I recently went for my C&P exam and would like your opinions on what percentage of rating I may receive.
The C&P was completed by a VA Doctor at a VA Facility. I know it is long, but I would appreciate any
input. Thanks in advance.
Name of patient/Veteran: 1. Medical record review ------------------------ [X] Other, describe: VBMS, CPRS, Civilian Records 2. Medical history ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: Skin Diseases c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided
e. Hearing loss, tinnitus and ear: No answer provided f. Sinus, nose, throat, dental and oral: No answer provided g. Breast: No answer provided h. Respiratory: No answer provided i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: The following conditions have been reported Joints and extremities: Ankle, Shoulder and Arm Miscellaneous musculoskeletal: Fibromyalgia n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: Chronic Fatigue Syndrome r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [ ] Yes [X] No 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness"
5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- No answer provided **************************************************************************** Skin Diseases 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? [ ] 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: [X] 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) [X] 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 skin condition? [X] Yes [ ] No [X] Tumors and neoplasms of the skin, including malignant melanoma Diagnosis: Squamous cell cancer left hand [X] Other skin condition Other diagnosis #1: Epidermal inclusion cyst Date of diagnosis: July 2013 and Aug 2014 Other diagnosis #2: Dyshidrosis Date of diagnosis: 1992 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's skin conditions (brief summary): Exposed to oil well fire soot during deployment. Unemployed since 2010. Onset 1992 of skin papules with itching in hands and forearms lastin 24-48 hours occuring singly and not in clusters. Patient pops lesion with return of clear fluid. No evaluation or treatment sought. Squamous cell cancer left hand with excision June 2013. Epidermal inclusion cyst excision mid back and left anterior ankle July 2013. Excision of intradermal melanocytic nevus left posterior scalp and epidermal inclusion cyst right posterior shoulder in Aug 2014. b. Do any of the Veteran's skin conditions cause scarring or disfigurement of the head, face or neck? [ ] Yes [X] No c. Does the Veteran have any benign or malignant skin neoplasms (including malignant melanoma)? [X] Yes [ ] No d. Does the Veteran have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma)? [ ] Yes [X] No 3. Treatment ------------ a. Has the Veteran been treated with oral or topical medications in the past 12 months for any skin condition? [ ] Yes [X] No b. Has the Veteran had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders? [ ] Yes [X] No 4. Debilitating and non-debilitating episodes --------------------------------------------- a. Has the Veteran had any debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis? [ ] Yes [X] No b. Has the Veteran had any non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months? No response provided. 5. Physical exam
a. Indicate the Veteran's visible skin conditions; indicate the approximate total body area and approximate total EXPOSED body area (face, neck and hands) affected on current examination (check all that apply): [X] The Veteran does not have any of the above listed visible skin conditions 6. Specific Skin Conditions --------------------------- Indicate the Veteran's specific skin conditions and complete all applicable subsequent questions (check all that apply): [X] Veteran does not have any of the specific skin conditions listed above 7. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [X] Yes [ ] No If yes, complete the following: b. Is the neoplasm [ ] Benign [X] Malignant c. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases? [X] Yes [ ] No; watchful waiting [X] Surgery If checked, describe: excision of SCC dorsal aspect of left hand Date(s) of surgery: 7-8-13 d. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? [ ] Yes [X] No e. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: No response provided. 8. Other pertinent physical findings, complications, conditions, signs and/or symptoms
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 9. Functional impact -------------------- Do any of the Veteran's skin conditions impact his or her ability to work? [ ] Yes [X] No 10. Remarks, if any: -------------------- No remarks provided. **************************************************************************** Medical Opinion 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? No If no, check all records reviewed: [X] Military service treatment records [X] Veterans Health Administration medical records (VA treatment
records) [X] Civilian medical records MEDICAL OPINION SUMMARY ----------------------- Exposed to oil well firesoot during deployment. Unemployed since 2010. 1. Fibromyalgia. The patient met the diagnostic criteria for fibromyalgia. Onset was gradual per patient upon return from his deployment. He became increasingly aware in 1999 and sought treatment in 2004-2006 time frame. He is on multiple medications for pain control. It is at least as likely as not that the fibromyalgia was related to SW Asia deployment 2. Chronic Fatigue Syndrome (CFS). The patient did not meet the diagnostic criteria for CFS. It is not likely that Fatigue was related to CFS or that it was incurred during his deployment in SW Asia 3. It is not likely that the squamous cell carcinoma of the left hand and epidermal inclusion cysts were related to his service in the military or to his deployment in SW Asia. 4. It is as least as likely as not that the tendinitis in the ankles and the degenerative joint disease of the AC joints in the shoulders were related to the deployment in SW Asia as the gradual onset occurred after his deployment in SW Asia although the patient did not seek treatment until later when he became increasingly debilitated RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Is the disability pattern of fatigue, joint pain, muscle pain and skin diseases related to a specific exposure event during servuice in SW Asia b. Indicate type of exam for which opinion has been requested: Skin disaease, Shoulder, Ankle, Fibromyalgia and Chronic Fatigue Syndrome TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL EVIDENCE ] I have reviewed the conflicting medical evidence and am providing the following opinion: See below
Fibromyalgia Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Military service treatment records [X] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Fibromyalgia 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: Exposed to oil well fire soot during deployment. Unemployed since 2010. Muscle and tendon pain x 1999 gradually increasing in severity 2004-2006 time frame. Pain noted over left forearm biceps thighs ankles back. Pain present more than 24 hours after exertion lasting up to one week before resolution. Pt wakes up with discomfort but increasing activity leads to increased pain from muscles.
b. Is continuous medication required for control of fibromyalgia symptoms? [ ] Yes [X] No c. Is the Veteran currently undergoing treatment for this condition? [X] Yes [ ] No If yes, describe: Trigger point injections, gabapentin 300 mg twice daily, naproxen 250 mg twice daily, hydrocodone 10 mg / acetaminophen 325 mg four times daily d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [ ] Yes [X] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia? [X] Yes [ ] No a. Findings, signs and symptoms (check all that apply): [X] Widespread musculoskeletal pain [X] Fatigue [X] Sleep disturbances [X] Anxiety b. Frequency of fibromyalgia symptoms (check all that apply): [X] Constant or nearly constant c. Does the Veteran have tender points (trigger points) for pain present? [X] Yes [ ] No [X] Low cervical region: at anterior aspect of the interspaces between transverse processes of C5-C7 If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Second rib: at second costochondral junction If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Occiput: at suboccipital muscle insertion If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Trapezius muscle: midpoint of upper border If checked, indicate side: [ ] Right [ ] Left [X] Both
[X] Supraspinatus muscle: above medial border of the scapular spine If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Lateral epicondyle: 2 cm distal to lateral epicondyle If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Gluteal: at upper outer quadrant of buttocks If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Greater trochanter: posterior to greater trochanteric prominence If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Knee: medial joint line If checked, indicate side: [ ] Right [ ] Left [X] Both 4. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): Tenderness over bilateral achilles tendons and over left deltoid ligament left ankle 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact --------------------- Does the Veteran's fibromyalgia impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of the Veteran's fibromyalgia, providing one or more examples: Patient was on workmens compensation 2006-2008 due to left ankle pain on ambulation. He had an exploratory laparascopic surgery in 2007 without a conclusive cause of his left ankle pain. In 2012 he had
similar pain on his right ankle lasting one week in duration. This occurred while climbing a hill and supporting most of his weight on his right ankle. 7. Remarks, if any: ------------------- No remarks provided. **************************************************************************** Chronic Fatigue Syndrome Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [ ] Yes [X] No If no, check all records reviewed: [X] Military service treatment records [X] Veterans Health Administration medical records (VA treatment records) [X] Civilian medical records 1. Diagnosis ------------ Does the Veteran now have or has/she ever been diagnosed with chronic fatigue syndrome? [ ] Yes [X] No 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's chronic fatigue syndrome: Exposed to oil well fire soot during deployment. Unemployed since 2010. Patient claims fatigue on arising in the morning. Fatigue worsens during the day. If patient exerts himself he will experience increased fatigue and muscle pain which can persist > 24 hours and may last up to one week. b. Is continuous medication required for control of chronic fatigue syndrome? [ ] Yes [X] No If yes, are the Veteran's symptoms controlled by continuous medication? [ ] Yes [ ] No c. Have other clinical conditions that may produce similar symptoms been excluded by history, physical examination and/or laboratory tests to the extent possible? [X] Yes [ ] No d. Did the Veteran have an acute onset of chronic fatigue syndrome? [ ] Yes [X] No e. Has debilitating fatigue reduced daily activity level to less than 50% of pre-illness level? [X] Yes [ ] No If yes, specify length of time daily activity level has been reduced to less than 50% of pre-illness level: [ ] Less than 6 months [X] 6 months or longer 3. Findings, signs and symptoms ------------------------------- a. Does the Veteran now have or has the Veteran had any findings, signs and symptoms attributable to chronic fatigue syndrome? [X] Yes [ ] No If yes, check all that apply: [X] Debilitating fatigue [X] Generalized muscle aches or weakness [X] Fatigue lasting 24 hours or longer after exercise b. Does the Veteran now have or has the Veteran had any cognitive impairment attributable to chronic fatigue syndrome? [ ] Yes [X] No c. Specify frequency of symptoms:
[X] Symptoms are nearly constant d. Do the Veteran's symptoms due to chronic fatigue syndrome restrict routine daily activities as compared to the pre-illness level? [X] Yes [ ] No If yes, specify % of restriction (check all that apply): [X] Symptoms restrict routine daily activities to 50% to 75% of the pre-illness level e. Do the Veteran's symptoms due to chronic fatigue syndrome result in periods of incapacitation? [ ] Yes [X] No 4. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms of chronic fatigue syndrome? [ ] Yes [X] No 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact -------------------- Does the Veteran's chronic fatigue syndrome impact his or her ability to work? [X] Yes [ ] No 7. Remarks, if any: ------------------- No remarks provided.
Ankle Conditions Disability Benefits Questionnaire Name of patient/Veteran: 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 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: [X] 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) [X] 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? [X] Yes [ ] No If yes, describe: Orthopedic surgeon workmens comp notes 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: ankle b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Deltoid ligament sprain (chronic/recurrent) Side affected: [ ] Right [X] Left [ ] Both [X] Tendonitis (achilles/peroneal/posterior tibial) Side affected: [ ] Right [ ] Left [X] Both Date of diagnosis: Right 2012 Date of diagnosis: Left 2006 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): exposure to oil well fire soot. Onset of left ankle pain with pain level 10/10 at onset in 2006. He underwent exploratory laparoscopic surgery in 2007 without a conclusive diagnosis after multiple attempts to treat pain. Pain was worse on ambulation. He was on workmens compensation from 2006 to 2008. In 2012 he experienced the same pain over the right ankle which had a duration of one week of pain with pain level 10/10. Pt unable to walk more than 1/8 mile and unable to stand for more than 20 minutes. He is unable to climb ladders which was part of his duties as a building maintenance worker. 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: see above c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: see above 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right ankle ----------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 10 degrees Plantar Flexion (0-45): 0 to 45 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender achilles tendon Is there objective evidence of crepitus? [ ] Yes [X] No Left ankle ---------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 10 degrees Plantar Flexion (0-45): 0 to 45 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender achilles tendon and left deltoid ligament 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? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use
over time: [X] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion? [X] Yes [ ] No Dorsiflexion (0-20): 0 to 5 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion? [X] Yes [ ] No Dorsiflexion (0-20): 0 to 5 degrees
Plantar Flexion (0-45): 0 to 45 degrees 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: [X] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms or range of motion? [X] Yes [ ] No Dorsiflexion (0-20): 0 to 5 degrees Plantar Flexion (0-45): 0 to 45 degrees 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: [X] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss during flare-ups. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion? [X] Yes [ ] No
Dorsiflexion (0-20): 0 to 5 degrees Plantar Flexion (0-45): 0 to 45 degrees 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 Please describe: see above history 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 Please describe: see above history 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if Veteran has ankylosis of the ankle a. Indicate severity of ankylosis and side affected (check all that apply): Right side: Left side: [ ] In plantar flexion [ ] In plantar flexion [ ] In dorsiflexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an inversion deformity [ ] With an eversion deformity [ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing position [ ] In poor weight-bearing position [ ] In poor weight-bearing position [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No Left ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No 7. Additional comments ---------------------- Does the Veteran now have or has he or she ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below: [X] Achilles tendonitis or achilles tendon rupture Indicate side affected: [ ] Right [ ] Left [X] Both Describe current symptoms: tender achilles tendons bilat limiting
dorsiflexion 8. Surgical procedures ---------------------- Indicate any surgical procedures that the Veteran has had performed and provide the additional information as requested (check all that apply): Right side: No response provided Left side: [X] Arthroscopic or other ankle surgery Type of surgery: Exploratory lapraroscopic surgery of left ankle Date of surgery: Dec 2007 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? [X] Yes [ ] No If yes, are any of these scars painful or unstable, have a total area equal to or greater than 39 square cm (6 square inches) or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.) [ ] Yes [X] No If no, provide location and measurements of scar in centimeters Location: left anterior ankle Measurements: length 2 cm X width 0.5 cm c. Comments, if any: No response provided 10. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided
11. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's ankle condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 12. Diagnostic testing ---------------------- a. Have imaging studies of the ankle been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 13. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: Patient has limited walking up to 1/8 mile. Further walking will cause increased diffuse muscular pain that will last up to one week. 14. Remarks, if any ------------------- No response provided
Shoulder and Arm Conditions Disability Benefits Questionnaire Name of patient/Veteran: 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 If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records)
[X] 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? [X] Yes [ ] No If yes, describe: Orthopedic surgeon workmens comp notes 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: Shoulder pain b. Select diagnoses associated with the claimed condition(s) (check all that apply): [X] Acromioclavicular joint osteoarthritis 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): exposed to oil well fire soot. Unemployed since 2010. Right hand dominant with onset left > right shoulder pain x 2013. Patient has difficulty on reaching overhead repetitively. Unable to throw baseballs footballs basketballs. Unable to carry more than 5 pounds for more than 20 minutes. b. Dominant hand: [X] Right [ ] Left [ ] Ambidextrous c. Does the Veteran report flare-ups of the shoulder or arm? [ ] Yes [X] No 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: see above 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 180 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 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 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 Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No Is there objective evidence of crepitus? [ ] Yes [X] No Left 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 150 degrees Abduction (0 to 180): 0 to 135 degrees External rotation (0 to 90): 0 to 90 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 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 Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No Is there objective evidence of crepitus? [ ] Yes [X] No 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? [X] Yes [ ] No Select all factors that cause this functional loss: Pain, Fatigue, Weakness ROM after three repetitions: Flexion (0 to 180): 0 to 155 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees Left 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? [X] Yes [ ] No Select all factors that cause this functional loss: Pain, Fatigue, Weakness ROM after three repetitions: Flexion (0 to 180): 0 to 150 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees
Internal rotation (0 to 90): 0 to 90 degrees c. Repeated use over time Right Shoulder -------------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion: [X] Yes [ ] No Flexion (0 to 180): 0 to 150 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees Left Shoulder ------------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time.
Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Fatigue, Weakness, Lack of endurance Able to describe in terms of range of motion: [X] Yes [ ] No Flexion (0 to 180): 0 to 150 degrees Abduction (0 to 180): 0 to 120 degrees External rotation (0 to 90): 0 to 90 degrees Internal rotation (0 to 90): 0 to 90 degrees d. Flare-ups: No response provided 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: None Left Shoulder ------------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No
Left Shoulder: Rate Strength: Forward flexion: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of 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: [ ] Yes [X] No Left Shoulder: [ ] Yes [X] No 7. Shoulder instability, dislocation or labral pathology
a. Is shoulder instability, dislocation or labral pathology suspected? [ ] 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? [X] Yes [ ] No If yes, complete questions 8b, 8d and 8e below: b. Does the Veteran have an AC joint condition or any other impairment of the clavicle or scapula? [X] Yes [ ] No If yes, indicate severity and side affected, and answer 8c below: [X] Other, describe: degenerative disease ac joint left shoulder [ ] Right [X] Left [ ] Both c. Does the clavicle or scapula condition affect range of motion of the shoulder (glenohumeral) joint? [ ] Yes [X] No d. Is there tenderness on palpation of the AC joint? [X] Yes [ ] No If yes, indicate side: [ ] Right [ ] Left [X] Both e. Cross-body adduction test (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint pathology.) [X] Positive [ ] Negative [ ] Unable to perform [ ] N/A If positive, side affected: [ ] Right [ ] Left [X] Both 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 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? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate shoulder: [ ] Right [X] Left [ ] Both 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: Xray with left AC joint degenerative disease. 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: See history 16. Remarks, if any: -------------------- No remarks provided
Question
Navigator
Hi All,
I recently went for my C&P exam and would like your opinions on what percentage of rating I may receive.
The C&P was completed by a VA Doctor at a VA Facility. I know it is long, but I would appreciate any
input. Thanks in advance.
Name of patient/Veteran:
1. Medical record review
------------------------
[X] Other, describe: VBMS, CPRS, Civilian Records
2. Medical history
------------------
a. No symptoms, abnormal findings or complaints: No answer provided
b. Skin and scars: Skin Diseases
c. Hematologic/lymphatic: No answer provided
d. Eye: No answer provided
e. Hearing loss, tinnitus and ear: No answer provided
f. Sinus, nose, throat, dental and oral: No answer provided
g. Breast: No answer provided
h. Respiratory: No answer provided
i. Cardiovascular: No answer provided
j. Digestive and abdominal wall: No answer provided
k. Kidney and urinary tract: No answer provided
l. Reproductive: No answer provided
m. Musculoskeletal: The following conditions have been reported
Joints and extremities: Ankle, Shoulder and Arm
Miscellaneous musculoskeletal: Fibromyalgia
n. Endocrine: No answer provided
o. Neurologic: No answer provided
p. Psychiatric: No answer provided
q. Infectious disease, immune disorder or nutritional deficiency: Chronic
Fatigue Syndrome
r. Miscellaneous conditions: No answer provided
3. Diagnosed illnesses with no etiology
---------------------------------------
From the conditions identified and for which Questionnaires were completed,
are there any diagnosed illnesses for which no etiology was established?
[ ] Yes [X] No
4. Additional signs and/or symptoms that may represent an "undiagnosed
illness" or "diagnosed medically unexplained chronic
multisymptom illness"
5. Physical Exam
----------------
Normal PE, except as noted on additional Questionnaires included as part of
this
report
6. Functional impact of additional signs and/or symptoms that may represent
an "undiagnosed illness" or "diagnosed medically
unexplained chronic
multisymptom illness"
-----------------------------------------------------------------------------
[ ] Yes [X] No
7. Remarks, if any:
-------------------
No answer provided
****************************************************************************
Skin Diseases
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?
[ ] 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:
[X] 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)
[X] 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 skin condition?
[X] Yes [ ] No
[X] Tumors and neoplasms of the skin, including malignant melanoma
Diagnosis: Squamous cell cancer left hand
[X] Other skin condition
Other diagnosis #1: Epidermal inclusion cyst
Date of diagnosis: July 2013 and Aug 2014
Other diagnosis #2: Dyshidrosis
Date of diagnosis: 1992
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
skin
conditions (brief summary):
Exposed to oil well fire soot during deployment. Unemployed since 2010.
Onset 1992 of skin papules with itching in hands and forearms lastin
24-48 hours occuring singly and not in clusters. Patient pops lesion
with return of clear fluid. No evaluation or treatment sought.
Squamous cell cancer left hand with excision June 2013. Epidermal
inclusion cyst excision mid back and left anterior ankle July 2013.
Excision of intradermal melanocytic nevus left posterior scalp and
epidermal inclusion cyst right posterior shoulder in Aug 2014.
b. Do any of the Veteran's skin conditions cause scarring or
disfigurement of
the head, face or neck?
[ ] Yes [X] No
c. Does the Veteran have any benign or malignant skin neoplasms (including
malignant melanoma)?
[X] Yes [ ] No
d. Does the Veteran have any systemic manifestations due to any skin
diseases
(such as fever, weight loss or hypoproteinemia associated with skin
conditions such as erythroderma)?
[ ] Yes [X] No
3. Treatment
------------
a. Has the Veteran been treated with oral or topical medications in the past
12 months for any skin condition?
[ ] Yes [X]
No
b. Has the Veteran had any treatments or procedures other than systemic or
topical medications in the past 12 months for exfoliative dermatitis or
papulosquamous disorders?
[ ] Yes [X] No
4. Debilitating and non-debilitating episodes
---------------------------------------------
a. Has the Veteran had any debilitating episodes in the past 12 months due
to
urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic
epidermal necrolysis?
[ ] Yes [X] No
b. Has the Veteran had any non-debilitating episodes of urticaria, primary
cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis
in the past 12 months?
No response provided.
5. Physical exam
a. Indicate the Veteran's visible skin conditions; indicate the
approximate
total body area and approximate total EXPOSED body area (face, neck and
hands) affected on current examination (check all that apply):
[X] The Veteran does not have any of the above listed visible skin
conditions
6. Specific Skin Conditions
---------------------------
Indicate the Veteran's specific skin conditions and complete all
applicable
subsequent questions (check all that apply):
[X] Veteran does not have any of the specific skin conditions listed above
7. Tumors and neoplasms
-----------------------
a. Does the Veteran have a benign or malignant neoplasm or metastases
related
to any of the diagnoses in the Diagnosis section?
[X] Yes [ ] No
If yes, complete the following:
b. Is the neoplasm
[ ] Benign [X] Malignant
c. Has the Veteran completed treatment or is the Veteran currently
undergoing
treatment for a benign or malignant neoplasm or metastases?
[X] Yes [ ] No; watchful waiting
[X] Surgery
If checked, describe: excision of SCC dorsal aspect of left
hand
Date(s) of surgery: 7-8-13
d. Does the Veteran currently have any residual conditions or complications
due to the neoplasm (including metastases) or its treatment, other than
those already documented in the report above?
[ ] Yes [X] No
e. If there are additional benign or malignant neoplasms or metastases
related to any of the diagnoses in the Diagnosis section, describe using
the above format:
No response provided.
8. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms
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
9. Functional impact
--------------------
Do any of the Veteran's skin conditions impact his or her ability to
work?
[ ] Yes [X] No
10. Remarks, if any:
--------------------
No remarks provided.
****************************************************************************
Medical Opinion
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? No
If no, check all records reviewed:
[X] Military service treatment records
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Civilian medical records
MEDICAL OPINION SUMMARY
-----------------------
Exposed to oil well firesoot during deployment.
Unemployed since 2010.
1. Fibromyalgia. The patient met the diagnostic criteria for fibromyalgia.
Onset was gradual per patient upon return from his deployment. He became
increasingly aware in 1999 and sought treatment in 2004-2006 time frame. He
is on multiple medications for pain control. It is at least as likely as not
that the fibromyalgia was related to SW Asia deployment
2. Chronic Fatigue Syndrome (CFS). The patient did not meet the diagnostic
criteria for CFS. It is not likely that Fatigue was related to CFS or that
it was incurred during his deployment in SW Asia
3. It is not likely that the squamous cell carcinoma of the left hand and
epidermal inclusion cysts were related to his service in the military or to
his deployment in SW Asia.
4. It is as least as likely as not that the tendinitis in the ankles and the
degenerative joint disease of the AC joints in the shoulders were related to
the deployment in SW Asia as the gradual onset occurred after his deployment
in SW Asia although the patient did not seek treatment until later when he
became increasingly debilitated
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Is the disability pattern of fatigue, joint
pain, muscle pain and skin diseases related to a specific exposure event
during servuice in SW Asia
b. Indicate type of exam for which opinion has been requested: Skin
disaease,
Shoulder, Ankle, Fibromyalgia and Chronic Fatigue Syndrome
TYPE OF MEDICAL OPINION PROVIDED: [ OPINION REGARDING CONFLICTING MEDICAL
EVIDENCE ]
I have reviewed the conflicting medical evidence and am providing the
following opinion: See below
Fibromyalgia
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes[X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Civilian medical records
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with
fibromyalgia? (This is the condition the Veteran is claiming or for which an
exam has been requested)
[X] Yes [ ] No
[X] Fibromyalgia
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
fibromyalgia condition:
Exposed to oil well fire soot during deployment. Unemployed since 2010.
Muscle and tendon pain x 1999 gradually increasing in severity
2004-2006 time frame. Pain noted over left forearm biceps thighs
ankles back. Pain present more than 24 hours after exertion lasting
up
to one week before resolution. Pt wakes up with discomfort but
increasing activity leads to increased pain from muscles.
b. Is continuous medication required for control of fibromyalgia symptoms?
[ ] Yes [X] No
c. Is the Veteran currently undergoing treatment for this condition?
[X] Yes [ ] No
If yes, describe:
Trigger point injections, gabapentin 300 mg twice daily, naproxen 250
mg twice daily, hydrocodone 10 mg / acetaminophen 325 mg four times
daily
d. Are the Veteran's fibromyalgia symptoms refractory to therapy?
[ ] Yes [X] No
3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to fibromyalgia?
[X] Yes [ ] No
a. Findings, signs and symptoms (check all that apply):
[X] Widespread musculoskeletal pain
[X] Fatigue
[X] Sleep disturbances
[X] Anxiety
b. Frequency of fibromyalgia symptoms (check all that apply):
[X] Constant or nearly constant
c. Does the Veteran have tender points (trigger points) for pain present?
[X] Yes [ ] No
[X] Low cervical region: at anterior aspect of the interspaces between
transverse processes of C5-C7
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Second rib: at second costochondral junction
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Occiput: at suboccipital muscle insertion
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Trapezius muscle: midpoint of upper border
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Supraspinatus muscle: above medial border of the scapular spine
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Lateral epicondyle: 2 cm distal to lateral epicondyle
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Gluteal: at upper outer quadrant of buttocks
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Greater trochanter: posterior to greater trochanteric prominence
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Knee: medial joint line
If checked, indicate side:
[ ] Right [ ] Left [X] Both
4. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms
-----------------------------------------------------------------------------
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis section above?
[X] Yes [ ] No
If yes, describe (brief summary):
Tenderness over bilateral achilles tendons and over left deltoid
ligament left ankle
5. Diagnostic testing
---------------------
Are there any significant diagnostic test findings and/or results?
[ ] Yes [X] No
6. Functional impact
---------------------
Does the Veteran's fibromyalgia impact his or her ability to work?
[X] Yes [ ] No
If yes, describe impact of the Veteran's fibromyalgia, providing one
or
more examples:
Patient was on workmens compensation 2006-2008 due to left ankle pain
on ambulation. He had an exploratory laparascopic surgery in 2007
without a conclusive cause of his left ankle pain. In 2012 he had
similar pain on his right ankle lasting one week in duration. This
occurred while climbing a hill and supporting most of his weight on
his right ankle.
7. Remarks, if any:
-------------------
No remarks provided.
****************************************************************************
Chronic Fatigue Syndrome
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Civilian medical records
1. Diagnosis
------------
Does the Veteran now have or has/she ever been diagnosed with chronic
fatigue
syndrome?
[ ] Yes [X] No
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
chronic
fatigue syndrome:
Exposed to oil well fire soot during deployment. Unemployed since 2010.
Patient claims fatigue on arising
in the morning. Fatigue worsens during the day. If patient exerts
himself he will experience increased fatigue and muscle pain which can
persist > 24 hours and may last up to one week.
b. Is continuous medication required for control of chronic fatigue
syndrome?
[ ] Yes [X] No
If yes, are the Veteran's symptoms controlled by continuous
medication?
[ ] Yes [ ] No
c. Have other clinical conditions that may produce similar symptoms been
excluded by history, physical examination and/or laboratory tests to the
extent possible?
[X] Yes [ ] No
d. Did the Veteran have an acute onset of chronic fatigue syndrome?
[ ] Yes [X] No
e. Has debilitating fatigue reduced daily activity level to less than 50% of
pre-illness level?
[X] Yes [ ] No
If yes, specify length of time daily activity level has been reduced
to
less than 50% of pre-illness level:
[ ] Less than 6 months [X] 6 months or longer
3. Findings, signs and symptoms
-------------------------------
a. Does the Veteran now have or has the Veteran had any findings, signs and
symptoms attributable to chronic fatigue syndrome?
[X] Yes [ ] No
If yes, check all that apply:
[X] Debilitating fatigue
[X] Generalized muscle aches or weakness
[X] Fatigue lasting 24 hours or longer after exercise
b. Does the Veteran now have or has the Veteran had any cognitive impairment
attributable to chronic fatigue syndrome?
[ ] Yes [X] No
c. Specify frequency of symptoms:
[X] Symptoms are nearly constant
d. Do the Veteran's symptoms due to chronic fatigue syndrome restrict
routine
daily activities as compared to the pre-illness level?
[X] Yes [ ] No
If yes, specify % of restriction (check all that apply):
[X] Symptoms restrict routine daily activities to 50% to 75% of the
pre-illness level
e. Do the Veteran's symptoms due to chronic fatigue syndrome result in
periods of incapacitation?
[ ] Yes [X] No
4. Other pertinent physical findings, scars, complications, conditions,
signs
and/or symptoms
-----------------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms of chronic fatigue
syndrome?
[ ] Yes [X] No
5. Diagnostic testing
---------------------
Are there any significant diagnostic test findings and/or results?
[ ] Yes [X] No
6. Functional impact
--------------------
Does the Veteran's chronic fatigue syndrome impact his or her ability
to
work?
[X] Yes [ ] No
7. Remarks, if any:
-------------------
No remarks provided.
Ankle Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
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
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:
[X] 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)
[X] 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?
[X] Yes [ ] No
If yes, describe:
Orthopedic surgeon workmens comp notes
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ: ankle
b. Select diagnoses associated with the claim condition(s) (Check all that
apply):
[X] Deltoid ligament sprain (chronic/recurrent)
Side affected: [ ] Right [X] Left [ ] Both
[X] Tendonitis (achilles/peroneal/posterior tibial)
Side affected: [ ] Right [ ] Left [X] Both
Date of diagnosis: Right 2012
Date of diagnosis: Left 2006
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):
exposure to oil well fire soot.
Onset of left ankle pain with pain level 10/10 at onset in 2006. He
underwent exploratory laparoscopic surgery in 2007 without a conclusive
diagnosis after multiple attempts to treat pain. Pain was worse on
ambulation. He was on workmens compensation from 2006 to 2008. In 2012 he
experienced the same pain over the right ankle which had a duration of one
week of pain with pain level 10/10. Pt unable to walk more than 1/8 mile
and
unable to stand for more than 20 minutes. He is unable to climb ladders
which was part of his duties as a building maintenance worker.
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:
see above
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ (regardless of
repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional
impairment in his or her own words:
see above
3. Range of motion (ROM) and functional limitations
---------------------------------------------------
a. Initial range of motion
Right ankle
-----------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 10 degrees
Plantar Flexion (0-45): 0 to 45 degrees
If abnormal, does the range of motion itself contribute to a functional
loss? [X] Yes, (please explain) [ ] No
Description of pain (select best response):
Pain noted on examination and causes functional loss
If noted on examination, which ROM exhibited pain (select all that apply)?
Dorsiflexion
Is there evidence of pain with weight bearing? [X] Yes [ ] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
tender achilles tendon
Is there objective evidence of crepitus? [ ] Yes [X] No
Left ankle
----------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Dorsiflexion (0-20): 0 to 10 degrees
Plantar Flexion (0-45): 0 to 45 degrees
If abnormal, does the range of motion itself contribute to a functional
loss? [X] Yes, (please explain) [ ] No
Description of pain (select best response):
Pain noted on examination and causes functional loss
If noted on examination, which ROM exhibited pain (select all that apply)?
Dorsiflexion
Is there evidence of pain with weight bearing? [X] Yes [ ] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
tender achilles tendon and left deltoid ligament
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?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive use
over time:
[X] The examination is medically consistent with the Veteran?s statements
describing functional loss with repetitive use over time.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss with repetitive use over time. Please
explain.
[ ] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss with repetitive use
over
time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness, Lack of endurance
Able to describe in terms of range of motion? [X] Yes [ ] No
Dorsiflexion (0-20): 0 to 5 degrees
Plantar Flexion (0-45): 0 to 45 degrees
Left ankle
----------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive use
over time:
[X] The examination is medically consistent with the Veteran?s statements
describing functional loss with repetitive use over time.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss with repetitive use over time. Please
explain.
[ ] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss with repetitive use
over
time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness, Lack of endurance
Able to describe in terms of range of motion? [X] Yes [ ] No
Dorsiflexion (0-20): 0 to 5 degrees
Plantar Flexion (0-45): 0 to 45 degrees
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:
[X] The examination is medically consistent with the Veteran?s statements
describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss during flare-ups. Please explain.
[ ] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss during flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-up?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness, Lack of endurance
Able to describe in terms or range of motion? [X] Yes [ ] No
Dorsiflexion (0-20): 0 to 5 degrees
Plantar Flexion (0-45): 0 to 45 degrees
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:
[X] The examination is medically consistent with the Veteran?s statements
describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran?s statements
describing functional loss during flare-ups. Please explain.
[ ] The examination is neither medically consistent or inconsistent with
the
Veteran?s statements describing functional loss during flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-up?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness, Lack of endurance
Able to describe in terms of range of motion? [X] Yes [ ] No
Dorsiflexion (0-20): 0 to 5 degrees
Plantar Flexion (0-45): 0 to 45 degrees
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
Please describe:
see above history
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
Please describe:
see above history
4. Muscle strength testing
--------------------------
a. Muscle strength - rate strength according to the following scale
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Right ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left ankle:
Rate Strength: Plantar Flexion: 5/5
Dorsiflexion: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
c. Comments, if any:
No response provided
5. Ankylosis
------------
Complete this section if Veteran has ankylosis of the ankle
a. Indicate severity of ankylosis and side affected (check all that apply):
Right side: Left side:
[ ] In plantar flexion [ ] In plantar flexion
[ ] In dorsiflexion [ ] In dorsiflexion
[ ] With an abduction deformity [ ] With an abduction deformity
[ ] With an inversion deformity [ ] With an inversion deformity
[ ] With an eversion deformity [ ] With an eversion deformity
[ ] In good weight-bearing position [ ] In good weight-bearing
position
[ ] In poor weight-bearing position [ ] In poor weight-bearing
position
[X] No ankylosis [X] No ankylosis
b. Comments, if any:
No response provided
6. Joint stability
------------------
Right ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
Left ankle
Is ankle instability or
dislocation suspected? [ ] Yes [X] No
7. Additional comments
----------------------
Does the Veteran now have or has he or she ever had "shin splints",
stress
fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus
(os calcis) or talus (astragalus), or has the Veteran had a talectomy
(astragalectomy)? [X] Yes [ ] No
If yes, indicate condition and complete the appropriate sections below:
[X] Achilles tendonitis or achilles tendon rupture
Indicate side affected: [ ] Right [ ] Left [X] Both
Describe current symptoms: tender achilles tendons bilat limiting
dorsiflexion
8. Surgical procedures
----------------------
Indicate any surgical procedures that the Veteran has had performed and
provide
the additional information as requested (check all that apply):
Right side:
No response provided
Left side:
[X] Arthroscopic or other ankle surgery
Type of surgery: Exploratory lapraroscopic surgery of left ankle
Date of surgery: Dec 2007
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? [X] Yes [ ] No
If yes, are any of these scars painful or unstable, have a total area
equal to or greater than 39 square cm (6 square inches) or are located on
the head, face or neck? (An "unstable scar" is one where, for
any reason,
there is frequent loss of covering of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters
Location: left anterior ankle
Measurements: length 2 cm X width 0.5 cm
c. Comments, if any:
No response provided
10. Assistive devices
---------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion,
although occasional locomotion by other methods may be possible?
[ ] Yes [X] No
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
No response provided
11. Remaining effective function of the extremities
---------------------------------------------------
Due to the Veteran's ankle condition, is there functional impairment of
an
extremity such that no effective functions remain other than that which would
be equally well served by an amputation with prosthesis? (Functions of the
upper extremity include grasping, manipulation, etc., while functions for the
lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
12. Diagnostic testing
----------------------
a. Have imaging studies of the ankle been performed and are the results
available? [X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings or results?
[ ] Yes [X] No
c. If any test results are other than normal, indicate relationship of
abnormal
findings to diagnosed conditions:
No response provided
13. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[X] Yes [ ] No
If yes, describe the functional impact of each condition, providing one or
more examples:
Patient has limited walking up to 1/8 mile. Further walking will cause
increased diffuse muscular pain that will last up to one week.
14. Remarks, if any
-------------------
No response provided
Shoulder and Arm Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
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
If no, check all records reviewed:
[X] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[X] 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?
[X] Yes [ ] No
If yes, describe:
Orthopedic surgeon workmens comp notes
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
Shoulder pain
b. Select diagnoses associated with the claimed condition(s) (check all that
apply):
[X] Acromioclavicular joint osteoarthritis
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):
exposed to oil well fire soot. Unemployed since 2010.
Right hand dominant with onset left > right shoulder pain x 2013.
Patient
has difficulty on reaching overhead repetitively. Unable to throw
baseballs
footballs basketballs. Unable to carry more than 5 pounds for more than 20
minutes.
b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous
c. Does the Veteran report flare-ups of the shoulder or arm?
[ ] Yes [X] No
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:
see above
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 180 degrees
Abduction (0 to 180): 0 to 120 degrees
External rotation (0 to 90): 0 to 90 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
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
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] No
Is there objective evidence of crepitus? [ ] Yes [X] No
Left 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 150 degrees
Abduction (0 to 180): 0 to 135 degrees
External rotation (0 to 90): 0 to 90 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
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
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] No
Is there objective evidence of crepitus? [ ] Yes [X] No
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? [X] Yes [ ] No
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness
ROM after three repetitions:
Flexion (0 to 180): 0 to 155 degrees
Abduction (0 to 180): 0 to 120 degrees
External rotation (0 to 90): 0 to 90 degrees
Internal rotation (0 to 90): 0 to 90 degrees
Left 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? [X] Yes [ ] No
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness
ROM after three repetitions:
Flexion (0 to 180): 0 to 150 degrees
Abduction (0 to 180): 0 to 120 degrees
External rotation (0 to 90): 0 to 90 degrees
Internal rotation (0 to 90): 0 to 90 degrees
c. Repeated use over time
Right Shoulder
--------------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive
use over time:
[X] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time.
Please explain.
[ ] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss with
repetitive
use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness, Lack of endurance
Able to describe in terms of range of motion: [X] Yes [ ] No
Flexion (0 to 180): 0 to 150 degrees
Abduction (0 to 180): 0 to 120 degrees
External rotation (0 to 90): 0 to 90 degrees
Internal rotation (0 to 90): 0 to 90 degrees
Left Shoulder
-------------
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive
use over time:
[X] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time.
Please explain.
[ ] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss with
repetitive
use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Fatigue, Weakness, Lack of endurance
Able to describe in terms of range of motion: [X] Yes [ ] No
Flexion (0 to 180): 0 to 150 degrees
Abduction (0 to 180): 0 to 120 degrees
External rotation (0 to 90): 0 to 90 degrees
Internal rotation (0 to 90): 0 to 90 degrees
d. Flare-ups: No response provided
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: None
Left Shoulder
-------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None
4. Muscle strength testing
--------------------------
a. Muscle strength - Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Right Shoulder: Rate Strength:
Forward flexion: 5/5
Abduction: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
Left Shoulder: Rate Strength:
Forward flexion: 5/5
Abduction: 5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
c. Comments, if any:
No response provided
5. Ankylosis
------------
Complete this section if the Veteran has ankylosis of 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: [ ] Yes [X] No
Left Shoulder: [ ] Yes [X] No
7. Shoulder instability, dislocation or labral pathology
a. Is shoulder instability, dislocation or labral pathology suspected?
[ ] 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?
[X] Yes [ ] No
If yes, complete questions 8b, 8d and 8e below:
b. Does the Veteran have an AC joint condition or any other impairment of the
clavicle or scapula?
[X] Yes [ ] No
If yes, indicate severity and side affected, and answer 8c below:
[X] Other, describe: degenerative disease ac joint left shoulder
[ ] Right [X] Left [ ] Both
c. Does the clavicle or scapula condition affect range of motion of the
shoulder (glenohumeral) joint?
[ ] Yes [X] No
d. Is there tenderness on palpation of the AC joint?
[X] Yes [ ] No
If yes, indicate side: [ ] Right [ ] Left [X] Both
e. Cross-body adduction test (Passively adduct arm across the patient's
body
toward the contralateral shoulder. Pain may indicate acromioclavicular
joint
pathology.)
[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A
If positive, side affected: [ ] Right [ ] Left [X] Both
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
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?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ ] No
If yes, indicate shoulder: [ ] Right [X] Left [ ] Both
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:
Xray with left AC joint degenerative disease.
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:
See history
16. Remarks, if any:
--------------------
No remarks provided
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