tinnitus Fibro Denial Statement False

[WVSERVER]

Looking for opinions on why I keep getting denied for Fibromyalgia I was diagnosed in the Air Force with it but the VBA and VAMC will not recognize it because I don't have enough tender point when I was active duty I was diagnosed with it due to fatigue and wide speared body pain. Here's my last C&P on the issue. I was emailing with a lane coach at my RO and asked why I keep getting denied when I have a diagnosis active service and have been to pain school, pain docs and PT. This was the coach's response. I provided two medical records to the coach from active service saying I was treated for fibro. I feel the exam proves the denial statement to be false.

I am leaning towards a reconsideration after I see a specialist at my VAMC I haven't been working all that much lately and can not afford a IMO right this second.

As for your claim we have quite a few options:

1. Request a reconsideration
2. Appeal the decision (within a year of your decision letter dated 12/18/2014)
3. After 1 year from your decision letter the Agency would need new and material evidence (from the examiners notes- it would be private medical evidence from a Rheumatologist)

The rating decision rendered on 12/17/2014 states the reason for the decision as “ a review of your service treatment reports reveals diagnosis of non-specific myalgia’s and myositis, meaning tenderness or pain in the muscles and inflammation of muscle tissues. You completed an examination on 9/19/2014 at that time the examiner could not provide a diagnosis of fibromyalgia, although you have symptoms. A medical opinion was and completed on 11/3/2014. However, a diagnosis of fibromyalgia still could not be rendered. The evidence does not show a current diagnosed disability. Service connection for fibromyalgia is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed.”

Date/Time: 19 Sep 2014 @ 1300
Note Title: COMPENSATION AND PENSION EXAMINATION
Location: MARTINSBURG VAMC
Signed By: CANETE,LUCILA Z
Co-signed By: CANETE,LUCILA Z
Date/Time Signed: 19 Sep 2014 @ 1600
-------------------------------------------------------------------------

LOCAL TITLE: COMPENSATION AND PENSION EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: SEP 19, 2014@13:00 ENTRY DATE: SEP 19, 2014@16:00:13
AUTHOR: CANETE,LUCILA Z EXP COSIGNER:
URGENCY: STATUS: COMPLETED

Fibromyalgia
Disability Benefits Questionnaire

Name of patient/Veteran:

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?
[X] Yes[ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

vbms efile; VAMC


1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with
fibromyalgia? (This is the condition the Veteran is claiming or for which an
exam has been requested)
[X] Yes [ ] No

[X] Fibromyalgia
Date of diagnosis: 2005

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
fibromyalgia condition:
33 years old USAirforce veteran from 2000 to 2006, is here for a
C&P
evaluation on his current condition of fibromylagia.
In 2003, he started coming unexplained fatigue which described
coming with similar symptoms when one suffers from flu-like symptoms
when one developes generalized muscle soreness, insides of both legs,
thighs, shoulder and neck areas and medial side of both arms and
achiness of both hands (described it as fatigue feeling). When he
would wear the body armour, he feels that his entire body feels sore
and touch of the armor which is heavy makes him feel the soreness.
More noticeable over the medical surfaces of the thighs. During his
active service he worked with Nuclear Program at Minot, Airforce
Base,
North Dakota he is on strict monitoring due to the sensitivity
concern
of the program. (Perosonal Reliability Program).
Around the same year 2003 the Base physician and several times
2003-2004. He was tried on Amytriptylline 25 mg po hs which helped X
2
months only to return back to his initial symptoms. 6 months before
he
left the USAirforce, he had sleep study done which confirmed sleep
apnea which he wears CPAP to date. It seemed to help his drowsiness
during the daytime but it has not affected his sensation of muscle
soreness. He had a medical board but was honorably discharged. He was
recommended not eligible to re-enlist and or serve the remaining 2
years of inactive reserve.
He has been coming here at Martinsburg VA since 2012 for scheduled
Compensation & Pension Evaluation. He has been placed on
Sertraline
for depression which did not help his body pain. It has been
discontinued and not on any medications. He sees the Pain Mgmt for
his
neck complaints and have an appointment for PT regarding the rest of
his body pains.
Reviewed vbms STRS efile:
11/10/2005: Routine Physical Examination
Note on his active problem list: Mylagias/Myositis
(Non-specified)
Multiple progress notes/Behavioral Clinic: Mild
Depression 2003/ Major Depression 2005/ Involutional Melancholia
2005.
Medications: Amitriptylline 25 mg po qd (prescribed to
problems with Depression) No specific mention that this was given for
fibromyalgia.
1/25/2005 Progress notes: Mentioned that member was seen prior for
fibromyalgia which responded well to Elavil a hs. Mention about
implication for his work statys (PRP) using Elavil. There as a
discussion with Dr. Higgins who mentioned that the medication causes
no limiting side effects, and is not being used for anti-depressant
purposes, that this case does not automatically require PRP
suspension.
Memorandum from XXXXwritten by TODD P Huhn,
CAPT, USAF, MC
XXXXXhas been seen for symptoms consistent with
fibromylgia, a condition of chronic muscle pain. He responded very
well to medication for this which he takes at night. This is not
being
used as an anti-depressant medication. After conferring with the
AFSPC PRP medical consultant, Lt. Col Higgins, we concurred that Sra
XXX was medically cleared to take this medication and maintain his
PRP clearance.
Routine H&P by an outpatient primary care provider at Martinsburg
VA 7/18/2014:
LOCAL TITLE: PHYSICIAN, PRIMARY CARE/OUTPATIENT CLINIC
STANDARD TITLE: PRIMARY CARE PHYSICIAN NOTE
DATE OF NOTE: JUL 18, 2014@08:59 ENTRY DATE: JUL 18,
2014@09:01:34

AUTHOR: VU,PETER D EXP COSIGNER:

URGENCY: STATUS: COMPLETED

CHIEF COMPLAINT: chronic neck strain w/ headache

PRESENT ILLNESS: said
he has chronic neck strain and occasional tension headache w/o any
trauma or
injury. pt said he needs clearance to participate in walk for
wellness at home.
pt gained some wt w/ BMI >35. Today,PT denies any SI or
HI,fever,chills,sob,cp,
productive cough, n/v,abdominal pain,vision problems, weakness,
dizziness,headache, change of bm,orthopnea, palpitation,syncope, LOC,
urinary or
stool incontinence, hematuria or hematochezia.

PAST HISTORY:
Active problems - Computerized Problem List is the source for the
following:

1. Recurrent major depression (SNOMED CT 66344007) 09/30/13
ASGHAR,ALI
2. Nonallopathic lesions of rib cage
3. Pain in Thoracic Spine 05/09/13
NEFF,SHAWN M
4. Somat Dysfunc Thorac Reg 05/09/13
NEFF,SHAWN M
5. Somat Dysfunc Cervic Reg 04/09/13
NEFF,SHAWN M
6. Cervicalgia 04/09/13
NEFF,SHAWN M
7. Headache
8. Hyperlipidemia 01/24/13
VU,PETER D
9. SUBJECTIVE TINNITUS 01/23/13
SHALLIS,JULIE
B
10. Depression 01/18/13
VU,PETER D
11. GERD 01/18/13
VU,PETER D
12. Anxiety 01/18/13
VU,PETER D
13. Cholelithiasis 01/18/13
VU,PETER D
14. Hx of tobacco user in remission 01/18/13
VU,PETER D
15. OSA on c-pap 01/18/13
VU,PETER D
16. Hx of tinnitus
01/18/13
VU,PETER D
17. Irritable Bowel Syndrome

PHYSICAL EXAM:
GENERAL: ambulatory, awake, alert, oriented x3,nad, pleasant,obese
young man.
HEENT: PERRLA. Clear oropharynx and tympanic membrane. no sinus
tenderness.
no cervical adenopathy.
NECK: No bruits or stiffness. Good ROM w/o difficulty but mild
discomfort on
rotation and moderate trapezius muscle stiffness on palpation.
CHEST: Chest normal shape and symmetrical.No masses,tenderness or
other
abnormalities
LUNGS: Clear, no crackles, wheezing, or rhonchi.
HEART: RSR, no murmurs, no gallop
ABDOMEN: obese. Soft, non tender, positive bowel sounds, liver and
spleen are
not palpable. No rebound tenderness to palpation.
BACK: No cva tenderness or point tenderness.slr negative.
EXTREMITIES: No edema. Good ROM w/o pain or difficulty. Good muscle
strength
and tone plus well developed muscle. nl sensation and good radial
pulse and capillary refill.
NEUROLOGICAL: Cranial nerve intact, no focal deficit, ambulatory w/o
difficulty.

ASSESSMENT:
- Hx of chronic neck strain: discussed and full explaination about
his
condition
and booklet about neck given w/ instruction for home exercise.
increase flexeril
to 10mg qhs prn w/advise of side effects and continue heating pad
alternate
w/icepack. pt already was tx by PT, chiropractor and pain school in
past. pt
said he does not want to be on pain medication. pt had xray of neck
in
past was
negative.
-hx of IBS: Discussed and tx w/ bentyl 10mg bid and metamucil and
f/u GI as
directed.
-hx GERD: on prilosec
-hx Depression/anxiety: stable and denies any SI or HI. f/u w/ MHC as
directed.
-hx of OSA:stable on C-pap

b. Is continuous medication required for control of fibromyalgia symptoms?
[ ] Yes [X] No

c. Is the Veteran currently undergoing treatment for this condition?
[ ] Yes [X] No

d. Are the Veteran's fibromyalgia symptoms refractory to therapy?
[X] Yes [ ] No

3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to fibromyalgia?
[X] Yes [ ] No

a. Findings, signs and symptoms (check all that apply):

[X] Widespread musculoskeletal pain
[X] Fatigue
[X] Sleep disturbances
[X] Headache
[X] Depression
[X] Irritable bowel symptoms

For all checked conditions, describe:
Musculoskeletal symtpoms: 1) constant sensation of 'muscle
fatigue/sore'on both anterior thighs, skin feels sore over the medial
portion of both thighs, localized sensitivity(soreness) over the
specific medial portion of both arms, bilateral scapular muscles and
back of his neck.
2) Feels tired even if he has not done anything but can still do his
routines both at home and at work.
3) He feels no motivation, problems with concentration, crying for no
reasons, feels anxiety and hx/o bouts of panic attack and chest pain
while in the active service. Diagnosed with Depression while in the
active service and was not placed on medication because he wants to
continue working with Nuclear Program. Taking a anti-depressants will
disqualify him from that program. He was evaluated by a psychologist.
He was receiving regular psychological therapy while in the active
service.
He is currently seen by psychologist here at Martinsburg VA and
received Cognitive Therapy and currently on the HOPE Program (Group
Therapy). No medications for depression given to date.
4) Hx/o IBS and is service connected for IBS. Takes Dicyclomine BID.
He
said his current meds seem to help him.


b. Frequency of fibromyalgia symptoms (check all that apply):

[X] Constant or nearly constant

c. Does the Veteran have tender points (trigger points) for pain present?
[ ] Yes [X] No

4. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms

-----------------------------------------------------------------------------
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis section above?
[ ] Yes [X] No

5. Diagnostic testing
---------------------
Are there any significant diagnostic test findings and/or results?
[ ] Yes [X] No

6. Functional impact
---------------------
Does the Veteran's fibromyalgia impact his or her ability to work?
[ ] Yes [X] No

7. Remarks, if any:
-------------------
He now works both patroling
and now in the office. He has so far able to carry on his duties as a
security officer.
Physical examination today revealed: (-) direct tenderness on palpation
over the occipital, supraspinatus, sternal, knees.
He points to overall sensation of soreness on his neck area, and
localized sensitivity on the bilateral thigh muscles and linear medial
thigh bilaterally and medial areas on both arms. Strength 5/5 all
throughout. Sensory are all WNL both upper and lower extremeties.

This is the second opinion given by the same doc

Medical Opinion
Disability Benefits Questionnaire

Name of patient/Veteran: WVSERVER

Indicate method used to obtain medical information to complete this
document:

[X] 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
[ ] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed? Yes

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
vbms efile/VAMC

MEDICAL OPINION SUMMARY
-----------------------
UPDATE Information for Clinical Diagnosis of Fibromyalgia:
Hints for early and cost-effective diagnosis of fibromyalgia

Chronic widespread musculoskeletal pain for =three months

Absence of other systemic condition accounting for pain

Excess tenderness in soft-tissues

Characteristic symptoms:

? "I hurt all over"

? "It feels like I always have the flu"

? Fatigue, sleep and mood disturbances

? IBS, irritable bladder, multiple other somatic complaints

Exclusion of structural or systemic disease

? Not a "fishing" expedition

? Avoid "screening" rheumatology tests

? Most efficient with early subspecialty referral
Recommended diagnostic workup for fibromyalgia

Establishing the diagnosis is an essential component of FM management.
Diagnostic criteria for FM include the ACR and the Canadian Consensus
Guidelines. A complete history, physical exam, and laboratory testing should
be done to exclude diseases that may mimic or complicate FM. Each patient
should be assessed for a =three-month history of chronic widespread pain;
patient self-report should be used as an index of pain. The presence of
tender points should be confirmed. However, tenderness is subjective and
depends upon the examiner's strength of palpation.

FM: fibromyalgia; ACR: American College of Rheumatology.

Data from: Goldenberg, DL, Burckhardt, C, Crofford, L. Management of
fibromyalgia syndrome. JAMA 2004; 292:2388.

Graphic 56396 Version 4.0
Mr. Booth have several of the subjective symptoms compatible with
Fibromyalgia as well as the other co-existing conditions which can exist
with
its diagnosis.
Review the STRS: He has been diagnosed with Non-specific Myalgias and
Myositis-active service. An opinion was made one time by his superior that
he has symptoms consistent with fibromyalgia and was given Elavil. It was
primarily indicated for it and not for depression and to be able to work
with
RPR (Nuclear facility).
Reviewed all his outpatient clinic follow-ups by his primary care provider
here at VAMC Martinsburg since 2012 and there has been no specific diagnosis
of Fibromyalgia. He was diagnosed with Chronic Neck pains, Headaches,
Depression on Rx.and He has been referred to Chiropractic Tx. multiple times
and has been DX as Somatic Dysfunction on the cervical and thoracic spines.
My physical examination during the C&P evaluation fall short of the
physical criteria of specific number of trigger points to diagnose
Fibromyalgia. His main sore spots has been primarily on his neck and
thoracic
areas, supraspinatus, soreness on both thighs.
He has not been referred by any of his primary care providers here at
Martinsbsurg to see a Rheumatologist to rule out any other inflammatory
musculoskeletal conditions. Reviewed earlier serological testings while in
the active service has been non-diagnostic.
At this point one can at least assume, that his documented symptoms noted
while in the active service are similar to his current symptoms. It is at
least as likely as not (50% probability) that his current multi-symptoms is
consistent with fibromylagia. He has not been referred to a Rheumatologist
who can evaluate him and confirm this diagnosis and have ruled out any other
rheumatological conditions. He is currently not treated for fibromylagia.
Comments on the functional loss/impairment questions: He has constant
soreness on his neck, trapezius muscle areas all the time however, he is
able
to accomplish all the ROM. I stand corrected that I should have noted pain
on
movement.

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: Clarification on the physical examination
done C&P evaluation on 9/2014: See 2507 request:

b. Indicate type of exam for which opinion has been requested: ACE-
Fibromylagia

*************************************************************************

/es/ LUCILA Z. CANETE,MD
PHYSICIAN

Edited April 20, 2015 by WVSERVER

[Fat]

It seems you were diagnosed on active duty, but the C&P exam doctor is not currently not diagnosing you with Fibromyalgia.

I would refute the denial letters non diagnosis with a private physician examination.

VA doctors can be wrong and a non biased second opinion might confirm a diagnosis of Fibromyalgia.

"NEVER GIVE UP"

[WVSERVER]

thanks for the reply

[Guest]

Looking for opinions on why I keep getting denied for Fibromyalgia I was diagnosed in the Air Force with it but the VBA and VAMC will not recognize it because I don't have enough tender point when I was active duty I was diagnosed with it due to fatigue and wide speared body pain. Here's my last C&P on the issue. I was emailing with a lane coach at my RO and asked why I keep getting denied when I have a diagnosis active service and have been to pain school, pain docs and PT. This was the coach's response. I provided two medical records to the coach from active service saying I was treated for fibro. I feel the exam proves the denial statement to be false.

I am leaning towards a reconsideration after I see a specialist at my VAMC I haven't been working all that much lately and can not afford a IMO right this second.

As for your claim we have quite a few options:

1. Request a reconsideration
2. Appeal the decision (within a year of your decision letter dated 12/18/2014)
3. After 1 year from your decision letter the Agency would need new and material evidence (from the examiners notes- it would be private medical evidence from a Rheumatologist)

The rating decision rendered on 12/17/2014 states the reason for the decision as “ a review of your service treatment reports reveals diagnosis of non-specific myalgia’s and myositis, meaning tenderness or pain in the muscles and inflammation of muscle tissues. You completed an examination on 9/19/2014 at that time the examiner could not provide a diagnosis of fibromyalgia, although you have symptoms. A medical opinion was and completed on 11/3/2014. However, a diagnosis of fibromyalgia still could not be rendered. The evidence does not show a current diagnosed disability. Service connection for fibromyalgia is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed.”

Date/Time: 19 Sep 2014 @ 1300
Note Title: COMPENSATION AND PENSION EXAMINATION
Location: MARTINSBURG VAMC
Signed By: CANETE,LUCILA Z
Co-signed By: CANETE,LUCILA Z
Date/Time Signed: 19 Sep 2014 @ 1600
-------------------------------------------------------------------------

LOCAL TITLE: COMPENSATION AND PENSION EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: SEP 19, 2014@13:00 ENTRY DATE: SEP 19, 2014@16:00:13
AUTHOR: CANETE,LUCILA Z EXP COSIGNER:
URGENCY: STATUS: COMPLETED

Fibromyalgia
Disability Benefits Questionnaire

Name of patient/Veteran:

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?
[X] Yes[ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

vbms efile; VAMC


1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with
fibromyalgia? (This is the condition the Veteran is claiming or for which an
exam has been requested)
[X] Yes [ ] No

[X] Fibromyalgia
Date of diagnosis: 2005

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
fibromyalgia condition:
33 years old USAirforce veteran from 2000 to 2006, is here for a
C&P
evaluation on his current condition of fibromylagia.
In 2003, he started coming unexplained fatigue which described
coming with similar symptoms when one suffers from flu-like symptoms
when one developes generalized muscle soreness, insides of both legs,
thighs, shoulder and neck areas and medial side of both arms and
achiness of both hands (described it as fatigue feeling). When he
would wear the body armour, he feels that his entire body feels sore
and touch of the armor which is heavy makes him feel the soreness.
More noticeable over the medical surfaces of the thighs. During his
active service he worked with Nuclear Program at Minot, Airforce
Base,
North Dakota he is on strict monitoring due to the sensitivity
concern
of the program. (Perosonal Reliability Program).
Around the same year 2003 the Base physician and several times
2003-2004. He was tried on Amytriptylline 25 mg po hs which helped X
2
months only to return back to his initial symptoms. 6 months before
he
left the USAirforce, he had sleep study done which confirmed sleep
apnea which he wears CPAP to date. It seemed to help his drowsiness
during the daytime but it has not affected his sensation of muscle
soreness. He had a medical board but was honorably discharged. He was
recommended not eligible to re-enlist and or serve the remaining 2
years of inactive reserve.
He has been coming here at Martinsburg VA since 2012 for scheduled
Compensation & Pension Evaluation. He has been placed on
Sertraline
for depression which did not help his body pain. It has been
discontinued and not on any medications. He sees the Pain Mgmt for
his
neck complaints and have an appointment for PT regarding the rest of
his body pains.
Reviewed vbms STRS efile:
11/10/2005: Routine Physical Examination
Note on his active problem list: Mylagias/Myositis
(Non-specified)
Multiple progress notes/Behavioral Clinic: Mild
Depression 2003/ Major Depression 2005/ Involutional Melancholia
2005.
Medications: Amitriptylline 25 mg po qd (prescribed to
problems with Depression) No specific mention that this was given for
fibromyalgia.
1/25/2005 Progress notes: Mentioned that member was seen prior for
fibromyalgia which responded well to Elavil a hs. Mention about
implication for his work statys (PRP) using Elavil. There as a
discussion with Dr. Higgins who mentioned that the medication causes
no limiting side effects, and is not being used for anti-depressant
purposes, that this case does not automatically require PRP
suspension.
Memorandum from XXXXwritten by TODD P Huhn,
CAPT, USAF, MC
XXXXXhas been seen for symptoms consistent with
fibromylgia, a condition of chronic muscle pain. He responded very
well to medication for this which he takes at night. This is not
being
used as an anti-depressant medication. After conferring with the
AFSPC PRP medical consultant, Lt. Col Higgins, we concurred that Sra
XXX was medically cleared to take this medication and maintain his
PRP clearance.
Routine H&P by an outpatient primary care provider at Martinsburg
VA 7/18/2014:
LOCAL TITLE: PHYSICIAN, PRIMARY CARE/OUTPATIENT CLINIC
STANDARD TITLE: PRIMARY CARE PHYSICIAN NOTE
DATE OF NOTE: JUL 18, 2014@08:59 ENTRY DATE: JUL 18,
2014@09:01:34

AUTHOR: VU,PETER D EXP COSIGNER:

URGENCY: STATUS: COMPLETED

CHIEF COMPLAINT: chronic neck strain w/ headache

PRESENT ILLNESS: said
he has chronic neck strain and occasional tension headache w/o any
trauma or
injury. pt said he needs clearance to participate in walk for
wellness at home.
pt gained some wt w/ BMI >35. Today,PT denies any SI or
HI,fever,chills,sob,cp,
productive cough, n/v,abdominal pain,vision problems, weakness,
dizziness,headache, change of bm,orthopnea, palpitation,syncope, LOC,
urinary or
stool incontinence, hematuria or hematochezia.

PAST HISTORY:
Active problems - Computerized Problem List is the source for the
following:

1. Recurrent major depression (SNOMED CT 66344007) 09/30/13
ASGHAR,ALI
2. Nonallopathic lesions of rib cage
3. Pain in Thoracic Spine 05/09/13
NEFF,SHAWN M
4. Somat Dysfunc Thorac Reg 05/09/13
NEFF,SHAWN M
5. Somat Dysfunc Cervic Reg 04/09/13
NEFF,SHAWN M
6. Cervicalgia 04/09/13
NEFF,SHAWN M
7. Headache
8. Hyperlipidemia 01/24/13
VU,PETER D
9. SUBJECTIVE TINNITUS 01/23/13
SHALLIS,JULIE
B
10. Depression 01/18/13
VU,PETER D
11. GERD 01/18/13
VU,PETER D
12. Anxiety 01/18/13
VU,PETER D
13. Cholelithiasis 01/18/13
VU,PETER D
14. Hx of tobacco user in remission 01/18/13
VU,PETER D
15. OSA on c-pap 01/18/13
VU,PETER D
16. Hx of tinnitus
01/18/13
VU,PETER D
17. Irritable Bowel Syndrome

PHYSICAL EXAM:
GENERAL: ambulatory, awake, alert, oriented x3,nad, pleasant,obese
young man.
HEENT: PERRLA. Clear oropharynx and tympanic membrane. no sinus
tenderness.
no cervical adenopathy.
NECK: No bruits or stiffness. Good ROM w/o difficulty but mild
discomfort on
rotation and moderate trapezius muscle stiffness on palpation.
CHEST: Chest normal shape and symmetrical.No masses,tenderness or
other
abnormalities
LUNGS: Clear, no crackles, wheezing, or rhonchi.
HEART: RSR, no murmurs, no gallop
ABDOMEN: obese. Soft, non tender, positive bowel sounds, liver and
spleen are
not palpable. No rebound tenderness to palpation.
BACK: No cva tenderness or point tenderness.slr negative.
EXTREMITIES: No edema. Good ROM w/o pain or difficulty. Good muscle
strength
and tone plus well developed muscle. nl sensation and good radial
pulse and capillary refill.
NEUROLOGICAL: Cranial nerve intact, no focal deficit, ambulatory w/o
difficulty.

ASSESSMENT:
- Hx of chronic neck strain: discussed and full explaination about
his
condition
and booklet about neck given w/ instruction for home exercise.
increase flexeril
to 10mg qhs prn w/advise of side effects and continue heating pad
alternate
w/icepack. pt already was tx by PT, chiropractor and pain school in
past. pt
said he does not want to be on pain medication. pt had xray of neck
in
past was
negative.
-hx of IBS: Discussed and tx w/ bentyl 10mg bid and metamucil and
f/u GI as
directed.
-hx GERD: on prilosec
-hx Depression/anxiety: stable and denies any SI or HI. f/u w/ MHC as
directed.
-hx of OSA:stable on C-pap

b. Is continuous medication required for control of fibromyalgia symptoms?
[ ] Yes [X] No

c. Is the Veteran currently undergoing treatment for this condition?
[ ] Yes [X] No

d. Are the Veteran's fibromyalgia symptoms refractory to therapy?
[X] Yes [ ] No

3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to fibromyalgia?
[X] Yes [ ] No

a. Findings, signs and symptoms (check all that apply):

[X] Widespread musculoskeletal pain
[X] Fatigue
[X] Sleep disturbances
[X] Headache
[X] Depression
[X] Irritable bowel symptoms

For all checked conditions, describe:
Musculoskeletal symtpoms: 1) constant sensation of 'muscle
fatigue/sore'on both anterior thighs, skin feels sore over the medial
portion of both thighs, localized sensitivity(soreness) over the
specific medial portion of both arms, bilateral scapular muscles and
back of his neck.
2) Feels tired even if he has not done anything but can still do his
routines both at home and at work.
3) He feels no motivation, problems with concentration, crying for no
reasons, feels anxiety and hx/o bouts of panic attack and chest pain
while in the active service. Diagnosed with Depression while in the
active service and was not placed on medication because he wants to
continue working with Nuclear Program. Taking a anti-depressants will
disqualify him from that program. He was evaluated by a psychologist.
He was receiving regular psychological therapy while in the active
service.
He is currently seen by psychologist here at Martinsburg VA and
received Cognitive Therapy and currently on the HOPE Program (Group
Therapy). No medications for depression given to date.
4) Hx/o IBS and is service connected for IBS. Takes Dicyclomine BID.
He
said his current meds seem to help him.


b. Frequency of fibromyalgia symptoms (check all that apply):

[X] Constant or nearly constant

c. Does the Veteran have tender points (trigger points) for pain present?
[ ] Yes [X] No

4. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms

-----------------------------------------------------------------------------
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis section above?
[ ] Yes [X] No

5. Diagnostic testing
---------------------
Are there any significant diagnostic test findings and/or results?
[ ] Yes [X] No

6. Functional impact
---------------------
Does the Veteran's fibromyalgia impact his or her ability to work?
[ ] Yes [X] No

7. Remarks, if any:
-------------------
He now works both patroling
and now in the office. He has so far able to carry on his duties as a
security officer.
Physical examination today revealed: (-) direct tenderness on palpation
over the occipital, supraspinatus, sternal, knees.
He points to overall sensation of soreness on his neck area, and
localized sensitivity on the bilateral thigh muscles and linear medial
thigh bilaterally and medial areas on both arms. Strength 5/5 all
throughout. Sensory are all WNL both upper and lower extremeties.

This is the second opinion given by the same doc

Medical Opinion
Disability Benefits Questionnaire

Name of patient/Veteran: WVSERVER

Indicate method used to obtain medical information to complete this
document:

[X] 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
[ ] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed? Yes

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
vbms efile/VAMC

MEDICAL OPINION SUMMARY
-----------------------
UPDATE Information for Clinical Diagnosis of Fibromyalgia:
Hints for early and cost-effective diagnosis of fibromyalgia

Chronic widespread musculoskeletal pain for =three months

Absence of other systemic condition accounting for pain

Excess tenderness in soft-tissues

Characteristic symptoms:

? "I hurt all over"

? "It feels like I always have the flu"

? Fatigue, sleep and mood disturbances

? IBS, irritable bladder, multiple other somatic complaints

Exclusion of structural or systemic disease

? Not a "fishing" expedition

? Avoid "screening" rheumatology tests

? Most efficient with early subspecialty referral
Recommended diagnostic workup for fibromyalgia

Establishing the diagnosis is an essential component of FM management.
Diagnostic criteria for FM include the ACR and the Canadian Consensus
Guidelines. A complete history, physical exam, and laboratory testing should
be done to exclude diseases that may mimic or complicate FM. Each patient
should be assessed for a =three-month history of chronic widespread pain;
patient self-report should be used as an index of pain. The presence of
tender points should be confirmed. However, tenderness is subjective and
depends upon the examiner's strength of palpation.

FM: fibromyalgia; ACR: American College of Rheumatology.

Data from: Goldenberg, DL, Burckhardt, C, Crofford, L. Management of
fibromyalgia syndrome. JAMA 2004; 292:2388.

Graphic 56396 Version 4.0
Mr. Booth have several of the subjective symptoms compatible with
Fibromyalgia as well as the other co-existing conditions which can exist
with
its diagnosis.
Review the STRS: He has been diagnosed with Non-specific Myalgias and
Myositis-active service. An opinion was made one time by his superior that
he has symptoms consistent with fibromyalgia and was given Elavil. It was
primarily indicated for it and not for depression and to be able to work
with
RPR (Nuclear facility).
Reviewed all his outpatient clinic follow-ups by his primary care provider
here at VAMC Martinsburg since 2012 and there has been no specific diagnosis
of Fibromyalgia. He was diagnosed with Chronic Neck pains, Headaches,
Depression on Rx.and He has been referred to Chiropractic Tx. multiple times
and has been DX as Somatic Dysfunction on the cervical and thoracic spines.
My physical examination during the C&P evaluation fall short of the
physical criteria of specific number of trigger points to diagnose
Fibromyalgia. His main sore spots has been primarily on his neck and
thoracic
areas, supraspinatus, soreness on both thighs.
He has not been referred by any of his primary care providers here at
Martinsbsurg to see a Rheumatologist to rule out any other inflammatory
musculoskeletal conditions. Reviewed earlier serological testings while in
the active service has been non-diagnostic.
At this point one can at least assume, that his documented symptoms noted
while in the active service are similar to his current symptoms. It is at
least as likely as not (50% probability) that his current multi-symptoms is
consistent with fibromylagia. He has not been referred to a Rheumatologist
who can evaluate him and confirm this diagnosis and have ruled out any other
rheumatological conditions. He is currently not treated for fibromylagia.
Comments on the functional loss/impairment questions: He has constant
soreness on his neck, trapezius muscle areas all the time however, he is
able
to accomplish all the ROM. I stand corrected that I should have noted pain
on
movement.

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: Clarification on the physical examination
done C&P evaluation on 9/2014: See 2507 request:

b. Indicate type of exam for which opinion has been requested: ACE-
Fibromylagia

*************************************************************************

The bottom line is you need a current diagnosis. Not trying to be insensitive to your situation but when you feel any of the symptoms of fibromyalgia, you need to see a doctor. You may also want to get your PCP to refer you to a rhuematologist.

[WVSERVER]

thanks for the reply I am in the process of getting a referral, I am also thinking of switching doc as I as secured messaged him many times about fibro then when I see him its a fight to get him to write anything down. The other thing I forgot to add is I forgot about the current diagnose part. This was the first time I have had a C&P doc bring that up my Active service diagnosis have always been good enough for service connection. I know I need to see the Doctor more but it comes to a point were my clinic start getting rude when I am there every week. I pretty much feel like I have the flu every day, and I feel way worse when I exert myself. It all I can do to work my one 8hr day and four 6hr days a week.

Edited April 21, 2015 by WVSERVER