hypertension Brain injury not TBI from SC AO IHD CABG

Mike_S · April 13, 2016

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. Like scarring, measure all of the scars on my chest and leg (to harvest veins) and don't include all of them in the notes. Edema in the leg from the vein harvest has been a problem since the surgery but cite the likely cause is a new BP med that I've taken for less than 2 years.

A brain injury secondary to IHD. Bypass surgery caused an injury possibly through a stroke that really affected my life. Learning about it 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. How would this brain injury be considered, would it be rated like a TBI?

I'm attaching the results. Sorry, the notes are long.

***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 --------------------------------

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: