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Rjohnson87

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PEB Forum Veteran
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Knee and Lower Leg Conditions Disability Benefits Questionnaire

Name of patient/Veteran: xxxx

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination


Request?
[X] Yes [ J 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: Chronic left knee pain (MEB condition)
Right knee pain


b. Select diagnoses associated with the claimed condition(s) apply):

(Check all that



[X] Knee meniscal tear
Side affected: [ J Right ICD Code: S83.2

[X] Left [ ] Both

Date of diagnosis: Left 10/2014

[X] Knee anterior cruciate ligament tear
Side affected: [ J Right [X] Left [ J Both ICD Code: S83.5
Date of diagnosis: Left 2013

[X] Arthritic conditions


[X] Arthritis, degenerative Side affected: [ J Right ICD Code: Ml9.9

[X] Left [ ] Both

Date of diagnosis: Left 11/2016

[X] Other (specify):

Other diagnosis: s/p Left ACL repair and reconstruction x 4, bilateral

MEDICAL RECORD Progress Notes

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menisecal repair Side affected: Left ICD code: S83.5
Date of diagnosis (left side): 2013
********************************************************************


c. Comments (if any): No right knee condition, disability or diagnosis. Normal exam.

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 knee and/or lower leg condition (brief summary):
Veteran was assisting an inebriated friend to walk home and he fell causing veteran to fall and injure his left knee. Somebody else assisted veteran and his friend to walk home and veteran went to the ER the next day and was diagnosed with a torn ACL. Veteran has had multiple repairs and revisions of his left knee:

#1 November 2013 Left ACL reconstruction with autologous hamstring tendon
#2 December 2014 Left ACL Replacement surgery with aurologous patellar tendon
#3 November 2016 Left ACL Replacement with cadaveric tendon
#4 September 2018 Left ACL Replacement with cadaveric tendon and medical meniscus cadaveric replacement

Veteran has had steroid knee injections and recently had a left knee block. See Progress Note below:



Note Text
Patient: xxxxxx Date: 13 May 2019 1430 TDT Appt Type: PROC
Treatment Facility: NH OKINAWA Clinic: PAIN MANAGEMENT CLINIC Provider: xxxxx
Patient Status: Outpatient

Reason for Appointment: L knee Genicular Block



A/P Last Updated [email protected] 13 May 2019 1548 TDT
1. Unilateral primary osteoarthritis, left knee: 31-year-old active duty









MEDICAL RECORD Progress Notes

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male with history of chronic left knee pain after
multiple surgeries and revisions. Patient is being medically separated from the military. He was trialed today with a left
genicular block which he tolerated well without complications.
Postprocedure precautions given to the patient as well as a
pain diary. We will follow up phone call to determine efficacy of this if he gets significant pain relief (>50%) we'll move
forward with radiofrequency ablation at the same nerves. Patient verbalizes understanding of the above, no barriers to
learning were identified and all questions were addressed. Procedure(s): -Nerve Block Other Branch x 1
-Fluoroscopy x 1​

Disposition Last Updated by [email protected] 13 May 2019 1549 TDT Released w/o Limitations
Follow up: as needed in the PAIN MANAGEMENT CLINIC clinic. - Comments: Follow-up phone call in 2-3 days by RN
xxxxx
Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated
understanding.
Signed By xxxxx (Physician) @ 13 May 2019 1550 Note Written by [email protected] 16 May 2019 0931 TDT
(Added after encounter was signed.)

Facility: NH Okinawa


b. Does the Veteran report flare-ups of the knee and/or lower leg?
[X] Yes [ ] No

If yes, document the Veteran's description of the flare-ups in his or her own words:
Increased pain in cold weather or when it rains.

c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time?
[X] Yes [ ] No

If yes, document the Veteran's description of functional loss or functional impairment in his or her own words:
Increased pain with repetitive walking or stairs. Unable to climb ladders.




MEDICAL RECORD Progress Notes

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3. Range of motion (ROM) and functional limitation

a. Initial range of motion Right Knee
[X) All normal
[ J Abnormal or outside of normal range
[ J Unable to test (please explain)
[ J Not indicated (please explain)


Flexion (O to 140): Extension (140 to 0):

Oto 140 degrees
140 to O degrees


Description of pain (select best response): No pain noted on exam

Is there evidence of pain with weight bearing? [ J Yes [X) No

Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [] Yes [X) No

Is there objective evidence of crepitus? [] Yes [X] No Left Knee
[ l All normal
[X] Abnormal or outside of normal range [] Unable to test (please explain)
[ l Not indicated (please explain)


Flexion (0 to 140): Extension (140 to O):

Oto 40 degrees
40 to O degrees







If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [] No
If yes, please explain:
Moderately severe decrease inflexion ROM


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

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 [ J No

If yes, describe including location, severity and relationship to condition(s):
Generalized knee tenderness.


Is there objective evidence of crepitus? [ J Yes [X) No

b. Observed repetitive use Right Knee
Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ J No
Is there additional functional loss or range of motion after three repetitions? [ J Yes [X) No

Left Knee

Is the Veteran able to perform repetitive use testing with at least three repetitions? [X) Yes [ J No
Is there additional functional loss or range of motion after three repetitions? [ J Yes [X) No

c. Repeated use over time Right Knee
Is the Veteran being examined immediately after repetitive use over time?
[ J 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.
[ J 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?
[ J Yes [X] No [ J Unable to say w/o mere speculation


Left Knee

Is the Veteran being examined immediately after repetitive use over time?
[ J 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.
[ J The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain.
[ J 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 [ J No [ J Unable to say w/o mere speculation Select all factors that cause this functional loss:
Pain​


Able to describe in terms of range of motion: [X) Yes Flexion (0 to 140): Oto 40 degrees
Extension (140 to 0): 40 to O degrees

[ ) No







d. Flare-ups Right Knee
Is the exam being conducted during a flare-up? [ J 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.
[ J The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain.
[ J 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?
[ J Yes [X) No [ J Unable to say w/o mere speculation

Left Knee




MEDICAL RECORD Progress Notes​

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Is the exam being conducted during a flare-up? [ J 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.
[ J 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?
[X) Yes [ J No [ J Unable to say w/o mere speculation Select all factors that cause this functional loss:
Pain


Able to describe in terms of range of motion: [X) Yes Flexion (0 to 140): Oto 40 degrees
Extension (140 to 0): 40 to O degrees

[ ) No







e. Additional factors contributing to disability Right Knee
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None

Left Knee

In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:
Disturbance of locomotion

Please describe additional contributing factors of disability: Difficulty ambulating as unable to flex left knee very much.


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
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MEDICAL RECORD Progress Notes

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5/5 Normal strength


Right Knee: Flexion:

Rate Strength: 5/5

Extension: 5/5
Is there a reduction in muscle strength? [ l Yes [X] No


Left Knee:
Flexion:

Rate Strength: 5/5

Extension: 5/5
Is there a reduction in muscle strength? [ l Yes [X] No

b. Does the Veteran have muscle atrophy?
[X] Yes ] No

If yes, is the muscle atrophy due to the claimed condition in the Diagnosis Section?
[X] Yes [ l No

For any muscle atrophy due to a diagnosis listed in Section 1., indicate side and specific location of atrophy, providing measurements in centimeters of normal side and corresponding atrophied side, measured at maximum muscle bulk.

[X] Left lower extremity (specify location of measurement such as 11 10c m above or below the knee"):
Location: 15 cm below inferior patellar rim Circumference of more normal side: 37cm Circumference of atrophied side: 35.5cm

c. Comments, if any:
15 cm above superior patellar rim: Normal side (Right): 48.5 cm
Atrophied side (Left): 44 cm


5. Ankylosis


Complete this section if the Veteran has ankylosis of the knee and/or lower leg.
a. Indicate severity of ankylosis and side affected (check all that apply) Right Side:
[] Favorable angle in full extension or in slight flexion between O and
10 degrees
Inflexion between 10 and 20 degrees
Inflexion between 20 and 45 degrees




MEDICAL RECORD Progress Notes

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[ J Extremely unfavorable, inflexion at an angle of 45 degrees or more [X) No ankylosis

Left Side:
[. J Favorable angle in full extension or in slight flexion between O and
10 degrees
Inflexion between 10 and 20 degrees
Inflexion between 20 and 45 degrees
Extremely unfavorable, inflexion at an angle of 45 degrees or more [X) No ankylosis

b. Indicate angle of ankylosis in degrees:
No response provided

c. Comments, if any: No response provided

6. Joint stability tests

a. Is there a history of recurrent subluxation?

Right: [X) None Slight Moderate Severe


Left: [X) None

Slight

Moderate Severe


b. Is there a history of lateral instability?


Right:

[X) None Slight

Moderate Severe



Left:

[X) None

Slight

Moderate Severe







c. Is there a history of recurrent effusion? [ ) Yes [X) No
d. Performance of joint stability testing Right Knee:
Was joint stability testing performed? [X) Yes
[ ) No
[ J Not indicated
[ J Indicated, but not able to perform

If joint stability testing was performed is there joint instability?
[ J Yes [X) No





MEDICAL RECORD Progress Notes

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If yes (joint stability testing was performed), complete the section below:

- Anterior instability (Lachman test)
[X] Normal
[] 1+ (0-5 millimeters)
[ J 2+ (5-10 millimeters)
[ J 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[] 1+ (0-5 millimeters)
[] 2+ (5-10 millimeters)
[] 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion)
[X] Normal
[] 1+ (0-5 millimeters)
[] 2+ (5-10 millimeters)
[] 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion)
[X] Normal
[ J 1+ (0-5 millimeters)
[ J 2+ (5-10 millimeters)
[] 3+ (10-15 millimeters)

Left Knee:

Was joint stability testing performed?​
[X] Yes [ ] No
[ l Not indicated
[] Indicated, but not able to perform​

If joint stability testing was performed is there joint instability?
[ l Yes [X] No

If yes (joint stability testing was performed), complete the section below:

- Anterior instability (Lachman test)
[X] Normal
[] 1+ (0-5 millimeters)
[] 2+ (5-10 millimeters)
[] 3+ (10-15 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
[] 1+ (0-5 millimeters)









MEDICAL RECORD Progress Notes

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[ J 2+ (5-10 millimeters)
[ J 3+ (10-15 millimeters)
- Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion)
[X) Normal
[ J l+ (0-5 millimeters)
[ J 2+ (5-10 millimeters)
[ J 3+ (10-15 millimeters)
- Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion)
[X) Normal
[ J l+ (0-5 millimeters)
[ J 2+ (5-10 millimeters)
[ J 3+ (10-15 millimeters)

e. Comments, if any: No response provided

7. Additional conditions

a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, 11 shin splints 11 (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment?
[ J Yes [X) No


b. Comments, if any: No response provided

8. Meniscal conditions

a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition?
[X) Yes J No

If yes, indicate severity and frequency of symptoms, and side affected:


Left Side:
[X) Meniscal tear

b. For all checked boxes above, describe: No response provided

9. Surgical procedures

Indicate any surgical procedures that the Veteran has had performed and provide







the additional information as requested (check all that apply):


Left Side:

[X] Meniscectomy, arthroscopic or other knee surgery not described above Type of surgery: ACL reconstructions x 4 + meniscal repair
Date of surgery: 9/17/18;
[X) Residual signs or symptoms due to meniscectomy, arthroscopic or other knee surgery not described above:
Describe residuals: Contained in this DBQ

10. 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?
[ J 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 J No

If yes, is there objective evidence that any of these scars are painful, 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.)
[X) Yes [ J No

If yes, also complete VA Form 21-0960F-1, Scars/Disfigurement.

c. Comments, if any: See SCARS DBQ


11. Assistive devices

a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible?
[X) Yes J No

If yes, identify assistive device(s) used (check all that apply and indicate frequency):

Assistive Device: Frequency of use:



[X] Brace(s) [X] Occasional J Regular [ ] Constant

b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:
Veteran occasionally wears a left knee brace for his left knee condition.


12. Remaining effective function of the extremities

Due to the Veteran's knee and/or lower leg condition(s), 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.)

[ J Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran.
[X] No

13. Diagnostic testing

a. Have imaging studies of the knee been performed and are the results available?
[X] Yes J No

If yes, is degenerative or traumatic arthritis documented?
[X] Yes [ J No

If yes, indicate knee: [ J Right [X] Left [ ] Both

b. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ J No

If yes, provide type of test or procedure, date and results (brief summary):
KNEE 3 VIEWS


Exm Date: MAY 20, [email protected]:05 Req Phys xxxxx
(Req'g Lo

Pat Loe: MTZ C&P IDES MEDICAL Img Loe: xxxxx RADIOLOGY
Service: Unknown





(Case 612-052019-334 COMPLETE) KNEE 3 VIEWS
Detailed) CPT:73562
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(RAD



xxxxxxxx CALIFORNIA HCSxxxxxxx Pt Loe: OUTPATIENT

Printed:06/18/2019 10:43
Vice SF 509




MEDICAL RECORD Progress Notes

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gastrocnemius, this is favored to represent a tug lesion. Differential diagnosis includes nonossifying fibroma. There is a small
lymph node in the popliteal fossa, measuring 0.7 cm in short axis, not individually enlarged by size criteria.


Impression: 1. Torn anterior cruciate ligament graft. 2. Medial meniscal tear. 3. Lateral meniscal tear. 4. Cortically-based osseous lesion of the posterior/medial distal femur as described. Differential diagnosis includes tug lesion or nonossifying fibroma.





SEE RADIOLOGIST'S REPORT

Primary Diagnostic Code: NONE Secondary Diagnostic Codes:


Facility: Landstuhl RMC



c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:
No response provided

14. 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 [ J No

If yes, describe the functional impact of each condition, providing one or more examples:
Veteran is unable to perform manual labor; he is able to perform sedentary labor.


15. Remarks, if any:


Additional exam request information:

For any joint condition, examiners should test the contralateral joint,
















unless medically contraindicated, and the examiner should address pain on both passive and active motion, and on both weightbearing and non-weight bearing. In addition to the questions on the DBQ, please respond to the following questions:



  1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) No


  1. Is there evidence of pain when the joint is used in non-weight bearing? (Yes/No/Cannot be performed or is not medically appropriate) No


  1. If yes, is the opposing joint undamaged (i.e. no abnormalities)? (Yes/No) N/A


If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. N/A



If no, the examiner is requested to state whether it is medically feasible to test the joint and if not to please state why the examiner

cannot test the range of motion of the opposing joint. Testing done. Active ROM= Passive ROM.

Scars/Disfigurement Disability Benefits Questionnaire




Name of patient/Veteran: xxxxxxxxx

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
[X] CPRS


1. Diagnosis

Does the Veteran have one or more scars anywhere on the body, or disfigurement of the head, face, or neck? Yes
Diagnosis #1: Left knee scars - some painful ICD code: L90.5
Date of diagnosis: 2013

Does the Veteran have any scars on the trunk or extremities (regions other than the head, face or neck): Yes

Does the Veteran have any scars or disfigurement of the head, face or neck: No

SECTION I: Scars of the trunk and extremities

1. Medical history

Describe the history (including cause/origin and course) of the Veteran's scar(s) of the trunk or extremities, (brief summary): Veteran has had multiple surgeries on his left knee resulting in painful scars.

Are any of the scars of the trunk or extremities painful: Yes Number of painful scars: 3
Description of the pain: Mild pain in 3 scars of the left knee, #1,#2 and​


#3 below.

Are any of the scars of the trunk or extremities unstable, with frequent loss of covering of skin over the scar: No

Are any of the scars of the trunk or extremities due to burns: No

2. Physical exam for scars on the trunk and extremities

2-1. Details of scar findings for the trunk and extremities Right upper extremity: No response provided
Left upper extremity: No response provided Right lower extremity: No response provided Left lower extremity: Affected
Location of scars on left lower extremity and number them: 1. Left
lateral knee
2. Left inferior knee
3. Left medial knee
4. Left knee midline
5. Left lateral knee
6. Left medial knee
Indicate the length and width of each scar: Scar #1: 9.5 x 0.5 cm
Scar #2: 3.5 x 1 cm
Scar #3: 4 x 0.5 cm
Scar #4: 8 x 0.3 cm
Scar #5: 1 x 0.4 cm
If additional scars, list using same format:
#6. 1.5 cm x 0.5 cm​

Do any of the scars have underlying soft tissue damage? (If yes, check all that apply)
Scar #2​

Anterior trunk: No response provided Posterior trunk: No response provided
2-2. Summary of scar findings for the trunk and extremities

Scars without underlying tissue damage: Ch:
Left lower extremity: Approximate total area: 11 cm2

Scars with underlying tissue damage:
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MEDICAL RECORD Progress Notes​

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Ch:
Left lower extremity: Approximate total area: 3.5 cm2​

SECTION II: Scars or other disfigurement of the head, face, or neck: No response provided


SECTION III: Miscellaneous

1. Limitation of function/other conditions

Do any of the scars (regardless of location) or disfigurement of the head, face or neck result in limitation of function (to include limitation of motion)? No

Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) associated with any scar (regardless of location) or disfigurement of the head, face or neck? No

2. Color photographs

Were color photographs for any scar(s) or disfiguring condition taken?: No

3. Functional impact

Does the Veteran's scar(s) (regardless of location) or disfigurement of the head, face or neck impact his or her ability to work? No

4. Remarks, if any: No response provided


Historical Questions


Is the Veteran's date of claim or date of intent to file, if applicable, on or prior to August 12, 2018?
[ J Yes [X) No

Historical Section I, Question 2-1. Details of scar findings for the trunk and extremeties

NOTE: For VA purposes, superficial non-linear scars are those not associated with underlying soft tissue damage, while deep non-linear scars are associated with underlying soft tissue damage.

Using the same scar numbering utilized in Section I Question 2-1 above, please indicate the anatomical regions affected and complete the
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MEDICAL RECORD Progress Notes​

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appropriate sections:

a. Left Lower Extremity
Types of scars and provide measurements:​


****************************************************************************


Peripheral Nerves Conditions
(not including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire​

Name of patient/Veteran:xxxxxx

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

Does the Veteran have a peripheral nerve condition or peripheral neuropathy?
[X] Yes [ ] No

Diagnosis #1: Left anterior leg numbness s/p surgery x 4 ICD code: G57
Date of diagnosis: 2014

2. Medical history

a. Describe the history (including onset and course) of the Veteran's peripheral nerve condition (brief summary):




MEDICAL RECORD Progress Notes

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Veteran has numbness in his anterior left knee below the patella due to his multiple ACL surgeries.

b. Dominant hand
[X) Right [) Left [ J Ambidextrous

3. Symptoms

a. Does the Veteran have any symptoms attributable to any peripheral nerve conditions?
[X) Yes [ J No


Constant pain (may be excruciating at times)
Right lower extremity: [X] None l Mild Moderate Left lower extremity: [X] None l Mild Moderate

Intermittent pain (usually dull)
Right lower extremity: [X] None Mild Moderate Left lower extremity: [X] None Mild Moderate

Paresthesias and/or dysesthesias
Right lower extremity: [X] None Mild Moderate Left lower extremity: [X] None Mild Moderate

Severe Severe


Severe Severe


Severe Severe



Numbness
Right lower extremity: Left lower extremity:

[X) None
[ J None

[ ] Mild
[X] Mild

Moderate Moderate

Severe Severe




4. Muscle strength testing
a. 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

Knee extension:
Right: [X] 5/5​
4/5​
3/5​
2/5
1/5​
0/5
Left: [X] 5/5​
4/5​
3/5​
2/5
1/5​
0/5

Ankle plantar flexion:
Right:​
[X]
5/5​
[ l
4/5​
3/5​
2/5
1/5​
0/5
Left:​
[X)
5/5​
[ l
4/5​
3/5​
2/5
1/5​
0




MEDICAL RECORD

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Progress Notes


Ankle dorsiflexion:
Right:​
[X) 5/5​
4/5​
3/5​
2/5​
1/5​
0/5
Left:​
[X) 5/5​
4/5​
3/5​
2/5​
1/5​
0/5

b. Does the Veteran have muscle atrophy? [X) Yes [ ] No

If muscle atrophy is present, indicate location: See Knee DBQ

5. Reflex exam

Rate deep tendon reflexes (DTRs) according to the following scale:

0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus 4+ Hyperactive with clonus

Knee:
Right:​
0​
1+
[X)
2+​
3+​
4+
Left:​
0​
1+
[X)
2+​
3+​
4+

Ankle:​
Right:​
0​
1+
[X)
2+​
3+​
4+
Left:​
0​
1+
[X)​
2+​
3+​
4+
6. Sensory exam​

Indicate results for sensation testing for light touch:


Upper anterior thigh (L2):
Right: [X) Normal [] Decreased Left: [X) Normal [ J Decreased

Absent Absent



Thigh/knee (L3/4): Right: [X) Normal Left: [X) Normal

Decreased Decreased

Absent Absent



Lower leg/ankle (L4/L5/Sl):
Right: [X) Normal [] Decreased Left: [ l Normal [X] Decreased

Absent Absent



Foot/toes (LS): Right: [X) Normal Left: [X) Normal

Decreased Decreased

Absent Absent





MEDICAL RECORD Progress Notes​

05/28/2019 12:30 ** CONTINUED FROM PREVIOUS PAGE**

7. Trophic changes

Does the Veteran have trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy?
[ l Yes [X] No

8. Gait

Is the Veteran's gait normal?
[ l Yes [X] No

If no, describe abnormal gait:
Straight left knee gait; limited left knee flexion.

Provide etiology of abnormal gait: Left knee surgeries

9. Special tests for median nerve

Were special tests indicated and performed for median nerve evaluation?
[ l Yes [X] No

10. Nerves Affected: Severity evaluation for upper extremity nerves and radicular groups

No response provided.

11. Nerves Affected: Severity evaluation for lower extremity nerves

a. Sciatic nerve
No response provided.

b. External popliteal (common peroneal) nerve No response provided.

c. Musculocutaneous (superficial peroneal) nerve No response provided.

d. Anterior tibial (deep peroneal) nerve
Right: [X] Normal [] Incomplete paralysis Complete paralysis Left: [ l Normal [X] Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:​
[X] Mild [] Moderate [] Severe

e. Internal popliteal (tibial) nerve No response provided.





MEDICAL RECORD Progress Notes

05/28/2019 12:30 ** CONTINUED FROM PREVIOUS PAGE**


f. Posterior tibial nerve No response provided.

g. Anterior crural (femoral) nerve No response provided.

h. Internal saphenous nerve No response provided.

i. Obturator nerve
No response provided.

j. External cutaneous nerve of the thigh No response provided.

k. Ilia-inguinal nerve
No response provided.

12. 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

Frequency of use:​

[X] Brace(s) [X] Occasional [ ] Regular l Constant
b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:
Veteran occasionally uses a left knee brace for his knee condition.

13. Remaining effective function of the extremities

Due to peripheral nerve 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. Other pertinent physical findings, complications, conditions, signs, symptoms and scars

a. Does the Veteran have any other pertinent physical findings,








MEDICAL RECORD Progress Notes



05/28/2019 12:30 ** CONTINUED FROM PREVIOUS PAGE**



complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above?

[ ] Yes [X] No



  1. 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?
[ l Yes [X] No



  1. Comments, if any:
No response provided.



  1. Diagnostic testing


  1. Have EMG studies been performed?
[ l Yes [X] No





  1. Are there any other significant diagnostic test findings and/or results?
[ l Yes [X] No





  1. Functional impact


Does the Veteran's peripheral nerve condition and/or peripheral neuropathy impact his or her ability to work?

[ ] Yes [X] No





  1. Remarks, if any:


No remarks provided.
 

RonG

Super Moderator
Staff Member
PEB Forum Veteran
Registered Member
I infer you want someone to "guess" your future rating, although I did not see a question (for members of this board) within your lengthy narrative.

You can make your own determination by using
38 CFR Book C, Schedule for Rating Disabilities

which can be found at 38 CFR Book C, Schedule for Rating Disabilities <---LINK

Good luck,
Ron
 

Rjohnson87

PEB Forum Regular Member
PEB Forum Veteran
Registered Member
I infer you want someone to "guess" your future rating, although I did not see a question (for members of this board) within your lengthy narrative.

You can make your own determination by using
38 CFR Book C, Schedule for Rating Disabilities

which can be found at 38 CFR Book C, Schedule for Rating Disabilities<---LINK

Good luck,
Ron
yes i have looked into ratings and wanted to get second and 3rd opinions. I know they are just opinions but every little bit helps and I know there are more seasoned individuals on here that are better at deciphering ratings than I am.
 

Andyfbaby

Member
Registered Member
HIGHLY advising you delete this post as it contains your PII (full social security number, DOB and full name).
 

RonG

Super Moderator
Staff Member
PEB Forum Veteran
Registered Member
HIGHLY advising you delete this post as it contains your PII (full social security number, DOB and full name).
Excellent point.

I'll delete (edit) his identifying information.

Good catch.

Ron
 

usarmy68e

PEB Forum Regular Member
PEB Forum Veteran
Registered Member
Here is the issue with that, I guessed mine and estimated it based upon the C&P Exams around 70%, I received my ratings and was offered 90% due to the rater reviewing both my medical records and the C&P exams stating that I had more in my exams than the C&P examiners gave due credit. All things considered we have guidelines and the Raters overall are the ones who can really choose how to do it. Best of luck to your process!

yes i have looked into ratings and wanted to get second and 3rd opinions. I know they are just opinions but every little bit helps and I know there are more seasoned individuals on here that are better at deciphering ratings than I am.
 

RonG

Super Moderator
Staff Member
PEB Forum Veteran
Registered Member
Here is the issue with that, I guessed mine and estimated it based upon the C&P Exams around 70%, I received my ratings and was offered 90% due to the rater reviewing both my medical records and the C&P exams stating that I had more in my exams than the C&P examiners gave due credit. All things considered we have guidelines and the Raters overall are the ones who can really choose how to do it. Best of luck to your process!
Excellent.

Ron
 

usarmy68e

PEB Forum Regular Member
PEB Forum Veteran
Registered Member
I never entered into this process attempting to make false claims, or take more than what I feel is an entitlement, that's just not what we were trained to do in my opinion. I do however read regulations, and this is an entitlement and the PEB acknowledges the injury happened in Iraq, therefore I feel like this shouldn't be too hard, but we never know, the worst thing that can happen is they say No.

Hopefully you will receive what you feel is appropriate.

Good luck,
Ron
 
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