I believe I'm looking at possible 70% for my PTSD but I'm confused about my left ankle which are my two unfitting conditions and I'm confused about the rest of it.
*PTSD - The SMs symptoms meet DSM 5 criteria for PTSD. Her symptoms have made her unable to do her job and she has had difficulty in school. She has cut herself off from many of her friends and is now less motivated and has difficulty interacting with her family. She reports significant panic attacks and hyperventilate when she goes shopping and tries to avoid leaving her house when possible.
*Left Ankle Instability- Has exhausted all conservative treatment regarding left ankle.
Left ankle plantar flexion 45 or greater
Left ankle plantar dorsiflexion extension 20 or grater
Left ankle post-test ROM
Plantar flexion 45 or greater
Left ankle plantar dorsiflexion extension 20 or grater
Anterior drawer test yes laxity compared to opposite side on both demonstrates laxity
Talar tilt test inversion and eversion stress laxity compared with opposite side both demonstrated laxity.
Right ankle condition- increased in joint laxity in bilateral ankle on exam
Right ankle planter flexion 45 or greater
Right ankle dorsiflexion extension 20 or greater
Right ankle post-test ROM
Posttest plantar flexion 45 or greater
Right ankle dorsiflexion extension 20 or greater
Varicose veins – veteran has vascular disease varicose veins and/ or post-phlebitic syndrome of any etiology. Symptoms relived when legs are elevated.
Dry eye syndrome – Assessment
1 S/P PRK completed while on active duty with residual Mild refractive error and long standing decreased vision right eye- strabismic amblyopia. +gross stereopsis intact
2. Hx of dry eyes is at least as likely as not due to #1
3. No other active ocular pathology seen at this time.
Hip: Right hip strain, ongoing symptoms, may worsen. Decreased ROM associated with pain.
Veteran has additional limitations in ROM. Veteran has functional loss and/or functional impairment. No functional loss for left lower extremity. Has less movement than normal and pain on movement on right.
Right hip flexion 90
Right hip objective evidence of painful motion 80
Right hip extension ends greater than 5
Right hip objective evidence of painful motion 5
Left hip flexion 105
Left hip no objective evidence of painful motion
Left hip extension ends greater than 5
Left hip no objective evidence of painful motion
ROM post test
Right hip flexion ended 80
Right hip extension ended 5
Left hip flexion 105
Left hip no objective evidence of painful motion
Left hip extension ends greater than 5
Left hip no objective evidence of painful motion
ROM post test
Left hip flexion ended 105
Left hip extension ended 5
Bilateral knee condition – decreased ROM associated with pain left knee flexion. The veteran has additional limitation in ROM of the knee and lower leg following repetitive-testing. The veteran has functional loss and or/functional impairment of the knee and lower leg. Less movement than normal both and pain on movement Left knee.
ROM
Right knee flexion 125
Right knee No objective evidence of painful motion
Right knee 0 or any degree or hyperextension
Left knee flexion 125
Left knee objective evidence of painful motion 120
Left knee 0 or any degree or hyperextension
Repetitive use testing
Right knee flexion 125
Right knee No objective evidence of painful motion
Right knee 0 or any degree or hyperextension
Left knee flexion 125
Left knee objective evidence of painful motion 120
Left knee 0 or any degree or hyperextension
Sciatica – never roots involved L4/L5/S1/S2/S3 both
Severity of radiculopathy and side affected
Right-Severe
Left-Moderate
Gerd – Has abdomen and viscera. Has had gerd since late 2000s.
Rhinitis – Veteran has Sinusitis and Rhinitis. Sinuses type Maxillary. impacts functional pt has missed time from work due to symptoms.
Lumbar strain – The veteran has functional loss and/or function impairment of the thoracolumbar spine back. Has tenderness in lower back. Veteran has IVDS of the thoracolumbar. Thoracolumbar spine condition impacts her work ability.
Intermittent pain
Right lower extremity- severe
Left lower extremity- moderate
Paresthesias and or/dysesthesias
Right lower extremity- sever
Left lower extremity-moderate
Numbness
Right lower extremity-Sever
Left lower extremity-moderate
Forward flexion ends 45
Objective evidence of painful motion begins 45
Extension ends 30 or greater
Objective evidence of painful motion begins 30 or greater
Right lateral flexion ends 15
Objective evidence of painful motion begins 15
Left lateral flexion ends 20
Objective evidence of painful motion begins 20
Right lateral rotation ends 30 or greater
Objective evidence of painful motion begins 30 or greater
Left lateral rotation ends 30 or greater
Objective evidence of painful motion begins 30 or greater
ROM post test
Forward flexion ends 45
Extension ends 30 or greater
Right lateral flexion ends 15
Left lateral flexion 20
Right lateral rotation ends 30 or greater
Left lateral rotation ends 30 or greater
*PTSD - The SMs symptoms meet DSM 5 criteria for PTSD. Her symptoms have made her unable to do her job and she has had difficulty in school. She has cut herself off from many of her friends and is now less motivated and has difficulty interacting with her family. She reports significant panic attacks and hyperventilate when she goes shopping and tries to avoid leaving her house when possible.
*Left Ankle Instability- Has exhausted all conservative treatment regarding left ankle.
Left ankle plantar flexion 45 or greater
Left ankle plantar dorsiflexion extension 20 or grater
Left ankle post-test ROM
Plantar flexion 45 or greater
Left ankle plantar dorsiflexion extension 20 or grater
Anterior drawer test yes laxity compared to opposite side on both demonstrates laxity
Talar tilt test inversion and eversion stress laxity compared with opposite side both demonstrated laxity.
Right ankle condition- increased in joint laxity in bilateral ankle on exam
Right ankle planter flexion 45 or greater
Right ankle dorsiflexion extension 20 or greater
Right ankle post-test ROM
Posttest plantar flexion 45 or greater
Right ankle dorsiflexion extension 20 or greater
Varicose veins – veteran has vascular disease varicose veins and/ or post-phlebitic syndrome of any etiology. Symptoms relived when legs are elevated.
Dry eye syndrome – Assessment
1 S/P PRK completed while on active duty with residual Mild refractive error and long standing decreased vision right eye- strabismic amblyopia. +gross stereopsis intact
2. Hx of dry eyes is at least as likely as not due to #1
3. No other active ocular pathology seen at this time.
Hip: Right hip strain, ongoing symptoms, may worsen. Decreased ROM associated with pain.
Veteran has additional limitations in ROM. Veteran has functional loss and/or functional impairment. No functional loss for left lower extremity. Has less movement than normal and pain on movement on right.
Right hip flexion 90
Right hip objective evidence of painful motion 80
Right hip extension ends greater than 5
Right hip objective evidence of painful motion 5
Left hip flexion 105
Left hip no objective evidence of painful motion
Left hip extension ends greater than 5
Left hip no objective evidence of painful motion
ROM post test
Right hip flexion ended 80
Right hip extension ended 5
Left hip flexion 105
Left hip no objective evidence of painful motion
Left hip extension ends greater than 5
Left hip no objective evidence of painful motion
ROM post test
Left hip flexion ended 105
Left hip extension ended 5
Bilateral knee condition – decreased ROM associated with pain left knee flexion. The veteran has additional limitation in ROM of the knee and lower leg following repetitive-testing. The veteran has functional loss and or/functional impairment of the knee and lower leg. Less movement than normal both and pain on movement Left knee.
ROM
Right knee flexion 125
Right knee No objective evidence of painful motion
Right knee 0 or any degree or hyperextension
Left knee flexion 125
Left knee objective evidence of painful motion 120
Left knee 0 or any degree or hyperextension
Repetitive use testing
Right knee flexion 125
Right knee No objective evidence of painful motion
Right knee 0 or any degree or hyperextension
Left knee flexion 125
Left knee objective evidence of painful motion 120
Left knee 0 or any degree or hyperextension
Sciatica – never roots involved L4/L5/S1/S2/S3 both
Severity of radiculopathy and side affected
Right-Severe
Left-Moderate
Gerd – Has abdomen and viscera. Has had gerd since late 2000s.
Rhinitis – Veteran has Sinusitis and Rhinitis. Sinuses type Maxillary. impacts functional pt has missed time from work due to symptoms.
Lumbar strain – The veteran has functional loss and/or function impairment of the thoracolumbar spine back. Has tenderness in lower back. Veteran has IVDS of the thoracolumbar. Thoracolumbar spine condition impacts her work ability.
Intermittent pain
Right lower extremity- severe
Left lower extremity- moderate
Paresthesias and or/dysesthesias
Right lower extremity- sever
Left lower extremity-moderate
Numbness
Right lower extremity-Sever
Left lower extremity-moderate
Forward flexion ends 45
Objective evidence of painful motion begins 45
Extension ends 30 or greater
Objective evidence of painful motion begins 30 or greater
Right lateral flexion ends 15
Objective evidence of painful motion begins 15
Left lateral flexion ends 20
Objective evidence of painful motion begins 20
Right lateral rotation ends 30 or greater
Objective evidence of painful motion begins 30 or greater
Left lateral rotation ends 30 or greater
Objective evidence of painful motion begins 30 or greater
ROM post test
Forward flexion ends 45
Extension ends 30 or greater
Right lateral flexion ends 15
Left lateral flexion 20
Right lateral rotation ends 30 or greater
Left lateral rotation ends 30 or greater
