Possible Positive At C&p

brokensoldier244th · May 21, 2015

So, im hoping that when the mental examiner for a mental C&P asks me near the end if I have already filed for SSDI or not, that is a positive?

Navy04 · May 21, 2015

Sounds like the exam went well bud, good luck and keep us posted

Navy4life · May 21, 2015

That sounds good...I think you are on your way to a favorable decision!

brokensoldier244th · May 22, 2015

I hope so. Im waiting for My Health Vet to update so I can see if they writeup for physical and mental are there.

CAS

brokensoldier244th · May 22, 2015

Here are the notes from my physical GM exam for IU. I had a mental one as well, which was my primary reason for filing for IU so Im not as worried about this one. Thoughts, though?

Male Reproductive System Conditions

Disability Benefits Questionnaire

Name of patient/Veteran: Satterfield, Cedric

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 (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:

none

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

[ ] 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

[ ] Other:

1. Diagnosis

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

Does the Veteran now have or has he ever been diagnosed with any conditions

of the male reproductive system?

[X] Yes [ ] No

[X] Erectile dysfunction

ICD code: . Date of diagnosis: many years

2. Medical history

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

a. Describe the history (including onset and course) of the Veteran's male

reproductive organ condition(s) (brief summary):

The veteran states that his ED has progressed to the point that he is

unable to have full penetration and ejaculation. He tried medication

in

the past ("I think Cialis") and it was ineffective. He states that

this

impacts his quality of life and his relationship with his wife.

b. Does the Veteran's treatment plan include taking continuous medication

for

the diagnosed condition?

[ ] Yes [X] No

c. Has the Veteran had an orchiectomy?

[ ] Yes [X] No

d. Is there any renal dysfunction due to condition?

[ ] Yes [X] No

3. Voiding dysfunction

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

Does the Veteran have a voiding dysfunction?

[ ] Yes [X] No

4. Erectile dysfunction

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

Does the Veteran have erectile dysfunction?

[X] Yes [ ] No

If yes, complete the following section:

a. Etiology of erectile dysfunction:

erectile dysfunction

b. If the Veteran has erectile dysfunction, is it as likely as not (at least

a 50% probability) attributable to one of the diagnoses in Section 1,

including residuals of treatment for this diagnosis?

[X] Yes [ ] No

If yes, specify the diagnosis to which the erectile dysfunction is as

likely as not attributable:

erectile dysfunction

c. If the Veteran has erectile dysfunction, is he able to achieve an

erection

sufficient for penetration and ejaculation without medication?

[ ] Yes [X] No

If no, has the Veteran used medications for treatment of his erectile

dysfunction?

[X] Yes [ ] No

If yes, is the Veteran able to achieve an erection sufficient for

penetration and ejaculation with medication?

[ ] Yes [X] No

5. Retrograde ejaculation

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

Does the Veteran have retrograde ejaculation?

[ ] Yes [X] No

6. Male reproductive organ infections

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

Does the Veteran have a history of chronic epididymitis, epididymo-orchitis

or prostatitis?

[ ] Yes [X] No

7. Physical exam

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

a. Penis

[ ] Normal

[ ] Not examined per Veteran's request

[ ] Not examined per Veteran's request; Veteran reports normal anatomy

with no penile deformity or abnormality

[X] Not examined; penis exam not relevant to condition

[ ] Abnormal

b. Testes

[ ] Normal

[ ] Not examined per Veteran's request

[ ] Not examined per Veteran's request; Veteran reports normal anatomy

with no testicular deformity or abnormality

[X] Not examined; testicular exam not relevant to condition

[ ] Abnormal

c. Epididymis

[ ] Normal

[ ] Not examined per Veteran's request

[ ] Not examined per Veteran's request; Veteran reports normal anatomy of

epididymis with no deformity or abnormality

[X] Not examined; epididymis exam not relevant to condition

[ ] Abnormal

d. Prostate

[ ] Normal

[ ] Not examined per Veteran's request

[X] Not examined; prostate exam not relevant to condition

[ ] Abnormal

8. Tumors and neoplasms

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

Does the Veteran have a benign or malignant neoplasm or metastases related

to

any of the diagnoses in the Diagnosis section?

[ ] Yes [X] No

9. 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 or symptoms?

[ ] Yes [X] No

10. Diagnostic testing

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

a. Has a testicular biopsy been performed?

[ ] Yes [X] No

b. Have any other imaging studies, diagnostic procedures or laboratory

testing been performed and are the results available?

[ ] Yes [X] No

11. Functional impact

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

Does the Veteran's male reproductive system condition(s), including

neoplasms, if any, impact his ability to work?

[ ] Yes [X] No

12. Remarks, if any:

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

This condition does not impact the veteran's ability to function in an

occupational environment.

Veteran already SC for this condition and GU exam well documented in VA

records (see 8/29/13 Urology clinic note for exam documenting normal GU

exam) so this exam was not repeated today.

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

Back (Thoracolumbar Spine) Conditions

Disability Benefits Questionnaire

Name of patient/Veteran: Satterfield, Cedric

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 (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:

none

1. Diagnosis

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

Does the Veteran now have or has he/she ever been diagnosed with a

thoracolumbar spine (back) condition?

[X] Yes [ ] No

Thoracolumbar Common Diagnoses:

No response provided.

Diagnosis #1: intervertebral disc syndrome lumbar spine; bilateral

lower

extremity radiculopathy

ICD code: .

Date of diagnosis: many years

2. Medical history

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

a. Describe the history (including onset and course) of the Veteran's

thoracolumbar spine (back) condition (brief summary):

The veteran's low back and bilateral radicular symptoms have gradually

worsened over the years. He states that for the last 3 months or so he's

been on FMLA leave due to a combination of back pain and mental health

issues. He normally works as a computer technical support engineer. His

back and bilateral radicular leg pain are now constant and flare up

frequently. He reports missing work on average at least once a week due

to

this condition. "I work on a computer and can remote from home" but

this

is not always practical. He takes continuous medication (Diclofenac and

Gabapentin) for these symptoms. His back and leg pain contributes to

poor

sleep at night and he sometimes sleeps in a chair.

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?

[X] Yes [ ] No

If yes, document the Veteran's description of the flare-ups in his or

her

own words:

"About a day a week" on average.

c. Does the Veteran report having any functional loss or functional

impairment of the thoracolumbar spine (back) (regardless of repetitive use)?

[X] Yes [ ] No

If yes, document the Veteran's description of functional loss or

functional impairment in his or her own words.

"I can't travel for work anymore" and "because of that I can't get

promoted"

"My wife has to drive me" if going long distances because "I have to

stop all the time to change positions" due to pain.

"I can't go to client sites"

"I've caught my toe and tripped on a step in my home" because "my

feet

are numb".

"I don't clean stuff around the house" and "I have to get my kids to

help"

"I have to be able to get up and changes positions"

3. Range of motion (ROM) and functional limitation

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

a. Initial range of motion

[ ] All normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Forward Flexion (0 to 90): 0 to 50 degrees

Extension (0 to 30): 0 to 20 degrees

Right Lateral Flexion (0 to 30): 0 to 10 degrees

Left Lateral Flexion (0 to 30): 0 to 15 degrees

Right Lateral Rotation (0 to 30): 0 to 20 degrees

Left Lateral Rotation (0 to 30): 0 to 25 degrees

If abnormal, does the range of motion itself contribute to a

functional loss? [X] Yes (please explain) [ ] No

If yes, please explain:

loss of full ROM

Description of pain (select best response):

Pain noted on exam and causes functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Forward Flexion, Extension, Right Lateral Flexion, Left Lateral

Flexion, Right Lateral Rotation, Left Lateral Rotation

Is there evidence of pain with weight bearing? [X] Yes [ ] No

Is there objective evidence of localized tenderness or pain on palpation

of the joints or associated soft tissue of the thoracolumbar spine

(back)?

[ ] Yes [X] No

b. Observed repetitive use

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three

repetitions? [ ] Yes [X] No

c. Repeated use over time

Is the Veteran being examined immediately after repetitive use over time?

[ ] Yes [X] No

If the examination is not being conducted immediately after

repetitive

use over time:

[ ] The examination is medically consistent with the Veteran's

statements describing functional loss with repetitive use over

time.

[ ] The examination is medically inconsistent with the Veteran's

statements describing functional loss with repetitive use over

time. Please explain.

[X] The examination is neither medically consistent or inconsistent

with the Veteran's statements describing functional loss with

repetitive use over time.

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

I am unable to opine whether pain, weakness, fatigability, or

incoordination could significantly limit functional ability during

flare-ups, or when the joint is used repeatedly over a period of

time.

I am unable to provide this information in terms of degrees of ROM

loss due to "pain on use or during flare-ups." The veteran was not

experiencing a flare up at the time of examination therefore I am

unable to render an opinion regarding functional ability during a

flare-up.

d. Flare-ups

Is the exam being conducted during a flare-up? [ ] Yes [X] No

If the examination is not being conducted during a flare-up:

[ ] The examination is medically consistent with the Veteran's

statements describing functional loss during flare-ups.

[ ] The examination is medically inconsistent with the Veteran's

statements describing functional loss during flare-ups. Please

explain.

[X] The examination is neither medically consistent or inconsistent

with the Veteran's statements describing functional loss during

flare-ups.

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with flare-ups?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

I am unable to opine whether pain, weakness, fatigability, or

incoordination could significantly limit functional ability during

flare-ups, or when the joint is used repeatedly over a period of

time.

I am unable to provide this information in terms of degrees of ROM

loss due to "pain on use or during flare-ups." The veteran was not

experiencing a flare up at the time of examination therefore I am

unable to render an opinion regarding functional ability during a

flare-up.

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine

(back)? [ ] Yes [X] No

f. Additional factors contributing to disability

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe: None

4. Muscle strength testing

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

a. Rate strength according to the following scale:

0/5 No muscle movement

1/5 Palpable or visible muscle contraction, but no joint movement

2/5 Active movement with gravity eliminated

3/5 Active movement against gravity

4/5 Active movement against some resistance

5/5 Normal strength

Hip flexion: