
similar
history to the C&P Gulf War Protocol examiner in 2002.
5. Physical Exam
----------------
Normal PE, except as noted on additional Questionnaires included as part of
this
report
6. Functional impact of additional signs and/or symptoms that may represent
an "undiagnosed illness" or "diagnosed medically unexplained chronic
multisymptom illness"
-----------------------------------------------------------------------------
[ ] Yes [X] No
7. Remarks, if any:
-------------------
The Veteran had a Persian Gulf Protocol exam (in CPRS) Sep 4, 2002, which
documents his fatigue. He wishes to clarify today that he's applying for an
increase rating on his headaches. Since the Headache DBQ was filled out by
his PCP and logged into VBMS on June 17, 2014, this examiner assumes no
additional headache DBQ is necessary, and it was not requested by VARO.
Further questionning reveals the Veteran does not have chronic fatigue
SYNDROME, but does have chronic fatigue. In addition he's requesting service
connection for sleep apnea and Tinnitus. Regarding Tinnitus, this will
require an Audio C&P consultation and opinion regarding tinnitus, and
these
have been requested.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
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? No
If no, check all records reviewed:
[X] Military service treatment records
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Other:
VBMS, VVA, CPRS with remote data
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Please provide a medical statement
explaining whether the Veteran's
disability pattern is: (1) an undiagnosed illness, (2) a diagnosable
but medically unexplained chronic multisymptom illness of unknown
etiology, (3) a diagnosable chronic multisymptom illness with a
partially explained etiology, or (4) a disease with a clear and
specific etiology and diagnosis.
If, after examining the Veteran and reviewing the claims file, you
determine that the Veteran's disability pattern is either (3) a
diagnosable chronic multi-symptom illness with a partially explained
etiology, or (4) a disease with a clear and specific etiology and
diagnosis, then please provide a medical opinion, with supporting
rational, as to whether it is "at least as likely as not" that the
disability pattern or diagnosed disease is related to a specific
exposure event experienced by the Veteran during service in
Southwest Asia.
Note: Veteran has verified service in the Gulf War, 8/1/1990- 3/15/1991.
Please see his statement, dated 6/17/2014 and labeled under
correspodence,
on VBMS.
b. Indicate type of exam for which opinion has been requested: sleep apnea
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: There are no studies of which I am aware which correlate sleep
apnea to Gulf War toxic chemicals, and sleep apnea generally is considered
to
be a condition in which loose, floppy tissues in the throat occlude the
passage of air during the relaxation of sleep. This Veteran has a narrow
posterior pharynx which is mildly and chronically inflamed as evidenced by
the mild redness and swelling in his throat. The question is what's causing
the swelling which causes the loose floppy tissues which in turn causes the
sleep apnea?
Toxic chemicals which possibly can cause the Veteran's symptoms are
discussed
on Form 21-2507 provided to this examiner.
This Veteran's array of inflammatory ailments as likely as not have common
origins in the metabolic dysfunctions which toxic chemicals can create.
The Veteran's diagnosable but medically unexplained chronic multisymptom
illnesses of partially-explained etiology are: Migraine Headaches and sleep
apnea. Undiagnosed illnesses are: Fatigue, and random muscle/joint pains. It
is at least as likely as not that these illnesses were caused by exposure to
toxic chemicals during the Gulf War.
Environmental toxins bind to proteins and are stored in fat and cause
up-regulation of the immune system with inflammatory cytokines. Without
detoxification, these toxic effects accumulate and can cause problems years
after initial exposure, especially if patients are taking medication. The
Veteran is taking Lexapro.
My conclusions are biologically plausible based on the following explanation
which is a brief outline describing several major biological responses to an
element that the body perceives as toxic. Examples of toxic substances are
burn pit smoke, formaldehyde in building materials, contaminated water,
vaccines, drugs, food or drink containing toxic chemicals (for example,
pesticides, artificial sweeteners, etc.). Illnesses usually develop
gradually
over many years.
Up-regulation and depletion of mucosal protective secretory IgA (SIgA), is
the first line of intestinal defense at the level of absorption sites. This
leaves the absorption sites vulnerable to assault and commonly leads to a
chronic condition called "leaky gut" (increased intestinal permeability).
This cascade of events leads to depletion of intestinal bacteria crucial to
the gut's ability to transport nutrients through the small intestine villi
into the blood. (biochemistry reviewed in The Second Brain, by Michael
Gershon, M.D.; other excellent references are "The Inside Tract", by Gerard
Mullin, MD, "Clean Gut" by Alejandro Junger, "The Blood Sugar Solution", by
Mark Hyman, MD, and "The Textbook of Functional Medicine", 2010)
Chronic leaky gut leads to dysregulation of systemic immune globulins. As
more toxins are allowed to enter the bloodstream, the immune system
constantly must be "on guard". This constant catabolic influence
up-regulates tissue damage at the same time the nutrient absorptive function
is crippled by leaky gut. The tissue is not able to be repaired at the same
rate it is broken down. Inflammatory conditions ensue.
As toxins enter the liver through the portal vein, Phase 1 and Phase 2 liver
detoxification functions are up-regulated and eventually depleted. This puts
a toxic load upon the circulatory system. Replenishment of liver
detoxification pathways depends upon optimum gut function and adequate,
ingestion of sulfur-bearing foods and dark leafy greens to supply the
crucial
glutathione pathway.
With compromised liver detoxification, the systemic immune globulins become
chronically up-regulated creating auto-immune conditions. The chronic immune
dysregulation which imposes a catabolic influence upon various tissues
depletes adrenal cortisol and the adrenal production cannot keep up with the
demand. The body's own anti-inflammatory process becomes inadequate.
More and more of the body's cellular energy production is allocated to
stabilizing the toxic degeneration. The adrenal glands produce more
adrenalin
in an attempt to derive energy from the muscles in order to meet the daily
needs of the person. This excess adrenalin de-sensitizes the cellular
insulin
receptors and leads to insulin-resistance syndrome depriving the cells of
optimum glucose transport. Blood glucose can increase and lead to diabetes
and other inflammatory conditions, due to tissue glycation.
The patient may rely more and more upon drugs in order just to "get by".
This brief biochemical explanation explains the cascade of events that can
progress from the toxic chemical exposure in the Persian Gulf to the
veteran's current inflammatory conditions. This examiner understands that
these conditions may not be listed as caused by exposure to toxic chemicals,
but with continuing inflammation, the probability increases to develop more
serious illnesses. This is why I've concluded that the veteran's conditions
noted above at least as likely as not are related to Persian Gulf
environmental toxins.
This examiner has practiced medicine since 1969 and has postgraduate
training
in Functional Medicine and nutritional biochemistry
SLEEP APNEA references
http://www.gulfwarvets.com/cgi-bin/ultimatebb.cgi?ubb=print_topic;f=1;t=00017
7
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1061276/
http://usatoday30.usatoday.com/news/health/2010-06-07-apnea_N.htm?csp=34news
http://www.national-toxic-encephalopathy-foundation.org/solvent.pdf
http://www.huffingtonpost.com/2013/02/07/gulf-war-syndrome-veterans_n_2634838
.html
http://donate.dav.org/site/PageServer?pagename=NewBilltoHelpTroopsExposedtoTo
xicBurnPits
*************************************************************************
****************************************************************************
Sleep Apnea
Disability Benefits Questionnaire
Name of patient/Veteran:
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?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
If no, check all records reviewed:
[X] 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
[X] 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
[X] Other:
VBMS, VVA, CPRS with remote data
1. Diagnosis
------------
Does the Veteran have or has he/she ever had sleep apnea?
[X] Yes [ ] No
[X] Mixed, components of both
ICD code: 327.23, 327.27 Date of diagnosis: 8/6/2014
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's sleep
disorder condition (brief summary):
The Veteran complains of tiredness since service in Desert Storm. He
wakes tired. If allowed, he could sleep 16 hours and wake tired. He
snores for at least the last 15 years. His wife says he thrashes and
swings his arms in sleep. His wife witnessed him not breathing in his
sleep. He rarely consulted doctors in service. There is no record of
sleep apnea related symptoms in the STR or records in the few years
post
service. Polysomnogram 8/6/2014 diagnosed moderate OSA with AHI of
16.3.
CPAP Titration sleep study on 9/13/2014 diagnosed moderate complex
obstructive and central sleep apnea. CPAP failed to correct the
AHI/CAHI
so he's completed an Adaptive Servo-Ventilation study on October 8,
2014. No report is available as of today.
b. Is continuous medication required for control of a sleep disorder
condition?
[ ] Yes [X] No
c. Does the veteran require the use of a breathing assistance device?
[X] Yes [ ] No
d. Does the Veteran require the use of a continuous positive airway pressure
(CPAP) machine?
[X] Yes [ ] No
3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to sleep apnea?
[X] Yes [ ] No
If yes, check all that apply:
[X] Persistent daytime hypersomnolence
4. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms
-----------------------------------------------------------------------------
a. 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?
[ ] Yes [X] No
b. 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?
[X] Yes [ ] No
If yes, describe (brief summary):
He has a narrow posterior pharynx and diffuse mild reddening of the
mucus membranes indicating chronic non-specific inflammation.
5. Diagnostic testing
---------------------
a. Has a sleep study been performed?
[X] Yes [ ] No
If yes, does the Veteran have documented sleep disorder breathing?
[X] Yes [ ] No
Date of sleep study: 8/6/2014
Facility where sleep study performed, if known: NeuroSleep
Results:
Moderate OSA with AHI 16.3. CPAP Titration report 9/13/2014
diagnosed moderate complex (obstructive and central) sleep apnea.
b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
6. Functional impact
--------------------
Does the Veteran's sleep apnea impact his or her ability to work?
[ ] Yes [X] No
7. Remarks, if any:
-------------------
No remarks provided.
Physician
-------------------------------------------------------------------------
-------------------- DoD Military Service Information -------------------
Source: DoD
No information was available that matched your selection.
----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------
I was a soldier so my son could be a farmer, his son a poet.
-John Adams
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airborne82_11b2p
I did end up with a 50% rating for sleep apnea with above c&p.
Navy04
Congrats bud, Great News!!!
Notorious Kelly
Glad to hear it, Airborne!
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