Rainder_X

I would file for it, provide them all the medical records. Then let them do C&P exam to prove or disprove your claim.

Any one have any clue why my claim would move backwards from pending notificationn.

My claim has bounced back and fourth quite a bit on this claim probably nothing to worry about for yours either.

I just moved to Pending Decision Approval today and am trying to get a general rang estimate of what I will be rated at based upon C&P My best guess is 20%-30% on the left shoulder and 10%- 20% on my RightShoulder and Arm Conditions Disability Benefits QuestionnaireName of patient/Veteran:Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review----------------------Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review--------------Evidence reviewed (check all that apply):[X] VA e-folder (VBMS or Virtual VA) [X] CPRS1. Diagnosis-----------a. List the claimed condition(s) that pertain to this DBQ: No response providedb. Select diagnoses associated with the claimed condition(s) (check all that apply):[X] Shoulder strain Side affected: [X] Right [ ] Left [ ]Both ICD Code: S46.911 Date of diagnosis: Right 2016[X] Bicipital tendonitis Side affected: [ ] Right [X] Left [ ] Both ICD Code: M75.8 Date of diagnosis: Left 2016c. Comments, if any: No response providedd. Was an opinion requested about this condition? [ ] Yes [X] No [ ] N/A2. Medical history-----------------a. Describe the history (including onset and course) of the Veteran's shoulder or arm condition (brief summary): VETERAN IS ALREADY SERVICE CONEECTED FOR BILATERAL SHOULDER CONDITION SYMPTOMS ARE PROGRESSING BILATERALLY BUT L>R. HE REPORTS LIMITED MOTION AND FUNCTIONING.b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrousc. Does the Veteran report flare-ups of the shoulder or arm? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: PROLONGED ARM USEd. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: FUNCTIONAL LIMITATIONS. L>R, HAS TO DO SOME FUNCTIONINGS ONLY WITH RIGHT BUT INCREASING LIMITATIONS BILATERALLY: BASED ON LEFT SHOULDER: CANNOT DO THE FOLLOWING FUNCTIONS AT ALL WITH LEFT SHOULDER. HAS 20-30% DIFFICULTY WITH RIGHT: WASH HAIR, WASH BACK, PUT ON CLOTHES OVERHEAD, CARRY ANYTHING OVER 10 POUNDS, CANNOT CHANGE A LIGHT BULB OVERHEAD OR PUT ITEMS ON HIGH SHELVES AT ALL. DIFFICULTY SLEEPING, CAN'T PLACE OBJECTS IN BACK POCKETS OR BUTTON UP HIS SHIRT. DIFFICULTY PUSHING HEAVY DOORS OR CARVING MEAT, FOR EXAMPLE. 3. Range of motion (ROM) and functional limitation-------------------------------------------------a. Initial range of motion Right Shoulder-------------[ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)Flexion (0 to 180): 0 to 140 degrees Abduction (0 to 180): 0 to 140 degrees External rotation (0 to 90): 0 to 60 degreesInternal rotation (0 to 90): 0 to 60 degreesIf abnormal, does the range of motion itself contribute to functional loss? [ ] Yes (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Abduction, External rotation, Internal rotationIs there evidence of pain with weight bearing? [X] Yes [ ] NoIs there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] NoIf yes, describe including location, severity and relationship to condition(s): TTPIs there objective evidence of crepitus? [X] Yes [ ] NoLeft Shoulder------------[ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)Flexion (0 to 180): 0 to 90 degreesAbduction (0 to 180): 0 to 90 degreesExternal rotation (0 to 90): 0 to 40 degreesInternal rotation (0 to 90): 0 to 20 degreesIf abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] NoIf yes, please explain: NO OVERHEAD USE Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)?Flexion, Abduction, External rotation, Internal rotationIs there evidence of pain with weight bearing? [X] Yes [ ] NoIs there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ]If yes, describe including location, severity and relationship to condition(s): TTPIs there objective evidence of crepitus? [X] Yes [ ] Nob. Observed repetitive use Right Shoulder------------Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] NoIs there additional functional loss or range of motion after three repetitions? [ ] Yes [X] NoLeft Shoulder------------Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] NoIs there additional functional loss or range of motion after three repetitions? [X] Yes [ ] NoSelect all factors that cause this functional loss: Pain, Fatigue ROM after three repetitions:Flexion (0 to 180): 0 to 80 degreesAbduction (0 to 180): 0 to 80 degreesExternal rotation (0 to 90): 0 to 30 degreesInternal rotation (0 to 90): 0 to 20 degreesc. Repeated use over time Right Shoulder-------------Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] NoIf the examination is not being conducted immediately after repetitive use over time:[X] 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. Please explain.[ ] 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? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss:Pain, Fatigue, Lack of endurance Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: S/ALeft Shoulder ------------Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] NoIf the examination is not being conducted immediately after repetitive use over time:[X] 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.[ ] 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? [X] Yes [ ] No [ ] Unable to say w/o mere speculationSelect all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance, IncoordinationAble to describe in terms of range of motion: [ ] Yes [X] No If no, please describe:d. Flare-ups Right Shoulder-------------Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up:[X] 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.[ ] 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? [X] Yes [ ] No [ ] Unable to say w/o mere speculationSelect all factors that cause this functional loss: Pain, Fatigue, Lack of endurance Able to describe in terms of range of motion: [ ] Yes [X] NoIf no, please describe: S/ALeft Shoulder------------Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up:[X] 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.[ ] 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? [X] Yes [ ] No [ ] Unable to say w/o mere speculationSelect all factors that cause this functional loss: Pain, Fatigue, Lack of endurance, IncoordinationAble to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: S/A e. Additional factors contributing to disability Right Shoulder-------------In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:Disturbance of locomotion Left Shoulder------------In addition to those addressed above, are there additional contributing factors of disability?Please select all that apply and describe:Instability of station, Disturbance of locomotion4. Muscle strength testing-------------------------a. Muscle strength -Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strengthRight Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] NoLeft Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] Nob. Does the Veteran have muscle atrophy? [ ] Yes [X] Noc. Comments, if any: No response provided5. Ankylosis-----------Complete this section if the Veteran has ankylosis of scapulohumeral (glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus move as one piece).a. Indicate severity of ankylosis and side affected (check all that apply):Right side: [ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis)[ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis)[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis)[X] No ankylosisLeft side:[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head (Favorable ankylosis)[ ] Ankylosis in abduction between favorable and unfavorable (Intermediate ankylosis)[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable ankylosis)[X] No ankylosisb. Comments, if any: No response provided6. Rotator cuff conditions-------------------------Is rotator cuff condition suspected?Right Shoulder: [ ] Yes [X] NoLeft Shoulder: [X] Yes [ ] NoIf "Yes" complete the following:Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation indicates a positive test; may signify rotator cuff tendinopathy or tear.)[ ] Positive [ ] Negative [X] Unable to perform [ ] N/AEmpty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner. Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear.) [ ] Positive [ ] Negative [X] Unable to perform [ ] N/AExternal Rotation/ Infraspinatus Strength Test (Patient holds arms at side with elbow flexed 90 degrees. Patient externally rotates against resistance. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear.) [ ] Positive [ ] Negative [X] Unable to perform [ ] N/A Lift-offSubscapularis Test (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may indicate subscapularis tendinopathy or tear.)[ ] Positive [ ] Negative [X] Unable to perform [ ] N/A7. Shoulder instability, dislocation or labral pathology-------------------------------------------------------a. Is shoulder instability, dislocation or labral pathology suspected? [X] Yes [ ] No If yes, complete questions 7b - 7d below:b. Is there a history of mechanical symptoms (clicking, catching, etc.)?[X] Yes [ ] NoIf yes, indicate side affected: [ ] Right [X] Left [ ] Bothc. Is there a history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint? [ ] Yes [X] Nod. Crank apprehension and relocation test (with patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of instability with further external rotation may indicate shoulder instability.)[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint conditions-----------------------------------------------------------------------------a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition suspected? [ ] Yes [X]No 9. Conditions or impairments of the humerus------------------------------------------a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus? [ ] Yes [X] Nob. Does the Veteran have malunion of the humerus with moderate or marked deformity? [ ] Yes [X] Noc. Does the humerus condition affect range of motion of the shoulder (glenohumeral) joint? No response provided d. Comments, if any: No response provided10. Surgical procedures----------------------No response provided11. Other pertinent physical findings, complications, conditions, signs, symptoms and scars-----------------------------------------------------------------------a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] Nob. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] Noc. Comments, if any: No response provided12. Assistive devices--------------------a. Does the Veteran use any assistive devices? [ ] Yes [X] Nob. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided13. Remaining effective function of the extremities--------------------------------------------------Due to the Veteran's shoulder and/or arm conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., 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] No14. Diagnostic testing---------------------a. Have imaging studies of the shoulder been performed and are the results available? [X] Yes [ ] NoIf yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] Nob. Are there any other significant diagnostic test findings or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): LEFT SHOULDER JOINT EFFUSION WITH TENDINOPATHYc. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided15. 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 impact of each of the Veteran's shoulder conditions providing one or more examples: NO HEAVY OR MODERATE WEIGHT CARRYING, NO OVERHEAD OR OVERSHOULDER MOVEMENTS16. Remarks, if any:-------------------No remarks provided I am thinking 20-30% but cant tell Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review -------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ----------- Does the Veteran have a peripheral nerve condition or peripheral neuropathy? [X] Yes [ ] No Diagnosis #1: LEFT ULNAR NEUROPATHY BY EMG ICD code: G56.02 Date of diagnosis: 2004 2. Medical history ---------------- a. Describe the history (including onset and course) of the Veteran's peripheral nerve condition (brief summary): VETERAN WAS SEEN ON MULTIPLE OCCASIONS FOR HIS ELBOW CONDITION WHICH EVENTUALLY STARTED DEVELOPING NEUROPATHY AS NOTED IN AN NCV/EMG IN 2004. THE STUDY SHOWED A" MILD COMPROMISE OF AT THE ELBOW OF THE FOCAL DEMYLENINATION OF THE SENSORY AND MOTOR FIBERS". HE NOW HAS SIGNS BY EXAM OF ULNAR NEUROPATHY. NO FURTHER EMG/NCV STUDIES HAVE BEEN DONE BUT SINCE THERE IS INCREASED SYMPTOMS AND FREQUENT USE OF THIS ARM, NEWER STUDIES MOST LIKELY WILL IDENTIFY AN INCREASE IN DYSFUNCTION. b. Dominant hand [X] Right [ ] Left [ ] Ambidextrous 3. Symptoms ---------- a. Does the Veteran have any symptoms attributable to any peripheral nerve conditions? [X] Yes [ ] No Constant pain (may be excruciating at times) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe 4. Muscle strength testing ------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Elbow flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Elbow extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Grip: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Pinch (thumb to index finger): Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? No response provided. 5. Reflex exam ------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam -------------- Indicate results for sensation testing for light touch: Shoulder area (C5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Hand/fingers (C6- Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [ ] Decreased [X] Absent Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Trophic changes ----------------- Does the Veteran have trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy? [ ] Yes [X] No 8. Gait ------ Is the Veteran's gait normal? [ ] Yes [X] No If no, describe abnormal gait: ANTALGIC Provide etiology of abnormal gait: KNEE, BACK 9. Special tests for median nerve -------------------------------- Were special tests indicated and performed for median nerve evaluation? [X] Yes [ ] No Phalen's sign: Right: [ ] Positive [X] Negative Left: [X] Positive [ ] Negative Tinel's sign: Right: [ ] Positive [X] Negative Left: [X] Positive [ ] Negative 10. Nerves Affected: Severity evaluation for upper extremity nerves and radicular groups ---------------------------------------------------------------------- a. Radial nerve (musculospiral nerve) Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis b. Median nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [ ] Mild [X] Moderate [ ] Severe c. Ulnar nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [ ] Mild [X] Moderate [ ] Severe d. Musculocutaneous nerve No response provided. e. Circumflex nerve No response provided. f. Long thoracic nerve No response provided. g. Upper radicular group (5th & 6th cervicals) No response provided. h. Middle radicular group No response provided. i. Lower radicular group No response provided. 11. Nerves Affected: Severity evaluation for lower extremity nerves ------------------------------------------------------------------ No response provided. 12. Assistive devices -------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities -------------------------------------------------- Due to peripheral nerve conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No. 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. 15. Diagnostic testing --------------------- a. Have EMG studies been performed? [X] Yes [ ] No Extremities tested: [X] Left upper extremity Results: [ ] Normal [X] Abnormal Date: 2004 b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact -------------------- Does the Veteran's peripheral nerve condition and/or peripheral neuropathy impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's peripheral nerve and/or peripheral neuropathy condition(s), providing one or more examples: VETERAN'S OCCUPATION REQUIRES EXTENSIVE WORKING WITH BOTH RIGHT AND LEFT ARMS/HANDS. SYMPTOMS WILL INCREASE. DIFFICULTY WITH : GRIP, HOLDING OBJECTS, USE OF COMPUTER/TYPING, MANUAL DEXTERITY, USE OF TOOLS 17. Remarks, if any: I am already at 10% SC on my left elbow Elbow and Forearm Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ---------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review -------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ----------- a. List the claimed condition(s) that pertain to this DBQ: No response provided. b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Ankylosis of elbow joint Side affected: Left 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 elbow or forearm condition (brief summary): ALREADY SERVICE CONNECTED FOR HIS ELBOW CONDITION WHICH HE SUSTAINED A FRACTURE IN 1997 ON AD. HE NOW HAS PAIN, NEUROPATHY AND ANKYLOSIS WITH SOME FUNCTIONAL LIMITATIONS b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous c. Does the Veteran report flare-ups of the elbow or forearm? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: PROLONGED ARM USE d. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: FUNCTIONAL LIMITATIONS: NO HEAVY LIFTING OR CARRYING, PAIN WITH SLEEP, POSITIVE NUMBNESS AND TINGLING WITH NEUROPATHY, NO OVERHEAD USE,AFFECTED COMPUTER USE 3. Range of motion (ROM) and functional limitation ------------------------------------------------- a. Initial range of motion Right Elbow ---------- [X] All Normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 145): 0 to 145 degrees Extension (145 to 0): 145 to 0 degrees Forearm supination (0 to 85): 0 to 85 degrees Forearm pronation (0 to 80): 0 to 80 degrees Description of pain (select best response): Pain noted on exam on rest/non-movement If noted on exam, which ROM exhibited pain (select all that apply)? Flexion 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 Elbow --------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 145): 0 to 135 degrees Extension (145 to 0): 145 to 25 degrees Forearm supination (0 to 85): 0 to 75 degrees Forearm pronation (0 to 80): 0 to 75 degrees If ROM is outside of normal range, but is normal for the Veteran (for reasons other than an elbow condition, such as age, body habitus, neurologic disease), please describe: VETERAN CAN FLEX BUT CANNOT COMPLETELY EXTEND If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: NO OVERHEAD MOVEMENTS Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Extension, Forearm supination, Forearm pronation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No Is there objective evidence of crepitus? [X] Yes [ ]No b. Observed repetitive use Right Elbow ---------- 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 Elbow --------- 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 Elbow ---------- 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: [X] 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. [ ] 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 [X] No [ ] Unable to say w/o mere speculation Left Elbow --------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance, Incoordination Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: S/A d. Flare-ups Right Elbow ---------- Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] 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. [ ] 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 [X] No [ ] Unable to say w/o mere speculation Left Elbow --------- Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran'sstatements describing functional loss during flare-ups. Please explain. [ ] 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? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance, Incoordination Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: S/A e. Additional factors contributing to disability Right Elbow ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left Elbow --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Less movement than normal due to ankylosis, adhesions, etc., Disturbance of locomotion 4. Muscle strength testing ------------------------- a. Muscle strength - Rate strength according to the following scale: [X] Right Elbow Flexion: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Extension: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Is there a reduction in muscle strength? [ ] Yes [X] No [X] Left Elbow Flexion: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Extension: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Is there a reduction in muscle strength? [X] Yes [ ] b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ----------- a. Indicate severity of ankylosis and side affected (check all that apply): [X] Right Side: [X] No ankylosis [ X] Left Side: [X] Has some degree of ankylosis If checked, provide degrees:25 b. Comments, if any: No response provided. 6. Additional comments --------------------- a. Does the Veteran have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation? [ ] Yes [X] No b. Comments, if any: No response provided. 7. Surgical procedures --------------------- No response provided 8. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 9. Assistive devices ------------------- a. Does the Veteran use any assistive devices? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 10. Remaining effective function of the extremities -------------------------------------------------- Due to the Veteran's elbow conditions, is there functional impairment of an extremity such that no effective functions remains other than that which would be equally well served by an amputation with prosthesis? [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 11. Diagnostic Testing --------------------- a. Have imaging studies of the elbow been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: DUE TO THE EXTENT OF VETERAN'S ELBOW CONDITION NOTED ON EXAM, AN MRI IS PENDING 12. Functional impact -------------------- No response provided 13. Remarks, if any: ------------------- No response provided