Hello everyone I'm looking for input on a recent exam I had. I am already service connected for billateral shoulders and ankles at 0% and already submitted a favorable DBQ which led to another exam. She really made me feel uncomfortable
Ankle Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: JOHN DOE
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
Question
mtbrad82
Hello everyone I'm looking for input on a recent exam I had. I am already service connected for billateral shoulders and ankles at 0% and already submitted a favorable DBQ which led to another exam. She really made me feel uncomfortable
Ankle Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: JOHN DOE
ACE and Evidence Review
-----------------------
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
JOHN DOE CONFIDENTIAL Page 4 of 26
[X] In-person examination
a. Evidence review
------------------
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
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
[X] 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)
[ ] Other:
[ ] No records were reviewed
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ: BILATERAL ANKLE
SPRAIN
b. Select diagnoses associated with the claim condition(s) (Check all that
apply):
[X] Lateral collateral ligament sprain (chronic/recurrent)
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: 844.0
Date of diagnosis: Right 2001
Date of diagnosis: Left 2001
[X] Deltoid ligament sprain (chronic/recurrent)
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: 845.0
Date of diagnosis: Right 2001
Date of diagnosis: Left 2001
JOHN DOE CONFIDENTIAL Page 5 of 26
c. Comments (if any): No response provided
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
ankle
condition (brief summary): VET HAS INTERMITTENT PAIN. VET TAKES PAIN
MEDICATIONS WITH SOME RELIEF. VET ALSO USES AN ANKLE BRACE.
VET DOES NOT DO MUCH PHYSICAL ACTIVITY.
b. Does the Veteran report flare-ups of the ankle?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or
her
own words:
"I AM NOT ABLE TO DO ANYTHING BUT SIT AROUND AND ICE IT"
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ (regardless of
repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional
impairment in his or her own words:
"NOT ABLE TO PARTICIPATE IN ANY SPORTS ACTIVITY"
"I WOULDN'T BE ABLE TO DO A PHYSICAL JOB"
3. Range of motion (ROM) and functional limitations
---------------------------------------------------
a. Initial range of motion
Right ankle
-----------
[X] All Normal
[ ] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 20 degrees
Plantar Flexion (0-45): 0 to 45 degrees
Description of pain (select best response):
No pain noted on exam
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [ ] Yes [X] No
JOHN DOE CONFIDENTIAL Page 6 of 26
Is there objective evidence of crepitus? [ ] Yes [X] No
Left ankle
----------
[X] All Normal
[ ] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 20 degrees
Plantar Flexion (0-45): 0 to 45 degrees
Description of pain (select best response):
No pain noted on exam
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [ ] Yes [X] No
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Right ankle
-----------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No
Left ankle
----------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No
c. Repeated use over time
Right ankle
-----------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
JOHN DOE CONFIDENTIAL Page 7 of 26
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
Left ankle
----------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
Right ankle
-----------
Is the examination being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran?s statements
describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss during flare-ups. Please explain.
[X] The examination
is neither medically consistent or inconsistent with the
Veteran?s statements describing functional loss during flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-up?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms or range of motion? [ ] Yes [X] No
If no, please describe:
AS PER VET'S STATEMENT
Left ankle
----------
Is the examination being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran?s statements
describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss during flare-ups. Please explain.
[X] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss during flare-ups.
JOHN DOE CONFIDENTIAL Page 8 of 26
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-up?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion? [ ] Yes [X] No
If no, please describe:
AS PER VET'S STATEMENT
e. Additional factors contributing to disability
Right ankle
-----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Disturbance of locomotion, Interference with standing
Left ankle
----------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Disturbance of locomotion, Interference with standing
4. Muscle strength testing
--------------------------
a. Muscle strength - rate strength according to the following scale
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Right ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
JOHN DOE CONFIDENTIAL Page 9 of 26
b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
c. Comments, if any:
No response provided
5. Ankylosis
------------
Complete this section if Veteran has ankylosis of the ankle
a. Indicate severity of ankylosis and side affected (check all that apply):
Right side: Left side:
[ ] In plantar flexion [ ] In plantar flexion
[ ] In dorsiflexion [ ] In dorsiflexion
[ ] With an abduction deformity [ ] With an abduction deformity
[ ] With an inversion deformity [ ] With an inversion deformity
[ ] With an eversion deformity [ ] With an eversion deformity
[ ] In good weight-bearing position [ ] In good weight-bearing
position
[ ] In poor weight-bearing position [ ] In poor weight-bearing
position
[X] No ankylosis [X] No ankylosis
b. Comments, if any:
No response provided
6. Joint stability
------------------
Right ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
Left ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
7. Additional comments
----------------------
Does the Veteran now have or has he or she ever had "shin splints",
stress
fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus
(os calcis) or talus (astragalus), or has the Veteran had a talectomy
(astragalectomy)? [X] Yes [ ] No
If yes, indicate condition and complete the appropriate sections below:
[X] Shin splints (medial tibial stress syndrome)
Indicate side affected: [ ] Right [ ] Left [X] Both
JOHN DOE CONFIDENTIAL Page 10 of 26
Does this condition affect ROM of ankle?
[ ] Yes (If "yes", complete ROM section of ankle on this DBQ)
[X] No
Does this condition affect ROM of knee?
[ ] Yes (If "yes", complete VA Form 21-0960M-9 Knee and Lower
Leg
Conditions)
[X] No
Describe current symptoms: VET DOES NOT HAVE ANY CURRENT SYMPTOMS
SECONDARY TO SHIN SPLINTS. VET IS ALSO NOT PHYSICALLY ACTIVE AS PER
HIS HISTORY
8. Surgical procedures
----------------------
No response provided
9. Other pertinent physical findings, complications conditions, signs,
symptoms
and scars
-------------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above? [ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above? [ ] Yes [X] No
c. Comments, if any:
No response provided
10. Assistive devices
---------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion,
although occasional locomotion by other methods may be possible?
[X] Yes [ ] No
If yes, identify assistive devices used (check all that apply and indicate
frequency):
[ ] Wheelchair
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[X] Brace(s)
Frequency of use: [X] Occasional [ ] Regular [ ] Constant
[ ] Crutches
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
JOHN DOE CONFIDENTIAL Page 11 of 26
[ ] Cane(s)
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Walker
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
[ ] Other:
Frequency of use: [ ] Occasional [ ] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
BILATERAL ANKLE CONDITION
11. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's ankle condition, is there functional impairment of
an
extremity such that no effective functions remain other than that which would
be equally well served by an amputation with prosthesis? (Functions of the
upper extremity include grasping, manipulation, etc., while functions for the
lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
12. Diagnostic testing
----------------------
a. Have imaging studies of the ankle been performed and are the results
available? [ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[ ] Yes [X] No
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
13. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[X] Yes [ ] No
JOHN DOE CONFIDENTIAL Page 12 of 26
If yes, describe the functional impact of each condition, providing one or
more examples:
AVOIDS PHYSICAL ACTIVITY
14. Remarks, if any
-------------------
No response provided
****************************************************************************
Shoulder and Arm Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: JOHN DOE
ACE and Evidence Review
-----------------------
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
a. Evidence review
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes [X] No
JOHN DOE CONFIDENTIAL Page 13 of 26
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
[X] 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)
[ ] Other:
[ ] No records were reviewed
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
BILATERAL SHOULDER STRAIN
b. Select diagnoses associated with the claimed condition(s) (check all that
apply):
[X] Shoulder strain
Side affected: [ ] Right [ ] Left [X] Both
ICD Code: 840.9
Date of diagnosis: Right 2005
Date of diagnosis: Left 2005
c. Comments, if any:
No response provided
d. Was an opinion requested about this condition?
[X] Yes [ ] No [ ] N/A
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
shoulder
or arm condition (brief summary):
VET HAS INTERMITTENT PAIN IN BILATERAL SHOULDERS. HE TAKES PAIN
MEDICATIONS TRAMADOL AND IBUPROFEN WHICH HELPS.
VET IS ABLE TO DO LIFTING AND CARRYING UPTO 20 LBS.
VET ALSO STATES THAT HE WAS COACHING HIS CHILD'S BASEBALL TEAM FROM
FEBRUARY TO APRIL OF 2015. HE STOPPED DUE TO SHOULDER PAIN.
JOHN DOE CONFIDENTIAL Page 14 of 26
b. Dominant hand:
[ ] Right [X] Left [ ] Ambidextrous
c. Does the Veteran report flare-ups of the shoulder or arm?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his
or
her own words:
"I AM NOT ABLE TO DO ANYTHING"
"IT CONSTANTLY BOTHERS ME NO MATTER WHAT MOVEMENT I DO"
d. Does the Veteran report having any functional loss or functional
impairment
of the joint or extremity being evaluated on this DBQ (regardless of
repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words:
"I AM NOT ABLE TO COACH FOR MY KIDS BASEBALL TEAM"
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
Right Shoulder
--------------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 180): 0 to 90 degrees
Abduction (0 to 180): 0 to 90 degrees
External rotation (0 to 90): 0 to 30 degrees
Internal rotation (0 to 90): 0 to 90 degrees
If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No
If yes, please explain:
HAS DIFFICULTY RAISING ARM ABOVE HIS SHOULDER ON TODAY'S EXAM
Description of pain (select best response):
Pain noted on exam and causes functional loss
If noted on exam, which ROM exhibited pain (select all that apply)?
Flexion, Abduction, External rotation
JOHN DOE CONFIDENTIAL Page 15 of 26
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [ ] Yes [X] No
Is there objective evidence of crepitus? [ ] Yes [X] No
Left Shoulder
-------------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 180): 0 to 90 degrees
Abduction (0 to 180): 0 to 90 degrees
External rotation (0 to 90): 0 to 30 degrees
Internal rotation (0 to 90): 0 to 90 degrees
If abnormal, does the range of motion itself contribute to functional
loss? [X] Yes (please explain) [ ] No
If yes, please explain:
HAS DIFFICULTY RAISING ARM ABOVE HIS SHOULDER ON TODAY'S EXAM
Description of pain (select best response):
Pain noted on exam and causes functional loss
If noted on exam, which ROM exhibited pain (select all that apply)?
Flexion, Abduction, External rotation
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [ ] Yes [X] No
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Right Shoulder
--------------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] No
Left Shoulder
JOHN DOE CONFIDENTIAL Page 16 of 26
-------------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] No
c. Repeated use over time
Right Shoulder
--------------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
AS PER VET'S STATMENT
Left Shoulder
-------------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
AS PER VET'S STATEMENT
d. Flare-ups
Right Shoulder
--------------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
JOHN DOE CONFIDENTIAL Page 17 of 26
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
AS PER VET'S STATEMENT
Left Shoulder
-------------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
AS PER VET'S STATEMENT
JOHN DOE CONFIDENTIAL Page 18 of 26
e. Additional factors contributing to disability
Right Shoulder
--------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc.
Please describe additional contributing factors of disability:
VET HAS GUARDING OF THE RIGHT SHOULDER WHEN DOING ROM MOVEMENTS
Left Shoulder
-------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc., Weakened
movement due to muscle or peripheral nerve injury, etc.
Please describe additional contributing factors of disability:
VET HAS GUARDING OF THE LEFT SHOULDER WHEN DOING ROM MOVEMENTS
4. Muscle strength testing
--------------------------
a. Muscle strength - Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Right Shoulder: Rate Strength:
Forward flexion: 4/5
Abduction: 4/5
Is there a reduction in muscle strength? [X] Yes [ ] No
If yes, is the reduction entirely due to the claimed condition in the
Diagnosis Section? [X] Yes [ ] No
Left Shoulder: Rate Strength:
Forward flexion: 4/5
Abduction: 4/5
Is there a reduction in muscle strength? [X] Yes [ ] No
If yes, is the reduction entirely due to the claimed condition in the
Diagnosis Section? [X] Yes [ ] No
JOHN DOE CONFIDENTIAL Page 19 of 26
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
c. Comments, if any:
No response provided
5. Ankylosis
------------
Complete this section if the Veteran has ankylosis of scapulohumeral
(glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus
move as one piece).
a. Indicate severity of ankylosis and side affected (check all that apply):
Right side:
[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head
(Favorable ankylosis)
[ ] Ankylosis in abduction between favorable and unfavorable
(Intermediate ankylosis)
[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable
ankylosis)
[X] No ankylosis
Left side:
[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head
(Favorable ankylosis)
[ ] Ankylosis in abduction between favorable and unfavorable
(Intermediate ankylosis)
[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable
ankylosis)
[X] No ankylosis
b. Comments, if any:
No response provided
6. Rotator cuff conditions
--------------------------
Is rotator cuff condition suspected?
Right Shoulder: [X] Yes [ ] No
If "Yes" complete the following:
Hawkins' Impingement Test (Forward flex the arm to 90 degrees with
the
elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
indicates a positive test; may signify rotator cuff tendinopathy or
tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
JOHN DOE CONFIDENTIAL Page 20 of 26
Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees.
Patient turns thumbs down and resists downward force applied by the
examiner. Weakness indicates a positive test; may indicate rotator cuff
pathology, including supraspinatus tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
External Rotation/ Infraspinatus Strength Test (Patient holds arms at
side
with elbow flexed 90 degrees. Patient externally rotates against
resistance. Weakness indicates a positive test; may be associated with
infraspinatus tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
Lift-off Subscapularis Test (Patient internally rotates arm behind lower
back, pushes against examiner's hand. Weakness indicates a positive
test;
may indicate subscapularis tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
Left Shoulder: [X] Yes [ ] No
If "Yes" complete the following:
Hawkins' Impingement Test (Forward flex the arm to 90 degrees with
the
elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
indicates a positive test; may signify rotator cuff tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees.
Patient turns thumbs down and resists downward force applied by the
examiner. Weakness indicates a positive test; may indicate rotator cuff
pathology, including supraspinatus tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
External Rotation/ Infraspinatus Strength Test (Patient holds arms at
side
with elbow flexed 90 degrees. Patient externally rotates against
resistance. Weakness indicates a positive test; may be associated with
infraspinatus tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
Lift-off Subscapularis Test (Patient internally rotates arm behind lower
back, pushes against examiner's hand. Weakness indicates a positive
test;
may indicate subscapularis tendinopathy or tear.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
7. Shoulder instability, dislocation or labral pathology
--------------------------------------------------------
a. Is shoulder instability, dislocation or labral pathology suspected?
JOHN DOE CONFIDENTIAL Page 21 of 26
[ ] Yes [X] No
8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint
conditions
------------------------------------------------------------------------------
a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular
joint condition suspected?
[ ] Yes [X] No
9. Conditions or impairments of the humerus
-------------------------------------------
a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail
shoulder), or fibrous union of the humerus?
[ ] Yes [X] No
b. Does the Veteran have malunion of the humerus with moderate or marked
deformity?
[ ] Yes [X] No
c. Does the humerus condition affect range of motion of the shoulder
(glenohumeral) joint?
No response provided
d. Comments, if any:
No response provided
10. Surgical procedures
-----------------------
No response provided
11. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above?
[ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above?
[ ] Yes [X] No
c. Comments, if any:
No response provided
JOHN DOE CONFIDENTIAL Page 22 of 26
12. Assistive devices
---------------------
a. Does the Veteran use any assistive devices?
[ ] Yes [X] No
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
No response provided
13. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's shoulder and/or arm conditions, is there functional
impairment of an extremity such that no effective function remains other than
that which would be equally well served by an amputation with prosthesis?
(Functions of the upper extremity include grasping, manipulation, etc., while
functions for the lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
14. Diagnostic testing
----------------------
a. Have imaging studies of the shoulder been performed and are the results
available?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[ ] Yes [X] No
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
15. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's shoulder
conditions
providing one or more examples:
HAS DIFFICULTY WITH OVERHEAD ACTIVITY AND LIFTING AND CARRYING OVER 20
LBS.
JOHN DOE CONFIDENTIAL Page 23 of 26
16. Remarks, if any:
--------------------
No remarks provided
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: JOHN DOE
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? No
If no, check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment
records)
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: REVIEW OF CONFLICTING EVIDENCE OF BILATERAL
SHOULDER CONDITION
JOHN DOE CONFIDENTIAL Page 24 of 26
b. Indicate type of exam for which opinion has been requested: SHOULDER
TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL
EVIDENCE ]
I have reviewed the conflicting medical evidence and am providing the
following opinion: 3. AS PER TODAY'S EXAM, THE ROM OF BILATERAL
SHOULDERS
WAS SIMILAR TO THE ROM OF C AND P EXAM DONE ON 5-28-2015.
4. THERE WAS NO NOTED DECREASE IN THE ROM AFTER REPETITIVE TESTING.
5. TODAY'S EXAM SHOWED MILD WEAKNESS BUT THERE WAS NO PAIN OR
TENDERNESS ON
PALPATION OF THE BILATERAL SHOULDERS. VET COMPLAINED OF PAIN ONLY WHEN
TRYING TO RAISE THE ARM ABOVE HIS SHOULDERS BILATERALLY
6. SOME OF THE ADDITIONAL LOSS IS SUBJECTIVE BUT I DO AGREE THAT THERE WAS
LESS MOVEMENT THAN NORMAL AND WEAKENED MOVEMENT ON TODAY'S EXAM.
10. VET DID NOT GIVE A HISTORY OF RECURRENT DISLOCATION ON TODAY'S
EXAM.
UPON QUESTIONING THE VET, HE HAS NOT BEEN EVALUATED FOR ANY SHOULDER
CONDITION SINCE LEAVING THE MILITARY. ON REVIEWING THE VA CLINICAL NOTES,
VET WAS SEEN SEVERAL TIMES BY ORTHOPEDICS BUT DID NOT GET EVALUATED FOR A
SHOULDER CONDITION.
11. MY EXAMINATION TODAY DID NOT DEMONSTRATE ANY TENDERNESS ON PALPATION OF
THE AC JOINT.
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: REVIEW OF CONFLICTING EVIDENCE FOR
BILATERAL
ANKLE CONDITION
b. Indicate type of exam for which opinion has been requested: ANKLE
TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL
EVIDENCE ]
I have reviewed the conflicting medical evidence and am providing the
following opinion: 3. TODAY'S ROM EXAM OF BILATERAL ANKLES WAS NORMAL.
4. REPETITIVE TESTING OF THE BILATERAL ANKLES ROM DID NOT SHOW ANY CHANGES
IN ROM
5. TODAY'S EXAM DID NOT SHOW ANY SWELLING OR TENDERNESS ON PALPATION OF
THE
BILATERAL ANKLES.
6. VET COMPLAINED OF DIMINISHED ABILITY TO DO PHYSICAL ACTIVITY WITH THE
BILATERAL ANKLES. NO WEAKENED MOVEMENT OR PAIN ON MOVEMENT WAS NOTED ON
JOHN DOE CONFIDENTIAL Page 25 of 26
TODAY'S OBJECTIVE EXAM.
9. BILATERAL JOINT INSTABILITY IS NOT SUSPECTED ON TODAY'S EXAM
10. VET COMPLAINED OF SHIN SPLINTS ON TODAY'S EXAM. NO TENDERNESS OF
THE
BILATERAL LOWER EXTREMITIES WERE NOTED ON TODAY'S EXAM. VET IS ALSO
NOT
PHYSICALLY ACTIVE AS PER HISTORY.
I REVIEWED VET'S CORRESPONDENCE DATED 10-16-2014 FOR SHOULDER AND ANKLE.
WHEN QUESTIONING THE VET WITH REGARDS TO TREATMENT RECEIVED FOR HIS ANKLES
AND SHOULDER AFTER LEAVING ACTIVE MILITARY SERVICE, VET INDICATED THAT HE
HAD NOT SOUGHT MEDICAL ATTENTION FOR IT NOR DID ANY WORKUP SUCH AS X-RAYS
WERE DONE FOR HIS ANKLES AND SHOULDER. HE DID SEE ORTHOPEDIC IN 2015 FOR
HIS
KNEE. HE WAS EVALUATED BY PCP IN 2014/2015 AND NO MENTION OF A BILATERAL
SHOULDER OR BILATERAL ANKLE CONDITION WAS NOTED ON HIS PROBLEM LISTS.
IT IS SPECULATION ON MY PART BUT I WOULD HAVE TO CONSIDER THAT HIS CURRENT
SYMPTOMS OF BILATERAL SHOULDER AND ANKLE PAIN MAY NOT BE RELATED TO ACTIVE
MILITARY SERVICE. HE DOES GIVE HISTORY OF COACHING HIS CHILD'S BASEBALL
TEAM
FOR A FEW MONTHS AFTER LEAVING ACTIVE MILITARY SERVICE. HE HAS NOT SOUGHT
MEDICAL ATTENTION FOR BILATERAL SHOULDERS AND ANKLES AFTER LEAVING ACTIVE
MILITARY SERVICE.
PLEASE NOTE THAT VET'S ATTITUDE ON TODAY'S EXAM WAS
COMBATIVE/ANGRY
*************************************************************************
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