C&p Exams All Done

[ssgtob1]

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?

[ssgtob1]

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]

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]

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]

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]

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]

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