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C-File Evidence Review - John Doe
VBMS Reviewer · vbms.review · May 2026
Case Posture Snapshot
Veteran is working as of 06/11/2026. Extracted records show service-connected bilateral knee conditions, PTSD with TBI, headaches, tinnitus, and TBI history, with later claims/decisions involving bilateral knees, GERD, back condition, and vertigo. The file contains multiple rating decisions, C&P examinations, STRs, VA treatment records, lay statements, and VR&E evidence, with several date and record-consistency items requiring verification.
Executive Evidence Summary
03/13/2023 knee DBQ documented left knee iliotibial band friction syndrome and right knee internal derangement with proximal tibia exostosis/loose bodies; flare-up flexion was estimated at 100 degrees bilaterally with extension 0 degrees.
00140-C&P Exam-20230313
00140-C&P Exam-20230313
Right knee evaluation was reduced from 20 percent to 10 percent effective 08/01/2023; codesheet also noted a separate noncompensable evaluation for right knee limitation of extension from 04/19/2022.
00100-Rating Decision - Codesheet-20230601
00100-Rating Decision - Codesheet-20230601
July 2022/October 2022 knee evidence reflected more severe right knee findings, including flexion limited to 16 to 30 degrees and extension limited to 5 to 9 degrees, with additional functional loss.
AutomatedDecisionLetter
AutomatedDecisionLetter
Service records and later opinions document in-service blast exposure/concussion history and bilateral knee evidence, including 09/22/2010 left IT band friction syndrome and multiple concussion evaluations.
01310-STR-20180706
01310-STR-20180706
2018 headache DBQ described very frequent completely prostrating and prolonged attacks causing severe economic inadaptability, contrasting with the 09/30/2014 examination.
01190-C&P Exam-20180801 Attorney verification
01190-C&P Exam-20180801 Attorney verification
September 2022 DBQs confirmed diagnoses of lumbosacral strain and GERD, while the vertigo examination found no objective evidence of vertigo or current vestibular diagnosis.
00520-C&P Exam-20220925
00520-C&P Exam-20220925
VR&E records documented vocational impairment, employment handicap, and serious employment handicap, but some entries conflict on combined rating and remaining entitlement.
00880-VA Form 28-1902b-20191104 Attorney verification
00880-VA Form 28-1902b-20191104 Attorney verification
Condition Evidence Board
| Condition | Evidence Found | Medical / Lay Evidence | Functional Impairment / Rating Signals | Attorney Review Flags |
|---|---|---|---|---|
| Bilateral knee conditions 09/22/2010 - 08/01/2023 |
Extensive STR, VA treatment, DBQ, imaging, lay, and decision evidence. | Medical: 03/13/2023 DBQ diagnosed left IT band friction syndrome and right internal derangement with proximal tibia exostosis and loose bodies. Treatment records document chronic pain, swelling, buckling, and orthopedic referral. Lay: Chronic pain since service, worsened by squatting, kneeling, stairs, prolonged standing/walking, and high-impact activity. |
Unable to run, squat, crawl, or comfortably climb ladders/stairs; work restrictions included no climbing, frequent bending, prolonged standing, or lifting over 20 pounds. 03/13/2023 flare-up flexion estimated at 100 degrees bilaterally. 2022 evidence reflected materially more severe right-knee ROM. | Severity differs materially between 2022 and 2023. Orthopedic consultation findings referenced in February 2023 are absent. 00140-C&P Exam-20230313 AutomatedDecisionLetter |
| PTSD with traumatic brain injury 08/31/2012 - 11/04/2019 |
Service records, VA treatment, DBQs, lay statements, decisions, and VR&E evidence. | Evidence describes irritability, suspiciousness, panic, anxiety, impaired impulse control, obsessional rituals, inability to maintain relationships, moderate memory/attention/executive impairment, impaired judgment, and neurobehavioral effects. | Significant occupational and social impairment, difficulty adapting to stressful work-like settings, and effects on job performance and employability. VR&E found vocational impairment and serious employment handicap. | 07/20/2018 PTSD DBQ reportedly contains conflicting diagnostic conclusions. Current work status should be checked against older VR&E unemployment evidence. 01000-Rating Decision - Narrative-20180912 |
| Tension headaches 09/30/2014 - 08/23/2018 |
Service/TBI history, 2014 and 2018 examinations, lay reports, and decision evidence. | 2018 DBQ diagnosed tension headaches with migraine-type symptoms, nausea, vomiting, photophobia, phonophobia, and visual/sensory changes. 2014 DBQ described non-prostrating headaches. | 2018 evidence indicated prostrating attacks more than monthly and severe economic inadaptability; Veteran reported losing two jobs and being sent home from work. | Severity evidence is inconsistent between 2014 and 2018 examinations. 01190-C&P Exam-20180801 |
| Lumbosacral strain 09/17/2022 - 10/19/2022 |
September 2022 DBQ and decision evidence. | DBQ diagnosed lumbosacral strain. Flexion 80 degrees, extension 25 degrees; pain, tenderness, and muscle spasm without radiculopathy, ankylosis, neurologic abnormalities, or IVDS. | Examiner stated no occupational impact and no additional loss after repetitive use. | Decision states no in-service back evidence; record includes lay report of blast-related onset. 00520-C&P Exam-20220925 |
| GERD 02/03/2022 - 10/19/2022 |
2022 treatment, September 2022 DBQ, and decision evidence. | Possible GERD assessed in February 2022; September DBQ diagnosed GERD with reflux and regurgitation. No dysphagia, pyrosis, anemia, weight loss, or severe impairment of health documented. | Examiner stated no work impact. Evidence supports reflux/regurgitation only. | No diagnostic imaging, endoscopy, biopsy, or laboratory testing reported. 00500-C&P Exam-20220926 |
| Vertigo 02/26/2012 - 10/19/2022 |
Evidence present, but current diagnosis evidence is negative. | Veteran reported morning lightheadedness and dizzy spells; examiner found no objective vertigo or current ear/peripheral vestibular diagnosis. Testing was normal. | No work impact documented. | Current-diagnosis evidence is unfavorable despite documented in-service dizziness. 00530-C&P Exam-20220925 |
| Bilateral hearing loss and tinnitus 09/23/2014 - 08/23/2018 |
Audiology exams, lay statements, STR audiograms, and decisions. | 2018 audiology showed mild bilateral sensorineural hearing loss that did not meet VA ratable criteria; tinnitus was linked to military noise exposure. | Veteran reported repetition needs, high TV volume, and tinnitus-related sleep disturbance. | Hearing-loss nexus appears favorable, but ratable criteria were not met. Tinnitus was granted at 10 percent. 01170-C&P Exam-20180801 |
Medical Evidence Summary
Bilateral knees: 03/13/2023 DBQ documented left IT band friction syndrome and right internal derangement with proximal tibia exostosis/loose bodies; flare-up flexion estimated at 100 degrees bilaterally. 00140-C&P Exam-20230313
Right knee: MRI review documented chondromalacia and two loose bodies up to 1 cm explaining pain, swelling, and recurrent buckling. HEALTH SUMMARY (Local)_ Adhoc Report
Lumbosacral strain / GERD: September 2022 DBQs diagnosed lumbosacral strain and GERD. 00520-C&P Exam-20220925 00500-C&P Exam-20220926
Vertigo: Examiner found no objective evidence of vertigo or current vestibular diagnosis. 00530-C&P Exam-20220925
PTSD/TBI and headaches: Decision evidence described severe psychiatric/neurobehavioral symptoms; headache DBQ described prostrating attacks with economic inadaptability. 01000-Rating Decision - Narrative-20180912 01190-C&P Exam-20180801
Lay Evidence Summary
Veteran reported constant bilateral knee pain with sharp flares, worsened by squatting, kneeling, stairs, prolonged standing/walking, and high-impact activity; inability to run and difficulty playing with his son. 00140-C&P Exam-20230313
Veteran reported a 2011 Afghanistan IED incident causing continued low-back strain, muscle tension, aches, and pain. 00520-C&P Exam-20220925
Veteran reported GERD symptoms since 2011 and worsening morning dizziness/lightheadedness since 2019. 00500-C&P Exam-20220926 00530-C&P Exam-20220925
Veteran reported worsening prostrating headaches and PTSD symptoms including anxiety, sleep difficulty, irritability, suspiciousness, panic, social withdrawal, and difficulty adapting to stressful situations. 01350-VA 21-526EZ-20180627 01210-C&P Exam-20180801
Functional Impairment Summary
Knees: Pain prevents squatting/crawling and limits ladders, confined spaces, hills, stairs, family activities, prolonged standing, bending, and lifting over 20 pounds.
PTSD / employment handicap: VR&E records document effects on performance, opportunities, coworkers, managers, missed work, employability, and serious employment handicap.
Headaches: Veteran reported losing two jobs and being sent home when visibly in pain.
Rating Criteria Evidence
03/13/2023 bilateral knee ROM was flexion 120 and extension 0, with painful active/passive motion and weight-bearing; flare-up flexion estimated at 100. No objective recurrent instability was found. 00140-C&P Exam-20230313
October 2022 decision evidence stated right-knee flexion was limited to 16-30 degrees and extension to 5-9 degrees. AutomatedDecisionLetter
2018 headache DBQ indicated prostrating attacks more than monthly productive of economic inadaptability. 01190-C&P Exam-20180801
GERD evidence documented reflux and regurgitation without considerable/severe impairment of health. PTSD/TBI decision language stated evidence did not meet 100-percent criteria.
VA Timeline & Deadline Signals
06/05/2023: Notice advised review options could be sought within one year; attorney should verify tolling or subsequent decision activity. AutomatedDecisionLetter
11/04/2022: Decision notice advised of review options within one year. AutomatedDecisionLetter
11/25/2022: Intent-to-file acknowledgment stated a completed application within one year could preserve the intent-to-file date. 00280-Intent to File Letter-20221125
Evidence Gaps & Needs Verification
No orthopedic consultation findings are included despite referral/consult placement in February 2023.
Right-knee instability history conflicts with normal objective instability testing.
07/20/2018 PTSD DBQ reportedly contains conflicting diagnostic conclusions.
Headache severity differs materially between 2014 and 2018 examinations.
Left-knee diagnosis evidence differs between 2014 and favorable 2018/later evidence.
GERD examination lacks diagnostic imaging, endoscopy, biopsy, or laboratory testing.
November 2019 VR&E records conflict on combined rating and remaining entitlement.
July 2018 QTC questionnaires were referenced without a specific day.
Source Index
00140-C&P Exam-20230313C&P Exam · 03/13/2023
Bilateral knee diagnoses, ROM, flare-up estimates, painful motion/weight-bearing, no objective instability.
Bilateral knee diagnoses, ROM, flare-up estimates, painful motion/weight-bearing, no objective instability.
00100-Rating Decision - Codesheet-20230601Rating Decision Codesheet · 06/01/2023
Right-knee reduction and separate limitation-of-extension evaluation.
Right-knee reduction and separate limitation-of-extension evaluation.
00110-Rating Decision - Narrative-20230601Rating Decision Narrative · 06/01/2023
Increased-rating claim, DBQ receipt, VAMC records, bilateral painful motion.
Increased-rating claim, DBQ receipt, VAMC records, bilateral painful motion.
DBQKNEELOWERV27DBQ · 07/25/2022
Bilateral diagnoses, ROM, functional impact, instability history, normal objective testing.
Bilateral diagnoses, ROM, functional impact, instability history, normal objective testing.
HEALTH SUMMARY (Local)_ Adhoc ReportVA Treatment Record · 02/09/2023
Chronic knee pain, swelling/buckling, MRI findings, orthopedic referral, reported job loss.
Chronic knee pain, swelling/buckling, MRI findings, orthopedic referral, reported job loss.
00520-C&P Exam-20220925C&P Exam · 09/25/2022
Lumbosacral strain, ROM, pain/tenderness/spasm, no radiculopathy or IVDS.
Lumbosacral strain, ROM, pain/tenderness/spasm, no radiculopathy or IVDS.
00500-C&P Exam-20220926C&P Exam · 09/17/2022
GERD diagnosis, medication, reflux/regurgitation, negative symptom findings.
GERD diagnosis, medication, reflux/regurgitation, negative symptom findings.
00530-C&P Exam-20220925C&P Exam · 09/17/2022
Reported dizziness, no objective vertigo, normal vestibular testing.
Reported dizziness, no objective vertigo, normal vestibular testing.
01190-C&P Exam-20180801C&P Exam · 07/19/2018
Tension headaches, prostrating attacks, economic inadaptability, reported job loss.
Tension headaches, prostrating attacks, economic inadaptability, reported job loss.
01210-C&P Exam-20180801C&P Exam · 07/20/2018
PTSD reports, occupational/social history, conflicting diagnostic conclusions.
PTSD reports, occupational/social history, conflicting diagnostic conclusions.
01000-Rating Decision - Narrative-20180912Rating Decision Narrative · 09/12/2018
PTSD/TBI symptoms, functional impairment, 100-percent criteria language.
PTSD/TBI symptoms, functional impairment, 100-percent criteria language.
01310-STR-20180706Service Treatment Records · 12/30/2014
Left IT band friction syndrome, concussion/blast history, behavioral-health symptoms.
Left IT band friction syndrome, concussion/blast history, behavioral-health symptoms.
00880-VA Form 28-1902b-20191104VR&E Counseling Record · 11/04/2019
Vocational impairment, employment handicap, serious employment handicap.
Vocational impairment, employment handicap, serious employment handicap.
00910-VA Form 28-1902w-20191104VR&E Needs Inventory · 11/04/2019
PTSD work effects, job performance, coworker/manager impact, employment history.
PTSD work effects, job performance, coworker/manager impact, employment history.
01460-Certificate of Release or Discharge-20141210DD214 · 08/08/2014
Honorable Marine Corps service, MOS 0311, Afghanistan service, Combat Action Ribbon.
Honorable Marine Corps service, MOS 0311, Afghanistan service, Combat Action Ribbon.
AutomatedDecisionLetterDecision · 09/01/2023
Decision and rating-criteria evidence.
Decision and rating-criteria evidence.
00040 / 00020-Third Party Correspondence-20240412Lay evidence · 04/12/2024
CLIN DOC_ Multi-Document / REPORT_ C&P Exam DetailMedical / STR evidence · 03/13/2023 and 02/22/2023