ssgtob1

Just checked ebenefits and my C&D claim went back to REVIEW OF EVIDENCE but I noticed it said Decision Notification Sent. I then checked my AB8 and Benefits Explorer and they both say 100%. Also there is now downloads for veterans preference and civil service letters. Wonder why it went back to REVIEW OF EVIDENCE?

100% on AB8 on ebenefits

Mine went from the alst C&P to prep for notification pretty fast as well, 5 days or so.

Sure wish it would spit it out a little faster....

Update: I have been sitting at PREP FOR NOTIFICATION for over a week. It says that it should be completed 10/25/2012 to 12/24/2014. Checking Ebenefits every 30 minutes is starting to become an addiction....

My claim has been at PENDING DECISION APPROVAL for a week now. Got a phone call on Saturday and the person from VARO San Diego said " I see that you put on your claim that you recieved separation pay, how much was it?" I would figure that means that I am at least rated something because they need the amount to figure out how much to re-coup (I was Air Force, so it is a percentage per month). Hopefully I have a little more information soon, the wait is killing me.

And as of today ebennies shows that my claim is in preparation for decision, hopefully I dont have to wait too long.

I got out in may and this is my first set of exams with the VA.

Did you mean that you have never seen so many C&P's? Did you arrive at 90% based off of the amount of the claims or what they actually are?

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] Chronic sinusitis ICD code: 473.9 Date of diagnosis: 2007 [X] Deviated nasal septum (traumatic) ICD code: 470 Date of diagnosis: 2007 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] Sinusitis [X] Deviated nasal septum (traumatic) 1. Sinusitis ------------ a. Indicate the sinuses/type of sinusitis currently affected by the Veteran's chronic sinusitis (check all that apply): [ ] None [ ] Maxillary [ ] Frontal [ ] Ethmoid [ ] Sphenoid [X] Pansinusitis b. Does the Veteran currently have any findings, signs or symptoms attributable to chronic sinusitis? [X] Yes [ ] No If yes, check all that apply: [ ] Chronic sinusitis detected only by imaging studies (see Diagnostic testing section) [X] Episodes of sinusitis [X] Near constant sinusitis If checked, describe frequency: Daily symptoms with exacerbation of infections every 2-3 months. [X] Headaches [X] Pain of affecte d sinus [X] Tenderness of affected sinus [ ] Purulent discharge [ ] Crusting [X] Other For all checked conditions, describe: Constant frontal hedaches with tenderness & pain and tenderness over all sinuses,increased with bending head foreward.Also difficulty breathing through both nares.The veteran relates that when he experiences a recurrence of exacerbation of his chronic sinus infections,he is incapacitated for a few days and not able to work. c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months? [X] Yes [ ] No If yes, provide the total number of non-incapacitating episodes over the past 12 months: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [X] 7 or more d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months? [ ] Yes [X] No NOTE: For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician. If yes, provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12 months: [ ] 1 [ ] 2 [ ] 3 or more e. Has the Veteran had sinus surgery? [X] Yes [ ] No If yes, specify type of surgery: [ ] Radical (open sinus surgery) [X] Endoscopic [X] Other: Nasal septoplasty X 2 Type of procedure, sinuses operated on and side(s): Bilateral sinus surgery to open all sinus passagways to nasal turbinates.Also nasal septoplasty.Surgeries in 2008 and 2009.Surgical reports not available at this time. Date(s) of surgery (if repeated sinus surgery, provide all dates of surgery): 2008 and 2009 If Veteran has had radical sinus surgery, did chronic osteomyelitis follow the surgery? [ ] Yes [ ] No f. Has the Veteran had repeated sinus-related surgical procedures performed? [X] Yes[ ] No 4. Deviated nasal septum (traumatic) ------------------------------------ a. Is there at least 50% obstruction of the nasal passage on both sides due to traumatic septal deviation? [ ] Yes [X] No b. Is the Veteran's deviated septum traumatic? [X] Yes [ ] No c. Is there complete obstruction on left side due to traumatic septal deviation? [ ] Yes [X] No d. Is there complete obstruction on right side due to traumatic septal deviation? [ ] Yes [X] No 6. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes[X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes[X] No c. Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages? [ ] Yes[X] No d. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala? [ ] Yes[X] No e. 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? [X] Yes[ ] No [ ] Magnetic resonance imaging (MRI) Date: Results: [X] Computed tomography (CT) Date: Multiple 2004-2010 Results: Frontal and Left Maxillary sinusitis.Last CAT scan suggestive of a pansinusitis. [ ] X-rays: Date: Results: [ ] Other: Date: Results: b. Has endoscopy been performed?: Yes If yes, complete the following: If yes, check all that apply: [X] Nasal endoscopy Date: 2007,2008 & 2010 Results: Not available,but resulted in Functional Endoscopic Surgeries. [ ] Laryngeal endoscopy Date: Results: [ ] Bronchoscopy Date: Results: [ ] Other endoscopy Date: Results: 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: ------------------- Current Case. VBMS available and was reviewed.The veteran was noted to have a deviated nasal septum on ENT examination in 2007.The etiology of the deviated nasal septum has not been established but is considered in most cases to be traumatic.The veteran denies any clinical history of allergies. CC: Sinusitis,Allergies,Status Post Septoplasty,Deviated septum, Sinusitus DX:Chronic Sinusitis, Deviated Septum RAT:Documented with CAT scans of the sinuses,and Functional Endoscopic Sinus Surgeries x 2 .The veteran denies any clinical history of allergies. PROG:Chronic not resolved with Rx and sinus surgeries

1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a shoulder and/or arm condition? [X] Yes [ ] No Diagnosis #1: Shoulder impingement ICD code: 726.2 Date of diagnosis: 2008 Side affected: [ ] Right [X] Left [ ] Both Diagnosis #2: Right shoulder tendonitis ICD code: 726.11 Date of diagnosis: 2008 Side affected: [X] Right [ ] Left [ ] Both 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's shoulder and/or arm condition (brief summary): The Veteran reports a history of right shoulder pain starting in 2008. He states that his shoulder was injured while lifting. He was seen and diagnosed with tendonitis in his right shoulder and treated with physical therapy. He reports that since his injury he continues to have right shoulder pain that is aggravated by lifting raising his arms above his head. The Veteran's left shoulder pain started in 2008. He denies any specific injury to his shoulder reports that his left shoulder pain is less painful that his right. He was diagnosed with an impingement on his left shoulder and treated with medications as need. He has not had any further treatment for this condition. b. Dominant hand: [ ] Right [X] Left [ ] Ambidextrous 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the shoulder and/or arm? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: The Veteran reports that his bilateral shoulder pain will flare-up with raising his arms above his head and doing arm circles which he tries to avoid. 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Right shoulder flexion Select where flexion ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 b. Right shoulder abduction Select where abduction ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 c. Left shoulder flexion Select where flexion ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 170 [ ] 175 [ ] 180 d. Left shoulder abduction Select where abduction ends (normal endpoint is 180 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 e. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a shoulder or arm condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------ a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Right shoulder post-test ROM Select where flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 Select where abduction ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 c. Left shoulder post-test ROM Select where flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 170 [ ] 175 [ ] 180 Select where abduction ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170 [ ] 175 [ ] 180 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the shoulder and arm following repetitive-use testing? [ ] Yes [X] No b. Does the Veteran have any functional loss and/or functional impairment of the shoulder and arm? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the shoulder and arm after repetitive use, indicate the contributing factors of disability below (check all that apply and indicate side affected): [X] Less movement than normal [ ] Right [ ] Left [X] Both [X] Excess fatigability [ ] Right [ ] Left [X] Both [X] Pain on movement [ ] Right [ ] Left [X] Both 7. Pain (pain on palpation) --------------------------- a. Does the Veteran have localized tenderness or pain on palpation of joints/soft tissue/biceps tendon of either shoulder? [X] Yes [ ] No If yes, shoulder affected: [ ] Right [ ] Left [X] Both b. Does the Veteran have guarding of either shoulder? [X] Yes [ ] No If yes, shoulder affected: [ ] Right [ ] Left [X] Both 8. Muscle strength testing -------------------------- 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 Shoulder abduction: 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 Shoulder forward 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 9. Ankylosis ------------ Does the Veteran have ankylosis of the glenohumeral articulation (shoulder joint)? [ ] Yes [X] No 10. Specific tests for rotator cuff conditions ---------------------------------------------- a. 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.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A b. 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.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A c. External rotation/Infraspinatus strength test (Patient holds arm 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.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A d. 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.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 11. History and specific tests for instability/dislocation/labral pathology --------------------------------------------------------------------------- a. Is there a history of mechanical symptoms (clicking, catching, etc.)? [X] Yes [ ] No If yes, side affected: [ ] Right [ ] Left [X] Both b. Is there a history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint? [ ] Yes [X] No c. Crank apprehension and relocation test (With patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of instability with further external rotation may indicate shoulder instability.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 12. History and specific tests for clavicle, scapula, acromioclavicular (AC) joint, and sternoclavicular joint conditions ---------------------------------------------------------------------------- a. Does the Veteran have an AC joint condition or any other impairment of the clavicle or scapula? [ ] Yes [X] No b. Is there tenderness on palpation of the AC joint? [ ] Yes [X] No c. Cross-body adduction test (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology.) [ ] Positive [X] Negative [ ] Unable to perform [ ] N/A 13. Joint replacement and/or other surgical procedures ------------------------------------------------------ a. Has the Veteran had a total shoulder joint replacement? [ ] Yes [X] No b. Has the Veteran had arthroscopic or other shoulder surgery? [ ] Yes [X] No c. Does the Veteran have any residual signs and/or symptoms due to arthroscopic or other shoulder surgery? [ ] Yes [X] No 14. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 15. 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) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 16. 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? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 17. Functional impact --------------------- Does the Veteran's shoulder condition impact his or her ability to work? [ ] Yes [X] No 18. REMARKS ----------- a. Remarks, if any: The V file was reviewed. Claimed condition: Left shoulder impingement, Right shoulder tendonitis Diagnosis: Left shoulder impingement, Right shoulder tendonitis Prognosis: This is a stable chronic condition Evidence: STRs, Clinical history External rotation 75 degrees right shoulder 80 degrees left shoulder Internal rotation 80 degrees bilateral shoulders.

1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No Cervical Spine Common Diagnoses: [ ] Ankylosing spondylitis [X] Cervical strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Segmental instability [ ] Spinal fusion [X] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Cervical sprain ICD code: 847.0 Date of diagnosis: 2005 Diagnosis #2: Cervical disc degeneration ICD code: 722.4 Date of diagnosis: 2014 Diagnosis #3: Cervical spinal stenosis ICD code: 723.0 Date of diagnosis: 2014 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's cervical spine (neck) condition (brief summary): The Veteran has a history of a head injury in 2005. He reports that while on a F 16 he was knocked out by a piece of equipment. He reports that he fell to the ground and has had neck pain intermittently since this time. The Veteran reports that he was treated with medication and then referred for physical therapy. He continues to have neck pain. X rays done for this exam show degenerative changes and stenosis of the C spine. 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the cervical spine (neck)? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: The Veteran reports that his neck pain will flare up with sitting and turning his neck to much. The Veteran's neck pain will flare up with reamining in once position for a prolonged period of time. 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Select where forward flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater b. Select where extension ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater c. Select where right lateral flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater d. Select where left lateral flexion ends (normal endpoint is 45 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater [X] Other: 60 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater [X] Other: 60 e. Select where right lateral rotation ends (normal endpoint is 80 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater f. Select where left lateral rotation ends (normal endpoint is 80 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater g. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a cervical spine (neck) condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------- a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Select where post-test forward flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater c. Select where post-test extension ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater d. Select where post-test right lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater e. Select where post-test left lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater [X] Other: 60 f. Select where post-test right lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater g. Select where post-test left lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the cervical spine (neck) following repetitive-use testing? [ ] Yes [X] No b. Does the Veteran have any functional loss and/or functional impairment of the cervical spine (neck)? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the cervical spine (neck) after repetitive use, indicate the contributing factors of disability below: [X] Less movement than normal [X] Excess fatigability [X] Pain on movement 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait) ---------------------------------------------------------------------------- a. Does the Veteran have localized tenderness or pain to palpation for joints/soft tissue of the cervical spine (neck)? [X] Yes [ ] No b. Does the Veteran have muscle spasm of the cervical spine resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No c. Does the Veteran have muscle spasms of the cervical spine not resulting in abnormal gait or abnormal spinal countour? [X] Yes [ ] No d. Does the Veteran have guarding of the cervical spine resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No e. Does the Veteran have guarding of the cervical spine not resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No 8. 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 Elbow 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 Elbow 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 Wrist 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 Wrist 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 Finger 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 Finger Abduction 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 9. 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 Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 10. Sensory exam ---------------- Provide results for sensation to light touch (dermatomes) testing: Shoulder area (C5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Hand/fingers (C6-8): Right: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 11. Radiculopathy ------------------ Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate location and severity of symptoms (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Numbness Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left upper 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) [X] Involvement of C5/C6 nerve roots (upper radicular group) d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe 12. Ankylosis ------------- Is there ankylosis of the spine? [ ] Yes [X] No 13. Other neurologic abnormalities ---------------------------------- Does the Veteran have any other neurologic abnormalities related to a cervical spine (neck) condition (such as bowel or bladder problems due to cervical myelopathy)? [ ] Yes [X] No 14. Intervertebral disc syndrome (IVDS) and incapacitating episodes ------------------------------------------------------------------- a. Does the Veteran have IVDS of the cervical spine? [ ] Yes [X] No 15. 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 16. Remaining effective function of the extremities ---------------------------------------------------- Due to a cervical spine (neck) 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.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 17. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? [ ] Yes [X] No 18. Diagnostic testing ---------------------- a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No b. Does the Veteran have a 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 19. Functional impact ---------------------- Does the Veteran's cervical spine (neck) condition impact on his or her ability to work? [ ] Yes [X] No 20. REMARKS ----------- a. Remarks, if any: The V file was reviewed. Claimed condition: Neck strain Diagnosis: Cervical strain, Cervical disc degeneration, Cervical spinal stenosis Prognosis: This is a stable chronic condition Evidence: STRs, Clinical history

1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a knee and/or lower leg condition? [X] Yes [ ] No Diagnosis #1: Patellofemoral syndrome left knee ICD code: 719.46 Date of diagnosis: 2005/2010 Side affected: [ ] Right [ ] Left [X] Both Diagnosis #2: Bakers cyst ICD code: 727.51 Date of diagnosis: 2010 Side affected: [ ] Right [X] Left [ ] Both Diagnosis #3: Patellar tendonitis ICD code: 726.64 Date of diagnosis: 2010 Side affected: [ ] Right [X] Left [ ] Both If there are additional diagnoses that pertain to knee and/or lower leg conditions, list using above format: Right knee degenerative arthritis 715 2014 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): The Veteran's right knee pain started in 2005. He reports that he would experience pain in his right knee with running and was diagnosed with patellofemoral syndrome. He was treated with RICE measures. X rays done for this exam show degenerative chages of the right knee tibial spine. The Veteran's left knee pain started in 2010 following his motorcycle accident. He denies any injury to his knee but reports that he was experience pain with going up and down the stairs, kneeling and running. He was seen in 2010 and was diagnosed with a left knee bakers cyst, patellofemoral syndrome, and patella tendonitis as well. The Veteran underwent physical therapy which did not help. He then had a lateral plica excision and synovectomy in 2011. He reports that his knee pain was worse after his knee surgery. He continues to have left knee pain. He was given a prescription knee brace to use as needed knee for his left knee pain. 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the knee and/or lower leg? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words The Veteran reports that his knee pain will flare up prolonged walking, going up and down stairs and running. 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Right knee flexion Select where flexion ends (normal endpoint is 140 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater b. Right knee extension Select where extension ends: [X] 0 or any degree of hyperextension (check this box if there is no limitation of extension) Select where objective evidence of painful motion begins: [X] 0 or any degree of hyperextension (check this box if there is no limitation of extension) c. Left knee flexion Select where flexion ends (normal endpoint is 140 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [X] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 or greater d. Left knee extension Select where extension ends: Unable to fully extend; extension ends at: [X] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater Select where objective evidence of painful motion begins: Or, painful motion on extension begins at: [X] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater e. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a knee and/or leg condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------ a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Right knee post-test ROM Select where post-test flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater Select where post-test extension ends: [X] 0 or any degree of hyperextension (check this box if there is no limitation of extension) c. Left knee post-test ROM Select where post-test flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater Unable to fully extend; extension ends at: [X] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the knee and lower leg following repetitive-use testing? [ ] Yes [X] No b. Does the Veteran have any functional loss and/or functional impairment of the knee and lower leg? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment or additional limitation of ROM of the knee and lower leg after repetitive use, indicate the contributing factors of disability below (check all that apply and indicate side affected): [X] Excess fatigability [ ] Right [X] Left [ ] Both [X] Pain on movement [ ] Right [ ] Left [X] Both [X] Swelling [ ] Right [X] Left [ ] Both [X] Disturbance of locomotion [ ] Right [X] Left [ ] Both 7. Pain (pain on palpation) --------------------------- Does the Veteran have tenderness or pain to palpation for joint line or soft tissues of either knee? [X] Yes [ ] No If yes, side affected: [ ] Right [X] Left [ ] Both 8. Muscle strength testing -------------------------- 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 Knee 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 9. Joint stability tests ------------------------ a. Anterior instability (Lachman test): Right: [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left: [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) b. Posterior instability (Posterior drawer test): Right: [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left: [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) c. Medial-lateral instability (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion): Right: [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left: [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) 10. Patellar subluxation/dislocation ------------------------------------ Is there evidence or history of recurrent patellar subluxation/dislocation? [ ] Yes [X] No 11. Additional conditions ------------------------- Does the Veteran now have or has he or she ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No 12. Meniscal conditions and meniscal surgery -------------------------------------------- Has the Veteran had any meniscal conditions or surgical procedures for a meniscal condition? [ ] Yes [X] No 13. Joint replacement and other surgical procedures --------------------------------------------------- a. Has the Veteran had a total knee joint replacement? [ ] Yes [X] No b. Has the Veteran had arthroscopic or other knee surgery not described above? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [X] Left [ ] Both Date and type of surgery: 2011 Plica excision and synovectomy c. Does the Veteran have any residual signs and/or symptoms due to arthroscopic or other knee surgery not described above? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [X] Left [ ] Both Describe residuals: Chronic left knee pain 14. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 15. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ----------------- [X] Brace(s) [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: The Veteran will use a prescription knee brace as needed for his left knee patella tendonitis. 16. 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.) [X] No 17. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate knee: [X] Right [ ] Left [ ] Both b. Does the Veteran have x-ray evidence of patellar subluxation? [ ] 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): 18. Functional impact --------------------- Does the Veteran's knee and/or lower leg condition(s) impact his or her ability to work? [ ] Yes [X] No 19. Remarks ----------- a. Remarks, if any: The V file was reviewed. For scar measurments see DBQ scar exam. Claimed condition: Right knee patellofemoral syndrome, left knee patellar tendonitis Diagnosis: Bilateral knee patellofemoral syndrome, left knee patellar tendonitis, right knee degenerative arthritis. Prognosis: This is a stable chronic condition Evidence: STRs, Clinical history

1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a hip and/or thigh condition? [X] Yes [ ] No Diagnosis #1: Hip sprain ICD code: 843.8 Date of diagnosis: 2006 Side affected: [X] Right [ ] Left [ ] Both 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's current hip/thigh condition(s) (brief summary): The Veteran reports a history of right hip pain starting in 2006. He reports that he was involved in a motor cycle accident and injured his right hip. He was seen and treated with Motrin. The Veteran reports that he continues to have pain in his right hip with squatting, prolonged sitting and twisting. He reports that he takes medication as needed for pain. 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the hip and/or thigh? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: The Veteran reports that his right hip pain will flare up with squatting, prolonged sitting and twisting. He will change positions, stretch and take medication as needed for pain. 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Right hip flexion Select where flexion ends (normal endpoint is 125 degrees): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [X] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 or greater b. Right hip extension Select where extension ends: [ ] 0 [ ] 5 [X] Greater than 5 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [X] Greater than 5 Is abduction lost beyond 10 degrees? [ ] Yes [X] No Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No Is rotation limited such that the Veteran cannot toe-out more than 15 degrees? [ ] Yes [X] No c. Left hip flexion No response provided. d. Left hip extension No response provided. e. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a hip condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------ a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Right hip post-test ROM Select where post-test flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [X] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 or greater Select where post-test extension ends: [ ] 0 [X] 5 or greater Is post-test abduction lost beyond 10 degrees? [ ] Yes [X] No Is post-test adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No Is post-test rotation limited such that the Veteran cannot toe-out more than 15 degrees? [ ] Yes [X] No c. Left hip post-test ROM No response provided. 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the hip and thigh following repetitive-use testing? [ ] Yes [X] No b. Does the Veteran have any functional loss and/or functional impairment of the hip and thigh? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the hip and thigh after repetitive use, indicate the contributing factors of disability below (check all that apply and indicate side affected): [X] Less movement than normal [X] Right [ ] Left [ ] Both [X] Excess fatigability [X] Right [ ] Left [ ] Both [X] Pain on movement [X] Right [ ] Left [ ] Both 7. Pain (pain on palpation) --------------------------- Does the Veteran have localized tenderness or pain to palpation for joints/soft tissue of either hip? [X] Yes [ ] No If yes, side affected: [X] Right [ ] Left [ ] Both 8. Muscle strength testing -------------------------- 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 Hip abduction: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Hip extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 9. Ankylosis ------------ Does the Veteran have ankylosis of either hip joint? [ ] Yes [X] No 10. Additional conditions ------------------------- Does the Veteran have malunion or nonunion of femur, flail hip joint or leg length discrepancy? [ ] Yes [X] No 11. Joint replacement and other surgical procedures --------------------------------------------------- a. Has the Veteran had a total hip joint replacement? [ ] Yes [X] No b. Has the Veteran had arthroscopic or other hip surgery? [ ] Yes [X] No c. Does the Veteran have any residual signs and/or symptoms due to arthroscopic or other hip surgery? [ ] Yes [X] No 12. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 13. 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 14. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's hip and/or thigh 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 16. Functional impact --------------------- Does the Veteran's hip and/or thigh condition impact his or her ability to work? [ ] Yes [X] No 17. Remarks ----------- a. Remarks, if any: The V file was reviewed. Claimed condition: Right hip strain Diagnosis: Right hip strain Prognosis: This is a stable chronic condition Evidence: STRs, Clinical history External rotation: 40 degrees right hip Internal rotation: 20 degrees right hip

1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a hand or finger condition? [X] Yes [ ] No Diagnosis #1: Hand strain ICD code: 842.10 Date of diagnosis: 2005 Side affected: [ ] Right [ ] Left [X] Both 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hand condition (brief summary): The Veteran has a history of pain in both of his hands starting in 2005. He denies any injury to his hands and reports that he would experience pain, stiffness and cranking in both of his hands that increases with gripping, and twisting with his hands. He reports that he was seen and had X rays and lab work that was normal. He has not had any further treatment for this condition. b. Dominant hand: [ ] Right [X] Left [ ] Ambidextrous 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the hand? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: The Veteran's bilateral hand pain will flare up with gripping things, twisting to open jars and using hand tools. 4. Initial range of motion (ROM) measurements --------------------------------------------- a. Is there limitation of motion or evidence of painful motion for any fingers or thumbs? [X] Yes [ ] No If yes, indicate digits affected (check all that apply): Right: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger Left: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger b. Ability to oppose thumb: Is there a gap between the thumb pad and the fingers? [ ] Yes [X] No c. Finger flexion: Is there a gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips? [X] Yes [ ] No If yes, indicate the gap: [X] Gap 1 inch (2.5 cm) or more Indicate fingers affected (check all that apply): Right: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger Left: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger Select where objective evidence of painful motion begins: [X] Painful motion begins at a gap of 1 inch (2.5 cm) or more Indicate fingers affected (check all that apply): Right: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger Left: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger d. Finger extension: Is there limitation of extension or evidence of painful motion for the index finger or long finger? [ ] Yes [X] No 5. ROM measurements after repetitive use testing ------------------------------------------------ a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Is there additional limitation of motion for any fingers post-test? [ ] Yes [X] No c. Ability to oppose thumb: Is there a gap between the thumb pad and the fingers post-test? [ ] Yes [X] No d. Finger flexion: Is there a gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test? [X] Yes [ ] No If yes, indicate the gap: [X] Gap 1 inch (2.5 cm) or more Indicate fingers affected (check all that apply): Right: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger Left: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger e. Finger extension: Is there limitation of extension for the index finger or long finger post-test? [ ] Yes [X] No 6. Functional loss and additional limitation of ROM --------------------------------------------------- a. Does the Veteran have any functional loss or functional impairment of any of the fingers or thumbs? [X] Yes [ ] No b. Does the Veteran have additional limitation in ROM of any of the fingers or thumbs following repetitive-use testing? [ ] Yes [X] No c. If the Veteran has functional loss, functional impairment or additional limitation of ROM of any of the fingers or thumbs after repetitive use, indicate the contributing factors of disability below (check all that apply; indicate digit and side affected): [X] Less movement than normal Right: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger Left: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger [X] Pain on movement Right: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger Left: [X] Index finger [X] Long finger [X] Ring finger [X] Little finger 7. Pain (pain on palpation) --------------------------- Does the Veteran have tenderness or pain to palpation for joints or soft tissue of either hand, including thumb and fingers? [X] Yes [ ] No If yes, side affected: [ ] Right [ ] Left [X] Both 8. Muscle strength testing -------------------------- 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 Hand grip: 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 9. Ankylosis ------------ a. Does the Veteran have ankylosis of the thumb and/or fingers? [ ] Yes [X] No c. Does the ankylosis condition result in limitation of motion of other digits or interference with overall function of the hand? [ ] Yes [X] No 10. Other pertinent physical findings, complications, conditions, signs and/or symptoms ------------------------------------------------------------------------ a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 11. Assistive devices and remaining function of the extremities --------------------------------------------------------------- a. Does the Veteran use any assistive devices? [ ] Yes [X] No 12. Remaining effective function of the extremities ---------------------------------------------------- Due to the Veteran's hand, finger or thumb 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 13. Diagnostic Testing ----------------------- a. Have imaging studies of the hands been performed and are the results available? [X] Yes [ ] No If yes, are there abnormal findings? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No 14. Functional impact --------------------- Do the Veteran's hand, thumb, or finger conditions impact his or her ability to work? [ ] Yes [X] No 15. Remarks ----------- a. Remarks, if any: The V file was reviewed. Claimed condition: Bilateral hands arthritis Diagnosis: Bilateral hand strain Prognosis: This is a stable chronic condition Evidence: STRs, Clinical history

1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: lumbar strain ICD code: 847.2 Date of diagnosis: 2006 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): The Veteran's back pain started in 2006. He reports that while bending he started to experience back pain. He was seen and given pain medication and then was treated with physical therapy, traction, and a tens unit. He now sees a chiropractor as needed. He had a MRI of his back that revealed disc disease. He reports that his pain will experience numbness and tingling shooting into his left leg. 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: The Veteran reports that his back pain will flare up with prolonged sitting and bending. He takes Motrin, mobic and naproxyn as needed for pain and has relief with laying down. 4. Initial range of motion (ROM) measurement -------------------------------------------- a. Select where forward flexion ends (normal endpoint is 90): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater b. Select where extension ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or greater c. Select where right lateral flexion ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater d. Select where left lateral flexion ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater e. Select where right lateral rotation ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater f. Select where left lateral rotation ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater g. If ROM for this Veteran does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a back condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurement after repetitive use testing ----------------------------------------------- a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No b. Select where post-test forward flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater c. Select where post-test extension ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or greater d. Select where post-test right lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater e. Select where post-test left lateral flexion ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater f. Select where post-test right lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater g. Select where post-test left lateral rotation ends: [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or greater 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the thoracolumbar spine (back) following repetitive-use testing? [ ] Yes [X] No b. Does the Veteran have any functional loss and/or functional impairment of the thoracolumbar spine (back)? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the thoracolumbar spine (back) after repetitive use, indicate the contributing factors of disability below: [X] Less movement than normal [X] Excess fatigability [X] Incoordination, impaired ability to execute skilled movements smoothly [X] Pain on movement 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait) ---------------------------------------------------------------------------- a. Does the Veteran have localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe: The lumbar spine is tender to palpation. b. Does the Veteran have muscle spasm of the thoracolumbar spine resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No c. Does the Veteran have muscle spasms of the thoracolumbar spine not resulting in abnormal gait or abnormal spinal countour? [X] Yes [ ] No d. Does the Veteran have guarding of the thoracolumbar spine resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No e. Does the Veteran have guarding of the thoracolumbar spine not resulting in abnormal gait or abnormal spinal countour? [X] Yes [ ] No 8. 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 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 9. 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+ 10. 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 11. Straight leg raising test ----------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 12. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [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: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] 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: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 13. Ankylosis ------------- Is there ankylosis of the spine? [ ] Yes [X] No 14. 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 15. Intervertebral disc syndrome (IVDS) and incapacitating episodes ------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] Yes [X] No 16. 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 17. 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 18. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? [ ] Yes [X] No 19. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [ ] Yes [X] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 20. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [ ] Yes [X] No 21. REMARKS ----------- a. Remarks, if any: The V file was reviewed. Claimed condition: Lower back strain Diagnosis: Lumbar strain Prognosis: This is a stable chronic condition Evidence: STRs, Clinical history

1. Diagnosis ------------ Does the Veteran now have or has he/she ever had an ankle condition? [X] Yes [ ] No If yes, provide only diagnoses that pertain to ankle condition(s): Diagnosis #1: Ankle sprain ICD code: 845 Date of diagnosis: 2005/2006 Side affected: [ ] Right [ ] Left [X] Both Diagnosis #2: Arthritis ICD code: 715 Date of diagnosis: 2014 Side affected: [X] Right [ ] Left [ ] Both 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's ankle condition (brief summary): The Veteran's right ankle pain started in 2005. He reports that he sprained right ankle and was treated with R.I.C.E. measures. He continues to roll his right ankle and has pain with prolonged walking. X rays done for this exam show arthritis of the right ankle. The Veteran's left ankle pain started in 2006. He reports that he sprained his ankle while climbing a ladder into a F 16. He was treated with R.I.C.E. measures and now experiences minor pain in his left ankle. 3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the ankle? [X] Yes [ ] No If yes, document the Veteran's description of the impact of flare-ups in his or her own words: The Veteran reports that his bilateral ankle pain will flare up with prolonged walking. 4. Initial range of motion (ROM) measurements: ---------------------------------------------- a. Right ankle plantar flexion Plantar flexion ends (normal endpoint is 45 degrees): 15 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater b. Right ankle dorsiflexion (extension) Dorsiflexion (extension) ends (normal endpoint is 20 degrees): 15 Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 or greater c. Left ankle plantar flexion Plantar flexion ends (normal endpoint is 45 degrees): 45 Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater d. Left ankle plantar dorsiflexion (extension) Dorsiflexion (extension) ends (normal endpoint is 20 degrees): 20 Select where objective evidence of painful motion begins: [X] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 or greater e. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than an ankle condition, such as age, body habitus, neurologic disease), explain: No response provided. 5. ROM measurements after repetitive use testing ------------------------------------------------ Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [ ] No a. Right ankle post-test ROM Post-test plantar flexion ends: 15 Post-test dorsiflexion (extension) ends: 15 b. Left ankle post-test ROM Post-test plantar flexion ends: 45 Post-test dorsiflexion (extension) ends: 20 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the ankle following repetitive-use testing? [ ] Yes [X] No b. Does the Veteran have any functional loss and/or functional impairment of the ankle? [X] Yes [ ] No c. If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the ankle after repetitive use, indicate the contributing factors of disability below (check all that apply and indicate side affected): [X] Less movement than normal [X] Right [ ] Left [ ] Both [X] Pain on movement [X] Right [ ] Left [ ] Both 7. Pain (pain on palpation) --------------------------- Does the Veteran have localized tenderness or pain on palpation of joints/soft tissue of either ankle? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both 8. Muscle strength testing -------------------------- 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 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 9. Joint stability ------------------ a. Anterior drawer test Is there laxity compared with opposite side? [ ] Yes [X] No [ ] Unable to test b. Talar tilt test (inversion/eversion stress) Is there laxity compared with opposite side? [ ] Yes [X] No [ ] Unable to test 10. Ankylosis ------------- Does the Veteran have ankylosis of the ankle, subtalar and/or tarsal joint? [ ] Yes [X] No 11. Additional conditions ------------------------- 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 12. Joint replacement and other surgical procedures ---------------------------------------------------- a. Has the Veteran had a total ankle joint replacement? [ ] Yes [X] No b. Has the Veteran had arthroscopic or other ankle surgery? [ ] Yes [X] No c. Does the Veteran have any residual signs and/or symptoms due to arthroscopic or other ankle surgery? [ ] Yes [X] No 13. Other pertinent physical findings, complications, conditions, signs and/or symptoms ------------------------------------------------------------------------ a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 14. 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 15. Remaining effective function of the extremities ---------------------------------------------------- Due to the Veteran's ankle 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 16. Diagnostic Testing ----------------------- a. Have imaging studies of the ankle been performed and are the results available? [X] Yes [ ] No If yes, are there abnormal findings? [X] Yes [ ] No If yes, indicate findings: [X] Degenerative or traumatic arthritis ankle: [X] Right [ ] Left [ ] Both b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 17. Functional impact ---------------------- Does the Veteran's ankle condition impact his or her ability to work? [ ] Yes [X] No 18. REMARKS ----------- a. Remarks, if any: The V file was reviewed. Claimed condition: Right ankle sprain Diagnosis: Bilateral ankle sprain, Right ankle degenerative Arthritis Prognosis: This is a stable chronic condition Evidence: STRs, Clinical history

1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Traumatic brain injury (TBI) ICD code: 850.9 Date of diagnosis: July 2006 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): 33 LH M served in USAF from Jan 2004 to May 2014. Pt states suffered a concussion in 2005 hit on head by part of F-16 wing at Edwards AFB. Pt states loss of consciousness for 2-3 minutes and next recalls being assisted by others and taken to local clinic for head wound requiring staples. Pt states told had mild concussion due to headache/nausea which lasted days. Pt states residuals from this injury were headaches. Rank at time of event was E-3 and left service as E-5. Pt states never evaluated by military TBI clinic. Review of C-file notes 7/17/06 evaluation after hit head on jet flap with laceration to top of head (4cm requiring sutures) with complaint of headache but no dizziness/nausea/emesis. States no loss of consciousness occurred and pt fully oriented with nonfocal exam. Diagnosis was open wound to scalp and headache. Pt seen for suture removals on 7/24/06 and again on 8/26/06 still complaining of headache related to above event. SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI ----------------------------------------------------------------------------- 1. Memory, attention, concentration, executive functions -------------------------------------------------------- [X] No complaints of impairment of memory, attention, concentration, or executive functions 2. Judgment ----------- [X] Normal 3. Social interaction --------------------- [X] Social interaction is routinely appropriate 4. Orientation -------------- [X] Always oriented to person, time, place, and situation 5. Motor activity (with intact motor and sensory system) -------------------------------------------------------- [X] Motor activity normal 6. Visual spatial orientation ----------------------------- [X] Normal 7. Subjective symptoms ---------------------- [X] No subjective symptoms 8. Neurobehavioral effects -------------------------- [X] No neurobehavioral effects 9. Communication ---------------- [X] Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. 10. Consciousness ----------------- [X] Normal SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks ----------------------------------------------------------------------------- 1. Residuals ------------ Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)? [X] Yes [ ] No If yes, check all that apply: [X] Headaches, including Migraine headaches 2. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms? [X] Yes [ ] No If yes, describe (brief summary): A/OX3, MMSE 30/30, speech nl Fundi sharp discs (no OS disc pallor) Cranial nerves 2-12 grossly intact except OS esophoria, Visual fields full, Pupils equal/round/reactive to light; no relative afferent pupillary defect Motor nl with nl tone Sensory normal PP throughout except decreased PP over left lateral 1/2 great toe and between lateral 1/2 of 2nd toe and medial 1/2 3rd toe Coord nl finger to nose/heel to shin bilaterally Gait nl with nl romberg/tandem Deep tendon reflexes trace - 1+ symmetric with bilat flexor plantar responses + tinels bilat wrist and left elbow; + phalens bilat no scalp scar noted 3. Diagnostic testing --------------------- a. Has neuropsychological testing been performed? [ ] Yes [X] No b. 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): Exam Date/Time 07/19/2006 15:22 Procedure Name SKULL SERIES (3) Report SKULL SERIES (3) 4. Functional impact -------------------- Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work? [ ] Yes [X] No 5. Remarks, if any: ------------------- Claimed Condition: Status post concussion Onset: 2006 Diagnosis: mild traumatic brain injury Rationale: History/exam/C-file. Note: only TBI residuals are migraine headaches Prognosis: unknown

1. Diagnosis ------------ Does the Veteran have a peripheral nerve condition or peripheral neuropathy? [X] Yes [ ] No Diagnosis #1: bilateral carpal tunnel syndrome (mild) ICD code: 354.0 Date of diagnosis: Aug 2014 Diagnosis #2: left toes digital neuropathy (mild) ICD code: 955.6 Date of diagnosis: Aug 2014 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's peripheral nerve condition (brief summary): Pt states claim of lower extremity bilateral numbness refers to left > right entire toes on left and right great toe paresthesias constant since 2006. Pt states no aggravating features and never seeked medical attention for this specifically. Pt also states in hands equally in both palmar surfaces involving all fingers which is episodic but daily since 2009. Pt states typing can trigger symptoms and resolves within minutes of stop typing. Pt states never treated with splints and no EMG for these conditions. b. Dominant hand [ ] Right [X] Left [ ] Ambidextrous 3. Symptoms ----------- a. Does the Veteran have any symptoms attributable to any peripheral nerve conditions? [X] Yes [ ] No Constant pain (may be excruciating at times) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe 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 Elbow 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 Elbow 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 Wrist 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 Wrist 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 Grip: 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 Pinch (thumb to index finger): 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 Biceps: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Knee: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Indicate results for sensation testing for light touch: Shoulder area (C5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Hand/fingers (C6-8): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 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: [ ] Normal [X] Decreased [ ] Absent 7. Trophic changes ------------------ Does the Veteran have trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy? [ ] Yes [X] No 8. Gait ------- Is the Veteran's gait normal? [X] Yes [ ] No 9. Special tests for median nerve --------------------------------- Were special tests indicated and performed for median nerve evaluation? [X] Yes [ ] No Phalen's sign: Right: [X] Positive [ ] Negative Left: [X] Positive [ ] Negative Tinel's sign: Right: [X] Positive [ ] Negative Left: [X] Positive [ ] Negative 10. Nerves Affected: Severity evaluation for upper extremity nerves and radicular groups ----------------------------------------------------------------------- a. Radial nerve (musculospiral nerve) Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis b. Median nerve Right: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [X] Mild [ ] Moderate [ ] Severe Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [X] Mild [ ] Moderate [ ] Severe c. Ulnar nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis d. Musculocutaneous nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis e. Circumflex nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis f. Long thoracic nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis g. Upper radicular group (5th & 6th cervicals) Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis h. Middle radicular group Right [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis i. Lower radicular group Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis 11. Nerves Affected: Severity evaluation for lower extremity nerves ------------------------------------------------------------------- a. Sciatic nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis b. External popliteal (common peroneal) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis c. Musculocutaneous (superficial peroneal) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis d. Anterior tibial (deep peroneal) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis e. Internal popliteal (tibial) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis f. Posterior tibial nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis g. Anterior crural (femoral) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis h. Internal saphenous nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis i. Obturator nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis j. External cutaneous nerve of the thigh Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis k. Ilio-inguinal nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis 12. 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 13. Remaining effective function of the extremities --------------------------------------------------- Due to peripheral nerve 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. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? [X] Yes [ ] No If yes, describe (brief summary): A/OX3, MMSE 30/30, speech nl Fundi sharp discs (no OS disc pallor) Cranial nerves 2-12 grossly intact except OS esophoria, Visual fields full, Pupils equal/round/reactive to light; no relative afferent pupillary defect Motor nl with nl tone Sensory normal PP throughout except decreased PP over left lateral 1/2 great toe and between lateral 1/2 of 2nd toe and medial 1/2 3rd toe Coord nl finger to nose/heel to shin bilaterally Gait nl with nl romberg/tandem Deep tendon reflexes trace - 1+ symmetric with bilat flexor plantar responses + tinels bilat wrist and left elbow; + phalens bilat 15. Diagnostic testing ---------------------- a. Have EMG studies been performed? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact --------------------- Does the Veteran's peripheral nerve condition and/or peripheral neuropathy impact his or her ability to work? [ ] Yes [X] No 17. Remarks, if any: -------------------- Claimed Condition: lower extremity bilateral numbness Onset: 2006 Diagnosis: left toes digital neuropathy (mild) Rationale: history/exam/C-file review. Note: a right lower extremity neuropathy was not identified to explain Veteran's claimed complaints. No diagnosis is established. Prognosis: unknown Claimed Condition: bilateral hand paresthesias (new claim) Onset: 2009 Diagnosis: bilateral carpal tunnel syndrome (mild) Rationale: history/exam Prognosis: unknown

1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a headache condition? [X] Yes [ ] No [X] Migraine including migraine variants ICD code: 346.10 Date of diagnosis: July 2006 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): Pt states onset of headaches after head injury in 2005. Headaches described as (no aura) left frontal throbbing associated with nausea (rare emesis) with photophobia. Frequency is once per wk and last all day without treatment. MOtrin helps moderately. Pt states he can work through headaches but be prefers to lie down. Review of C-file notes 7/17/06 evaluation after hit head on jet flap with laceration to top of head (4cm requiring sutures) with complaint of headache but no dizziness/nausea/emesis. States no loss of consciousness occurred and pt fully oriented with nonfocal exam. Diagnosis was open wound to scalp and headache. Pt seen for suture removals on 7/24/06 and again on 8/26/06 still complaining of headache related to above event. b. Does the Veteran's treatment plan include taking medication for the diagnosed condition? [X] Yes [ ] No If yes, describe treatment (list only those medications used for the diagnosed condition): prn motrin 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pulsating or throbbing head pain [X] Pain localized to one side of the head [X] Pain worsens with physical activity 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] Nausea [X] Vomiting [X] Sensitivity to light c. Indicate duration of typical head pain [X] Less than 1 day d. Indicate location of typical head pain [X] Left 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? [X] Yes [ ] No If yes, indicate frequency, on average, of prostrating attacks over the last several months: [X] Once every month b. Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [ ] Yes [X] No 5. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): A/OX3, MMSE 30/30, speech nl Fundi sharp discs (no OS disc pallor) Cranial nerves 2-12 grossly intact except OS esophoria, Visual fields full, Pupils equal/round/reactive to light; no relative afferent pupillary defect Motor nl with nl tone Sensory normal PP throughout except decreased PP over left lateral 1/2 great toe and between lateral 1/2 of 2nd toe and medial 1/2 3rd toe Coord nl finger to nose/heel to shin bilaterally Gait nl with nl romberg/tandem Deep tendon reflexes trace - 1+ symmetric with bilat flexor plantar responses + tinels bilat wrist and left elbow; + phalens bilat 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [ ] Yes [X] No 8. Remarks, if any: ------------------- Claimed Condition: Headache syndrome Onset: 2006 Diagnosis: migraine without aura Rationale: history/exam/C-file review Prognosis: unknown

1. Medical history ------------------ Does the Veteran report recurrent tinnitus: Yes Date and circumstances of onset of tinnitus: Veteran reports constant bilateral tinnitus, left greater than right, described as a "ringing" sound, onset in 2008 during deployment to Iraq. 2. Etiology of tinnitus ----------------------- At least as likely as not (50% probability or greater) caused by or a result of military noise exposure. Rationale: Review of available service treatment records revealed the notation "Subjective tinnitus" on a "Chronic Problems" list dated 5/21/13. With service treatment records documentation showing diagnosis of tinnitus during military service, it is this examiner's opinion that the veteran's reported tinnitus is at least as likely as not related to his military service. 3. Functional impact of tinnitus -------------------------------- Does the Veteran's tinnitus impact ordinary conditions of daily life, including ability to work: No 4. Remarks, if any, pertaining to tinnitus: ------------------------------------------- CLAIMED CONDITION: TINNITUS DIAGNOSIS: TINNITUS RATIONALE: SERVICE TREATMENT RECORDS AND VETERAN'S REPORT AT THIS C&P EXAM PROGNOSIS: GOOD NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.

Ok here goes: 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes[ ] No ICD code: 300. If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Unspecified anxiety disorder ICD code: 300. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): none 2. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ] Not shown in records reviewed 3. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[ ] No[X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ a. Medical record review: Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [ ] Yes[X] No 3. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Chronic sleep impairment Behavioral observations: The veteran was seen for 45 minutes. His VBMS file was reviewed prior to the interview. The limits of confidentiality were explained to him and he agreed to participate in the C&P evaluation. He was alert, fully oriented and cooperative. He was well groomed. Mood was good, affect was euthymic. Speech and thought content were within normal limits. Thought processes were logical and goal-directed. No evidence or report of delusions or hallucinations. Memory and attention appeared grossly intact. Insight and judgment were fair. The veteran denied current suicidal or homicidal ideation. 4. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [X] Yes[ ] No If yes, describe: mild irritability 5. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 6. Remarks (including any testing results), if any: --------------------------------------------------- claimed condition: Anxiety diagnosis: unspecified anxiety disorder rationale: meets DSM-5 criteria prognosis: good, symptoms are mild

Please delete....double post mistake

Hi all, I am new here and have a quick question about my C&P exams. I have many, and can copy and paste them all here if need be, but they all state: Does the Veteran's wrist condition impact his or her ability to work? [] Yes [x ] No Does that mean that I wont be rated for any of these conditions?