Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
Diagnosis #1: Degenerative changes lumbar spine
ICD code: 715.9
Date of diagnosis: 12/1992
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
The Veteran indicates while in service he fell from truck striking lower
back on vehicle. He was evaluated at base medical facility. He indicates
he had difficult straightening lower back with radiation pain right lower
extremity. He indicates intermittant pain lower back since that time
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 indicates lifting heavy objects causes increased pain. He
indicates bending or twisting causes increased pain. Prolonged sitting
or standing causes increased stiffness and pain.
b. Select where extension ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[X] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 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
c. Select where post-test extension ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [X] 25 [ ] 30 or
g
reater
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
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:
Tenderness L2-L5 paravertebral musculature worse on the right
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?
[ ] Yes [X] 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?
[ ] 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
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: [X] Negative [ ] 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: [ ] None [ ] Mild [X] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Numbness
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower 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 L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
If checked, indicate: [X] Right [ ] Left [ ] Both
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [ ] Mild [X] 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?
[X] Yes [ ] No
b. If yes, has the Veteran had any incapacitating episodes over the past
12 months due to IVDS?
[ ] 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?
[X] Yes [ ] No
b. Does the Veteran have a thoracic vertebral fracture with loss of 50
percent or more of height?
[ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
(Case 3422 COMPLETE) SPINE LUMBOSACRAL MIN 4 VIEWS (RAD
Detailed) CPT:72110
Reason for Study: Evaluate degenerative change Compensation
and
Pension
Clinical History:
Report Status: Verified Date Reported: OCT
23, 2014
Date Verified: OCT
23, 2014
Report:
LS spine
Degenerative change evaluation
AP oblique lateral projections
Findings: Hypertrophic changes are seen throughout, greater
at
the L5-S1 level. There is no compression fracture. No
lysis/no
listhesis. Pedicles are intact There is prominent disc space
narrowing of the L5-S1 disc space.
Impression:
1. Degenerative changes are seen which are greater at the
lower
lumbar levels particularly the L5-S1 disc space. There is
facet
arthropathy of the L4-5 and L5-S1 facet joints There is some
thinning of the pars bilaterally although no definite pars
defect
is seen.
20. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or her
ability to work?
[X] Yes [ ] No
If yes describe the impact of each of the Veteran's thoracolumbar
spine (back) conditions providing one or more examples:
The Veteran indicates lifting heavy objects causes increased pain.
He indicates lower back pain results in disrupted sleep with
decreased productivity. Prolonged sitting or standing causes
incrased stiffness and pain
21. REMARKS
-----------
a. Remarks, if any:
No comments provided.
Hip and Thigh Conditions
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever had a hip and/or thigh
condition?
[X] Yes [ ] No
Diagnosis #1: Degenerative changes right hip
ICD code: 715.9
Date of diagnosis: about 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 indicates onset pain right hip with no discrete injury. He
ascribes hip pain to alteration of gait and alteration of stance from
degenerative changes left knee and previous internal derangement left
knee
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 indicates walking on uneven surface causes increased pain.
He indicates kneeling or squatting causes increased pain. Prolonged
standing causes increased stiffness and pain.
4. Initial range of motion (ROM) measurements
---------------------------------------------
a. Right hip flexion
Select where flexion ends (normal endpoint is 125 degrees):
Select where objective evidence of painful motion begins:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 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
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
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
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] No functional loss for left lower extremity
[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 to palpation for
joints/soft tissue of either hip?
[ ] Yes [X] No
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
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
15. Diagnostic Testing
----------------------
a. Have imaging studies of the hip been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate hip: [X] Right [ ] Left [ ] Both
b. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
(Case 3420 COMPLETE) HIP 2 OR MORE VIEWS (RAD
Detailed) CPT:73510
Proc Modifiers : RIGHT
Reason for Study: Evaluate degenerative change Compensation
and
Pension
Clinical History:
Report Status: Verified Date Reported: OCT
23, 2014
Date Verified: OCT
23, 2014
Report:
Right hip
Evaluate degenerative change
AP oblique projections
Findings: There is no fracture. There is no AVN. Joint space
appears preserved There is a very small ossicle lateral to
the
acetabulum measuring 2 x 2 millimeters.
Impression:
1. There is no evidence of fracture. There is no significant
joint space narrowing.
16. Functional impact
---------------------
Does the Veteran's hip and/or thigh condition impact his or her ability to
work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's hip and/or thigh
conditions providing one or more examples:
The Veteran indicates walking on uneven surface causes increased
pain.
He indicates cold exposure causes increased pain. prolonged standing
causes increased stiffness and pain
17. Remarks
-----------
a. Remarks, if any:
Adduction right hip 25 degrees abduction 45 degrees external rotation 60
degrees internal rotation 40 degrees after repetitive motions adduction
25
degrees abduction 45 degrees external rotation 60 degrees internal
rotation 40 degrees
Knee and Lower Leg Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
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: Degenerative changes left knee
ICD code: 715.9
Date of diagnosis: 6/1988
Side affected: [ ] Right [X] Left [ ] Both
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 indicates while training in service he fell from height
with internal derangement left knee. He was evaluated at base medical
facility. He subsequently underwent arthroscopic repair tear lateral
meniscus and he had strain anterior cruciate ligament. He indicates
ongoing pain since that time
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 indicates lifting heavy objects causes increased pain.
He indicates descending stairs causes increased pain. He indicates
kneeling or squatting causes increased pain. Prolonged sitting or
standing causes increased stiffness or pain.
d. Left 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] No objective evidence of painful motion
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
[X] 0 or any degree of hyperextension (check this box if there is
no
limitation of extension)
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?
[X] Yes [ ] 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] No functional loss for right lower extremity attributable to claimed
condition
[X] Less movement than normal [ ] Right [X] Left [ ] Both
[X] Pain on movement [ ] Right [X] Left [ ] Both
[X] Disturbance of locomotion [ ] Right [X] Left [ ] Both
[X] Interference with sitting
[ ] 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
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?
[X] Yes [ ] No
a. Does the Veteran now have or has he or she ever had a meniscus (semilunar
cartilage) condition?
[X] Yes [ ] No
If yes, indicate severity and frequency of symptoms, and side affected:
[X] Meniscal tear [ ] Right [X] Left [ ] Both
[X] Frequent episodes of joint "locking" [ ] Right [X] Left [ ] Both
[X] Frequent episodes of joint pain [ ] Right [X] Left [ ] Both
b. Has the Veteran had a meniscectomy?
[X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
Date of surgery: 3/28/90
c. Does the Veteran have any residual signs and/or symptoms due to a
meniscectomy?
[X] Yes [ ] No
Describe residuals: The Veteran indicacates persistant pain left knee
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?
[ ] Yes [X] No
c. Does the Veteran have any residual signs and/or symptoms due to
arthroscopic or other knee surgery not described above?
[ ] 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?
[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) [ ] Occasional [X] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
The Veteran indicates he uses brace for increased support and for
increased stability
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: [ ] Right [X] 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):
8/8/14 MRI left knee
Medial meniscus tear extending to inferior articular margin
18. Functional impact
---------------------
Does the Veteran's knee and/or lower leg condition(s) impact his or her
ability to work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's knee and/or
lower
leg conditions providing one or more examples:
The Veteran indicates lifting heavy objects causes increased pain.
Prolonged sitting or standing causes increased stiffness and pain.
19. Remarks
-----------
a. Remarks, if any: No response provided
b. Mitchell criteria:
Knee Mitchell side: Left
Reason ROM in Degrees
Cannot specify Please provide rationale:
When completing any musculoskeletal DBQ, additional information is
required to comply with a recent US Court of Appeals for Veterans Claims
(CAVC) decision in the case of Mitchell v. Shinseki, relating to
functional limitations. In the section of the DBQ titled "Functional
loss and additional limitation in ROM," additional questions must be
addressed. For each joint examined, please provide an opinion.
1. Whether pain, weakness, fatigability, or
incoordination could significantly limit functional ability during
flare-ups, or when the joint is used repeatedly over a period of time,
and
2. Describe any such additional limitation due to pain,
weakness, fatigability, or incoordination, and if feasible, this opinion
should be expressed in terms of the degrees of additional ROM loss due
to
"pain on use or during flare-ups".
3. If such opinion is not feasible, please state and
provide an explanation as to why the opinion cannot be rendered.
In my opinion it is at least as likely as not that
pain,weakness,fatigability, or incoordination could significantly limit
functional ability during flare-ups, or when the joint is used
repeatedly
over a period of time. This is applicable to the claimed degenerative
changes left knee degenerative changes lumbar spine and degenerative
changes right hip. The extent to which these additional conditions would
limit functional ability or if they at all pertain would be dependent on
the amount of repetitive use the forcefulnees of the movements the
period
of time over which these movements occur or the severity of exacerbation
of the condition. The additional limitations and the reduction of range
of motion would be dependent on the conditions impacting repetitive use
or the severity of exacerbations.
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed? Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Relationship of claimed degenerative
changes
lumbar spine and claimed degenerative changes left knee to service
b. Indicate type of exam for which opinion has been requested: DBQ back DBQ
knee
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: In my opinion the claimed degenerative changes lumbar spine
and
claimed degenerative changes left knee is at least aslikely as not caused by
the claimed injuries in service. The note from 12/8/92 indicates lower back
pain after fall from truck striking lower back. He indicates intermittant
pain lower back with radiculopathy since that time. The note from 7/29/14
indicates degenerative changes left knee with history of lateral
meniscectomy
and partial ACL tear from injuury in service 1988. The note from 6/26/89
indicates pain left knee with repair ACL about a year previously. The
Veteran indicates ongoing pain left knee since internal derangement left
knee
in service
a. Opinion from general remarks: Relationship of claimed degenerative
changes
right hip to service
b. Indicate type of exam for which opinion has been requested: DBQ hip
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE
CONNECTION ]
a. The condition claimed is at least as likely as not (50% or greater
probability) proximately due to or the result of the Veteran's service
connected condition.
c. Rationale: In my opinion the claimed degenerative changes right hip is at
least as likely as not proximately due to the claimed degenerative changes
left knee. The right hip condition likely results from alteration of gait
and
alteration of stance resulting from the claimed degenerative changes left
knee and internal derangement left knee. The ongoing pain right hip is
compatible with alteration of gait and alteration of stance resulting from
left knee condition
Hearing Loss and Tinnitus
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed: Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file: DoD Records - No records.
VistaWeb - No audio information.
DOEHRS Data Repository - Audiograms located.
Veteran provided writer with audio information.
This exam is for: Hearing loss and/or tinnitus (audiologist, performing
current exam)
SECTION 1: HEARING LOSS (HL)
-----------------------------
1. Objective Findings
---------------------
a. Puretone thresholds in decibels (air conduction):
RIGHT EAR
+==============================================================+
| A | B | C | D | E | F | G |
|========+========+========+========+========+========+========+========+
| 500 | 1000 | 2000 | 3000 | 4000 | 6000 | 8000 | Avg Hz |
| Hz* | Hz | Hz | Hz | Hz | Hz | Hz | (B-E)**|
|========+========+========+========+========+========+========+========|
| 10 | 10 | 20 | 20 | 25 | 40 | 45 | 19 |
+=======================================================================+
LEFT EAR
+==============================================================+
| A | B | C | D | E | F | G |
|========+========+========+========+========+========+========+========+
| 500 | 1000 | 2000 | 3000 | 4000 | 6000 | 8000 | Avg Hz |
| Hz* | Hz | Hz | Hz | Hz | Hz | Hz | (B-E)**|
|========+========+========+========+========+========+========+========|
| 10 | 10 | 15 | 20 | 20 | 80 | 75 | 16 |
+=======================================================================+
* The puretone threshold at 500 Hz is not used in determining the
evaluation but is used in determining whether or not a ratable hearing
loss exists.
** The average of B, C, D, and E.
*** CNT - Could Not Test
b. Were there one or more frequency(ies) that could not be tested: No
c. Validity of puretone test results: Test results are valid for rating
purposes.
d. Speech Discrimination Score (Maryland CNC word list):
+=======================+
| RIGHT EAR | 86% |
|=============+=========|
| LEFT EAR | 84% |
+=======================+
e. Appropriateness of Use of Word Recognition Score (Maryland CNC word
list):
Right Ear:
Is Word Discrimination Score available? Yes
Word Discrimination Score appropriateness:
Use of word recognition score is appropriate for this Veteran.
Left Ear:
Is Word Discrimination Score available? Yes
Word Discrimination Score appropriateness:
Use of word recognition score is appropriate for this Veteran.
f. Audiologic Findings
Summary of Immittance (Tympanometry) Findings:
+=============================================================================+
| | RIGHT EAR | LEFT EAR
|
|=====================+===========================+===========================|
| Acoustic immittance | [X] Normal [ ] Abnormal | [X] Normal [ ] Abnormal
|
[ ] Sensorineural hearing loss (in the frequency range of 500-4000 Hz)*
ICD code:
[X] Sensorineural hearing loss (in the frequency range of 6000 Hz or
higher frequencies)** ICD code: 389.16
[ ] Significant changes in hearing thresholds in service***
LEFT EAR
--------
[ ] Normal hearing
[ ] Conductive hearing loss ICD code:
[ ] Mixed hearing loss ICD code:
[ ] Sensorineural hearing loss (in the frequency range of 500-4000 Hz)*
ICD code:
[X] Sensorineural hearing loss (in the frequency range of 6000 Hz or
higher frequencies)** ICD code: 389.16
[X] Significant changes in hearing thresholds in service***
NOTES:
* The Veteran may have hearing loss at a level that is not considered to
be
a disability for VA purposes. This can occur when the auditory
thresholds are greater than 25 dB at one or more frequencies in the
500-4000 Hz range.
** The Veteran may have impaired hearing, but it does not meet the criteria
to be considered a disability for VA purposes. For VA purposes, the
diagnosis of hearing impairment is based upon testing at frequency
ranges
of 500, 1000, 2000, 3000, and 4000 Hz. If there is no HL in the
500-4000
Hz range, but there is HL above 4000 Hz, check this box.
*** The Veteran may have a significant change in hearing threshold in
service, but it does not meet the criteria to be considered a disability
for VA purposes. (A significant change in hearing threshold may
indicate
noise exposure or acoustic trauma.)
3. Etiology
-----------
Right Ear
Was there a permanent positive threshold shift (worse than reference
threshold) greater than normal measurement variability at any frequency
between 500 and 6000 Hz for the right ear? No
Opinion provided for the right ear: Yes
If present, is the Veteran's right ear hearing loss at least a
s likely as
not (50% probability or greater) caused by or a result of an event in
military service? No
Rationale (Provide rationale for either a yes, no answer or speculation
reason): C-File was carefully reviewed. Although there was a positive
history of military noise exposure, there were no shifts in hearing
between enlistment audiogram (09/17/1987) and last audiogram in C-File
(01/11/1991).
Did hearing loss exist prior to service? No
Left Ear
Was there a permanent positive threshold shift (worse than reference
threshold) greater than normal measurement variability at any frequency
between 500 and 6000 Hz for the left ear? Yes
Opinion provided for the left ear: Yes
If present, is the Veteran's left ear hearing loss at least as likely as
not (50% probability or greater) caused by or a result of an event in
military service? Yes
Rationale (Provide rationale for either a yes, no answer or speculation
reason): C-File carefully reviewed. Positive history of military noise
exposure and a baseline shift in hearing (left ear) has occurred from
his enlistment audiogram (09/17/1987) and last audiogram in C-File
(01/11/1991). The shift in hearing threshold is consistent with a
noise
injury incurred during military service period.
Did hearing loss exist prior to service? No
4. Functional impact of hearing loss
------------------------------------
Does the Veteran's hearing loss impact ordinary conditions of daily life,
including ability to work: No
5. Remarks, if any, pertaining to hearing loss:
-----------------------------------------------
Military: United States Army - 03/08/1988 to 05/09/1994
Military Noise Exposure: MOS - Light Wheel Vehicle Mechanic, which has a
high probability of noise exposure. Veteran was exposed to: diesel
engines and weapons fire. He reported the use of hearing protection.
Non-combat.
Pre Military Noise Exposure: Denied
Post Military Noise Exposure: Denied noise exposure.
Recreational Noise Exposure: Denied
Veteran reported the following:
Family History of Hearing Loss - Parents (presbycusis).
IV Antibiotics
Hearing Loss - Veteran has noticed a bilateral hearing loss since his
military service. He stated, "My fiance is fed up with repeating herself
so much. I don't watch TV anymore or listen to music. I also have a
hard
time hearing on the phone."
Tinnitus - Please see tinnitus section for details.
Veteran denied the following:
Ear Pain
Ear Drainage
Aural Fullness
Ear Surgery
History of Ear Infections
History of a Perforated Tympanic Membrane
Ear Trauma
Heart Attack
CVA/TIA
Diabetes
Dizziness
Chemotherapy/Radiation Treatments
Head Injury
C&P Results:
Otoscopy: Clear canal with visualization of the tympanic membrane,
bilaterally.
Tympanometry: Type A; Normal, bilaterally.
Acoustic Reflexes: Commensurate with audiogram, bilaterally.
Acoustic Reflex Decay: Negative, bilaterally and commensurate with
normal/sensory etiology.
RIGHT Ear: Hearing is within normal limits (250Hz - 4000Hz).
Mild/moderate (6000Hz - 8000Hz) high frequency sensorineural hearing
loss.
LEFT Ear: Hearing is within normal limits (250Hz - 4000Hz). Severe
(6000Hz - 8000Hz) high frequency sensorineural hearing loss.
C-File Review:
DD-214 Confirms MOS
Enlistment Audiogram - 09/17/1987
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 0 0 10 5 5 0
L 5 5 0 5 0 10
Hearing is within normal limits (500Hz - 6000Hz), bilaterally.
Reference Audiogram - 05/25/1989
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 5 0 10 5 0 10
L 0 0 0 5 0 20
Hearing is within normal limits (500Hz - 6000Hz), bilaterally.
Reference Audiogram - 04/11/1990
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 0 0 10 5 5 0
L 0 0 0 5 0 15
Hearing is within normal limits (500Hz - 6000Hz), bilaterally.
Reference Audiogram - 01/11/1991 (Last Audiogram in C-File)
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 15 10 15 10 10 5
L 15 5 5 5 0 40
RIGHT Ear: Hearing is within normal limits (500Hz - 6000Hz).
LEFT Ear: Hearing is within normal limits (500Hz - 4000Hz). Mild hearing
loss at 6000Hz.
Today's C&P Results - 10/23/2014
250Hz 500Hz 1000Hz 1500Hz 2000Hz 3000Hz 4000Hz 6000Hz 8000Hz
R 10 10 10 15 20 20 25 40 45
L 10 10 10 10 15 20 20 80 75
RIGHT Ear: Hearing is within norma limits (250Hz - 4000Hz).
Mild/moderate
(6000Hz - 8000Hz) high frequency sensorineural hearing loss.
LEFT Ear: Hearing is within normal limits (250Hz - 4000Hz). Severe
(6000Hz - 8000Hz) high frequency sensorineural hearing loss.
RIGHT Ear: There was a 15dB shift at 500Hz between enlistment audiogram
(09/17/1987) and last audiogram in C-File (01/11/1991), however it has
since recovered based on today's C&P results. Therefore, no
permanent
threshold shift in hearing during military service period in the right
ear.
LEFT Ear: There was a 30dB shift in hearing threshold at 6000Hz between
his enlistment audiogram (09/17/1987) and the last audiogram in C-File
(01/11/1991). This permanent threshold shift is consistent with a noise
injury incurred during military service period.
SECTION 2: TINNITUS
--------------------
1. Medical history
------------------
Does the Veteran report recurrent tinnitus: Yes
Date and circumstances of onset of tinnitus: Veteran reported bilateral
tinnitus. The tinnitus was described as a, "high pitched squeal." He
notices the tinnitus more so when it is quiet. Veteran has noticed the
tinnitus since qualifying with his M-16 in the "90's."
2. Etiology of tinnitus
-----------------------
At least as likely as not (50% probability or greater) caused by or a result
of military noise exposure.
Rationale: C-File carefully reviewed. Positive history of military noise
exposure and a baseline shift in hearing (left ear) occurred from his
enlistment audiogram (09/17/1987) and last audiogram (01/11/1991) in
C-File. The shift in hearing threshold (left ear) is consistent with an
in-service incurrence of hearing impairment from acoustic trauma.
Tinnitus
is a common symptom of acoustic trauma.
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::
--------------------------------------------
No response provided
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
Question
Burt
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
Thoracolumbar Common Diagnoses:
[ ] Ankylosing spondylitis
[ ] Lumbosacral strain
[X] Degenerative arthritis of the spine
[ ] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: Degenerative changes lumbar spine
ICD code: 715.9
Date of diagnosis: 12/1992
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
The Veteran indicates while in service he fell from truck striking lower
back on vehicle. He was evaluated at base medical facility. He indicates
he had difficult straightening lower back with radiation pain right lower
extremity. He indicates intermittant pain lower back since that time
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 indicates lifting heavy objects causes increased pain. He
indicates bending or twisting causes increased pain. Prolonged sitting
or standing causes increased stiffness and pain.
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 [ ] 40 [ ] 45
[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [X] 80 [ ] 85 [ ] 90 or greater
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
[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
b. Select where extension ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[X] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 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 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [X] 80 [ ] 85 [ ] 90 or greater
c. Select where post-test extension ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [X] 25 [ ] 30 or
g
reater
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
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:
Tenderness L2-L5 paravertebral musculature worse on the right
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?
[ ] Yes [X] 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?
[ ] 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
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: [ ] 5/5 [X] 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: [X] Negative [ ] 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: [ ] None [ ] Mild [X] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Numbness
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower 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 L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
If checked, indicate: [X] Right [ ] Left [ ] Both
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [ ] Mild [X] 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?
[X] Yes [ ] No
b. If yes, has the Veteran had any incapacitating episodes over the past
12 months due to IVDS?
[ ] 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?
[X] Yes [ ] No
b. Does the Veteran have a thoracic vertebral fracture with loss of 50
percent or more of height?
[ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
(Case 3422 COMPLETE) SPINE LUMBOSACRAL MIN 4 VIEWS (RAD
Detailed) CPT:72110
Reason for Study: Evaluate degenerative change Compensation
and
Pension
Clinical History:
Report Status: Verified Date Reported: OCT
23, 2014
Date Verified: OCT
23, 2014
Report:
LS spine
Degenerative change evaluation
AP oblique lateral projections
Findings: Hypertrophic changes are seen throughout, greater
at
the L5-S1 level. There is no compression fracture. No
lysis/no
listhesis. Pedicles are intact There is prominent disc space
narrowing of the L5-S1 disc space.
Impression:
1. Degenerative changes are seen which are greater at the
lower
lumbar levels particularly the L5-S1 disc space. There is
facet
arthropathy of the L4-5 and L5-S1 facet joints There is some
thinning of the pars bilaterally although no definite pars
defect
is seen.
20. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or her
ability to work?
[X] Yes [ ] No
If yes describe the impact of each of the Veteran's thoracolumbar
spine (back) conditions providing one or more examples:
The Veteran indicates lifting heavy objects causes increased pain.
He indicates lower back pain results in disrupted sleep with
decreased productivity. Prolonged sitting or standing causes
incrased stiffness and pain
21. REMARKS
-----------
a. Remarks, if any:
No comments provided.
b. Mitchell criteria:
provided DBQ knee
****************************************************************************
Hip and Thigh Conditions
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever had a hip and/or thigh
condition?
[X] Yes [ ] No
Diagnosis #1: Degenerative changes right hip
ICD code: 715.9
Date of diagnosis: about 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 indicates onset pain right hip with no discrete injury. He
ascribes hip pain to alteration of gait and alteration of stance from
degenerative changes left knee and previous internal derangement left
knee
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 indicates walking on uneven surface causes increased pain.
He indicates kneeling or squatting causes increased pain. Prolonged
standing causes increased stiffness and 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 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[X] 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 [ ] 30
[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [X] 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:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 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
Select where flexion ends (normal endpoint is 125 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 [X] 125 or greater
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 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 or greater
d. Left hip extension
Select where extension ends:
[ ] 0 [ ] 5 [X] Greater than 5
Select where objective evidence of painful motion begins:
[X] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 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
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 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100
[X] 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
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 [X] 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
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] No functional loss for left lower extremity
[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 to palpation for
joints/soft tissue of either hip?
[ ] Yes [X] No
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
Left: [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
Left: [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
Left: [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
15. Diagnostic Testing
----------------------
a. Have imaging studies of the hip been performed and are the results
available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate hip: [X] Right [ ] Left [ ] Both
b. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
(Case 3420 COMPLETE) HIP 2 OR MORE VIEWS (RAD
Detailed) CPT:73510
Proc Modifiers : RIGHT
Reason for Study: Evaluate degenerative change Compensation
and
Pension
Clinical History:
Report Status: Verified Date Reported: OCT
23, 2014
Date Verified: OCT
23, 2014
Report:
Right hip
Evaluate degenerative change
AP oblique projections
Findings: There is no fracture. There is no AVN. Joint space
appears preserved There is a very small ossicle lateral to
the
acetabulum measuring 2 x 2 millimeters.
Impression:
1. There is no evidence of fracture. There is no significant
joint space narrowing.
16. Functional impact
---------------------
Does the Veteran's hip and/or thigh condition impact his or her ability to
work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's hip and/or thigh
conditions providing one or more examples:
The Veteran indicates walking on uneven surface causes increased
pain.
He indicates cold exposure causes increased pain. prolonged standing
causes increased stiffness and pain
17. Remarks
-----------
a. Remarks, if any:
Adduction right hip 25 degrees abduction 45 degrees external rotation 60
degrees internal rotation 40 degrees after repetitive motions adduction
25
degrees abduction 45 degrees external rotation 60 degrees internal
rotation 40 degrees
Adduction left hip 25 degrees abduction 45 degrees external rotation 60
degrees internal rotation 40 degrees after repetitive motions adduction
25
degrees abduction 45 degrees external rotation 60 degrees internal
rotation 40 degrees
b. Mitchell criteria:
provided DBQ knee
****************************************************************************
Knee and Lower Leg Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
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: Degenerative changes left knee
ICD code: 715.9
Date of diagnosis: 6/1988
Side affected: [ ] Right [X] Left [ ] Both
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 indicates while training in service he fell from height
with internal derangement left knee. He was evaluated at base medical
facility. He subsequently underwent arthroscopic repair tear lateral
meniscus and he had strain anterior cruciate ligament. He indicates
ongoing pain since that time
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 indicates lifting heavy objects causes increased pain.
He indicates descending stairs causes increased pain. He indicates
kneeling or squatting causes increased pain. Prolonged sitting or
standing causes increased stiffness or pain.
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:
[X] 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 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] No objective evidence of painful motion
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 [X] 80 [ ] 85
[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115
[ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 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 [X] 70 [ ] 75 [ ] 80 [ ] 85
[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115
[ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 140 or greater
d. Left 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] No objective evidence of painful motion
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 [X] 135 [ ] 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 [X] 80 [ ] 85
[ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115
[ ] 120 [ ] 125 [ ] 130 [ ] 135 [ ] 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)
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?
[X] Yes [ ] 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] No functional loss for right lower extremity attributable to claimed
condition
[X] Less movement than normal [ ] Right [X] Left [ ] Both
[X] Pain on movement [ ] Right [X] Left [ ] Both
[X] Disturbance of locomotion [ ] Right [X] Left [ ] Both
[X] Interference with sitting
[ ] 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: [ ] 5/5 [X] 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?
[X] Yes [ ] No
a. Does the Veteran now have or has he or she ever had a meniscus (semilunar
cartilage) condition?
[X] Yes [ ] No
If yes, indicate severity and frequency of symptoms, and side affected:
[X] Meniscal tear [ ] Right [X] Left [ ] Both
[X] Frequent episodes of joint "locking" [ ] Right [X] Left [ ] Both
[X] Frequent episodes of joint pain [ ] Right [X] Left [ ] Both
b. Has the Veteran had a meniscectomy?
[X] Yes [ ] No
If yes, indicate side affected: [ ] Right [X] Left [ ] Both
Date of surgery: 3/28/90
c. Does the Veteran have any residual signs and/or symptoms due to a
meniscectomy?
[X] Yes [ ] No
Describe residuals: The Veteran indicacates persistant pain left knee
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?
[ ] Yes [X] No
c. Does the Veteran have any residual signs and/or symptoms due to
arthroscopic or other knee surgery not described above?
[ ] 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?
[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) [ ] Occasional [X] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
The Veteran indicates he uses brace for increased support and for
increased stability
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: [ ] Right [X] 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):
8/8/14 MRI left knee
Medial meniscus tear extending to inferior articular margin
18. Functional impact
---------------------
Does the Veteran's knee and/or lower leg condition(s) impact his or her
ability to work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's knee and/or
lower
leg conditions providing one or more examples:
The Veteran indicates lifting heavy objects causes increased pain.
Prolonged sitting or standing causes increased stiffness and pain.
19. Remarks
-----------
a. Remarks, if any: No response provided
b. Mitchell criteria:
Knee Mitchell side: Left
Reason ROM in Degrees
Cannot specify Please provide rationale:
When completing any musculoskeletal DBQ, additional information is
required to comply with a recent US Court of Appeals for Veterans Claims
(CAVC) decision in the case of Mitchell v. Shinseki, relating to
functional limitations. In the section of the DBQ titled "Functional
loss and additional limitation in ROM," additional questions must be
addressed. For each joint examined, please provide an opinion.
1. Whether pain, weakness, fatigability, or
incoordination could significantly limit functional ability during
flare-ups, or when the joint is used repeatedly over a period of time,
and
2. Describe any such additional limitation due to pain,
weakness, fatigability, or incoordination, and if feasible, this opinion
should be expressed in terms of the degrees of additional ROM loss due
to
"pain on use or during flare-ups".
3. If such opinion is not feasible, please state and
provide an explanation as to why the opinion cannot be rendered.
In my opinion it is at least as likely as not that
pain,weakness,fatigability, or incoordination could significantly limit
functional ability during flare-ups, or when the joint is used
repeatedly
over a period of time. This is applicable to the claimed degenerative
changes left knee degenerative changes lumbar spine and degenerative
changes right hip. The extent to which these additional conditions would
limit functional ability or if they at all pertain would be dependent on
the amount of repetitive use the forcefulnees of the movements the
period
of time over which these movements occur or the severity of exacerbation
of the condition. The additional limitations and the reduction of range
of motion would be dependent on the conditions impacting repetitive use
or the severity of exacerbations.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed? Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
notes CPRS notes Vista web
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Relationship of claimed degenerative
changes
lumbar spine and claimed degenerative changes left knee to service
b. Indicate type of exam for which opinion has been requested: DBQ back DBQ
knee
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: In my opinion the claimed degenerative changes lumbar spine
and
claimed degenerative changes left knee is at least aslikely as not caused by
the claimed injuries in service. The note from 12/8/92 indicates lower back
pain after fall from truck striking lower back. He indicates intermittant
pain lower back with radiculopathy since that time. The note from 7/29/14
indicates degenerative changes left knee with history of lateral
meniscectomy
and partial ACL tear from injuury in service 1988. The note from 6/26/89
indicates pain left knee with repair ACL about a year previously. The
Veteran indicates ongoing pain left knee since internal derangement left
knee
in service
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Relationship of claimed degenerative
changes
right hip to service
b. Indicate type of exam for which opinion has been requested: DBQ hip
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE
CONNECTION ]
a. The condition claimed is at least as likely as not (50% or greater
probability) proximately due to or the result of the Veteran's service
connected condition.
c. Rationale: In my opinion the claimed degenerative changes right hip is at
least as likely as not proximately due to the claimed degenerative changes
left knee. The right hip condition likely results from alteration of gait
and
alteration of stance resulting from the claimed degenerative changes left
knee and internal derangement left knee. The ongoing pain right hip is
compatible with alteration of gait and alteration of stance resulting from
left knee condition
*************************************************************************
STAFF PHYSICIAN
Signed: 10/28/2014 12:57
-------------------------------------------------------------------------
Hearing Loss and Tinnitus
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed: Yes
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file: DoD Records - No records.
VistaWeb - No audio information.
DOEHRS Data Repository - Audiograms located.
Veteran provided writer with audio information.
This exam is for: Hearing loss and/or tinnitus (audiologist, performing
current exam)
SECTION 1: HEARING LOSS (HL)
-----------------------------
1. Objective Findings
---------------------
a. Puretone thresholds in decibels (air conduction):
RIGHT EAR
+==============================================================+
| A | B | C | D | E | F | G |
|========+========+========+========+========+========+========+========+
| 500 | 1000 | 2000 | 3000 | 4000 | 6000 | 8000 | Avg Hz |
| Hz* | Hz | Hz | Hz | Hz | Hz | Hz | (B-E)**|
|========+========+========+========+========+========+========+========|
| 10 | 10 | 20 | 20 | 25 | 40 | 45 | 19 |
+=======================================================================+
LEFT EAR
+==============================================================+
| A | B | C | D | E | F | G |
|========+========+========+========+========+========+========+========+
| 500 | 1000 | 2000 | 3000 | 4000 | 6000 | 8000 | Avg Hz |
| Hz* | Hz | Hz | Hz | Hz | Hz | Hz | (B-E)**|
|========+========+========+========+========+========+========+========|
| 10 | 10 | 15 | 20 | 20 | 80 | 75 | 16 |
+=======================================================================+
* The puretone threshold at 500 Hz is not used in determining the
evaluation but is used in determining whether or not a ratable hearing
loss exists.
** The average of B, C, D, and E.
*** CNT - Could Not Test
b. Were there one or more frequency(ies) that could not be tested: No
c. Validity of puretone test results: Test results are valid for rating
purposes.
d. Speech Discrimination Score (Maryland CNC word list):
+=======================+
| RIGHT EAR | 86% |
|=============+=========|
| LEFT EAR | 84% |
+=======================+
e. Appropriateness of Use of Word Recognition Score (Maryland CNC word
list):
Right Ear:
Is Word Discrimination Score available? Yes
Word Discrimination Score appropriateness:
Use of word recognition score is appropriate for this Veteran.
Left Ear:
Is Word Discrimination Score available? Yes
Word Discrimination Score appropriateness:
Use of word recognition score is appropriate for this Veteran.
f. Audiologic Findings
Summary of Immittance (Tympanometry) Findings:
+=============================================================================+
| | RIGHT EAR | LEFT EAR
|
|=====================+===========================+===========================|
| Acoustic immittance | [X] Normal [ ] Abnormal | [X] Normal [ ] Abnormal
|
|=====================+===========================+===========================|
| Ipsilateral | |
|
| Acoustic Reflexes | [X] Normal [ ] Abnormal | [X] Normal [ ] Abnormal
|
|=====================+===========================+===========================|
| Contralateral | |
|
| Acoustic Reflexes | [X] Normal [ ] Abnormal | [X] Normal [ ] Abnormal
|
|=====================+===========================+===========================|
| Unable to interpret | |
|
| reflexes due to | [ ] | [ ]
|
| artifact | |
|
|=====================+===========================+===========================|
| Unable to obtain/ | |
|
| maintain seal | [ ] | [ ]
|
+=============================================================================+
2. Diagnosis
------------
RIGHT EAR
---------
[ ] Normal hearing
[ ] Conductive hearing loss ICD code:
[ ] Mixed hearing loss ICD code:
[ ] Sensorineural hearing loss (in the frequency range of 500-4000 Hz)*
ICD code:
[X] Sensorineural hearing loss (in the frequency range of 6000 Hz or
higher frequencies)** ICD code: 389.16
[ ] Significant changes in hearing thresholds in service***
LEFT EAR
--------
[ ] Normal hearing
[ ] Conductive hearing loss ICD code:
[ ] Mixed hearing loss ICD code:
[ ] Sensorineural hearing loss (in the frequency range of 500-4000 Hz)*
ICD code:
[X] Sensorineural hearing loss (in the frequency range of 6000 Hz or
higher frequencies)** ICD code: 389.16
[X] Significant changes in hearing thresholds in service***
NOTES:
* The Veteran may have hearing loss at a level that is not considered to
be
a disability for VA purposes. This can occur when the auditory
thresholds are greater than 25 dB at one or more frequencies in the
500-4000 Hz range.
** The Veteran may have impaired hearing, but it does not meet the criteria
to be considered a disability for VA purposes. For VA purposes, the
diagnosis of hearing impairment is based upon testing at frequency
ranges
of 500, 1000, 2000, 3000, and 4000 Hz. If there is no HL in the
500-4000
Hz range, but there is HL above 4000 Hz, check this box.
*** The Veteran may have a significant change in hearing threshold in
service, but it does not meet the criteria to be considered a disability
for VA purposes. (A significant change in hearing threshold may
indicate
noise exposure or acoustic trauma.)
3. Etiology
-----------
Right Ear
Was there a permanent positive threshold shift (worse than reference
threshold) greater than normal measurement variability at any frequency
between 500 and 6000 Hz for the right ear? No
Opinion provided for the right ear: Yes
If present, is the Veteran's right ear hearing loss at least a
s likely as
not (50% probability or greater) caused by or a result of an event in
military service? No
Rationale (Provide rationale for either a yes, no answer or speculation
reason): C-File was carefully reviewed. Although there was a positive
history of military noise exposure, there were no shifts in hearing
between enlistment audiogram (09/17/1987) and last audiogram in C-File
(01/11/1991).
Did hearing loss exist prior to service? No
Left Ear
Was there a permanent positive threshold shift (worse than reference
threshold) greater than normal measurement variability at any frequency
between 500 and 6000 Hz for the left ear? Yes
Opinion provided for the left ear: Yes
If present, is the Veteran's left ear hearing loss at least as likely as
not (50% probability or greater) caused by or a result of an event in
military service? Yes
Rationale (Provide rationale for either a yes, no answer or speculation
reason): C-File carefully reviewed. Positive history of military noise
exposure and a baseline shift in hearing (left ear) has occurred from
his enlistment audiogram (09/17/1987) and last audiogram in C-File
(01/11/1991). The shift in hearing threshold is consistent with a
noise
injury incurred during military service period.
Did hearing loss exist prior to service? No
4. Functional impact of hearing loss
------------------------------------
Does the Veteran's hearing loss impact ordinary conditions of daily life,
including ability to work: No
5. Remarks, if any, pertaining to hearing loss:
-----------------------------------------------
Military: United States Army - 03/08/1988 to 05/09/1994
Military Noise Exposure: MOS - Light Wheel Vehicle Mechanic, which has a
high probability of noise exposure. Veteran was exposed to: diesel
engines and weapons fire. He reported the use of hearing protection.
Non-combat.
Pre Military Noise Exposure: Denied
Post Military Noise Exposure: Denied noise exposure.
Recreational Noise Exposure: Denied
Veteran reported the following:
Family History of Hearing Loss - Parents (presbycusis).
IV Antibiotics
Hearing Loss - Veteran has noticed a bilateral hearing loss since his
military service. He stated, "My fiance is fed up with repeating herself
so much. I don't watch TV anymore or listen to music. I also have a
hard
time hearing on the phone."
Tinnitus - Please see tinnitus section for details.
Veteran denied the following:
Ear Pain
Ear Drainage
Aural Fullness
Ear Surgery
History of Ear Infections
History of a Perforated Tympanic Membrane
Ear Trauma
Heart Attack
CVA/TIA
Diabetes
Dizziness
Chemotherapy/Radiation Treatments
Head Injury
C&P Results:
Otoscopy: Clear canal with visualization of the tympanic membrane,
bilaterally.
Tympanometry: Type A; Normal, bilaterally.
Acoustic Reflexes: Commensurate with audiogram, bilaterally.
Acoustic Reflex Decay: Negative, bilaterally and commensurate with
normal/sensory etiology.
RIGHT Ear: Hearing is within normal limits (250Hz - 4000Hz).
Mild/moderate (6000Hz - 8000Hz) high frequency sensorineural hearing
loss.
LEFT Ear: Hearing is within normal limits (250Hz - 4000Hz). Severe
(6000Hz - 8000Hz) high frequency sensorineural hearing loss.
C-File Review:
DD-214 Confirms MOS
Enlistment Audiogram - 09/17/1987
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 0 0 10 5 5 0
L 5 5 0 5 0 10
Hearing is within normal limits (500Hz - 6000Hz), bilaterally.
Reference Audiogram - 05/25/1989
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 5 0 10 5 0 10
L 0 0 0 5 0 20
Hearing is within normal limits (500Hz - 6000Hz), bilaterally.
Reference Audiogram - 04/11/1990
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 0 0 10 5 5 0
L 0 0 0 5 0 15
Hearing is within normal limits (500Hz - 6000Hz), bilaterally.
Reference Audiogram - 01/11/1991 (Last Audiogram in C-File)
500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz
R 15 10 15 10 10 5
L 15 5 5 5 0 40
RIGHT Ear: Hearing is within normal limits (500Hz - 6000Hz).
LEFT Ear: Hearing is within normal limits (500Hz - 4000Hz). Mild hearing
loss at 6000Hz.
Today's C&P Results - 10/23/2014
250Hz 500Hz 1000Hz 1500Hz 2000Hz 3000Hz 4000Hz 6000Hz 8000Hz
R 10 10 10 15 20 20 25 40 45
L 10 10 10 10 15 20 20 80 75
RIGHT Ear: Hearing is within norma limits (250Hz - 4000Hz).
Mild/moderate
(6000Hz - 8000Hz) high frequency sensorineural hearing loss.
LEFT Ear: Hearing is within normal limits (250Hz - 4000Hz). Severe
(6000Hz - 8000Hz) high frequency sensorineural hearing loss.
RIGHT Ear: There was a 15dB shift at 500Hz between enlistment audiogram
(09/17/1987) and last audiogram in C-File (01/11/1991), however it has
since recovered based on today's C&P results. Therefore, no
permanent
threshold shift in hearing during military service period in the right
ear.
LEFT Ear: There was a 30dB shift in hearing threshold at 6000Hz between
his enlistment audiogram (09/17/1987) and the last audiogram in C-File
(01/11/1991). This permanent threshold shift is consistent with a noise
injury incurred during military service period.
SECTION 2: TINNITUS
--------------------
1. Medical history
------------------
Does the Veteran report recurrent tinnitus: Yes
Date and circumstances of onset of tinnitus: Veteran reported bilateral
tinnitus. The tinnitus was described as a, "high pitched squeal." He
notices the tinnitus more so when it is quiet. Veteran has noticed the
tinnitus since qualifying with his M-16 in the "90's."
2. Etiology of tinnitus
-----------------------
At least as likely as not (50% probability or greater) caused by or a result
of military noise exposure.
Rationale: C-File carefully reviewed. Positive history of military noise
exposure and a baseline shift in hearing (left ear) occurred from his
enlistment audiogram (09/17/1987) and last audiogram (01/11/1991) in
C-File. The shift in hearing threshold (left ear) is consistent with an
in-service incurrence of hearing impairment from acoustic trauma.
Tinnitus
is a common symptom of acoustic trauma.
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::
--------------------------------------------
No response provided
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
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