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ssgtob1
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Posts posted by ssgtob1
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100% on AB8 on ebenefits
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SSG,
Sorry the wait is driving you crazy. I submitted my Current FDC in June 14, and I just had the C&Ps on Tues. Now two days later I check the status and I am at Prep for Notification. I don't know if it is a good or bad thing. This claim was for 7 or 8 conditions. Either way good luck to the both of us. God Bless
Mine went from the alst C&P to prep for notification pretty fast as well, 5 days or so.
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The date is a random date they generate to keep us all guessing. The computer spits out a letter to be mailed and some fat body has to fold it then spin around in his chair and hand it to another fat body who puts it in an envelope who hands it off to another fat body for a stamp and seal, then into the mailing box.
Sure wish it would spit it out a little faster....
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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....
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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.
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And as of today ebennies shows that my claim is in preparation for decision, hopefully I dont have to wait too long.
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I got out in may and this is my first set of exams with the VA.
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Ive never seen so c@ps...
My moneys on an total of 90% rating
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?
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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?
Success!......i Think
in Success Stories
Posted
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?