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Question
zuluvictor81
Sorry i can not figure out how to format this better... But long story short i am posting this for a friend since both her and I are confused on how this either of these 2 DBQS read. on one hand the examiner seems say yes and then later on says no but maybe so but then probably not but mostly yes, so if any one can translate all this that would be awesome since this is a 10 year old claim that was remand to the AMC for further development.
Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXX 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 thoracolumbar spine (back) condition? [X] Yes [ ] No
Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture
2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): veteran is SC for a lumbosacral strain
veteran reports during the last mission, was in C-130 aircraft, landed hard felt something pop in my back, onset of back pain, approx 2003.
veteran reports dx with sprynix of the thoracic spine, in 2005 follows with VA neurology XXXXXX. aqua therapy, no benefit with chiropractor, ADVSIED AGAINTS INJECTIONS TO SPINE. pain and radicular symproms progressively worse.
veteran reports back pain from thoracic spine to lumbosacral region with radicular symptoms down both legs, veteran reports foot drop both feet, documented by neurologist. back pain constant back pain 8/10. flares - with any bending and twisting, any lifting, standing more than 10 minutes, sitting more than 30 minutes, walking more than 30 minutes, walking up down stairs with radicular symptoms. alleviated: moist heat, tens unit
b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: see above
c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. pain with prolonges standind/sitting and walking
3. Range of motion (ROM) and functional limitation ------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 30 degrees Extension (0 to 30): 0 to 5 degrees Right Lateral Flexion (0 to 30): 0 to 10 degrees Left Lateral Flexion (0 to 30): 0 to 15 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees
If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No
Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion, Right Lateral Rotation, Left Lateral Rotation Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): ttp paraspinal muscles throacic, lumbar sacral region b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No
c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: speculative
d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: speculative
e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below:
Guarding: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below:
f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Disturbance of locomotion, Interference with sitting, Interference with standing 4. Muscle strength testing ------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam ------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus
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+ 6. Sensory exam -------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Thigh/knee (L3/4): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] Absent 7. Straight leg raising test --------------------------- Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform
8. Radiculopathy --------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Paresthesias and/or dysesthesias Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Numbness Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe
b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 9. Ankylosis ----------- Is there ankylosis of the spine? [ ] Yes [X] No
10. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No
11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ---------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No
12. 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? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ---------------- [X] Brace(s) [X] Occasional [ ] Regular [ ] Constant [X] Other: tens unit [ ] Occasional [X] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities -------------------------------------------------- Due to a thoracolumbar spine (back) 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.; functions of the lower extremity include balance and propulsion, etc.) [X] No
14. 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 15. Diagnostic testing --------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [ ] Yes [X] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact -------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: due to this veterans pain, I do not recommend significant physical labor (IE construction work) or physical work of a moderate nature (grocery store/department store), but sedentary employment with restrictions is still possible. 17. Remarks, if any: -------------------
DIAGNOSIS: CHRONIC LUMBAR STRAIN, SERVICE CONNECTED
Please address the "Correia" questions found near the bottom of this exam request.
****************************************************************************
Additional exam request information:
For any joint condition, examiners should test the contralateral joint, unless medically contraindicated, and the examiner should address pain on both passive and active motion, and on both weightbearing and non weightbearing. In addition to the questions on the DBQ, please respond to the following questions:
1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate)
not medically appropriate
2. Is there evidence of pain when the joint is used in non-weight bearing? (Yes/No/Cannot be performed or is not medically appropriate)
not medically appropriate
3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? (Yes/No)
If yes, conduct range of motion testing for the opposing joint and provide ROM measurements.
If no, the examiner is requested to state whether it is medically feasible to test the joint and if not to please state why the examiner cannot test the range of motion of the opposing joint.
============================================== Mitchell vs. Shinseki: It is my medical opinion that it is more likely than not (greater than 50/50 probability) that pain, but not weakness, fatigability or incoordination, could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time and that there is additional limitation due to pain with change in the baseline range of motion due to "pain on use or during flare-ups." It would be pure speculation to state what additional ROM loss would be present due to pain on use or during flare-ups since the veteran is not examined during a flare-up.
4. Schedule the Veteran for a VA examination to determine the current severity of her lumbosacral strain. The examiner is requested to delineate all symptomology associated with, and the current severity of, the lumbosacral strain. The appropriate Disability Benefits Questionnaire (DBQs) should be filled out for this purpose if possible.
The examiner should specifically test the Veteran's lumbar spine range of motion in active motion, passive motion, weight-bearing, and nonweight bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she
should clearly explain why this is so.
The examiner should specifically address whether the Veteran's syrinx and leg numbness are manifestations of her lumbosacral strain.
This veteran with bilateral lower extremity radiculopathy as noted on examination. This veteran's bilateral lower extremity radiculopathy is less likely secondary to SC lumbosacral strain. There is no cause and effect between lumbosacral strain and radiculopathy. There is no objective evidence for denegerative changes as documented on lumbosacral x-ray in 2015 or thoracic MRI in 2016, a cause for radiculopathy. According to note dated NOV 25, 2015 " pHONE NOTE: SPOKE WITH NEUROLOGY THIS DATE APX 246PM DISCUSSE FINDING S AND ALTERGAIT WITH SUSPECION OF UPPER MOTOR NEURONE PROBLEM POSSIBLE CEREBELLUM
ORIGIN. wAS TOLD CONDITION IS BEING WORKED UP BY HIM AND FURTHER FOLLOW UP AND TESTING PENDING."
Therfore this veteran's lower extremity radiculopathy is at least as likely as not secondary to upper motor neuron problem located in the brain. currently beingworked up through neurology."
There is no causal relationship between the Veteran's SC lumboscacral strain and finding of the syrinx at C8 and T1 as noted on MRI. The syrinx is being followed by neurology.
Gynecological Conditions Disability Benefits Questionnaire
Edited by zuluvictor81Name of patient/Veteran: XXXXXXXX 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 she ever had a gynecological condition? Yes Diagnosis #1: endometriosis ICD code: Date of diagnosis: 2002 Diagnosis #2: Vit B12 Deficiency ICD code: Date of diagnosis: 2012 Diagnosis #3: Chronic Pelvic pain ICD code: Date of diagnosis: 9/2000 If there are additional gynecological diagnoses, list using above format: menorrhagia
dx 2012 2. Medical history ----------------- Describe the history (including cause, onset and course) of each of the Veteran's gynecological conditions: vetean reports dx with HPV had colposcopy while on active duty. last pap normal.
veteran reports heavy bleeding while on active duty with severe pelvic pain. Veteran reports since MST experience h/o heavy bleeding/cramping/abdmoninal pain, lasts 1-2 weeks. While on active duty was placed on numerous birth control pills, given lupron injections, not affective. Continues to experience heavy menstrual flow with severe pelvic pain and painful intercourse. Currently on norplant, with no improvement in menstrual flow, heavy flow with blood clots, reports was advised hysterectomy for severe abdominal pain, veteran declined at that time.
laparscopy in service 2001, due to abdominal and heavy bleeding: "craters in uterus and cervic, thinning of the lining."
in 2001: colposcopy due to +ve HPV, pap q 6 months,
================================= veteran reports B-12 low and iron level low. takes B12 oral form. methocobolin.
g1-p2, vaginal delvery x2 pap, 2016, wnl, 3. Symptoms ---------- Does the Veteran currently have symptoms related to a gynecological condition, including any diseases, injuries or adhesions of the female reproductive organs? Yes If yes, indicate current symptoms, including frequency and severity of pain, if any: (check all that apply) [X] Severe pain: Constant pain [X] Pelvic pressure [X] Frequent or continuous menstrual disturbances
4. Treatment ----------- a. Has the Veteran had treatment for symptoms/findings for any diseases, injuries and/or adhesions of the reproductive organs? Yes If yes, specify condition(s), organ(s) affected, and treatment: lupron on active duty 10/2000- 12/2000: per history discontinued, not helpful norplant currently ibuprofen/Aleve as needed- for pelvic pain. Date of treatment: see above b. Does the Veteran currently require treatment or medications [for symptoms?] related to reproductive tract conditions? Yes If yes, list current treatment/medications and the reproductive organ condition(s) being treated: B12 oral replacement- daily, IM not affective Norplant- continous ferrous sulfate as needed with decrease in iron count c. If yes, indicate effectiveness of treatment in controlling symptoms:
[X] Symptoms are not controlled by continuous treatment: for the following organ/condition: [X] Conditions of the uterus 5. Conditions of the vulva ------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vulva (to include vulvovaginitis)? No 6. Conditions of the vagina -------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vagina? No 7. Conditions of the cervix -------------------------- Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the cervix? Yes If yes, describe: abnormal pap while on active duty AS-CUS with +ve HPV, high grade. colposcopy x1 while on active duty.
repeat paps with AS-CUS, neg for HPV. 8. Conditions of the uterus -------------------------- a. Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the uterus? Yes b. Has the Veteran had a hysterectomy? No c. Does the Veteran have uterine prolapse? No
d. Does the Veteran have uterine fibroids, enlargement of the uterus and/or displacement of the uterus? No e. Has the Veteran been diagnosed with any other diseases, injuries, adhesions or other conditions of the uterus? Yes If yes, describe: Endometriosis, clinical diagnosis, laparscopy in 2001, wnl, endometrial biopsy 2001 neg. . Lapraoscopy in 2012 wnl. 9. Conditions of the Fallopian tubes ----------------------------------- Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the Fallopian tubes (to include pelvic inflammatory disease)? No 10. Conditions of the ovaries ---------------------------- a. Has the Veteran undergone menopause? No b. Has the Veteran undergone partial or complete oophorectomy? No c. Does the Veteran have evidence of complete atrophy of 1 or both ovaries? Unknown d. Has the Veteran been diagnosed with any other diseases, injuries, adhesions and/or other conditions of the ovaries? No 11. Incontinence --------------- Does the Veteran have urinary incontinence/leakage? Yes
If yes, is the urinary incontinence/leakage due to a gynecologic condition? Yes If yes, condition causing it: residual of vaginal deliveries x2 If yes, check all that apply: [X] Stress incontinence
12. Fistulae ----------- a. Does the Veteran have a rectovaginal fistula? No b. Does the Veteran have a urethrovaginal fistula? No response provided. 13. Endometriosis ---------------- Has the Veteran been diagnosed with endometriosis? Yes If yes, does the Veteran currently have any findings, signs or symptoms due to endometriosis? Yes If yes, check all that apply: [X] Pelvic pain [X] Heavy bleeding [X] Irregular bleeding
If yes, indicate effectiveness of treatment in controlling symptoms: [X] Symptoms of endometriosis are not controlled by continuous treatment
14. Complications and residuals of pregnancy or other gynecologic procedures --------------------------------------------------------------------------- a. Has the Veteran had any surgical complications of pregnancy? No b. Has the Veteran had any other complications resulting from obstetrical or gynecologic conditions or procedures? No 15. 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? No b. Is the neoplasm No response provided. c. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? No response provided. d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: No response provided. 16. 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? 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? No c. Comments, if any: No response provided. 17. Diagnostic testing --------------------- a. Has the Veteran had laparoscopy? Yes If yes, provide date(s) and facility where performed, and results: laprascopy 2002: for pelvic pain, unrepsonsive to lupron, OCPS and NSAIDS " pt had approX A 6 WEEK UTERUS, SLIGHTLY SOFT, questional increased vascularity. otherwise no other abnormalities noted.
laprascopy 2011: chronic pain results: "normal appears uterus, Tubes aND ovaries. no adhesions. no pathology noted in pelvis" b. Has the Veteran been diagnosed with anemia? No c. Has the Veteran had any other diagnostic testing and if so, are there significant findings and/or results? Yes 18. Functional impact -------------------- Does the Veteran's gynecological condition(s) impact her ability to work? No
19. Remarks, if any: ------------------- diagnosis:
endometriosis
chronic pelvic pain B12 deficiency
menorrhagia
Veteran with h/o colposcopy 2002 while on active duty secondary to abnormal paps x2 ASC-US with pos HPV diagnosed in 2001. Subsequent paps with diagnosis of ASC-US with neg HPV results: 10/2005: neg pap; 2/2008: neg pap; 7/2015: ASC-US with HPV neg. There is no objective evidence for a chronic disability.
This veteran with a diagnosis of endometriosis is a continuation of the Endometriosis first diagnosed while on active duty and documented by C&P exam 4/2006,by Dr. Sogor, Obstetrican/Gynecologist. Eventhough while on active duty diagnostic laprascopy was documented as "normal" and endometrial biopsy was neg and repeat laparoscopy in 2012 was documented to be "within normal limits.", this veteran continues to exibit clinical signs of endometriosis as first documented while on active duty and C&P examination 4/10/2006 by Dr. Sogor, Obstetrican/Gynecologist as evidence by persistant chronic pain.
This veteran's B12 deficiency is less likely as not secondary to this veteran's menorrhagia. According to medical literature there is no cause an affect relationship between Vitamin B12 deficiency and heavy menstrual bleeding. Veteran with normal CBC levels from 2005-until present, expect one time low levels 8/2008, otherwise with no evidence for anemia. There is no evidence for an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. This veteran's B12 defiencency is a known condition with specific causes to included poor diet and decrease of intrinsic factor.
============================================
Active duty service dates:
Branch: XXXXXXXX
EOD: 07/21/1999
RAD: 07/20/2005
DBQ GYN Gynecological conditions:
The Veteran has important information in his or her electronic claims folder
in VBMS and Virtual VA. Please review both folders and state that they were reviewed in your report.
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
OPINION: Direct service connection
Does the Veteran have a diagnosis of (a) menstrual cramps that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) Veteran testified at her Oct. 2016 Board hearing that she had a B 12 deficiency as a result of heavy bleeding which was not addressed by the examiner; VA examiner must also address the possibility of the Veteran's
menstrual cramp disorder pre-existing her active service during service?
see below
Rationale must be provided in the appropriate section.
Examiner: Please state whether the Veteran has a diagnosis of Female Sexual Arousal Disorder (FSAD). If additional examination(s) are required, please request and/or perform as necessary.
The veteran has a diagnosis of Female sexual arousal disorder is at least as likely as not (50/50 probability) caused by or a result of Chronic pelvic pain, residual of Endometriosis and MST. The veteran answered affirmatively to screening questions for FSAD.
========================
Please arrange for the Veteran to undergo an appropriate VA examination in connection with her claim for entitlement to service connection for a menstrual cramp disorder. The claims file should be made available to and reviewed by the examiner. All indicated studies should be performed and all findings should be reported in detail. Based on the examination and review of the record, the examiner should address the following:
(a) Please diagnose any present menstrual disorders to include HPV and endometriosis.
The examiner should consider and discuss as necessary the following:
(i) The June 2015 VA treatment record noting a diagnosis of HPV; and
(ii) The Veteran's October 2016 Board hearing testimony indicating her B-12 deficiency was a result of heavy bleeding.
(b) Is it at least as likely as not (a 50 percent or greater probability) that the signs or symptoms of the Veteran's menstrual disorder represent an objective indication of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to the Veteran's Persian gulf service?
NO
(c) If the answer to (b) is no, does the evidence of record clearly and unmistakably show that the Veteran had a menstrual disability that existed prior to her entry onto active duty?
YES, There is evidence in the STRs that the veteran had menstrual disturbance to include menstrual cramping and intermittent pelvic pain secondary to ruptured ovarian cyst prior to entering service. Pain was described as intermittent and improved after starting BCPs.
The examiner should consider and discuss as necessary the following:
(i) An April 2006 VA examination noting the Veteran reported having ovarian
cysts at age 16;
(ii) A November 2006 VA treatment record noting the Veteran reported being prescribed oral contraceptives due to menstrual cramping at age 16;
(ii) An August 2011 VA treatment record noting the Veteran had a history of
ovarian cysts and ruptures as early as age 16; and
(iii) A July 2014 VA examination for irritable bowel syndrome noting the Veteran reported she had heavy periods for all of her life.
(d) If the answer to (c) is yes, does the evidence of record clearly and unmistakably show that the preexisting menstrual disorder was not aggravated
by service or that any increase in disability was due to the natural progression of the disability?
NO, there is objective evidence that pre-existing menstrual cramping and intermiitent pelvic pain was aggravated beyond normal progression secondary to service. Per History, veteran reported started to experience intense and wide spread pelvic pain and menstrual cramping post MST incident while on active duty. Multiple trials of differenct BCPs with no improvement of symptoms. Veteran with h/o Lupron injections for pelvic pain for 6 months with no benefit While on active duty pelvic ultrasound in 2000 with no evidence for ovarian cysts. Laparscopy 2002 within normal limits with normal ovaries and no evidence of cysts In 2000 veetran was dx with chronic pelvic pain. Veteran was diagnosed with Endometriosis, clinically, while on active duty.
The examiner is informed that aggravation is defined for legal purposes as a
chronic worsening of the underlying condition versus a temporary flare-up of
symptoms beyond its natural progression.
Please identify any such evidence with specificity.
(e) If the answer to either (c) or (d) is no, is it at least as likely as not (a 50 percent or greater probability) that any diagnosed menstrual disorder is etiologically related to the Veteran's active service?
Yes, the veteran's diagnosis of chronic pelvic pain and endometriosis is etiologically related to the veteran's active service. The veteran's current chronic pelvic pain and endometriosis is a continuation of the conditions first documented while on active duty.
Yes, the veteran's menorrhagia is a progression of this veteran's chronic pelvic pain and endometriosis first diagnosed while on active duty.
The examiner should consider and discuss as necessary the following:
(i) The Veteran's September 2000 and March 2001 STRs noting treatment for endometriosis; and
(ii) The Veteran's October 2015 VA examination for PTSD noting the Veteran experienced military sexual trauma.
The examiner should set forth a complete rationale for all findings and conclusions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so
and note what, if any, additional evidence would permit such an opinion to be made.
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I see what you mean about the Yes's and No's in the BACK & Lower Extremity DBQ. A couple things caught my eye. 1. The mention of the Vet being capable of some sort of Sedentary work, takes I
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