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soriol36

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About soriol36

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    E-3 Seaman

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    Wellington, FL

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  • Service Connected Disability
    10%
  • Branch of Service
    Army

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  1. thank you for the info. I found out she used my 2014 MRI not my current MRI with was done a month ago which has been flaged by my doctor.
  2. Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: osteoarthritis lumbaar spine Date of diagnosis: 2014 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Vet says he has dull lower back pain for about 2 yrs and shooting pain electric like radiating to the rt upper leg with numbness and tingling to the foot for several hours daily, precipitated by prolonged sitting or laying or standing . The latter symptoms began 5 mos ago. He has flare up almost every day precipitated by bending or lack of sleep. He stops what he is doing for a few minutes during the flare up. He says naprosyn is not effective. He drinks etoh to relieved the pain. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: see above c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. see in recliner most of the day 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 70 degrees Extension (0 to 30): 0 to 20 degrees Right Lateral Flexion (0 to 30): Left Lateral Flexion (0 to 30): Right Lateral Rotation (0 to 30): Left Lateral Rotation (0 to 30): 0 to 25 degrees 0 to 25 degrees 0 to 30 degrees 0 to 30 degrees Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [ ] Yes [X] No b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare- up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare- ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare- ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [ ] Yes [X] No f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 0/5 [ ] 4/5 [ ] 4/5 [ ] 3/5 [ ] 3/5 [ ] 2/ [ ] 2/5 [ ] 1/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 0/5 [ ] 3/5 [ ] 3/5 [ ] 3/5 [ ] 3/5 [ ] 3/5 [ ] 3/5 [ ] 3/5 [ ] 3/5 [ ] 2/5 [ ] 2/5 [ ] 2/5 [ ] 2/5 [ ] 2/5 [ ] 2/5 [ ] 2/5 [ ] 2/5 [ ] 1/5 [ ] 1/5 [ ] 1/5 [ ] 1/5 [ ] 1/5 [ ] 1/5 [ ] 1/5 [ ] 1/5 b. Does the Veteran have muscle atrophy? No response provided. 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 Left: [ ] 0 Ankle: Right: [ ] 0 Left: [ ] 0 [ ] 1+ [ ] 1+ [ ] 1+ [ ] 1+ [X] 2+ [X] 2+ [X] 2+ [X] 2+ [ ] 3+ [ ] 3+ [ ] 3+ [ ] 3+ [ ] 4+ [ ] 4+ [ ] 4+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] Absent Thigh/knee (L3/4): Right: [ ] Normal [ ] Decreased [X] Absent Lower leg/ankle (L4/L5/S1): Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] Absent Foot/toes (L5): Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ---------------------------------------------------------------- ------- a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] Yes [X] No 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ---------------------------------------------------------------- -------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? No response provided b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): mri lumbar spine 2014 1. Mild to moderate L4/L5, and mild L2/L3, and L3/L4 facet joint degenerative disease. 2. No degenerative disc disease of the lumbar spine. Mild lumbar spine scoliosis is stable. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [ ] Yes [X] No 17. Remarks, if any: -------------------- The absent light touch on both lowwer extremities cnnot be explained by the imaging of the lumbar spine. Vet had admitted chronically drinking a lot of otoh but does not appear intoxicated this exam. This may explain the absent sensation. ****************** 1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) yes 2. Is there evidence of pain when the joint is used in non- weight bearing? (Yes/No/Cannot be performed or is not medically appropriate) yes 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? (Yes/No) If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. If no, the examiner is requested to state whether it is medically feasible to test the joint and if not to please state why the examiner cannot test the range of motion of the opposing joint. **************************************************************************** Hip and Thigh Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: No response provided b. Select diagnoses associated with the claimed condition(s) (Check all that apply): c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? Yes 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hip or thigh condition: Vet complains of bilateral hip pain, the right worse than the left. This pain is the same as described with the back pain radiating to the legs. There is a keloid on the right anterior upper leg which he says was noted during service. He cannot recall injury to the thigh. Vet has not complained of the hip pain to his provider. b. Does the Veteran report flare-ups of the hip or thigh? [X] Yes [ ] No If yes, document the Veteran's description of the of flare- ups in his or her own words: same as the back flare up c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: he says he has to sit most of the time. ( Vet is not employed) 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right hip --------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): Extension (0-30): Abduction (0-45): Adduction (0-25): 0 to 100 degrees 0 to 30 degrees 0 to 30 degrees 0 to 25 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 40 degrees Internal Rotation (0-40): 0 to 20 degrees If ROM is outside of normal range, but is normal for the Veteran (for reasons other than an hip condition, such as age, body habitus, neurologic disease), please describe: body habitus contributes to decreased rom If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes, (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion, Adduction, External rotation, Internal rotation Is there evidence of pain with weight bearing? [X] Yes No [ ] Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): vet verbalizing pzin onlateral thigh and anterior joint Is there objective evidence of crepitus? [ ] Yes Left hip -------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) [X] No Flexion (0-125): Extension (0-30): Abduction (0-45): Adduction (0-25): 0 to 100 degrees 0 to 30 degrees 0 to 30 degrees 0 to 25 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 40 degrees Internal Rotation (0-40): 0 to 20 degrees If ROM is outside of normal range, but is normal for the Veteran (for reasons other than an hip condition, such as age, body habitus, neurologic disease), please describe: body habitus contributes to decreased If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes, (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion, Adduction, External rotation, Internal rotation Is there evidence of pain with weight bearing? [X] Yes No [ ] Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): vet verbalizing pzin onlateral thigh and anterior joint Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right hip --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No Left hip -------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right hip --------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsisten with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not obsersved Left hip -------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not observed d. Flare-ups Right hip --------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not observed Left hip -------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not observed e. Additional factors contributing to disability Right hip --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left hip -------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes Left Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes b. Does the Veteran have muscle atrophy? [ ] Yes [X] No [X] No [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ No response provided 6. Additional conditions ------------------------ a. Does the Veteran have malunion or nonunion of femur, flail hip joint or leg length discrepancy? [ ] Yes [X] No b. Comments, if any: No response provided 7. Surgical procedures ---------------------- No response provided 8. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ---------------------------------------------------------------- ------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 9. Assistive devices -------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 10. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's hip or thigh conditions, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 11. Diagnostic testing ---------------------- a. Have imaging studies of the hip or thigh been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 12. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [ ] Yes [X] No 13. Remarks, if any: -------------------- 1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) yes 2. Is there evidence of pain when the joint is used in non- weight bearing? (Yes/No/Cannot be performed or is not medically appropriate) yes 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? (Yes/No) If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. If no, the examiner is requested to state whether it is medically feasible to test the joint and if not to please state why the examiner cannot test the range of motion of the opposing joint. rom done bil **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: bil knees b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Patellofemoral pain syndrome Side affected: [ ] Right [ ] Left [X] Both Date of diagnosis: Right 1997 Date of diagnosis: Left 1997 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Vet is sc for bil retropatellar pain syndome with chondoromalacia. He has sx since 1997. He was treated with physicla therapy and cortison injection to the right knee x 3 in 2014. He says this was not effective. The knees hurt daily, flares up after accidental trauma. The joints swell, buckle frequently, wears brace when he leaves the house. During flare up he says he can't move, stays in a recliner for hours. Today knee pain is worse because he has been on his feet earlier today. ( he came in walking independently but with antalgic gait. The swelling lasts several hours improves with leg elevation. b. Does the Veteran report flare-ups of the knee and/or lower leg? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: see above c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [ ] Yes [X] No 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Right Knee ---------- [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 100 degrees Extension (140 to 0): 100 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: vet walking with anlagic gait Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): pain on palpation patella, supereior , inferior, and medial lateral border, jt lines Is there objective evidence of crepitus? [ ] Yes Left Knee --------- [ ] All normal [X] Abnormal or outside of normal range [X] No [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 100 degrees Extension (140 to 0): 100 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: et walking with anlagic gait Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): pain on palpation patella, supereior , inferior, and medial lateral border, jt lines Is there objective evidence of crepitus? [ ] Yes b. Observed repetitive use [X] No Right Knee ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No c. Repeated use over time Right Knee ---------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation Left Knee --------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation d. Flare-ups Right Knee ---------- Is the exam being conducted during a flare-up? [X] Yes Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain [] No Able to describe in terms of range of motion: [X] Yes [] No Flexion (0 to 140): 0 to 100 degrees Extension (140 to 0): 100 to 0 degrees Left Knee --------- Is the exam being conducted during a flare-up? [X] Yes Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain [] No Able to describe in terms of range of motion: [X] Yes [] No Flexion (0 to 140): 0 to 100 degrees Extension (140 to 0): 100 to 0 degrees e. Additional factors contributing to disability Right Knee ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left Knee --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Knee: Flexion: Extension: Is there a reduction in muscle strength? Left Knee: Flexion: Extension: Is there a reduction in muscle strength? b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ No response provided Rate Strength: 5/5 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Right: [X] None [ ] Slight [ ] Moderate Left: [X] None [ ] Slight [ ] Moderate b. Is there a history of lateral instability? [ ] Severe [ ] Severe Right: [X] None [ ] Slight [ ] Moderate [ ] Severe 5/5 Rate Strength: 5/5 [ ] Yes [ ] Yes [X] No [X] No 5/5 Left: [X] None [ ] Slight [ ] Moderate [ ] Severe c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing Right Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left Knee Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: No response provided 7. Additional conditions ------------------------ a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No b. Comments, if any: No response provided 8. Meniscal conditions ---------------------- a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided 9. Surgical procedures ---------------------- No response provided 10. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------- ------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [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? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): mri bil knee 2014 1. Grade I chondromalacia over the lateral tibia plateau. 2. A cyst in the lateral tibia plateau under the lateral tibial spine is suggestive of ganglion cyst. c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions No response provided 14. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [ ] Yes [X] No 15. Remarks, if any: -------------------- 1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) yes 2. Is there evidence of pain when the joint is used in non- weight bearing? (Yes/No/Cannot be performed or is not medically appropriate)yes 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? (Yes/No) If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. If no, the examiner is requested to state whether it is medically feasible to test the joint and if not to please state why the examiner cannot test the range of motion of the opposing joint. rom done bil **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Is the Veteran's Left Thigh pain at least as likely as not (50 percent or greater probability) proximately due to or the result of scoliosis lumbar spine with musculoskeletal pain? TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] b. The condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: Levoscoliosis does not result in hip pathology. The levoscoliosis is mild. There is no evidence of lumbar disc disease to cause radiculopathy to both thighs or legs.
  3. Yes I only get 10%. Yes I have been getting treatment at VA since 2012 and civilian doctor prior to 2012 for those disabilities and I have been on medication since I left the military for hypertension and migraines.
  4. I submitted a claim with a few new disabilities and to reopen the following disabilities shown below that were non service connected (as rated in 2007). To my surprise, I found the following statement on one of my C&Ps resutls. INCREASE CLAIMS: The veteran is claiming an increase in her service connected: " Hypertension " Asthma with allergic rhinitis " Migraine headaches " Mitral Valve Disorder " Right knee PFS " Lumbar Back Strain **Please note that the record currently does not show the veteran as service-connected for headaches, heart condition, right knee, or lumbar condition. However, errors were found in a previous rating decision, and service connection was warranted in 2007 based on her C&P exam completed within one year of service. Therefore, these issues will be treated as increase exams. Please have the examiner evaluate the current level of each disability, perform all tests as needed, and include results in the examination report. My question is how do I go about this? How do I get a copy of my C&P for 2007? I cannot believe that they made a mistake and never contacted me about it. My ebenefits still showing those disabilities as non-service connected.
  5. Got it. Thanks for the advice. I will get the letters and will write a statement. My claim stills under review so I think I have time to submit this evidence. Thank you so much for your advice :)
  6. Hi thanks for your input. Yes I can two or three per week, it varies. But I was very clear when I told him than I also use Excedrin because I feel like it works better on me sometimes and he neglected to add that statement to the notes. The problem with the medication is that I do not take every single day I only take them when I get the attacks.
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  8. Tell me what you guys think. I told the examiner that I take my medication as needed when I get my migraines and for the duration of the attacks and that I also take Excedrin. But he got nerves to insinuate that I lied about my medications!! and then look at my results. He marked less than frequent attacks when I specifically told how often I get the attacks. The examiner was very rude... 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: 784.0 Date of diagnosis: is SC for that 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): Veteran states that she is taking the Butalbital every day every 4-6 hours or 4 times a day. However, this is not consistent with the prescription refill. I asked her twice if she was taking the Butalbital 4 times a day every day and she replied in the affirmative. She states that her headaches last from 1 day to weeks. Veteran states that she misses 2-3 days a week due to headaches. This is her statement. 10/27/14 (Mail) released 10/28/14 RENEWED FROM RX # 4676332 2/5/15 (Mail) released 2/6/15 3/27/15 (Mail) released 3/30/15 5/3/15 (Mail) released 5/5/15 7/2/15 (Mail) released 7/2/15 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): Fioricet 4 times a day every day 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Constant head pain [X] Pulsating or throbbing head pain [X] Pain localized to one side of the head [X] Pain on both sides 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 [X] Sensitivity to sound [X] Sensory changes (such as feeling of pins and needles in extremities) c. Indicate duration of typical head pain [X] More than 2 days d. Indicate location of typical head pain [X] Both sides 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] With less frequent attacks 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? [ ] Yes [X] No 6. Diagnostic testing --------------------- 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): CT of the head in October 19, 2015 was totally normal 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: Per veteran statement, she states that she misses 2-3 days per week due to her headaches. She works for the school district at Palm Beach County School district. 8. Remarks, if any: ------------------- The veteran states that in the last month, her left eye twitches when she has a migraine attack.
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