Here is my TBI C&P which lasted 20 minutes only. I'm thinking of 0%-10%. Thanks in advance
Muscle Injuries
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes[X] No
If no, check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment records)
E-FOLDER ON VBMS.
SECTION I: DIAGNOSIS
--------------------
Does the Veteran now have or has he/she ever been diagnosed with a muscle injury?
[X] Yes[ ] No
Diagnosis #1: RESIDUALS OF CLOSED LEFT RIB FRACTURE
Date of diagnosis: S/C
Side affected: [ ] Right [X] Left [ ] Both
SECTION II: HISTORY OF MUSCLE INJURY
------------------------------------
a. Does the Veteran have a penetrating muscle injury, such as a gunshot or shell fragment wound?
[ ] Yes[X] No
b. Does the Veteran have a non-penetrating muscle injury (such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)?
[X] Yes[ ] No
c. Describe the history (including onset and course) of the Veteran's muscle
injury: (brief summary):
THIS EXAM IS FOR CURRENT STATUS OF S/C LEFT RIB FRACTURE. PATIENT SAYS HE GETS OCCASIONAL MILD PAIN IN LEFT RIB IF SITS TOO LONG BUT NO NEED OF MEDICINE.
d. Dominant hand
[X] Right[ ] Left[ ] Ambidextrous
SECTION III: LOCATION OF MUSCLE INJURY
--------------------------------------
1. Shoulder girdle and arm
--------------------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the shoulder girdle or arm?
[ ] Yes[X] No
2. Forearm and hand
-------------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the forearm or hand?
[ ] Yes[X] No
3. Foot and leg
---------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the foot or leg?
[ ] Yes[X] No
4. Pelvic girdle and thigh
--------------------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the pelvic girdle or thigh?
[ ] Yes[X] No
5. Torso and neck
-----------------
Does the Veteran now have or has he/she ever had an injury to a muscle group in the torso and/or neck?
[ ] Yes[X] No
6. Additional conditions
------------------------
a. Does the Veteran have a history of rupture of the diaphragm with herniation?
[ ] Yes[X] No
b. Does the Veteran have a history of an extensive muscle hernia of any muscle, without other injury to the muscle?
[ ] Yes[X] No
c. Does the Veteran have a history of injury to the facial muscles?
[ ] Yes[X] No
SECTION IV: MUSCLE INJURY EXAM
------------------------------
1. Scar, fascia and muscle findings
-----------------------------------
a. Does the Veteran have any scar(s) associated with a muscle injury?
[ ] Yes[X] No
b. Does the Veteran have any known fascial defects or evidence of fascial defects associated with any muscle injuries?
[ ] Yes[X] No
c. Does the Veteran's muscle injury(ies) affect muscle substance or function?
[ ] Yes[X] No
2. Cardinal signs and symptoms of muscle disability
Due to the Veteran's muscle conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran.
[X] No
3. Other pertinent physical findings, complications, conditions, signs and/or symptoms
Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms?
[ ] Yes[X] No
4. Diagnostic Testing
---------------------
a. Have imaging studies been performed and are the results available?
[X] Yes[ ] No
b. Is there x-ray evidence of retained metallic fragments (such as shell fragments or shrapnel) in any muscle group?
[ ] Yes[X] No
c. Were electrodiagnostic tests done?
[ ] Yes[X] No
d. Are there any other significant diagnostic test findings and/or results?
[X] Yes[ ] No
If yes, provide type of test or procedure, date and results (brief summary):
Exam Date/Time 09/03/2014
Procedure Name
CHEST 2 VIEWS, FRONTAL & LATERAL
Impression
No active lung disease.
Report
Cardiomediastinal silhouette is normal in size, shape and position. The lungs are clear bilaterally with sharp costophrenic angles and posterior recesses. The osseous structures and soft tissues are intact.
5. Functional impact
--------------------
Does the Veteran's muscle injury(ies) impact his or her ability to work, such as resulting in inability to keep up with work requirements due to muscle injury(ies)?
[ ] Yes[X] No
6. Remarks, if any:
-------------------
THERE IS NO TENDERNESS AT SITE WHICH PATIENT MENTIONED HE HAD CLOSED RIB FRACTURE. THERE IS NO EVIDENCE OF OTHER RESIDUALS ON CURRENT EXAM.
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:
[ ] 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:
E-FOLDER ON VBMS.
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a headache condition?
[X] Yes [ ] No
[X] Migraine including migraine variants
Date of diagnosis: S/C
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary):
THIS EXAM IS FOR CURRENT STATUS OF S/C HEADACHE DUE TO TBI. PATIENT SAYS HE GETS MILD CONSTANT HEADACHE IN BACK AND OCCASIONALLY GETS LEFT SIDE HEADACHE 4-5 TIMES A WEEK WHICH IS MILD TO MODERATE AND LAST FOR ABOUT AN AN HOUR AND SUBSIDE AFTER REST OR MEDICINE.
b. Does the Veteran's treatment plan include taking medication for thediagnosed condition?
[X] Yes [ ] No
If yes, describe treatment (list only those medications used for the diagnosed condition):
GABAPENTIN 600 MG PO TID
3. Symptoms
-----------
a. Does the Veteran experience headache pain?
[X] Yes [ ] No
[X] Constant head pain
[X] Pain localized to one side of the head
b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain)
[X] Yes [ ] No
[X] Nausea
[X] Sensitivity to light
[X] Sensitivity to sound
c. Indicate duration of typical head pain
[X] Less than 1 day
d. Indicate location of typical head pain
[X] Left side of head
4. Prostrating attacks of headache pain
---------------------------------------
a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain?
[ ] Yes [X] No
5. 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?
[ ] Yes [X] No
6. Diagnostic testing
---------------------
Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief summary):
9/23/2014
Unremarkable MRI of the brain.
7. Functional impact
--------------------
Does the Veteran's headache condition impact his or her ability to work?
[X] A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary):
OCCASINALLY FORGETFULLNESS
2. Judgment
-----------
[X] Normal
3. Social interaction
---------------------
[X] Social interaction is routinely appropriate
4. Orientation
--------------
[X] Always oriented to person, time, place, and situation
5. Motor activity (with intact motor and sensory system)
Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)?
Indicate method used to obtain medical information to complete this document:
In-person examination Evidence review
-----------------
Was the Veteran's VA claims file (hard copy paper C-file) reviewed: No
Check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment records)
[X] Other: E-FOLDER ON VBMS.
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with an ear or peripheral vestibular condition? Yes
Other diagnosis #1: SUBJECTIVE DIZZINESS/ VERTIGO BY HISTORY.
Date of diagnosis: 2014
2. Medical history
------------------
Description of the history (including onset and course) of the Veteran's ear or peripheral vestibular condition: PATIENT SAYS HE STARTED GETTING
DIZZINESS MANY TIME AGO BUT WENT TO DOCTOR FEW MONTHS AGO. SEEN PRIVATE ENT AND HE GAVE SOME MEDICINE. DIZZINESS IS INTERMITTENT LASTS FOR FEW MINUTES AND TAKES REST. NOT ALWAYS WITH HEADACHES. DURING ATTACK FEELS HE IS SPINNING AND MAY LOSE BALANCE.
Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition: Yes
Medications used for the diagnosed condition:
DON'T NO THE NAME BUT GIVEN BY PRIVATE ENT DOCTOR.
3. Vestibular conditions
------------------------
Does the Veteran have any of the following findings, signs or symptoms attributable to Meniere's syndrome (endolymphatic hydrops), a peripheral vestibular condition or another diagnosed condition from Section 1: No
4. Infectious, inflammatory and other ear conditions
Does the Veteran have any of the following findings, signs or symptoms attributable to chronic ear infection, inflammation, cholesteatoma or any of the diagnoses in Section 1: No
5. Surgical treatment
---------------------
Has the Veteran had surgical treatment for any ear condition: No
Does the Veteran have any residuals as a result of the surgery: No
6. Physical exam
----------------
External ear:
Normal
Ear canal:
Normal
Tympanic membrane:
Normal
Gait:
Normal
Romberg test:
Normal or negative
Dix Hallpike test (Nylen-Barany test) for vertigo:
Normal, no vertigo or nystagmus during test
Limb coordination test (finger-nose-finger):
Normal
7. Tumors and neoplasms
-----------------------
Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section: No
8. Other pertinent physical findings, 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 in the Diagnosis section above: No
9. Diagnostic testing
---------------------
Have diagnostic imaging studies or other diagnostic procedures been performed: Yes
Magnetic resonance imaging (MRI)
Date: 9/23/2014
Results: Unremarkable MRI of the brain.
Has the Veteran had an audiogram: No
Are there any other significant diagnostic test findings and/or results: No
10. Functional impact
---------------------
Do any of the Veteran's ear or peripheral vestibular conditions impact his or her ability to work? No
11. Remarks, if any: No response provided
---------------------
NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.
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] Veterans Health Administration medical records (VA treatment records)
[X] Other:
E-FOLDER ON VBMS.
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER.
**All evidence needed for review is available electronically through VBMS**
The Veteran has filed a fully developed claim. Please expedite.
Date of claim: 09/29/2014
Days pending: 22
Veteran has a power of attorney.
Please send a courtesy copy of the exam notice letter to PARALYZED VETERANS
OF AMERICA, INC.
The Veteran will need to report for the following exam(s):
Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete the DBQ.
Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report.
The Veteran is service connected for residuals rib fracture which is currently evaluated at 0%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error.
Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete the DBQ.
Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report.
***The Veteran is service connected for traumatic brain injury with subjective memory impairment and headaches which is currently evaluated at 10%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error.
If the Veteran has a co-existing psychiatric condition, please state, to the extent possible, which emotional/behavioral signs and symptoms are part of a co-morbid mental disorder and which represent residuals of TBI. If it is impossible to make such a determination without speculation, please state so.
*** The Veteran is claiming that his dizziness was proximately due to or the result of his service connected traumatic brain injury with subjective memory impairment and headaches.
Opinion Requested:
Is the Veteran's dizziness at least as likely as not (50 percent or greater probability) proximately due to or the result of his service connected traumatic brain injury with subjective memory impairment and headaches.
Rationale must be provided in the appropriate section below. Your review is not limited to the evidence identified on this request form, or tabbed in the claims folder. If an examination or additional testing is required, obtain them prior to rendering your opinion.
If not caused, but aggravated by service, please provide the following information:
" The baseline manifestations of the aggravation which are due to the effects of the disease or injury.
" The increased manifestations which, in your opinion, are proximately due to the service connected disability based on medical considerations.
" The medical considerations supporting an opinion, that increased manifestations of a non-service connected disease or injury are proximately due to the service connected disability.
===========================================
b. Indicate type of exam for which opinion has been requested:
DIZZINESS/VERTIGO
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.
c. Rationale: AFTER REVIEWING E-FOLDER, VA TREATMENT RECORDS PATIENT COMPLAINED HAVING DIZZINESS/VERTIGO IN 2014 THAT IS SIX YEARS AFTER INSIDENT OF MILD TBI. THESE LONG TIME DELAY BETWEEN TBI INSIDENT AND SYMPTOMS ARE NOT CONSISTENT WITH PATTERN OF MILD TBI.
Question
manni
Here is my TBI C&P which lasted 20 minutes only. I'm thinking of 0%-10%. Thanks in advance
Muscle Injuries
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes[X] No
If no, check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment records)
E-FOLDER ON VBMS.
SECTION I: DIAGNOSIS
--------------------
Does the Veteran now have or has he/she ever been diagnosed with a muscle injury?
[X] Yes[ ] No
Diagnosis #1: RESIDUALS OF CLOSED LEFT RIB FRACTURE
Date of diagnosis: S/C
Side affected: [ ] Right [X] Left [ ] Both
SECTION II: HISTORY OF MUSCLE INJURY
------------------------------------
a. Does the Veteran have a penetrating muscle injury, such as a gunshot or shell fragment wound?
[ ] Yes[X] No
b. Does the Veteran have a non-penetrating muscle injury (such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)?
[X] Yes[ ] No
c. Describe the history (including onset and course) of the Veteran's muscle
injury: (brief summary):
THIS EXAM IS FOR CURRENT STATUS OF S/C LEFT RIB FRACTURE. PATIENT SAYS HE GETS OCCASIONAL MILD PAIN IN LEFT RIB IF SITS TOO LONG BUT NO NEED OF MEDICINE.
d. Dominant hand
[X] Right[ ] Left[ ] Ambidextrous
SECTION III: LOCATION OF MUSCLE INJURY
--------------------------------------
1. Shoulder girdle and arm
--------------------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the shoulder girdle or arm?
[ ] Yes[X] No
2. Forearm and hand
-------------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the forearm or hand?
[ ] Yes[X] No
3. Foot and leg
---------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the foot or leg?
[ ] Yes[X] No
4. Pelvic girdle and thigh
--------------------------
Does the Veteran now have or has he/she ever had an injury to a muscle group of the pelvic girdle or thigh?
[ ] Yes[X] No
5. Torso and neck
-----------------
Does the Veteran now have or has he/she ever had an injury to a muscle group in the torso and/or neck?
[ ] Yes[X] No
6. Additional conditions
------------------------
a. Does the Veteran have a history of rupture of the diaphragm with herniation?
[ ] Yes[X] No
b. Does the Veteran have a history of an extensive muscle hernia of any muscle, without other injury to the muscle?
[ ] Yes[X] No
c. Does the Veteran have a history of injury to the facial muscles?
[ ] Yes[X] No
SECTION IV: MUSCLE INJURY EXAM
------------------------------
1. Scar, fascia and muscle findings
-----------------------------------
a. Does the Veteran have any scar(s) associated with a muscle injury?
[ ] Yes[X] No
b. Does the Veteran have any known fascial defects or evidence of fascial defects associated with any muscle injuries?
[ ] Yes[X] No
c. Does the Veteran's muscle injury(ies) affect muscle substance or function?
[ ] Yes[X] No
2. Cardinal signs and symptoms of muscle disability
---------------------------------------------------
Does the Veteran have any of the following signs and/or symptoms attributable to any muscle injuries?
[X] Yes[ ] No
If yes, check all that apply, and indicate side affected, muscle group and frequency/severity.
[X] Fatigue-pain
If checked, indicate side affected: [ ] Right [X] Left [ ] Both
Indicate muscle group(s) affected (I-XXIII) if possible: LEFT RIBS
Indicate frequency/severity:
[X] Occasional[ ] Consistent[ ] Consistent at a more severe level
3. Muscle strength testing
--------------------------
Rate strength according to the following scale:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
Shoulder abduction (Group III)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Elbow flexion (Group V)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Elbow extension (Group VI)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist flexion (Group VII)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist extension (Group VIII)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Hip flexion (Group XVI)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee flexion (Group XIII)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee extension (Group XIV)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion (Group XI)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion (Group XII)
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
If other movements/muscle groups were tested, specify:
THORACIC MUSCLE GROUPS.
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Does the Veteran have muscle atrophy?
[ ] Yes[X] No
SECTION V: OTHER
----------------
1. Assistive devices
--------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible?
[ ] Yes[X] No
2. Remaining effective function of the extremities
--------------------------------------------------
Due to the Veteran's muscle conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran.
[X] No
3. Other pertinent physical findings, complications, conditions, signs and/or symptoms
----------------------------------------------------------------------
Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms?
[ ] Yes[X] No
4. Diagnostic Testing
---------------------
a. Have imaging studies been performed and are the results available?
[X] Yes[ ] No
b. Is there x-ray evidence of retained metallic fragments (such as shell fragments or shrapnel) in any muscle group?
[ ] Yes[X] No
c. Were electrodiagnostic tests done?
[ ] Yes[X] No
d. Are there any other significant diagnostic test findings and/or results?
[X] Yes[ ] No
If yes, provide type of test or procedure, date and results (brief summary):
Exam Date/Time 09/03/2014
Procedure Name
CHEST 2 VIEWS, FRONTAL & LATERAL
Impression
No active lung disease.
Report
Cardiomediastinal silhouette is normal in size, shape and position. The lungs are clear bilaterally with sharp costophrenic angles and posterior recesses. The osseous structures and soft tissues are intact.
5. Functional impact
--------------------
Does the Veteran's muscle injury(ies) impact his or her ability to work, such as resulting in inability to keep up with work requirements due to muscle injury(ies)?
[ ] Yes[X] No
6. Remarks, if any:
-------------------
THERE IS NO TENDERNESS AT SITE WHICH PATIENT MENTIONED HE HAD CLOSED RIB FRACTURE. THERE IS NO EVIDENCE OF OTHER RESIDUALS ON CURRENT EXAM.
****************************************************************************
Headaches (including Migraine Headaches)
Disability Benefits Questionnaire
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:
[ ] 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:
E-FOLDER ON VBMS.
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a headache condition?
[X] Yes [ ] No
[X] Migraine including migraine variants
Date of diagnosis: S/C
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary):
THIS EXAM IS FOR CURRENT STATUS OF S/C HEADACHE DUE TO TBI. PATIENT SAYS HE GETS MILD CONSTANT HEADACHE IN BACK AND OCCASIONALLY GETS LEFT SIDE HEADACHE 4-5 TIMES A WEEK WHICH IS MILD TO MODERATE AND LAST FOR ABOUT AN AN HOUR AND SUBSIDE AFTER REST OR MEDICINE.
b. Does the Veteran's treatment plan include taking medication for thediagnosed condition?
[X] Yes [ ] No
If yes, describe treatment (list only those medications used for the diagnosed condition):
GABAPENTIN 600 MG PO TID
3. Symptoms
-----------
a. Does the Veteran experience headache pain?
[X] Yes [ ] No
[X] Constant head pain
[X] Pain localized to one side of the head
b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain)
[X] Yes [ ] No
[X] Nausea
[X] Sensitivity to light
[X] Sensitivity to sound
c. Indicate duration of typical head pain
[X] Less than 1 day
d. Indicate location of typical head pain
[X] Left side of head
4. Prostrating attacks of headache pain
---------------------------------------
a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain?
[ ] Yes [X] No
5. 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?
[ ] Yes [X] No
6. Diagnostic testing
---------------------
Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief summary):
9/23/2014
Unremarkable MRI of the brain.
7. Functional impact
--------------------
Does the Veteran's headache condition impact his or her ability to work?
[ ] Yes [X] No
8. Remarks, if any:
-------------------
No remarks provided.
****************************************************************************
Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes[X] No
If no, check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment records)
[X] Other:
E-FOLDER ON VBMS.
SECTION I: Diagnosis and medical history
----------------------------------------
1. Diagnosis
------------
Does the Veteran now have or has he/she ever had a traumatic brain injury
(TBI) or any residuals of a TBI?
[X] Yes [ ] No
[X] Traumatic brain injury (TBI)
Date of diagnosis: S/C
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary):
THIS EXAM IS FOR CURRENT STATUS OF S/C TBI. PATIENT SAYS SINCE ABOUT AND YEAR GETTING DIZZINESS AND THINKS IT IS DUE TO TBI.
SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI
-----------------------------------------------------------------------------
1. Memory, attention, concentration, executive functions
--------------------------------------------------------
[X] A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary):
OCCASINALLY FORGETFULLNESS
2. Judgment
-----------
[X] Normal
3. Social interaction
---------------------
[X] Social interaction is routinely appropriate
4. Orientation
--------------
[X] Always oriented to person, time, place, and situation
5. Motor activity (with intact motor and sensory system)
--------------------------------------------------------
[X] Motor activity normal
6. Visual spatial orientation
-----------------------------
[X] Normal
7. Subjective symptoms
----------------------
[X] Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships.
Examples are: mild or occasional headaches, mild anxiety If the Veteran has subjective symptoms, describe (brief summary):
MILD HEADACHE, SUBJECTIVE DIZZINESS
8. Neurobehavioral effects
--------------------------
[X] No neurobehavioral effects
9. Communication
----------------
[X] Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language.
10. Consciousness
-----------------
[X] Normal
SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks
-----------------------------------------------------------------------------
1. Residuals
------------
Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)?
[X] Yes [ ] No
2. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms
-----------------------------------------------------------------------------
No answer provided.
3. Diagnostic testing
---------------------
a. Has neuropsychological testing been performed?
[ ] Yes [ ] No
b. Have diagnostic imaging studies or other diagnostic procedures been performed?
[ ] Yes [ ] No
c. Has laboratory testing been performed?
[ ] Yes [ ] No
d. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [ ] No
4. Functional impact
--------------------
No answer provided.
5. Remarks, if any:
-------------------
No remarks provided.
****************************************************************************
Ear Conditions
(including Vestibular and Infectious Conditions)
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this document:
In-person examination Evidence review
-----------------
Was the Veteran's VA claims file (hard copy paper C-file) reviewed: No
Check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment records)
[X] Other: E-FOLDER ON VBMS.
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with an ear or peripheral vestibular condition? Yes
Other diagnosis #1: SUBJECTIVE DIZZINESS/ VERTIGO BY HISTORY.
Date of diagnosis: 2014
2. Medical history
------------------
Description of the history (including onset and course) of the Veteran's ear or peripheral vestibular condition: PATIENT SAYS HE STARTED GETTING
DIZZINESS MANY TIME AGO BUT WENT TO DOCTOR FEW MONTHS AGO. SEEN PRIVATE ENT AND HE GAVE SOME MEDICINE. DIZZINESS IS INTERMITTENT LASTS FOR FEW MINUTES AND TAKES REST. NOT ALWAYS WITH HEADACHES. DURING ATTACK FEELS HE IS SPINNING AND MAY LOSE BALANCE.
Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition: Yes
Medications used for the diagnosed condition:
DON'T NO THE NAME BUT GIVEN BY PRIVATE ENT DOCTOR.
3. Vestibular conditions
------------------------
Does the Veteran have any of the following findings, signs or symptoms attributable to Meniere's syndrome (endolymphatic hydrops), a peripheral vestibular condition or another diagnosed condition from Section 1: No
4. Infectious, inflammatory and other ear conditions
----------------------------------------------------
Does the Veteran have any of the following findings, signs or symptoms attributable to chronic ear infection, inflammation, cholesteatoma or any of the diagnoses in Section 1: No
5. Surgical treatment
---------------------
Has the Veteran had surgical treatment for any ear condition: No
Does the Veteran have any residuals as a result of the surgery: No
6. Physical exam
----------------
External ear:
Normal
Ear canal:
Normal
Tympanic membrane:
Normal
Gait:
Normal
Romberg test:
Normal or negative
Dix Hallpike test (Nylen-Barany test) for vertigo:
Normal, no vertigo or nystagmus during test
Limb coordination test (finger-nose-finger):
Normal
7. Tumors and neoplasms
-----------------------
Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section: No
8. Other pertinent physical findings, 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 in the Diagnosis section above: No
9. Diagnostic testing
---------------------
Have diagnostic imaging studies or other diagnostic procedures been performed: Yes
Magnetic resonance imaging (MRI)
Date: 9/23/2014
Results: Unremarkable MRI of the brain.
Has the Veteran had an audiogram: No
Are there any other significant diagnostic test findings and/or results: No
10. Functional impact
---------------------
Do any of the Veteran's ear or peripheral vestibular conditions impact his or her ability to work? No
11. Remarks, if any: No response provided
---------------------
NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
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] Veterans Health Administration medical records (VA treatment records)
[X] Other:
E-FOLDER ON VBMS.
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER.
**All evidence needed for review is available electronically through VBMS**
The Veteran has filed a fully developed claim. Please expedite.
Date of claim: 09/29/2014
Days pending: 22
Veteran has a power of attorney.
Please send a courtesy copy of the exam notice letter to PARALYZED VETERANS
OF AMERICA, INC.
The Veteran will need to report for the following exam(s):
DBQ NEURO TBI Review
DBQ MUSC Muscle injuries
___________________________________________________________________________
DBQ MUSC Muscle injuries:
Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete the DBQ.
Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report.
The Veteran is service connected for residuals rib fracture which is currently evaluated at 0%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error.
***************************************************************************
DBQ NEURO TBI Review:
Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete the DBQ.
Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report.
***The Veteran is service connected for traumatic brain injury with subjective memory impairment and headaches which is currently evaluated at 10%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error.
If the Veteran has a co-existing psychiatric condition, please state, to the extent possible, which emotional/behavioral signs and symptoms are part of a co-morbid mental disorder and which represent residuals of TBI. If it is impossible to make such a determination without speculation, please state so.
*** The Veteran is claiming that his dizziness was proximately due to or the result of his service connected traumatic brain injury with subjective memory impairment and headaches.
Opinion Requested:
Is the Veteran's dizziness at least as likely as not (50 percent or greater probability) proximately due to or the result of his service connected traumatic brain injury with subjective memory impairment and headaches.
Rationale must be provided in the appropriate section below. Your review is not limited to the evidence identified on this request form, or tabbed in the claims folder. If an examination or additional testing is required, obtain them prior to rendering your opinion.
If not caused, but aggravated by service, please provide the following information:
" The baseline manifestations of the aggravation which are due to the effects of the disease or injury.
" The increased manifestations which, in your opinion, are proximately due to the service connected disability based on medical considerations.
" The medical considerations supporting an opinion, that increased manifestations of a non-service connected disease or injury are proximately due to the service connected disability.
===========================================
b. Indicate type of exam for which opinion has been requested:
DIZZINESS/VERTIGO
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.
c. Rationale: AFTER REVIEWING E-FOLDER, VA TREATMENT RECORDS PATIENT COMPLAINED HAVING DIZZINESS/VERTIGO IN 2014 THAT IS SIX YEARS AFTER INSIDENT OF MILD TBI. THESE LONG TIME DELAY BETWEEN TBI INSIDENT AND SYMPTOMS ARE NOT CONSISTENT WITH PATTERN OF MILD TBI.
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