C&p Exams All Done

ssgtob1 · August 25, 2014

Hi all,

I am new here and have a quick question about my C&P exams. I have many, and can copy and paste them all here if need be, but they all state: Does the Veteran's wrist condition impact his or her ability to work? [] Yes [x ] No

Does that mean that I wont be rated for any of these conditions?

NavyWife · August 25, 2014

Not necessarily.

What matters is did the doc make a statement similar to, "the veterans wrist condition is at least as likely as not related to military service".

The second thing to look at is what boxes were checked off regarding the degree of disability. Then compare those to the rating schedule for your condition.

Navy04 · August 25, 2014

As NavyWife stated bud, you will have to post the Exam Reports on here, for us to give you a reasonable idea. Good luck and keep us posted

ssgtob1 · August 25, 2014

Ok here goes:

1. Diagnosis

------------

a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes[ ] No

ICD code: 300.

If the Veteran currently has one or more mental disorders that conform to

DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Unspecified anxiety disorder

ICD code: 300.

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): none

2. Differentiation of symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes[X] No

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes[X] No[ ] Not shown in records reviewed

3. Occupational and social impairment

-------------------------------------

a. Which of the following best summarizes the Veteran's level of

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment due to mild or transient symptoms

which decrease work efficiency and ability to perform occupational

tasks only during periods of significant stress, or; symptoms

controlled by medication

b. For the indicated level of occupational and social impairment, is it

possible to differentiate what portion of the occupational and social

impairment indicated above is caused by each mental disorder?

[ ] Yes[ ] No[X] No other mental disorder has been diagnosed

c. If a diagnosis of TBI exists, is it possible to differentiate what

portion

of the occupational and social impairment indicated above is caused by

the

TBI?

[ ] Yes[ ] No[X] No diagnosis of TBI

SECTION II:

-----------

Clinical Findings:

------------------

1. Evidence review

------------------

a. Medical record review:

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?

[X] Yes[ ] No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed?

[ ] Yes[X] No

If no, check all records reviewed:

[X] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[X] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

b. Was pertinent information from collateral sources reviewed?

[ ] Yes[X] No

3. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Anxiety

[X] Chronic sleep impairment

Behavioral observations:

The veteran was seen for 45 minutes. His VBMS file was reviewed prior

to the interview. The limits of confidentiality were explained to him

and he agreed to participate in the C&P evaluation. He was alert,

fully

oriented and cooperative. He was well groomed. Mood was good, affect

was euthymic. Speech and thought content were within normal limits.

Thought processes were logical and goal-directed. No evidence or

report

of delusions or hallucinations. Memory and attention appeared grossly

intact. Insight and judgment were fair. The veteran denied current

suicidal or homicidal ideation.

4. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[X] Yes[ ] No

If yes, describe:

mild irritability

5. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes[ ] No

6. Remarks (including any testing results), if any:

---------------------------------------------------

claimed condition: Anxiety

diagnosis: unspecified anxiety disorder

rationale: meets DSM-5 criteria

prognosis: good, symptoms are mild

ssgtob1 · August 25, 2014

1. Medical history

------------------

Does the Veteran report recurrent tinnitus: Yes

Date and circumstances of onset of tinnitus: Veteran reports constant

bilateral tinnitus, left greater than right, described as a "ringing"

sound, onset in 2008 during deployment to Iraq.

2. Etiology of tinnitus

-----------------------

At least as likely as not (50% probability or greater) caused by or a result

of military noise exposure.

Rationale: Review of available service treatment records revealed the

notation "Subjective tinnitus" on a "Chronic Problems" list dated 5/21/13.

With service treatment records documentation showing diagnosis of tinnitus

during military service, it is this examiner's opinion that the veteran's

reported tinnitus is at least as likely as not related to his military

service.

3. Functional impact of tinnitus

--------------------------------

Does the Veteran's tinnitus impact ordinary conditions of daily life,

including ability to work: No

4. Remarks, if any, pertaining to tinnitus:

-------------------------------------------

CLAIMED CONDITION: TINNITUS

DIAGNOSIS: TINNITUS

RATIONALE: SERVICE TREATMENT RECORDS AND VETERAN'S REPORT AT THIS

C&P

EXAM

PROGNOSIS: GOOD

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran's

application.

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever been diagnosed with a headache

condition?

[X] Yes [ ] No

[X] Migraine including migraine variants

ICD code: 346.10 Date of diagnosis: July 2006

2. Medical History

------------------

a. Describe the history (including onset and course) of the Veteran's

headache conditions (brief summary):

Pt states onset of headaches after head injury in 2005. Headaches

described as (no aura) left frontal throbbing associated with nausea

(rare emesis) with photophobia. Frequency is once per wk and last all

day without treatment. MOtrin helps moderately. Pt states he can work

through headaches but be prefers to lie down. Review of C-file notes

7/17/06 evaluation after hit head on jet flap with laceration to top of

head (4cm requiring sutures) with complaint of headache but no

dizziness/nausea/emesis. States no loss of consciousness occurred and

pt fully oriented with nonfocal exam. Diagnosis was open wound to

scalp

and headache. Pt seen for suture removals on 7/24/06 and again on

8/26/06 still complaining of headache related to above event.

b. Does the Veteran's treatment plan include taking medication for the

diagnosed condition?

[X] Yes [ ] No

If yes, describe treatment (list only those medications used for the

diagnosed condition):

prn motrin

3. Symptoms

-----------

a. Does the Veteran experience headache pain?

[X] Yes [ ] No

[X] Pulsating or throbbing head pain

[X] Pain localized to one side of the head

[X] Pain worsens with physical activity

b. Does the Veteran experience non-headache symptoms associated with

headaches? (including symptoms associated with an aura prior to headache

pain)

[X] Yes [ ] No

[X] Nausea

[X] Vomiting

[X] Sensitivity to light

c. Indicate duration of typical head pain

[X] Less than 1 day

d. Indicate location of typical head pain

[X] Left side of head

4. Prostrating attacks of headache pain

---------------------------------------

a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating

attacks of migraine / non-migraine headache pain?

[X] Yes [ ] No

If yes, indicate frequency, on average, of prostrating attacks over the

last several months:

[X] Once every month

b. Does the Veteran have very prostrating and prolonged attacks of

migraines/non-migraine pain productive of severe economic inadaptability?

[ ] Yes [X] No

5. Other pertinent physical findings, complications, conditions, signs

and/or

symptoms

-----------------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[X] Yes [ ] No

If yes, describe (brief summary):

A/OX3, MMSE 30/30, speech nl

Fundi sharp discs (no OS disc pallor)

Cranial nerves 2-12 grossly intact except OS esophoria, Visual fields

full, Pupils equal/round/reactive to light; no relative afferent

pupillary defect

Motor nl with nl tone

Sensory normal PP throughout except decreased PP over left lateral 1/2

great toe and between lateral 1/2 of 2nd toe and medial 1/2 3rd toe

Coord nl finger to nose/heel to shin bilaterally

Gait nl with nl romberg/tandem

Deep tendon reflexes trace - 1+ symmetric with bilat flexor plantar

responses

+ tinels bilat wrist and left elbow; + phalens bilat

7. Functional impact

--------------------

Does the Veteran's headache condition impact his or her ability to work?

[ ] Yes [X] No

8. Remarks, if any:

-------------------

Claimed Condition: Headache syndrome

Onset: 2006

Diagnosis: migraine without aura

Rationale: history/exam/C-file review

Prognosis: unknown

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran have a peripheral nerve condition or peripheral neuropathy?

[X] Yes [ ] No

Diagnosis #1: bilateral carpal tunnel syndrome (mild)

ICD code: 354.0

Date of diagnosis: Aug 2014

Diagnosis #2: left toes digital neuropathy (mild)

ICD code: 955.6

Date of diagnosis: Aug 2014

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

peripheral nerve condition (brief summary):

Pt states claim of lower extremity bilateral numbness refers to left

>

right entire toes on left and right great toe paresthesias constant

since 2006. Pt states no aggravating features and never seeked medical

attention for this specifically. Pt also states in hands equally in

both palmar surfaces involving all fingers which is episodic but daily

since 2009. Pt states typing can trigger symptoms and resolves within

minutes of stop typing. Pt states never treated with splints and no

EMG

for these conditions.

b. Dominant hand

[ ] Right [X] Left [ ] Ambidextrous

3. Symptoms

-----------

a. Does the Veteran have any symptoms attributable to any peripheral nerve

conditions?

[X] Yes [ ] No

Constant pain (may be excruciating at times)

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Intermittent pain (usually dull)

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Paresthesias and/or dysesthesias

Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Numbness

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

4. Muscle strength testing

--------------------------

a. Rate strength according to the following scale:

0/5 No muscle movement

1/5 Palpable or visible muscle contraction, but no joint movement

2/5 Active movement with gravity eliminated

3/5 Active movement against gravity

4/5 Active movement against some resistance

5/5 Normal strength

Elbow flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Elbow extension:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Wrist flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Wrist extension:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Grip:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Pinch (thumb to index finger):

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Knee extension:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Ankle plantar flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Ankle dorsiflexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

b. Does the Veteran have muscle atrophy?

[ ] 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

Biceps:

Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Triceps:

Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Brachioradialis:

Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Knee:

Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Ankle:

Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+

6. Sensory exam

---------------

Indicate results for sensation testing for light touch:

Shoulder area (C5):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Inner/outer forearm (C6/T1):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Hand/fingers (C6-8):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Upper anterior thigh (L2):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Thigh/knee (L3/4):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [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: [ ] Normal [X] Decreased [ ] Absent

7. Trophic changes

------------------

Does the Veteran have trophic changes (characterized by loss of extremity

hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy?

[ ] Yes [X] No

8. Gait

-------

Is the Veteran's gait normal?

[X] Yes [ ] No

9. Special tests for median nerve

---------------------------------

Were special tests indicated and performed for median nerve evaluation?

[X] Yes [ ] No

Phalen's sign:

Right: [X] Positive [ ] Negative

Left: [X] Positive [ ] Negative

Tinel's sign:

Right: [X] Positive [ ] Negative

Left: [X] Positive [ ] Negative

10. Nerves Affected: Severity evaluation for upper extremity nerves and

radicular groups

-----------------------------------------------------------------------

a. Radial nerve (musculospiral nerve)

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

b. Median nerve

Right: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis

If Incomplete paralysis is checked, indicate severity:

[X] Mild [ ] Moderate [ ] Severe

Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis

If Incomplete paralysis is checked, indicate severity:

[X] Mild [ ] Moderate [ ] Severe

c. Ulnar nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

d. Musculocutaneous nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

e. Circumflex nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

f. Long thoracic nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

g. Upper radicular group (5th & 6th cervicals)

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

h. Middle radicular group

Right [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

i. Lower radicular group

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

11. Nerves Affected: Severity evaluation for lower extremity nerves

-------------------------------------------------------------------

a. Sciatic nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

b. External popliteal (common peroneal) nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

c. Musculocutaneous (superficial peroneal) nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

d. Anterior tibial (deep peroneal) nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

e. Internal popliteal (tibial) nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

f. Posterior tibial nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

g. Anterior crural (femoral) nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

h. Internal saphenous nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

i. Obturator nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

j. External cutaneous nerve of the thigh

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

k. Ilio-inguinal nerve

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

12. Assistive devices

---------------------

a. Does the Veteran use any assistive devices as a normal mode of

locomotion,

although occasional locomotion by other methods may be possible?

[ ] Yes [X] No

13. Remaining effective function of the extremities

---------------------------------------------------

Due to peripheral nerve conditions, is there functional impairment of an

extremity such that no effective function remains other than that which

would

be equally well served by an amputation with prosthesis? (Functions of the

upper extremity include grasping, manipulation, etc., while functions for

the

lower extremity include balance and propulsion, etc.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

14. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

-----------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms?

[X] Yes [ ] No

If yes, describe (brief summary):

A/OX3, MMSE 30/30, speech nl

Fundi sharp discs (no OS disc pallor)

Cranial nerves 2-12 grossly intact except OS esophoria, Visual

fields full, Pupils equal/round/reactive to light; no relative

afferent pupillary defect

Motor nl with nl tone

Sensory normal PP throughout except decreased PP over left lateral

1/2 great toe and between lateral 1/2 of 2nd toe and medial 1/2 3rd

toe

Coord nl finger to nose/heel to shin bilaterally

Gait nl with nl romberg/tandem

Deep tendon reflexes trace - 1+ symmetric with bilat flexor plantar

responses

+ tinels bilat wrist and left elbow; + phalens bilat

15. Diagnostic testing

----------------------

a. Have EMG studies been performed?

[ ] Yes [X] No

b. Are there any other significant diagnostic test findings and/or results?

[ ] Yes [X] No

16. Functional impact

---------------------

Does the Veteran's peripheral nerve condition and/or peripheral neuropathy

impact his or her ability to work?

[ ] Yes [X] No

17. Remarks, if any:

--------------------

Claimed Condition: lower extremity bilateral numbness

Onset: 2006

Diagnosis: left toes digital neuropathy (mild)

Rationale: history/exam/C-file review. Note: a right lower extremity

neuropathy was not identified to explain Veteran's claimed complaints.

No diagnosis is established.

Prognosis: unknown

Claimed Condition: bilateral hand paresthesias (new claim)

Onset: 2009

Diagnosis: bilateral carpal tunnel syndrome (mild)

Rationale: history/exam

Prognosis: unknown

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever had a traumatic brain injury

(TBI) or any residuals of a TBI? (This is the condition the Veteran is

claiming or for which an exam has been requested)

[X] Yes [ ] No

[X] Traumatic brain injury (TBI)

ICD code: 850.9

Date of diagnosis: July 2006

2. Medical history

------------------

Describe the history (including onset and course) of the Veteran's TBI and

residuals attributable to TBI (brief summary):

33 LH M served in USAF from Jan 2004 to May 2014. Pt states suffered a

concussion in 2005 hit on head by part of F-16 wing at Edwards AFB. Pt

states loss of consciousness for 2-3 minutes and next recalls being

assisted by others and taken to local clinic for head wound requiring

staples. Pt states told had mild concussion due to headache/nausea which

lasted days. Pt states residuals from this injury were headaches. Rank

at time of event was E-3 and left service as E-5. Pt states never

evaluated by military TBI clinic.

Review of C-file notes 7/17/06 evaluation after hit head on jet flap with

laceration to top of head (4cm requiring sutures) with complaint of

headache but no dizziness/nausea/emesis. States no loss of consciousness

occurred and pt fully oriented with nonfocal exam. Diagnosis was open

wound to scalp and headache. Pt seen for suture removals on 7/24/06 and

again on 8/26/06 still complaining of headache related to above event.

SECTION II: Assessment of facets of TBI-related cognitive impairment and

subjective symptoms of TBI

-----------------------------------------------------------------------------

1. Memory, attention, concentration, executive functions

--------------------------------------------------------

[X] No complaints of impairment of memory, attention, concentration, or

executive functions

2. Judgment

-----------

[X] Normal

3. Social interaction

---------------------

[X] Social interaction is routinely appropriate

4. Orientation

--------------

[X] Always oriented to person, time, place, and situation

5. Motor activity (with intact motor and sensory system)

--------------------------------------------------------

[X] Motor activity normal

6. Visual spatial orientation

-----------------------------

[X] Normal

7. Subjective symptoms

----------------------

[X] No subjective symptoms

8. Neurobehavioral effects

--------------------------

[X] No neurobehavioral effects

9. Communication

----------------

[X] Able to communicate by spoken and written language (expressive

communication) and to comprehend spoken and written language.

10. Consciousness

-----------------

[X] Normal

SECTION III: Additional residuals, other findings, diagnostic testing,

functional impact and remarks

-----------------------------------------------------------------------------

1. Residuals

------------

Does the Veteran have any subjective symptoms or any mental, physical or

neurological conditions or residuals attributable to a TBI (such as migraine

headaches or Meniere's disease)?

[X] Yes [ ] No

If yes, check all that apply:

[X] Headaches, including Migraine headaches

2. Other pertinent physical findings, scars, complications, conditions,

signs

and/or symptoms

-----------------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms?

[X] Yes [ ] No

If yes, describe (brief summary):

A/OX3, MMSE 30/30, speech nl

Fundi sharp discs (no OS disc pallor)

Cranial nerves 2-12 grossly intact except OS esophoria, Visual fields

full, Pupils equal/round/reactive to light; no relative afferent

pupillary

defect

Motor nl with nl tone

Sensory normal PP throughout except decreased PP over left lateral 1/2

great toe and between lateral 1/2 of 2nd toe and medial 1/2 3rd toe

Coord nl finger to nose/heel to shin bilaterally

Gait nl with nl romberg/tandem

Deep tendon reflexes trace - 1+ symmetric with bilat flexor plantar

responses

+ tinels bilat wrist and left elbow; + phalens bilat

no scalp scar noted

3. Diagnostic testing

---------------------

a. Has neuropsychological testing been performed?

[ ] Yes [X] No

b. Are there any other significant diagnostic test findings and/or results?

[X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief

summary):

Exam Date/Time

07/19/2006 15:22

Procedure Name

SKULL SERIES (3)

Report

SKULL SERIES (3)

4. Functional impact

--------------------

Do any of the Veteran's residual conditions attributable to a traumatic

brain

injury impact his or her ability to work?

[ ] Yes [X] No

5. Remarks, if any:

-------------------

Claimed Condition: Status post concussion

Onset: 2006

Diagnosis: mild traumatic brain injury

Rationale: History/exam/C-file. Note: only TBI residuals are migraine

headaches

Prognosis: unknown

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever had an ankle condition?

[X] Yes [ ] No

If yes, provide only diagnoses that pertain to ankle condition(s):

Diagnosis #1: Ankle sprain

ICD code: 845

Date of diagnosis: 2005/2006

Side affected: [ ] Right [ ] Left [X] Both

Diagnosis #2: Arthritis

ICD code: 715

Date of diagnosis: 2014

Side affected: [X] Right [ ] Left [ ] Both

2. Medical history

------------------

Describe the history (including onset and course) of the Veteran's ankle

condition (brief summary):

The Veteran's right ankle pain started in 2005. He reports that he

sprained right ankle and was treated with R.I.C.E. measures. He continues

to roll his right ankle and has pain with prolonged walking. X rays done

for this exam show arthritis of the right ankle.

The Veteran's left ankle pain started in 2006. He reports that he

sprained

his ankle while climbing a ladder into a F 16. He was treated with

R.I.C.E. measures and now experiences minor pain in his left ankle.

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the ankle?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in

his or her own words:

The Veteran reports that his bilateral ankle pain will flare up with

prolonged walking.

4. Initial range of motion (ROM) measurements:

----------------------------------------------

a. Right ankle plantar flexion

Plantar flexion ends (normal endpoint is 45 degrees): 15

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

b. Right ankle dorsiflexion (extension)

Dorsiflexion (extension) ends (normal endpoint is 20 degrees): 15

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 or greater

c. Left ankle plantar flexion

Plantar flexion ends (normal endpoint is 45 degrees): 45

Select where objective evidence of painful motion begins:

[X] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

d. Left ankle plantar dorsiflexion (extension)

Dorsiflexion (extension) ends (normal endpoint is 20 degrees): 20

Select where objective evidence of painful motion begins:

[X] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 or greater

e. If ROM does not conform to the normal range of motion identified above

but

is normal for this Veteran (for reasons other than an ankle condition,

such as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurements after repetitive use testing

------------------------------------------------

Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

a. Right ankle post-test ROM

Post-test plantar flexion ends: 15

Post-test dorsiflexion (extension) ends: 15

b. Left ankle post-test ROM

Post-test plantar flexion ends: 45

Post-test dorsiflexion (extension) ends: 20

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the ankle following

repetitive-use testing?

[ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of

the ankle?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment and/or

additional limitation of ROM of the ankle after repetitive use, indicate

the contributing factors of disability below (check all that apply and

indicate side affected):

[X] Less movement than normal [X] Right [ ] Left [ ] Both

[X] Pain on movement [X] Right [ ] Left [ ] Both

7. Pain (pain on palpation)

---------------------------

Does the Veteran have localized tenderness or pain on palpation of

joints/soft tissue of either ankle?

[X] Yes [ ] No

If yes, indicate side affected: [ ] Right [ ] Left [X] Both

8. Muscle strength testing

--------------------------

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

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

9. Joint stability

------------------

a. Anterior drawer test

Is there laxity compared with opposite side?

[ ] Yes [X] No [ ] Unable to test

b. Talar tilt test (inversion/eversion stress)

Is there laxity compared with opposite side?

[ ] Yes [X] No [ ] Unable to test

10. Ankylosis

-------------

Does the Veteran have ankylosis of the ankle, subtalar and/or tarsal joint?

[ ] Yes [X] No

11. Additional conditions

-------------------------

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

12. Joint replacement and other surgical procedures

----------------------------------------------------

a. Has the Veteran had a total ankle joint replacement?

[ ] Yes [X] No

b. Has the Veteran had arthroscopic or other ankle surgery?

[ ] Yes [X] No

c. Does the Veteran have any residual signs and/or symptoms due to

arthroscopic or other ankle surgery?

[ ] Yes [X] No

13. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

------------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[ ] Yes [X] No

14. 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

15. Remaining effective function of the extremities

----------------------------------------------------

Due to the Veteran's ankle 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

16. Diagnostic Testing

-----------------------

a. Have imaging studies of the ankle been performed and are the results

available?

[X] Yes [ ] No

If yes, are there abnormal findings?

[X] Yes [ ] No

If yes, indicate findings:

[X] Degenerative or traumatic arthritis

ankle: [X] Right [ ] Left [ ] Both

b. Are there any other significant diagnostic test findings and/or results?

[ ] Yes [X] No

17. Functional impact

----------------------

Does the Veteran's ankle condition impact his or her ability to work?

[ ] Yes [X] No

18. REMARKS

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Right ankle sprain

Diagnosis: Bilateral ankle sprain, Right ankle degenerative Arthritis

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

ssgtob1 · August 25, 2014

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

Diagnosis #1: lumbar strain

ICD code: 847.2

Date of diagnosis: 2006

2. Medical history

------------------

Describe the history (including onset and course) of the Veteran's

thoracolumbar spine (back) condition (brief summary):

The Veteran's back pain started in 2006. He reports that while bending he

started to experience back pain. He was seen and given pain medication

and then was treated with physical therapy, traction, and a tens unit.

He now sees a chiropractor as needed. He had a MRI of his back that

revealed disc disease. He reports that his pain will experience numbness

and tingling shooting into his left leg.

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the

thoracolumbar spine (back)?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in

his or her own words:

The Veteran reports that his back pain will flare up with prolonged

sitting and bending. He takes Motrin, mobic and naproxyn as needed for

pain and has relief with laying down.

4. Initial range of motion (ROM) measurement

--------------------------------------------

a. Select where forward flexion ends (normal endpoint is 90):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45

[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70

[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45

[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70

[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater

b. Select where extension ends (normal endpoint is 30):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20

[ ] 25 [ ] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20

[ ] 25 [ ] 30 or greater

c. Select where right lateral flexion ends (normal endpoint is 30):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [X] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [X] 30 or greater

d. Select where left lateral flexion ends (normal endpoint is 30):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [X] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [X] 30 or greater

e. Select where right lateral rotation ends (normal endpoint is 30):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 or greater

f. Select where left lateral rotation ends (normal endpoint is 30):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 or greater

g. If ROM for this Veteran does not conform to the normal range of motion

identified above but is normal for this Veteran (for reasons other than a

back condition, such as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurement after repetitive use testing

-----------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

b. Select where post-test forward flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [X] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater

c. Select where post-test extension ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or

greater

d. Select where post-test right lateral flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or

greater

e. Select where post-test left lateral flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or

greater

f. Select where post-test right lateral rotation ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or

greater

g. Select where post-test left lateral rotation ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30 or

greater

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the thoracolumbar

spine (back) following repetitive-use testing?

[ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of

the thoracolumbar spine (back)?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment and/or

additional limitation of ROM of the thoracolumbar spine (back) after

repetitive use, indicate the contributing factors of disability below:

[X] Less movement than normal

[X] Excess fatigability

[X] Incoordination, impaired ability to execute skilled movements

smoothly

[X] Pain on movement

7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)

----------------------------------------------------------------------------

a. Does the Veteran have localized tenderness or pain to palpation for

joints

and/or soft tissue of the thoracolumbar spine (back)?

[X] Yes [ ] No

If yes, describe:

The lumbar spine is tender to palpation.

b. Does the Veteran have muscle spasm of the thoracolumbar spine resulting

in

abnormal gait or abnormal spinal countour?

[ ] Yes [X] No

c. Does the Veteran have muscle spasms of the thoracolumbar spine not

resulting in abnormal gait or abnormal spinal countour?

[X] Yes [ ] No

d. Does the Veteran have guarding of the thoracolumbar spine resulting in

abnormal gait or abnormal spinal countour?

[ ] Yes [X] No

e. Does the Veteran have guarding of the thoracolumbar spine not resulting

in

abnormal gait or abnormal spinal countour?

[X] Yes [ ] No

8. 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

9. 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+

10. 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

11. Straight leg raising test

-----------------------------

Provide straight leg raising test results:

Right: [X] Negative [ ] Positive [ ] Unable to perform

Left: [ ] Negative [X] Positive [ ] Unable to perform

12. 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: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Paresthesias and/or dysesthesias

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Numbness

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left 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)

No response provided.

d. Indicate severity of radiculopathy and side affected:

Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe

Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe

13. Ankylosis

-------------

Is there ankylosis of the spine? [ ] Yes [X] No

14. 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

15. Intervertebral disc syndrome (IVDS) and incapacitating episodes

-------------------------------------------------------------------

a. Does the Veteran have IVDS of the thoracolumbar spine?

[ ] Yes [X] No

16. 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

17. 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

18. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

-----------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms?

[ ] Yes [X] No

19. 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

20. Functional impact

---------------------

Does the Veteran's thoracolumbar spine (back) condition impact on his or her

ability to work?

[ ] Yes [X] No

21. REMARKS

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Lower back strain

Diagnosis: Lumbar strain

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever had a hand or finger condition?

[X] Yes [ ] No

Diagnosis #1: Hand strain

ICD code: 842.10

Date of diagnosis: 2005

Side affected: [ ] Right [ ] Left [X] Both

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's hand

condition (brief summary):

The Veteran has a history of pain in both of his hands starting in 2005.

He denies any injury to his hands and reports that he would experience

pain, stiffness and cranking in both of his hands that increases with

gripping, and twisting with his hands. He reports that he was seen and

had X rays and lab work that was normal. He has not had any further

treatment for this condition.

b. Dominant hand:

[ ] Right [X] Left [ ] Ambidextrous

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the hand?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in

his or her own words:

The Veteran's bilateral hand pain will flare up with gripping

things,

twisting to open jars and using hand tools.

4. Initial range of motion (ROM) measurements

---------------------------------------------

a. Is there limitation of motion or evidence of painful motion for any

fingers or thumbs?

[X] Yes [ ] No

If yes, indicate digits affected (check all that apply):

Right:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

Left:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

b. Ability to oppose thumb: Is there a gap between the thumb pad and the

fingers?

[ ] Yes [X] No

c. Finger flexion: Is there a gap between any fingertips and the proximal

transverse crease of the palm or evidence of painful motion in attempting

to touch the palm with the fingertips?

[X] Yes [ ] No

If yes, indicate the gap:

[X] Gap 1 inch (2.5 cm) or more

Indicate fingers affected (check all that apply):

Right:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

Left:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

Select where objective evidence of painful motion begins:

[X] Painful motion begins at a gap of 1 inch (2.5 cm) or more

Indicate fingers affected (check all that apply):

Right:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

Left:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

d. Finger extension: Is there limitation of extension or evidence of painful

motion for the index finger or long finger?

[ ] Yes [X] No

5. ROM measurements after repetitive use testing

------------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

b. Is there additional limitation of motion for any fingers post-test?

[ ] Yes [X] No

c. Ability to oppose thumb: Is there a gap between the thumb pad and the

fingers post-test?

[ ] Yes [X] No

d. Finger flexion: Is there a gap between any fingertips and the proximal

transverse crease of the palm in attempting to touch the palm with the

fingertips post-test?

[X] Yes [ ] No

If yes, indicate the gap:

[X] Gap 1 inch (2.5 cm) or more

Indicate fingers affected (check all that apply):

Right:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

Left:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

e. Finger extension: Is there limitation of extension for the index finger

or

long finger post-test?

[ ] Yes [X] No

6. Functional loss and additional limitation of ROM

---------------------------------------------------

a. Does the Veteran have any functional loss or functional impairment of any

of the fingers or thumbs?

[X] Yes [ ] No

b. Does the Veteran have additional limitation in ROM of any of the fingers

or thumbs following repetitive-use testing?

[ ] Yes [X] No

c. If the Veteran has functional loss, functional impairment or additional

limitation of ROM of any of the fingers or thumbs after repetitive use,

indicate the contributing factors of disability below (check all that

apply; indicate digit and side affected):

[X] Less movement than normal

Right:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

Left:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

[X] Pain on movement

Right:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

Left:

[X] Index finger

[X] Long finger

[X] Ring finger

[X] Little finger

7. Pain (pain on palpation)

---------------------------

Does the Veteran have tenderness or pain to palpation for joints or soft

tissue of either hand, including thumb and fingers?

[X] Yes [ ] No

If yes, side affected: [ ] Right [ ] Left [X] Both

8. Muscle strength testing

--------------------------

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

Hand grip:

Right:[X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

9. Ankylosis

------------

a. Does the Veteran have ankylosis of the thumb and/or fingers?

[ ] Yes [X] No

c. Does the ankylosis condition result in limitation of motion of other

digits or interference with overall function of the hand?

[ ] Yes [X] No

10. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

------------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[ ] Yes [X] No

11. Assistive devices and remaining function of the extremities

---------------------------------------------------------------

a. Does the Veteran use any assistive devices?

[ ] Yes [X] No

12. Remaining effective function of the extremities

----------------------------------------------------

Due to the Veteran's hand, finger or thumb conditions, is there

functional

impairment of an extremity such that no effective function remains other

than that which would be equally well served by an amputation with

prosthesis? (Functions of the upper extremity include grasping,

manipulation, etc., while functions for the lower extremity include

balance and propulsion, etc.)

[ ] Yes, functioning is so diminished that amputation with prosthesis

would equally serve the Veteran.

[X] No

13. Diagnostic Testing

-----------------------

a. Have imaging studies of the hands been performed and are the results

available?

[X] Yes [ ] No

If yes, are there abnormal findings?

[ ] Yes [X] No

b. Are there any other significant diagnostic test findings or results?

[ ] Yes [X] No

14. Functional impact

---------------------

Do the Veteran's hand, thumb, or finger conditions impact his or her ability

to work?

[ ] Yes [X] No

15. Remarks

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Bilateral hands arthritis

Diagnosis: Bilateral hand strain

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever had a hip and/or thigh

condition?

[X] Yes [ ] No

Diagnosis #1: Hip sprain

ICD code: 843.8

Date of diagnosis: 2006

Side affected: [X] Right [ ] Left [ ] Both

2. Medical history

------------------

Describe the history (including onset and course) of the Veteran's current

hip/thigh condition(s) (brief summary):

The Veteran reports a history of right hip pain starting in 2006. He

reports that he was involved in a motor cycle accident and injured his

right hip. He was seen and treated with Motrin. The Veteran reports that

he continues to have pain in his right hip with squatting, prolonged

sitting and twisting. He reports that he takes medication as needed for

pain.

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the hip and/or

thigh?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in

his or her own words:

The Veteran reports that his right hip pain will flare up with

squatting, prolonged sitting and twisting. He will change positions,

stretch and take medication as needed for pain.

4. Initial range of motion (ROM) measurements

---------------------------------------------

a. Right hip flexion

Select where flexion ends (normal endpoint is 125 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [X] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ]

100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [X] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 or greater

b. Right hip extension

Select where extension ends:

[ ] 0 [ ] 5 [X] Greater than 5

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [X] Greater than 5

Is abduction lost beyond 10 degrees?

[ ] Yes [X] No

Is adduction limited such that the Veteran cannot cross legs?

[ ] Yes [X] No

Is rotation limited such that the Veteran cannot toe-out more than 15

degrees?

[ ] Yes [X] No

c. Left hip flexion

No response provided.

d. Left hip extension

No response provided.

e. If ROM does not conform to the normal range of motion identified above

but

is normal for this Veteran (for reasons other than a hip condition, such

as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurements after repetitive use testing

------------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

b. Right hip post-test ROM

Select where post-test flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [X] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 or greater

Select where post-test extension ends:

[ ] 0 [X] 5 or greater

Is post-test abduction lost beyond 10 degrees?

[ ] Yes [X] No

Is post-test adduction limited such that the Veteran cannot cross

legs?

[ ] Yes [X] No

Is post-test rotation limited such that the Veteran cannot toe-out

more

than 15 degrees?

[ ] Yes [X] No

c. Left hip post-test ROM

No response provided.

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the hip and thigh

following repetitive-use testing?

[ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of

the hip and thigh?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment and/or

additional limitation of ROM of the hip and thigh after repetitive use,

indicate the contributing factors of disability below (check all that

apply and indicate side affected):

[X] Less movement than normal [X] Right [ ] Left [ ] Both

[X] Excess fatigability [X] Right [ ] Left [ ] Both

[X] Pain on movement [X] Right [ ] Left [ ] Both

7. Pain (pain on palpation)

---------------------------

Does the Veteran have localized tenderness or pain to palpation for

joints/soft tissue of either hip?

[X] Yes [ ] No

If yes, side affected: [X] Right [ ] Left [ ] Both

8. Muscle strength testing

--------------------------

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

Hip abduction:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Hip extension:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

9. Ankylosis

------------

Does the Veteran have ankylosis of either hip joint?

[ ] Yes [X] No

10. Additional conditions

-------------------------

Does the Veteran have malunion or nonunion of femur, flail hip joint or leg

length discrepancy?

[ ] Yes [X] No

11. Joint replacement and other surgical procedures

---------------------------------------------------

a. Has the Veteran had a total hip joint replacement?

[ ] Yes [X] No

b. Has the Veteran had arthroscopic or other hip surgery?

[ ] Yes [X] No

c. Does the Veteran have any residual signs and/or symptoms due to

arthroscopic or other hip surgery?

[ ] Yes [X] No

12. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

-----------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[ ] Yes [X] No

13. 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

14. Remaining effective function of the extremities

---------------------------------------------------

Due to the Veteran's hip and/or thigh 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

16. Functional impact

---------------------

Does the Veteran's hip and/or thigh condition impact his or her ability to

work?

[ ] Yes [X] No

17. Remarks

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Right hip strain

Diagnosis: Right hip strain

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

External rotation: 40 degrees right hip

Internal rotation: 20 degrees right hip

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever had a knee and/or lower leg

condition?

[X] Yes [ ] No

Diagnosis #1: Patellofemoral syndrome left knee

ICD code: 719.46

Date of diagnosis: 2005/2010

Side affected: [ ] Right [ ] Left [X] Both

Diagnosis #2: Bakers cyst

ICD code: 727.51

Date of diagnosis: 2010

Side affected: [ ] Right [X] Left [ ] Both

Diagnosis #3: Patellar tendonitis

ICD code: 726.64

Date of diagnosis: 2010

Side affected: [ ] Right [X] Left [ ] Both

If there are additional diagnoses that pertain to knee and/or lower

leg

conditions, list using above format:

Right knee degenerative arthritis 715 2014

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's knee

and/or lower leg condition (brief summary):

The Veteran's right knee pain started in 2005. He reports that he

would

experience pain in his right knee with running and was diagnosed with

patellofemoral syndrome. He was treated with RICE measures. X rays

done

for this exam show degenerative chages of the right knee tibial spine.

The Veteran's left knee pain started in 2010 following his motorcycle

accident. He denies any injury to his knee but reports that he was

experience pain with going up and down the stairs, kneeling and

running. He was seen in 2010 and was diagnosed with a left knee

bakers

cyst, patellofemoral syndrome, and patella tendonitis as well. The

Veteran underwent physical therapy which did not help. He then had a

lateral plica excision and synovectomy in 2011. He reports that his

knee pain was worse after his knee surgery. He continues to have left

knee pain. He was given a prescription knee brace to use as needed

knee

for his left knee pain.

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the knee

and/or

lower leg?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups

in his or her own words

The Veteran reports that his knee pain will flare up prolonged

walking, going up and down stairs and running.

4. Initial range of motion (ROM) measurements

---------------------------------------------

a. Right knee flexion

Select where flexion ends (normal endpoint is 140 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater

b. Right knee extension

Select where extension ends:

[X] 0 or any degree of hyperextension (check this box if there is

no

limitation of extension)

Select where objective evidence of painful motion begins:

[X] 0 or any degree of hyperextension (check this box if there is

no

limitation of extension)

c. Left knee flexion

Select where flexion ends (normal endpoint is 140 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [X] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 or greater

d. Left knee extension

Select where extension ends:

Unable to fully extend; extension ends at:

[X] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

Select where objective evidence of painful motion begins:

Or, painful motion on extension begins at:

[X] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

e. If ROM does not conform to the normal range of motion identified above

but

is normal for this Veteran (for reasons other than a knee and/or leg

condition, such as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurements after repetitive use testing

------------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

b. Right knee post-test ROM

Select where post-test flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater

Select where post-test extension ends:

[X] 0 or any degree of hyperextension (check this box if there is

no

limitation of extension)

c. Left knee post-test ROM

Select where post-test flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 [ ] 85

[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115

[ ] 120 [ ] 125 [ ] 130 [ ] 135 [X] 140 or greater

Unable to fully extend; extension ends at:

[X] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the knee and lower

leg following repetitive-use testing?

[ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of

the knee and lower leg?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment or additional

limitation of ROM of the knee and lower leg after repetitive use,

indicate

the contributing factors of disability below (check all that apply and

indicate side affected):

[X] Excess fatigability [ ] Right [X] Left [ ] Both

[X] Pain on movement [ ] Right [ ] Left [X] Both

[X] Swelling [ ] Right [X] Left [ ] Both

[X] Disturbance of locomotion [ ] Right [X] Left [ ] Both

7. Pain (pain on palpation)

---------------------------

Does the Veteran have tenderness or pain to palpation for joint line or soft

tissues of either knee?

[X] Yes [ ] No

If yes, side affected: [ ] Right [X] Left [ ] Both

8. Muscle strength testing

--------------------------

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

Knee 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

9. Joint stability tests

------------------------

a. Anterior instability (Lachman test):

Right: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

Left: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

b. Posterior instability (Posterior drawer test):

Right: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

Left: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

c. Medial-lateral instability (Apply valgus/varus pressure to knee in

extension and 30 degrees of flexion):

Right: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

Left: [X] Normal [ ] 1+ (0-5 millimeters)

[ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters)

10. Patellar subluxation/dislocation

------------------------------------

Is there evidence or history of recurrent patellar subluxation/dislocation?

[ ] Yes [X] No

11. Additional conditions

-------------------------

Does the Veteran now have or has he or she ever had "shin splints" (medial

tibial stress syndrome), stress fractures, chronic exertional compartment

syndrome or any other tibial and/or fibular impairment?

[ ] Yes [X] No

12. Meniscal conditions and meniscal surgery

--------------------------------------------

Has the Veteran had any meniscal conditions or surgical procedures for a

meniscal condition?

[ ] Yes [X] No

13. Joint replacement and other surgical procedures

---------------------------------------------------

a. Has the Veteran had a total knee joint replacement?

[ ] Yes [X] No

b. Has the Veteran had arthroscopic or other knee surgery not described

above?

[X] Yes [ ] No

If yes, indicate side affected: [ ] Right [X] Left [ ] Both

Date and type of surgery: 2011 Plica excision and synovectomy

c. Does the Veteran have any residual signs and/or symptoms due to

arthroscopic or other knee surgery not described above?

[X] Yes [ ] No

If yes, indicate side affected: [ ] Right [X] Left [ ] Both

Describe residuals: Chronic left knee pain

14. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

-----------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[X] Yes [ ] No

If yes, are any of the scars painful and/or unstable, or is the total

area of all related scars greater than 39 square cm (6 square

inches)?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[ ] Yes [X] No

15. Assistive devices

---------------------

a. Does the Veteran use any assistive device(s) as a normal mode of

locomotion, although occasional locomotion by other methods may be

possible?

[X] Yes [ ] No

If yes, identify assistive device(s) used (check all that apply and

indicate frequency):

Assistive Device: Frequency of use:

----------------- -----------------

[X] Brace(s) [X] Occasional [ ] Regular [ ] Constant

b. If the Veteran uses any assistive devices, specify the condition and

identify the assistive device used for each condition:

The Veteran will use a prescription knee brace as needed for his left

knee patella tendonitis.

16. 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.)

[X] No

17. 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: [X] Right [ ] Left [ ] Both

b. Does the Veteran have x-ray evidence of patellar subluxation?

[ ] 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):

18. Functional impact

---------------------

Does the Veteran's knee and/or lower leg condition(s) impact his or her

ability to work?

[ ] Yes [X] No

19. Remarks

-----------

a. Remarks, if any:

The V file was reviewed. For scar measurments see DBQ scar exam.

Claimed condition: Right knee patellofemoral syndrome, left knee patellar

tendonitis

Diagnosis: Bilateral knee patellofemoral syndrome, left knee patellar

tendonitis, right knee degenerative arthritis.

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever been diagnosed with a cervical

spine (neck) condition?

[X] Yes [ ] No

Cervical Spine Common Diagnoses:

[ ] Ankylosing spondylitis

[X] Cervical strain

[X] Degenerative arthritis of the spine

[ ] Intervertebral disc syndrome

[ ] Segmental instability

[ ] Spinal fusion

[X] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

Diagnosis #1: Cervical sprain

ICD code: 847.0

Date of diagnosis: 2005

Diagnosis #2: Cervical disc degeneration

ICD code: 722.4

Date of diagnosis: 2014

Diagnosis #3: Cervical spinal stenosis

ICD code: 723.0

Date of diagnosis: 2014

2. Medical history

------------------

Describe the history (including onset and course) of the Veteran's cervical

spine (neck) condition (brief summary):

The Veteran has a history of a head injury in 2005. He reports that while

on a F 16 he was knocked out by a piece of equipment. He reports that he

fell to the ground and has had neck pain intermittently since this time.

The Veteran reports that he was treated with medication and then referred

for physical therapy. He continues to have neck pain. X rays done for this

exam show degenerative changes and stenosis of the C spine.

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the cervical

spine (neck)?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in

his or her own words:

The Veteran reports that his neck pain will flare up with sitting and

turning his neck to much.

The Veteran's neck pain will flare up with reamining in once position

for a prolonged period of time.

4. Initial range of motion (ROM) measurements

---------------------------------------------

a. Select where forward flexion ends (normal endpoint is 45 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

b. Select where extension ends (normal endpoint is 45 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

c. Select where right lateral flexion ends (normal endpoint is 45 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

d. Select where left lateral flexion ends (normal endpoint is 45 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

[X] Other: 60

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

[X] Other: 60

e. Select where right lateral rotation ends (normal endpoint is 80 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

f. Select where left lateral rotation ends (normal endpoint is 80 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

g. If ROM does not conform to the normal range of motion identified above

but

is normal for this Veteran (for reasons other than a cervical spine

(neck)

condition, such as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurements after repetitive use testing

-------------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

b. Select where post-test forward flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

c. Select where post-test extension ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

d. Select where post-test right lateral flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

e. Select where post-test left lateral flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

[X] Other: 60

f. Select where post-test right lateral rotation ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

g. Select where post-test left lateral rotation ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the cervical spine

(neck) following repetitive-use testing?

[ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of

the cervical spine (neck)?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment and/or

additional limitation of ROM of the cervical spine (neck) after

repetitive

use, indicate the contributing factors of disability below:

[X] Less movement than normal

[X] Excess fatigability

[X] Pain on movement

7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)

----------------------------------------------------------------------------

a. Does the Veteran have localized tenderness or pain to palpation for

joints/soft tissue of the cervical spine (neck)?

[X] Yes [ ] No

b. Does the Veteran have muscle spasm of the cervical spine resulting in

abnormal gait or abnormal spinal countour?

[ ] Yes [X] No

c. Does the Veteran have muscle spasms of the cervical spine not resulting

in

abnormal gait or abnormal spinal countour?

[X] Yes [ ] No

d. Does the Veteran have guarding of the cervical spine resulting in

abnormal

gait or abnormal spinal countour?

[ ] Yes [X] No

e. Does the Veteran have guarding of the cervical spine not resulting in

abnormal gait or abnormal spinal countour?

[ ] Yes [X] No

8. Muscle strength testing

--------------------------

a. Rate strength according to the following scale:

0/5 No muscle movement

1/5 Palpable or visible muscle contraction, but no joint movement

2/5 Active movement with gravity eliminated

3/5 Active movement against gravity

4/5 Active movement against some resistance

5/5 Normal strength

Elbow flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Elbow extension

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Wrist flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Wrist extension:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Finger 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

Finger Abduction

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

9. Reflex exam

--------------

Rate deep tendon reflexes (DTRs) according to the following scale:

0 Absent

1+ Hypoactive

2+ Normal

3+ Hyperactive without clonus

4+ Hyperactive with clonus

Biceps:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Triceps:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Brachioradialis:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

10. Sensory exam

----------------

Provide results for sensation to light touch (dermatomes) testing:

Shoulder area (C5):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Inner/outer forearm (C6/T1):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Hand/fingers (C6-8):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

11. Radiculopathy

------------------

Does the Veteran have radicular pain or any other signs or symptoms due to

radiculopathy?

[X] Yes [ ] No

a. Indicate location and severity of symptoms (check all that apply):

Constant pain (may be excruciating at times)

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Intermittent pain (usually dull)

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Paresthesias and/or dysesthesias

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Numbness

Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ]

Severe

Left upper extremity: [X] None [ ] 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 C5/C6 nerve roots (upper radicular group)

d. Indicate severity of radiculopathy and side affected:

Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe

Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe

12. Ankylosis

-------------

Is there ankylosis of the spine? [ ] Yes [X] No

13. Other neurologic abnormalities

----------------------------------

Does the Veteran have any other neurologic abnormalities related to a

cervical spine (neck) condition (such as bowel or bladder problems due to

cervical myelopathy)?

[ ] Yes [X] No

14. Intervertebral disc syndrome (IVDS) and incapacitating episodes

-------------------------------------------------------------------

a. Does the Veteran have IVDS of the cervical spine?

[ ] Yes [X] No

15. 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

16. Remaining effective function of the extremities

----------------------------------------------------

Due to a cervical spine (neck) 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.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

17. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

-----------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms?

[ ] Yes [X] No

18. Diagnostic testing

----------------------

a. Have imaging studies of the cervical spine been performed and are the

results available?

[X] Yes [ ] No

If yes, is arthritis (degenerative joint disease) documented?

[X] Yes [ ] No

b. Does the Veteran have a 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

19. Functional impact

----------------------

Does the Veteran's cervical spine (neck) condition impact on his or her

ability to work?

[ ] Yes [X] No

20. REMARKS

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Neck strain

Diagnosis: Cervical strain, Cervical disc degeneration, Cervical spinal

stenosis

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

ssgtob1 · August 25, 2014

1. Diagnosis

------------

Does the Veteran now have or has he/she ever had a shoulder and/or arm

condition?

[X] Yes [ ] No

Diagnosis #1: Shoulder impingement

ICD code: 726.2

Date of diagnosis: 2008

Side affected: [ ] Right [X] Left [ ] Both

Diagnosis #2: Right shoulder tendonitis

ICD code: 726.11

Date of diagnosis: 2008

Side affected: [X] Right [ ] Left [ ] Both

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

shoulder and/or arm condition (brief summary):

The Veteran reports a history of right shoulder pain starting in 2008.

He states that his shoulder was injured while lifting. He was seen

and

diagnosed with tendonitis in his right shoulder and treated with

physical therapy. He reports that since his injury he continues to

have right shoulder pain that is aggravated by lifting raising his

arms

above his head.

The Veteran's left shoulder pain started in 2008. He denies any

specific injury to his shoulder reports that his left shoulder pain is

less painful that his right. He was diagnosed with an impingement on

his left shoulder and treated with medications as need. He has not

had

any further treatment for this condition.

b. Dominant hand:

[ ] Right [X] Left [ ] Ambidextrous

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of the shoulder

and/or arm?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in

his or her own words:

The Veteran reports that his bilateral shoulder pain will flare-up

with raising his arms above his head and doing arm circles which he

tries to avoid.

4. Initial range of motion (ROM) measurements

---------------------------------------------

a. Right shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

b. Right shoulder abduction

Select where abduction ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

c. Left shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 170

[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 170

[ ] 175 [ ] 180

d. Left shoulder abduction

Select where abduction ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

e. If ROM does not conform to the normal range of motion identified above

but

is normal for this Veteran (for reasons other than a shoulder or arm

condition, such as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurements after repetitive use testing

------------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No

b. Right shoulder post-test ROM

Select where flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [X] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

Select where abduction ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

c. Left shoulder post-test ROM

Select where flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 170

[ ] 175 [ ] 180

Select where abduction ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [X] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the shoulder and

arm

following repetitive-use testing?

[ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of

the shoulder and arm?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment and/or

additional limitation of ROM of the shoulder and arm after repetitive

use,

indicate the contributing factors of disability below (check all that

apply and indicate side affected):

[X] Less movement than normal [ ] Right [ ] Left [X] Both

[X] Excess fatigability [ ] Right [ ] Left [X] Both

[X] Pain on movement [ ] Right [ ] Left [X] Both

7. Pain (pain on palpation)

---------------------------

a. Does the Veteran have localized tenderness or pain on palpation of

joints/soft tissue/biceps tendon of either shoulder?

[X] Yes [ ] No

If yes, shoulder affected: [ ] Right [ ] Left [X] Both

b. Does the Veteran have guarding of either shoulder?

[X] Yes [ ] No

If yes, shoulder affected: [ ] Right [ ] Left [X] Both

8. Muscle strength testing

--------------------------

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

Shoulder abduction:

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

Shoulder forward 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

9. Ankylosis

------------

Does the Veteran have ankylosis of the glenohumeral articulation (shoulder

joint)?

[ ] Yes [X] No

10. Specific tests for rotator cuff conditions

----------------------------------------------

a. Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the

elbow bent to 90 degrees. Internally rotate arm. Pain on internal

rotation

indicates a positive test; may signify rotator cuff tendinopathy or

tear.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

b. Empty-can test (Abduct arm to 90 degrees and forward flex 30 degrees.

Patient turns thumbs down and resists downward force applied by the

examiner. Weakness indicates a positive test; may indicate rotator cuff

pathology, including supraspinatus tendinopathy or tear.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

c. External rotation/Infraspinatus strength test (Patient holds arm at side

with elbow flexed 90 degrees. Patient externally rotates against

resistance. Weakness indicates a positive test; may be associated with

infraspinatus tendinopathy or tear.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

d. Lift-off subscapularis test (Patient internally rotates arm behind lower

back, pushes against examiner's hand. Weakness indicates a positive test;

may indicate subscapularis tendinopathy or tear.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

11. History and specific tests for instability/dislocation/labral pathology

---------------------------------------------------------------------------

a. Is there a history of mechanical symptoms (clicking, catching, etc.)?

[X] Yes [ ] No

If yes, side affected: [ ] Right [ ] Left [X] Both

b. Is there a history of recurrent dislocation (subluxation) of the

glenohumeral (scapulohumeral) joint?

[ ] Yes [X] No

c. Crank apprehension and relocation test (With patient supine, abduct

patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of

instability with further external rotation may indicate shoulder

instability.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

12. History and specific tests for clavicle, scapula, acromioclavicular (AC)

joint, and sternoclavicular joint conditions

----------------------------------------------------------------------------

a. Does the Veteran have an AC joint condition or any other impairment of

the

clavicle or scapula?

[ ] Yes [X] No

b. Is there tenderness on palpation of the AC joint?

[ ] Yes [X] No

c. Cross-body adduction test (Passively adduct arm across the patient's body

toward the contralateral shoulder. Pain may indicate acromioclavicular

joint pathology.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

13. Joint replacement and/or other surgical procedures

------------------------------------------------------

a. Has the Veteran had a total shoulder joint replacement?

[ ] Yes [X] No

b. Has the Veteran had arthroscopic or other shoulder surgery?

[ ] Yes [X] No

c. Does the Veteran have any residual signs and/or symptoms due to

arthroscopic or other shoulder surgery?

[ ] Yes [X] No

14. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

-----------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[ ] Yes [X] No

15. Remaining effective function of the extremities

---------------------------------------------------

Due to the Veteran's shoulder and/or arm conditions, is there functional

impairment of an extremity such that no effective function remains other

than

that which would be equally well served by an amputation with prosthesis?

(Functions of the upper extremity include grasping, manipulation, etc)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

16. Diagnostic Testing

----------------------

a. Have imaging studies of the shoulder 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 and/or results?

[ ] Yes [X] No

17. Functional impact

---------------------

Does the Veteran's shoulder condition impact his or her ability to work?

[ ] Yes [X] No

18. REMARKS

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Left shoulder impingement, Right shoulder tendonitis

Diagnosis: Left shoulder impingement, Right shoulder tendonitis

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

External rotation 75 degrees right shoulder 80 degrees left shoulder

Internal rotation 80 degrees bilateral shoulders.

ssgtob1 · August 25, 2014

SECTION I: Diagnosis:

---------------------

Does the Veteran now have or has he/she ever been diagnosed with a sinus,

nose, throat, larynx, or pharynx condition? (This is the condition the

Veteran is claiming or for which an exam has been requested)

[X] Yes [ ] No

[X] Chronic sinusitis ICD code: 473.9 Date of diagnosis: 2007

[X] Deviated nasal septum (traumatic)

ICD code: 470 Date of diagnosis: 2007

SECTION III: Nose, throat, larynx or pharynx conditions

-------------------------------------------------------

Does the Veteran have any of the following nose, throat, larynx or pharynx

conditions?

[X] Yes [ ] No

[X] Sinusitis

[X] Deviated nasal septum (traumatic)

1. Sinusitis

------------

a. Indicate the sinuses/type of sinusitis currently affected by the

Veteran's

chronic sinusitis (check all that apply):

[ ] None [ ] Maxillary [ ] Frontal

[ ] Ethmoid [ ] Sphenoid [X] Pansinusitis

b. Does the Veteran currently have any findings, signs or symptoms

attributable to chronic sinusitis?

[X] Yes [ ] No

If yes, check all that apply:

[ ] Chronic sinusitis detected only by imaging studies (see Diagnostic

testing section)

[X] Episodes of sinusitis

[X] Near constant sinusitis

If checked, describe frequency:

Daily symptoms with exacerbation of infections every 2-3 months.

[X] Headaches

[X] Pain of affecte

d sinus

[X] Tenderness of affected sinus

[ ] Purulent discharge

[ ] Crusting

[X] Other

For all checked conditions, describe:

Constant frontal hedaches with tenderness & pain and tenderness over

all

sinuses,increased with bending head foreward.Also difficulty breathing

through both nares.The veteran relates that when he experiences a

recurrence of exacerbation of his chronic sinus infections,he is

incapacitated for a few days and not able to work.

c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis

characterized

by headaches, pain and purulent discharge or crusting in the past 12

months?

[X] Yes [ ] No

If yes, provide the total number of non-incapacitating episodes over the

past 12 months:

[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [X] 7 or more

d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring

prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months?

[ ] Yes [X] No

NOTE: For VA purposes, an incapacitating episode of sinusitis means one

that requires bed rest and treatment prescribed by a physician.

If yes, provide the total number of incapacitating episodes of sinusitis

requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12

months:

[ ] 1 [ ] 2 [ ] 3 or more

e. Has the Veteran had sinus surgery?

[X] Yes [ ] No

If yes, specify type of surgery:

[ ] Radical (open sinus surgery) [X] Endoscopic [X] Other: Nasal

septoplasty X 2

Type of procedure, sinuses operated on and side(s):

Bilateral sinus surgery to open all sinus passagways to nasal

turbinates.Also nasal septoplasty.Surgeries in 2008 and 2009.Surgical

reports not available at this time.

Date(s) of surgery (if repeated sinus surgery, provide all dates of

surgery):

2008 and 2009

If Veteran has had radical sinus surgery, did chronic osteomyelitis

follow

the surgery?

[ ] Yes [ ] No

f. Has the Veteran had repeated sinus-related surgical procedures performed?

[X] Yes[ ] No

4. Deviated nasal septum (traumatic)

------------------------------------

a. Is there at least 50% obstruction of the nasal passage on both sides due

to traumatic septal deviation?

[ ] Yes [X] No

b. Is the Veteran's deviated septum traumatic?

[X] Yes [ ] No

c. Is there complete obstruction on left side due to traumatic septal

deviation?

[ ] Yes [X] No

d. Is there complete obstruction on right side due to traumatic septal

deviation?

[ ] Yes [X] No

6. Other pertinent physical findings, scars, complications, conditions,

signs

and/or symptoms

-----------------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes[X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[ ] Yes[X] No

c. Does the Veteran have loss of part of the nose or other scars of the nose

exposing both nasal passages?

[ ] Yes[X] No

d. Does the Veteran have loss of part of the nose or other scars causing

loss

of part of one ala?

[ ] Yes[X] No

e. Does the Veteran have loss of part of the nose or other scars causing

other obvious disfigurement?

[ ] Yes[X] No

SECTION IV: Diagnostic testing

------------------------------

a. Have imaging studies of the sinuses or other areas been performed?

[X] Yes[ ] No

[ ] Magnetic resonance imaging (MRI) Date:

Results:

[X] Computed tomography (CT) Date: Multiple 2004-2010

Results:

Frontal and Left Maxillary sinusitis.Last CAT scan suggestive of a

pansinusitis.

[ ] X-rays:

Date:

Results:

[ ] Other:

Date:

Results:

b. Has endoscopy been performed?: Yes

If yes, complete the following:

If yes, check all that apply:

[X] Nasal endoscopy Date: 2007,2008 & 2010

Results:

Not available,but resulted in Functional Endoscopic Surgeries.

[ ] Laryngeal endoscopy Date:

Results:

[ ] Bronchoscopy Date:

Results:

[ ] Other endoscopy Date:

Results:

c. Has the Veteran had a biopsy of the larynx or pharynx?: No

d. Has the Veteran had pulmonary function testing to assess for upper airway

obstruction due to laryngeal stenosis?: No

e. Are there any other significant diagnostic test findings and/or results?:

No

SECTION V: Functional impact and remarks

----------------------------------------

1. Functional impact

--------------------

Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact

his or her ability to work?

[ ] Yes [X] No

2. Remarks, if any:

-------------------

Current Case. VBMS available and was reviewed.The veteran was noted to have

a deviated nasal septum on ENT examination in 2007.The etiology of the

deviated nasal septum has not been established but is considered in most

cases to be traumatic.The veteran denies any clinical history of allergies.

CC: Sinusitis,Allergies,Status Post Septoplasty,Deviated septum, Sinusitus

DX:Chronic Sinusitis, Deviated Septum

RAT:Documented with CAT scans of the sinuses,and Functional Endoscopic Sinus

Surgeries x 2 .The veteran denies any clinical history of allergies.

PROG:Chronic not resolved with Rx and sinus surgeries

NavyWife · August 26, 2014

I can only give an opinion on the conditions I am familiar with.

TBI service connection but at 0%.

Migraine service connection at 30%

Mental health 0 or 10%.

If you have other records in your medical file that would support a higher rating for any of those then it's possible the rater may go with that evidence, but those are the numbers I see based on the C&P.

killemall · August 26, 2014

Ive never seen so c@ps...

My moneys on an total of 90% rating

ssgtob1 · August 26, 2014

Ive never seen so c@ps...
My moneys on an total of 90% rating

Did you mean that you have never seen so many C&P's? Did you arrive at 90% based off of the amount of the claims or what they actually are?

killemall · August 26, 2014

There's so much stuff going on.....

But I defiently agree with the 10% mental health or Tbi...

Then the 30% headaches

Then I think 10 or 20 for the shoulder is service connected

Your getting 10% for tinitus

So just off the things that seem obvious your already around 50%

Then you've got spine hip and neck plus hand wrist stuff going on.

Is this all your exit exam?

Did you just get out of military?

ssgtob1 · August 26, 2014

I got out in may and this is my first set of exams with the VA.

Sign In

Announcements

Have Questions? Get Answers.

Tips on posting on the forums.

Who's Online 2 Members, 0 Anonymous, 20 Guests (See full list)

C&p Exams All Done

Question

Link to comment

Share on other sites

Top Posters For This Question

Popular Days

Top Posters For This Question

Popular Days

22 answers to this question

Recommended Posts

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Link to comment

Share on other sites

Join the conversation

Important Information