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  • 14 Questions about VA Disability Compensation Benefits Claims

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

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

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

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dapilgrim

C&P

Question

I had a C&P for about 12 different items this is the best i can do as far as editing this and pasting. Can someone interpret or tell me what it means.

1. Evidence Review -----------------Evidence reviewed (check all that apply):

[X] VA e-folder [X] CPRS

2. Medical History -----------------

a. No symptoms, abnormal findings or complaints: No answer provided

b. Skin and scars: No answer provided

c. Hematologic/lymphatic: No answer provided

d. Eye: No answer provided

e. Hearing loss, tinnitus and ear: No answer provided

f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx

g. Breast: No answer provided

h. Respiratory: No answer provided

i. Cardiovascular: No answer provided

j. Digestive and abdominal wall: No answer provided

k. Kidney and urinary tract: No answer provided

l. Reproductive: No answer provided

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VA Health Summary (Continuity of Care Document)

m. Musculoskeletal: The following conditions have been reported

Joints and extremities: Shoulder and Arm

Feet: Flatfeet

Miscellaneous musculoskeletal: Fibromyalgia

n. Endocrine: No answer provided

o. Neurologic: Headaches (including Migraine Headaches)

p. Psychiatric: No answer provided

q. Infectious disease, immune disorder or nutritional deficiency: No answer provided

r. Miscellaneous conditions: No answer provided

3. Diagnosed illnesses with no etiology --------------------------------------

From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [ ] Yes [X] No

4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------

Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [ ] Yes [X] No

5. Physical Exam ---------------

Normal PE, except as noted on additional Questionnaires included as part of this report

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VA Health Summary (Continuity of Care Document)

6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------

[ ] Yes [X] No

7. Remarks, if any: ------------------

No answer provided

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

Shoulder and Arm Conditions Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

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):

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VA Health Summary (Continuity of Care Document)

[X] VA e-folder [X] CPRS

1. Diagnosis -----------a. List the claimed condition(s) that pertain to this DBQ: No response provided

b. Select diagnoses associated with the claimed condition(s) (check all that apply):

[X] Rotator cuff tendonitis Side affected: [ ] Right [X] Left [ ] Both ICD Code: M75.80 Date of diagnosis: Left 2018

[X] Rotator cuff tear Side affected: [ ] Right [X] Left [ ] Both ICD Code: M66.811 Date of diagnosis: Left 2018

[X] Acromioclavicular joint osteoarthritis Side affected: [ ] Right [ ] Left [X] Both ICD Code: M19.019 Date of diagnosis: Right 2019 Date of diagnosis: Left 2018

c. Comments, if any: No response provided

d. Was an opinion requested about this condition? [ ] Yes [X] No [ ] N/A

2. Medical history -----------------a. Describe the history (including onset and course) of the Veteran's shoulder or arm condition (brief summary):

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VA Health Summary (Continuity of Care Document)

The veteran reports that while in Germany he was a medic and required to carry very large and heavy bags and kits of equipment several times a week and he started having bilateral shoulder pain. He reports the pain started in his right shoulder but currently is more in the left shoulder. He reports the pain worsen while in Alabama. He reports having medical evaluation for the right shoulder. He reports at that time he was having sharp pains in the left shoulder and aching pains when sleeping affecting his sleep and the right has more soreness. He reports that he has had recent medical evaluation for the left shoulder and had testing completed and has completed physical therapy and his MD recommends dry needling but the veteran has refused this treatment. He reports taking pain medication for the pain and previously using pain cream, sports tape and stretching. Available str supports one medical evaluation in 1989 for right shoulder pain.

b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous

c. Does the Veteran report flare-ups of the shoulder or arm? [X] Yes [ ] No

If yes, document the Veteran's description of the flare-ups in his or her own words: moving arms, lifting/carrying items, extending arms out from the body left or right laterally, lying down on the arms

d. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (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: moving arms, lifting/carrying items, extending arms out from the body left or right laterally, lying down on the arms

3. Range of motion (ROM) and functional limitation -------------------------------------------------

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VA Health Summary (Continuity of Care Document)

a. Initial range of motion

Right Shoulder -------------[ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)

Flexion (0 to 180): 0 to 70 degrees Abduction (0 to 180): 0 to 80 degrees External rotation (0 to 90): 0 to 50 degrees Internal rotation (0 to 90): 0 to 40 degrees

If abnormal, does the range of motion itself contribute to functional loss? [ ] Yes (please explain) [X] No

Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss

If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Abduction, External rotation, Internal 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 joint or associated soft tissue? [ ] Yes [X] No

Is there objective evidence of crepitus? [ ] Yes [X] No

Left Shoulder ------------[ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)

Flexion (0 to 180): 0 to 40 degrees Abduction (0 to 180): 0 to 45 degrees

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VA Health Summary (Continuity of Care Document)

External rotation (0 to 90): 0 to 40 degrees Internal rotation (0 to 90): 0 to 90 degrees

If abnormal, does the range of motion itself contribute to functional loss? [ ] Yes (please explain) [X] No

Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss

If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Abduction, External rotation, Internal 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 joint or associated soft tissue? [X] Yes [ ] No

If yes, describe including location, severity and relationship to condition(s): top of shoulder

Is there objective evidence of crepitus? [X] Yes [ ] No

b. Observed repetitive use

Right Shoulder -------------Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No

Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No

Left Shoulder ------------Is the Veteran able to perform repetitive use testing with at least three repetitions? [ ] Yes [X] No

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VA Health Summary (Continuity of Care Document)

If no, provide reason: unable to perform due to pain

c. Repeated use over time

Right Shoulder -------------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: [X] 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. [ ] 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: not witnessed by examiner

Left Shoulder ------------Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No

If the examination is not being conducted immediately after repetitive

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VA Health Summary (Continuity of Care Document)

use over time: [X] 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. [ ] 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: not witnessed by examiner

d. Flare-ups

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

If the examination is not being conducted during a flare-up: [X] 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. [ ] 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

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VA Health Summary (Continuity of Care Document)

If unable to say w/o mere speculation, please explain: not witnessed by examiner

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

If the examination is not being conducted during a flare-up: [X] 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. [ ] 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: not witnessed by examiner

e. Additional factors contributing to disability

Right Shoulder -------------In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Weakened movement due to muscle or peripheral nerve injury, etc.

Left Shoulder ------------In addition to those addressed above, are there additional contributing

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VA Health Summary (Continuity of Care Document)

factors of disability? Please select all that apply and describe: Weakened movement due to muscle or peripheral nerve injury, etc.

4. Muscle strength testing -------------------------a. Muscle strength - 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

Right Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No

Left Shoulder: Rate Strength: Forward flexion: 4/5 Abduction: 4/5 Is there a reduction in muscle strength? [X] Yes [ ] No

If yes, is the reduction entirely due to the claimed condition in the Diagnosis Section? [X] Yes [ ] No

b. Does the Veteran have muscle atrophy? [ ] Yes [X] No

c. Comments, if any: No response provided

5. Ankylosis -----------Complete this section if the Veteran has ankylosis of scapulohumeral

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VA Health Summary (Continuity of Care Document)

(glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus move as one piece).

a. Indicate severity of ankylosis and side affected (check all that apply):

Right side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis) [ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis) [ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis) [X] No ankylosis

Left side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis) [ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis) [ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis) [X] No ankylosis

b. Comments, if any: No response provided

6. Rotator cuff conditions -------------------------Is rotator cuff condition suspected?

Right Shoulder: [ ] Yes [X] No

Left Shoulder: [X] Yes [ ] No If "Yes" complete the following:

Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation indicates a positive test; may signify rotator cuff tendinopathy or tear.)

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VA Health Summary (Continuity of Care Document)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner. Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

External Rotation/ Infraspinatus Strength Test (Patient holds arms at side with elbow flexed 90 degrees. Patient externally rotates against resistance. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Lift-off Subscapularis Test (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may indicate subscapularis tendinopathy or tear.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

7. Shoulder instability, dislocation or labral pathology -------------------------------------------------------a. Is shoulder instability, dislocation or labral pathology suspected? [ ] Yes [X] No

8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint conditions -----------------------------------------------------------------------------a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition suspected? [ ] Yes [X] No

9. Conditions or impairments of the humerus ------------------------------------------a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus? [ ] Yes [X] No

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VA Health Summary (Continuity of Care Document)

b. Does the Veteran have malunion of the humerus with moderate or marked deformity? [ ] Yes [X] No

c. Does the humerus condition affect range of motion of the shoulder (glenohumeral) joint? [ ] Yes [X] No

d. Comments, if any: No response provided

10. Surgical procedures ----------------------No response provided

11. 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

12. Assistive devices --------------------a. Does the Veteran use any assistive devices?

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VA Health Summary (Continuity of Care Document)

[ ] Yes [X] No

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 the Veteran's shoulder and/or arm conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No

14. Diagnostic testing ---------------------a. Have imaging studies of the shoulder been performed and are the results available? [X] Yes [ ] No

If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No

If yes, indicate shoulder: [ ] Right [ ] Left [X] Both

b. Are there any other significant diagnostic test findings or results? [X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief summary): 1/3/2019 right shoulder x-ray Impression: Mild to moderate AC joint spurring.

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VA Health Summary (Continuity of Care Document)

8/14/2018 left shoulder x-ray Impression: Mild degenerative change of the acromioclavicular joint.

8/04/2018 left shoulder MRI Impression:

Supraspinatus and infraspinatus tendinopathy. Additionally tiny partial articular surface tear involving the distal fibers the supraspinatus tendon.

AC joint osteoarthritis with inferior projecting osteophytes stress response as well as small amount of fluid within subacromial subdeltoid bursa. Findings can be a cause for impingement. Correlate clinically.

c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided

15. Functional impact --------------------Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No

If yes, describe the impact of each of the Veteran's shoulder conditions providing one or more examples: The veteran reports that moving his arms laterally from the body and carrying and lifting items causes increased pain.

16. Remarks, if any: -------------------Gulf War Statement:

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VA Health Summary (Continuity of Care Document)

____(1) An undiagnosed illness ____(2) A diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (chronic fatigue, fibromyalgia and functional bowel disease) ____(3) A diagnosable chronic multi-symptom illness with a partially explained etiology __X__(4) A disease with a clear and specific etiology and diagnosis

Bilateral shoulder arthritis and left shoulder rotator cuff tear and tendonitis is at less as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia.

The veteran's above diagnosis of bilateral shoulder conditions is noted post military service. Available str has documented one medical evaluation for right shoulder pain and silent for left shoulder complaints. There is no documented chronicity of shoulder complaints/conditions. The veteran also notes this occurred prior to gulf service and available str noted right shoulder complaints in 1989.

ROM: A goniometer was used to measure ROM.

CORREIA STATEMENTS: PASSIVE RANGE OF MOTION (CLAIMED JOINT/S): _____There is no objective evidence of pain on passive range of motion testing. __X___There is objective evidence of pain on passive range of motion testing. _____Passive ROM of the spine was not performed as it is not feasible to do this in a safe and reasonable manner. _____Passive ROM is medically inappropriate and was not performed because ***

NON-WEIGHTBEARING (OF THE CLAIMED JOINT/S): __X___There is no objective evidence of pain when the joint is used in non-weight bearing. _____There is objective evidence of pain when the joint is used in non-weight bearing. _____Non-weight bearing assessment is not applicable. There is no objective

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VA Health Summary (Continuity of Care Document)

evidence of pain when the spine is in a non-weight bearing position at rest. _____Non-weight bearing assessment is medically inappropriate and was not performed because ***

OPPOSING (UNCLAIMED) JOINT: _____The opposing joint is undamaged with no exam abnormalities; see ROM noted above. __X___The opposing joint does have evidence of damage as indicated by the exam abnormalities documented above. _____Opposing joint assessment is not applicable because the spine does not have an opposing joint. _____Opposing joint assessment is medically inappropriate and was not performed because *** _____ Assessment of the opposing/unclaimed joint is not applicable because both joints were claimed and evaluated as documented above.

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

Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

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

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VA Health Summary (Continuity of Care Document)

Evidence Review --------------Evidence reviewed (check all that apply):

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

SECTION I: Diagnosis: --------------------Does the Veteran now have or has he/she ever been diagnosed with a sinus, nose, throat, larynx, or pharynx condition? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No

[X] Allergic rhinitis ICD code: J30.9 Date of diagnosis: 1982

SECTION II: Medical history --------------------------

The veteran reports that he started having issues with allergic rhinitis while in Germany around 1988-1989. He states he started having runny nose, swelling/itchy of his eyes, scratchy throat and sneezing. He reports having a medical evaluation and was taking Sudafed. He reports that over the years his symptoms have continued and are more during the spring and fall but can occur other times as well. He reports he continues to follow up with pcp and takes Claritin when symptoms occur. Available str supports a diagnosis in 1982 and additional medical evaluation in 2002.

SECTION III: Nose, throat, larynx or pharynx conditions ------------------------------------------------------Does the Veteran have any of the following nose, throat, larynx or pharynx conditions? [X] Yes [ ] No

[X] Rhinitis

2. Rhinitis ----------

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VA Health Summary (Continuity of Care Document)

a. Is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis? [X] Yes [ ] No

b. Is there complete obstruction on the left side due to rhinitis? [ ] Yes [X] No

c. Is there complete obstruction on the right side due to rhinitis? [ ] Yes [X] No

d. Is there permanent hypertrophy of the nasal turbinates? [X] Yes [ ] No

e. Are there nasal polyps? [ ] Yes [X] No

f. Does the Veteran have any of the following granulomatous conditions? [ ] Yes [X] No

If yes, check all that apply: [ ] Granulomatous rhinitis [ ] Rhinoscleroma [ ] Wegener's granulomatosis [ ] Lethal midline granuloma [ ] Other granulomatous infection, describe:

6. 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 answer provided

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VA Health Summary (Continuity of Care Document)

d. Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages? [ ] Yes[X] No

e. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala? [ ] Yes[X] No

f. Does the Veteran have loss of part of the nose or other scars causing other obvious disfigurement? [ ] Yes[X] No

SECTION IV: Diagnostic testing -----------------------------a. Have imaging studies of the sinuses or other areas been performed? [ ] Yes[X] No

b. Has endoscopy been performed?: No

c. Has the Veteran had a biopsy of the larynx or pharynx?: No

d. Has the Veteran had pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis?: No

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

SECTION V: Functional impact and remarks ---------------------------------------1. Functional impact -------------------Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact his or her ability to work? [ ] Yes [X] No

2. Remarks, if any: ------------------Gulf War Statement: ____(1) An undiagnosed illness

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VA Health Summary (Continuity of Care Document)

____(2) A diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (chronic fatigue, fibromyalgia and functional bowel disease) ____(3) A diagnosable chronic multi-symptom illness with a partially explained etiology _X___(4) A disease with a clear and specific etiology and diagnosis

allergic rhinitis is at less as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The diagnosis of allergic rhinitis occured prior to Gulf war service.

Allergic rhinitis, often called allergies or hay fever, occurs when your immune system overreacts to particles in the air that you breathe-you are allergic to them. Your immune system attacks the particles in your body, causing symptoms such as sneezing and a runny nose. You probably know that pollens from trees, grasses, and weeds cause allergic rhinitis. Many people have allergies to dust mites, animal dander, cockroaches, and mold as well. Things in the workplace, such as cereal grain, wood dust, chemicals, or lab animals, can also cause allergic rhinitis.

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

Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No

ACE and Evidence Review ----------------------

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VA Health Summary (Continuity of Care Document)

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 -----------a. List the claimed condition(s) that pertain to this DBQ: No response provided

b. Select diagnoses associated with the claimed condition(s):

[X] Flat foot (pes planus) ICD code: M21.4 Side affected: Both Date of diagnosis: Right: 1986 Date of diagnosis: Left: 1986

[X] Hallux valgus ICD Code: M20.12 Side affected: Left Date of diagnosis: Left 2018

[X] Arthritic conditions

[X] Arthritis, degenerative ICD Code: M19.079 Side affected: Left Date of diagnosis: Left 2018

c. Comments (if any):

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No response provided

d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A

2. Medical history -----------------a. Describe the history (including onset and course) of the Veteran's foot condition (brief summary): The veteran reports that he has always had bilateral foot pain. He reports going into the military he was told he had flat feet. He reports that over time the boots that he wore caused pain and rubbing of this feet on the top of his left foot and caused squeezing of his toes causing increased pain at the left great toe with redness. He denies medical evaluation during service or after and reports wearing sneakers with gel insoles but denies purchasing or being prescribed inserts. Available str supports pes planus noted on enlistment paperwork and silent for foot complaints.

b. Does the Veteran report pain of the foot being evaluated on this DBQ? [X] Yes [ ] No

If yes, document the Veteran's description of pain in his or her own words: aching pains in bilateral heels and bilateral plantar surface of the feet, left great toe, lateral, medial and top of left foot

c. Does the Veteran report that flare-ups impact the function of the foot? [X] Yes [ ] No

If yes, document the Veteran's description of flare-ups in his or her own words: walking and standing

d. Does the Veteran report having any functional loss or functional impairment of the foot being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No

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If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: walking and standing

3. Flatfoot (pes planus) -----------------------a. Does the Veteran have pain on use of the feet? [X] Yes [ ] No

If yes, indicate side affected: [ ] Right [ ] Left [X] Both

If yes, is the pain accentuated on use? [X] Yes [ ] No

If yes, indicate side affected: [ ] Right [ ] Left [X] Both

b. Does the Veteran have pain on manipulation of the feet? [X] Yes [ ] No

If yes, indicate side affected: [ ] Right [ ] Left [X] Both

If yes, is the pain accentuated on manipulation? [X] Yes [ ] No

If yes, indicate side affected: [ ] Right [ ] Left [X] Both

c. Is there indication of swelling on use? [ ] Yes [X] No

d. Does the Veteran have characteristic callouses? [ ] Yes [X] No

e. Effects of use of arch supports, built-up shoes or orthotics: No response provided

f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [X] Yes [ ] No

If yes, indicate side affected: [ ] Right [ ] Left [X] Both

Is the tenderness improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [ ] No [X] N/A

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VA Health Summary (Continuity of Care Document)

LEFT - [ ] Yes [ ] No [X] N/A

g. Does the Veteran have decreased longitudinal arch height of one or both feet on weight-bearing? [X] Yes [ ] No

If yes, indicate side affected: [ ] Right [ ] Left [X] Both

h. Is there objective evidence of marked deformity of one or both feet (pronation, abduction etc.)? [ ] Yes [X] No

i. Is there marked pronation of one or both feet? [ ] Yes [X] No

j. For one or both feet, does the weight-bearing line fall over or medial to the great toe? [ ] Yes [X] No

k. Is there a lower extremity deformity other than pes planus, causing alteration of the weight-bearing line? [ ] Yes [X] No

l. Does the Veteran have "inward" bowing of the Achilles tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of one or both feet? [ ] Yes [X] No

m. Does the Veteran have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet? [ ] Yes [X] No

n. Comments: No comments provided

4. Morton's neuroma (Morton's disease) and metatarsalgia -------------------------------------------------------a. Does the Veteran have Morton's neuroma? [ ] Yes [X] No

b. Does the Veteran have metatarsalgia? [ ] Yes [X] No

c. Comments: No comments provided

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5. Hammer toe ------------a. Which toes are affected on each side?

RIGHT: [X] None

LEFT: [X] None

b. Comments: No response provided

6. Hallux valgus ---------------a. Does the Veteran have symptoms due to a hallux valgus condition? [X] Yes [ ] No

If yes, indicate severity:

[X] Mild or moderate symptoms Side affected: [ ] Right [X] Left [ ] Both

b. Has the Veteran had surgery for hallux valgus? [ ] Yes [X] No

c. Comments: No comments provided

7. Hallux rigidus ----------------a. Does the Veteran have symptoms due to hallux rigidus? [ ] Yes [X] No

b. Comments: No comments provided

8. Acquired pes cavus (clawfoot) -------------------------------a. Effect on toes due to pes cavus (check all that apply):

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[X] None

b. Pain and tenderness due to pes cavus (check all that apply): [X] None

c. Effect on plantar fascia due to pes cavus (check all that apply): [X] None

d. Dorsiflexion and varus deformity due to pes cavus (check all that apply): [X] None

e. Comments: No comments provided

9. Malunion or nonunion of tarsal or metatarsal bones ----------------------------------------------------No response provided

10. Foot injuries and other conditions -------------------------------------a. Does the Veteran have any foot injuries or other foot conditions not already described? [ ] Yes [X] No

b. Indicate severity and side affected: No response provided

c. Does the foot condition chronically compromise weight bearing? No response provided

d. Does the foot condition require arch supports, custom orthotic inserts or shoe modifications? No response provided

e. Comments: No comments provided

11. Surgical procedures ----------------------a. Has the Veteran had foot surgery (arthroscopic or open)? [ ] Yes [X] No

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b. Does the Veteran have any residual signs or symptoms due to arthroscopic or other foot surgery? No response provided

12. Pain -------RIGHT FOOT:

Is there pain on physical exam? [X] Yes [ ] No

If yes, (there is pain on physical exam), does the pain contribute to functional loss? [X] Yes [ ] No

(Further description of limitations requested in Section XIII below.)

LEFT FOOT:

Is there pain on physical exam? [X] Yes [ ] No

If yes, (there is pain on physical exam), does the pain contribute to functional loss? [X] Yes [ ] No

(Further description of limitations requested in Section XIII below.)

13. Functional loss and limitation of motion -------------------------------------------a. Contributing factors of disability (check all that apply and indicate side affected):

[X] Pain on weight-bearing Side affected: [ ] Right [ ] Left [X] Both

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[X] Disturbance of locomotion Side affected: [ ] Right [ ] Left [X] Both

[X] Interference with standing Side affected: [ ] Right [ ] Left [X] Both

Contributing factors of disability associated with limitation of motion:

b. Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time?

RIGHT FOOT: [ ] Yes [X] No

LEFT FOOT: [ ] Yes [X] No

c. Is there any other functional loss during flare-ups or when the foot is used repeatedly over a period of time?

RIGHT FOOT: [ ] Yes [X] No

LEFT FOOT: [ ] Yes [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: No comments provided

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15. Assistive devices --------------------a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No

b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided.

16. Remaining effective function of the extremities --------------------------------------------------Due to the Veteran's foot condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No

17. Diagnostic testing ---------------------a. Have imaging studies of the foot been performed and are the results available? [X] Yes [ ] No

If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No

If yes, indicate foot: [ ] Right [X] Left [ ] Both

b. Are there any other significant diagnostic test findings or results? [X] Yes [ ] No

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

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summary): 1/3/2019 bilateral weight bearing x-rays

There is bilateral pes planus. There is mild hallux valgus on the left. Some mild degenerative change involves the left first MTP joint. No soft tissue swelling.

Impression: Degenerative change as above.

c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition: No response provided

18. Functional impact --------------------Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No

If yes, describe the functional impact of each condition, providing one or more examples: The veteran reports due to the continues standing and walking that is required of his job he must sit and rest due to the pain.

19. Remarks, if any: -------------------Gulf War Statement: ____(1) An undiagnosed illness ____(2) A diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (chronic fatigue, fibromyalgia and functional bowel disease) ____(3) A diagnosable chronic multi-symptom illness with a partially explained etiology _X___(4) A disease with a clear and specific etiology and diagnosis

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pes planus/hallux valgus/degenerative arthritis is at less as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia.

Available str has documented pes planus on enlistment paperwork which was prior to Gulf war service. The available str is silent for medical evaluations for hallux valgus or degenerative arthritis. These were diagnosed in 2019 post military service.

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

Fibromyalgia Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

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):

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[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 fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested) [ ] Yes [X] No

2. Medical history -----------------a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: The veteran reports that he feels tired all the time and does not sleep well. He reports soreness from chest down to abdomen. He denies medical evaluation for fibromyalgia, diagnosis or taking medications. Available str and mtr is silent for diagnosis or treatment for fibromyalgia.

b. Is continuous medication required for control of fibromyalgia symptoms? [ ] Yes [X] No

c. Is the Veteran currently undergoing treatment for this condition? [ ] Yes [X] No

d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [ ] Yes [X] No

3. Findings, signs and symptoms ------------------------------Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia? [X] Yes [ ] No

a. Findings, signs and symptoms (check all that apply):

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[X] Stiffness [X] Fatigue [X] Sleep disturbances [X] Headache [X] Anxiety [X] Irritable bowel symptoms

For all checked conditions, describe:

b. Frequency of fibromyalgia symptoms (check all that apply):

[X] Episodic with exacerbations

c. Does the Veteran have tender points (trigger points) for pain present? [ ] Yes [X] No

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 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

5. Diagnostic testing --------------------Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No

6. Functional impact --------------------Does the Veteran's fibromyalgia impact his or her ability to work?

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[X] Yes [ ] No

If yes, describe impact of the Veteran's fibromyalgia, providing one or more examples: He reports that when he has symptoms he has to rest and take a break and reports pacing himself at work.

7. Remarks, if any: ------------------Gulf War Statement: ____(1) An undiagnosed illness ____(2) A diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (chronic fatigue, fibromyalgia and functional bowel disease) __X__(3) A diagnosable chronic multi-symptom illness with a partially explained etiology ____(4) A disease with a clear and specific etiology and diagnosis

fibromyalgia is at less as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia.

Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals.

The veteran's available str and mtr is silent for complaints, treatment or diagnosis of fibromyalgia. Unable to make formal diagnosis due to lack of objective evidence confirming diagnosis, testing or treatment. Symptom frequency, intensity and duration are per self-report only and not confirmed in the claims file.

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

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Headaches (including Migraine Headaches) Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

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 headache condition? [ ] Yes [X] No

2. Medical History -----------------a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): The veteran reports that he has a "knot" that swells on the right side of neck intermittently that causes a dull aching pain on the right side of his head. He reports this occurs about several times a month and the

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headaches can last 1-2 days. He reports increased blurred vision. He states the swelling of the "knot" occurs more when he has a cold. Available str and mtr is silent for diagnosis or treatment of headaches.

b. Does the Veteran's treatment plan include taking medication for the diagnosed condition? [ ] Yes [X] No

3. Symptoms ----------a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pain localized to one side of the head [X] Other, describe: aching on the right side of the head

b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain) [X] Yes [ ] No [X] Changes in vision (such as scotoma, flashes of light, tunnel vision) c. Indicate duration of typical head pain [X] 1-2 days d. Indicate location of typical head pain [X] Right side of head

4. Prostrating attacks of headache pain --------------------------------------a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [ ] Yes [X] No

5. 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?

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[ ] 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.

6. Diagnostic testing --------------------Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No

7. Functional impact -------------------Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No

If yes, describe the impact of the Veteran's headache condition, providing one or more examples: He reports that he has difficulty concentrating due to the head pain.

8. Remarks, if any: ------------------Gulf War Statement: ____(1) An undiagnosed illness ____(2) A diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (chronic fatigue, fibromyalgia and functional bowel disease) __X__(3) A diagnosable chronic multi-symptom illness with a partially explained etiology ____(4) A disease with a clear and specific etiology and diagnosis

headache is at less as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia.

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The veteran's available str and mtr is silent for complaints, treatment or diagnosis of headaches. Unable to make formal diagnosis due to lack of objective evidence confirming diagnosis, testing or treatment. Symptom frequency, intensity and duration are per self-report only and not confirmed in the claims file.

/es/ xxxxxxxxxx NURSE PRACTITIONER Signed: 01/04/2019 09:06

Encounter

Date/Time Encounter Type Encounter Description

Reason Provider Source

Jan 03, 2019, 01:00 PM

OFFICE CONSULTATION

GENERAL INTERNAL MEDICINE

Encounter for other administrative examinations ICD10 Z02.89 with Provider Comments: Encounter for other Administrative Examinations

xxxxxxxxxxxxxxxxxxx

xxxxxxxxxxxxxxxxxxx

Encounter Notes

The included Outpatient Encounter Notes are available 3 calendar days after completion and include a maximum of the 5 most recent notes associated with the Outpatient Encounter. The data comes from all VA treatment facilities.

Date/Time Encounter Note Provider

Jan 03, 2019, 01:00 PM C & P EXAMINATION NOTE : LOCAL TITLE: C&P EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 03, 2019@13:00 ENTRY DATE: JAN 04, 2019@09:02:50 AUTHOR: xxxxxxxxxxxxxxxxxxx EXP COSIGNER: URGENCY: STATUS: COMPLETED

Heart Conditions: (Including Ischemic & Non-ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery)

xxxxxxxxxxxxxxxxxxx

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Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

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] Other heart condition, specify below Other diagnosis #1: first degree block & atrial prematur deplorization ICD code: I44.0 Date of diagnosis: SC 2014

2. Medical History -----------------

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a. Describe the history (including onset and course) of the Veteran's heart condition(s) (brief summary): The veteran is service connected for 1-degree AV block with premature depolarization. The veteran reports that he is followed by pcp and currently not prescribed medications for this condition but does take aspirin daily. He reports that he has random episodes of chest pain and feeling of his heart skipping beats and has shortness of breath on exertion. he reports having testing such as EKG and Echo completed in 2017. He reports the chest pains can be dull and at times sharp causing him to to not complete activities.

b. Do any of the Veteran's heart conditions qualify within the generally accepted medical definition of ischemic heart disease (IHD)? [ ] Yes [X] No

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: No response provided.

d. Is continuous medication required for control of the Veteran's heart condition? [ ] Yes [X] No

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?

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[ ] Yes [X] No

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? [ ] Yes [X] No

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: 80

b. Rhythm: [X] Regular [ ] Irregular

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

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[ ] 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: [X] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Left lower extremity: [X] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+

i. Blood pressure: 161/85

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? [ ] Yes [X] No

c. Comments, if any: No response provided

13. Diagnostic Testing ---------------------a. Is there evidence of cardiac hypertrophy?

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[ ] 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: 1/3/2019

Result: [X] Other, describe: sinus rhythm with 1st degree A-V block

[X] Echocardiogram Date of echocardiogram: 9/6/2017 Left ventricular ejection fraction (LVEF): 55 %

Wall motion: [X] Normal [ ] Abnormal, describe: Wall thickness: [X] Normal [ ] Abnormal, describe:

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. Exercise stress test No response provided.

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

[X] Exercise stress testing is not required as part of Veteran's current treatment plan and this test is not without significant risk

c. [X] Interview-based METs test

Date of interview-based METs test: 1/3/2019

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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] Angina [X] Other, describe: "heart skipping beats"

Results of interview-based METs test METs level on most recent interview-based METs test:

[X] (>7-10 METs) This METs level has been found to be consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, jogging (6 mph)

d. Has the Veteran had both an exercise stress test and an interview-based METs test? [ ] Yes [X] No

e. Is the METs level limitation provided above due solely to the heart condition(s) that the Veteran is claiming in the Diagnosis Section? [X] Yes [ ] No

If yes, skip 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.) No response provided.

g. Comments, if any: No response provided.

15. Functional impact --------------------

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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: The veteran reports that he has to stop and rest when symptoms occur.

16. Remarks, if any ------------------No remarks provided.

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

Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

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)

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[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: No response provided.

Diagnosis #1: degenerative arthritis lumbar spine ICD code: M47.9 Date of diagnosis: 2018

2. Medical history -----------------a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): The veteran reports that he started having back pain during military service while in Germany and worsen while in Alabama. He states he had a medical evaluation during service and was prescribed Motrin. He states the center of his back is a constant pain and the lower back hurts intermittently more after lying down for extended periods and wakes with soreness and stiffness. He denies continued medical evaluation after military service. He states he use stretching for the pain. Available str supports one medical evaluation for back pain during military service.

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: lying down, lifting items, exercise

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

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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. lying down, lifting items, exercise

3. Range of motion (ROM) and functional limitation -------------------------------------------------a. Initial range of motion

[ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)

Forward Flexion (0 to 90): 0 to 50 degrees Extension (0 to 30): 0 to 20 degrees Right Lateral Flexion (0 to 30): 0 to 30 degrees Left Lateral Flexion (0 to 30): 0 to 10 degrees Right Lateral Rotation (0 to 30): 0 to 10 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees

If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes (please explain) [X] No

Description of pain (select best response): Pain noted on exam but does not result in/cause 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

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If yes, describe including location, severity and relationship to condition(s): right side of back

b. Observed repetitive use

Is the Veteran able to perform repetitive use testing with at least three repetitions? [ ] Yes [X] No If no, please provide reason: unable to perform due to pain

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: [X] 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. [ ] 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: not witnessed by examiner

d. Flare-ups

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

If the examination is not being conducted during a flare-up: [X] 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. [ ] 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: not witnessed by examiner

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [ ] Yes [X] No

f. Additional factors contributing to disability

In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Weakened movement due to muscle or peripheral nerve injury, etc.

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

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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: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

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:

XXXXXXXXXXXX CONFIDENTIAL Page 56 of 125

VA Health Summary (Continuity of Care Document)

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: [X] Normal [ ] Decreased [ ] Absent

Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent

Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent

Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent

7. Straight leg raising test ---------------------------Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform

8. Radiculopathy ---------------Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No

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VA Health Summary (Continuity of Care Document)

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: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Paresthesias and/or dysesthesias Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] 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) No response provided.

d. Indicate severity of radiculopathy and side affected:

Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe

Left: [X] Not affected [ ] Mild [ ] 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)?

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VA Health Summary (Continuity of Care Document)

[ ] Yes [X] No

11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] 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? [ ] Yes [X] No

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

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VA Health Summary (Continuity of Care Document)

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? [X] Yes [ ] 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? [X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief summary): 1/3/2019 lumbar spine x-ray Impression: Minimal scoliosis or positional curvature of the lumbar spine. Vertebral body heights and intervertebral disc spaces are maintained. Small endplate osteophyte formation at the T10-T11. Mild facet arthropathy of the lower lumbar spine. There is round density in the right upper quadrant. Diagnostic considerations include large gallstone or renal stone. Recommend further evaluation with right upper quadrant ultrasound.

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VA Health Summary (Continuity of Care Document)

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: The veteran reports that the extended walking and lifting items on his job causes increased back pain and he must sit and rest due to the pain.

17. Remarks, if any: -------------------ROM: A goniometer was used to measure ROM.

CORREIA STATEMENTS: PASSIVE RANGE OF MOTION (CLAIMED JOINT/S): _____There is no objective evidence of pain on passive range of motion testing. _____There is objective evidence of pain on passive range of motion testing. __X___Passive ROM of the spine was not performed as it is not feasible to do this in a safe and reasonable manner. _____Passive ROM is medically inappropriate and was not performed because ***

NON-WEIGHTBEARING (OF THE CLAIMED JOINT/S): _____There is no objective evidence of pain when the joint is used in non-weight bearing. _____There is objective evidence of pain when the joint is used in non-weight bearing. __X___Non-weight bearing assessment is not applicable. There is no objective evidence of pain when the spine is in a non-weight bearing position at rest. _____Non-weight bearing assessment is medically inappropriate and was not performed because ***

OPPOSING (UNCLAIMED) JOINT: _____The opposing joint is undamaged with no exam abnormalities; see ROM

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VA Health Summary (Continuity of Care Document)

noted above. _____The opposing joint does have evidence of damage as indicated by the exam abnormalities documented above. __X___Opposing joint assessment is not applicable because the spine does not have an opposing joint. _____Opposing joint assessment is medically inappropriate and was not performed because *** _____ Assessment of the opposing/unclaimed joint is not applicable because both joints were claimed and evaluated as documented above.

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

Medical Opinion Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXX 216921540

ACE and Evidence Review ----------------------Indicate method used to obtain medical information to complete this document:

[X] In-person examination

Evidence Review --------------Evidence reviewed (check all that apply):

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

MEDICAL OPINION SUMMARY ----------------------

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VA Health Summary (Continuity of Care Document)

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: Does the veteran have a diagnosis of (a) low back condition with pain that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) treatment during service?

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

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

b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.

c. Rationale: The veteran has a diagnosis of lumbar spine arthritis that was found on x-ray conducted on 1/3/2019. He had one medical evaluation per str during active military service in 1990 for pain and the next documented complaints of back pain or symptoms is noted in 2018 in available mtr. There is no medical evidence to support chronicity of symptoms that the veterans current complaints are related to military service.

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

/es/ xxxxxxxxxx NURSE PRACTITIONER Signed: 01/04/2019 09:02

Encounter

Date/Time Encounter Type Encounter Description

Reason Provider Source

Jan 03, 2019, 08:30 AM

DISABILITY EXAMINATION

GENERAL INTERNAL MEDICINE

Encounter for other administrative examinations ICD10 Z02.89 with Provider Comments: Encounter for other Administrative Examinations

xxxxxxxxxxxxxxxxxxx

xxxxxxxxxxxxxxxxxxx

XXXXXXXXXXXX CONFIDENTIAL Page 63 of 125

VA Health Summary (Continuity of Care Document)

Encounter Notes

There are no associated notes for this encounter.

Encounter

Date/Time Encounter Type Encounter Description

Reason Provider Source

Dec 31, 2018, 03:00 PM

COLLJ & INTERPJ DATA EA 30 D

HT NON-VIDEO MONITORING

Essential (primary) hypertension ICD10 I10. with Provider Comments: Essential (Primary) Hypertension (ICD-10-CM I10.)

xxxxxxxxxxxxxxxxxxx T

xxxxxxxxxxxxxxxxxxx

Encounter Notes

The included Outpatient Encounter Notes are available 3 calendar days after completion and include a maximum of the 5 most recent notes associated with the Outpatient Encounter. The data comes from all VA treatment facilities.

Date/Time Encounter Note Provider

Dec 31, 2018, 04:01 PM CARE COORDINATION HOME TELEHEALTH SUMMARIZATION NOTE : LOCAL TITLE: HT MONTHLY MONITOR NOTE STANDARD TITLE: CARE COORDINATION HOME TELEHEALTH SUMMARIZATION DATE OF NOTE: DEC 31, 2018@16:01 ENTRY DATE: DEC 31, 2018@16:02:38 AUTHOR: xxxxxxxxxxxxxxxxxxx T EXP COSIGNER: URGENCY: STATUS: COMPLETED

The Veteran is enrolled in the Home Telehealth (HT) program for COPD and continues to be monitored via HT technology. The data sent by the Veteran is reviewed and analyzed by the HT staff, who provide ongoing case management and Veteran health education while communicating and collaborating with the health care team as appropriate. This note covers a total of 30 minutes for the month monitored.

Month monitored: December 2018

/es/ xxxxxxxxxxxxxxxxxxx MSN, RN, BC Care Coordinator, Home Telehealth Signed: 12/31/2018 16:45

T

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VA Health Summary (Continuity of Care Document)

Encounter

Date/Time Encounter Type Encounter Description

Reason Provider Source

Dec 06, 2018, 07:30 AM

THERAPEUTIC EXERCISES

PHYSICAL THERAPY

Unspecified injury of left shoulder and upper arm, sequela ICD10 S49.92XS with Provider Comments: Injury of shoulder region (SCT 125594001)

xxxxxxxxxxxxxxxxxxx

xxxxxxxxxxxxxxxxxxx

Encounter Notes

The included Outpatient Encounter Notes are available 3 calendar days after completion and include a maximum of the 5 most recent notes associated with the Outpatient Encounter. The data comes from all VA treatment facilities.

Date/Time Encounter Note Provider

Dec 06, 2018, 07:40 AM PHYSICAL MEDICINE REHAB DISCHARGE NOTE : LOCAL TITLE: PM&RS DISCHARGE PROGRESS NOTE STANDARD TITLE: PHYSICAL MEDICINE REHAB DISCHARGE NOTE DATE OF NOTE: DEC 06, 2018@07:40 ENTRY DATE: DEC 06, 2018@07:40:33 AUTHOR: J EXP COSIGNER: URGENCY: STATUS: COMPLETED

Provisional Diagnosis by Provider: L shoulder pain Date of onset/Referral: 08/14/18 Precautions/Limitations: none Date of Recertification: Dec 20,2018 Visit #: 6/6 Treatment Time: 10 mins therex

Patient is a 53 year old BLACK OR AFRICAN AMERICAN MALE referred for physical therapy by NP Morman CC: PA Louthian for evaluation and treatment.

SUBJECTIVE: Sharp shoulder pain improved. GROC score is +4. Only issue is reaching out to the sides or sleeping on his R shoulder. Has not really been doing his HEP over the last couple weeks for no explained reason. "I wonder if they can do another x-ray in a couple months to see if my shoulder got better".

Baseline Measures: --Mean Pain Score

 

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VA Health Summary (Continuity of Care Document)

Best: 0 Current: 0 Worst: 3

--Outcome measure (NDI, ODI, WOMAC, etc.): SPADI score 26/50 pain and 29/80 function 55/130 total

Baseline Measures: --Mean Pain Score Best: 3 = I have uncomfortable pain, but I can usually tolerate it. Current: 3 = I have uncomfortable pain, but I can usually tolerate it. Worst: 8 = I have pain so intense it is hard to walk, talk and is disabling.

--Outcome measure (NDI, ODI, WOMAC, etc.): SPADI score 40/50 pain and 87/130 function 87/130 total

O: Brief HEP review. Encouraged to complete each exercise twice weekly at a minimum.

Educated/Discussed shoulder mechanics, preventative medicine theory. Informed that any osteophytosis or degenerative changes noted prior to PT efforts will still be there, tried to relay how we are working on changing biomechanics over time not pathology.

ASSESSMENT: Physical Therapy Impression/Diagnosis: L AC joint arthropathy/osteophytosis with known RTC tendinopathy. HEP has helped. Pain and function with significant clinical improvement.

Rehabilitation Prognosis- (considering adherence, commitment, motivation, distance, chronicity etc.) fair+

Based on discussion today and/or patient performance or response to interventions, one could expect or assume adherence to PT is: good

Goals in PT (Short and Long Term)- in 6 tx I and adherence with HEP MID in mean VAS pain score

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VA Health Summary (Continuity of Care Document)

MID in PSFS score GROC score 2+ or better

PLAN: d/c from PT.

Planned duration/frequency: n/a

Patient is in agreement with our attendance policy and the above plan of care and verbalized understanding.

/es/ xxxxxxxxxxxxxxxxxxx DPT, OMT-C, CERT.DN, CCI Signed: 12/06/2018 07:57

Encounter

Date/Time Encounter Type Encounter Description Reason Pro

 

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Posted (edited)

I may have missed read this report  as it was very long with different conditions to address...so it is quite confusing to say the least, but what I did read don't look like this examiner did you any favors...

I would say you will be denied on 90% of what your claiming   maybe 10% for nasal rintinnitus  <miss spelled...  but other members  can chime in here and give their opinion

Edited by Buck52

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Posted (edited)

This 125 page report, for 12 different conditions is difficult for us to evaluate.  Instead, if you have the software, search for the phrase, "at least as likely as not" and see which conditions, if any, will be sc.  You can apply the Caluza elements which are documented.   I apologize, in advance, if my response offends you.  However, its in your best interest to do much of the work yourself, and understand which conditions you have a nexus for.  

 

You posted:

Quote

The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.

c. Rationale: The veteran has a diagnosis of lumbar spine arthritis that was found on x-ray conducted on 1/3/2019. He had one medical evaluation per str during active military service in 1990 for pain and the next documented complaints of back pain or symptoms is noted in 2018 in available mtr. There is no medical evidence to support chronicity of symptoms that the veterans current complaints are related to military service.

The quoted statement, above, means you have a "negative" nexus, and wont be getting sc for this condition, UNLESS you have another doctor who can/will provide a nexus.  

You can read the entire 125 page report, and see for yourself which of these have the statement "at least as likely as not" related to military service.  Frankly, Im not going to read the entire 125 page report and do it for you..it isnt even in your best interest for me to do so.  You are better off doing that yourself.  I dont mind teaching, but Im not doing everything for you.  

Edited by broncovet

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