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Bobbo
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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 QuestionnaireName 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: F43.122. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD Code: F43.12Mental 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 headaches3. 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
productivityb. 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 setting5. 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: 2/18/20092. 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 headaches2. 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 QuestionnaireName 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 monthb. 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 QuestionnaireName 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 reviewedDiagnosis
---------
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: 2003Medical 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 daysEsophageal 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? NoDiagnostic 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 ormore 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 QuestionnaireName 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 provided4. 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 QuestionnaireName 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 degreesDescription 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 degreesDescription 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] NoLeft 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] Noc. 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 ankylosisLeft 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 ankylosisb. 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 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] 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 performIf 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/ab. 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 [ ] Constantb. 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] No13. 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 QuestionnaireName of patient/Veteran:
Indicate method used to obtain medical information to complete this document:
[X] In-person examinationEvidence 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 [ ] BothSECTION 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 strengthElbow 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
C&P Exam Results - Need Help Deciphering
in Veterans Compensation & Pension Exams
Posted
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!