lumbosacral Ime Report, Opinions?

[kevin4998]

XXXXXX, M.D., M.S., CIME

XXXX N. XXXX Street, Suite XXX

XXXXX,XXXXX, 12345

xx.com

April 8, 2012

NAME OF CLAIMANT: EDITED

DATE OF EXAMINATION: 03/27/2012

MEDICAL RECORDS: Reviewed

HISTORY:

The claimant, Mr. EDITED, is a 46-year-old military veteran. He suffers from numerous

medical conditions and is in the process of filing for VA and Social Security disability benefits.

Based upon information provided by the claimant he has chronic low back pain, diabetes, IBS,

GERD, Barrett’s esophagus, major depression, and anxiety.

The past surgical history includes appendectomy, cholecystectomy, and two back surgeries.

Medications include insulin, pantoprazole, glipizide, simvastatin, lisinopril, ciprofloxacin,

morphine, buproprion, trazodone, venlafaxine

He states that he last worked in February of 2011 and that currently he sits at home, watches

TV, uses the computer, and occasionally cleans. He has little energy for cleaning and it causes

him pain. He denies any current hobbies, and states he last went fishing in the 1980s prior to

military service. He states he can sit at his computer for 30 minutes at a time. He states that

while working as a correctional officer he fell on ice and hit his tailbone, for which he received

compensation. His primary complaint currently is back pain.

CURRENT COMPLAINTS:

Mr. EDITED complains of constant, dull, low back pain rated 5-6/10 which worsens with activity to 10/10. He gets pain down the back of both legs. He sleeps on his side only, avoiding tailbone

pressure. He also has noticed numbness of his feet in the last year.

The claimant reports limitations with walking more that 10 minutes, difficulty dealing with people,

difficulty climbing stairs due to lifting legs, difficulty standing more that a few minutes, and

diarrhea and constipation.

PHYSICAL EXAMINATION:

General: NAD, gait antalgic

Heart: RRR, no murmurs

Lungs: CTAB

Abdomen: Soft, nontender, nondistended

Examination of the spine reveals the following range of motion:

Flexion is from 0 to 20 degrees

Extension is from 0 to 10 degrees

Left rotation is from 0 to 20 degrees

Right rotation is from 0 to 20 degrees

Left lateral flexion is from 0 to 20 degrees

Right laterl flexion is from 0 to 20 degrees

There is no ankylosis of the spine. Surgical scars are present. Reflexes are within normal

limits. Muscle strength testing is within normal limits.

Diagnosis: Chronic lumbosacral strain s/p surgical correction

Diagnosis: GERD with Barrett’s esophagus

DISCUSSION:

It is my opinion based on review of the available medical records, my training, and my clinical

experience that the claimant’s chronic lumbosacral strain and GERD with Barrett’s esophagus

originated during his military service. The claimant’s GERD and chronic lumbosacral strain

are well documented in the service medical records. No evidence was present suggesting that

these conditions were present prior to service. Therefore, it is at least as likely as not that the

claimant’s chronic lumbosacral strain and GERD with Barrett’s esophagus are a result of his

military service.

The claimant consented to the examination. Female assistant AA was present throughout the

examination. I have not provided care for this claimant. I have seen this claimant one time

on the above date for the purpose of evaluating medical impairment. Evaluation is focused to

the conditions listed above. The claimant tolerated the examination well without any change in

symptomatology.

The above analysis is based upon the available information at this time. It is assumed that the

information provided to me is correct. If more information becomes available at a later date, it

may or may not change the opinions rendered in this evaluation.

Respectfully submitted,

XXX X. XXXXX, M.D., M.S., CIME

Board Certified, Occupational Medicine

Edited April 9, 2012 by carlie
Dr's name and address edited out by Admin

[Berta]

"The claimant’s GERD and chronic lumbosacral strain

are well documented in the service medical records. No evidence was present suggesting that

these conditions were present prior to service"

Was this opinion prepared when you first filed, or did VA deny it already?

I assume, since the IME states the SMRs reveal GERD and the back strain, that this was not denied yet .

Of course the VA will hone it on this as it is a post service injury:

“He states that

while working as a correctional officer he fell on ice and hit his tailbone, for which he received

compensation. His primary complaint currently is back pain.”

Was the IME doctor given any medical records from that fall (X rays or MRIs etc) that completely separate this from the chronic lumbar strain?

Does your medical record reveal a continuous chronicity of symptoms and treatment for the lumbar strain since you left the military?

If you have records f continuous treatment for the lumbar problem since service, then VA cannot blame all of your pain on te post service accident. (I assume this was post service as to the ice fall-please correct me if I am wrong)

Did the doctor directly refer to (or have you attached to the IME copy you are sending to VA), the dated copies of the actual SMRs that document the inservice GERD and the lumbar strain?

Others will chime in here too. I always look for the landmines (anything weak or debatable) the VA will focus on and hopefully I am wrong.

It is often best sometimes to wait for a SOC and results from a C & P exam before getting an IMO. That way the IMO doctor has a lot more to work with, and they know exactly what evidence from VA that they have to overcome.

They also will have an idea of the credentials and/or expertise of the VA examiner.

[kevin4998]

"The claimant’s GERD and chronic lumbosacral strain

are well documented in the service medical records. No evidence was present suggesting that

these conditions were present prior to service"

Was this opinion prepared when you first filed, or did VA deny it already?

I assume, since the IME states the SMRs reveal GERD and the back strain, that this was not denied yet .

Of course the VA will hone it on this as it is a post service injury:

I am still in "gathering information", I filed last year in March I believe.

“He states that

while working as a correctional officer he fell on ice and hit his tailbone, for which he received

compensation. His primary complaint currently is back pain.”

Was the IME doctor given any medical records from that fall (X rays or MRIs etc) that completely separate this from the chronic lumbar strain?

Yes, and the case is closed. I have another IME from that accident stating that in his opinion that my on going pain is due to prior issues before my fall and not related at all to my fall. (he worded much better)

Does your medical record reveal a continuous chronicity of symptoms and treatment for the lumbar strain since you left the military?

Yes, I have had issues since the first year of my military service, and have had documented compliants and diagnoses after my military time... including the forementioned surgeries.

If you have records f continuous treatment for the lumbar problem since service, then VA cannot blame all of your pain on te post service accident. (I assume this was post service as to the ice fall-please correct me if I am wrong). You are correct, I actually believe that the fall was related to my on going back issues.. i was carrying items in both hands and loss my balance .. because I was being so careful of any sudden movements (to prevent more pain then I already was in).

Did the doctor directly refer to (or have you attached to the IME copy you are sending to VA), the dated copies of the actual SMRs that document the inservice GERD and the lumbar strain?

No he did not actually refer to any documents, but I have a folder with all documents, index and highlighted of pertiniant information and even numbered. I plan on hiring another IME in the near future (SSD claim in front of judge in May and I am positive that my lawyer will pull me through) with the back pay from that. This is actually my second IME, the next one should fill in any gaps because he is going to address my issues in more detail and with suggestions here. Like my Barrett's is not actually listed in my SMR, and it was diagnosed AFTER my VA claim being filed. So it needs to be added as a secondary condition. IBS is not fully addressed which IS in my SMR but I know I need the Colonoscopy (oh joy)yet. I have that for just as many years as the rest(23 plus years) and I do have it chronic.. I know they will find signs of it in my lower bowels.. the question is how much damage has been done over the years. The GERD was listed in my SMR several times and they also mentioned my Hiatel Hernia which would be the cause.

Prior service, I was never injured or hospitalised for anything so they will not find anything pre-military at all on me.

The only things that I am claiming that I believe I will have a hard time with is Depression, Anxiety and PTSD.. I know they will only consider these togather. I am having a very difficult time getting my phsyc docs thru va, to believe me that my Depression and Anxiety is sever.. the last visit my doc told me that everyone has issues and can basically get over them.. where I do not feel that way. Heck I can not even talk to him about my PTSD as of yet because he believes I can be get better.. which I do not feel that way at all. He told me thier was no since in continueing counseling if I felt that way. With out counseling I am screwed on claims.. so not sure what to do about it.

Sorry for rambling but between the SSD and VA and trying to get organised.. I can get off topic quickly

Others will chime in here too. I always look for the landmines (anything weak or debatable) the VA will focus on and hopefully I am wrong.

It is often best sometimes to wait for a SOC and results from a C & P exam before getting an IMO. That way the IMO doctor has a lot more to work with, and they know exactly what evidence from VA that they have to overcome.

They also will have an idea of the credentials and/or expertise of the VA examiner.

[Berta]

“I have another IME from that accident stating that in his opinion that my on going pain is due to prior issues before my fall and not related at all to my fall. (he worded much better)”

GREAT!

“Yes, I have had issues since the first year of my military service, and have had documented compliants and diagnoses after my military time... including the forementioned surgeries. “

Double GREAT!

“The only things that I am claiming that I believe I will have a hard time with is Depression, Anxiety and PTSD. “

Depression can certainly be casued by dealing with chronic pain.It takes a medical nexus statement for that.

Your PTSD claim (PTSD is an anxiety disorder) will fall under new PTSD criteria.

It will require VA MH diagnosis as well as proof of stressor.

The new PTSD criteria is in our PTSD forum ere-I will bump it up if it is not on the first topic page-

while the new PTSD regs have relaxed the 'stressor' requirement for many veterans, others have found it difficult to even obtain a VA diagnosis and, unfortunately, the regs will not except an IMO diagnosis

of PTSD.

There is also Definitions of what a stressor is and isnt here at hadit.

Often a vet should focus in on depression for SC rather then PTSD.

Then again it depends what diagnosis they have and if the stressor doesnt fall into the 'hostile activity' and MOS part in the new regs, then JSRRC will attempt to verify the stressor.

[carlie]

XXXXXX, M.D., M.S., CIME

XXXX N. XXXX Street, Suite XXX

XXXXX,XXXXX, 12345

xx.com

April 8, 2012

NAME OF CLAIMANT: EDITED

DATE OF EXAMINATION: 03/27/2012

MEDICAL RECORDS: Reviewed

HISTORY:

The claimant, Mr. EDITED, is a 46-year-old military veteran. He suffers from numerous

medical conditions and is in the process of filing for VA and Social Security disability benefits.

Based upon information provided by the claimant he has chronic low back pain, diabetes, IBS,

GERD, Barrett’s esophagus, major depression, and anxiety.

The past surgical history includes appendectomy, cholecystectomy, and two back surgeries.

Medications include insulin, pantoprazole, glipizide, simvastatin, lisinopril, ciprofloxacin,

morphine, buproprion, trazodone, venlafaxine

Where did the documentation of surgical history and meds come from ?

He states that he last worked in February of 2011 and that currently he sits at home, watches

TV, uses the computer, and occasionally cleans. He has little energy for cleaning and it causes

him pain. He denies any current hobbies, and states he last went fishing in the 1980s prior to

military service. He states he can sit at his computer for 30 minutes at a time.

He states that while working as a correctional officer he fell on ice and hit his tailbone, for which he received

compensation. His primary complaint currently is back pain.

The statement above might be OK for SSA BUT WILL BE VERY NEGATIVE FOR VBA PURPOSES.

CURRENT COMPLAINTS:

Mr. EDITED complains of constant, dull, low back pain rated 5-6/10 which worsens with activity to 10/10. He gets pain down the back of both legs. He sleeps on his side only, avoiding tailbone

pressure. He also has noticed numbness of his feet in the last year.

The claimant reports limitations with walking more that 10 minutes, difficulty dealing with people,

difficulty climbing stairs due to lifting legs, difficulty standing more that a few minutes, and

diarrhea and constipation.

Do you have documentation showing continuity of care for the above conditions from active duty separation

to current time ?

PHYSICAL EXAMINATION:

General: NAD, gait antalgic

Heart: RRR, no murmurs

Lungs: CTAB

Abdomen: Soft, nontender, nondistended

Examination of the spine reveals the following range of motion:

Flexion is from 0 to 20 degrees

Extension is from 0 to 10 degrees

Left rotation is from 0 to 20 degrees

Right rotation is from 0 to 20 degrees

Left lateral flexion is from 0 to 20 degrees

Right laterl flexion is from 0 to 20 degrees

There is no ankylosis of the spine. Surgical scars are present. Reflexes are within normal

limits. Muscle strength testing is within normal limits.

Diagnosis: Chronic lumbosacral strain s/p surgical correction

Diagnosis: GERD with Barrett’s esophagus

DISCUSSION:

It is my opinion based on review of the available medical records, my training, and my clinical

experience that the claimant’s chronic lumbosacral strain and GERD with Barrett’s esophagus

originated during his military service. The claimant’s GERD and chronic lumbosacral strain

are well documented in the service medical records.

What is in the "review of the available medical records" ? Were these SMR/STR's,

private provider, VAMC. This needs to be stated or referenced to support this medical

opinion with full medical rationale.

From what is posted the "available medical records" could be from a veterinarian.

​What medical test were done for the current diagnosis of GERD with Barrett's esophagus ?

What is the CAUSE of the Gerd as it relates to active duty and also the lumbosacral strain?

No evidence was present suggesting that these conditions were present prior to service.

The sentence above would probably just negate that you had any difficulties

of these conditions prior to active duty - that could have been AGGRAVATED by active duty.

But it does not in any way provide much support for SC.

Therefore, it is at least as likely as not that the claimant’s chronic lumbosacral strain and GERD with Barrett’s esophagus

are a result of his military service.

I don't see any medical rationale to support this opinion. When did you separate from active duty ?

Just because you did not have a pre-existing condition that was not aggravated from active duty does not

equate to a fact of the condition being a result of active duty. What is documented on active duty that

resulted in these residual conditions?

If you don't have active duty documentation and continuity of care I feel VBA will deny the lumbosacral strain

as due to, "He states that while working as a correctional officer he fell on ice and hit his tailbone, for which he received

compensation. His primary complaint currently is back pain."

The claimant consented to the examination. Female assistant AA was present throughout the

examination. I have not provided care for this claimant. I have seen this claimant one time

on the above date for the purpose of evaluating medical impairment. Evaluation is focused to

the conditions listed above. The claimant tolerated the examination well without any change in

symptomatology.

The above analysis is based upon the available information at this time. It is assumed that the

information provided to me is correct. If more information becomes available at a later date, it

may or may not change the opinions rendered in this evaluation.

Respectfully submitted,

XXX X. XXXXX, M.D., M.S., CIME

Board Certified, Occupational Medicine

The above in blue is the way I see this going. - carlie

[kevin4998]

Where did the documentation of surgical history and meds come from?

SMR documented statements, private doctor(s) notes for surgical and the meds is my current meds as prescribed from the VA (straight from My Health Vet).

The statement above might be OK for SSA BUT WILL BE VERY NEGATIVE FOR VBA PURPOSES.

This is the statement from my first IME which was in direct relation to the fall I had:

“IMPRESSION: Mr. EDIT is a 45 year old male with a long history of chronic lower

Back pain requiring L4-5 bilateral percutaneous discectomies, epidural steroid

Injections and a L4-5 decompressive laminectomy in 2005. On December 14, 2010.

Mr. EDIT suffered a fall at work in which he slipped on ice and landed on his right

buttock. His current diagnosis related to his December 14. 2010 work injury is right

sacroilitis. He is status post a sacroiliac injection with a reported four day period of

relief. He reports no change in his chronic back problems and no new radiculopathy or

back related hip/leg symptoms.

Mr. EDIT current symptoms include persistent right SI pain, but this is no longer

acute as his provocative SI testing was of little significance. A short heel lift on the left

may be beneficial due to the slight elevation of his pelvis on the right but that he can do

without a prescription. Given the chronicity of his generalized low back pain, severity of

o· depression and lack of acute SI findings. no further treatment for his sacroiliitis appears

indicated. He has had physical therapy, medications and the 51 injection. I do not feel

he is a candidate for a SI fusion given his history of back surgery, radiculopathy and

chronic pain. Therefore. I conclude that Mr. EDIT has reached Maximum Medical

Improvement and no further surgical or non-surgical treatment would benefit his right

sacroltinis.

From a functional standpoint. I do not feel Mr. EDIT is capable of work in any capacity.

Given his depression, chronic low back pain. , and surgical history. I would recommend

that he pursue SSDI. I expect he is totally and permanently disabled. However, I do

not feel that the sacroilitis is contributing to his ongoing disability. He continued to work

after the S1 injury and acknowledges that his present disability is due to his pre-injury

back condition and depression. Neither of these diagnoses were caused or affected by

The December 14, 2010 incident.”

Do you have documentation showing continuity of care for the above conditions from active duty separation to current time?

I have seen at least a half a dozen family doctors, neurologist and physical therapist(s) over the course of the last 15 years(sevice: 87-97) since I left the service and for the most part I have all that documentation.

What is in the "review of the available medical records”? Were these SMR/STR's,

private provider, VAMC. This needs to be stated or referenced to support this medical

opinion with full medical rationale.

From what is posted the "available medical records" could be from a veterinarian

SMR’s, doctor notes, MRI notes and VA records which I am in possession of and will be taking them to C&P exam when I go and be hand delivering them to the Indianapolis VARO(I believe that the correct place, I know where.. just not the correct name :/) office.

What medical test were done for the current diagnosis of GERD with Barrett's esophagus?

What is the CAUSE of the Gerd as it relates to active duty and also the lumbosacral strain

SMR stated I had Hiatal Hernia and GERD several times during my ten years of service. Family doctor notes indicate continuation of the problem with discussions and prescribed meds for it over the years after service. This pass year I had an Endoscopy showing Barrett’s, which I should be able to get that listed as secondary to GERD.

The sentence above would probably just negate that you had any difficulties

of these conditions prior to active duty - that could have been AGGRAVATED by active duty.

But it does not in any way provide much support for SC.

As mentioned above, I do have lower back issues, GERD, IBS, Hiatal Hernia noted several times in my SMR with medication prescribed. There was no actual test preformed, but discussion and notes by the medical department and then medication issued with the fore mentioned items placed in SMR.

I served 1987-1997 in the engineering department as a Damage Controlmen. Yes, I am a Gulf War Vet.

[john999]

This is sort of what happens when you mix work-related injuries with military injuries. Both parties point their fingers at the other party and blame them for the disability. What it takes is plently of IMO/IME reports. I had the same problem. I worked for the post office. They hired me with a 10% VA rating from a mental illness. Over the years they did all they could to aggravate it. Finally when I could not work any more I filed for workers compensation, SSD, OPM and TDIU (I had 30% by then). I never went back to work. I got one thing at a time. I had to finally choose between getting TDIU and continuing to get OWCP (WC) but that was no problem. I had many IMO's. It took a couple of years. I did not plan any of this, but the USPS threw me in the briar patch.

John