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soriol36
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Posts posted by soriol36
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In my case, I was denied service connection for my knees and back pain in July 2015. The rationale they provided was that even though, I have medical treatment records from service showing that I suffered from knees pain and back pain, the VA could not grant service connection disability just on the basis of pain. I have service treatment records and post-separation treatment records from the VA medical medical center, however this was not enough as I didn't have a medical diagnosis for these conditions.
If I am understanding this correctly, this means that I should be granted service connected disability for these conditions. I already have a claim to reopen these conditions, I wonder how this new rulling will affect my claim?
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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.
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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 [ ] NoACE 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 [ ] NoThoracolumbar 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 fractureDiagnosis #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 tothe 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 [ ] NoIf 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 lossIf noted on exam, which ROM exhibited pain (select all that apply)?
Forward Flexion, Extension, Right Lateral Flexion, Left Lateral
FlexionIs 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] Nob. Observed repetitive use
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] NoIs there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] Noc. Repeated use over time
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] NoIf the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran'sstatements 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 speculationd. 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'sstatements describing functional loss during flare-
ups.
[ ] The examination is medically inconsistent with the Veteran'sstatements 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 speculatione. Guarding and muscle spasm
Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [ ] Yes [X] Nof. 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: None4. 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 strengthHip flexion: Right: [X] 5/5
5 [ ] 1/5
[ ] 0/5Left: [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 [ ] 0/5Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 0/5Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 0/5Great 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 clonusKnee: 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] AbsentLeft: [ ] Normal [ ] Decreased [X] Absent
Thigh/knee (L3/4):
Right: [ ] Normal [ ] Decreased [X] AbsentLower leg/ankle (L4/L5/S1):
Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] AbsentFoot/toes (L5):
Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] Absent7. 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] No9. 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] No11. 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 oflocomotion, 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 impairmentof an extremity such that no effective function remains other than that which
would be equally well served by an amputation with prosthesis? (Functions ofthe 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 providedb. 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] Noc. Comments, if any: No response provided
15. Diagnostic testing
----------------------
a. Have imaging studies of the thoracolumbar spine been performed and are theresults available? [X] Yes [ ] No
If yes, is arthritis documented?
[X] Yes [ ] Nob. 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
jointdegenerative 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) yes2. Is there evidence of pain when the joint is used in non- weight
bearing? (Yes/No/Cannot be performed or is not medicallyappropriate) 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 [ ] NoACE 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 responseprovided
b. Select diagnoses associated with the claimed condition(s) (Check all that
apply):
c. Comments (if any): No response providedd. 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 orthigh 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 [ ] NoIf 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 motionRight 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] NoExternal 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 romIf 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 [ ] NoIf 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] NoExternal 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] NoDescription of pain (select best response):
Pain noted on exam but does not result in/cause functional lossIf 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 [ ] NoIf 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 [ ] NoIs there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] NoLeft hip
--------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] NoIs there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] Noc. Repeated use over time
Right hip
---------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] NoIf the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran?sstatements 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 withrepetitive 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 speculationIf 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] NoIf the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran?sstatements 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 speculationIf 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] NoIf the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran?s statementsdescribing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statementsdescribing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent withthe 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 speculationIf unable to say w/o mere speculation, please explain: not observed
Left hip
--------
Is the examination being conducted during a flare-up? [ ] Yes [X] NoIf the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran?s statementsdescribing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statementsdescribing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent withthe 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 speculationIf 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 strengthRight Hip
Rate Strength: Flexion: 5/5Extension: 5/5 Abduction: 5/5
Is there a reduction in muscle strength? [ ] Yes
Left Hip
Rate Strength: Flexion: 5/5Extension: 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 provided6. Additional conditions
------------------------
a. Does the Veteran have malunion or nonunion of femur, flail hip joint orleg length discrepancy? [ ] Yes [X] No
b. Comments, if any: No response provided7. Surgical procedures ----------------------
No response provided8. 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] Nob. 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] Noc. 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] Nob. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition: No
response provided10. Remaining effective function of the extremities ---------------------------------------------------
Due to the Veteran's hip or thigh conditions, is there functional impairmentof an extremity such that no effective functions remain other than that which
would be equally well served by an amputation with prosthesis? (Functions ofthe 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 theresults 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) yes2. Is there evidence of pain when the joint is used in non- weight
bearing? (Yes/No/Cannot be performed or is not medically appropriate) yes3. 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 [ ] NoACE 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 1997c. 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 kneeand/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 abovec. Does the Veteran report having any functional loss or
functional impairmentof the joint or extremity being evaluated on this DBQ, including but not
limited to repeated use over time?
[ ] Yes [X] No3. Range of motion (ROM) and functional limitation --------------------------------------------------
a. Initial range of motionRight 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) [ ] NoIf yes, please explain:
vet walking with anlagic gaitDescription of pain (select best response):
Pain noted on exam and causes functional lossIf noted on exam, which ROM exhibited pain (select all that apply)?
Flexion
Is there evidence of pain with weight bearing? [X] Yes [ ] NoIs there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] NoIf yes, describe including location, severity and relationship to
condition(s):
pain on palpation patella, supereior , inferior, and mediallateral
border, jt lines
Is there objective evidence of crepitus? [ ] YesLeft 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) [ ] NoIf yes, please explain:
et walking with anlagic gaitDescription of pain (select best response):
Pain noted on exam but does not result in/cause functional lossIf noted on exam, which ROM exhibited pain (select all that apply)?
Flexion
Is there evidence of pain with weight bearing? [X] Yes [ ] NoIs there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] NoIf yes, describe including location, severity and relationship to
condition(s):
pain on palpation patella, supereior , inferior, and mediallateral
border, jt lines
Is there objective evidence of crepitus? [ ] Yesb. Observed repetitive use
[X] No
Right Knee
----------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] NoIs there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] NoLeft Knee
---------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] Noc. Repeated use over time
Right Knee
----------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] NoIf the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran'sstatements describing functional loss with repetitive
use over time.
[ ] The examination is medically inconsistent with the Veteran'sstatements 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 speculationLeft Knee
---------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] NoIf the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran'sstatements describing functional loss with repetitive
use over time.
[ ] The examination is medically inconsistent with the Veteran'sstatements describing functional loss with repetitive use over time.
Please explain.[X] The examination is neither medically consistent or
inconsistent withthe 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 speculationd. Flare-ups
Right Knee
----------
Is the exam being conducted during a flare-up? [X] YesDoes pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculationSelect 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 degreesLeft Knee
---------
Is the exam being conducted during a flare-up? [X] YesDoes pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculationSelect 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 degreese. 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: NoneLeft Knee
---------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None4. 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 strengthRight 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 providedRate 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 testingRight 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] NoIf 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 extensionand 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] NoIf 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 extensionand 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 patellardislocation, "shin splints" (medial tibial stress syndrome),
stress
fractures, chronic exertional compartment syndrome or any other tibialand/or fibular impairment? [ ] Yes [X] No
b. Comments, if any: No response provided8. Meniscal conditions
----------------------
a. Does the Veteran now have or has he or she ever had a meniscus (semilunarcartilage) condition? [ ] Yes [X] No
b. For all checked boxes above, describe: No response provided
9. Surgical procedures ----------------------
No response provided10. 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] Nob. 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] Noc. 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 andidentify 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 resultsavailable?
[X] Yes [ ] NoIf 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 20141. 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] No15. 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) yes2. Is there evidence of pain when the joint is used in non- weight
bearing? (Yes/No/Cannot be performed or is not medically appropriate)yes3. 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 testthe range of motion of the opposing joint. rom done bil
****************************************************************************
Medical Opinion
Disability Benefits QuestionnaireName 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 lumbarspine 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 causeradiculopathy to both thighs or legs.
-
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.
-
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.
-
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 :)
-
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.
-
Deleted duplicate post
-
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.
IU Granted - Question
in TDIU Unemployability Claims
Posted
Hello All,
I have a question about IU. My husband had an appeal since 2014 for IU and sleep apnea as secondary for PTSD. I just checked vets.gov and it shows that they issue a statement of the case on June 22, 2018 for his sleep apnea issue (which it was denied), however they granted his IU. I went to check ebenefits and his disabilities still show 80% but his benefit summary letter shows he is been rated at 100%. However, the currently award amount did not change or reflected the 100% amount. My question is, how long would it take for the summary letter to reflects the actual award amount (which it should be around $3,500)?