Jump to content


  • veteranscrisisline-badge-chat-1.gif

  • Fund HadIt.com

    168%
    $2,528.00 of $1,500.00 Donate Now
  • Advertisemnt

  • 14 Questions about VA Disability Compensation Benefits Claims

    questions-001@3x.png

    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
    Continue Reading
     
  • Most Common VA Disabilities Claimed for Compensation:   

    tinnitus-005.pngptsd-005.pnglumbosacral-005.pngscars-005.pnglimitation-flexion-knee-005.pngdiabetes-005.pnglimitation-motion-ankle-005.pngparalysis-005.pngdegenerative-arthitis-spine-005.pngtbi-traumatic-brain-injury-005.png

  • Advertisemnt

  • VA Watchdog

  • Advertisemnt

  • Ads

  • Can a 100 percent Disabled Veteran Work and Earn an Income?

    employment 2.jpeg

    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

  • 0

I wanted to frag the examiner but maybe a medal is due


Question

I just had a C&P for a number of issues related to IHD and am amazed at the ways they find to reject claims.

I will discuss those in another post and bring up the most important one in this post.

A brain injury secondary to IHD. Bypass surgery caused an injury possibly through a stroke that really affected my life. Learning about and then trying to connect it to IHD has been the problem.

Most likely than not is the term he used and I hope it helps my TDIU claim

I'm attaching the results.

 

 

***Note: Your health care team may not have all of the information from

your Personal Health Record unless you share it with them. Contact your

health care team if you have questions about your health information.***

 

Key:  Double dashes (--) mean there is no information to display.

 

 

Name:              Date of Birth: 24 Oct 1947

 

------------------------ DOWNLOAD REQUEST SUMMARY -----------------------

 

System Request Date/Time:  01 Mar 2016 @ 1730

File Name:                 mhv__20160301_1730.txt

 

Date Range Selected:       17 Feb 2015 to 17 Feb 2016

Data Types Selected:

  My HealtheVet Account Summary

  VA Notes

 

--------------------- MY HEALTHEVET ACCOUNT SUMMARY ---------------------

 

Source: VA

 

Authentication Status:         Authenticated

Authentication Date:           06 Oct 2010

Authentication Facility ID:    546

Authentication Facility Name:  Miami FL VAMC

 

   VA Treating Facility                     Type

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

   Miami FL VAMC                            na

   Great Lakes Healthcare System            na

   VBA BRLS                                 na

   VBA CORP                                 na

   ENROLLMENT SYSTEM REENGINEERING          na

   DEPARTMENT OF DEFENSE DEERS              na

   AUSTIN MHV                               na

   ST. LOUIS MO VAMC-JC DIVISION            na

 

------------------------------- VA NOTES --------------------------------

 

Source: VA

Last Updated: 01 Mar 2016 @ 1648

 

Sorted By: Date/Time (Descending)

 

VA Notes from January 1, 2013 forward are available 3 calendar days after 

they have been completed and signed by all required members of your VA 

health care team. If you have any questions about your information please 

visit the FAQs or contact your VA health care team. 

 

=========================================================================

Date/Time:               17 Feb 2016 @ 1000

Note Title:              C&P EXAM

Location:                Miami FL VAMC

Signed By:               PEREZ-RIVAS,JOSE F

Co-signed By:            PEREZ-RIVAS,JOSE F

Date/Time Signed:        17 Feb 2016 @ 1611

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

 

 LOCAL TITLE: C&P EXAM                                           

STANDARD TITLE: C & P EXAMINATION NOTE                          

DATE OF NOTE: FEB 17, 2016@10:00     ENTRY DATE: FEB 17, 2016@16:11:47      

      AUTHOR: PEREZ-RIVAS,JOSE F   EXP COSIGNER:                           

     URGENCY:                            STATUS: COMPLETED                     

 

 

                                 Medical Opinion

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   

    

    Indicate method used to obtain medical information to complete this 

document:

    

    [ ] Review of available records (without in-person or video telehealth

        examination) using the Acceptable Clinical Evidence (ACE) process 

because

        the existing medical evidence provided sufficient information on which 

to

        prepare the DBQ and such an examination will likely provide no 

additional

        relevant evidence.

    [ ] Review of available records in conjunction with a telephone interview

        with the Veteran (without in-person or telehealth examination) using the

        ACE process because the existing medical evidence supplemented with a

        telephone interview provided sufficient information on which to prepare

        the DBQ and such an examination would likely provide no additional

        relevant evidence.

    [ ] Examination via approved video telehealth

    [X] In-person examination

    

    Evidence review

    ---------------

    Was the Veteran's VA claims file reviewed? No

    

      If no, check all records reviewed:

      

        [X] Veterans Health Administration medical records (VA treatment 

records)

        [X] Civilian medical records

        [X] Other:

              VBMS, VIRTUAL VA

              

 

    MEDICAL OPINION SUMMARY

    -----------------------

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Direct service connection

 

    Does the Veteran have a diagnosis of (a) ISCHEMIC HEART DISEASE that is at 

    least as likely as not (50 percent or greater probability) incurred in or 

    caused by (the) due to Agent Orange exposure in Vietnam during service?

 

 

    b. Indicate type of exam for which opinion has been requested: ISCHEMIC 

HEART

    DISEASE

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

    CONNECTION ] 

 

    a. The condition claimed was at least as likely as not (50% or greater

    probability) incurred in or caused by the claimed in-service injury, event 

or

    illness.   

 

    c. Rationale: Veteran did service militarily in Vietnam, where he was

    probably exposed to Agent Orange. On 2/05/2006 was admitted with an acute MI

    to a local hospital leading to a Quadruple CABG on 2/08/2006. Therefore he

    has a diagnosis of (a) ISCHEMIC HEART DISEASE that is at least as likely as

    not (50 percent or greater probability) incurred in or caused by (the) due 

to

    Agent Orange exposure in Vietnam during service.

 

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

 

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Secondary Service Connection.

 

    Is the Veteran's EDEMA at least as likely as not (50 percent or greater

    probability) proximately due to or the result of ISCHEMIC HEART DISEASE?

 

 

 

 

    b. Indicate type of exam for which opinion has been requested: EDEMA

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE

    CONNECTION ]

 

    b. The condition claimed is less likely than not (less than 50%

    probability) proximately due to or the result of the Veteran's service

    connected condition.   

 

    c. Rationale: Veteran's bilateral leg edema is clinically due to a

    combination of venous/lymphatic insufficiency of both lower extremities plus

    the continuous use of moderate doses of the antihypertensive Nifedipine,

    which is a drug that causes leg edema in a significantly large number of

    patients. The bilateral leg edema is definitely not due to (decompensated)

    IHD as Veteran is definitely not in heart failure.

 

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

 

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Secondary Service Connection.

 

    Is the Veteran's HYPERTENSION SECONDARY TO IHD at least as likely as not (50 

 

    percent or greater probability) proximately due to or the result of ISCHEMIC 

 

    HEART DISEASE?

 

 

    b. Indicate type of exam for which opinion has been requested: HYPERTENSION

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE

    CONNECTION ]

 

    b. The condition claimed is less likely than not (less than 50%

    probability) proximately due to or the result of the Veteran's service

    connected condition.   

 

    c. Rationale: Hypertension in this Veteran preceded the development of IHD

    for years. Therefore, Hypertension is not secondary to IHD.

 

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

 

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Secondary Service Connection.

 

    Is the Veteran's SCARRING SECONDARY TO IHD at least as likely as not (50 

    percent or greater probability) proximately due to or the result of ISCHEMIC 

 

    HEART DISEASE?

 

 

    b. Indicate type of exam for which opinion has been requested: SCARRING 

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE

    CONNECTION ]

 

    a. The condition claimed is at least as likely as not (50% or greater

    probability) proximately due to or the result of the Veteran's service

    connected condition.     

 

    c. Rationale: The residual scars in the midsternum and in the left leg are

    the results of the open heart surgery and of the veins obtained to do the

    venous-arterial grafts respectively. Such procedures were required in view 

of

    Veteran's critical Ischemic Heart Disease. Hence, technically, the scars are

    proximately the result of Veteran's Ischemic Heart Disease.

 

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

 

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Secondary Service Connection.

 

    Is the Veteran's E. D. SECONDARY TO IHD at least as likely as not (50 

    percent or greater probability) proximately due to or the result of ISCHEMIC 

 

    HEART DISEASE?

 

 

    b. Indicate type of exam for which opinion has been requested: E.D.

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE

    CONNECTION ]

 

    a. The condition claimed is at least as likely as not (50% or greater

    probability) proximately due to or the result of the Veteran's service

    connected condition.     

 

    c. Rationale: Erectile Dysfunction is often a disease of vascular origin. 

The

    penile endothelial bed is considered a specialized extension of the

    peripheral vascular system, responding similarly to various stimuli in order

    to maintain homeostasis, playing a particular regulatory role in the

    modulation of vascular smooth muscle (VSM) tone which is crucial for normal

    erectile function. The small diameter of the cavernosal penile arteries plus

    the high content of endothelium and VSM may make the penile vascular bed a

    sensitive indicator of systemic vascular disease. Thus, the penis is a

    vascular organ that is sensitive to changes in oxidative stress and systemic

    Nitrogen Oxide (NO) levels. It is also sensitive to local modifications in

    the vasculature, making the penis an organ supposed to precede vascular

    systemic alterations. Therefore, ED has a higher incidence in patients with

    Ischemic Heart Disease, a disease which it often precedes but

 at times also

    follows. Therefore, Veteran's E. D. is at least as likely as not (50 percent

    or greater probability) proximately due to or the result of ISCHEMIC HEART

    DISEASE as a reflection of the affliction of the arteries by 

atherosclerosis.

 

    Besides, ED is also considered to frequently occur in Hypogonadism, but the

    evidence of this latter was obviated years later (IHD in 2003 vs 

Hypogonadism

    in 2010). Nevertheless, Hypogonadism has also contributed to the ED after 

the

    initial onset of this latter due predominantly to atherosclerosis.

 

 

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

 

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Secondary Service Connection.

 

    Is the Veteran's BRAIN INJURY SECONDARY TO IHD at least as likely as not (50 

 

    percent or greater probability) proximately due to or the result of ISCHEMIC 

 

    HEART DISEASE?

 

 

    b. Indicate type of exam for which opinion has been requested: BRAIN INJURY

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE

    CONNECTION ]

 

    a. The condition claimed is at least as likely as not (50% or greater

    probability) proximately due to or the result of the Veteran's service

    connected condition.     

 

    c. Rationale: From the Neurologic standpoint, Veteran's intellectual and

    motor function was fundamentally normal and completely preserved before the

    CABG. Shortly after being discharged post-CABG, he started to experience

    significant intellectual changes. Eventual Neuropsychological Testing showed

    apparent "deficits in verbal memory retrieval, ideational fluency,

    visuocontruction, and graphomotor skills" w/ mild cerebral impairment noted,

    which was non-specific. However, he never had any motor impairment other 

than

    very mild unstable gait with imbalance on physical activities and occasional

    lightheadedness, symptoms that had their onset some time after the initial

    intellectual ones. It is well known that one of the complications of Open

    Heart Surgery during the extracorporeal circulation pump, is the occurrence

    of strokes, either embolic or due to central (brain) circulatory 

obstruction.

 

    Taking into consideration the timing of the events, it is most likely than

    not that this Veteran's left occipital brain infarction was technically

    proximately due to IHD as a result of the CABG that was required to improve

    his coronary artery circulation. 

 

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

 

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Secondary Service Connection.

 

    Is the Veteran's GERD SECONDARY TO IHD at least as likely as not (50 percent 

 

    or greater probability) proximately due to or the result of ISCHEMIC HEART 

    DISEASE?

 

 

    b. Indicate type of exam for which opinion has been requested: GERD

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE

    CONNECTION ]

 

    b. The condition claimed is less likely than not (less than 50%

    probability) proximately due to or the result of the Veteran's service

    connected condition.   

 

    c. Rationale: Some people might theorize that GERD might be secondary to IHD

    citing published articles that have not undergone critical appraisal as part

    of the evidence-based medicine. Regarding GERD, there is no peer-reviewed

    evidence in the scientific medical literature that it could be due, either

    directly or secondarily, to IHD.

 

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

 

    RESTATEMENT OF REQUESTED OPINION: 

 

    a. Opinion from general remarks: Secondary Service Connection.

 

    Is the Veteran's SLEEP APNEA SECONDARY TO IHD at least as likely as not (50 

    percent or greater probability) proximately due to or the result of ISCHEMIC 

 

    HEART DISEASE?

 

 

 

    b. Indicate type of exam for which opinion has been requested: SLEEP APNEA

 

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE

    CONNECTION ]

 

    b. The condition claimed is less likely than not (less than 50%

    probability) proximately due to or the result of the Veteran's service

    connected condition.   

 

    c. Rationale: Some people might theorize that SLEEP APNEA might be secondary

    to IHD citing published articles that have not undergone critical appraisal

    as part of the evidence-based medicine.

    The arguable proposition that lack of physical activity due to IHD might 

make

    the patients gain weight and, thus, precipitate or aggravate the Sleep Apnea

    has been presented, but this theoretical argument lacks firm substrate. Such

    argument would try to push onto trying to establish a connection or to force

    a theoretical justification to make the IHD in some way be related to the

    Sleep Apnea.  

 

    The current peer-reviewed medical literature overview of sleep apnea states

    that the most important risk factors for obstructive sleep apnea (OSA) are

    advancing age, male gender, obesity, and craniofacial or upper airway soft

    tissue abnormalities. 

     

    Regarding SLEEP APNEA, there is no scientific evidence in the medical

    litearature that it could be due, either directly or secondarily, to IHD.

     

 

 

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

 

 

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

 

 

                                  Hypertension

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   

    

    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 

Examination

    Request?

    [X] Yes   [ ] No

    

 

    ACE and Evidence Review

    -----------------------

    Indicate method used to obtain medical information to complete this 

document:

    

    [X] In-person examination

    

 

    Evidence Review

    ---------------

    Evidence reviewed (check all that apply):

    

    [X] VA e-folder (VBMS or Virtual VA)

    [X] CPRS

 

 

    1. Diagnosis

    ------------

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

hypertension

    or isolated systolic hypertension based on the following criteria:

    [X] Yes   [ ] No

    

        [X] Hypertension

              ICD code: 38341003             Date of diagnosis: 1995

              

    2. Medical history

    ------------------

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

       hypertension condition (brief summary):

          68 y/o male Veteran with Hx of Hypertension requesting secondary

          service connection due to Ischemic Heart Disease.

           

          Veteran has had History of Hypertension since at least the mid 90's

          according to him and was being medically treated while living in

          Chicago with oral antihypertensive therapy. Over the years he required

          adjustments of his oral antihypertensive therapy. His BP still

          fluctuates.

 

          No actual Hx to suggest classical angina, syncope, LV Failure, TIA or

          palpitations.

          

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

for

       hypertension or isolated systolic hypertension?

       [X] Yes   [ ] No

       

       If yes, list only those medications used for the diagnosed conditions:

          Carvedilol, Nifedipine, Hydralazine

          

    c. Was the Veteran's initial diagnosis of hypertension or isolated systolic

       hypertension confirmed by blood pressure (BP) readings taken 2 or more

       times on at least 3 different days?

       [ ] Yes   [ ] No   [X] Unknown

       

 

 

 

    d. Does the Veteran have a history of a diastolic BP elevation to

       predominantly 100 or more?

       [ ] Yes   [X] No

       

    3. Current blood pressure readings

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

                                Systolic Diastolic

       Blood pressure reading 1:  148  / 70     Date: 2/17/2016

       Blood pressure reading 2:  145  / 70     Date: 2/17/2016

       Blood pressure reading 3:  145  / 70     Date: 2/17/2016

 

       Average Blood Pressure Reading: 146 / 70

       

    4. Other pertinent physical findings, complications, conditions, signs,

       symptoms and scars

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

    a. Does the Veteran have any other pertinent physical findings,

       complications, conditions, signs or symptoms related to the conditions

       listed in the Diagnosis Section above?

       [ ] Yes   [X] No

       

    b. 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

       

    c. Comments, if any:

       No response provided

       

    5. Functional impact

    --------------------

    Does the Veteran's hypertension or isolated systolic hypertension impact his

    or her ability to work?

    [ ] Yes   [X] No

    

 

    6. Remarks, if any

    ------------------

       VETERAN'S HYPERTENSION CONDITION WOULD BE EXPECTED TO LIMIT HIS

       OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING,

       SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING,

       PULLING. HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN

       EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE

       PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS-- see

       under CNS--) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF REST AND

       POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY 2 HOURS. HE DOES HAVE

       REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO

       MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL

       INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO THE 

ABOVE

       MENTIONED RECOVERY PERIODS.

       

 

 

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

 

 

           Heart Conditions:  (Including Ischemic & Non-ischemic Heart

           Disease, Arrhythmias, Valvular Disease and Cardiac Surgery)

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   

    

    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 

Examination

    Request?

    [X] Yes  [ ] No

    

 

    ACE and Evidence Review

    -----------------------

    Indicate method used to obtain medical information to complete this 

document:

    

    [X] In-person examination

    

 

    Evidence Review

    ---------------

    Evidence reviewed (check all that apply):

    

    [X] VA e-folder (VBMS or Virtual VA)

    [X] CPRS

 

 

    1. Diagnosis

    ------------

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

    condition?

    [X] Yes   [ ] No

    

       [X] Acute, subacute, or old myocardial infarction

                ICD code: 1755008 Date of diagnosis: 2/05/2006

 

       [X] Coronary artery disease

                ICD code: 233817007Date of diagnosis: 2003

 

       [X] Coronary Artery Bypass Graft

                ICD code: 399261000Date of diagnosis: 2/08/2006

 

    2. Medical History

    ------------------

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

       condition(s) (brief summary):

         68 y/o male, a non diabetic with Hx of previous cigarette smoking of 1

         1/2 PPD (QUIT 2/05/2006), Hx of Hypertension and Dyslipidemia. He is a

         Vietnam Veteran with Hx of Ischemic Heart Disease, S/P Quadruple CABG 

on

         2/08/2006 who is asking for direct service connection in account of

         Agent Orange exposure while in Vietnam.

 

         He moved from Chicago to Florida in 1998 and requested medical service

         in the VA where he was initially seen on March 10/2001. At that time a

         Hx of chest pain was elicited as having had its onset three years 

prior,

         reason for which Veteran had already had a Stress Test in Chicago and 

it

         did not show ischemia. In 2003 his chest pain kept recurring and he was

         submitted to a Nuclear Stress Test at the Miami VA on 11/20/2003 and it

         demonstrated moderate ischemia of the distal anterior wall. He was

         advised a Cardiac Cath but he declined and he claims that he never had

         it done until his episode of severe chest pain on February 5, 2006 when

         he was admitted to North Ridge Hospital with a diagnosis of an acute

         subendocardial infarction, leading to a diagnostic cardiac cath and 

then

         followed by the Quadruple CABG on 2/08/2006. 

 

         He claims that after his CABG in 2006 he has not had any kind of chest

         pain. However, he has had exertional tiredness, exertional dyspnea and

         leg edema, reason for which he has been submitted to additional

         cardiovascular diagnostic studies, including  Nuclear Stress Tests in

         2014 and 2015 and both times the Stress Tests have been negative for

         ischemia. 

 

         Goes to the Gym three times a week and walks slow on the treadmill for

         about 5 minutes and lifts some weight. Gets dyspnea to more than

         mild-to-moderate exertion although his physical activities are limited

         in account of getting tired and developing headaches. He develops

         shortness  of breath after walking short distances, doing light yard

         work or washing the car and frequently needs to sit down to rest.

         However, he does not have an actual Hx to suggest classical angina,

         syncope, LV Failure, TIA or palpitations. Uses pressure stockings for

         his leg edema. 

         

         

    b. Do any of the Veteran's heart conditions qualify within the generally

       accepted medical definition of ischemic heart disease (IHD)?

       [X] Yes   [ ] No

       

            If yes, list the conditions that qualify:

              Severe Coronary artery obstruction

              

              

    c. Provide the etiology, if known, of each of the Veteran's heart 

conditions,

       including the relationship/causality to other heart conditions,

       particularly the relationship/causality to the Veteran's IHD conditions,

       if any:

       

          Heart condition #1:  Provide etiology

            ATEHROSCLEROSIS OF THE CORONARY ARTERIES

            

            

    d. Is continuous medication required for control of the Veteran's heart

       condition?

       [X] Yes   [ ] No

       

          If yes, list medications required for the Veteran's heart condition

          (include name of medication and heart condition it is used for, such 

as

          atenolol for myocardial infarction or atrial fibrillation):

            Baby Aspirin, Carvedilol, Nifedipine, Hydralazine, Atorvastatin

            

            

    3. Myocardial infarction (MI)

    -----------------------------

    Has the Veteran had a myocardial infarction (MI)?

    [ ] Yes   [X] No

    

    4. Congestive Heart Failure (CHF)

    ---------------------------------

    Has the Veteran had congestive heart failure (CHF)?

    [ ] Yes   [X] No

    

    5. Arrhythmia

    -------------

    Has the Veteran had a cardiac arrhythmia?

    [X] Yes   [ ] No

    

       Type of arrhythmia (check all that apply):

       [X] Other cardiac arrhythmia, specify:  Frequent Ventricular Premature

 

 

                     Beats

                     

           If checked, indicate frequency:

           [ ] Constant   [X] Intermittent (paroxysmal)

           

           If intermittent, indicate number of episodes in the past 12 months:

           [ ] 0   [X] 1-3   [ ]  More than 4

           

           Indicate how these episodes were documented (check all that apply)

           [X] Holter

           

    6. Heart valve conditions

    -------------------------

    Has the Veteran had a heart valve condition?

    [ ] Yes   [X] No

    

    7. Infectious heart conditions

    ------------------------------

    Has the Veteran had any infectious cardiac conditions, including active

    valvular infection (including rheumatic heart disease), endocarditis,

    pericarditis or syphilitic heart disease?

    [ ] Yes   [X] No

    

    8. Pericardial adhesions

    ------------------------

    Has the Veteran had pericardial adhesions?

    [ ] Yes   [X] No

    

    9. Procedures

    -------------

    Has the Veteran had any non-surgical or surgical procedures for the 

treatment

    of a heart condition?

    [X] Yes   [ ] No

    

       If yes, indicate the non-surgical or surgical procedures the Veteran has

       had for the treatment of heart conditions (check all that apply):

       

       [X] Coronary artery bypass surgery

       

             Indicate date of admission for treatment and treatment facility:

               FEBRUARY 08, 2006 NORTH RIDGE HOSPITAL, OAKLAND PARK, FL

               

             Indicate the condition that resulted in the need for this

             procedure/treatment:

               SEVERE CORONARY ARTERY OBSTRUCTION WITH ANGINA PECTORIS

               

 

    10. Hospitalizations

    --------------------

    Has the Veteran had any other hospitalizations for the treatment of heart

    conditions (other than for non-surgical and surgical procedures described

    above)?

    [ ] Yes   [X] No

    

    11. Physical exam

    -----------------

    a. Heart rate: 79

 

    b. Rhythm: [X] Regular   [ ] Irregular

    

    c. Point of maximal impact: [ ] Not palpable   [ ] 4th intercostal space

                                [X] 5th intercostal space

                                [ ] Other, specify:

    d. Heart sounds: [X] Normal   [ ] Abnormal, specify:

    e. Jugular-venous distension: [ ] Yes   [X] No

    

    f. Auscultation of the lungs: [X] Clear   [ ] Bibasilar rales

                                  [ ] Other, describe:

    g. Peripheral pulses:

         Dorsalis pedis:    [X] Normal   [ ] Diminished   [ ] Absent

         Posterior tibial:  [X] Normal   [ ] Diminished   [ ] Absent

 

    h. Peripheral edema:

         Right lower extremity: [ ] None   [ ] Trace

                                [ ] 1+     [ ] 2+   [ ] 3+   [X] 4+

                                

         Left lower extremity:  [ ] None   [ ] Trace

                                [ ] 1+     [ ] 2+   [X] 3+   [ ] 4+

                                

    i. Blood pressure: 146/70

 

    12. Other pertinent physical findings, complications, conditions, signs,

        symptoms and scars

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

    a. 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

       

    b. 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?

       [X] Yes   [ ] No

       

           If yes, are any of these scars painful or unstable, have a total area

           equal to or greater than 39 square cm (6 square inches), or are

           located on the head, face or neck?  (An "unstable scar" is one where,

           for any reason, there is frequent loss of covering of the skin over

           the scar.)

           [ ] Yes   [X] No

           

               If no, provide location and measurements of scar in centimeters.

                  Location: #1 MIDSTERNAL longitudianl

                  Measurements:  length 17.0cm  X  width 0.6cm

                  

    c. Comments, if any:

         #2 Left proximal thigh medially:    length  8.5 cm  x width 0.6 cm

         #3 Left distal thigh medially:      length  11.3 cm  x width 0.9 cm

         #4 #3 Left proximal leg medially:   length  5.3 cm   x width 0.7 cm

         

    13. Diagnostic Testing

    ----------------------

    a. Is there evidence of cardiac hypertrophy?

       [ ] Yes   [X] No

       

    b. Is there evidence of cardiac dilatation?

       [ ] Yes   [X] No

       

    c. Diagnostic tests

    

       Indicate all testing completed; provide only most recent results which

       reflect the Veteran's current functional status (check all that apply):

       

       [X] EKG              Date of EKG: 1/25/2016

       

           Result:

           [X] Other, describe:   Sinus rhythm with Premature atrial complexes

                         with Aberrant conduction. RSR' or QR pattern in V1

                         suggests right ventricular conduction delay. Borderline

                         ECG.

 

       [X] Chest x-ray      Date of CXR: 4/11/2013

       

           Result:

           [X] Normal   [ ] Abnormal, describe:

       [X] Echocardiogram      Date of echocardiogram: 10/11/2012

           Left ventricular ejection fraction (LVEF):  50-55 %

           

           Wall motion:

           [ ] Normal   [X] Abnormal, describe:

                              Regional wall motion abnormalities can not be

                              excluded due to limited visualization of

                              endocardial borders.

                              

           Wall thickness:

           [X] Normal   [ ] Abnormal, describe:

       [X] Holter monitor      Date of Holter monitor: 1/28/2016

           Result:

           [ ] Normal   [X] Abnormal, describe:

                              PREDOMINANT RHYTHM:

                                Sinus rhythm

 

                              Slowest rhythm recorded:

                                65 /min: Sinus rhythm

 

                              Fastest rhythm recorded:

                                Rate: 128/min. Sinus tachycardia

 

                              PERTINENT FINDINGS:

                              Ventricular ectopic beats:

                                Isolated: 1527

                                Begeminal cycles: 0

                                Couplets: 5

                                NSVT: 0

                                Runs: 0

 

                              Supraventricular ectopic beats:

                                Isolated: 27

                                Begeminal cycles: 0

                                Couplets: 1

                                SVT: 0

                                Runs: 0

 

                              Bradyarrhythmia recorded:

                                Pauses, longest pause 1

 

                              A-V block:

                                No

 

                              Patient recorded symptoms:

                                Patient recorded symptoms - No

 

                              COMMENTS:

                              24 hour Holter monitoring done

                              Predominant rhythm was sinus rhythm

                              Frequent PVCs as described above

                              Occasional PACs

                              

                              

       [X] Coronary artery angiogram      Date of angiogram: 2/06/2006

           Result:

           [ ] Normal   [X] Abnormal, describe:

 

 

                              Severe Triple Vessels Coronary Artery Disease.

                              Normal size left ventricular chamber with apical

                              hypokinesis and mildly reduced left ventricular

                              ejection fraction of 40% to 45%.

                              

                              

 

    14. METs Testing

    ----------------

    Indicate all testing completed; provide only most recent results which

    reflect the Veteran's current functional status (check all that apply):

    

    a. [X] Exercise stress test

    

           Date of most recent exercise stress test: 1/25/2016

 

           Results: Negative for ischemai

 

           METs level the Veteran performed, if provided: 6.4

 

           Did the test show ischemia?

           [ ] Yes   [X] No

           

    b. If an exercise stress test was not performed, provide reason:

         No response provided.

         

    c. [X] Interview-based METs test

    

           Date of interview-based METs test: 2/17/2016

 

           Symptoms during activity:

             The METs level checked below reflects the lowest activity level at

             which the Veteran reports any of the following symptoms 

attributable

             to a cardiac condition (check all symptoms that the Veteran reports

             at the indicated METs level of activity):

             

             [X] Dyspnea

             [X] Fatigue

           Results of interview-based METs test

             METs level on most recent interview-based METs test:

             

             [X] (>3-5 METs)   This METs level has been found to be consistent

                               with activities such as light yard work 

(weeding),

                               mowing lawn (power mower), brisk walking (4 mph)

                               

    d. Has the Veteran had both an exercise stress test and an interview-based

       METs test?

       [X] Yes   [ ] No

       

           If yes, indicate which results most accurately reflect the Veteran's

           current cardiac functional level:

           [X] Exercise stress test    [ ] Interview-based METs test    [ ] N/A

           

    e. Is the METs level limitation provided above due solely to the heart

       condition(s) that the Veteran is claiming in the Diagnosis Section?

       [ ] Yes   [X] No

       

           If no, complete Section 14f.

           

    f. What is the estimated METs level due solely to the cardiac condition(s)

       listed above?  (If this is different than METs reported above because of

       co-morbid conditions, provide METs level and Rationale below.)

       

          METs level

          METs level on most recent interview-based METs test:

          

             [X]  The limitation in METs level is due to multiple medical

                 conditions including the heart condition(s); it is not possible

                 to accurately estimate the percent of METs limitation

                 attributable to each medical condition

                 

             Rationale:

             Veteran has lightheadedness and becomes unstable when walking more

             than shorter distances, thus preventing him from walking adequately

             on a treadmill as his walking is slow.

 

             The last available Echo was done on 10/11/2012 and reported a LVEF

             of 50-55% but the most recent Nuclear Stress Test done on 1/25/2016

             reported a calculated LVEF of 56% which more accurately reflects 

the

             veteran's current cardiac functional level.

             

             

    g. Comments, if any:

         No response provided.

         

    15. Functional impact

    ---------------------

    Does the Veteran's heart condition(s) impact his or her ability to work?

    [X] Yes   [ ] No

    

       If yes, describe impact of each of the Veteran's heart conditions,

       providing one or more examples:

         VETERAN'S HEART'S CONDITION WOULD BE EXPECTED TO LIMIT HIS OCCUPATIONAL

         CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING, SQUATTING, 

CLIMBING,

         WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING, PULLING. HOWEVER,

         SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN EMPLOYMENT IN

         THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE PRESUMABLE ABSENCE

         OF OTHER COEXISTING LIMITING MEDICAL CONDITIONS-- see under CNS--) THAT

         WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF REST AND POSTURAL

         CHANGES, LIKE FOR 10 MINUTES EVERY 2 HOURS. HE DOES HAVE REASONABLE

         CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO BE ABLE TO MANAGE

         MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW RELATIVELY

         COMPLEX INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED 

TO

         THE ABOVE MENTIONED RECOVERY PERIODS.

         

    16. Remarks, if any

    -------------------

          Veteran's bilateral leg edema is clinically due to a combination of

          venous/lymphatic insufficiency of both lower extremities plus the

          continuouds use of moderate doses of the antihypertensive Nifedipine.

          The bilateral leg edeme is definitely not due to heart failure

          presently.

          

 

 

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

 

 

                               Scars/Disfigurement

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   

    

    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 

Examination

    Request?

    [X] Yes   [ ] No

    

 

    ACE and Evidence Review

    -----------------------

    Indicate method used to obtain medical information to complete this 

document:

    

    [X] In-person examination

    

 

    Evidence Review

    ---------------

    Evidence reviewed (check all that apply):

    

    [X] VA e-folder (VBMS or Virtual VA)

    [X] CPRS

 

 

    1. Diagnosis

    ------------

    Does the Veteran have one or more scars anywhere on the body, or

    disfigurement of the head, face, or neck? Yes

       Diagnosis #1: SCARS POST-CABG

       ICD code: 275322007

       Date of diagnosis: FEBRUARY, 2006

 

    Does the Veteran have any scars on the trunk or extremities (regions other

    than the head, face or neck): Yes

    

    Does the Veteran have any scars or disfigurement of the head, face or neck:

    No

    

    SECTION I:  Scars of the trunk and extremities

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

    1. Medical history

    ------------------

    Describe the history (including cause/origin and course) of the Veteran's

    scar(s) of the trunk or extremities, (brief summary): 68 y/o male Veteran

    with a midsternal scar due to a previous CABG on 2/08/2006 as well as a left

    leg scar from the veins obtained to do the venous grafts to the coronary

    arteries. He is requesting secondary service connection as due to Ischemic

    Heart Disease.

 

    His linear scars are not painful but they are unstable -keloid-.

    

    Are any of the scars of the trunk or extremities painful: No

 

    Are any of the scars of the trunk or extremities unstable, with frequent

    loss of covering of skin over the scar: Yes

      Number of unstable scars: 4

      Description of the loss of covering of skin over the scar: #1 Mid sternal

      scar longitudinal     

      #2 Left proximal thigh medially    

      #3 Left distal thigh medially       

      #4 Left proximal leg medially

 

    Are any of the scars BOTH painful and unstable: No

 

    Are any of the scars of the trunk or extremities due to burns: No

 

    2. Physical exam for scars on the trunk and extremities

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

 

 

    2-1. Details of scar findings for the trunk and extremities

      Right upper extremity: Not affected

      

      Left upper extremity: Not affected

      

      Right lower extremity: Not affected

      

      Left lower extremity: Affected

        Location of scars on left lower extremity and number them: #1 Left

        proximal thigh medially     

        #2 Left distal thigh medially      

        #3 Left proximal leg medially

        Types of scars and provide measurements:

          Linear

            Length of each linear scar:

               Scar #1:8.5 x 0.6 cm      Scar #2:11.3 x 0.9 cm      Scar #3:5.3 

x

               0.7 cm

 

      Anterior trunk: Affected

        Location of scars on anterior trunk and number them: #1 Mid sternum,

        longitudinal

        Types of scars and provide measurements:

          Linear

            Length of each linear scar:

               Scar #1:17.0 x 0.6 cm

 

      Posterior trunk: Not affected

      

    2-2. Summary of nonlinear scar areas for the trunk and extremities

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

      Superficial non-linear scars: None

 

      Deep non-linear scars: None

 

    SECTION II:  Scars or other disfigurement of the head, face, or neck: No 

response 

    provided

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

    

    SECTION III:  Miscellaneous

    ---------------------------

    1. Limitation of function/other conditions

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

    Do any of the scars (regardless of location) or disfigurement of the head,

    face, or neck result in limitation of function? No

    

    Does the Veteran have any other pertinent physical findings, complications,

    conditions, signs or symptoms (such as muscle or nerve damage) associated

    with any scar (regardless of location) or disfigurement of the head, face, 

or

    neck? No

    

    2. Color photographs

    --------------------

    Color photographs for any scars or disfiguring conditions of the head, face,

    or neck: Photographs not indicated

    

    3. Functional impact

    --------------------

    Does the Veteran's scar(s) (regardless of location) or disfigurement of the

    head, face, or neck impact his or her ability to work? No

 

    4. Remarks, if any:

    -------------------

      VETERAN'S SCARS CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS

      OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL

      ACTIVITIES OR THOSE INVOLVING REPEATED BENDING, TWISTING AND LIFTING AS 

THE

      SCARS ARE NOT PAINFUL. FOR SUCH REASONS THEY WOULD NOT PRECLUDE HIM ON

      OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING

      LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under 

Heart

      and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO

      MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL

      INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY

      COEXISTING LIMITING MEDICAL LIMITATIONS.

      

    NOTE:  VA may request additional medical information, including additional

           examinations if necessary to complete VA's review of the Veteran's

           application.

 

 

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

 

 

                              Esophageal Conditions

        (Including gastroesophageal reflux disease (GERD), hiatal hernia

                         and other esophageal disorders)

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   

    

    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 

Examination

    Request?

    [X] Yes   [ ] No

    

 

    ACE and Evidence Review

    -----------------------

    Indicate method used to obtain medical information to complete this 

document:

    

    [X] In-person examination

    

 

    Evidence Review

    ---------------

    Evidence reviewed (check all that apply):

    

    [X] VA e-folder (VBMS or Virtual VA)

    [X] CPRS

 

 

    Diagnosis

    ---------

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

    esophageal condition? Yes

      Gastroesophageal reflux disease (GERD)

                              ICD code: 235595009     Date of diagnosis: 1995

 

    Medical history

    ---------------

    Description of the history (including onset and course) of the Veteran's

    esophageal conditions: 68 y/o male Veteran with Hx of GERD for which he is

    requesting secondary service connection due to Ischemic Heart Disease.

 

    He started having symptoms of reflux in the 90's before he moved to Florida

    from Chicago in 1998. He states that he used to carry tums in his pocket 

"all

    the time" to get relief of his reflux symptomatology. While still in 

Chicago,

    he had an Upper Endoscopy privately but he does not remember the results

    other than he did not have an ulcer. However, over the years, the reflux got

    worse and has had the need to take medications regularly, specifically

    Omeprazole daily. If he does not take it regularly, his reflux gets worse.

    Once he keeps taking it daily, he rarely has reflux or any other symptoms.

    

    Does the Veteran's treatment plan include taking continuous medication for

    the diagnosed condition? Yes

      Medications used for the diagnosed condition: Omeprazole

      

    Signs and symptoms

    ------------------

    Does the Veteran have any of the following signs or symptoms due to any

    esophageal conditions (including GERD)? Yes

      Sign and Symptoms:

        Reflux

 

    Esophageal stricture, spasm and diverticula

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

    Does the Veteran have an esophageal stricture, spasm of esophagus

    (cardiospasm or achalasia), or an acquired diverticulum of the esophagus? No

    

    Other pertinent physical findings, complications, conditions, signs, symptoms 

and 

    scars

    

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

    Does the Veteran have any other pertinent physical findings, complications,

    conditions, signs or symptoms related to any conditions listed in the

    Diagnosis Section above? No

 

    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

 

    Diagnostic Testing

    ------------------

    Have diagnostic imaging studies or other diagnostic procedures been

    performed? No

    

    Has laboratory testing been performed? Yes

      CBC                     Date of test: 12/01/2015

                              Hemoglobin: 16.0

                              Hematocrit: 47.9

                              White blood cell count: 6.3

                              Platelets: 245

                              

    Are there any other significant diagnostic test findings and/or results? No

    

    Functional impact

    -----------------

    Do any of the Veteran's esophageal conditions impact on his or her ability 

to

    work? No

    

    Remarks, if any:

    ----------------

       VETERAN'S GERD CONDITION PER SE WOULD NOT BE BE EXPECTED TO LIMIT HIS

       OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING UNINTERRUPTED PHYSICAL

       ACTIVITIES OR THOSE INVOLVING PROLONGED SITTING, REPEATED BENDING,

       TWISTING AND LIFTING AS THE GERD IS UNDER ADEQUATE CONTROL WITH HIS

       MEDICATION. FOR SUCH REASONS GERD WOULD NOT PRECLUDE HIM ON OBTAINING AN

       EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING LIMITING MEDICAL

       CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart and under

 

 

       CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO MANAGE 

MOST

       REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL

       INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY

       COEXISTING LIMITING MEDICAL LIMITATIONS.

       

    NOTE: VA may request additional medical information, including additional

          examinations if necessary to complete VA's review of the Veteran's

          application.

 

 

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

 

 

                                   Sleep Apnea

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   

    

    Indicate method used to obtain medical information to complete this 

document:

    

    [ ] Review of available records (without in-person or video telehealth

        examination) using the Acceptable Clinical Evidence (ACE) process 

because

        the existing medical evidence provided sufficient information on which 

to

        prepare the DBQ and such an examination will likely provide no 

additional

        relevant evidence.

    [ ] Review of available records in conjunction with a telephone interview

        with the Veteran (without in-person or telehealth examination) using the

        ACE process because the existing medical evidence supplemented with a

        telephone interview provided sufficient information on which to prepare

        the DBQ and such an examination would likely provide no additional

        relevant evidence.

    [ ] Examination via approved video telehealth

    [X] In-person examination

    

    Evidence review

    ---------------

    Was the Veteran's VA claims file reviewed?

    [ ] Yes   [X] No

    

      If yes, list any records that were reviewed but were not included in the

      Veteran's VA claims file:

      

        

      If no, check all records reviewed:

      

        [ ] 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)

        [X] Civilian medical records

        [ ] Interviews with collateral witnesses (family and others who have

            known the Veteran before and after military service)

        [ ] No records were reviewed

        [X] Other:

              VBMS, VIRTUAL VA

              

    1. Diagnosis

    ------------

    Does the Veteran have or has he/she ever had sleep apnea?

    [X] Yes   [ ] No

    

       [X] Obstructive

              ICD code:  73430006            Date of diagnosis: 6/15/2012

 

    2. Medical history

    ------------------

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

       disorder condition (brief summary):

         68 y/o male Veteran with Hx of Obstructive Sleep Apnea requesting

         secondary service connection due to Ischemic Heart Disease.

 

         Veteran claims that he was told the first time that he was a heavy

         snorer by a friend (he has been divorced since the early '90s) with 

whom

         he shared a hotel room around 2007. He has been chronically tired 

during

         daytime with daytime hypersomnolence. Then he was eventually requested

         to have Sleep Study done on 6/15/2012 at the Miami VA confirming the

         presence of Sleep Apnea. Was initiated on CPAP and his symptomatology

         has significantly improved. However, because of his residual cognitive

         impairment after the stroke, he knew about the existence of the drug

         Modafinil and asked to be prescribed with it and it has helped some

         regarding his cognitive impairment more than anything else, besides the

         additional help to his cognitive function by the CPAP.

         

    b. Is continuous medication required for control of a sleep disorder

       condition?

       [X] Yes   [ ] No

       

           If yes, list only those medications required for the Veteran's sleep

           disorder condition:

             MODAFINIL

             

    c. Does the veteran require the use of a breathing assistance device?

       [ ] Yes   [X] No

       

    d. Does the Veteran require the use of a continuous positive airway pressure

       (CPAP) machine?

       [X] Yes   [ ] No

       

    3. Findings, signs and symptoms

    -------------------------------

    Does the Veteran currently have any findings, signs or symptoms attributable

    to sleep apnea?

    [X] Yes   [ ] No

    

        If yes, check all that apply:

        [X] Persistent daytime hypersomnolence

 

    4. Other pertinent physical findings, complications, conditions, signs 

and/or

       symptoms

    

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

    a. Does the Veteran have any scars (surgical or otherwise) related to any

       conditions or to the treatment of any conditions listed in the Diagnosis

       section above?

       [ ] Yes   [X] No

       

    b. Does the Veteran have any other pertinent physical findings,

       complications, conditions, signs and/or symptoms related to any 

conditions

       listed in the Diagnosis section above?

       [ ] Yes   [X] No

       

    5. Diagnostic testing

    ---------------------

    a. Has a sleep study been performed?

       [X] Yes   [ ] No

       

           If yes, does the Veteran have documented sleep disorder breathing?

           [X] Yes   [ ] No

           

           Date of sleep study:  6/15/2012

           

           Facility where sleep study performed, if known:  MIAMI VAMC

           

           Results:

             Severe obstructive sleep apnea hypopnea syndrome relieved by nasal

             CPAP @ 9.0 cm H20

             

    b. Are there any other significant diagnostic test findings and/or results?

       [ ] Yes   [X] No

       

         

    6. Functional impact

    --------------------

    Does the Veteran's sleep apnea impact his or her ability to work?

    [ ] Yes   [X] No

    

          

    7. Remarks, if any:

    -------------------

    PROVIDED THAT VETERAN USES THE CPAP REGULARLY, HIS SLEEP APNEA CONDITION PER

    SE WOULD NOT BE BE EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY

    THOSE REQUIRING UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING SIMPLE

    INTELLECTUAL TASKS. FOR SUCH REASON SLEEP APNEA WOULD NOT PRECLUDE HIM ON

    OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING

    LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under Heart

    and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE ABLE TO

    MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO FOLLOW GENERAL

    INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO ANY

    COEXISTING LIMITING MEDICAL LIMITATIONS.

    

 

 

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

 

 

                Central Nervous System and Neuromuscular Diseases

         (except Traumatic Brain Injury, Amyotrophic Lateral Sclerosis, 

            Parkinson's Disease, Multiple Sclerosis, Headaches, TMJ 

         Conditions, Epilepsy, Narcolepsy, Peripheral Neuropathy, Sleep 

               Apnea, Cranial Nerve Disorders, Fibromyalgia, and 

                            Chronic Fatigue Syndrome)

                       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?

    [ ] Yes[X] No

    

      If no, check all records reviewed:

      

        [X] Veterans Health Administration medical records (VA treatment 

records)

        [X] Civilian medical records

        [X] Other:

              VBMS, VIRTUAL VA

              

 

    1. Diagnosis

    ------------

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

    nervous system (CNS) condition?

    [X] Yes   [ ] No

    

    [X] Vascular diseases   ICD code: 275526006  Date of diagnosis:  2006

            [X] Thrombosis, TIA or cerebral infarction

            [X] Cerebral arteriosclerosis

 

    2. Medical history

    ------------------

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

central

       nervous conditions (brief summary):

       68 y/o male Veteran with Hx of  a brain injury due to a stroke and 

Veteran

       is requesting it as secondarily service connected due to Ischemic Heart

       Disease.

 

       Veteran had the CABG on 2/08/2006 and was discharged on 2/13/2006 from

       North Ridge Hospital, in Oakland Park, Florida. Within the next few days

       post-discharge he started noticing that was impossible for him to keep 

his

       previous abilities on doing computer programming and mathematic analyses

       (he is a Phsyics and Mathematics Major and with Master of Physics

       providing data to different clients, whom he lost due to his inability to

       keep working) as he used to do before. Brain MRI revealed that Veteran 

had

       had a stroke. Neuropsychological testing showed apparent "deficits in

       vebral memory retrieval, ideational 

       fluency, visuocontruction, and graphomotor skills" w/ mild cerebral

       impairment 

       noted, which was non-specific. However, he never had any motor impairment

       other than very mild unstable gait with imbalance on physical activities

       and occasional lightheadedness, symptoms that still recur. He has never

       taken any medication post-stroke other than his Baby Aspirin and his

       regular blood pressure medications. At times he also develops headaches 

if

       he exercises more than usual and needs to stop his activities with

       resolution of the headache.

 

 

 

 

       

       

    b. Does the Veteran's central nervous system condition require continuous

       medication for control?

       [ ] Yes   [X] No

       

    c. Does the Veteran have an infectious condition?

       [ ] Yes   [X] No

       

       If yes, is it active?

       [ ] Yes   [ ] No

       

    d. Dominant hand

       [X] Right   [ ] Left   [ ] Ambidextrous

       

    3. Conditions, signs and symptoms

    ---------------------------------

    a. Does the Veteran have any muscle weakness in the upper and/or lower

       extremities?

       [ ] Yes   [X] No

       

    b. Does the Veteran have any pharynx and/or larynx and/or swallowing

       conditions?

       [ ] Yes   [X] No

       

    c. Does the Veteran have any respiratory conditions (such as rigidity of the

       diaphragm, chest wall or laryngeal muscles)?

       [ ] Yes   [X] No

       

    d. Does the Veteran have sleep disturbances?

       [X] Yes   [ ] No

       

       If yes, check all that apply:

       [X] Sleep apnea requiring the use of breathing assistance device such as

           continuous positive airway pressure (CPAP) machine

 

    e. Does the Veteran have any bowel functional impairment?

       [ ] Yes   [X] No

       

    f. Does the Veteran have voiding dysfunction causing urine leakage?

       [X] Yes   [ ] No

       

       If yes, please check one:

       [X] Does not require/does not use absorbent material

 

    g. Does the Veteran have voiding dysfunction causing signs and/or symptoms 

of

       urinary frequency?

       [X] Yes   [ ] No

       

       If yes, check all that apply:

       [X] Daytime voiding interval between 1 and 2 hours

       [X] Nighttime awakening to void 2 times

 

    h. Does the Veteran have voiding dysfunction causing findings, signs and/or

       symptoms of obstructed voiding?

       [X] Yes   [ ] No

       

       If yes, check all signs and symptoms that apply:

       [X] Hesitancy

             If checked, is hesitancy marked?

             [ ] Yes   [X] No

       [X] Slow or weak stream

             If checked, is stream markedly slow or weak?

             [ ] Yes   [X] No

       [X] Decreased force of stream

             If checked, is force of stream markedly decreased?

             [ ] Yes   [X] No

 

    i. Does the Veteran have voiding dysfunction requiring the use of an

       appliance?

       [ ] Yes       [X] No

       

    j. Does the Veteran have a history of recurrent symptomatic urinary tract

       infections?

       [ ] Yes   [X] No

       

    k. Does the Veteran (if male) have erectile dysfunction?

       [X] Yes   [ ] No

       

       If yes, is the erectile dysfunction as likely as not (at least a 50%

       probability) attributable to a CNS disease (including treatment or

       residuals of treatment)?

       [ ] Yes   [X] No

       

       If no, provide the etiology of the erectile dysfunction:

           Low testosterone level (on Testosterone replacement twice a month)

           

       If no, is the Veteran able to achieve an erection (with medication)

       sufficient for penetration and ejaculation?

       [X] Yes   [ ] No

       

    4. Neurologic exam

    ------------------

    a. Speech

       [X] Normal   [ ] Abnormal

       

    b. Gait

       [ ] Normal   [X] Abnormal, describe:

                        Mildly unstable gait when/if Veteran walks fast or 

longer

                        distances due predominantly to residual lightheadedness

                        post-stroke. The gait is fundamentally stable otherwise.

                        

    c. Strength

         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

           

       Elbow flexion:

           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:

           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:

           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:

           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

 

       Grip:

           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

 

       Pinch (thumb to index finger):

           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:

           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:

           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:     

           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

 

 

 

    d. Deep tendon reflexes (DTRs)

         Rate reflexes according to the following scale:

           0   Absent

           1+ Decreased

           2+ Normal

           3+ Increased without clonus

           4+ Increased with clonus

           

       Biceps:

           Right:[ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

           Left: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

 

       Triceps:

           Right:[ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

           Left: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

 

       Brachioradialis:

           Right:[ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

           Left: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

 

       Knee:

           Right:[ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

           Left: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

 

       Ankle:

           Right:[ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

           Left: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+

 

    e. Does the Veteran have muscle atrophy attributable to a CNS condition?

       [ ] Yes   [X] No

       

    f. Summary of muscle weakness in the upper and/or lower extremities

       attributable to a CNS condition (check all that apply):

       

       Right upper extremity muscle weakness:

       [X] None

 

       Left upper extremity muscle weakness:

       [X] None

 

       Right lower extremity muscle weakness:

       [X] None

 

       Left lower extremity muscle weakness:

       [X] None

 

    5. Tumors and neoplasms

    -----------------------

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

related

       to any of the diagnoses in the Diagnosis section?

       [ ] Yes   [X] No

       

    6. 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 related to any conditions

       listed in the Diagnosis section above?

       [ ] Yes   [X] No

       

    7. Mental health manifestations due to CNS condition or its treatment

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

    a. Does the Veteran have depression, cognitive impairment or dementia, or 

any

       other mental health conditions attributable to a CNS disease and/or its

       treatment?

       [ ] Yes   [X] No

       

    8. Differentiation of Symptoms or Neurologic Effects

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

    Are you able to differentiate what portion of the symptomatology or

    neurologic effects above are caused by each diagnosis?

    [ ] Yes   [X] No

    

    9. Assistive devices

    --------------------

    a. Does the Veteran use any assistive device(s) as a normal mode of

       locomotion, although occasional locomotion by other methods may be

       possible?

       [ ] Yes   [X] No

       

    10. Remaining effective function of the extremities

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

    Due to a CNS condition, 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

 

    11. Diagnostic testing

    ----------------------

    a. Have imaging studies been performed?

       [X] Yes   [ ] No

       

       If yes, provide most recent results, if available:

           HEAD CT WITH & W/O CONTRAST 11/25/2014:

           Findings: There is a large old left occipital infarction. Brain 

                 volume is otherwise normal. There is no abnormal parenchymal 

                 density elsewhere in the brain. There is no mass, mass effect, 

                 hydrocephalus or abnormal extra-axial fluid collection. There is 

 

                 no abnormal enhancement. The dural venous sinuses enhance 

                 normally. There is moderate atherosclerotic calcification of the 

 

                 cavernous internal carotid arteries and trace atherosclerotic 

                 calcification of the intradural vertebral arteries. The included 

 

                 paranasal sinuses and mastoid air cells are clear. There is no 

                 skull fracture or suspicious osseous lesion.  

                  

               Impression:

                  

                  

                 1. Old left occipital infarction.  

                  

                 2. No mass, hydrocephalus or enhancing lesion.  

           

           

    b. Have PFTs been performed?

       [ ] Yes   [X] No

       

    c. If PFTs have been performed, is the flow-volume loop compatible with 

upper

       airway obstruction?

       [ ] Yes   [ ] No

       

    d. Are there any other significant diagnostic test findings and/or results?

       [ ] Yes   [X] No

       

    12. Functional impact

    ---------------------

    Do the Veteran's central nervous system disorders impact his or her ability

    to work?

    [X] Yes   [ ] No

    

    If yes, describe impact of each of the Veteran's central nervous system

    disorder condition(s), providing one or more examples:

       VETERAN'S POST-STROKE CONDITION WOULD BE EXPECTED TO LIMIT HIS

       OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING FAST WALKING,

       SQUATTING, CLIMBING, WALKING UPSTAIRS FOR MORE THAT 2 FLIGHTS, PUSHING,

       PULLING AND THOSE ACTIVITIES RELATED TO MORE THAN SIMPLE INTELLECTUAL

       CONCENTRATION. His Neuropsychologic Testing identified "deficits in 

vebral

       memory retrieval, ideational fluency, visuocontruction, and graphomotor

       skills" w/ mild cerebral impairment noted, which was non-specific.

       HOWEVER, SUCH LIMITATIONS WOULD NOT PRECLUDE HIS OBTAINING OF AN

       EMPLOYMENT IN THOSE SEDENTARY TYPE OF JOBS, LIKE DESK JOBS (IN THE

       PRESUMABLE ABSENCE OF OTHER COEXISTING OR ADDITIONAL LIMITING MEDICAL

       CONDITIONS) THAT WOULD PROVIDE HIM WITH INTERMITTENT PERIODS OF PHYSICAL

       AND MENTAL REST AND POSTURAL CHANGES, LIKE FOR 10 MINUTES EVERY HOUR. HE

       DOES HAVE REASONABLE CAPABILITY FOR THE USE OF HIS UPPER EXTREMITIES TO 

BE

       ABLE TO MANAGE MOST OF SEDENTARY JOB ACTIVITIES AND HE IS ABLE TO FOLLOW

       GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE ADAPTED TO

       THE ABOVE MENTIONED RECOVERY PERIODS.

       

    13. Remarks, if any:

    --------------------

    No remarks provided.

    

 

 

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

 

 

                       Male Reproductive System Conditions

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   

    

    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 

Examination

    Request?

    [X] Yes   [ ] No

    

 

    ACE and Evidence Review

    -----------------------

    Indicate method used to obtain medical information to complete this 

document:

    

    [X] In-person examination

    

 

    Evidence Review

    ---------------

    Evidence reviewed (check all that apply):

    

    [X] VA e-folder (VBMS or Virtual VA)

    [X] CPRS

 

 

    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: 397803000 Date of diagnosis: 2006

 

       [X] Other male reproductive system condition (specify diagnosis, 

providing

           only diagnoses that pertain to male reproductive system.)

 

           Other diagnosis #1:  HYPOGONADISM

              ICD code:  48130008

              Date of diagnosis:  12/16/2010

              

    2. Medical history

    ------------------

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

       reproductive organ condition(s) (brief summary):

         68 y/o male Veteran with Hx of Erectile Dysfunction (ED) and  

requesting

         secondary service connection due to Ischemic Heart Disease.

 

         He claims that he developed ED after the Open Heart Surgery (CABG) and

         has required the use of medication (Sildenafil) which has helped him

         some. However, in 2012 he was also found with very low testosterone

         level and has been on chronic replacement injection replacement therapy

         (patches and creams did not work) twice a month with initial 

improvement

         and not much afterwards. However, he claims that the testosterone has

         helped him to stay more alert.

 

         He claims that with the use of Viagra he has been able to have enough

         erection to be capable of acceptable penetration.

 

         He is being followed by both the VA Urologist as well as the private

         Urologist. The latter sees him at least every 3 months. He had the last

         digital prostate exam around 3 months ago and was told that his 

prostate

         was "mildly" enlarged but no other urologic-related abnormalities.

         

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

for

       the diagnosed condition?

       [X] Yes   [ ] No

       

           List medications taken for the diagnosed condition:

             Testosterone Injections

             

    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?

    [X] Yes   [ ] No

    

    If yes, complete the following sections:

    

    a. Etiology of voiding dysfunction:

         Unknown but BPH has been presumed as the cause

         

    b. Does the voiding dysfunction cause urine leakage?

       [X] Yes   [ ] No

       

           Indicate severity (check one):

              [X] Does not require the wearing of absorbent material

              [ ] Requires absorbent material which must be changed less than 2

                  times per day

              [ ] Requires absorbent material which must be changed 2 to 4 times

                  per day

              [ ] Requires absorbent material which must be changed more than 4

                  times per day

              [ ] Other, describe:

    c. Does the voiding dysfunction require the use of an appliance?

       [ ] Yes   [X] No

       

    d. Does the voiding dysfunction cause increased urinary frequency?

       [X] Yes   [ ] No

           If yes, check all that apply:

              [ ] Daytime voiding interval between 2 and 3 hours

              [X] Daytime voiding interval between 1 and 2 hours

              [ ] Daytime voiding interval less than 1 hour

              [X] Nighttime awakening to void 2 times

              [ ] Nighttime awakening to void 3 to 4 times

              [ ] Nighttime awakening to void 5 or more times

 

    e. Does the voiding dysfunction cause signs or symptoms of obstructed

       voiding?

       [X] Yes   [ ] No

           If yes, check all that apply:

              [X] Hesitancy

                  If checked, is hesitancy marked?

                     [ ] Yes   [X] No

              [X] Slow stream

                  If checked, is stream markedly slow?

                     [ ] Yes   [X] No

              [X] Weak stream

                  If checked, is stream markedly weak?

                     [ ] Yes   [X] No

              [X] Decreased force of stream

                  If checked, is force of stream markedly decreased?

                     [ ] Yes   [X] No

    f. Are there any other obstructive symptoms?

       [ ] 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:

          ATHEROSCLEROSIS (as occurs with IHD) and HYPOGONADISM

          

    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:

              Initially due ATHEROSCLEROSIS (as occurs with IHD) and aventually

              maintained/worsened by HYPOGONADISM

              

    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?

               [X] Yes   [ ] 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

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

           with no penile deformity or abnormality

       [ ] Not examined; penis exam not relevant to condition

       [ ] Abnormal

 

    b. Testes

       [ ] Normal

       [ ] Not examined per Veteran's request

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

           with no testicular deformity or abnormality

       [ ] Not examined; testicular exam not relevant to condition

       [ ] Abnormal

 

    c. Epididymis

       [ ] Normal

       [ ] Not examined per Veteran's request

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

           epididymis with no deformity or abnormality

       [ ] Not examined; epididymis exam not relevant to condition

       [ ] Abnormal

 

    d. Prostate

       [ ] Normal

       [X] Not examined per Veteran's request

       [ ] 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,

       symptoms and scars

    

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

    a. 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

       

 

 

    b. 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

       

    c. Comments, if any:

       No response provided.

       

    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?

       [X] Yes   [ ] No

       

           If yes, provide type of test or procedure, date and results (brief

           summary):

              TESTOSTERONE 12/16/2010   122     ng/dL       

                    Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL

                    Eval:                   MALE >50 YEARS 193-740 ng/dL

              =========================================

              TESTOSTERONE 3/18/2011     84     ng/dL      

                    Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL

                    Eval:                   MALE >50 YEARS 193-740 ng/dL

              ========================================

              TESTOSTERONE  12/01/2015   53     ng/dL     

                    Eval: REFERENCE RANGES: MALE <50 YEARS 249-836 ng/dL

                    Eval:                   MALE >50 YEARS 193-740 ng/dL

              ========================================

              TOTAL PSA 8/11/2015      3.59     ng/mL      0.00 - 4.00 

              ========================================

 

              

              

    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:

    --------------------

        VETERAN'S ERECTILE DYSFUNCTION (ED) CONDITION PER SE WOULD NOT BE BE

        EXPECTED TO LIMIT HIS OCCUPATIONAL CHOICES, PARTICULARLY THOSE REQUIRING

        UNINTERRUPTED PHYSICAL ACTIVITIES OR THOSE INVOLVING PROLONGED SITTING,

        REPEATED BENDING, TWISTING AND LIFTING. GERD WOULD NOT PRECLUDE HIM ON

        OBTAINING AN EMPLOYMENT IN THE PRESUMABLE ABSENCE OF OTHER COEXISTING

        LIMITING MEDICAL CONDITIONS (WHICH VETERAN DOES HAVE-please see under

        Heart and under CNS--). HE DOES HAVE STILL REASONABLE CAPABILITY TO BE

        ABLE TO MANAGE MOST REGULAR SIMPLE JOB ACTIVITIES AND HE IS ABLE TO

        FOLLOW GENERAL INSTRUCTIONS. HOWEVER, HIS ACTIVITES WOULD NEED TO BE

        ADAPTED TO ANY COEXISTING LIMITING MEDICAL LIMITATIONS.

        

 

 

/es/ J. F. Perez-Rivas, MD

Physician, Pembroke Pines OPC

Signed: 02/17/2016 16:11

Link to post
Share on other sites
  • Answers 3
  • Created
  • Last Reply

Top Posters For This Question

Popular Days

Top Posters For This Question

Popular Posts

If your denied on most of these conditions  I would question this examiners credentials for speciality medicine. and go see a specialist for IME/IMO to rebuttal this examiner. Also chec

3 answers to this question

Recommended Posts

  • 0
  • HadIt.com Elder

Yeah, "most likely" = "more likely". I hope the rater is competent enough to understand the difference. Good luck!

Link to post
Share on other sites
  • 0
  • Moderator

If your denied on most of these conditions 

I would question this examiners credentials for speciality medicine.

and go see a specialist for IME/IMO to rebuttal this examiner.

Also check and copy your medical notes from my healthyvet notes...that pertain to your claim use as evidence.

...jmo

..............Buck

  • Like 1
Link to post
Share on other sites
  • 0

The examiner is a Cardiologist so that part is good. The two screwups are the denial for edema which he believes is caused by one of my BP meds Nifedopine which I've only taken for two years. I have had the edema since my bypass surgery and it is caused by the harvesting of veins in my leg for parts.

The scarring is from the same proceedure plus the chest incision.He only measured 3 scars on my leg. There are four scars on my leg. He missed one and that one is the missing 10 cm/sq needed for a 10% rating.

Is there any way to get this corrected before the RO rates this, or am I stuck waiting 2 or 3 years for a NOD or CUE?

For those claims and all of the othersI have used sworn lay testimony, scholarly medical articles and my medical records to try to make my point. That was all done using Chris Attigs ebooks and claims workbook. Asknods book was also very helpful in many other ways, as was this and many other forums.

 

Link to post
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Guest
Answer this question...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

  • Ads

  • Ads

  • Similar Content

    • By Matt Birchfield
      Afternoon all.
       
      I have been doing some research into Tinnitus and claiming secondary for Insomnia and Hypertension. I have a 10% for Tinnitus and 0% for hearing loss (submarine sonar tech), but honestly the lack of sleep is beating me down. I have not gotten a full night in several years. I usually get 5-6 hrs a night, with multiple interruptions due to what I feel is my ears ringing. 
      I did a search on the forum here for tinnitus and Insomnia but the last post was from 2012, hence the new thread.
      I was able to find 3 cases where the VA ruled in favor of the member for secondary insomnia and secondary hypertension, Case numbers: 1207104, 1522463, and 1600946. The last case was for insomnia only. I also have a study that is an Examination of the relationship between Insomnia and Tinnitus, DOI: 10.1177/1179557318781078
      My question is how do I get this all linked together? I plan on going to my primary care and taking this evidence to him (He's a retired commander) and see what his thoughts are, but I was also referred to you guys as the knowledgeable peeps. 
       
      Thanks
       
      Matt
    • By Pastor Kodiak
      Yesterday, I received the Judgment from the Administrative Law Judge that handled my appeal. I am using a VA-trained/approved attorney and the judge found in our favor. After 40 years of fighting with the VA. I filed my original claim the second day after my discharge. It was denied over and over again for all these years.
      I think what made a difference this time was the attorney pointing out that my VA psychologist that I'd been seeing for years, had diagnosed me and then the VA sent me to a specific non-VA psychologist for my C&P and she diagnosed me the exact same way and advised that I should receive a 100% rating for my PTSD. 
      They denied the claim (again) and when I got the decision letter explaining all the evidence they used to make their decision, they didn't include the report from my shrink or the C&P shrink. 
      So, now that service-connection is founded and they've already determined my rating (from the C&P already done), do I too have to go back to sleep for months and months? Sadly, my attorney is on vacation (of all the times to go on vacation...) and his paralegal doesn't feel comfortable telling me what to expect next...
    • By VietnamVetSis
      Has anyone had any luck with claiming Sleep Apnea as secondary to Hypertension and/or Arteriosclerotic Heart Disease ?  My husband has service connection for both hypertension and heart disease and now a current diagnosis and medical equipment for sleep apnea.  I've read where VA has approved hypertension secondary to sleep apnea and heart disease secondary to sleep apnea, but not the other way around. If anyone has an archived VA citation in this regard, or personal experience, would greatly appreciate hearing about it.    Thanks all.
    • By Shake-n-Bake
      I am still awaiting the notification letter with full details but, according to eBenefits, they have denied my claim for hypertension secondary to PTSD. The basis of my claim was not so much that the PTSD caused the hypertension (although I suspect it may have), but that my PTSD aggravates the hypertension. It looks like the decision was based on the C&P examiners opinion that my hypertension is caused by my weight, rather than my PTSD. His notes do not address the issue of the one aggravating the other. I guess I'll appeal the decision, although I'm not sure how that process works, or really what I'll be able to say, or do, differently to help my case. Below is a redacted copy of the C&P exam notes, if anyone would be so kind as to offer an opinion and/or advice. It bears noting that in his remarks, he states that in 2009 I weighed 160 pounds and my blood pressure was normal. However, I thought 140/90 was the upper threshold of normal. The evidence he is citing reflects a reading of 142/86. Does the VA use a different criteria, because 142 is not normal by generally accepted hypertension parameters. Also, he states that the BP readings used to diagnose are not present, but I did the medical records from when I was diagnosed and they show a reading of 150/110 at that time. So, I would have to say that his statement is factually untrue, based on that the evidence that I submitted.
      ---------------------------
      Hypertension Disability Benefits Questionnaire Name of patient/Veteran: Shake-N-Bank Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with hypertension or isolated systolic hypertension based on the following criteria: [X] Yes [ ] No [X] Hypertension ICD code: 00 Date of diagnosis: 2013 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hypertension condition (brief summary): noted to have high blood pressure and begun on medication on 2013. Had normal pressure in 2009 and weight of 160 pounds. b. Does the Veteran's treatment plan include taking continuous medication for hypertension or isolated systolic hypertension? [X] Yes [ ] No If yes, list only those medications used for the diagnosed conditions: lisinopril c. Was the Veteran's initial diagnosis of hypertension or isolated systolic hypertension confirmed by blood pressure (BP) readings taken 2 or more times on at least 3 different days? [ ] Yes [ ] No [X] Unknown d. Does the Veteran have a history of a diastolic BP elevation to predominantly 100 or more? [ ] Yes [X] No 3. Current blood pressure readings ---------------------------------- Systolic Diastolic Blood pressure reading 1: 138 / 82 Date: 8/23/2017 Blood pressure reading 2: 122 / 78 Date: 8/23/2017 Blood pressure reading 3: 126 / 80 Date: 8/2017 Average Blood Pressure Reading: 128 / 80 4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the Diagnosis Section above? [X] Yes [ ] No If yes, describe (brief summary): 8/11/2017 209 lb b. 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 c. Comments, if any: No response provided 5. Functional impact -------------------- Does the Veteran's hypertension or isolated systolic hypertension impact his or her ability to work? [ ] Yes [X] No 6. Remarks, if any ------------------ No remarks provided. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Shake-N-Bake ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: relation of hypertension to PTSD b. Indicate type of exam for which opinion has been requested: hypertension TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] b. The condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: The pressures used to diagnose hypertension are not available but apparently were there in 2013 when he was started on medication. He has gained nearly 40 pounds of weight since 23009. This is the most likely caused of his hypertension and the PTSD is less likely than not. ************************************************************************* /es/ FRANCIS M REMBERT MD
    • By Shake-n-Bake
      I just had two C&P exams this morning and am trying to keep a positive mindset, but the glass looks half empty to me. Maybe someone else can offer some insight on my situation.
      Since April, I have been rated at 60%; 50% for PTSD and 10% for tinnitus. The claims process for those went pretty smoothly, really, and I was awarded my disability ratings in very short time. I have since then filed three additional claims. My intent to file was back in April, but I submitted the claims on July 25. These three claims are for hypertension secondary to PTSD, sleep apnea secondary to PTSD and for hearing loss. Today I had my C&P exams for the hearing loss and hypertension. I have heard nothing about scheduling a C&P for the sleep apnea.
      My first exam this morning was for hypertension. I was diagnosed with hypertension, by a private doctor, about 4 years ago and have been on medication since then and am currently being treated by the VA for my hypertension. My hypertension isn't very severe, but it is outside of normal parameters and has been this way consistently for quite a few years. Even though I wasn't officially diagnosed until 2013, I have (and submitted) evidence of prior medical records that show high blood pressure readings well before my actual diagnosis. I don't think I meet the criteria for anything more than a 0% rating, but that's all I really want, or need. I believe I have bradycardia (abnormally low pulse), as a result of my high blood pressure. My blood pressure has always fluctuated and spiked in relation to my PTSD symptoms, so I certainly think the PTSD aggravates my blood pressure, but I don't feel good about my C&P exam from this morning. The doctor was one of the weirdest people I've come across at the VA, so it was hard to get a good read on him. All he did was take my blood pressure 3, or maybe 4, times, all from my right arm, while I was seated. He wanted to know when I was first diagnosed and how many times they had taken my blood pressure during the visit in which I was diagnosed. I told him it was in 2013 and, although I didn't recall how many times they took a blood pressure reading, I did remember how high it was when I was diagnosed. I tried to discuss the evidence I had submitted to support my having actually had high blood pressure before my 2013 diagnosis, but he shut me down. He said anything that I sent in with my claim wasn't his concern. All he was doing was "checking the boxes" on my blood pressure exam and someone else would look at everything that was submitted. This doesn't make sense to me. Isn't the purpose of the C&P exam to look at the evidence, as well render an opinion? I have already been diagnosed with hypertension and am receiving treatment. I'm guessing my blood pressure readings from the C&P exam are within normal parameters...that's what the medication is for. I don't understand the point of putting me through this dog and pony show, but I certainly didn't walk out of there feeling good about it.
      Next, I had my audiology exam for my hearing loss claim. I just had a audiology exam a little less than 2 months ago from a VA contractor and was subsequently issued hearing aids from the VA about a month ago. As I mentioned earlier, I already receive compensation for tinnitus, so part of me feels like the VA has already conceded that I had sufficient noise exposure in-service to cause damage, but I have also heard of people winning on tinnitus and losing on hearing loss. Since I had just recently had an audiology exam, I was only given an abbreviated C&P exam for my hearing. The audiologist stated that the contractor had not "submitted a full report", or something to that effect, so she only needed to do a partial test today. She asked me a little about my in-service noise exposure, as well as about my civilian occupations. It was over pretty quickly. I didn't feel quite as bad, or confused about that one as the hypertension C&P, but both of them seemed rushed and indifferent. 
      When I got home, I logged in to eBenefits to check on something unrelated and decided to look at my claim status. It had gone from Gathering Evidence to Preparation for Decision, since the last time I had checked on it. How could it be in Preparation for Decision? Mind you, I just had two C&P exams a couple of hours before. There is no way those reports had been sent in and considered already, so it had to have moved to Preparation for Decision a day, or more ago. Since I have not been scheduled for a C&P exam for my SA secondary to PTSD, I suspect now that they don't plan to give me an exam for the sleep apnea. The fact that they'd already moved my claim to Preparation for Decision before my exams leaves me with the impression that my claims are doomed to denial. Realistically, both the hypertension and hearing loss should each be rated at 0%, so that won't get me an increase in disability pay anyway, but a positive decision on the SA would. I also need the 0% ones, though, because of their relationship to other problems I have.
      I'm a little confused by all of this and am certainly not feeling hopeful about my prospects at this point. Am I jumping to conclusion prematurely, or am I making a reasonable conclusion that things aren't going my way? It's been less than 30 days since my claims were filed and it's already been moved to Preparation for Decision before my C&P exams. I don't know what that means, but it doesn't seem good.
  • Ads

  • Our picks

    • I already get compensation for bladder cancer for Camp Lejeune Water issue, now that it is added to Agent Orange does it mean that the VA should pay me the difference between Camp Lejeune and 1992 when I retired from the Marine Corps or do I have to re-apply for it for Agent Orange, or will the VA look at at current cases already receiving bladder cancer compensation. I’m considered 100% Disabled Permanently 
      • 10 replies
    • 5,10, 20 Rule
      The 5, 10, 20 year rules...



      Five Year Rule) If you have had the same rating for five or more years, the VA cannot reduce your rating unless your condition has improved on a sustained basis. All the medical evidence, not just the reexamination report, must support the conclusion that your improvement is more than temporary.



      Ten Year Rule) The 10 year rule is after 10 years, the service connection is protected from being dropped.



      Twenty Year Rule) If your disability has been continuously rated at or above a certain rating level for 20 or more years, the VA cannot reduce your rating unless it finds the rating was based on fraud. This is a very high standard and it's unlikely the rating would get reduced.



      If you are 100% for 20 years (Either 100% schedular or 100% TDIU - Total Disability based on Individual Unemployability or IU), you are automatically Permanent & Total (P&T). And, that after 20 years the total disability (100% or IU) is protected from reduction for the remainder of the person's life. "M-21-1-IX.ii.2.1.j. When a P&T Disability Exists"



      At 55, P&T (Permanent & Total) or a few other reasons the VBA will not initiate a review. Here is the graphic below for that. However if the Veteran files a new compensation claim or files for an increase, then it is YOU that initiated to possible review.



      NOTE: Until a percentage is in place for 10 years, the service connection can be removed. After that, the service connection is protected.



      ------



      Example for 2020 using the same disability rating



      1998 - Initially Service Connected @ 10%



      RESULT: Service Connection Protected in 2008



      RESULT: 10% Protected from reduction in 2018 (20 years)



      2020 - Service Connection Increased @ 30%



      RESULT: 30% is Protected from reduction in 2040 (20 years)
        • Thanks
        • Like
      • 53 replies
    • Post in New BVA Grants
      While the BVA has some discretion here, often they "chop up claims".  For example, BVA will order SERVICE CONNECTION, and leave it up to the VARO the disability percent and effective date.  

      I hate that its that way.  The board should "render a decision", to include service connection, disability percentage AND effective date, so we dont have to appeal "each" of those issues over then next 15 years on a hamster wheel.  
        • Like
    • Finally heard back that I received my 100% Overall rating and a 100% PTSD rating Following my long appeal process!

      My question is this, given the fact that my appeal was on the advanced docket and is an “Expedited” appeal, what happens now and how long(ish) is the process from here on out with retro and so forth? I’ve read a million things but nothing with an expedited appeal status.

      Anyone deal with this situation before? My jump is from 50 to 100 over the course of 2 years if that helps some. I only am asking because as happy as I am, I would be much happier to pay some of these bills off!
        • Like
      • 18 replies
    • I told reviewer that I had a bad C&P, and that all I wanted was a fair shake, and she even said, that was what she was all ready viewed for herself. The first C&P don't even  reflect my Treatment in the VA PTSD clinic. In my new C&P I was only asked about symptoms, seeing shit, rituals, nightmares, paying bills and about childhood, but didn't ask about details of it. Just about twenty question, and  nothing about stressor,
  • Ads

  • Popular Contributors

  • Ad

  • Latest News
×
×
  • Create New...

Important Information

{terms] and Guidelines