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Question
Breedlove
Can anyone help me to understand my c&p exam notes? I would like to know what it all means and what kind of rating if any I am looking at.
Thank you
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] Examination via approved video telehealth
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 had a skin condition?
[X] Yes [ ] No
[X] Psoriasis
ICD code: xxx Date of diagnosis: 8/30/2008
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's skin
conditions (brief summary):
The Vet was initially seen for his "rash" in 2008 per his STR. He was
diagnosed with psoriasis and it is mainly located on his abdomen,
arms,
legs and thighs. He uses a steroid cream and urea 40% to treat. He is
currently stable as long as he uses the medication.
b. Do any of the Veteran's skin conditions cause scarring (regardless of
location), or disfigurement of the head, face or neck?
[X] Yes [ ] No
If yes, indicate skin condition and describe scarring and/or
disfigurement:
slight redness of the skin with patches
If yes, are any of these scars painful or unstable, have a total area
equal to or greater than 39 square cm (6 square inches), or are
located on the head, face or neck? (An "unstable scar" is one where,
for any reason, there is frequent loss of covering of the skin over
the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters.
Location: abd/arms/hands/legs/thighs
Measurements: length 20cm X width 1cm
c. Does the Veteran have any benign or malignant skin neoplasms (including
malignant melanoma)?
No response provided.
d. Does the Veteran have any systemic manifestations due to any skin
diseases
(such as fever, weight loss or hypoproteinemia associated with skin
conditions such as erythroderma)?
[ ] Yes [X] No
e. Comments, if any:
No response provided.
3. Treatment
------------
a. Has the Veteran been treated with oral or topical medications in the past
12 months for any skin condition?
[X] Yes [ ] No
[X] Topical corticosteroids
If checked, list medication(s): clobetasol/urea 40%
Specify condition medication used for: psoriasis
Total duration of medication use in past 12 months:
[ ] < 6 weeks
[X] 6 weeks or more, but not constant
[ ] Constant/near-constant
b. Has the Veteran had any treatments or procedures other than systemic or
topical medications in the past 12 months for exfoliative dermatitis or
papulosquamous disorders?
[ ] Yes [X] No
4. Debilitating and non-debilitating episodes
---------------------------------------------
a. Has the Veteran had any debilitating episodes in the past 12 months due
to
urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic
epidermal necrolysis?
[ ] Yes [X] No
b. Has the Veteran had any non-debilitating episodes of urticaria, primary
cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis
in the past 12 months?
[ ] Yes [X] No
5. Physical exam
----------------
a. Indicate the Veteran's visible skin conditions; indicate the approximate
total body area and approximate total EXPOSED body area (face, neck and
hands) affected on current examination (check all that apply):
[X] Psoriasis
Total body area
[ ] None [ ] <5% [X] 5% to <20% [ ] 20% to 40% [ ] >40%
EXPOSED area
[ ] None [X] <5% [ ] 5% to <20% [ ] 20% to 40% [ ] >40%
b. For each skin condition, give specific diagnosis and describe appearance
and location:
No response provided.
6. Specific Skin Conditions
---------------------------
No response provided.
7. Tumors and neoplasms
-----------------------
a. Does the Veteran have a benign or malignant neoplasm or metastases
related
to any of the diagnoses in the Diagnosis section?
[ ] Yes [X] No
8. Other pertinent physical findings, complications, conditions, signs or
symptoms
-----------------------------------------------------------------------------
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. Comments, if any:
No response provided.
9. Functional impact
--------------------
Do any of the Veteran's skin conditions impact his or her ability to work?
[ ] Yes [X] No
10. Remarks, if any:
--------------------
His mild psoriasis is currently stable as long as he uses his medication
****************************************************************************
Ankle Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] Examination via approved video telehealth
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: Ankle Conditions
b. Select diagnoses associated with the claim condition(s) (Check all that
apply):
[X] Lateral collateral ligament sprain (chronic/recurrent)
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: xxx
Date of diagnosis: Right 2005/2009
Date of diagnosis: Left 2005/2009
c. Comments (if any): Vet was on airborne status
d. Was an opinion requested about this condition (Internal VA only)?
[ ] Yes [ ] No [X] N/A
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's ankle
condition (brief summary): Vet relates rolling injuries of his ankles 2005
&
2009. X-rays revealed no fractures and he was treated for sp
rains with ace
wraps and medication along with activity modification. He relates that he
has "weak" ankles and wears high top boots to prevent injury.
b. Does the Veteran report flare-ups of the ankle?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or her
own words:
If he tries to run or walks on an uneven surface
c. 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)?
[ ] Yes [X] No
3. Range of motion (ROM) and functional limitations
---------------------------------------------------
a. Initial range of motion
Right ankle
-----------
[X] All Normal
[ ] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 20 degrees
Plantar Flexion (0-45): 0 to 45 degrees
Description of pain (select best response):
Pain noted on exam but does not result in/cause functional loss
If noted on examination, which ROM exhibited pain (select all that apply)?
Dorsiflexion, Plantar Flexion
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 ankle
----------
[X] All Normal
[ ] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 20 degrees
Plantar Flexion (0-45): 0 to 45 degrees
Description of pain (select best response):
Pain noted on exam but does not result in/cause functional loss
If noted on examination, which ROM exhibited pain (select all that apply)?
Dorsiflexion, Plantar Flexion
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
b. Observed repetitive use
Right ankle
-----------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Left ankle
----------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
c. Repeated use over time
Right ankle
-----------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive use
over time:
[ ] The examination is medically consistent with the Veteran?s statements
describing functional loss with repetitive use over time.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss with repetitive use over time. Please
explain.
[X] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss with repetitive use
over
time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not examined with repeat use over time
Left ankle
----------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive use
over time:
[ ] The examination is medically consistent with the Veteran?s statements
describing functional loss with repetitive use over time.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss with repetitive use over time. Please
explain.
[X] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss with repetitive use
over
time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not examined with repeat use over time
d. Flare-ups
Right ankle
-----------
Is the examination being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran?s statements
describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss during flare-ups. Please explain.
[X] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss during flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-up?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not flared
Left ankle
----------
Is the examination being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran?s statements
describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss during flare-ups. Please explain.
[X] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss during flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-up?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not flared
e. Additional factors contributing to disability
Right ankle
-----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
More movement than normal due to flail joints, fracture nonunions, etc.
Please describe:
notes weakness in ankle allowing more movement
Left ankle
----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
More movement than normal due to flail joints, fracture nonunions, etc.
Please describe:
notes weakness in ankle allowing more movement
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 ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
c. Comments, if any:
No response provided
5. Ankylosis
------------
Complete this section if Veteran has ankylosis of the ankle
a. Indicate severity of ankylosis and side affected (check all that apply):
Right side: Left side:
[ ] In plantar flexion [ ] In plantar flexion
[ ] In dorsiflexion [ ] In dorsiflexion
[ ] With an abduction deformity [ ] With an abduction deformity
[ ] With an inversion deformity [ ] With an inversion deformity
[ ] With an eversion deformity [ ] With an eversion deformity
[ ] In good weight-bearing position [ ] In good weight-bearing
position
[ ] In poor weight-bearing position [ ] In poor weight-bearing
position
[X] No ankylosis [X] No ankylosis
b. Comments, if any:
No response provided
6. Joint stability
------------------
Right ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
Left ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
7. Additional comments
----------------------
Does the Veteran now have or has he or she ever had "shin splints", stress
fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus
(os calcis) or talus (astragalus), or has the Veteran had a talectomy
(astragalectomy)? [ ] Yes [X] No
8. Surgical procedures
----------------------
No response provided
9. 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
10. 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
11. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's ankle condition, is there functional impairment of an
extremity such that no effective functions remain 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
12. Diagnostic testing
----------------------
a. Have imaging studies of the ankle been performed and are the results
available? [X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[ ] Yes [X] No
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
13. 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.)?
[ ] Yes [X] No
14. Remarks, if any
-------------------
1. Is there evidence of pain on passive range of motion testing? YES
2. Is there evidence of pain when the joint is used in non-weight
bearing? YES
3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? NO.
The contralateral ankle has the same problem of weakness or increased
movement and pain but with normal range of motion.
****************************************************************************
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] Examination via approved video telehealth
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
Thoracolumbar Common Diagnoses:
[ ] Ankylosing spondylitis
[ ] Lumbosacral strain
[X] Degenerative arthritis of the spine
[X] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: Lumbago
ICD code: xxx
Date of diagnosis: 2010
Diagnosis #2: Facet Arthropathy L4-5
ICD code: xxx
Date of diagnosis: 2011
Diagnosis #3: Bulging Disc L4-5 (disc protrusion)
ICD code: xxx
Date of diagnosis: 2011
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Vet relates developing low back pain ~2010. He was seen for this in 2010.
He was again seen for LBP with radiation of pain and muscle spasms
4/5/2011 and for sciatica in 5/2011. He had several facet injections
which
helped temporarily. He now c/o of continuous pain ranging from 2-10/10
pain level. He takes NSAID's as needed.
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:
With frequent bending, walking more than 1 mile, standing for more
than 30 minutes w/o a break and with any running
c. Does the Veteran report having any functional loss or functional
impairment of the thoracolumbar spine (back) (regardless of repetitive
use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words.
He can not bend as far as he used to due to pain.
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 45 degrees
Extension (0 to 30): 0 to 15 degrees
Right Lateral Flexion (0 to 30): 0 to 30 degrees
Left Lateral Flexion (0 to 30): 0 to 30 degrees
Right Lateral Rotation (0 to 30): 0 to 30 degrees
Left Lateral Rotation (0 to 30): 0 to 30 degrees
If abnormal, does the range of motion itself contribute to a
functional loss? [X] Yes (please explain) [ ] No
If yes, please explain:
~ 50% loss of ROM with flexion & extension
Description of pain (select best response):
Pain noted on exam and causes functional loss
If noted on exam, which ROM exhibited pain (select all that apply)?
Forward Flexion, Extension, Right Lateral Flexion, Left Lateral
Flexion, Right Lateral Rotation, Left Lateral Rotation
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation
of the joints or associated soft tissue of the thoracolumbar spine
(back)?
[X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
TTP in the soft tissue of the LS spine; no spasms noted
b. Observed repetitive use
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No
c. Repeated use over time
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after
repetitive
use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time. Please explain.
[X] The examination is neither medically consistent or inconsistent
with the Veteran's statements describing functional loss with
repetitive use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not examined with repeat use over time
d. Flare-ups
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not flared
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: None
4. Muscle strength testing
--------------------------
a. Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Hip flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [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
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
5. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Knee:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
6. Sensory exam
---------------
Provide results for sensation to light touch (dermatome) testing:
Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [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: [ ] Negative [X] Positive [ ] Unable to perform
Left: [ ] Negative [X] Positive [ ] Unable to perform
8. Radiculopathy
----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[ ] Yes [X] No
9. Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No
10. Other neurologic abnormalities
----------------------------------
Does the Veteran have any other neurologic abnormalities or findings related
to a thoracolumbar spine (back) condition (such as bowel or bladder
problems/pathologic reflexes)?
[ ] Yes [X] No
11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
-----------------------------------------------------------------------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[X] Yes [ ] No
b. If yes to question 11a above, has the Veteran had any episodes of acute
signs and symptoms due to IVDS that required bed rest prescribed by a
physician and treatment by a physician in the past 12 months?
[ ] Yes [X] No
12. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion, although occasional locomotion by other methods may be
possible?
[ ] 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
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?
[ ] Yes [X] No
16. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or her
ability to work?
[X] Yes [ ] No
If yes describe the impact of each of the Veteran's thoracolumbar
spine (back) conditions providing one or more examples:
His ability to bend is compromised; he has trouble crossing his
legs to put on his shoes and he can not bend down to do so. His
ability to lift is about "half what it used to be".
17. Remarks, if any:
--------------------
He rates his pain on average as 4-5/10 which would be moderate on a scale of
mild, moderate or severe.
****************************************************************************
****************************************************************************
Knee and Lower Leg Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] Examination via approved video telehealth
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:
Bilateral Knee Pain
b. Select diagnoses associated with the claimed condition(s) (Check all that
apply):
[X] The Veteran does not have a current diagnosis associated with any claimed
condition listed above in 1a.
c. Comments (if any): The Veteran has bilateral knee pain that fits into
patellofemoral pain syndrome. He was not seen for this medically so there are
no notes in his STR. I told him that I would do the exam and submit the DBQ
for
review.
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 knee
and/or lower leg condition (brief summary):
Vet relates that shortly after boot camp he began having knee pain around
his patellae bilaterally. This would get worse with frequent climbing of
stairs, road marches and running on hard surfaces. He denies swelling,
locking or giving out of his knees.
b. Does the Veteran report flare-ups of the knee and/or lower leg?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or
her own words:
with going up stairs, kneeling or frequent getting up from a sitting
position
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ, including but not
limited to repeated use over time?
[ ] Yes [X] No
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
Right Knee
----------
[X] All normal
[ ] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 140 degrees
Extension (140 to 0): 140 to 0 degrees
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, Extension
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):
slight TTP of the patella
Is there objective evidence of crepitus? [ ] Yes [X] No
Left Knee
---------
[X] All normal
[ ] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140): 0 to 140 degrees
Extension (140 to 0): 140 to 0 degrees
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, Extension
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):
sl TTP of the patella
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Right Knee
----------
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 Knee
---------
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
c. Repeated use over time
Right Knee
----------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time.
Please explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss with repetitive
use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not examined with repeat use over time
Left Knee
---------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time.
Please explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss with repetitive
use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not examined with repeat use over time
d. Flare-ups
Right Knee
----------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not flared
Left Knee
---------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
not flared
e. Additional factors contributing to disability
Right Knee
----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None
Left Knee
---------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None
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 Knee: Rate Strength:
Flexion: 5/5
Extension: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left Knee: Rate Strength:
Flexion: 5/5
Extension: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] 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 the knee and/or lower
leg.
a. Indicate severity of ankylosis and side affected (check all that apply):
Right Side:
[ ] Favorable angle in full extension or in slight flexion between 0 and
10 degrees
[ ] In flexion between 10 and 20 degrees
[ ] In flexion between 20 and 45 degrees
[ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more
[X] No ankylosis
Left Side:
[ ] Favorable angle in full extension or in slight flexion between 0 and
10 degrees
[ ] In flexion between 10 and 20 degrees
[ ] In flexion between 20 and 45 degrees
[ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more
[X] No ankylosis
b. Indicate angle of ankylosis in degrees:
No response provided
c. Comments, if any:
No response provided
6. Joint stability tests
------------------------
a. Is there a history of recurrent subluxation?
Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
b. Is there a history of lateral instability?
Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
c. Is there a history of recurrent effusion?
[ ] Yes [X] No
d. Performance of joint stability testing
Right Knee:
Was joint stability testing performed?
[X] Yes
[ ] No
[ ] Not indicated
[ ] Indicated, but not able to perform
If joint stability testing was performed is there joint instability?
[ ] Yes [X] No
If yes (joint stability testing was performed), complete the section
below:
- Anterior instability (Lachman test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
Left Knee:
Was joint stability testing performed?
[X] Yes
[ ] No
[ ] Not indicated
[ ] Indicated, but not able to perform
If joint stability testing was performed is there joint instability?
[ ] Yes [X] No
If yes (joint stability testing was performed), complete the section
below:
- Anterior instability (Lachman test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
[ ] 1+ (0-5 millimeters)
[ ] 2+ (5-10 millimeters)
[ ] 3+ (10-15 millimeters)
e. Comments, if any:
+ patellar grind R=L
7. Additional conditions
------------------------
a. Does the Veteran now have or has he or she ever had recurrent patellar
dislocation, "shin splints" (medial tibial stress syndrome), stress
fractures, chronic exertional compartment syndrome or any other tibial
and/or fibular impairment?
[ ] Yes [X] No
b. Comments, if any:
No response provided
8. Meniscal conditions
----------------------
a. Does the Veteran now have or has he or she ever had a meniscus (semilunar
cartilage) condition?
[ ] Yes [X] No
b. For all checked boxes above, describe:
No response provided
9. Surgical procedures
----------------------
No response provided
10. 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
11. 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
12. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's knee and/or lower leg condition(s), 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
13. Diagnostic testing
----------------------
a. Have imaging studies of the knee been performed and are the results
available?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
14. 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:
Pain increases with frequent kneeling and going up stairs.
15. Remarks, if any:
--------------------
His pain is mild to moderate at present (2-4/10)
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] Examination via approved video telehealth
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: The Veteran is claiming service connection
for dermatitis / psoriasis.
Please examine the Veteran for a chronic disability related to his or her
claimed condition and indicate the current level of severity.
b. Indicate type of exam for which opinion has been requested: Psoriasis
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: I reviewed VBMS and CPRS.
His psoriasis was initially noted in 2008. There is no evidence that this
existed prior to service. Therefore, the psoriasis is at least as likely as
not incurred in or caused by the claimed in-service injury, event or
illness.
In short, it started in the service.
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: The Veteran is claiming service connection
for ankle pain. Please examine
the Veteran for a chronic disability related to his or her claimed condition
and indicate the current level of severity.
b. Indicate type of exam for which opinion has been requested: Ankle
Conditions
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: I reviewed VBMS and CPRS.
Based on my review of his STR's he has had injuries to his ankle's. On exam,
he has a weakness and laxity with inversion of his ankles consistent with
recurrent injuries. He was on airborne/jump status.Therefore, the claimed
condition is at least as likely as not incurred in or caused by the claimed
in-service injury, event, or illness.
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: The Veteran is claiming service connection
for lower back pain. Please
examine the Veteran for a chronic disability related to his or her claimed
condition and indicate the current level of severity.
b. Indicate type of exam for which opinion has been requested: back
condition(s)
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: I reviewed VBMS and CPRS.
He has ample documentation of back injuries and pain that were not present
prior to his service. He has documented disease from an MRI done 2/25/2011
(facet arthropathy and disc protrusion L4-5). He was also on airborne jump
status. Therefore, the back conditions are at least as likely as not
incurred
in or caused by the claimed in-service injury, event or illness.
*************************************************************************
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NoTheEnemy
I looked at your exam and quickly rated it. It looks like you should expect 40% overall. 10 for skin, 10 for right ankle, 10 for left ankle and 20 for thoracolumbar spine. Unless this is a pre-dischar
NoTheEnemy
You're welcome. Evidence of a chronic condition and evidence showing that it is at least as likely as not that the condition manifested during service is crucial when it comes to any claimed condition
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