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I'm currently 70% went in for cp on chronic fatigue and increase for headaches. Any thoughts? VA Doc seams to make good case for sc sleep apnea as well?

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

Diagnostics

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.

/es/

Physician

Signed: 10/21/2014 14:14

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

-------------------- DoD Military Service Information -------------------

Source: DoD

No information was available that matched your selection.

----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------

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