Read Disability Claims Articles
View All Forums | Chats and Other Events | Donate | Blogs | New Users | Search | Rules
- 0
Back C&p Exam: Need To Know What Write Up Saying In Eng...
Rate this question
Read Disability Claims Articles
View All Forums | Chats and Other Events | Donate | Blogs | New Users | Search | Rules
Rate this question
Question
marinejay
I need some help deciphering this C&P exam, I am currently at 20% and I would like to know what this is saying in plain english
my take is I will get 10% for sciatica or radicopothy and maybe get an increase, but I think i'll be able to keep my current rating of 20%. any input would greatly be appreciated.
I took out all of the gargable and just left the docs answers bolded...
____________________________________________________________________________________________________
Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the Veteran's VA claims file:
current VA studies
1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses:
[X] Intervertebral disc syndrome
2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary):
The veteran states that his back condition has worsened since he was first rated for it in 2003. He states that the radiation of the pain into the right leg is more frequent and more intense, and sometimes goes into the left leg as well. Does not like taking narcotic pain medication but finds he has to do it more often now. No bladder or bowel dysfunction.
3. Flare-ups ------------ Does the Veteran report that flare-ups impact the function of the thoracolumbar spine (back)? [X] Yes [ ] No
If yes, document the Veteran's description of the impact of flare-ups in his or her own words:
States that if he does something too physically demanding his pain will increase for 1-2 days, but is unable to quantify any changes in ROM.
Not having a flare up at the time of this exam.
4. Initial range of motion (ROM) measurement -------------------------------------------- a. Select where forward flexion ends (normal endpoint is 90):
[ x] 70
Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 60
b. Select where extension ends (normal endpoint is 30):] [X] 25
Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 20
c. Select where right lateral flexion ends (normal endpoint is 30): [X] 30 or greater
Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 30 or greater
d. Select where left lateral flexion ends (normal endpoint is 30): [X] 30 or greater
Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 30 or greater
e. Select where right lateral rotation ends (normal endpoint is 30): [X] 30 or greater
Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 30 or greater
f. Select where left lateral rotation ends (normal endpoint is 30): [X] 30 or greater
Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 30 or greater
g. If ROM for this Veteran does not conform to the normal range of motion
identified above but is normal for this Veteran (for reasons other than a back condition, such as age, body habitus, neurologic disease), explain:
No response provided.
5. ROM measurement after repetitive use testing ----------------------------------------------- a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
[X] Yes [ ] No b. Select where post-test forward flexion ends: [X] 75
c. Select where post-test extension ends: [X] 20
d. Select where post-test right lateral flexion ends: X] 30 or greater
e. Select where post-test left lateral flexion ends: [X] 30 or greater
f. Select where post-test right lateral rotation ends: [X] 30 or greater
g. Select where post-test left lateral rotation ends: [X] 30 or greater
6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the thoracolumbar
spine (back) following repetitive-use testing? [ ] Yes [X] No
b. Does the Veteran have any functional loss and/or functional impairment of the thoracolumbar spine (back)? [X] Yes [ ] No
c. If the Veteran has functional loss, functional impairment and/or
additional limitation of ROM of the thoracolumbar spine (back) after repetitive use, indicate the contributing factors of disability below:
[X] Less movement than normal
[X] Weakened movement
[X] Pain on movement
[X] Interference with sitting, standing and/or weight-bearing
7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait) ---------------------------------------------------------------- ------------
a. Does the Veteran have localized tenderness or pain to palpation for joints
and/or soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No
If yes, describe: lumbar paravertebral tenderness
b. Does the Veteran have muscle spasm of the thoracolumbar spine resulting in
abnormal gait or abnormal spinal countour? [ ] Yes [X] No
c. Does the Veteran have muscle spasms of the thoracolumbar spine not
resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No
d. Does the Veteran have guarding of the thoracolumbar spine resulting in
abnormal gait or abnormal spinal countour? [ ] Yes [X] No
e. Does the Veteran have guarding of the thoracolumbar spine not resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No
8. 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
Hip flexion: Right: [X] 5/5 Left: [X] 5/5
Knee extension: Right: [X] 5/5 5 Left: [X] 5/5
Ankle plantar flexion: Right: [X] 5/5 5 Left: [X] 5/5
Ankle dorsiflexion: Right: [X] 5/5 Left: [X] 5/5
Great toe extension: Right: [X] 5/5 Left: [X] 5/5
b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
9. 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: [x ] 2+ Left: [x ] 2+
Ankle: Right: [x ] 2+ Left: [ x] 2+
10. Sensory exam ---------------- Provide results for sensation to light touch (dermatome) testing:
Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased
Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased
Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased
Foot/toes (L5): Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased
11. Straight leg raising test ----------------------------- Provide straight leg raising test results:
Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform
12. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No
a. Indicate symptoms' location and severity (check all that apply):
No response provided.
b. Does the Veteran have any other signs or symptoms of radiculopathy?
[ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply)
[X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [X] Right [ ] Left [ ] Both THIS SEEMS VERY CONFUSING WHAT LOOKING AT QUESTION #12 SAYING NO.. NEED HELP HERE
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe
13. Ankylosis ------------- Is there ankylosis of the spine? [ ] Yes [X] No
14. Other neurologic abnormalities ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No
15. Intervertebral disc syndrome (IVDS) and incapacitating episodes ---------------------------------------------------------------- ---
a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No
b. If yes, has the Veteran had any incapacitating episodes over the past
12 months due to IVDS? [ ] Yes [X] No
16. 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? [ ] Yes [X] No
17. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) 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.; functions of the lower extremity include balance and propulsion, etc.)
[X] No
18. Other pertinent physical findings, complications, conditions, signs
and/or symptoms ---------------------------------------------------------------- ------- a. 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? [ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? [ ] Yes [X] No
19. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the
results available? [X] Yes [ ] No
If yes, is arthritis documented? [ ] Yes [X] No
b. Does the Veteran have a thoracic vertebral fracture with loss of 50
percent or more of height? [ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
20. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her
ability to work? [X] Yes [ ] No
If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples:
interferes with prolonged sitting
21. Remarks, if any: -------------------- No remarks provided.
Link to comment
Share on other sites
Top Posters For This Question
2
2
1
Popular Days
Jan 26
2
Jan 25
1
Jan 28
1
Jan 29
1
Top Posters For This Question
marinejay 2 posts
Navy04 2 posts
63SIERRA 1 post
Popular Days
Jan 26 2014
2 posts
Jan 25 2014
1 post
Jan 28 2014
1 post
Jan 29 2014
1 post
4 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now