Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
b/l shoulder pain
b. Select diagnoses associated with the claimed condition(s) (check all that
apply):
[X] Arthritic conditions
[X] Arthritis, degenerative
Side affected: Both
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):
The veteran reports b/l shoulder pain since 2001. Imaging reveals b/l AC
joint DJD. Treatment has included PT, massages and NSAIDs. Now, the
shoulders hurt daily.
b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous
c. Does the Veteran report flare-ups of the shoulder or arm?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or
her own words:
"carrying things make it worse"
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)?
[ ] Yes [X] No
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
Right Shoulder
--------------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 180): 0 to 90 degrees
Abduction (0 to 180): 0 to 80 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
If yes, please explain:
difficulty with overhead activities
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? [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):
anterior, mild
Is there objective evidence of crepitus? [ ] Yes [X] No
Left Shoulder
-------------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 180): 0 to 90 degrees
Abduction (0 to 180): 0 to 70 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
If yes, please explain:
difficulty with overhead activities
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? [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):
anterior, mild
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Right Shoulder
--------------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] No
Left Shoulder
-------------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] No
c. Repeated use over time
Right Shoulder
--------------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
Left Shoulder
-------------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
Right Shoulder
--------------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
Left Shoulder
-------------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
e. Additional factors contributing to disability
Right Shoulder
--------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc.
Left Shoulder
-------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc.
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
------------
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: AC joint DJD
[ ] Right [ ] Left [X] Both
c. Does the clavicle or scapula condition affect range of motion of the
shoulder (glenohumeral) joint?
[X] Yes [ ] 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.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
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 [ ] Left [X] 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:
No response provided
15. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's shoulder conditions
providing one or more examples:
difficulty with overhead activities, lifting heavy objects
16. Remarks, if any:
--------------------
No remarks provided
Question
Kinfolk
Shoulder Possible Rating???
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
b/l shoulder pain
b. Select diagnoses associated with the claimed condition(s) (check all that
apply):
[X] Arthritic conditions
[X] Arthritis, degenerative
Side affected: Both
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):
The veteran reports b/l shoulder pain since 2001. Imaging reveals b/l AC
joint DJD. Treatment has included PT, massages and NSAIDs. Now, the
shoulders hurt daily.
b. Dominant hand:
[X] Right [ ] Left [ ] Ambidextrous
c. Does the Veteran report flare-ups of the shoulder or arm?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or
her own words:
"carrying things make it worse"
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)?
[ ] Yes [X] No
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
Right Shoulder
--------------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 180): 0 to 90 degrees
Abduction (0 to 180): 0 to 80 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
If yes, please explain:
difficulty with overhead activities
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? [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):
anterior, mild
Is there objective evidence of crepitus? [ ] Yes [X] No
Left Shoulder
-------------
[ ] All Normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 180): 0 to 90 degrees
Abduction (0 to 180): 0 to 70 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
If yes, please explain:
difficulty with overhead activities
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? [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):
anterior, mild
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Right Shoulder
--------------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] No
Left Shoulder
-------------
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] No
c. Repeated use over time
Right Shoulder
--------------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
Left Shoulder
-------------
Is the Veteran being examined immediately after repetitive use over time?
[X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
Right Shoulder
--------------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
Left Shoulder
-------------
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
e. Additional factors contributing to disability
Right Shoulder
--------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc.
Left Shoulder
-------------
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe:
Less movement than normal due to ankylosis, adhesions, etc.
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
------------
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: AC joint DJD
[ ] Right [ ] Left [X] Both
c. Does the clavicle or scapula condition affect range of motion of the
shoulder (glenohumeral) joint?
[X] Yes [ ] 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.)
[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A
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 [ ] Left [X] 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:
No response provided
15. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's shoulder conditions
providing one or more examples:
difficulty with overhead activities, lifting heavy objects
16. Remarks, if any:
--------------------
No remarks provided
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