Ok as many of you know, I am 100% P&T. I got a call two weeks ago that said to Report to Ft Worth VA on 4/6/16 for an Exam. The VA lady on phone said that it was for a New Condition. Yet, I have not submitted anything to the VA. Well on Ebenefits it shows that a New Claim was submitted on 2/29/16. So I go to the exam and below is C&P or Review, whatever the VA is calling it. I am SC for:
The Claim on Ebenefits states it is New and for Voiding dysfunction associated with Epididymitis with Varicocele (NEW) and Status is already at Prep for Decision.
I am trying to figure out WTH is going on. Can you guys please assist me.
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: left inguinal scar due to scrotal surgery 2012
ICD code: unknown
Date of diagnosis: 2012
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): see DBQ URINARY TRACT
for history
Are any of the scars of the trunk or extremities painful: Yes
Number of painful scars: 1
Description of the pain: constant pain left scrotal and inguinal area
Are any of the scars of the trunk or extremities unstable, with frequent
loss of covering of skin over the scar: No
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: Not affected
Anterior trunk: Affected
Location of scars on anterior trunk and number them: left inguinal
Types of scars and provide measurements:
Linear
Length of each linear scar:
Scar #1: 4 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? Yes
Indicate which scars (regardless of location) or disfigurement of the
head,
face, or neck are causing the limitation and describe the specific
limitations: The left inguinal scar is tender to palpation. It causes
constant pain which contributes to the veteran's Pelvic Floor
Dysfunction,
and interferes with physical activities.
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? Yes
Impact of the Veteran's scar(s) (regardless of location) or
disfigurement
of the head, face, or neck, providing one or more examples: The left
inguinal scar interferes with physical activities.
4. Remarks, if any: No response provided
--------------------
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
/es/
Urinary Tract (Including Bladder and Urethra) Conditions
(Excluding Male Reproductive System)
Disability Benefits Questionnaire
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 condition
of the bladder or urethra of the urinary tract? (This is the condition the
Veteran is claiming or for which an exam has been requested)
[X] Yes [ ] No
Diagnosis #1: voiding dysfunction associated with epididymitis with
varicocele
ICD code: unknown
Date of diagnosis: 2012
2. Medical history
------------------ Describe the history (including onset and course) the Veteran's urinary
tract
condition (brief summary):
The veteran was treated for epididymitis in 2008. He was subsequently
diagnosed in 2012 with varicocele and epididymal cyst. He underwent left
scrotal surgery in 2012. He has had constant pain since that time, and
has developed voiding dysfuction. He was diagnosed with pelvic floor
dysfunction on a recent Urology exam and has been scheduled for
biofeedback. 3. Voiding dysfunction
----------------------
Does the Veteran have a voiding dysfunction?
[X] Yes [ ] No
a. Etiology of voiding dysfunction (i.e., relationship of voiding
dysfunction
to any condition in the Diagnosis section):
pelvic floor dysfunction
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:
[X] Daytime voiding interval less than 1 hour
[X] 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?
[X] Yes [ ] No
[X] Weak stream
If checked, is stream markedly weak?
[X] Yes [ ] No
[X] Decreased force of stream
If checked, is force of stream markedly decreased?
[X]If checked, is force of stream markedly decreased?
[X] Yes [ ] No
4. Urolithiasis
---------------
Does the Veteran have a history of urethral or bladder calculi (cysto- or
urethrolithiasis)?
[ ] Yes [X] No
5. Bladder or urethral infection
--------------------------------
Does the Veteran have a history of recurrent symptomatic bladder or urethral
infections?
[ ] Yes [X] No
6. Other bladder/urethral conditions
------------------------------------
a. Does the Veteran have any findings, signs, or symptoms attributable to a
bladder fistula?
[ ] Yes [X] No
b. Does the Veteran have any findings, signs or symptoms attributable to a
urethral fistula?
[ ] Yes [X] No
c. Does the Veteran have a neurogenic or a severely dysfunctional bladder?
[ ] Yes [X] No
d. Does the Veteran have a bladder injury?
[ ] Yes [X] No
e. Has the Veteran had other bladder surgery?
[ ] Yes [X] No
f. Is there any renal dysfunction due to condition?
[ ] Yes [X] No
7. Tumors and neoplasms
-----------------------
Does the Veteran have a benign or malignant neoplasm or metastases related
to
any of the diagnoses in the Diagnosis section?
[ ] Yes [X] No
8. Other pertinent physical findings, complicationsconditions, 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?
[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.)
[X] Yes [ ] No
c. Comments, if any:
No answer provided
9. Diagnostic testing
---------------------
Has the Veteran had diagnostic testing and if so, are there significant
findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
cystoscopy Oct 2015:
Flow rate/PVR:
Qmax 8.7
Qavg 3.8
V Vol 150
PVR 5
Severe LUTS
Findings:
1) Pendulous urethra: Normal
2) Bulbar urethra: Normal
3) Membranous urethra: Sphincter competent
4) Prostatic urethra: no obstructing lobes
5) Bladder neck: Patent
6) Bladder mucosa: Normal
7) Left ureteral orifice: Normal
8) Right ureteral orifice: Normal
- likely pelvic floor dysfunctionUDS Feb 2016:
PVR 0cc
UDS vol Pves EMG (pt with bowel spasms, study reported
w/Pves)
FS 34cc 5cmH20 154
FDV 111 4 162
SDV 126 3 138
Urge 154 2 148
Max 176 4 160
A: pt w
ith frequency, nocturia, post void dribbling. No evidence of
UIC on
study. Strongly suspect PFD. 10. Functional impact
--------------------- Does the Veteran's condition(s) of the bladder or urethra impact his or
herability to work?
[X] Yes [ ] No
If yes, describe impact of each of the Veteran's bladder or
urethra
conditions, providing one or more examples:
Constant chronic scrotal pain interferes with physical activities.
11. Remarks, if any:
-------------------- According to the medical reference UpToDate, chronic pelvic pain is a risk
factor for the development of Pelvic Floor Dysfunction. It is considered at
least as likely as not that this veteran's Pelvic Floor Dysfunction is
secondary to his SC condition of epididymitis and scrotal surgery and that
the "voiding dysfunction associated with epididymitis with
varicocele" is
associated with Pelvic Floor Dysfunction.
DOES IT LOOK LIKE THE VA IS TRYING TO TAKE AWAY MY 40% for VOIDING DYSFUNCTION SECONDARY TO MY TESTICULAR SURGERY? I AM SO TIRED OF THE VA RUNNING ME IN THE GROUND GUYS. GOD BLESS!!!
Question
Navy04
Ok as many of you know, I am 100% P&T. I got a call two weeks ago that said to Report to Ft Worth VA on 4/6/16 for an Exam. The VA lady on phone said that it was for a New Condition. Yet, I have not submitted anything to the VA. Well on Ebenefits it shows that a New Claim was submitted on 2/29/16. So I go to the exam and below is C&P or Review, whatever the VA is calling it. I am SC for:
Epididymitis with Varicocele 0% Granted 2/25/2013
Secondary Erectile Dysfunction 0% Granted 9/25/2013
Secondary Voiding Dysfunction 40% Granted 02/13/2014
The Claim on Ebenefits states it is New and for Voiding dysfunction associated with Epididymitis with Varicocele (NEW) and Status is already at Prep for Decision.
I am trying to figure out WTH is going on. Can you guys please assist me.
Scars/Disfigurement
Disability Benefits Questionnaire
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: left inguinal scar due to scrotal surgery 2012
ICD code: unknown
Date of diagnosis: 2012
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): see DBQ URINARY TRACT
for history
Are any of the scars of the trunk or extremities painful: Yes
Number of painful scars: 1
Description of the pain: constant pain left scrotal and inguinal area
Are any of the scars of the trunk or extremities unstable, with frequent
loss of covering of skin over the scar: No
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: Not affected
Anterior trunk: Affected
Location of scars on anterior trunk and number them: left inguinal
Types of scars and provide measurements:
Linear
Length of each linear scar:
Scar #1: 4 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? Yes
Indicate which scars (regardless of location) or disfigurement of the
head,
face, or neck are causing the limitation and describe the specific
limitations: The left inguinal scar is tender to palpation. It causes
constant pain which contributes to the veteran's Pelvic Floor
Dysfunction,
and interferes with physical activities.
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? Yes
Impact of the Veteran's scar(s) (regardless of location) or
disfigurement
of the head, face, or neck, providing one or more examples: The left
inguinal scar interferes with physical activities.
4. Remarks, if any: No response provided
--------------------
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
/es/
Urinary Tract (Including Bladder and Urethra) Conditions
(Excluding Male Reproductive System)
Disability Benefits Questionnaire
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 condition
of the bladder or urethra of the urinary tract? (This is the condition the
Veteran is claiming or for which an exam has been requested)
[X] Yes [ ] No
Diagnosis #1: voiding dysfunction associated with epididymitis with
varicocele
ICD code: unknown
Date of diagnosis: 2012
2. Medical history
------------------
Describe the history (including onset and course) the Veteran's urinary
tract
condition (brief summary):
The veteran was treated for epididymitis in 2008. He was subsequently
diagnosed in 2012 with varicocele and epididymal cyst. He underwent left
scrotal surgery in 2012. He has had constant pain since that time, and
has developed voiding dysfuction. He was diagnosed with pelvic floor
dysfunction on a recent Urology exam and has been scheduled for
biofeedback.
3. Voiding dysfunction
----------------------
Does the Veteran have a voiding dysfunction?
[X] Yes [ ] No
a. Etiology of voiding dysfunction (i.e., relationship of voiding
dysfunction
to any condition in the Diagnosis section):
pelvic floor dysfunction
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:
[X] Daytime voiding interval less than 1 hour
[X] 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?
[X] Yes [ ] No
[X] Weak stream
If checked, is stream markedly weak?
[X] Yes [ ] No
[X] Decreased force of stream
If checked, is force of stream markedly decreased?
[X]If checked, is force of stream markedly decreased?
[X] Yes [ ] No
4. Urolithiasis
---------------
Does the Veteran have a history of urethral or bladder calculi (cysto- or
urethrolithiasis)?
[ ] Yes [X] No
5. Bladder or urethral infection
--------------------------------
Does the Veteran have a history of recurrent symptomatic bladder or urethral
infections?
[ ] Yes [X] No
6. Other bladder/urethral conditions
------------------------------------
a. Does the Veteran have any findings, signs, or symptoms attributable to a
bladder fistula?
[ ] Yes [X] No
b. Does the Veteran have any findings, signs or symptoms attributable to a
urethral fistula?
[ ] Yes [X] No
c. Does the Veteran have a neurogenic or a severely dysfunctional bladder?
[ ] Yes [X] No
d. Does the Veteran have a bladder injury?
[ ] Yes [X] No
e. Has the Veteran had other bladder surgery?
[ ] Yes [X] No
f. Is there any renal dysfunction due to condition?
[ ] Yes [X] No
7. Tumors and neoplasms
-----------------------
Does the Veteran have a benign or malignant neoplasm or metastases related
to
any of the diagnoses in the Diagnosis section?
[ ] Yes [X] No
8. Other pertinent physical findings, complicationsconditions, 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?
[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.)
[X] Yes [ ] No
c. Comments, if any:
No answer provided
9. Diagnostic testing
---------------------
Has the Veteran had diagnostic testing and if so, are there significant
findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
cystoscopy Oct 2015:
Flow rate/PVR:
Qmax 8.7
Qavg 3.8
V Vol 150
PVR 5
Severe LUTS
Findings:
1) Pendulous urethra: Normal
2) Bulbar urethra: Normal
3) Membranous urethra: Sphincter competent
4) Prostatic urethra: no obstructing lobes
5) Bladder neck: Patent
6) Bladder mucosa: Normal
7) Left ureteral orifice: Normal
8) Right ureteral orifice: Normal
- likely pelvic floor dysfunctionUDS Feb 2016:
PVR 0cc
UDS vol Pves EMG (pt with bowel spasms, study reported
w/Pves)
FS 34cc 5cmH20 154
FDV 111 4 162
SDV 126 3 138
Urge 154 2 148
Max 176 4 160
A: pt w
ith frequency, nocturia, post void dribbling. No evidence of
UIC on
study. Strongly suspect PFD.
10. Functional impact
---------------------
Does the Veteran's condition(s) of the bladder or urethra impact his or
herability to work?
[X] Yes [ ] No
If yes, describe impact of each of the Veteran's bladder or
urethra
conditions, providing one or more examples:
Constant chronic scrotal pain interferes with physical activities.
11. Remarks, if any:
--------------------
According to the medical reference UpToDate, chronic pelvic pain is a risk
factor for the development of Pelvic Floor Dysfunction. It is considered at
least as likely as not that this veteran's Pelvic Floor Dysfunction is
secondary to his SC condition of epididymitis and scrotal surgery and that
the "voiding dysfunction associated with epididymitis with
varicocele" is
associated with Pelvic Floor Dysfunction.
DOES IT LOOK LIKE THE VA IS TRYING TO TAKE AWAY MY 40% for VOIDING DYSFUNCTION SECONDARY TO MY TESTICULAR SURGERY? I AM SO TIRED OF THE VA RUNNING ME IN THE GROUND GUYS. GOD BLESS!!!
Link to comment
Share on other sites
Top Posters For This Question
7
3
2
1
Popular Days
Apr 10
4
May 10
3
Apr 9
2
Apr 11
2
Top Posters For This Question
Navy04 7 posts
flores97 3 posts
iceturkee 2 posts
Buck52 1 post
Popular Days
Apr 10 2016
4 posts
May 10 2016
3 posts
Apr 9 2016
2 posts
Apr 11 2016
2 posts
Popular Posts
Navy04
Thank you guys, and yes this was a C&P Review or Exam, whatever the VA is calling it, from this past Wednesday. I just dont know what is going on. I fought so hard to get the P&T, yet I always
Navy04
Update 5/8!!!! I am stunned and dont know what to say. The VA and FU**** Govt always seems to find a way to get to me. I looked in the mail box today, and there was the official Big White
flores97
Navy04, that c&p looked like it was in your favor, try not to stress(which is easier said than done). Notice the examiner consistently marked "Yes" for the question "Does the Veterans condition of
15 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now