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Bobbo

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About Bobbo

  • Rank
    E-2 Recruit

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  • Service Connected Disability
    50%
  • Branch of Service
    USMC

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  1. Thanks for the input everyone, it helped me put all their writing into a bit more of a perspective of where I stand. Today my claim status went to "Preparation for Decision" so hopefully I have an answer soon!
  2. Hello all, I just completed my first round of C&P exams in almost 10 years and would like some help decoding what they mean and what percent these issues may now be rated at. I was originally denied for TBI, rated at 30% for PTSD, 10% for my shrapnel wound in arm, 10% GERD, 10% for Tinnitus, and 0% for both of my Knees and Bunions which are all service-connected. I also submitted new claims for Migraines, TBI (since I was denied in 2007), TMJ, and Sleep Paralysis but have yet to be seen for the TMJ or Sleep Paralysis. Any help or insight would be appreciated! Thanks, Bob -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL HEALTH 16257 STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT DATE OF NOTE: JAN 29, 2016@14:30 ENTRY DATE: JAN 29, 2016@16:44:20 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: Bob SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: F43.12 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.12 Mental Disorder Diagnosis #2: Panic Disorder without agoraphobia ICD Code: F41.0 Comments, if any: Secondary to PTSD b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): TB,I migraine headaches 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes[ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes[X] No[ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Panic disorder is secondary to PTSD c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes[ ] No[ ] Not shown in records reviewed d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes[X] No[ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis: PTSD and mild TBI share similar symptoms and cannot be differentiated without speculation. 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes[X] No[ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: PTSD and mild TBI share similar symptoms and cannot be differentiated without speculation. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [X] Yes[ ] No[ ] No diagnosis of TBI If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: 100% of the veteran's social and occupational impairment is due to his PTSD SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [ ] Yes[X] No 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: The veteran is a 32 year old married Caucasian male who lives his wife and in-laws in CA. He states that he moved in with in-laws just a few months ago. His wife is 6 months pregnant and they have a 10 month old son. He states that his parents live close by. He has 9 siblings living in California and the Northwest, and he has good relationships with his family members. b. Relevant Occupational and Educational history: The veteran is a high school graduate. He joined the Marine Corps shortly following graduation and served from 2002 to 2006. He was in the infantry. During that time, he had 3 deployments to Iraq and was wounded by shrapnel. He was awarded the Combat Action Badge, Iraq Campaign Medal and the Purple Heart. He received an honorable discharge with the rank of E4. Following discharge, he worked part-time odd jobs and attempted to go to school. He has been at CSUMB for over 3 years and anticipate graduating this spring. He is also working part-time as a race ticket collector. He states that he was let go from his previous job due to feeling overwhelmed by people and missing too many days. c. Relevant Mental Health history, to include prescribed medications and family mental health: The veteran is being seen today for a PTSD review evaluation. He has 30% service connected disability for PTSD and was evaluated in 2006-2007 at PAVAMC. This exam was not found in the VBMS file. He had a neuropsych assessment in 04/2009 by Dr # and revealed slight weakness in memory functioning. He is currently going to the VA Clinic and sees Dr # for medication. He takes Venafaxine. CURRENT COMPLAINTS: The veteran complained of sleep disturbance. He has difficulty going to sleep and wakes frequenly from nightmares. States that the nighmares began after starting medication. He has panic attacks that are triggered when startled, particularly when driving. He is anxious in public and becomes irritable over little things. His concentration and memory are poor. MENTAL STATUS EXAM: Appearance: Appropriately attired with good grooming and hygiene Cooperation: Cooperative with interview and pleasant Psychomotor: No gross psychomotor agitation or retardation noted Eye Contact: Good Speech: Clear with regular rate and rhythm Mood: Dysphoric and anxious Affect: Congruent with mood Thought Content: Denied S/I, H/I, no psychotic thoughts evident Thought Process: Linear, goal oriented Perception: Denies auditory/visual hallucinations Cognitive: No gross cognitive impairment evident Insight: WNL Judgment: WNL Orientation: Full d. Relevant Legal and Behavioral history: No legal or behavioral problems reported. e. Relevant Substance abuse history: The veteran drinks 3-4 beers a couple times/month. He states that his use is heavy at times. Denies legal problems related to alcohol use. Denies use of illegal drugs. f. Other, if any: No response provided. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting 5. Behavioral Observations: --------------------------- Mental status exam reveals a casually dressed veteran. He was cooperative with the evaluation process and willing to respond to questions. His affect was controlled and appropriate. His mood was dysphoric and anxious. His cognitive functions were intact. He was fully oriented and alert. No indication of hallucinations, delusions or psychotic process. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- DSM-5 criteria were used for this evaluation. The veteran meets DSM-5 diagnostic criteria for PTSD. The veteran presents today with symptoms of PTSD and secondary panic disorder that interfere with his social and occupational functioning. His condition appears somewhat worse than on his previous exam. He has panic attacks 2-3 times per week that are triggered when driving. PTSD symptoms include feeling nervous, anxious, and tense, problems with anger and irritability, feelings of sadness and depression, poor sleep, nightmares, hypervigilance, and difficulty in his interpersonal relationships. I reviewed the TBI exam of Dr. # and agree with the findings. There is no change to my diagnoses or report. Consultant, Ambulatory Care Signed: 01/29/2016 16:44 ------------------------------------------------------------------------- ========================================================================= Date/Time: 19 Jan 2016 @ 0830 Note Title: C&P NEUROLOGY Location: VA Palo Alto Health Care Sys Signed By: Co-signed By: Date/Time Signed: 19 Jan 2016 @ 1436 ------------------------------------------------------------------------- LOCAL TITLE: C&P NEUROLOGY STANDARD TITLE: NEUROLOGY C & P EXAMINATION CONSULT DATE OF NOTE: JAN 19, 2016@08:30 ENTRY DATE: JAN 19, 2016@14:36:20 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) Disability Benefits Questionnaire * Internal VA or DoD Use Only* Name of patient/Veteran: Bob Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Other: Records from VBMS and CPRS were reviewed. SECTION I: Diagnosis and medical history ---------------------------------------- 1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Traumatic brain injury (TBI) ICD code: S06.2 Date of diagnosis: 2/18/2009 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): In mid 2006 while in Iraq, he was riding in a Humvee which was hit by an IED. He could not recall any specific head injury or loss of consciousness. He felt dazed and having memory disturbance after this incident. After this incident, he had 2 more exposure to IED blast while riding in the Humvee in mid 2006. He did not have any specific head injury or loss of consciousness from these 2 incidents. Again, he only recall being dazed and having short term memory disturbance following these 2 incidents. When he returned back to the U.S. in 10/2006, he started having headaches. SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI ----------------------------------------------------------------------------- 1. Memory, attention, concentration, executive functions -------------------------------------------------------- [X] A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary): Patient reports having short term memory disturbance following his IED exposure. For example, he would forget recent conversations and forget where he place his keys, wallet, and phones. 2. Judgment ----------- [X] Normal 3. Social interaction --------------------- [X] Social interaction is routinely appropriate 4. Orientation -------------- [X] Always oriented to person, time, place, and situation 5. Motor activity (with intact motor and sensory system) -------------------------------------------------------- [X] Motor activity normal 6. Visual spatial orientation ----------------------------- [X] Normal 7. Subjective symptoms ---------------------- [X] Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples are: mild or occasional headaches, mild anxiety If the Veteran has subjective symptoms, describe (brief summary): Patient has short term memory disturbance and headaches following his exposure to IEDs. 8. Neurobehavioral effects -------------------------- [X] One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. If the Veteran has any neurobehavioral effects, describe (brief summary): Patient has symptoms of irritability, impulsivity, lack of motivation, verbal aggression, and lack of empathy when he return back to the U.S in 10/2006. 9. Communication ---------------- [X] Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. 10. Consciousness ----------------- [X] Normal SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks ----------------------------------------------------------------------------- 1. Residuals ------------ Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)? [X] Yes[ ] No If yes, check all that apply: [X] Headaches, including Migraine headaches 2. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms? [ ] Yes [X] No 3. Diagnostic testing --------------------- a. Has neuropsychological testing been performed? [X] Yes [ ] No If yes, provide date: 3/27/2009 Results: Most of the patient's current cognitive abilities are within normal limits compared to the general population. Compared to his premorbid functioning his present test results do not indicate a significant decline in cognitive functioning; however, he is exhibiting a slight weakness in memory abilities. Memory complaints are common in patients who have PTSD, anxiety, and depression and his emotional distress could account entirely for his cognitive symptoms. It is also possible that his memory difficulties are the result of his exposure to the IED blasts while in Iraq in 2006. b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 4. Functional impact -------------------- Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work? [ ] Yes [X] No 5. Remarks, if any: ------------------- The patient reports having short term memory disturbance and headaches following his exposure to IEDs in 2006. Thus, he is at least as likely as not to have had a mild TBI from these exposures. His symptoms of headaches and short term memory disturbance are stable so far. While having these symptoms, he has been able to attend school for the past 7-8 years and he will be completing his degree for business administration soon. **************************************************************************** Headaches (including Migraine Headaches) Disability Benefits Questionnaire Name of patient/Veteran: Bob Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: Records from VBMS and CPRS were reviewed. 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: G43.9 Date of diagnosis: 1/19/2016 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): Patient started having headaches after his exposure to the IEDs in 2006. They are described a sharp pain in the frontal head region which gradually spread to the whole head associated with nausea and light and sound sensitivity which would usually last 3-4 hours occurring once a week. Patient prefers to go to sleep when he has these headaches. 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): Aleve as needed. 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pain on both sides of the head 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] Sensitivity to light [X] Sensitivity to sound c. Indicate duration of typical head pain [X] Less than 1 day 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] Once every month b. Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [ ] Yes [X] No 5. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [ ] Yes [X] No 8. Remarks, if any: ------------------- The patient was exposed to 3 IED blasts in mid 2006 and he started having migraine headaches in 10/2006. Thus, it is at least as likely as not that these migraine headaches are related to his exposure to IED blasts while in Iraq in 2006. /es/ STAFF PHYSICIAN, NEUROLOGY Signed: 01/19/2016 14:36 ------------------------------------------------------------------------- ========================================================================= Date/Time: 13 Jan 2016 @ 1300 Note Title: C&P EXAMINATION Location: VA Palo Alto Health Care Sys Signed By: Co-signed By: Date/Time Signed: 14 Jan 2016 @ 1356 ------------------------------------------------------------------------- LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 13, 2016@13:00 ENTRY DATE: JAN 14, 2016@13:56:19 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED **************************************************************************** Esophageal Conditions (Including gastroesophageal reflux disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire Name of patient/Veteran: Bob Indicate method used to obtain medical information to complete this document: In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed: Yes List any records that were reviewed but were not included in the Veteran's VA claims file: VBMS, CPRS reviewed Diagnosis --------- Does the Veteran now have or has he/she ever been diagnosed with an esophageal condition? Yes Gastroesophageal reflux disease (GERD) ICD code: K21 Date of diagnosis: 2003 Medical history --------------- Description of the history (including onset and course) of the Veteran's esophageal conditions: Vet reports severe heartburn, belching with rise of acid into back of throat and sometimes mouth, foul taste, with pain swallowing foods, often food sticking , sharp pain radiating to chest and left shoulder area, interfering with sleep and sometimes he awakens with these symptoms. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition: Yes Medications used for the diagnosed condition: omeprazole, also tums, alka seltzer Signs and symptoms ------------------ Does the Veteran have any of the following signs or symptoms due to any esophageal conditions (including GERD)? Yes Sign and Symptoms: Persistently recurrent epigastric distress Dysphagia Pyrosis Reflux Regurgitation Pain Substernal Arm Shoulder Sleep disturbance caused by esophageal reflux Frequency of symptom recurrence per year: 4 or more Average duration of episodes of symptoms: 1-9 days Nausea Frequency of episodes of nausea per year: 4 or more Average duration of episodes of nausea: 1-9 days Esophageal stricture, spasm and diverticula ------------------------------------------- Does the Veteran have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus? No Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- 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? No 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? No Diagnostic Testing ------------------ Have diagnostic imaging studies or other diagnostic procedures been performed? No Has laboratory testing been performed? Yes Other, specify: he was tested for H.Pylori and treated for it , though stool testing apparently was not done Date of test: 2014 Results: + Are there any other significant diagnostic test findings and/or results? No Functional impact ----------------- Do any of the Veteran's esophageal conditions impact on his or her ability to work? Yes Impact of each of the Veteran's esophageal conditions, providing one or more examples: He reports pain that distracts him from work/interrupts work, and odor of reflux affects his face-to-face interactions with customers. Remarks, if any: No response provided ----------------- NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire Name of patient/Veteran: Bob ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination a. Evidence Review Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VBMS, CPRS reviewed b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 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): [X] Other (specify) Other diagnosis: bilateral bunions Side affected: Both ICD code: M20.1 Date of diagnosis (right side): 2002 Date of diagnosis (left side): 2002 ******************************************************************** 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 foot condition (brief summary): Bilateral bunions, pain on bunions in both feet, swelling of feet in bunion area. attributes to use of boots in military. Treated with motrin. No surgery b. Does the Veteran report pain of the foot being evaluated on this DBQ? [X] Yes [ ] No If yes, document the Veteran's description of pain in his or her own words: throbbing, hot pain, swollen feet causes pressure in both socks and shoes daily, 7/10 pain lasting 30 min to 2 hours. c. Does the Veteran report that flare-ups impact the function of the foot? [X] Yes [ ] No If yes, document the Veteran's description of flare-ups in his or her own words: He notes it interferes with working, hiking, exercise, daily errands, activities d. Does the Veteran report having any functional loss or functional impairment of the foot 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: as above 3. Flatfoot (pes planus) ------------------------ No response provided 4. Morton's neuroma (Morton's disease) and metatarsalgia -------------------------------------------------------- No response provided 5. Hammer toe ------------- No response provided 6. Hallux valgus ---------------- a. Does the Veteran have symptoms due to a hallux valgus condition? [X] Yes [ ] No If yes, indicate severity: [X] Mild or moderate symptoms Side affected: [ ] Right [ ] Left [X] Both b. Has the Veteran had surgery for hallux valgus? [ ] Yes [X] No c. Comments: mild tenderness to the right hallux bunion, more tender on the left with greater angulation at the left. 7. Hallux rigidus ----------------- No response provided 8. Acquired pes cavus (clawfoot) -------------------------------- No response provided 9. Malunion or nonunion of tarsal or metatarsal bones ----------------------------------------------------- No response provided 10. Foot injuries and other conditions -------------------------------------- No response provided 11. Surgical procedures ----------------------- a. Has the Veteran had foot surgery (arthroscopic or open)? [ ] Yes [X] No b. Does the Veteran have any residual signs or symptoms due to arthroscopic or other foot surgery? No response provided 12. Pain -------- RIGHT FOOT: Is there pain on physical exam? [ ] Yes [X] No If no, but the Veteran reported pain in his/her medical history, please provide rationale below. pain with walking/use LEFT FOOT: Is there pain on physical exam? [ ] Yes [X] No If no, but the Veteran reported pain in his/her medical history, please provide rationale below. pain with walking/use 13. Functional loss and limitation of motion -------------------------------------------- a. Contributing factors of disability (check all that apply and indicate side affected): [X] No functional loss for left lower extremity attributable to claimed condition [X] No functional loss for right lower extremity attributable to claimed condition Contributing factors of disability associated with limitation of motion: b. Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [ ] Yes [X] No LEFT FOOT: [ ] Yes [X] No c. Is there any other functional loss during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [ ] Yes [X] No LEFT FOOT: [ ] Yes [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No c. Comments: No comments provided 15. Assistive devices --------------------- a. Does the Veteran use any assistive device 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 16. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's foot 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., 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 17. Diagnostic testing ---------------------- a. Have imaging studies of the foot 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 condition: No response provided 18. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: Vet reports foot pain and swelling which causes him to take more frequent breaks, interrupting his work, to take off his shoes and/or socks to relieve pressure and swelling of his feet/bunions. Causes discomfort which translates to bad mood affecting his customer service skills. 19. Remarks, if any: -------------------- No remarks provided **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Bob ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination a. Evidence review Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VBMS, CPRS reviewed b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: chondromalacia patella b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Other (specify): Other diagnosis: chondromalacia patella Side affected: Both ICD code: M22 Date of diagnosis (right side): 2004 Date of diagnosis (left side): 2004 ******************************************************************** 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): He notes pain and stiffness when sedentary or sitting and wehn running or hiking, his knees can give out with severe pain. He treats with ice, ibuprofen and rest after severe pain. 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: He notes flareups as excruciating pain knees feel like they will give out and lose ability to lock. Occurs weekly to multiple times a week. 9/10 pain lasting 2-3 hours. Pain to touch during flareups. 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? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: any strenuous physical activities along with work as it is difficult to sit for long periods of time without getting up and walking to amke knees feel better. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Right Knee ---------- [X] All normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees Description of pain (select best response): No pain noted on exam Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No Left Knee --------- [X] All normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees Description of pain (select best response): No pain noted on exam Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right Knee ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right Knee ---------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not being examined after period of repeated use over time or during a flareup. Left Knee --------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not being examined after period of repeated use over time or during a flareup. d. Flare-ups Right Knee ---------- Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not being examined after period of repeated use over time or during a flareup. Left Knee --------- Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not being examined after period of repeated use over time or during a flareup. e. Additional factors contributing to disability Right Knee ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left Knee --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe b. Is there a history of lateral instability? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing Right Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: 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? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below. [X] "Shin splints" (medial tibial stress syndrome) Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of knee? [ ] Yes [X] No Does this condition affect ROM of ankle? [ ] Yes [X] No Describe current symptoms: n/a 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? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ----------------- [X] Brace(s) [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: occasional knee brace, for flareups 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): Prior knee x-rays in 2007 were normal. c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 14. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: Kees are constantly stiff and create pain when sitting for short or prolonged periods, when doing manual labor his knees have a tendancy to cause extreme pain especially when walking and carrying weight which often causes them to give out on him. These conditions cause him to take breaks more often, with less work being done. The pain can cause him to be in a foul mood, which can translate into poor customer service, and poor interactions with other employees, management. 15. Remarks, if any: -------------------- No response provided **************************************************************************** Muscle Injuries Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes[ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VBMS, CPRS reviewed SECTION I: DIAGNOSIS -------------------- Does the Veteran now have or has he/she ever been diagnosed with a muscle injury? [X] Yes[ ] No Diagnosis #1: left bicep shrapnel ICD code: Y36 Date of diagnosis: 2004 Side affected: [ ] Right [X] Left [ ] Both SECTION II: HISTORY OF MUSCLE INJURY ------------------------------------ a. Does the Veteran have a penetrating muscle injury, such as a gunshot or shell fragment wound? [X] Yes[ ] No b. Does the Veteran have a non-penetrating muscle injury (such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)? [ ] Yes[X] No c. Describe the history (including onset and course) of the Veteran's muscle injury: (brief summary): He has a shrapnel wound in arm from grenade in his upper left arm from a firefight for which he received a Purple Heart. He notes now that he will have some weakness/pain/tingling in the left arm bicep after holding his child for a long time. Scar is one cm x one cm round, not tender, and palpable shapnel is more proximal, in arm, not beneath the scar. d. Dominant hand [X] Right[ ] Left[ ] Ambidextrous SECTION III: LOCATION OF MUSCLE INJURY -------------------------------------- 1. Shoulder girdle and arm -------------------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the shoulder girdle or arm? [X] Yes[ ] No If yes, check muscle group(s) and side affected (check all that apply): [X] Group V: Flexor muscles of elbow: biceps, brachialis, brachioradialis Side affected: [ ] Right [X] Left [ ] Both 2. Forearm and hand ------------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the forearm or hand? [ ] Yes[X] No 3. Foot and leg --------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the foot or leg? [ ] Yes[X] No 4. Pelvic girdle and thigh -------------------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the pelvic girdle or thigh? [ ] Yes[X] No 5. Torso and neck ----------------- Does the Veteran now have or has he/she ever had an injury to a muscle group in the torso and/or neck? [ ] Yes[X] No 6. Additional conditions ------------------------ a. Does the Veteran have a history of rupture of the diaphragm with herniation? [ ] Yes[X] No b. Does the Veteran have a history of an extensive muscle hernia of any muscle, without other injury to the muscle? [ ] Yes[X] No c. Does the Veteran have a history of injury to the facial muscles? [ ] Yes[X] No SECTION IV: MUSCLE INJURY EXAM ------------------------------ 1. Scar, fascia and muscle findings ----------------------------------- a. Does the Veteran have any scar(s) associated with a muscle injury? [X] Yes[ ] No If yes, indicate severity of scar(s) caused by the muscle injury(ies) (check all that apply if there is more than one area or type of scarring): [X] Minimal scar(s) b. Does the Veteran have any known fascial defects or evidence of fascial defects associated with any muscle injuries? [ ] Yes[X] No c. Does the Veteran's muscle injury(ies) affect muscle substance or function? [ ] Yes[X] No 2. Cardinal signs and symptoms of muscle disability --------------------------------------------------- Does the Veteran have any of the following signs and/or symptoms attributable to any muscle injuries? [ ] Yes[X] No 3. Muscle strength testing -------------------------- Rate strength according to the following scale: 0/5 No muscle movement 1/5 Visible muscle movement, but no joint movement 2/5 No movement against gravity 3/5 No movement against resistance 4/5 Less than normal strength 5/5 Normal strength Elbow flexion (Group V) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Does the Veteran have muscle atrophy? [ ] Yes[X] No SECTION V: OTHER ---------------- 1. 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 2. Remaining effective function of the extremities -------------------------------------------------- Due to the Veteran's muscle conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 3. Other pertinent physical findings, complications, conditions, signs and/or symptoms ---------------------------------------------------------------------- Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms? [ ] Yes[X] No 4. Diagnostic Testing --------------------- a. Have imaging studies been performed and are the results available? [ ] Yes[X] No b. Is there x-ray evidence of retained metallic fragments (such as shell fragments or shrapnel) in any muscle group? [ ] Yes[X] No c. Were electrodiagnostic tests done? [ ] Yes[X] No d. Are there any other significant diagnostic test findings and/or results? [ ] Yes[X] No 5. Functional impact -------------------- Does the Veteran's muscle injury(ies) impact his or her ability to work, such as resulting in inability to keep up with work requirements due to muscle injury(ies)? [ ] Yes[X] No 6. Remarks, if any: ------------------- No remarks provided. /es/ STAFF PHYSICIAN, AMBULATORY CARE Signed: 01/14/2016 13:56
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