Is my disability approved? If so, what should be my rating?

[Mrdbraggs]

DATE OF NOTE: JAN 10, 2019@10:00 ENTRY DATE: JAN 10, 2019@15:22:13
AUTHOR: HAMPTON,SHERRY L EXP COSIGNER: URGENCY: STATUS: COMPLETED
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: BRAGGS, D
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)
[X] CPRS
[X] Other (please identify other evidence reviewed):
JOINT LEGACY VIEWER
 BRAGGS, D CONFIDENTIAL Page 36 of 67
   MEDICAL OPINION SUMMARY -----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Was the Veteran's flatfoot, bilateral (which
clearly and unmistakably
existed prior to service) aggravated beyond its natural progression by (the)complaint of chronic pes planus and arch pain during service?
b. Indicate type of exam for which opinion has been requested: FOOT
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR AGGRAVATION OF A CONDITION THAT EXISTED PRIOR TO SERVICE ]
a. The claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service event, injury or illness.
c. Rationale: THE VETERANS ENTRANCE PHYSICAL DOCUMENTS BILATERAL PES PLANUS
ASYMPTOMATIC. THE VETERAN'S STRS DOCUMENT COMPLAINTS OF FOOT PAIN IN AUGUST
OF 1992 - TWO MONTHS UPON ENTERING SERVICE, OCTOBER 1992 AND IN JUNE OF 1993 WITH A DIAGNOSIS OF PES PLANUS AND REPORT OF FOOT FASCIAL PAIN. THE VA MEDICAL RECORDS ALSO HAVE MULTIPLE DOCUMENTS WITH COMPLAINTS OF FOOT PAIN
AND
A DIAGNOSIS OF PES PLANUS, CORRELATING TO THE VETERAN'S DIAGNOSIS WHILE
IN SERVICE.
  *************************************************************************
/es/ SHERRY L HAMPTON, P.A. PHYSICIAN ASSISTANT
Signed: 01/10/2019 15:22
      Date/Time:
   10 Jan 2019 @ 1000
  Note Title:
  COMP & PEN ORTHOPAEDIC EXAM
  Location:
  Dallas TX VAMC
  Signed By:
  HAMPTON,SHERRY L
 Co-signed By:
  HAMPTON,SHERRY L
  Date/Time Signed:
 11 Jan 2019 @ 0935
        Note
      
  BRAGGS, D CONFIDENTIAL Page 37 of 67
   LOCAL TITLE: COMP & PEN ORTHOPAEDIC EXAM
STANDARD TITLE: ORTHOPEDIC SURGERY C & P EXAMINATION CONSULT DATE OF NOTE: JAN 10, 2019@10:00 ENTRY DATE: JAN 11, 2019@09:35:08
AUTHOR: HAMPTON,SHERRY L EXP COSIGNER: URGENCY: STATUS: COMPLETED
*** COMP & PEN ORTHOPAEDIC EXAM Has ADDENDA ***
Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire
Name of patient/Veteran: BRAGGS, D
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)
[X] CPRS
[X] Other (please identify other evidence reviewed):
JOINT LEGACY VIEWER
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ:
BILATERAL PES PLANUS
b. Select diagnoses associated with the claimed condition(s):
[X] Flat foot (pes planus)
Side affected: Both
Date of diagnosis: Right: 1992 Date of diagnosis: Left: 1992

 BRAGGS, D CONFIDENTIAL Page 38 of 67
   [X] Plantar fasciitis
Side affected: Both
Date of diagnosis: Right 1993 Date of diagnosis: Left 1993
[X] Arthritic conditions
[X] Arthritis, degenerative
Side affected: Both
Date of diagnosis: Right 2018 Date of diagnosis: Left 2018
c. Comments (if any): No response provided
d. Was an opinion requested about this condition (internal VA only)? [X] Yes [ ] No [ ] N/A
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
foot
condition (brief summary):
THE VETERAN IS A 45 YO MALE WHO SERVED IN THE ARMY FROM 1992 TO 1996. HE IS HERE FOR A AGGRAVATION OF A PRE-EXISTING PES PLANUS. HE REPORTS HAVING
SUCH
SEVERE FOOT PAIN DURING SERVICE HE PERIODICALLY COULD NOT WALK. HIS FOOT PAIN CONTINUED AFTER LEAVING SERVICE. CURRENTLY HE HAS BILATERAL FOOT PAIN AT A 5-6/10 INTENSITY WITH BOTH FEET HAVING EQUAL INTENSITY. HE STATES HE TRIED ARCH SUPPORTS BUT HIS PAIN WAS WORSE. HE HAS NOT HAD CUSTOM ORTHODICS. HE REPORTS HIS PAIN AS AS AN ACHE WITH SHARP JABS. HE HAS PAIN WITH OR WITHOUT WEIGHT BEARING. WALKING OR STANDING MAKES IT WORSE. HIS
FEET
WILL PERIODICALLY SWELL.
IN 2016 HE DISLOCATED HIS RIGHT GREAT TOE WHEN HE WAS DRIVING WITH NO SHOES
AND WAS INVOLVED IN AN ACCIDENT. HE WENT TO THE HARRIS ED WHERE HIS TOE WAS
REDUCED. HE CONTINUED TO HAVE PAIN AND EVENTUALLY SAW AN OUTSIDE PODIATRIST WHO TOLD HIM HE HAD SOFT TISSUE DAMAGE. HE HAD HIS JOINT FUSED IN 2017. HIS SCAR IS NOT TENDER.
b. Does the Veteran report pain of the foot being evaluated on this DBQ? [X] Yes [ ] No
If yes, document the Veteran's description of pain in his or her own
words:
ACHING WITH SHARP JABS

 BRAGGS, D CONFIDENTIAL Page 39 of 67
   c. Does the Veteran report that flare-ups impact the function of the foot? [X] Yes [ ] No
If yes, document the Veteran's description of flare-ups in his or her
own words:
HE REPPORTS HIS PAIN INCREASES IN INTENSITY ONCE A MONTH LASTING TWO DAYS.
d. Does the Veteran report having any functional loss or functional impairment of the foot 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:
HE CANNOT PROLONG STAND OR WALK. HE CANNOT RUN. HE HAS DIFFICUTLY PLAYING WITH HIS CHILDREN AND CANNOT DRIVE. HIS WIFE DRIVES HIM.
3. Flatfoot (pes planus)
------------------------
a. Does the Veteran have pain on use of the feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both If yes, is the pain accentuated on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
b. Does the Veteran have pain on manipulation of the feet? [X] Yes
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
If yes, is the pain accentuated on manipulation? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both c. Is there indication of swelling on use? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
d. Does the Veteran have characteristic callouses? [ ] Yes [X] No e. Effects of use of arch supports, built-up shoes or orthotics:
Tried But Remains Symptomatic -----------------------------
Device Side Not Relieved:
[X] Arch Supports [ ] Right [ ] Left [X] Both
[ ] No

 BRAGGS, D CONFIDENTIAL Page 40 of 67
   f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
Is the tenderness improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A
LEFT - [ ] Yes [X] No [ ] N/A
g. Does the Veteran have decreased longitudinal arch height of one or both feet
on weight-bearing? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
h. Is there objective evidence of marked deformity of one or both feet (pronation, abduction etc.)? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
i. Is there marked pronation of one or both feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
Is the condition improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A
LEFT - [ ] Yes [X] No [ ] N/A
j. For one or both feet, does the weight-bearing line fall over or medial to the great toe? [ ] Yes [X] No
k. Is there a lower extremity deformity other than pes planus, causing alteration of the weight-bearing line? [ ] Yes [X] No
l. Does the Veteran have "inward" bowing of the Achilles tendon (i.e., hindfoot
valgus, with lateral deviation of the heel) of one or both feet? [X] Yes [ ] No
If yes, indicate side affected: [ ] Right [ ] Left [X] Both
m. Does the Veteran have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet?
[ ] Yes [X] No
n. Comments: No comments provided
4. Morton's neuroma (Morton's disease) and metatarsalgia --------------------------------------------------------

 BRAGGS, D CONFIDENTIAL Page 41 of 67
   a. Does the Veteran have Morton's neuroma? [ ] Yes [X] No
b. Does the Veteran have metatarsalgia? [ ] Yes [X] No
c. Comments: No comments provided
5. Hammer toe
-------------
a. Which toes are affected on each side?
RIGHT: [X] None
LEFT:
[X] None
b. Comments: No response provide d
6. Hallux valgus
----------------
a. Does the Veteran have symptoms due to a hallux valgus condition?
[ ] Yes [X] No
b. Has the Veteran had surgery for hallux valgus? [ ] Yes [X] No
c. Comments: No comments provided
7. Hallux rigidus
-----------------
a. Does the Veteran have symptoms due to hallux rigidus?
[X] Yes [ ] No
If yes, indicate severity (check all that apply):
[X] Mild or moderate symptoms
Side affected: [X] Right [ ] Left [ ] Both
b. Comments: THIS IS SECONDARY TO THE FUSION OF THE RIFHT FIRST MTPJ IN 2017 AND UNRELATED TO THE CLAIMED CONDITION.
8. Acquired pes cavus (clawfoot) --------------------------------
a. Effect on toes due to pes cavus (check all that apply):
[X] None
[ ] Right [ ] Left [X] Both

 BRAGGS, D CONFIDENTIAL Page 42 of 67
   b. Pain and tenderness due to pes cavus (check all that apply): [X] None
[ ] Right [ ] Left [X] Both
c. Effect on plantar fascia due to pes cavus (check all that apply): [X] None
[ ] Right [ ] Left [X] Both
d. Dorsiflexion and varus deformity due to pes cavus (check all that apply): [X] None
[ ] Right [ ] Left [X] Both
e. Comments: No comments provided
9. Malunion or nonunion of tarsal or metatarsal bones -----------------------------------------------------
No response provided
10. Foot injuries and other conditions
--------------------------------------
a. Does the Veteran have any foot injuries or other foot conditions not
already described?
[X] Yes [ ] No
If yes, describe the foot injury or other conditions (including
frequency and physical exam findings) and complete question b. (severity
and side affected).
HE HAD A RIGHT GREAT TOE DISLOCATION IN 2016 DURING A MVA WHILE DRIVING BAREFOOT.
b. Indicate severity and side affected:
[X] Moderately severe [X] Right [ ] Left [ ] Both
c. Does the foot condition chronically compromise weight bearing? [ ] Yes [X] No
d. Does the foot condition require arch supports, custom orthotic inserts or shoe modifications?
[ ] Yes [X] No
e. Comments: No comments provided
11. Surgical procedures
-----------------------
a. Has the Veteran had foot surgery (arthroscopic or open)?
[X] Yes [ ] No
If yes, indicate side affected, type of procedure and date of surgery:

 BRAGGS, D CONFIDENTIAL Page 43 of 67
   [X] Right foot procedure: RIGHT GREAT TOE FUSION Date of surgery: 2017
b. Does the Veteran have any residual signs or symptoms due to arthroscopic or other foot surgery?
[X] Yes [ ] No
If yes, describe residuals: LOSS OF MOTION
12. Pain --------
RIGHT FOOT:
Is there pain on physical exam? [X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
LEFT FOOT:
Is there pain on physical exam? [X] Yes [ ] No
If yes, (there is pain on physical exam), does the pain contribute to functional loss?
[X] Yes [ ] No
(Further description of limitations requested in Section XIII below.)
13. Functional loss and limitation of motion --------------------------------------------
a. Contributing factors of disability (check all that apply and indicate side
affected):
[X] Pain on movement
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Pain on non weight-bearing
Side affected: [ ] Right [ ] Left [X] Both
[X] Swelling

 BRAGGS, D CONFIDENTIAL Page 44 of 67
   Side affected: [ ] Right [ ] Left [X] Both
[X] Disturbance of locomotion
Side affected: [ ] Right [ ] Left [X] Both
[X] Interference with standing
Side affected: [ ] Right [ ] Left [X] Both
[X] Lack of endurance
Side affected: [ ] Right [ ] Left [X] Both
Contributing factors of disability associated with limitation of motion:
b. Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time?
RIGHT FOOT: [X] Yes [ ] No
If yes, (there is a functional loss due to pain, during flare-ups
and/or when the joint is used repeatedly over a period of time) please describe the functional loss:
CANNOT PRLONG STAND OR WALK
LEFT FOOT: [X] Yes [ ] No
If yes, (there is a functional loss due to pain, during flare-ups
and/or when the joint is used repeatedly over a period of time) please describe the functional loss:
CANNOT PRLONG STAND OR WALK
c. Is there any other functional loss during flare-ups or when the foot is used
repeatedly over a period of time? RIGHT FOOT: [ ] Yes [X] No
LEFT FOOT: [ ] Yes [X] No
14. 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

 BRAGGS, D CONFIDENTIAL Page 45 of 67
   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: RIGHT FOOT MTPJ
Measurements: Length 6.5cm X width 0.3cm
c. Comments: RIGHT FOOT DORSAL MTPJ - 1.5 X 0.2 CM
15. Assistive devices
---------------------
a. Does the Veteran use any assistive devices as a normal mode of locomotion,
although occasional locomotion by other methods may be possible? [X] Yes [ ] No
If yes, identify assistive devices used (check all that apply and indicate frequency):
Assistive Device: -----------------
[X] Cane(s)
Frequency of use: -----------------
[X] Occasional [ ] Regular [ ] Constant
b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:
CANE FOR STABILITY
16. Remaining effective function of the extremities ---------------------------------------------------
Due to the Veteran's foot condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the
upper extremity include grasping, manipulation, etc., 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
17. Diagnostic testing
----------------------
a. Have imaging studies of the foot been performed and are the results

 BRAGGS, D CONFIDENTIAL Page 46 of 67
   available?
[X] Yes [ ] No
If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No
If yes, indicate foot: [ ] 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 condition:
THE VETERANS FEET HAVE MILD DJD WHICH IS MORE THAN LIKELY A PROGRESSION OF HIS PES PLANUS AND CHRONIC PLANTAR FASCIITIS.
18. 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:
THE VETERAN WOULD NOT BE ABLE TO WORK A JOB THAT REQUIRED PROLONGED STANDING AND WALKING, SQUATTING, OR CLIMBING.
19. Remarks, if any:
--------------------
1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate)
YES
2. Is there evidence of pain when the joint is used in non-weight bearing? (Yes/No/Cannot be performed or is not medically appropriate)
YES
3. If yes, is the opposing joint undamaged (i.e. no abnormalities)?
BOTH ARE ABNORMAL
If yes, conduct range of motion testing for the opposing joint and provide ROM measurements.
PASSIVE AND ACTIVE RANGE OF MOTION ARE THE SAME.

 BRAGGS, D CONFIDENTIAL Page 47 of 67
*******************************************************************************
 **********
BILATERAL FOOT MILD DJD IS MOST LIKELY A PROGRESSION OF THE VETERAN'S SYMPTOMATIC PES PLANUS AND CHRONIC PLANTAR FASCIITIS.
/es/ SHERRY L HAMPTON, P.A. PHYSICIAN ASSISTANT
Signed: 01/11/2019 09:35
01/11/2019 ADDENDUM STATUS: COMPLETED
THE VETERAN WAS ADVISED OF HIS XRAY RESULTS AND ADVISED TO F/U WITH PCP OR OUTSIDE PODIATRIST. XRAY WITH OA FINDINGS THAT WERE PREVIOUSLY DIAGNOSED BY XRAY WITH THE OUTSIDE PODIATRIST. THE VETERAN EXPERESSED UNDERSTANDING AND AGREED WITH PLAN OF CARE.
/es/ SHERRY L HAMPTON, P.A. PHYSICIAN ASSISTANT
Signed: 01/11/2019 09:40

[doc25]

1 hour ago, Mrdbraggs said:

They awarded me with 50% for my feet. 

 

Congrats!