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Kinfolk

C&P results

Question

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

 

Edited by Kinfolk

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