Hello every I was wondering if I can get some input on my recent comp & Pen
left ankle, residuals of left medial malleolus fracture 30%
left foot arthritis 10%
scars, left ankle and heel 30%
PTSD with major depression disorder, severe 100%
Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire Name of patient/Veteran: Googe, Alex 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 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: No response provided b. Select diagnoses associated with the claimed condition(s): [X] Arthritic conditions [X] Arthritis, degenerative ICD Code: M19.1 Side affected: Left Date of diagnosis: Left 2015 c. Comments (if any):
No response provided d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A
2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's foot condition (brief summary): Mr. Googe was on active duty from 7/28/1982 until 5/14/1986 and is service connected for his left ankle. Today he is requesting evaluation of his left foot. He sustained a left ankle sprain in 1983 and a left ankle medial malleolar avulsion fracture on 8/21/1984 while he was playing sports. He was treated conservatively but continued to have mild left ankle pain. He states that he underwent left ankle arthroscopic surgery at the Providence, RI VAMC in 2003. He has been followed by the CT VA system since at least 2005 by the Podiatry and the Orthopedic sections. He was found to have left ankle arthritis and underwent a left ankle arthrotomy with removal of osteophytes on 8/28/2006. He did well from 2006 until 2011 when he developed increased left ankle pain. He underwent left ankle arthroscopic surgery with removal of loose bodies on 2/20/2011. Unfortunately he developed left foot pain and underwent a left ankle subtalar fusion on 3/20/2015. He was last seen by the Orthopedic clinic on 5/29/2015 doing well except for some numbness in his toes and was ambulating full weight bearing using a CAM walker boot. Today he states that he has constant moderate left foot and ankle pain. He also has constant numbness in his left foot 2nd-5th toes. He states that he does not have any left foot/ankle pain with rest, but develops immediate left foot/ankle pain with any weight bearing. He works full time for the North Hampton VA in the substance abuse clinic and states that has missed #10 days since his surgery because of his left foot/ankle pain. He uses a cane and states that he can only walk about #50 yards before he has to stop walking because of his pain. He has difficulty performing indoor chore and does not perform any outdoor chores because of his left foot and ankle pain. He takes Gabapentin but he does not take any pain medication. He has a left leg Arizona ankle brace which he does not wear because of discomfort and he developed calluses.
2017: Update L ankle : The veteran describes daily pain , which this am is a 9/10. It will wake him up from sleep. The lowest level the pain is at is an 8/10. The pain is described at the incision points and over the screws as being sharp. The location is on the medial and lateral aspect of his ankle over the malleolus. He also has throbbing pain over the lateral aspect of the ankle the starts from the talar region and wraps around to the front of his ankle. He has numbness in the little toe and the next adjacent toe. In sural distrubution. He wears the Arizona brace when possible, but the swelling in the ankle prevents regular use. He uses ice in the evening to aid with swelling and pain relief. He reports that he has daily flare ups when he has to walk any distance, (5-10 yards). The veteran ambulates with a cane at all times. He is scheduled for another revision surgery over the summer.
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: He has pain which wakes him up from sleep
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: Daily with walking or putting on his shoe. He has trouble climbing stairs and this aggravates the ankle pain.
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: Cannot walk more than 5 -10 yards without pain. He has great difficulty with stairs.
3. Flatfoot (pes planus) ------------------------
a. Does the Veteran have pain on use of the feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [X] Left [ ] Both If yes, is the pain accentuated on use? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [X] Left [ ] Both b. Does the Veteran have pain on manipulation of the feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [X] Left [ ] Both If yes, is the pain accentuated on manipulation? [X] Yes [ ] No c. Is there indication of swelling on use? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [X] Left [ ] Both d. Does the Veteran have characteristic callouses? [X] Yes [ ]
If yes, indicate side affected: [ ] Right [ ] Left [X] Both e. Effects of use of arch supports, built-up shoes or orthotics: No response provided f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [ ] Yes [X] No
g. Does the Veteran have decreased longitudinal arch height of one or both feet on weight-bearing? [ ] Yes [X] No
h. Is there objective evidence of marked deformity of one or both feet (pronation, abduction etc.)? [ ] Yes [X] No
i. Is there marked pronation of one or both feet? [ ] Yes [X] No 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 [X] Left [ ] 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? [X] Yes [ ] No If yes,
indicate side affected: [ ] Right [X] Left [ ] Both Is the marked inward displacement and severe spasm of the Achilles tendon improved by orthopedic shoes or appliances? LEFT - [ ] Yes [X] No [ ] N/A n. Comments: No comments provided
4. Morton's neuroma (Morton's disease) and metatarsalgia -------------------------------------------------------- a. Does the Veteran have Morton's neuroma? [ ] Yes [X] No b. Does the Veteran have metatarsalgia? [ ] Yes No [X]
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 provided
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? [ ] Yes [X] No b. Comments: No comments provided
8. Acquired pes cavus (clawfoot) -------------------------------- a. Effect on toes due to pes cavus (check all that apply): [X] None 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] Shortened plantar fascia [ ] Right [ ] Left [X] Both d. Dorsiflexion and varus deformity due to pes cavus (check all that apply): [X] None 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? [ ] Yes [X] No
b. Indicate severity and side affected: No response provided
c. Does the foot condition chronically compromise weight bearing? No response provided
d. Does the foot condition require arch supports, custom orthotic inserts or shoe modifications? No response provided 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: [X] Left foot procedure: Date of surgery: 2015 b. Does the Veteran have any residual signs or symptoms due to arthroscopic or other foot surgery? [X] Yes [ ] No If yes, describe residuals: Pain and slight numbness in two small toes on left foot.
12. Pain -------- RIGHT FOOT: Is there pain on physical exam? [ ] Yes [X] No If no, but the Veteran reported pain in his/her medical history, please provide rationale below. No response provided
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] Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-ups, contracted scars, etc.)
Side affected: [ ] Right [X] Left [ ] Both [X] Pain on movement Side affected: [ ] Right [X] Left [ ] Both [X] Pain on weight-bearing Side affected: [ ] Right [X] Left [ ] Both [X] Interference with standing Side affected: [ ] Right [X] Left [ ] Both [X]
Lack of endurance Side affected: [ ] Right [X] Left [ ] 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: [ ] Yes [X] No
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: Difficulty with walking, standing or climbing
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: [X] Yes [ ] No If yes, describe: Decreased ability to walk 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? [X] Yes [ ] No If yes, describe (brief summary): Foot: If yes, describe the foot injury or other conditions (including frequency and physical exam findings) and complete question
b. (severity and side affected). Left foot and ankle exam: 1)Inspection- he has multiple surgical scars 2)Palpation- he has moderate tenderness over his medial ankle, lateral ankle, posterior ankle and he anterior ankle area. He also mild tenderness over his 2nd-5th metatarsals.
3)Sensation- He has slight decrease touch sensation over his 2nd-5th toes.
4)Motor exam- ankle flexion and extension is 4/5, toes are 3/5 in flexion and extension. 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: see ankle exam Measurements: Length cm X width cm
c. Comments: Left lower extremity: Affected Location of scars on left lower extremity and number them: scar # 1- anterior to medial malleolus- painful scar
# 2- left foot near lateral ankle- new scar, painful scar
# 3 and 4- two arthroscopic scars medial and lateral ankle- non-tender scar
# 5- calf- new scar, painful Types of scars and provide measurements: Superficial non-linear Length and width of each superficial non-linear scar: Scar #1: 5 X 0.4 cm Scar #2: 6 X 0.3 cm Scar #3: 1.5 X 0.4 cm Scar #4: 1.5 X 0.4 cm Scar #5: 5 X 1.7 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: Frequency of use: ----------------- ----------------- [X] Brace(s) [ ] Occasional [X] Regular [ ] Constant [X] Cane(s) [ ] Occasional [X] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided.
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 available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate foot: [ ] Right [X] Left [ ] Both b. Are there any other significant diagnostic test findings or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary):
xam Date/Time 02/24/2017 14:47 Procedure Name CT LOWER EXTREMITY W/O CONT Reason for Study Evaluate possible subtalar fusion (left ankle) Clinical History PROVIDER CONTACT #477-3634 Impression Status post talonavicular fusion with intact hardware. Further bony fusion is seen along the posterior subtalar joint. Report Indication: Evaluate subtalar fusion Study: CT of the left ankle without intravenous contrast Comparison: 11/4/2016 Findings: Patient is status post subtalar fusion with 2 screws extending through the posterior and middle subtalar joints. The screws are intact. There is no evidence of any lucency at the metal bone interfaces. There is further fusion of the posterior subtalar joint. No effusion is seen at the middle facet. c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition: Directly related to traumatic injury and surgical repairs.
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 patient has an incompletely fused surgical repair of the left ankle with DJD and sensation changes over the toes resulting in difficulty walking, weight bearing, and climbing stairs.
19. Remarks, if any: -------------------- The veteran's S/c Left foot condition is currently stable based on the most recent objective evidence. Right Evaluation of bilateral joints for comparison is required. If evaluation of the contralateral joint is not possible or not medically appropriate, please provide an explanation. Is the contralateral joint uninjured / normal?
Yes Pain with non-weight bearing (at rest)? None noted on exam.
Does not result in/cause functional loss Causes functional loss. Please describe: N/A Pain with passive ROM? None noted on exam. Does not result in/cause functional loss Causes functional loss. Please describe: N/A Pain with weight bearing? Cannot be performed or is not medically appropriate None noted on exam Yes Does not result in/cause functional loss. Causes functional loss.