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Hobby

  1. Has anyone ever heard of any of these three codes being given separate ratings? I realize these are all rated by the range of motion, with the only exception being IDS, which can be rated by how many times you are placed on bed rest (incapacitating episodes). I'm getting a lot of conflicting information about this, as some people seem to think there are special circumstances which the VA will separate at least some of these out. But, no one can explain what those circumstances would be. 1. thoracolumbar strain (5237) http://www.militarydisabilitymadeeasy.com/thespine.html 2. intervertebral disc syndrome (5243) 3. ankylosing spondylitis (5243) 4. degenerative arthritis (5003) http://www.militarydisabilitymadeeasy.com/diseasesofthemusculoskeletalsystem.html#a ^^ This is in my spine but obviously not enough to be coded 5242, degenerative arthritis of the spine
  2. I was rated 20% for my shoulder due to many dislocations and 10% for cervical strain. I applied for lower back condition thru the DAV. It was denied because they stated the scoliosis I have is not service related. I appealed and asked for a hearing. Since I didn't mention scoliosis in the claim I'm not sure why that is all that they looked at. I've had a back Xray which showed "2. Mild anterior endplate spurring, with disc heights maintained. 3. Thoracic dextroscoliosis, measuring 22 degrees" Which I'm told is indicative of degenerative disc disease and/or arthritis. However, I don't have any in service medical treatment records for my back because I never complained due to fear of losing my flight status as a pilot. I'm being seen by a private sector doctor and getting facet joint injections and medial branch block. How should I appeal this? Should I get a nexus letter stating the arthritis was caused by my service on active duty as a pilot? Or should I ask the doctor to tie my lower back condition in as a secondary condition to cervical strain or shoulder problems?
  3. I served in the Marine Corps from 1980-2000. During Boot Camp and throughout my 20 career and even now, I suffer from incapacitating lower back pain, which is far worse today than it was during my years of active duty. The back issue was noted during my VA exam upon retirement, and didn't receive at rating in 2000 after I retired. In 2014, I decide to file a claim due issues with my, which had worsened. In May 2015, I was awarded a 10% disability rating under VA Code 5235. I know for a fact the lower back pain I experience today is a direct result of the trauma, wear and tear and misuse of my back during my military career. A recent MRI shows (Mild facet hypertrophic changes with congenital shortening of the lumbar vertebral pedicles resulting in mild narrowing of the neural foramen at the L3-4 through L5-S1 levels bilaterally. The central canal is patent throughout the lumbar region). My Doctor stated these are just terms that mean I have Degenerative Arthritis. I'm trying to determine if I should file a secondary claim for this issue under my current disability rating for my back pain or approach the Degenerative Arthritis as a separate claim seeing the range of motion has already established under my current disability rating?
  4. Can someone please explain how a C & P examiner can write what he or she pleases without regard to the examination? I finally got to look at the x-ray results and examiner's notes from my C & P exam. I couldn't bend forward 60 degrees if I had someone forcing me forward and may have made it to 45 degrees with pain during the exam. Can a NOD be for a specific disability(s) or does it have to be for everything in the notification? Is there an alternative to a NOD when the examiner made numerous incorrect entries in his notes? Finally, in the decision it states "xxxxx unless the evidence shows: xxxx xxxx abnormal spinal contour such as scoliosis." Does that not contradict the x-ray report that says "mild scoliotic curvature is present"? X-ray report: Report: Lumbosacral spine: Examination of the lumbosacral spine demonstrates intact bony structures. Mild scoliotic curvature is present. An Paravertebral soft tissues appear normal. The intravertebral disc spaces demonstrate diffuse degenerative changes throughout the lower thoracic spine. There is degenerative disc narrowing at L1-2, L2-3, L4-5 and L5-S1. Disc vacuum is present at L5-S1 with loss of normal disc space at L4-5 and articular sclerosis. Second-degree spondylolisthesis is present at this level. There is advanced posterior element sclerosis from L3-S1. Marginal hypertrophic spur formation occurs at all lumbar levels. No acute injury is identified. Sacroiliac articulations are anatomic with bilateral articular sclerosis. Impression: Lumbosacral spine with degenerative disc disease. L4-5 spondylolisthesis. Diffuse posterior element sclerosis. Degenerative osteophyte formation. END Decision notification: We have assigned a 10 percent evaluation for your arthritis, thoracic spine based on: Localized tenderness not resulting in abnormal gait or abnormal spinal contour. Additional symptom(s) include: Combined range of motion of the thoracolumbar spine within normal range Forward flexion of the thoracolumbar spine within normal range Painful motion upon examination The provisions of 38 CFR 4.40 AND 4.45 concerning functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, as cited in DeLuca v. Brown and Mitchell v. Shinseki, have been considered and applied under 38 CFR 4.59. A higher evaluation of 20 percent is not warranted for degenerative arthritis of the spine unless the evidence shows: Combined range of motion of the thoracolumbar spine not greater than 120 degrees: or, Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, Muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Additionally, a higher evaluation of 20 percent is not warranted for degenerative arthritis of the spine unless the evidence shows: X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations.
  5. Well, I just sent out this email and sure hope I get a helpful reply. If I do not have a reply by Friday morning I am going to my VA Regional Office in person and try to get to the bottom of this. carlie Under Secretary Veterans Benefits Administration U.S. Department of Veterans Affairs March 31,2015 Your Honorable Allison A. Hickey, My name is Carlie. I am an honorably discharged US Army veteran. I am in receipt of service connected disability at the 100 percent rate along with SMC/S, adjudicated to be permanent and total by both the Social Security Administration and the VBA. Service Connected conditions by the VBA are as follows: Major Depressive Disorder 100%, effective date March 23, 2004 Seizure Disorder 40%, effective date 1978, day following separation Impaired Hearing 0%, effective date over 10 years Bronchitis,Chronic 60%, effective date over 5 years Degenerative Arthritis of the Spine 30%, effective date over 5 years Ear Disease 10%, effective date over five years Superficial Scars 0%, effective date April,26 2005 Traumatic Brain Disease 10%,effective date over 5 years Bursitis 0%, effective date over 5 years Tinnitus 10%, effective date over 5 years SMC/S, effective date March 23,2004 DEA & Chapter 35 benefits granted, effective date 2004 Full Commissary and Base Exchange privileges, etc. ALL of the above conditions are of record with my VAMC and Vet Center,as being static in nature, with no improvement for over ten years. Today I had an appointment at Bay Pines VAMC, with my psychiatrist. While I was in this appointment I received a telephone message stating, "Ms Carlie this is XXXXX calling from the Compensation and Pension Department here at the VA. We've received a request from the Regional Office to get you scheduled for an evaluation for your service connected disability. If you could please call me as soon as you receive my message, my number is XXX XXX XXXX, extension XXXXX. Thank you." I listened to the message above as I was walking from my psychiatrist appointment, to the hospital next door for a thyroid ultrasound appointment. I then came home and called my psychiatrist and am waiting for a return call. I need your help as I feel this unneeded and unjustified C&P examination, is just plain emotional torture from the St.Petersburg, Fl. VA Regional Office. I have no claims open for additional benefits or claims that are in process or under appeal. All of my prior claim issues are of record as being fully satisfied and closed. I can not understand this additional C&P examination request made by the St.Petersburg VA Regional Office. I feel that this is doing nothing wasting resources another veteran could be utilizing and traumatizing me and probably many more veterans that are already sick, physically, mentally and of the VBA process as a whole. I already have concerns and horrible anxiety in even attending yet another additional C&P examination. All that needs to happen is that I get assigned a C&P examiner that's in a foul mood, got a ticket on their way into work, has their own stress such as a sick child or family member and BOOM !, I get a letter stating my benefits are revoked. This really should not happen as I have received continuity of care from Bay Pines VAMC and St. Petersburg Vet Center, for decades. As I stated, this should not happen, but knowing what I do know, I do know that it is a big possibility. So here I sit with my anxiety at a very high level, getting ready to take some of my VAMC RX's anxiety medication's. I ask this, at a time when there continues to be a huge back log, VBA and VHA are under the gun so to speak, with the media on a daily basis, when resources are limited . . . WHY, is the St.Petersburg Regional Office, requesting this additional C&P exam. Going by the regulation below, they should not be requesting this examination, so about all I can conclude is they want to torment veterans. Is it possible for you to help me with this situation. The last four of my social are XXXX. My phone number is XXX XXX XXXX. My address is: Carlie XXX - Helpavet Ave Sinkingin, XX. XXXXX This issue is time sensitive. Thanks you for any help or direction you might be able to provide. Carlie 38 CFR - Clearly states: §3.327 Reexaminations. (a) General. Reexaminations, including periods of hospital observation, will be requested whenever VA determines there is a need to verify either the continued existence or the current severity of a disability. Generally, reexaminations will be required if it is likely that a disability has improved, or if evidence indicates there has been a material change in a disability or that the current rating may be incorrect. Individuals for whom reexaminations have been authorized and scheduled are required to report for such reexaminations. Paragraphs (b) and © of this section provide general guidelines for requesting reexaminations, but shall not be construed as limiting VA's authority to request reexaminations, or periods of hospital observation, at any time in order to ensure that a disability is accurately rated. (Authority: 38 U.S.C. 501) (b) Compensation cases—(1) Scheduling reexaminations. Assignment of a prestabilization rating requires reexamination within the second 6 months period following separation from service. Following initial Department of Veterans Affairs examination, or any scheduled future or other examination, reexamination, if in order, will be scheduled within not less than 2 years nor more than 5 years within the judgment of the rating board, unless another time period is elsewhere specified. (2) No periodic future examinations will be requested. In service-connected cases, no periodic reexamination will be scheduled: (i) When the disability is established as static; (ii) When the findings and symptoms are shown by examinations scheduled in paragraph (b)(2)(i) of this section or other examinations and hospital reports to have persisted without material improvement for a period of 5 years or more; (iii) Where the disability from disease is permanent in character and of such nature that there is no likelihood of improvement; (iv) In cases of veterans over 55 years of age, except under unusual circumstances; (v) When the rating is a prescribed scheduled minimum rating; or (vi) Where a combined disability evaluation would not be affected if the future examination should result in reduced evaluation for one or more conditions. © Pension cases. In nonservice-connected cases in which the permanent total disability has been confirmed by reexamination or by the history of the case, or with obviously static disabilities, further reexaminations will not generally be requested. In other cases further examination will not be requested routinely and will be accomplished only if considered necessary based upon the particular facts of the individual case. In the cases of veterans over 55 years of age, reexamination will be requested only under unusual circumstances. Cross Reference: Failure to report for VA examination. See §3.655. [26 FR 1585, Feb. 24, 1961, as amended at 30 FR 11855, Sept. 16, 1965; 36 FR 14467, Aug. 6, 1971; 55 FR 49521, Nov. 29, 1990; 60 FR 27409, May 24, 1995]
  6. I have the following disabilities rated by the VA: lumbosacral strain with degenerative arthritis and vertebral fracture 20% Service Connected right shoulder strain with glenohumeral joint osteoarthritis 20% Service Connected left shoulder strain with AC joint osteoarthritis and calcific tendinitis residuals of arthroscopic or other shoulder surgery 20% Service Connected These stem from a parachute malfunction and later exacerbated by a fall with full diving equipment (dbl 90s). I had chronic shoulder pain my whole career. I continued to have this post retirement and the pain, numbness and some weakness advanced down both arms and hands. After seeking help in 2012, I got an MRI and nerve conduction study. The results were: Cervical Spondylosis with Radiculopathy C3-C4, C5-C6, C6-C7 and there is evidence of a mild-moderate chronic right C6-C8 root lesions without ongoing denervation The doctors intimate that this would have been evident if I had an MRI on active duty. My SMR indicates the requirement but one was never ordered. WWP, my VSO, thinks I won't get this service connected because I never complained about my neck. I disagree because the shoulder pain was also disguised the diagnosis and neck pain isn't always present and the shoulders, arms, and hands problems are resulting from the nerve damage. I have been on opiates for years and the VA is ordering a new MRI and xrays. Both doctors say this is consistent with the shoulder injury and could be an inadequate diagnosis while on active duty. I don't know yet, if I can get them to opine. Nevertheless, should I submit a NOD, new claim, Cervical Spondylosis with Radiculopathy secondary to the rated disabilities, vice versa, or some combination? I really am at a loss on how to proceed. Thanks in advance for your comments.
  7. Sorry i can not figure out how to format this better... But long story short i am posting this for a friend since both her and I are confused on how this either of these 2 DBQS read. on one hand the examiner seems say yes and then later on says no but maybe so but then probably not but mostly yes, so if any one can translate all this that would be awesome since this is a 10 year old claim that was remand to the AMC for further development. Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXXX 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 ----------- Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture 2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): veteran is SC for a lumbosacral strain veteran reports during the last mission, was in C-130 aircraft, landed hard felt something pop in my back, onset of back pain, approx 2003. veteran reports dx with sprynix of the thoracic spine, in 2005 follows with VA neurology XXXXXX. aqua therapy, no benefit with chiropractor, ADVSIED AGAINTS INJECTIONS TO SPINE. pain and radicular symproms progressively worse. veteran reports back pain from thoracic spine to lumbosacral region with radicular symptoms down both legs, veteran reports foot drop both feet, documented by neurologist. back pain constant back pain 8/10. flares - with any bending and twisting, any lifting, standing more than 10 minutes, sitting more than 30 minutes, walking more than 30 minutes, walking up down stairs with radicular symptoms. alleviated: moist heat, tens unit b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: see above c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. pain with prolonges standind/sitting and walking 3. Range of motion (ROM) and functional limitation ------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 30 degrees Extension (0 to 30): 0 to 5 degrees Right Lateral Flexion (0 to 30): 0 to 10 degrees Left Lateral Flexion (0 to 30): 0 to 15 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No 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)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion, Right Lateral Rotation, Left Lateral Rotation Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): ttp paraspinal muscles throacic, lumbar sacral region b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: speculative d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: speculative e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Guarding: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Disturbance of locomotion, Interference with sitting, Interference with standing 4. Muscle strength testing ------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam ------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 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 -------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Thigh/knee (L3/4): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [ ] Decreased [X] Absent Left: [ ] Normal [ ] Decreased [X] Absent 7. Straight leg raising test --------------------------- Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy --------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 9. Ankylosis ----------- Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ---------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No 12. Assistive devices -------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ---------------- [X] Brace(s) [X] Occasional [ ] Regular [ ] Constant [X] Other: tens unit [ ] Occasional [X] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities -------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] 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 imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [ ] Yes [X] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact -------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: due to this veterans pain, I do not recommend significant physical labor (IE construction work) or physical work of a moderate nature (grocery store/department store), but sedentary employment with restrictions is still possible. 17. Remarks, if any: ------------------- DIAGNOSIS: CHRONIC LUMBAR STRAIN, SERVICE CONNECTED Please address the "Correia" questions found near the bottom of this exam request. **************************************************************************** Additional exam request information: For any joint condition, examiners should test the contralateral joint, unless medically contraindicated, and the examiner should address pain on both passive and active motion, and on both weightbearing and non weightbearing. In addition to the questions on the DBQ, please respond to the following questions: 1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) not medically appropriate 2. Is there evidence of pain when the joint is used in non-weight bearing? (Yes/No/Cannot be performed or is not medically appropriate) not medically appropriate 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? (Yes/No) If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. If no, the examiner is requested to state whether it is medically feasible to test the joint and if not to please state why the examiner cannot test the range of motion of the opposing joint. ============================================== Mitchell vs. Shinseki: It is my medical opinion that it is more likely than not (greater than 50/50 probability) that pain, but not weakness, fatigability or incoordination, could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time and that there is additional limitation due to pain with change in the baseline range of motion due to "pain on use or during flare-ups." It would be pure speculation to state what additional ROM loss would be present due to pain on use or during flare-ups since the veteran is not examined during a flare-up. 4. Schedule the Veteran for a VA examination to determine the current severity of her lumbosacral strain. The examiner is requested to delineate all symptomology associated with, and the current severity of, the lumbosacral strain. The appropriate Disability Benefits Questionnaire (DBQs) should be filled out for this purpose if possible. The examiner should specifically test the Veteran's lumbar spine range of motion in active motion, passive motion, weight-bearing, and nonweight bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. The examiner should specifically address whether the Veteran's syrinx and leg numbness are manifestations of her lumbosacral strain. This veteran with bilateral lower extremity radiculopathy as noted on examination. This veteran's bilateral lower extremity radiculopathy is less likely secondary to SC lumbosacral strain. There is no cause and effect between lumbosacral strain and radiculopathy. There is no objective evidence for denegerative changes as documented on lumbosacral x-ray in 2015 or thoracic MRI in 2016, a cause for radiculopathy. According to note dated NOV 25, 2015 " pHONE NOTE: SPOKE WITH NEUROLOGY THIS DATE APX 246PM DISCUSSE FINDING S AND ALTERGAIT WITH SUSPECION OF UPPER MOTOR NEURONE PROBLEM POSSIBLE CEREBELLUM ORIGIN. wAS TOLD CONDITION IS BEING WORKED UP BY HIM AND FURTHER FOLLOW UP AND TESTING PENDING." Therfore this veteran's lower extremity radiculopathy is at least as likely as not secondary to upper motor neuron problem located in the brain. currently beingworked up through neurology." There is no causal relationship between the Veteran's SC lumboscacral strain and finding of the syrinx at C8 and T1 as noted on MRI. The syrinx is being followed by neurology. Gynecological Conditions Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXXX 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 ----------- Does the Veteran now have or has she ever had a gynecological condition? Yes Diagnosis #1: endometriosis ICD code: Date of diagnosis: 2002 Diagnosis #2: Vit B12 Deficiency ICD code: Date of diagnosis: 2012 Diagnosis #3: Chronic Pelvic pain ICD code: Date of diagnosis: 9/2000 If there are additional gynecological diagnoses, list using above format: menorrhagia dx 2012 2. Medical history ----------------- Describe the history (including cause, onset and course) of each of the Veteran's gynecological conditions: vetean reports dx with HPV had colposcopy while on active duty. last pap normal. veteran reports heavy bleeding while on active duty with severe pelvic pain. Veteran reports since MST experience h/o heavy bleeding/cramping/abdmoninal pain, lasts 1-2 weeks. While on active duty was placed on numerous birth control pills, given lupron injections, not affective. Continues to experience heavy menstrual flow with severe pelvic pain and painful intercourse. Currently on norplant, with no improvement in menstrual flow, heavy flow with blood clots, reports was advised hysterectomy for severe abdominal pain, veteran declined at that time. laparscopy in service 2001, due to abdominal and heavy bleeding: "craters in uterus and cervic, thinning of the lining." in 2001: colposcopy due to +ve HPV, pap q 6 months, ================================= veteran reports B-12 low and iron level low. takes B12 oral form. methocobolin. g1-p2, vaginal delvery x2 pap, 2016, wnl, 3. Symptoms ---------- Does the Veteran currently have symptoms related to a gynecological condition, including any diseases, injuries or adhesions of the female reproductive organs? Yes If yes, indicate current symptoms, including frequency and severity of pain, if any: (check all that apply) [X] Severe pain: Constant pain [X] Pelvic pressure [X] Frequent or continuous menstrual disturbances 4. Treatment ----------- a. Has the Veteran had treatment for symptoms/findings for any diseases, injuries and/or adhesions of the reproductive organs? Yes If yes, specify condition(s), organ(s) affected, and treatment: lupron on active duty 10/2000- 12/2000: per history discontinued, not helpful norplant currently ibuprofen/Aleve as needed- for pelvic pain. Date of treatment: see above b. Does the Veteran currently require treatment or medications [for symptoms?] related to reproductive tract conditions? Yes If yes, list current treatment/medications and the reproductive organ condition(s) being treated: B12 oral replacement- daily, IM not affective Norplant- continous ferrous sulfate as needed with decrease in iron count c. If yes, indicate effectiveness of treatment in controlling symptoms: [X] Symptoms are not controlled by continuous treatment: for the following organ/condition: [X] Conditions of the uterus 5. Conditions of the vulva ------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vulva (to include vulvovaginitis)? No 6. Conditions of the vagina -------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vagina? No 7. Conditions of the cervix -------------------------- Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the cervix? Yes If yes, describe: abnormal pap while on active duty AS-CUS with +ve HPV, high grade. colposcopy x1 while on active duty. repeat paps with AS-CUS, neg for HPV. 8. Conditions of the uterus -------------------------- a. Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the uterus? Yes b. Has the Veteran had a hysterectomy? No c. Does the Veteran have uterine prolapse? No d. Does the Veteran have uterine fibroids, enlargement of the uterus and/or displacement of the uterus? No e. Has the Veteran been diagnosed with any other diseases, injuries, adhesions or other conditions of the uterus? Yes If yes, describe: Endometriosis, clinical diagnosis, laparscopy in 2001, wnl, endometrial biopsy 2001 neg. . Lapraoscopy in 2012 wnl. 9. Conditions of the Fallopian tubes ----------------------------------- Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the Fallopian tubes (to include pelvic inflammatory disease)? No 10. Conditions of the ovaries ---------------------------- a. Has the Veteran undergone menopause? No b. Has the Veteran undergone partial or complete oophorectomy? No c. Does the Veteran have evidence of complete atrophy of 1 or both ovaries? Unknown d. Has the Veteran been diagnosed with any other diseases, injuries, adhesions and/or other conditions of the ovaries? No 11. Incontinence --------------- Does the Veteran have urinary incontinence/leakage? Yes If yes, is the urinary incontinence/leakage due to a gynecologic condition? Yes If yes, condition causing it: residual of vaginal deliveries x2 If yes, check all that apply: [X] Stress incontinence 12. Fistulae ----------- a. Does the Veteran have a rectovaginal fistula? No b. Does the Veteran have a urethrovaginal fistula? No response provided. 13. Endometriosis ---------------- Has the Veteran been diagnosed with endometriosis? Yes If yes, does the Veteran currently have any findings, signs or symptoms due to endometriosis? Yes If yes, check all that apply: [X] Pelvic pain [X] Heavy bleeding [X] Irregular bleeding If yes, indicate effectiveness of treatment in controlling symptoms: [X] Symptoms of endometriosis are not controlled by continuous treatment 14. Complications and residuals of pregnancy or other gynecologic procedures --------------------------------------------------------------------------- a. Has the Veteran had any surgical complications of pregnancy? No b. Has the Veteran had any other complications resulting from obstetrical or gynecologic conditions or procedures? No 15. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? No b. Is the neoplasm No response provided. c. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? No response provided. d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: No response provided. 16. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ---------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? No 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? No c. Comments, if any: No response provided. 17. Diagnostic testing --------------------- a. Has the Veteran had laparoscopy? Yes If yes, provide date(s) and facility where performed, and results: laprascopy 2002: for pelvic pain, unrepsonsive to lupron, OCPS and NSAIDS " pt had approX A 6 WEEK UTERUS, SLIGHTLY SOFT, questional increased vascularity. otherwise no other abnormalities noted. laprascopy 2011: chronic pain results: "normal appears uterus, Tubes aND ovaries. no adhesions. no pathology noted in pelvis" b. Has the Veteran been diagnosed with anemia? No c. Has the Veteran had any other diagnostic testing and if so, are there significant findings and/or results? Yes 18. Functional impact -------------------- Does the Veteran's gynecological condition(s) impact her ability to work? No 19. Remarks, if any: ------------------- diagnosis: endometriosis chronic pelvic pain B12 deficiency menorrhagia Veteran with h/o colposcopy 2002 while on active duty secondary to abnormal paps x2 ASC-US with pos HPV diagnosed in 2001. Subsequent paps with diagnosis of ASC-US with neg HPV results: 10/2005: neg pap; 2/2008: neg pap; 7/2015: ASC-US with HPV neg. There is no objective evidence for a chronic disability. This veteran with a diagnosis of endometriosis is a continuation of the Endometriosis first diagnosed while on active duty and documented by C&P exam 4/2006,by Dr. Sogor, Obstetrican/Gynecologist. Eventhough while on active duty diagnostic laprascopy was documented as "normal" and endometrial biopsy was neg and repeat laparoscopy in 2012 was documented to be "within normal limits.", this veteran continues to exibit clinical signs of endometriosis as first documented while on active duty and C&P examination 4/10/2006 by Dr. Sogor, Obstetrican/Gynecologist as evidence by persistant chronic pain. This veteran's B12 deficiency is less likely as not secondary to this veteran's menorrhagia. According to medical literature there is no cause an affect relationship between Vitamin B12 deficiency and heavy menstrual bleeding. Veteran with normal CBC levels from 2005-until present, expect one time low levels 8/2008, otherwise with no evidence for anemia. There is no evidence for an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. This veteran's B12 defiencency is a known condition with specific causes to included poor diet and decrease of intrinsic factor. ============================================ Active duty service dates: Branch: XXXXXXXX EOD: 07/21/1999 RAD: 07/20/2005 DBQ GYN Gynecological conditions: The Veteran has important information in his or her electronic claims folder in VBMS and Virtual VA. Please review both folders and state that they were reviewed in your report. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION: Direct service connection Does the Veteran have a diagnosis of (a) menstrual cramps that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) Veteran testified at her Oct. 2016 Board hearing that she had a B 12 deficiency as a result of heavy bleeding which was not addressed by the examiner; VA examiner must also address the possibility of the Veteran's menstrual cramp disorder pre-existing her active service during service? see below Rationale must be provided in the appropriate section. Examiner: Please state whether the Veteran has a diagnosis of Female Sexual Arousal Disorder (FSAD). If additional examination(s) are required, please request and/or perform as necessary. The veteran has a diagnosis of Female sexual arousal disorder is at least as likely as not (50/50 probability) caused by or a result of Chronic pelvic pain, residual of Endometriosis and MST. The veteran answered affirmatively to screening questions for FSAD. ======================== Please arrange for the Veteran to undergo an appropriate VA examination in connection with her claim for entitlement to service connection for a menstrual cramp disorder. The claims file should be made available to and reviewed by the examiner. All indicated studies should be performed and all findings should be reported in detail. Based on the examination and review of the record, the examiner should address the following: (a) Please diagnose any present menstrual disorders to include HPV and endometriosis. The examiner should consider and discuss as necessary the following: (i) The June 2015 VA treatment record noting a diagnosis of HPV; and (ii) The Veteran's October 2016 Board hearing testimony indicating her B-12 deficiency was a result of heavy bleeding. (b) Is it at least as likely as not (a 50 percent or greater probability) that the signs or symptoms of the Veteran's menstrual disorder represent an objective indication of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to the Veteran's Persian gulf service? NO (c) If the answer to (b) is no, does the evidence of record clearly and unmistakably show that the Veteran had a menstrual disability that existed prior to her entry onto active duty? YES, There is evidence in the STRs that the veteran had menstrual disturbance to include menstrual cramping and intermittent pelvic pain secondary to ruptured ovarian cyst prior to entering service. Pain was described as intermittent and improved after starting BCPs. The examiner should consider and discuss as necessary the following: (i) An April 2006 VA examination noting the Veteran reported having ovarian cysts at age 16; (ii) A November 2006 VA treatment record noting the Veteran reported being prescribed oral contraceptives due to menstrual cramping at age 16; (ii) An August 2011 VA treatment record noting the Veteran had a history of ovarian cysts and ruptures as early as age 16; and (iii) A July 2014 VA examination for irritable bowel syndrome noting the Veteran reported she had heavy periods for all of her life. (d) If the answer to (c) is yes, does the evidence of record clearly and unmistakably show that the preexisting menstrual disorder was not aggravated by service or that any increase in disability was due to the natural progression of the disability? NO, there is objective evidence that pre-existing menstrual cramping and intermiitent pelvic pain was aggravated beyond normal progression secondary to service. Per History, veteran reported started to experience intense and wide spread pelvic pain and menstrual cramping post MST incident while on active duty. Multiple trials of differenct BCPs with no improvement of symptoms. Veteran with h/o Lupron injections for pelvic pain for 6 months with no benefit While on active duty pelvic ultrasound in 2000 with no evidence for ovarian cysts. Laparscopy 2002 within normal limits with normal ovaries and no evidence of cysts In 2000 veetran was dx with chronic pelvic pain. Veteran was diagnosed with Endometriosis, clinically, while on active duty. The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms beyond its natural progression. Please identify any such evidence with specificity. (e) If the answer to either (c) or (d) is no, is it at least as likely as not (a 50 percent or greater probability) that any diagnosed menstrual disorder is etiologically related to the Veteran's active service? Yes, the veteran's diagnosis of chronic pelvic pain and endometriosis is etiologically related to the veteran's active service. The veteran's current chronic pelvic pain and endometriosis is a continuation of the conditions first documented while on active duty. Yes, the veteran's menorrhagia is a progression of this veteran's chronic pelvic pain and endometriosis first diagnosed while on active duty. The examiner should consider and discuss as necessary the following: (i) The Veteran's September 2000 and March 2001 STRs noting treatment for endometriosis; and (ii) The Veteran's October 2015 VA examination for PTSD noting the Veteran experienced military sexual trauma. The examiner should set forth a complete rationale for all findings and conclusions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made.
  8. I've been wanting to put a claim in for arthritis that I've developed after my discharge, however, I was told I should wait after my appeal was completed or it could hold up the process. I have two remanded items left which my RO estimates will be completed in 6-9 months. What I'm wondering is, is it too late to file? I EASd back in September 2012. In my medical records from service I had complaints of knee and ankle instability. After a couple of years I started having a lot of pain in my feet, ankles, and knees. When I went to the doctor they said I had degenerative arthritis in my feet and ankles, and the beginning signs of arthritis in my knees. I've already been service connected for arthritis in my left shoulder and right thumb. I'm currently 28 years old. I've also started having the same pain in my right shoulder as my left. Is it too late to put in a claim for these? Would they even relate it to military service since I've been out for 5 years? I feel like I'd be too young to develop arthritis based on my age. Could I use the instability from my time in service as a link to my current arthritis? For my right shoulder, could I claim it secondary to my left shoulder (overuse due to compensating for left shoulder pain and weakness)? I realize it would be based on current medical evidence, medical evidence in service, and and nexus relating it, just wondering of likelihood of being approved.
  9. Hi to all, Great site!!! I was hoping I could get some help deciphering the below C&P results. I am currently 10% on both knees for knee strain. I submitted to get an increase for the left knee, and to also get a secondary left hip Service connection from the bad knee.... Any help would be greatly apprciated! Curt 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 [X] Other (please identify other evidence reviewed): X-rays 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: osteoarthritis b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Osteoarthritis, hip Side affected: [ ] Right [ ] Left [X] Both ICD Code: M16.0 Date of diagnosis: Right 2016 Date of diagnosis: Left 2016 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? Yes 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hip or thigh condition: Claims for secondary service connection for the veterans left hip secondary or proximally due to results of his chronic left knee strain has been requested. On close questioning the veteran reported he had insidious onset of mild bilateral hip pain for the past 15 years. Veteran's stated that he slipped and fell June 9, 2014. Veteran claims that his service-connected left knee gave way causing him to fall,thereby sustaining a comminuted fracture of his left patella requiring an open reduction internal fixation June 10, 2014. Due to traumatic injury of his left knee an escalation of left hip pain and stiffness has ccurred. September 30 2016 bilateral radiographs of the hips: Early DJD arthritis of both hips. Current complaints constant left hip pain with stiffness. Treatment: No surgery or injections to date. b. Does the Veteran report flare-ups of the hip or thigh? [ ] Yes [X] No c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: See description of functional loss and impairment of work restrictions below 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right hip --------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): 0 to 110 degrees Extension (0-30): 0 to 20 degrees Abduction (0-45): 0 to 40 degrees Adduction (0-25): 0 to 20 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 40 degrees Internal Rotation (0-40): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: Loss of range of motion is a functional loss Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion, Extension, Abduction, Adduction, External rotation, Internal rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Slight to moderate tenderness anterior acetabular region Is there objective evidence of crepitus? [ ] Yes [X] No Left hip -------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): 0 to 105 degrees Extension (0-30): 0 to 20 degrees Abduction (0-45): 0 to 30 degrees Adduction (0-25): 0 to 15 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 40 degrees Internal Rotation (0-40): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: Loss of range of motion is a functional loss Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion, Extension, Abduction, Adduction, External rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Slight to moderate tenderness anterior acetabular region s there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right hip --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No Left hip -------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right hip --------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [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 [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Unable examine over a period of time Left hip -------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [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 [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Unable examine over a period of time d. Flare-ups: Not applicable e. Additional factors contributing to disability Right hip --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Disturbance of locomotion Left hip -------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Disturbance of locomotion 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 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 hip. a. Indicate severity of ankylosis and side affected Right side: Left side: [ ] Favorable, in flexion at [ ] Favorable, in flexion at an angle between 20 and an angle between 20 and 40 degrees, and slight 40 degrees, and slight abduction or adduction abduction or adduction [ ] Intermediate, between [ ] Intermediate, between favorable and unfavorable favorable and unfavorable [ ] Unfavorable, extremely [ ] Unfavorable, extremely unfavorable ankylosis, unfavorable ankylosis, foot not reaching ground, foot not reaching ground, crutches needed crutches needed [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Additional conditions ------------------------ a. Does the Veteran have malunion or nonunion of femur, flail hip joint or leg length discrepancy? [ ] Yes [X] No b. Comments, if any: No response provided 7. Surgical procedures ---------------------- No response provided 8. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 9. Assistive devices -------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 10. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's hip or thigh conditions, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 11. Diagnostic testing ---------------------- a. Have imaging studies of the hip or thigh been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate hip: [ ] Right [ ] Left [X] Both b. 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): HIPS BILATERAL 3-4 VIEWS (D) (RAD Detailed) CPT:73522 Reason for Study: pain Clinical History: Patient weight: 252.5 lb [114.8 kg] (04/29/2016 09:07) Report Status: Verified Date Reported: SEP 30, 2016 Date Verified: SEP 30, 2016 Verifier E-Sig: Report: Bilateral hips and pelvis, 3 views Comparison: None FINDINGS: Bone density appears normal. There is satisfactory anatomic alignment of the hip joint. Both hip joints are mildly narrowed. Rest of the pelvis appears normal. Degenerative changes in the lumbar spine. Surgical clips in the left groin area. Periarticular soft tissues appear within normal limits. Impression: Early DJD arthritis of both hips. c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 12. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: Claimed limitations due to comorbidity of hip and knee: Lift/carry: 10 pounds Prolonged standing: 15 minutes Prolonged sitting: 25-30 minutes Walk on flat land: 200 feet but less than ? mile. Avoid uneven terrain, no steep slopes, no hiking or camping Cannot run/jump Limited repetitive use activities: Stooping, squatting, pulling/pushing, sweeping/ mopping, but no digging, gardening, kneeling, crawling, or bike riding Limited climbing stairs and 2-3 foot step stool but no ladders. 13. Remarks, if any: -------------------- Veteran claims subjective chronic constant pain involving the joint, therefore there is pain throughout the entire arc of movement whether active or passive motion was performed. 1. Is there evidence of pain on passive range of motion testing? Yes 2. Is there evidence of pain when the joint is used in nonweightbearing? Yes 3. If yes is the opposite joint undamaged (i.e. no abnormalities)? No, radiographs report bilateral degenerative arthritis. **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): X-rays 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: Chronic knee strain ORIF comminuted fracture left patella 2014 Degenerative joint disease bilateral knee b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Knee strain Side affected: [ ] Right [ ] Left [X] Both ICD Code: S 83.90 Date of diagnosis: Right 2003 Date of diagnosis: Left 2003 [X] Knee joint osteoarthritis Side affected: [ ] Right [ ] Left [X] Both ICD Code: M 17.10 Date of diagnosis: Right 2006 Date of diagnosis: Left 2006 [X] Other (specify): Other diagnosis: closed comminuted fracture patella Side affected: Left ICD code: S 82.00 Date of diagnosis (left side): 2016 ******************************************************************** 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): Veteran has been service-connected bilateral knee strain. 2006 for bilateralxray reported bilaterial DJD. bilateral knee strain's. Veteran's stated that he slipped and fell June 9, 2014. Veteran claims that his service-connected left knee gave way causing him to fall,thereby sustaining a comminuted fracture of his left patella requiring an open reduction internal fixation June 10, 2014. Escalation of pain and stiffness has occurred since the injury. Current complaints: Constant pain, recurrent swelling, gives way with crepitance. b. Does the Veteran report flare-ups of the knee and/or lower leg? [ ] Yes [X] No 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: See description of functional loss and impairment of work restrictions below. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Right Knee ---------- [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 115 degrees Extension (140 to 0): 115 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: Loss of range of motion is a functional loss 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 Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Mild anterior knee pain Is there objective evidence of crepitus? [ ] Yes [X] No Left Knee --------- [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 100 degrees Extension (140 to 0): 100 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: See description of functional loss and impairment of work restrictions below. 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 Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Slight to moderate periarticular tenderness Is there objective evidence of crepitus? [X] Yes [ ] No b. Observed repetitive use Right Knee ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right Knee ---------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [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 [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Unable to examine over a period of time 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: [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 [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Unable to examine over a period of time d. Flare-ups Not applicable 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: Disturbance of locomotion 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: Flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Knee: Rate Strength: Flexion: 4/5 Extension: 4/5 Is there a reduction in muscle strength? [X] Yes [ ] No If yes, is the reduction entirely due to the claimed condition in the Diagnosis Section? [X] Yes [ ] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe b. Is there a history of lateral instability? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe c. Is there a history of recurrent effusion? [X] Yes [ ] No If yes, describe: Recurrent swelling occurs d. Performance of joint stability testing Right Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: No response provided 7. Additional conditions ------------------------ a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No b. Comments, if any: No response provided 8. Meniscal conditions ---------------------- a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided 9. Surgical procedures ---------------------- Indicate any surgical procedures that the Veteran has had performed and provide the additional information as requested (check all that apply): Left Side: [X] Meniscectomy, arthroscopic or other knee surgery not described above Type of surgery: arthrotomy with open reduction internal fixation comminuted fracture patella Date of surgery: June 10, 2014 [X] Residual signs or symptoms due to meniscectomy, arthroscopic or other knee surgery not described above: Describe residuals: increasing pain and stiffness. 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? [X] Yes [ ] No If yes, is there objective evidence that any of these scars are painful, unstable, have a total area equal to or greater than 39 square cm (6 square inches) or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.) [ ] Yes [X] No If no, provide location and measurements of scar in centimeters. Location: anterior midline left knee Measurements: length 13cm X width 0.4cm c. Comments, if any: No response provided 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate knee: [ ] Right [ ] Left [X] Both 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): KNEE LEFT 2 VIEW (RAD Detailed) CPT:73560 Proc Modifiers : LEFT CPT Modifiers : LT LEFT SIDE (PROCEDURES DONE ON THE LEFT SIDE OF THE BODY) Reason for Study: left knee pain Clinical History: The veteran continues to experience left knee pain since fracturing his patella on a fall in June 2015. 2 views left knee on 4/29/2016. Comparison none. Patellar fractures are again seen. 2 fixation devices are seen overlying the patella. Mild tricompartmental osteophytes are seen consistent with degenerative change. No significant joint effusion. Surgical clips overlie the right thigh. Impression: Fractures across the patella are present. Fixation hardware is seen overlying the patella. KNEES ROUTINE 3 VIEWS (RAD Inactive) CPT:73562 Proc Modifiers : BILATERAL EXAM CPT Modifiers : 50 BILATERAL PROCEDURE Clinical History: (C&P) Hx of degenerative joint disease Report: REPORT: Four views of both knees, 01/30/2006. Comparison is made with examination of 10/03/2003. On the lateral view, there is ossification which has the appearance of a fabella, however, it was not present on the prior examination and could possibly represent either a fabella or a loose body. On the left there are also very small osteophytes at the proximal and distal tip of the patella. On the right there are also very small osteophytes at the superior and posterior aspect of the articular surface of the patella. There also is enthesophyte formation on the right at the proximal and distal tips of the patella. On the sunrise view, there are small concave defects of the medial aspect of the articular surface of the medial condyle of the distal femur bilaterally. These are not visualized on the lateral views or tunnel views, and may be developmental rather than small osteochondritis dissecans defects bilaterally. These are medial to the articular surface opposite the patella. There is a small osteophyte at the tip of the lateral most intercondylar eminence of the tibial plateau on the right. Impression: 1. Minimal degenerative change bilaterally. I doubt loose body on the left. 2. I also doubt osteochondritis dissecans of the articular surface of the distal femur medial to the patellar articular surface. 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: Claimed limitations due to comorbidity of hip and knee: Lift/carry: 10 pounds Prolonged standing: 15 minutes Prolonged sitting: 25-30 minutes Walk on flat land: 200 feet but less than ? mile. Avoid uneven terrain, no steep slopes, no hiking or camping Cannot run/jump Limited repetitive use activities: Stooping, squatting, pulling/pushing, sweeping/ mopping, but no digging, gardening, kneeling, crawling, or bike riding Limited climbing stairs and 2-3 foot step stool but no ladders. 15. Remarks, if any: -------------------- Veteran claims subjective chronic constant pain involving the joint, therefore there is pain throughout the entire arc of movement whether active or passive motion was performed. 1. Is there evidence of pain on passive range of motion testing? Yes 2. Is there evidence of pain when the joint is used in nonweightbearing? Yes 3. If yes is the opposite joint undamaged (i.e. no abnormalities)? No, radiographs report bilateral degenerative arthritis **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): X-rays MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Secondary service connection: Is the veterans left hip at least as likely as not (50% or greater probability) proximally due to or the results of chronic left knee strain? b. Indicate type of exam for which opinion has been requested: left hip TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ] a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: Claims for secondary service connection for the veterans left hip secondary or proximally due to results of his chronic left knee strain has been requested. On close questioning the veteran reported he had insidious onset of mild bilateral hip pain for the past 15 years. Veteran's stated that he slipped and fell June 9, 2014. Veteran claims that his service-connected left knee gave way causing him to fall,thereby sustaining a comminuted fracture of his left patella requiring an open reduction internal fixation June 10, 2014. Due to traumatic injury of his left knee an escalation of left hip pain and stiffness has ccurred. September 30 2016 bilateral radiographs of the hips: Early DJD arthritis of both hips. Veteran has developed chronic bilateral degenerative changes of the hips, his complaints of aggravation due to the injury of his left knee is substantiated by the current physical examination. Additionally the veteran has altered gait probably due to his bilateral service-connected knee conditions. *************************************************************************
  10. Hello All, I am a 41yr old disabled vet (70%) Degenerative Arthritus of the left Knee 20%Degenerative Arthritus of the Right knee 20%Degenerative Disc Disease of the Lumbar Spine 10%Radiculopathy Right Lower Extremity 10%Radiculopathy Left Lower Extremity 10%Degenerative Tears, Bilateral Knees 20%Tinnitus 10% This exam was scheduled 1 week after my back surgery (Fusion of L4/L5). Hip and Thigh Conditions Disability Benefits Questionnaire 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) 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: B/L HIP STRAIN DX 9-16 SECONDARY TO LUMBAR SPINE COND. b. Select diagnoses associated with the claimed condition(s) (Check all that apply): c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? Yes 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hip or thigh condition: 16 W/U DX AS ABOVE PAIN STANDING B/L MRI WNL. TX MEDS. b. Does the Veteran report flare-ups of the hip or thigh? [ ] Yes [X] No c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [ ] Yes [X] No 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right hip --------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): 0 to 90 degrees Extension (0-30): 0 to 30 degrees Abduction (0-45): 0 to 45 degrees Adduction (0-25): 0 to 25 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 60 degrees Internal Rotation (0-40): 0 to 40 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes, (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion 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? [X] Yes [ ] No Is there objective evidence of crepitus? [ ] Yes [X] No Left hip -------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): 0 to 90 degrees Extension (0-30): 0 to 30 degrees Abduction (0-45): 0 to 45 degrees Adduction (0-25): 0 to 25 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 60 degrees Internal Rotation (0-40): 0 to 40 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes, (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion 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 hip --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No Left hip -------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right hip --------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Left hip -------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. d. Flare-ups: Not applicable e. Additional factors contributing to disability Right hip --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left hip -------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against so me resistance 5/5 Normal strength Right Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? No response provided c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the hip. a. Indicate severity of ankylosis and side affected Right side: Left side: [ ] Favorable, in flexion at [ ] Favorable, in flexion at an angle between 20 and an angle between 20 and 40 degrees, and slight 40 degrees, and slight abduction or adduction abduction or adduction [ ] Intermediate, between [ ] Intermediate, between favorable and unfavorable favorable and unfavorable [ ] Unfavorable, extremely [ ] Unfavorable, extremely unfavorable ankylosis, unfavorable ankylosis, foot not reaching ground, foot not reaching ground, crutches needed crutches needed [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Additional conditions ------------------------ No response provided 7. Surgical procedures ---------------------- No response provided 8. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 9. Assistive devices -------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 10. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's hip or thigh conditions, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 11. Diagnostic testing ---------------------- a. Have imaging studies of the hip or thigh been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? No response provided c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 12. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [ ] Yes [X] No 13. Remarks, if any: -------------------- No response provided !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: PUGH 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) 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [ ] Degenerative arthritis of the spine [X] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: PO DISC FUSION LUMBAR 2-17 Date of diagnosis: 2-17 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): AS ABOVE, DONE DUE TO R SCIATICA ,DROP R FOOT. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: PAIN c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. LESS MOTION 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 20 degrees Extension (0 to 30): 0 to 10 degrees Right Lateral Flexion (0 to 30): 0 to 10 degrees Left Lateral Flexion (0 to 30): 0 to 10 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees 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)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion, Right Lateral Rotation, Left Lateral Rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): LUMBAR PAIN b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No 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 d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Interference with sitting, Interference with standing 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 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 Great toe 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 b. Does the Veteran have muscle atrophy? No response provided. 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 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 --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Intermittent pain (usually dull) Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [X] Right [ ] Left [ ] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities ---------------------------------- No response provided 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [X] Yes [ ] No If yes, select the total duration over the past 12 months: PO SURGERY c. If yes to question 11b above, provide the following documentation that supports the Yes response: [X] Medical history as described by the Veteran only, without documentation: AS ABOVE [ ] Medical history as shown and documented in the Veteran's file: [ ] Other, describe: 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [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) [ ] Occasional [X] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] 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? [X] Yes [ ] No If yes, is there objective evidence that any of these scars are painful, unstable, have a total area equal to or greater than 39 square cm (6 square inches), or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.) [ ] Yes [X] No If no, provide location and measurements of scar in centimeters. Location: NEW DRESSING NOT REMOVED Measurements: length cm X width cm c. Comments, if any: No response provided 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [ ] Yes [X] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? No response provided. c. Are there any other significant diagnostic test findings and/or results? No response provided. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [ ] Yes [X] No
  11. Hello. I went for my fibromyalgia C&P exam and just got the results from myhealthvet. It looks like it was several DBQ's including my back now. Can someone explain these results. I only see one error which is my pain is refractory to medicine. They have my pain is constant but then state NO to the refractory to medicine question. But anyways what do you guys think. IT IS LONG. Sorry. Attached & pasted MHV Fibro.docx CONFIDENTIAL Page 4 of 31 VA Notes Source: VA Last Updated: 30 Jan 2017 @ 1321 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Date/Time: 18 Jan 2017 @ 0800 Note Title: C&P GENERAL MEDICAL - AMIE/CAPRI Location: Fayetteville NC VAMC Signed By: Co-signed By: Date/Time Signed: 25 Jan 2017 @ 1740 Note LOCAL TITLE: C&P GENERAL MEDICAL - AMIE/CAPRI STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 18, 2017@08:00 ENTRY DATE: JAN 25, 2017@17:40:38 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Gulf War General Medical Examination Disability Benefits Questionnaire * Internal VA or DoD Use Only* Name of patient/Veteran: 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 CONFIDENTIAL Page 5 of 31 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 2. Medical History ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided e. Hearing loss, tinnitus and ear: No answer provided f. Sinus, nose, throat, dental and oral: No answer provided g. Breast: No answer provided h. Respiratory: No answer provided i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: The following conditions have been reported Spine: Back (Thoracolumbar Spine) Conditions Miscellaneous musculoskeletal: Fibromyalgia CONFIDENTIAL Page 6 of 31 n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [X] Yes [ ] No Diagnosis #1: Fibromyalgia ICD code: M79.7 Date of diagnosis: approx. 2007 Name of Questionnaire: DBQ Neuro Fibromyalgia 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [ ] Yes [X] No 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- CONFIDENTIAL Page 7 of 31 The E-VBMs, CPRS, JlV, Veteran's history and documents carried in by the patient were all reviewed and carefully considered during this exam. Diagnosis: 1. Fibromyalgia, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. ************************************************************************** The examination was initiated and completed by provider Debra Barton FNP, and administratively reviewed and closed by clinical lead Dr. June Roberts. **************************************************************************** Fibromyalgia 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 [X] Other (please identify other evidence reviewed): JLV CONFIDENTIAL Page 8 of 31 Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Fibromyalgia ICD code: M79.7 Date of diagnosis: approx. 2007 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: The Veteran has a history of active military service in the United States Army highest rank E5 and a Admits to service in Iraq 6/18/04-5/28/05. He presents for Gulf War Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire. He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness). Veteran reports he has had diffuse pain throughout his "joints" and CONFIDENTIAL Page 9 of 31 other locations since he got out of the military. He has had X-rays of the wrist, ankle, knees and back to evaluate for degenerative an inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia. b. Is continuous medication required for control of fibr omyalgia symptoms? [X] Yes [ ] No If yes, list only those medications required for the Veteran's fibromyalgia condition: Gabapentin c. Is the Veteran currently undergoing treatment for this condition? [X] Yes [ ] No If yes, describe: He has been advised on a exercise program and search into a biofeedback program. d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [ ] Yes [X] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia? [X] Yes [ ] No a. Findings, signs and symptoms (check all that apply): [X] Widespread musculoskeletal pain [X] Stiffness [X] Sleep disturbances [X] Paresthesias [X] Headache [X] Depression For all checked conditions, describe: Veteran has had a sleep study and has milds OSA, sleep efficiency was 70%. He has headaches bitemporal that may be associated with his sinus issues. He has parathesias when he tries to sleep. He has been diagnosed with PTSD. b. Frequency of fibromyalgia symptoms (check all that apply): [X] Constant or nearly constant CONFIDENTIAL Page 10 of 31 [X] Often precipitated by environmental or emotional stress or overexertion If checked, describe: Overexertion and extreme cold will exacerbate his symptoms. c. Does the Veteran have tender points (trigger points) for pain present? [X] Yes [ ] No [X] All bilaterally [X] Low cervical region: at anterior aspect of the interspaces between transverse processes of C5-C7 If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Second rib: at second costochondral junction If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Occiput: at suboccipital muscle insertion If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Trapezius muscle: midpoint of upper border If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Supraspinatus muscle: above medial border of the scapular spine If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Lateral epicondyle: 2 cm distal to lateral epicondyle If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Gluteal: at upper outer quadrant of buttocks If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Greater trochanter: posterior to greater trochanteric prominence If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Knee: medial joint line If checked, indicate side: [ ] Right [ ] Left [X] Both 4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars CONFIDENTIAL Page 11 of 31 ----------------------------------------------------------------------- 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 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact --------------------- Does the Veteran's fibromyalgia impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of the Veteran's fibromyalgia, providing one or more examples: Veteran is not able to climb stairs, descend stairs or bend (squat) repeatedly and has to ask others to cover those tasks for him. He is not able to do repetitive task or he starts hurting and has to stop. The Veteran is unable to participate in heavy physical prolonged labor. The Fibromyalgia does not preclude participation in sedentary employment. 7. Remarks, if any: ------------------- The examination was initiated and completed by provider DEBRA BARTON AND REVIEWED BY DESL LEAD AND CLOSED. **************************************************************************** Non-degenerative Arthritis (including inflammatory, autoimmune crystalline and infectious arthritis) and dysbaric osteonecrosis 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 CONFIDENTIAL Page 12 of 31 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 [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: chronic multi-symptom illness(pain throughout his body) b. Select diagnoses associated with the claimed condition(s): No response provided CONFIDENTIAL Page 13 of 31 c. Comments (if any): Diagnosis Degenerative Disc Disease Lumbar Spine L5/S1 date of diagnosis 6/6/2016 ICD 10 M43.06 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 inflammatory, autoimmune, crystalline or infectious arthritis or Dysbaric Osteonecrosis. (brief summary) The Veteran has a history of active military service in the United States Army highest rank E5 Admits to service in Iraq 6/18/04-5/28/05. He presents for a Gulf War Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire. He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness). Veteran reports he has had diffuse pain throughout his "joints" and other locations since he got out of the military. He has had X-rays of the wrist, ankle, knees and back to evaluate for degenerative an inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia. Review of the radiographs of the wrist, ankle, and knees showed no osseus abnormality. The lumbar spine showe mild L5-S1 disc disease. b. Does the Veteran require continuous use of medication for the arthritis condition? [ ] Yes [X] No c. Has the Veteran lost weight due to arthritis condition? [ ] Yes [X] No d. Does the Veteran have anemia due to the arthritis condition? [ ] Yes [X] No 3. Joint Involvement -------------------- a. Does the Veteran have pain (with or without joint movement) attributable to this arthritis condition? [X] Yes [ ] No If yes, indicate affected joints [ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint CONFIDENTIAL Page 14 of 31 For all checked joints, describe involvement: Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He started complaining of low back pain and pain in some of his other joints. In 2007 he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC. b. Does the Veteran have any limitation of joint movement attributable to the arthritis condition? [X] Yes [ ] No If yes, indicate affected joints [ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint For all checked joints describe limitation of movement: The Veteran has problems with back flexion, extension, RL bending and LL bending. c. Does the Veteran have any joint deformities attributable to the arthritis condition? [ ] Yes [X] No d. Comments No response provided 4. Systemic involvement other than joints ----------------------------------------- a. Does the Veteran have any involvement of any systems, other than joints, attributable to this arthritis condition? [ ] Yes [X] No b. Comments: No response provided 5. Incapacitating and non-incapacitating exacerbations ------------------------------------------------------ a. Due to the arthritis condition, does the Veteran have exacerbations which are not incapacitating? [ ] Yes [X] No b. Due to the arthritis condition, does the Veteran have exacerbations which are incapacitating? [X] Yes [ ] No If yes, indicate frequency of incapacitating exacerbations per year (on average): [ ] 0 [ ] 1 [X] 2 [ ] 3 [ ] 4 or more Indicate the total duration of incapacitation over the past 12 months: [X] < 1 week [ ] 1 week to < 2 weeks [ ] 2 weeks to < 4 weeks [ ] 4 weeks to < 6 weeks [ ] 6 weeks or more Date of most recent incapacitating exacerbation: approx. 11/2016 CONFIDENTIAL Page 15 of 31 Duration of most recent incapacitating exacerbation: less than one day Describe incapacitating exacerbation: Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10 on a 0-10 scale. c. Is the Veteran's arthritis manifested by constitutional manifestations associated with active joint involvement which are totally incapacitating? [ ] Yes [X] No d. Is the Veteran's arthritis manifested by weight loss and anemia productive of severe impairment of health? [ ] Yes [X] No e. Is the Veteran's arthritis manifested by severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods? [ ] Yes [X] No f. Is the Veteran's arthritis manifested by symptoms combinations productive of definite impairment of health objectively supported by examination findings? [ ] Yes [X] No g. Comments: No response provided 6. 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 7. Assistive devices -------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided CONFIDENTIAL Page 16 of 31 8. Remaining effective function of the extremities -------------------------------------------------- Due to the Veteran's arthritis condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 9. Diagnostic testing --------------------- a. Have imaging studies been performed and are the results available? [X] Yes [ ] No [X] X-ray Area(s) imaged: Lumbar spine Date: 6/6/2016 Results: L5-S1 degenerative disc diseae b. Have laboratory studies been performed? [X] Yes [ ] No If yes, check all that apply: [X] Erythrocyte sedimentation rate (ESR) Date of test: 6/2/16 Results: 3 [X] C-reactive protein Date of test: 6/2/16 Results: < 2.9 [X] Rheumatoid factor (RF) Date of test: 9/19/13 Results: <10 [X] CBC Date of test: 6/2/16 Hemoglobin: 14.5 Hematocrit: 41.2 White blood cell count: 5.69 Platelets: 243 [X] Other, specify: CCP IgG Ab Date of test: 6/2/16 Results: <16 c. Has the Veteran had a joint aspiration or synovial fluid analysis? [ ] Yes [X] No d. Has the Veteran had a biopsy (e.g., skin, nerve, fat, rectum, kidney)? [ ] Yes [X] No CONFIDENTIAL Page 17 of 31 e. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No f. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: Report: Lumbosacral spine Clinical data: pain Comparison: none. Findings: Alignment: Normal. Vertebral bodies: Normal. Intervertebral disc spaces: Mild narrowing L5-S1. Facet Joints: Normal. Soft Tissues: Normal. Other: Impression: 1. Mild L5-S1 disc disease. Veteran has Degenerative disc disease, not a Rheumatic disease. The Veteran has palpable spasms of the lumbar spine which correlates to the degenerative changes on the lumbar spine x-ray. 10. 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: Veteran is unable to lift more than 30 lbs. He can't sit or stand for extended periods of time. He is unable to participate in prolonge heavy physical labor. The diagnosed lumbar spine condition does not preclude participation in sedentary employment. 11. Remarks, if any: -------------------- Veteran has degenerative arthritic conditions and Fibromyalgia; not inflammatory arthritic conditions. **************************************************************************** Back (Thoracolumbar Spine) Conditions CONFIDENTIAL Page 18 of 31 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 [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia CONFIDENTIAL Page 19 of 31 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Degenerative disc disease L5-S1 ICD code: M43.06 Date of diagnosis: 6/6/2016 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He started complaining of low back pain and pain in some of his other joints. In 2007 he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC. There he was evaluated and diagnosed with fibromyalgia and degenerative joint/disc disease of the low back and it was opined that it was related to his service experience. However, the Veteran does not recall the diagnosis or any follow-up. He has complained of the low back pain and chronic polyarthralgias since enrolling at the FVAMC in September of 2013. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10 CONFIDENTIAL Page 20 of 31 on a 0-10 scale. c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. He does not lift over 30 pounds. He does not play sports or enjoy things with his children as his back will act up. He is unable to ride in a car for a long period of time without his back flaring up. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 70 degrees Extension (0 to 30): 0 to 25 degrees Right Lateral Flexion (0 to 30): 0 to 25 degrees Left Lateral Flexion (0 to 30): 0 to 25 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 25 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: Veteran is unable to lift more than 30 lbs. Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Veteran has spasm in the lumbosacral area that is tender. CONFIDENTIAL Page 21 of 31 b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [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 speculation Select all factors that cause this functional loss: Pain, Lack of endurance ability over Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Pain and or endurance are limiting the Veteran's functional without repeated use over time. Based on the clinical exam today and the Veteran's statements it is plausible to concur that time he would be more limited. I am not able to determine actual degrees of decreased ROM however. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No CONFIDENTIAL Page 22 of 31 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 speculation Select all factors that cause this functional loss: Pain, Weakness, Lack of endurance Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Pain, weakness and or endurance are limiting the Veteran's functional ability without being in a flare-up. Based on the clinical exam today and the Veteran's statements it is plausible to concur that during a flare-up he would be more limited. I am not able to determine actual degrees of decreased ROM however. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: Musle spasm present in the lumbosacral paraspinals related to the way the Veteran hols his back. Guarding: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: Guarding of the lower back that results in muscle spasm. CONFIDENTIAL Page 23 of 31 f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Interference with sitting, Interference with standing Please describe additional contributing factors of disability: Veteran is not able to sit or stand for extended periods of time without experiencing more pain and spasms. 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 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 Great toe 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 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent CONFIDENTIAL Page 24 of 31 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus 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 --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities CONFIDENTIAL Page 25 of 31 ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] Yes [X] No 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] 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 CONFIDENTIAL Page 26 of 31 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: Veteran is unable to lift more than 30 lbs. He can't sit or stand for extended periods of time. He can otherwise perform his job duties. 17. Remarks, if any: -------------------- There was a thorough review of E-BVMs, CPRS and JLV as well as a focused history from the Veteran regarding his Southwest Asia Service. The Veteran claimed an unexplained chronic multi-symptom illness of pain throughout his body which included low back pain. The low back bain is diagnosed as 1. Degenerative Arthritis of the Spine. M43.06. It is a disease with a clear and specific etiology and diagnosis that is separate from the Fibromyalgia. The Degenerative Arthritis of The Spine is at least as likely as not (50 % probability) that it is related to the Veteran's Military Service. Rationale: The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by a Rehab specialist who opined the back problems were related to his military service. The Veteran did have negative x-rays at that time, however in June of 2016 his X-ray is indicating degenerative changes of the lumbar spine. The Veteran reports job duty changes while CONFIDENTIAL Page 27 of 31 serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. CONFIDENTIAL Page 28 of 31 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: DBQ General Medical Gulf War: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. Please examine and evaluate this Veteran with Southwest Asia service for any chronic disability pattern. Please review the claims file as part of your evaluation and state that it was reviewed. The Veteran has claimed a disability pattern related to Medically unexplained chronic multi-symptom illness (pain throughout his body). Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (1) an undiagnosed illness; or (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, then no medical opinion or rationale is required as these conditions are presumed to be caused by service in the Southwest Asia theater of operations. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a CONFIDENTIAL Page 29 of 31 medical opinion, with supporting rational, as to whether it is "at least as likely as not" that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) review of the record is NOT restricted to the evidence listed below. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Tab D (Federal treatment record in VBMS): VETERAN PROVIDED HIS COPY OF TREATMENT FROM THE VA dated 12/04/2016 Tab B (Veteran's statement in VBMS): Veteran provided statement on how his pain is reflected throughout his entire body. dated 12/04/2016 Tab A (DD Form 214 in VBMS): DD 214, Iraqi Campaign Medal noted dated 12/04/2016 Tab C (Federal treatment record in VBMS): CAPRI MEDICAL FROM THE DURHAM, FAYETTEVILLE, AND WILKES-BARRE VAMC dated 12/16/2016 Please direct any questions regarding this request to: Mike Theriot 8810 Rio San Diego Dr San Diego, CA 92108 Phone number: 6194005515 Email: mike.theriot@va.gov b. Indicate type of exam for which opinion has been requested: DBQ FIBRO TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The Veteran was diagnosed with Fibromyalgia in approximately 2007 after serving in SWA in 6/18/04-5/28/05. He underwent an extensive evaluation and inflammatory/other rheumatological disorders were ruled out. He meets the diagnostic criteria for fibromyalgia. It is not an undiagnosed illness. It is not a disease with a clear and specific etiology. However, it CONFIDENTIAL Page 30 of 31 is a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. I am unable to state with any degree of certainty which environmental hazards could have caused the disease. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Contention: medically unexplained chronic multisymptom illness ( pain through out his body) b. Indicate type of exam for which opinion has been requested: DBQ ARTH/BACK TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The contention of medically unexplained chronic multisymptom illness ( pain through out his body) diagnosed as degenerative arthritis of the lumbar spine(also see fibromyalgia template). The diagnosis of djd lumbar spine is not an undiagnosed illness, and is not a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, and did not result from exposure to environmental hazard due to service in SWA. The degerative arthritis of the lumbar spine has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of helicopters. All of which could put increased stress on the lumbar spine, and many of the exercises are carried out with rucks on you back. Thus opined as above. ************************************************************************* Contention: Lumbar Spine Condition due to active military service. Medical Opinion: It is as least as likely as not a 50/50% probability that the Veteran claimed medically unexplained chronic multisymptom illness ( pain through out his body), diagnosed as degenerative disc disease lumbar spine was incurred in or resulted from active military service. Rationale: The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by CONFIDENTIAL Page 31 of 31 a Rehab specialist who opined the back problems were related to his military service. The Veteran reports job duty changes while serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details. The degerative arthritis of the lumbar spine has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of helicopters. All of which could put increased stress on the lumbar spine, and many of the exercises are carried out with rucks on you back. Thus opined as above. THIS DOCUMENT WAS ORIGINALLY INITIATED BY: BARTON,DEBRA A /es/ June L ROBERTS MD Signed: 01/25/2017 17:40 END OF MY HEALTHEVET PERSONAL INFORMATION REPORT
  12. Can anyone help me to understand my c&p exam notes? I would like to know what it all means and what kind of rating if any I am looking at. Thank you 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] Examination via approved video telehealth Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis: ------------- Does the Veteran now have or has he/she ever had a skin condition? [X] Yes [ ] No [X] Psoriasis ICD code: xxx Date of diagnosis: 8/30/2008 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's skin conditions (brief summary): The Vet was initially seen for his "rash" in 2008 per his STR. He was diagnosed with psoriasis and it is mainly located on his abdomen, arms, legs and thighs. He uses a steroid cream and urea 40% to treat. He is currently stable as long as he uses the medication. b. Do any of the Veteran's skin conditions cause scarring (regardless of location), or disfigurement of the head, face or neck? [X] Yes [ ] No If yes, indicate skin condition and describe scarring and/or disfigurement: slight redness of the skin with patches If yes, are any of these scars painful or unstable, have a total area equal to or greater than 39 square cm (6 square inches), or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.) [ ] Yes [X] No If no, provide location and measurements of scar in centimeters. Location: abd/arms/hands/legs/thighs Measurements: length 20cm X width 1cm c. Does the Veteran have any benign or malignant skin neoplasms (including malignant melanoma)? No response provided. d. Does the Veteran have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma)? [ ] Yes [X] No e. Comments, if any: No response provided. 3. Treatment ------------ a. Has the Veteran been treated with oral or topical medications in the past 12 months for any skin condition? [X] Yes [ ] No [X] Topical corticosteroids If checked, list medication(s): clobetasol/urea 40% Specify condition medication used for: psoriasis Total duration of medication use in past 12 months: [ ] < 6 weeks [X] 6 weeks or more, but not constant [ ] Constant/near-constant b. Has the Veteran had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders? [ ] Yes [X] No 4. Debilitating and non-debilitating episodes --------------------------------------------- a. Has the Veteran had any debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis? [ ] Yes [X] No b. Has the Veteran had any non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months? [ ] Yes [X] No 5. Physical exam ---------------- a. Indicate the Veteran's visible skin conditions; indicate the approximate total body area and approximate total EXPOSED body area (face, neck and hands) affected on current examination (check all that apply): [X] Psoriasis Total body area [ ] None [ ] <5% [X] 5% to <20% [ ] 20% to 40% [ ] >40% EXPOSED area [ ] None [X] <5% [ ] 5% to <20% [ ] 20% to 40% [ ] >40% b. For each skin condition, give specific diagnosis and describe appearance and location: No response provided. 6. Specific Skin Conditions --------------------------- No response provided. 7. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 8. Other pertinent physical findings, complications, conditions, signs or symptoms ----------------------------------------------------------------------------- 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. Comments, if any: No response provided. 9. Functional impact -------------------- Do any of the Veteran's skin conditions impact his or her ability to work? [ ] Yes [X] No 10. Remarks, if any: -------------------- His mild psoriasis is currently stable as long as he uses his medication **************************************************************************** Ankle 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] Examination via approved video telehealth 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: Ankle Conditions b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Lateral collateral ligament sprain (chronic/recurrent) Side affected: [ ] Right [ ] Left [X] Both ICD Code: xxx Date of diagnosis: Right 2005/2009 Date of diagnosis: Left 2005/2009 c. Comments (if any): Vet was on airborne status d. Was an opinion requested about this condition (Internal VA only)? [ ] Yes [ ] No [X] N/A 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's ankle condition (brief summary): Vet relates rolling injuries of his ankles 2005 & 2009. X-rays revealed no fractures and he was treated for sp rains with ace wraps and medication along with activity modification. He relates that he has "weak" ankles and wears high top boots to prevent injury. b. Does the Veteran report flare-ups of the ankle? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: If he tries to run or walks on an uneven surface c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [ ] Yes [X] No 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right ankle ----------- [X] All Normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar 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 ankle ---------- [X] All Normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar 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 b. Observed repetitive use Right ankle ----------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Left ankle ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No c. Repeated use over time Right ankle ----------- 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 examined with repeat use over time Left ankle ---------- 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 examined with repeat use over time d. Flare-ups Right ankle ----------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not flared Left ankle ---------- Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not flared e. Additional factors contributing to disability Right ankle ----------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: More movement than normal due to flail joints, fracture nonunions, etc. Please describe: notes weakness in ankle allowing more movement Left ankle ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: More movement than normal due to flail joints, fracture nonunions, etc. Please describe: notes weakness in ankle allowing more movement 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 ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 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 Veteran has ankylosis of the ankle a. Indicate severity of ankylosis and side affected (check all that apply): Right side: Left side: [ ] In plantar flexion [ ] In plantar flexion [ ] In dorsiflexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an inversion deformity [ ] With an eversion deformity [ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing position [ ] In poor weight-bearing position [ ] In poor weight-bearing position [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No Left ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No 7. Additional comments ---------------------- Does the Veteran now have or has he or she ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)? [ ] Yes [X] No 8. Surgical procedures ---------------------- No response provided 9. 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 10. 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 11. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's ankle condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 12. Diagnostic testing ---------------------- a. Have imaging studies of the ankle 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: No response provided 13. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [ ] Yes [X] No 14. Remarks, if any ------------------- 1. Is there evidence of pain on passive range of motion testing? YES 2. Is there evidence of pain when the joint is used in non-weight bearing? YES 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? NO. The contralateral ankle has the same problem of weakness or increased movement and pain but with normal range of motion. **************************************************************************** Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] Examination via approved video telehealth Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [X] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Lumbago ICD code: xxx Date of diagnosis: 2010 Diagnosis #2: Facet Arthropathy L4-5 ICD code: xxx Date of diagnosis: 2011 Diagnosis #3: Bulging Disc L4-5 (disc protrusion) ICD code: xxx Date of diagnosis: 2011 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Vet relates developing low back pain ~2010. He was seen for this in 2010. He was again seen for LBP with radiation of pain and muscle spasms 4/5/2011 and for sciatica in 5/2011. He had several facet injections which helped temporarily. He now c/o of continuous pain ranging from 2-10/10 pain level. He takes NSAID's as needed. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: With frequent bending, walking more than 1 mile, standing for more than 30 minutes w/o a break and with any running c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. He can not bend as far as he used to due to pain. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 45 degrees Extension (0 to 30): 0 to 15 degrees Right Lateral Flexion (0 to 30): 0 to 30 degrees Left Lateral Flexion (0 to 30): 0 to 30 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: ~ 50% loss of ROM with flexion & extension 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)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion, Right Lateral Rotation, Left Lateral Rotation Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): TTP in the soft tissue of the LS spine; no spasms noted b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not examined with repeat use over time d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not flared e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [ ] Yes [X] No f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 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? [ ] Yes [X] No 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 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 --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] 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 imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: His ability to bend is compromised; he has trouble crossing his legs to put on his shoes and he can not bend down to do so. His ability to lift is about "half what it used to be". 17. Remarks, if any: -------------------- He rates his pain on average as 4-5/10 which would be moderate on a scale of mild, moderate or severe. **************************************************************************** **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] Examination via approved video telehealth 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: Bilateral Knee Pain b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] The Veteran does not have a current diagnosis associated with any claimed condition listed above in 1a. c. Comments (if any): The Veteran has bilateral knee pain that fits into patellofemoral pain syndrome. He was not seen for this medically so there are no notes in his STR. I told him that I would do the exam and submit the DBQ for review. d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Vet relates that shortly after boot camp he began having knee pain around his patellae bilaterally. This would get worse with frequent climbing of stairs, road marches and running on hard surfaces. He denies swelling, locking or giving out of his knees. 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: with going up stairs, kneeling or frequent getting up from a sitting position c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [ ] Yes [X] No 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Right Knee ---------- [X] All normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees Description of pain (select best response): 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, Extension 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? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): slight TTP of the patella Is there objective evidence of crepitus? [ ] Yes [X] No Left Knee --------- [X] All normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees Description of pain (select best response): 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, Extension 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? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): sl TTP of the patella Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right Knee ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Right Knee ---------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: not examined with repeat use over time 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 examined with repeat use over time 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 flared 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 flared 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: Flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Knee: Rate Strength: Flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe b. Is there a history of lateral instability? Right: [X] None [ ] Slight [ ] Moderate [ ] Severe Left: [X] None [ ] Slight [ ] Moderate [ ] Severe c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing Right Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: + patellar grind R=L 7. Additional conditions ------------------------ a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No b. Comments, if any: No response provided 8. Meniscal conditions ---------------------- a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided 9. Surgical procedures ---------------------- No response provided 10. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 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: Pain increases with frequent kneeling and going up stairs. 15. Remarks, if any: -------------------- His pain is mild to moderate at present (2-4/10) **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] Examination via approved video telehealth Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: The Veteran is claiming service connection for dermatitis / psoriasis. Please examine the Veteran for a chronic disability related to his or her claimed condition and indicate the current level of severity. b. Indicate type of exam for which opinion has been requested: Psoriasis TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: I reviewed VBMS and CPRS. His psoriasis was initially noted in 2008. There is no evidence that this existed prior to service. Therefore, the psoriasis is at least as likely as not incurred in or caused by the claimed in-service injury, event or illness. In short, it started in the service. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: The Veteran is claiming service connection for ankle pain. Please examine the Veteran for a chronic disability related to his or her claimed condition and indicate the current level of severity. b. Indicate type of exam for which opinion has been requested: Ankle Conditions TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: I reviewed VBMS and CPRS. Based on my review of his STR's he has had injuries to his ankle's. On exam, he has a weakness and laxity with inversion of his ankles consistent with recurrent injuries. He was on airborne/jump status.Therefore, the claimed condition is at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: The Veteran is claiming service connection for lower back pain. Please examine the Veteran for a chronic disability related to his or her claimed condition and indicate the current level of severity. b. Indicate type of exam for which opinion has been requested: back condition(s) TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: I reviewed VBMS and CPRS. He has ample documentation of back injuries and pain that were not present prior to his service. He has documented disease from an MRI done 2/25/2011 (facet arthropathy and disc protrusion L4-5). He was also on airborne jump status. Therefore, the back conditions are at least as likely as not incurred in or caused by the claimed in-service injury, event or illness. *************************************************************************
  13. ...Or is this another way they would benefit from holding off on making me permanent, besides what my kids aren't getting in College? It seems like I should qualify but, since I reached 100% "naturally", I don't have a TDIU ruling either. Here are my ratings, do you think they are shortchanging me? I almost never leave my house, either, btw. Thanks, SMC is very confusing to me. 70% post-traumatic stress disorder (also claimed as adjustment disorder) 50% obstructive sleep apnea 50% sinusitis (claimed as chronic pansinusitis) 30% headache syndrome to include occipital neuralgia (claimed as migraine headaches and occipital nerve impingement) 20% carpal tunnel syndrome, right upper extremity to include lower radicular group and cubital tunnel syndrome post excision of arteriovenous malformation (also claimed as peripheral nerve injury shoulder, neuritis median nerve right arm) 20% status post cervical vertebral fusion C4-C6 to include myofascial pain syndrome (claimed as herniated disc (c5-c6) left, cervical spondylosis) 10% degenerative arthritis of the spine to include lumbago, lumbar spondylosis and myofascial pain syndrome (claimed as lumbar bulging disc l4-l5) 10% left peroneal neuropathy (claimed as deep peroneal nerve atrophy) 10% varicose veins, right lower extremity (also claimed as venous reflux disease) 10% varicose veins, left lower extremity (also claimed as venous reflux disease) 10% seborrheic dermatitis 0% radiculopathy, left upper extremity 0% carpal metacarpal arthritis, right hand (claimed as osteoarthritis right hand) 0% vasomotor rhinitis (also claimed as nasal polyps)  0% lliotibial band friction syndrome, right thigh 0% ganglion cyst, left wrist (claimed as ganglion left/right wrist) 0% meralgia paresthetica, right lower extremity
  14. If you want a particlular benefit, such as "Space A" travel, I simply suggest you show up with your id and present it, then shut up, and let the Space A attendee decide if you are eligible or not. Its not your job to decide if you are eligible..its the space A' attendee's job. Let him do his job. If you look closely at an id card for 100% disabled Vets and retiree's, you notice barely any difference. Mine says, "Exchange, MWR, Commissary" and the term "disabled" is nowhere to be found on my id card. IM sorry I dont hear well enough to hear/contribute to the podcast, (which I recommend, by the way), but I will still put in my 2 cents worth. Sometimes, its better to beg for forgiveness than to ask for permission. At my nearby military post, the retiree and the 100% Vet cards are pretty much interchangeable. I'm often confused for a "retiree". Remember, the VA does not issue us Tshirts and make mandantory us wear a label "100% disabled Veteran". Instead, we are free to choose whether to identify as a disabled Veteran, or not disclose, at our option. Years ago, I went through a state Voc Rehab plan, where they outlined the policy of "to disclose or not disclose" our disability(s). The bottom line is we choose to who/when we disclose our disabilities. Our medical records are private. There are privacy laws, and we are protected. My wife used to be a nurse, and they take privacy laws seriously, with a "need to know". A nurse I dont know, can not legally walk up to me and demand to know my medical history. However, if she is treating me at a hospital or clinic, she has a need to know my medical background, but even then I get to choose how much I disclose. My wife was prohibited (under threat of being fired) of discussing medical conditions UNLESS the patient gave the "ok"..go ahead and talk to them about it. Can you see that our medical records are private, and we need not disclose unless we choose? In a similar way, I need not list my disabilities, medical records, dates of treatment, etc., with the "Space A" attendee. I hand them my id card, and it speaks for itself. Now, I dont recommend fraud. No. We have been issued this ID card, and I let the person reading it do their job..that is, to see if I qualify or not. I dont answer "health questions" to the Space A attendee, as he is not treating me, and need not know my medical history, and I do not have to disclose my disability percentage, or other health details, unless I so choose. We dont have to disclose the last time we had sex, our list of disabilitis, if any, our doctor's name, or the list of meds we take. Before I could get a handicap placcard, (good to park in a handicap zone in my state), I asked my doctor (as I have it documented that I have severe degenerative arthritis of the knees, NOT currently sc for knees) Based on this, I simply recommend you "show up" with your id card, and request military space a travel. This technique (assuming I qualify, and let them tell me no) works with almost everything on base. I have been issued this id card in a proper manner, going through the channels. I am not required to disclose my disabilities, but may do so at my soul discretion and, to the degree that I choose. A space A attendee does not have a "need to know" my health history or list of disabilities, if any. For eligibility for benefits that are exclusively for 100% disabled Vets only, the VA has a letter. It does not say you are 10% for hearing loss, 10% for tinnitus, and it does not say whether or not you have ED. It simply states whether or not you are 100% p and t. When I print the letter, I get to choose whether or not I include "special monthly compensation" or not. This is a good idea. THERE may be cases when a Veteran may choose to disclose SMC awarded, at what level, such as it someone was applying for a loan and needed all the income he could get to qualify. That may be an instance where I would consider disclosing SMC's, but, generally, its none of their business what disabilities I have. If they try to press, I will say something like: "Very well, you want all my medical details to decide if I get on this plane. I have presented my id card as proof, and this was apparently insufficient for you. Before I give more details about myself, I need to verify who you are. Please give me your credit card number, pin code, expiration date, mother's maiden name, place of birth, ssn, and bank routing numbers, and then, after verification, I will disclose my full medical record. In the interim, I gave you my proof with my ID, so let me on the darn plane. All this said, I do think the policy should be implemented which allows disabled Vets to use Space A. However, the military, like VA, has someone there interpreting his rules, and people do things differently. The military, like VA, is not a unified body, where everyone does everything the same. I say you hand them your id card, and answer as few a questions as possible about your health as well as your years of service. (That is, whether you are retired, disabled, medically retired, Coast guard retired, contractor eligible, etc, etc, etc.)
  15. Can I get SMC awarded back to original Effective Date? Not having been aware of the SMC at all, has anyone ever successfully been awarded SMC back to their original Effective Date? In reading these blogs, I came across a webpage providing an overview of all SMC’s. One line stood out: “If the VA did not give Special Monthly Compensation in a case that qualifies, the veteran can request for his case to be reviewed, and Special Monthly Compensation will then be given dating back to the original VA Rating Decision.” I plan on filing for SMC “L”: – In regular need of another person to help dress, clean, feed himself, and use the restroom (aid and attendance) My justification is that I have always needed assistance from my wife to dress and sometimes bathe as a direct result of: Lumbar Spine degenerative disc disease with thoracolumbar strain (rheumatoid arthritis-lower back, upper back herniated discs, and thoracic spine stenosis) 40% Service Connected Cervical spondylosis with degenerative arthritis 20% Service Connected Radiculopathy, right upper extremity 20% Service Connected Radiculopathy, right lower extremity 10% Service Connected I’m in constant pain while the condition is getting worse, i.e. loss of feeling/strength in right arm.
  16. I went in for an increase of my back, left knee and left hip. I was seen by a overly nice female examiner that turns out to be a nurse practitioner and the outcome of this c&p was shocking to say the least! When we got done talking for a least a half an hour she said "oh this is only for an increase so lets take a look at your back. She never used a geinommeter or any device to measure my ROM but said to turn around and face the chair and bend over which I did to approx. 30 degree range and she said OK that's all we need. The next couple of days i read this on e-benefits 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 ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Page 20 of 66 Diagnosis #1: Degenerative Disc Disease of the Lumbar Spine ICD code: M47.0 Date of diagnosis: already service connected Diagnosis #2: Lumbar radiculoapthy ICD code: M54.16 Date of diagnosis: already service connected 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Since the veteran is already service connected for his condition, this exam will focus on his current status. He reports pain in his lower back that is rated a "7". He takes Hydrocodone i tab by mouth a few times per week. No surgery to his lower back. He denies that he has had steroid injections, or pain medication injections. He has lumbar radiculopathy that is constant. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: this will occur about once per week that will last for most of the day with a pain level of a "8-9". Precipitating factors: unknown. c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. limited ROM of the lumbar spine is in itself a functional limitation of the lumbar spine. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 65 degrees Extension (0 to 30): 0 to 20 degrees Page 21 of 66 Right Lateral Flexion (0 to 30): 0 to 15 degrees Left Lateral Flexion (0 to 30): 0 to 15 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: limited ROM of the lumbar spine is in itself a functional limitation of the lumbar spine. 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)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion, Right Lateral Rotation, Left Lateral Rotation Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): he does have localized tenderness noted to the lumbar spine on the spinal cord and on either side of the spinal cord. b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over Page 22 of 66 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: There was a question on the 2507 that asks whether pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over period of time. There really is no way to predict functional ability during a flare-up when it is not witnessed. This would be subjective, presumptive and speculative at best and an opinion is not feasible and cannot be rendered. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss d uring 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: There was a question on the 2507 that asks whether pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over period of time. There really is no way to predict functional ability during a flare-up when it is not witnessed. This would be subjective, presumptive and speculative at best and an opinion is not feasible and cannot be rendered. e. Guarding and muscle spasm Page 23 of 66 Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Localized tenderness: [ ] None [X] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: he walks with a slight forward bend to his back due to the pain f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Disturbance of locomotion, Interference with sitting, Interference with standing Please describe additional contributing factors of disability: he cannot walk over 15-20 minutes at the time. He cannot sit for greater than 10-20 minutes and standing for over 15 minutes. 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 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 Page 24 of 66 Great toe 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 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 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 --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform Page 25 of 66 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- Page 26 of 66 a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] Yes [X] No 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ----------------- [X] Cane(s) [ ] Occasional [X] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: for his lower back and radicular symptoms 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] 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 Page 27 of 66 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): MRI LUMBAR SPINE W/O (JUN 09, 2014@07:51) Report: MRI Lumbar Spine Sagittal STIR and sagittal and axial T1 weighted, T2 weighted images of the lumbosacral spine were obtained. Findings: Comparison to MRI of the lumbar spine on 8/4/11. Normal alignment of the lumbar sacral spine is visualized. Heterogenuos bone marrow signal is noted likely due to degenerative changes. L5-S1 Modic type II changes. At T12-L1, L1-2 there is disc desiccation, mild diffuse disc bulging with mild facet joint hypertrophy without significant neural foramina narrowing. Normal appearance for the patient's age. At L2 L3 there is a right paracentral and foraminal disc protrusion with extrusion and mild superior migration, producing narrowing of the right lateral recess and posterior displacement of the right L3 nerve root. Protrusion contacts and produce mild displacement of the a right L2 nerve root within the neural foramen. At L3-4 mild disc narrowing and desiccation, diffuse disc bulging without significant central spinal canal narrowing. Mild bilateral facet Page 28 of 66 joint hypertrophy without significant neural foramen narrowing. Unchanged in comparison to prior At L4-5 there is disc narrowing, bulging and desiccation with moderate facet joint hypertrophy, ligamentum flavum hypertrophy and bilateral mild neural foramina narrowing. Unchanged in comparison to the prior. At L5-S1 severe disc narrowing and desiccation with moderate facet joint hypertrophy, ligamentum flavum hypertrophy and bilateral mild neural foramina narrowing. There is a mild degenerative retrolisthesis of L5 on S1. Unchanged in comparison to the prior. The conus medullaris ends at the lower portion of L2 body. Cauda equina demonstrated no compression. No evidence of paraspinous soft tissue abnormality. Impression: 1. L2 L3 right paracentral and foraminal disc protrusion with extrusion and mild superior migration, producing mild displacement of the right L2 nerve within the neural foramen and the right L3 nerve within the lateral recess. Please correlate clinically for right L2 and/or L3 radiculopathies. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: He has pain in his lower back on a daily basis. He has missed 9 days of work over the past year due specificially to his lower back. 17. Remarks, if any: -------------------- Page 29 of 66 No medical opinion was requested for this already service connected disability. I checked and they reduced me from 30% to 10% off of this exam! I checked the cfr and here's what i found The Spine Rating General Rating Formula for Diseases and Injuries of the Spine Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis20 Is it me or according to this it should be rated at at least 20% even with the bad ROM reading?
  17. I was diagnosed with degenerative arthritis in my right shoulder with a range of motion of 40°. They awarded me 30%. According to the schedule of ratings degenerative arthritis is supposed to be rated under diagnostic code 5200. DC 5200 says intermediate between favorable and unfavorable for major is 40%. Have they made a mistake? What should I do?
  18. In my past threads i posted that in 2014 i put in a claim for hip pain, and after x-rays and C&P was denied service connection.I did not put in a NOD. Fast forward to 2016. Put in claim for hip pain secondary to knee, sacroiliac joint and back arthritis. Two weeks later BBE came. Denied service connection,states lost med records. Well after some fuming i gathered my evidence in my copy of my service medical records and made an appointment with my VA PCP. I showed her where in 1984 a had a bad auto accident that involved my entire left side. After showing this to her i explained that i was denied service connection for my hip and asked her if she would write me a statement explaining that this could have resulted in my hip pain. She said no problem!! WOW. Ok Went on e-benifits this morning and low and behold here is the letter..... to whom it may concern veteran ------ is DOB- -------, is under ,my care since June 2011. Review of record shows , vet had a MVA in 1984, while in service, that affected ------- his left side, left knee, left side of back , & hip, His hip pain has increased since then x ray shows degenerative arthritis, which in my opinion is as likely as not is a result of trauma to his left side including hip in 2008 while in service if you have any question or concern, please feel free to contact me /es/ SAROJ B SHARMA MD STAFF PHYSICIAN Signed: 05/02/2016 16:35. I think that this should be enough evidence to include my emergency record of the accident that they conveniently lost to RE-OPEN my 2014 claim for service connection of left hip. What do you guys think? I just wish that everyone of us vets had a great PCP like i do that actually cares for us vets and will go beyond what is required to help....
  19. In another post I had tons of questions regarding my claim and the TKR! Thanks all those who helped! I hope I put this one in the right topic! I was told to go to my VA and get copies of my clinic visits and my surgical reports, which I did yesterday! I have a couple questions/concerns that I fear may make me ineligible. Clinic Notes: Several times it was mentioned that I wanted the TKR on my right knee (fact), I was concerned about this until you get to the clinic note where we met with the surgeon and he stated "Mr XX wants the surgery for fancy word for TKR, given the state of advanced end stage degenerative arthritis, and his young age I agree and that the TKR is the best chance of improvement, Mr XXX will also require TKR on his left knee in near future." Will the fact that I stated I want the TKR become an issue? Also, in the progress notes it states "residuals from previous ACL repair" are they saying that my knee needed a TKR because of the ACL repair? That happened prior to the military and I received a waiver with MRI that showed NO signs of degenerative arthritis or degenerative joint disease. Finally they also did MRI's on my back, and now they are saying I have DJD in that area as well. Can I get that connected to my right knee which is SC? Can I get my left knee SC do to favoring my right knee for so long it affected my walk? Below are some notes about my knee, please let me know any input you have or if you need additional information, I have it all in from of me. Progress Notes: Impression: Residuals from previous ACL repair. Significant increase of degenerative changes involving the right knee complex since 12/2003 (last review) Surgical Notes: Preoperative Diagnosis: 1) Right knee end-stage degerative joing disease. 2) Prior ACL reconstructions, right knee. Same notes for posoperative. Radiology Reports: Large suprapateller effusion progressed since prior MRI, soft tissue of ligamentous injury cannot be excluded.
  20. I was just getting gas at my local corner gas station. They had a photo of a Vet there, and asked for donations for his widow. Being a curious fellow, I had to ask. She responded that the deceased got gas, soda, etc, there almost every evening. He told her the Va had diagnosed "a pulled muscle" and sent him home. A couple months later VA diagnosed "headaches"..and sent him home. About 3 months later this Vet was dead from brain cancer. This is the VAMC I use. I can see exactly why it happens. You get maybe 2 minutes with the doctor WHEN you can get an appointment. Dont have several things wrong with you because they only want to hear about "one", your "major" complaint. They always ask me "Why am I here?" I had to fight the VA for 2 years to get them to take a special Xray to diagnose a leg length discrepency. My physical Therapist had asked me over 2 years ago, "Did you know one leg is longer than the other?" No. I did not. So, I finally got an appointment after about 5 months with an orthopedic doc who said that the PT was nuts, I did not have a leg length discrepency, and the only way to know for sure was a special X ray of both legs with a yardstick taped on the xray table. I said, Ok, lets do it. The doc responded, "The VA does not do that xray". But he sent me for a smaller, less determinative knee xray. While I was there, the x ray tech asked why, if I have different length legs, did the doc not order this special xray? I responded the doc said, "Va does not do those." She said, "Well, Im an Xray tech and I do that xray about 3 times a month." So, the doc was lying. I finally complained to my patient advocate (shouldnt the doctor advocate for his patients?), and did get the applicable xray. Sure enough it showed degenerative arthritis with one leg longer than the other. So,. I had to put up with this pain for an extra 2 years. I think I will contact the brain cancer widow and suggest she sue the VAMC that failed to diagnose his brain cancer until it was to late, and strongly suggest an attorney. You see, VA will pull this stuff as long as they can get away with it.
  21. Because of the pure number of disabilities I have posting them as a sig would be ridiculous. I started my MS battle shortly after I was diagnosed 3 years ago, I was diagnosed with its symptoms almost 25 years ago after I got out so I was able to make service connection requirements. I started out at 30% disabled at the beginning, then fought to 40% a few years back because of my hips. MS got me to 70%, but my VSO had no secondaries and told me not to file them till after i was rated for MS. I filed my secondaries myself and am now at 90% (93.165%) The claim is partially awarded but has 4 more pending claims. The rater actually called me and told me they are pulling the original MRI's and medical records from 25 years ago to see if all the original decisions and dates are rated and set correctly including the MS rating and date. It's a big step forward, now I have to fight the last few inches, Just waiting for the results. tinnitus 10% voiding dysfunction secondary to multiple sclerosis 20% cervical spine strain 10% low back strain 10% bowel function impairment secondary to multiple sclerosis 10% right lower extremity impairment secondary to multiple sclerosis 10% right upper extremity impairment secondary to multiple sclerosis 10% degenerative arthritis of right hip joint 10% multiple sclerosis 30% adjustment disorder with mixed anxiety and depressed mood 30% left upper extremity impairment secondary to multiple sclerosis 10% left lower extremity impairment secondary to multiple sclerosis 10% multiple sclerosis with sleep apnea 50% left hip joint degenerative arthritis 10%
  22. Has anyone had knee replacement surgery done at VA? I would like to know details, such as when, which VA, did the doc know what he was doing, and did you get a good result. I would also like to know the brand or type of fake knee, and did you have pain, and how long to recover. I just found out yesterday I have severe degenerative arthritis (both knees) AND a leg length disparity. (One leg is shorter than the other). I will likely have to have knee replacement surgery. I was told this also about 3 to 4 years ago, but the pain is worse now. Also, my condition has worsened significantly since a 2014 x ray. My PCP doc's nurse says that the VA "wont do" a TKR if your BMI is above 35, and mine is apparently 35.8. She said that means I will need to lose 5 to 10 pounds which is doable.
  23. I am unfamiliar with SSDI. I have an attorney, so I am not drawn into the bureaucracy like with the VA. They submitted my claim and put together the required documents, including my 2k page service records. I am currently 44. I just did a few questionnaires sent to me directly from SS. They almost seemed like they were in lieu of an exam. Is this possible? I have not seen any SS Doctor's or received any requests to do so. I am a 100% scheduler, but too young for P&T, I guess. What can I expect next? Here is a list of my rated disabilities (many are lowballed, a few are completely missing, awaiting C-File): 70% post-traumatic stress disorder (also claimed as adjustment disorder) 10% varicose veins, right lower extremity (also claimed as venous reflux disease) 10% 10% degenerative arthritis of the spine to include lumbago, lumbar spondylosis and myofascial pain syndrome (claimed as lumbar bulging disc l4-l5) 50% sinusitis (claimed as chronic pansinusitis) 20% carpal tunnel syndrome, right upper extremity to include lower radicular group and cubital tunnel syndrome post excision of arteriovenous malformation (also claimed as peripheral nerve injury shoulder, neuritis median nerve right arm) 0% carpal metacarpal arthritis, right hand (claimed as osteoarthritis right hand) 0% vasomotor rhinitis (also claimed as nasal polyps) 30% headache syndrome to include occipital neuralgia (claimed as migraine headaches and occipital nerve impingement) 20% status post cervical vertebral fusion C4-C6 to include myofascial pain syndrome (claimed as herniated disc (c5-c6) left, cervical spondylosis) 0% radiculopathy, left upper extremity  0% lliotibial band friction syndrome, right thigh 0% ganglion cyst, left wrist (claimed as ganglion left/right wrist) 0% meralgia paresthetica, right lower extremity 10% seborrheic dermatitis 10% Service Connected 50% obstructive sleep apnea 10% left peroneal neuropathy (claimed as deep peroneal nerve atrophy) 10% varicose veins, left lower extremity (also claimed as venous reflux disease)
  24. I got a letter a week ago that the VA wants to reduce the rating I currently have for Degenerative Arthritis of the Spine from 20% to 10%. I have had the 20% rating for over 5 years. The disability is the result of an injury that occurred when I was in the military and is well documented. I have prepared a statement contesting the reduction, but I'd like someone to read through it to see if I could be messing anything up. This is my first post here, so I'm not sure if this is a valid request for these forums. Here is the statement I have so far. Any advice or information is appreciated. -------------------------------------------------------------------------------- This statement is in response to the proposed reduction of my disability rating for thoracic spine degenerative joint disease with kyphoscoliosis from 20% to 10%. As stated in §4.71a—Schedule of Ratings–Musculoskeletal System, The Spine, “muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis” are to be rated at 20%. The presence of kyphoscoliosis, caused by the muscle spasms and guarding which resulted from my injury, should continue to be rated at 20%, as indicated in the aforementioned Schedule of Ratings. Additionally, my current rating of 20% for thoracic spine degenerative joint disease with kyphoscoliosis has been in effect for over five years and is thus afforded ‘Protection of 5-year stabilized ratings’ as stated in 38 CFR Part 5, § 5.171. Under this protection, the rating cannot be reduced without showing Material improvement. For the following reasons, Material Improvement, as detailed in 38 CFR Part 5, § 5.171 (c), has not been shown: During the VA Examination, dated January 20, 2016, the VA examiner did not use any medical instrument to measure the combined range of motion of the thoracolumbar spine or the forward flexion of the thoracolumbar spine. Therefore, there is no evidence that the measurements taken during the VA Examination, dated November 28, 2014, represent a sustainable material improvement. I have discussed my incapacitating exacerbations with muscle spasms with my VA primary care doctor during every checkup and continue to receive medication to treat these episodes. There has been no sustained improvement in either the frequency or the severity of these incapacitating exacerbations and, due to recent restrictions on medications I can take (explained below), there has been an increase in the daily pain, inflammation, and muscle spasms that I experience. Between once and twice a month, an incapacitating exacerbation is triggered by events as common place as moving laundry from the washer into the dryer, putting a trash bag into the alley dumpster or picking up one of my kids, indicating that no improvement has been maintained under the ordinary conditions of life. I have daily pain, inflammation, and muscle spasms that are a direct result of the disability discussed here. I also experience incapacitating episodes which occur an average of once to twice a month. During these episodes, my movement, strength, and mobility is severely limited for at least a full day. These episodes can be triggered by events as common place as moving laundry from the washer into the dryer, putting a trash bag into the alley dumpster, or picking up one of my kids. In the past, to manage the daily aspects of my disability, my VA primary care doctor prescribed Etodolac, a nonsteroidal anti-inflammatory drug (NSAID), to minimize the inflammation and reduce muscle spasms. Within the last few years, I was diagnosed with Kidney disease and told by my VA Nephrologist that I am no longer able to take any NSAIDs. Since I have stopped taking Etodolac, my daily pain has increased making everyday tasks more difficult and increasing the number of debilitating episodes I experience. I have also been prescribed Cyclobenzaprine, a muscle relaxant, to manage the daily aspects of my disability as well as the debilitating episodes. When taking Cyclobenzaprine I always experience drowsiness and trouble concentrating, which are documented side effects to the medication. Because of these side effects, I am not able to take Cyclobenzaprine on a regular basis to manage the daily pain, inflammation, and muscle spasms. If, after the review of the information provided above, the reviewers still hold to the decision to reduce my current rating for thoracic spine degenerative joint disease with kyphoscoliosis from 20% to 10%, then I request a personal hearing.
  25. I have been having a lot of left and right knee pain the past several months. Sometimes I get pain in left knee just standing for a few minutes and have a problem with fully extending both knees during knee exercises. I reviewed my SMRs and it is documented that I complained of left knee pain on 5 occasions while serving in the military back in the 70s and 80s. Post service medical records document 2 occasions for left knee pain. Could not find any documentation for right knee pain. I am assuming that my knee problems might be as a result of abnormal gait putting more stress on my knee joints due to established service connected disabilities listed below. I use a walking cane and a rollator walker. Recently I received an increase for Plantar Fascittis from 0% to 30%, established SC for right hip at 10% for osteoarthritis and left hip at 10% for osteoarthritis, right radiculopathy, right lower extremity sciatic nerve at 10%, and degenerative joint disease of the lumbosacral spine with spondylosis and intervertebral disc syndrome at 20% (used to be rated as Degenerative arthritis of the Thoracic and lumber spine at 10%), which brought my final degree of disability to 80%. My next visit to my VA primary care doctor is scheduled for 22 Feb 16 and my next visit to my Medicare primary care doctor is scheduled for 2 Mar 16. I intend to advise both of my knee problems at those appointments, with the hope of one of them referring me to a knee doctor or at least referring me for knee X-rays. My question is: If X-rays show a problem with my knees, should I file for direct SC for my left knee or should I file left and right knee secondary to plantar fascittis, hip osteoarthritis, and/or degenerative joint disease of the lumbosacral spine with spondylosis and intervertebral disc syndrome? Your thoughts and guidance will be greatly appreciated Dick Hill
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