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sgtdjusmc

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sgtdjusmc last won the day on April 2

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About sgtdjusmc

  • Rank
    E-3 Seaman

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  • Military Rank
    SGT
  • Location
    Texas

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  • Service Connected Disability
    80
  • Branch of Service
    Marines/National Guard

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  1. Creating high GFR 47, labs done at the VA 40 days after discharge
  2. Here it is. I love when they say it doesn’t exist when the VA gave me the diagnoses
  3. Everyone has those symptoms downrange working 12 on 12 off; fatigue etc. No one goes to sick call in the infantry for all that. I just got off deployment last august and left the national guard in May so I have contact with everyone.
  4. thanks for this. Their denial is the one line. They didn't even give me a C&P. So its a coincidence my kidneys are fine right before deployment and not fine right after? Chronic is just the diagnosis they kidney disease. Its actually termed renal dysfunction in the CFR. From what I understand these days, both from guys who went with me and my friend at the VBA is all conditions claimed within a year of discharge are presumed to have been because of military service. They are supposed to give general medical exams from head to toe and if they give you a diagnoses its presumed it occurred on active duty. At least three of my guys went through this. They also never went to sick call downrange and got rated.
  5. just said it didn't manifest in the military. I think they just skipped over within a year of discharge because they asked for medical opinions on all my claimed conditions.
  6. The reason was it didn't manifest while on active duty. They asked for medical opinions on all my conditions so I think they just skipped over the year within discharge rules. it should be under renal dysfunction. 7530 I believe
  7. I have had annual blood tests at the VA for at least 5 years prior to deployment. All showed normal Creatine levels and GFR (except one 57 GR just prior). When I returned I had another round of blood tests 40 days post discharge. The VA Dr. diagnosed me with chronic kidney disease since my creatine was high and GFR was 47. The VA denied my claim out right. Shouldn't this be presumptive since it was within a year of discharge?
  8. can you post your C&P? also, arthritis of major and minor joints are taken into account. To your questions; YES.
  9. yes I have had that experience. I went to a board certified surgeon with the DBQ. Probative value wiped out the ridiculous VA determination.
  10. thanks. I see she did check hypoactive reflex for the left ankle so maybe it will go to 40%
  11. I am thinking 20, 20, 20. Anyone see anything else? 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 [X] Other (please identify other evidence reviewed): JOINT L 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: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [X] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: LUMBAR DDD Date of diagnosis: 2015 BY MRI Diagnosis #2: THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION Date of diagnosis: SERVICE CONNECTED Diagnosis #3: BILATERAL RADICULOPATHY Date of diagnosis: 2018 2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): THE VETERAN IS A 42 YO MALE WHO SERVED IN THE MARINE CORP FROM 1995 TO 1999, THE MARINE CORP RESERVE FROM 1999 - 2001, AND THE NATIONAL GUARD FROM 2001 TO 2003 AND AGAIN FROM 2016 TO PRESENT DAY WITH DEPLOYMENT TO AFRICA FROM 2017 TO 2018. HE IS HERE FOR A CURRENT LEVEL OF DISABILITY EXAM FOR THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION. HE REPORTS SINCE HIS LAST COMP AND PEN EVALUATION AROUND 2013 HE HAS WORSENING PAIN WITH ONSET OF RADICULOPATHY IN BOTH LEGS. HIS PAIN LEVEL RANGE IS FROM A 5-9/10 WITH A THROBBING CHARACTER HAVING OVERLYING SHARP JABS. HE IS STIFF AFTER SITTINIG AND IN THE MORNING. HIS MORNING STIFFNESS WILL LAST 1-2 HOURS. HE STATES IN REGARDS TO HIS RADICULOPATHY HIS LEFT IS WORSE THAN HIS RIGHT AND EXTEND TO HIS FEET BILATERALLY. HE PREVIOUS TREATMENT INCLUDES PHYSICAL THERAPY, CHIROPRACTIC CARE. HE DENIES ANY SURGERY. HE JUST ANOTHER ROUND OF PHYSICAL THERAPY. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: HIS PAIN WILL ELEVATE TO A 9/10 TWICE A WEEK LASTING A FEW HOURS TRIGGERED BY OVERACTIVITY. HE WILL REST AND USE PAIN CONTROL. c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (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. HE REPORTS HE DIFFICULTY WALKING FOR LONG DISTANCES, CANNOT SIT IN A HARD CHAIR, HAS PROBLEM SOCIAL FUNCTION ACTIVITIES AND PLYAING WITH HIS CHILDREN. HE CANNOT LIFT OVER 15 POUNDS OR STAND MORE THAN 30 MINTUES. HE HAS PROBLEMS WITH ANY MOVEMENT THAT REQUIRES BENDING, LIKE PUTTING ON HIS SHOES. HE HAS DIFFICULTY CONCENTRATING WHEN HIS PAIN ELEVATES. HE HAS DIFFICULTY DRIVING OVER AN HOUR. 3. Range of motion (ROM) and functional limitation ------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 35 degrees Extension (0 to 30): 0 to 10 degrees Right Lateral Flexion (0 to 30): 0 to 15 degrees Left Lateral Flexion (0 to 30): 0 to 15 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: HE WOULD NOT BE ABLE TO RETREIVE AN ITEM FROM THE FLOOR 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)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion, Right Lateral Rotation, Left Lateral Rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): TENDERNESS OVER THE LUMBAR VERTEBRAE, PARASPINOUS MUSCLES, BILATERAL SI JOINTS AND BILATERAL SCIATIC NERVES. b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] 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? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: HE HAS NOT USED HIS BACK REPEATEDLY. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] 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. [X] 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? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: HE WAS NOT HAVING A FLARE. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [ ] Yes [X] No f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Less movement than normal due to ankylosis, adhesions, etc., Disturbance of locomotion, Interference with sitting, Interference with standing, Other (please describe) Please describe additional contributing factors of disability: INTERFERENCE WITH LIFTING. 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 Hip flexion: 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 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 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 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam -------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Straight leg raising test --------------------------- Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy --------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Numbness Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe 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: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 9. Ankylosis ----------- Is there ankylosis of the spine? [ ] Yes [X] No 10. 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 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ---------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No 12. 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 [ ] 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 [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: BACK BRACE FOR SUPPORT 13. 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 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? [ ] 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? [ ] Yes [X] No c. Comments, if any: No response provided 15. 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? [X] Yes [ ] 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? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): For Official Use Only Click image to open viewer Priority: MRI LUMBAR SPINE WO CONTRAST Proc Ord: MRI LUMBAR SPINE WWO CONTRAST Exm Date: NOV 07, 2015@11:21 Req Phys: Pat Loc: DAL PACT CL10-I2NURSE (Req'g L Img Loc: MRI Service: Unknown (Case 7346 COMPLETE) MRI LUMBAR SPINE WO CONTRAST (MRI Detailed) CPT:72148 Reason for Study: low back pain chronic Clinical History: as above Report Status: Verified Date Reported: NOV 07, 2015 Date Verified: NOV 07, 2015 Verifier E-Sig:/ES/LENA A OMAR, M.D. Report: MRI Lumbar Spine without contrast dated 11/7/2015 Clinical History: 38-year-old male with history of low back pain chronic Comparison: Radiograph 8/28/2015 Technique: Sagittal and axial T1 and T2, as well as axial PD sequences were obtained of the lumbar spine. Findings: Vertebral body height, alignment, and marrow signal are preserved throughout the lumbar spine. There is either focal fat or hemangioma in the L1 vertebral body. Vertebral bodies are unremarkable. The conus terminates at L1-L2. There is no significant canal or neural foraminal stenosis. No areas of abnormal signal within the cord are seen. There is a tiny central disc protrusion at L5-S1 without any significant narrowing of the thecal sac or neural foramen. Small amount of fluid is present in the facet joints in the lumbar spine. Visualized paraspinal soft tissues are unremarkable. Impression: 1. Essentially unremarkable MRI of the lumbar spine except for a tiny central disc protrusion at L5-S1 without any significant narrowing of the thecal sac or neural foramen. Primary Diagnostic Code: ABNORMAL /LAO 16. 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: THE VETERAN WORKS AS AN ACCOUNTANT. HE SITS FOR LONG PERIODS AT WORK WHICH ELEVATES HIS BACK PAIN AND DECREASES HIS CONCENTRATION AND WORK CAPACITY. HE WOULD NOT BE ABLE TO WORK A PHYSICALLY DEMANDING JOB REQUIRING PROLONGED WALKING, STANDING OR REPEATED HEAVY LIFTING. HE ALSO WOULD REQUIRE THE ABILITY TO MOVE FROM SITTING TO STANDING POSTIONS WITH A SEDENTARY JOB SUCH AS THE ONE HIS IS CURRENTLY WORKING. 17. Remarks, if any: ------------------- 1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) YES 2. Is there evidence of pain when the joint is used in non-weight bearing? (Yes/No/Cannot be performed or is not medically appropriate) YES 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? NA If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. PASSIVE AND ACTIVE RANGE OF MOTION ARE THE SAME. ***************************************************************************** ********** THE VETERAN HAS A SERVICE CONNECTION FOR THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION. THIS IS A CHRIOPRACTIC DIAGNOSIS \: "segmental dysfunction, a motion theory concept that states that two articulating joint surfaces cannot interact optimally if they are misaligned. Basis of vertebral subluxation and theory of illness. SYNONUMS FOR SEGMENTAL DYSFUNCTION OF THE LUMBAR SPINE ARE: LOW BACK PAIN, LUMBAGO, LUMBALGIA. GIVEN THE SERVICE CONNECTED DIAGNOSIS IS BROAD BASED AND GENERAL BY DEFINITION, THE VETERANS CONFIRMED DIAGNOSIS OF LUBMAR DDD WITH COMPLICATIONS OF BILATERAL LEG RADICULOPATHY WOULD BE INCLUDING AND THEREFORE ALSO SERVICE CONNECTED. OF NOTE THE VETERAN COMPLAINED OF BACK PAIN, PAIN IN ARMS, LEGA NAD JOINTS DURING HIS DEPLOYMENT IN 2017 TO 2018 WHICH MORE THAN LIKELY WAS DUE TO HIS LUMBAR DDD WITH RADICULOPATHY.
  12. I have a VA diagnoses for depression, lower back pain and tinittus, with zero for bilateral hearing loss. All are connected except depression. Which condition would most likely allow for a secondary of depression? thanks
  13. I can see three ways for 10% rating. Anyone see anything else? Thanks for the help Back (ThoracolumbarSpine) Conditions Disability Benefits Questionnaire 3. Flare-ups Does the Veteran report that flare-ups impact the function of the thoracolumbar spine (back)? [X] Yes [] No COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION SSN: VA Claim Number: VES Number: TheVeteran is applying to the U.S.Department of Veterans Affairs(VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim. 1. Diagnosis Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [] No If yes, provide only diagnoses that pertain to thoracolumbar spine (back) conditions: Diagnosis #1:Thoracolumbarspinesegmental dysfunction ICD code:739 Date of diagnosis:2013 If there are additional diagnoses pertaining to thoracolumbar spine (back) conditions, list using above format: 2. Medical history Describe the history (including onset and course) of the Veteran’s thoracolumbar spine (back) condition (brief summary). The veteran was involved in a MVA accident on 12/16/1996. Following this accident the veteran developed lowback pain, but he did not seek medical treatment. The veteran reports going through physical therapy and being followed by a chiropractor with little improvement due to worsening pain in 2013 –x-rays at this time were unremarkable. Since then, the condition has only worsened. The veteran reports symptoms of lowback pain with pain radiating to the left leg, as well as an associated tingling sensation. The veteran ices as needed and uses Ibuprofen and Tylenol with fair response. Measure ROM with a goniometer, rounding each measurement to the nearest 5 degrees. During the measurements, observe the point at which painful motion begins, evidenced by visible behavior such as facial expression, wincing, etc. Report initial measurements below. Following the initial assessment of ROM, performrepetitive-use testing. For VA purposes, repetitive-use testing must be included in all exams. The VA has determined that 3 repetitions of ROM (at minimum) can serve as a representative test of the effect of repetitive use. After the initial measurement, reassess ROM after 3 repetitions. Report post-test measurements in section 5. a. Select where forward flexion ends (normal endpoint is 90): [] 0[] 5[] 10[] 15[] 20[] 25[] 30[] 35[] 40 [] 45[] 50[] 55[]60[] 65[] 70[X] 75[] 80[] 85[] 90 or greater Select where objective evidence of painful motion begins: [] No objective evidence of painful motion [] 0[] 5[] 10[] 15[] 20[] 25[] 30[] 35[] 40 [] 45[] 50[] 55[] 60[] 65[] 70[X] 75[] 80[] 85[] 90 or greater b. Select where extension ends (normal endpoint is 30): [] 0[] 5[] 10[] 15[X] 20[] 25[] 30 or greater Select where objective evidence of painful motion begins: [] No objective evidence of painful motion [] 0[] 5[] 10[] 15[X] 20[] 25[] 30 or greater c. Select where right lateral flexion ends (normal endpoint is 30): [] 0[] 5[] 10[X] 15[] 20[] 25[] 30 or greater Select where objective evidence of painful motion begins: [] No objective evidence of painful motion [] 0[] 5[] 10[X] 15[] 20[] 25[] 30 or greater d. Select where left lateral flexion ends (normal endpoint is 30): [] 0[] 5[] 10[] 15[X] 20[] 25[] 30 or greater Select where objective evidence of painful motion begins: [] No objective evidence of painful motion [] 0[] 5[] 10[] 15[X] 20[] 25[] 30 or greater e. Select where right lateral rotation ends (normal endpoint is 30): [] 0[] 5[] 10[] 15[] 20[X] 25[] 30 or greater Select where objective evidence of painful motion begins: [] No objective evidence of painful motion [] 0[] 5[] 10[] 15[] 20[X] 25[] 30 or greater f. Select where left lateral rotation ends (normal endpoint is 30): [] 0[] 5[] 10[] 15[] 20[X] 25[] 30 or greater Select where objective evidence of painful motion begins: [] No objective evidence of painful motion [] 0[] 5[] 10[] 15[] 20[X] 25[] 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 aback condition, such as age, body habitus, neurologic disease), explain: 5. ROM measurement after repetitive-use testing a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? [X] Yes [] No If unable, provide reason: If Veteran isunable to performrepetitive-use testing, skip to section 6. DBQBack (Thoracolumbar Spine) Conditions Page2of12 COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION If Veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions. b. Select where post-test forward flexion ends: [] 0[] 5[] 10[] 15[] 20[] 25[] 30[] 35[] 40[] 45 [] 50[] 55[] 60[] 65[] 70[X] 75[] 80[] 85[] 90 or greater c. Select where post-test extension ends: [] 0[] 5[] 10[] 15[X] 20[] 25[] 30 or greater d. Select where post-test right lateral flexion ends: [] 0[] 5[]10[X] 15[] 20[] 25[] 30 or greater e. Select where post-test left lateral flexion ends: [] 0[]5[] 10[] 15[X] 20[] 25[] 30 or greater f. Select where post-test right lateral rotation ends: [] 0[] 5[] 10[] 15[] 20[X] 25[] 30 or greater g.Select where post-test left lateral rotation ends: [] 0[] 5[] 10[] 15[] 20[X] 25[] 30 or greater 6. Functional loss and additional limitation in ROM The following section addresses reasons for functional loss, if present, and additional loss of ROMafter repetitive-use testing, if present. The VA defines functional loss as the inability to performnormal working movements of the body with normal excursion, strength, speed, coordination and/or endurance. a. Does the Veteran have additional limitationin 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 [] More movement than normal [] Weakened movement [] Excess fatigability [] Incoordination, impaired ability to execute skilled movements smoothly [X] Pain on movement [] Swelling [] Deformity [] Atrophy of disuse [] Instability of station [] Disturbance of locomotion [X] Interference with sitting, standing and/or weight-bearing [] Other, describe: 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: Guarding upon palpation of the paraspinal muscles bilaterally. b. Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? DBQBack (Thoracolumbar Spine) Conditions Page3of12 COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION [X] Yes []No If yes, is it severe enough to result in: (check all that apply) [] Abnormal gait [] Abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis [X] Guarding and/or muscle spasm is present, but do not result in abnormal gait or spinal contour 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 [] All normal Hip flexion: 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 Knee extension: Right:[X] 5/5[] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 Left:[] 5/5[X] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 Ankleplantar flexion Right:[X] 5/5[] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 Left:[] 5/5[X] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 Ankle dorsiflexion: Right:[X] 5/5[] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 Left:[] 5/5[X] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 Great toe extension: Right:[X] 5/5[] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 Left:[] 5/5[X] 4/5[] 3/5[] 2/5[] 1/5[] 0/5 b. Does the Veteran have muscle atrophy? [] Yes [X]No If muscle atrophy is present, indicate location: Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk: Normal side:cm Atrophied side:cm 9. Reflex exam Rate deep tendon reflexes (DTRs) according to the following scale: 0Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus [X] All normal Knee: Right:[] 0[] 1+[X] 2+[] 3+[] 4+ Left:[] 0[] 1+[X] 2+[] 3+[] 4+ Ankle: DBQBack (Thoracolumbar Spine) Conditions Page4of12 COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION Right:[] 0[] 1+[X] 2+[] 3+[] 4+ Left:[] 0[] 1+[X] 2+[] 3+[] 4+ Please state the etiology if reflexes are abnormal (0, 1+, 3+, 4+): 10. Sensory exam Provide results for sensation to light touch (dermatome) testing: [X] All normal Upper anterior thigh (L2): Right:[X] Normal[] Decreased[] Absent Left:[X] Normal[] Decreased[] Absent Thigh/knee (L3/4): Right:[X] Normal[] Decreased[] Absent Left:[X] Normal[] Decreased[] Absent Lower leg/ankle (L4/L5/S1): Right:[X] Normal[] Decreased[] Absent Left:[X] Normal[] Decreased[] Absent Foot/toes (L5): Right:[X] Normal[] Decreased[] Absent Left:[X] Normal[] Decreased[] Absent Other sensory findings, if any: 11. Straight leg raising test (This test can be performed with the Veteran seated or supine. Raise each straightened leg until pain begins, typically at 30-70 degrees of elevation. The test is positive ifthe pain radiates below the knee, not merely in the back or hamstrings. Pain is often increased on dorsiflexion of the foot, and relieved by knee flexion. A positive test suggests radiculopathy, often due to disc herniation). Provide straight leg raising test results: Right: [X] Negative [] 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 If yes, complete the following section: a. Indicate symptoms’ location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [] None[] Mild[] Moderate[] Severe Left lower extremity: [] None[] Mild[] Moderate[] Severe Intermittent pain (usually dull) Right lower extremity: [] None[] Mild [] Moderate []Severe Left lower extremity: [] None [] Mild [] Moderate[] Severe DBQBack (Thoracolumbar Spine) Conditions Page5of12 COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION Paresthesias and/or dysesthesias Right lower extremity: [] None[] Mild[] Moderate[] Severe Left lower extremity: [] None[] Mild[] Moderate[] Severe Numbness Right lower extremity: [] None[] Mild[] Moderate[] Severe Left lower extremity: [] None[] Mild[] Moderate [] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [] Yes []No If yes, describe: c. Indicate nerve roots involved: (check all that apply) [] Involvement of L2/L3L/L4 nerve roots (femoral nerve) If checked, indicate: [] Right [] Left []Both [] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [] Right [] Left [] Both [] Other nerves (specify nerve and side(s) affected): d. Indicate severity of radiculopathy and side affected: Right: [] Not affected [] Mild [] Moderate [] Severe Left: [] Not affected [] Mild [] Moderate [] Severe Additional Clinician Notes: There is not enough objective evidence to support a diagnosis for the claimed left lower extremity radiculopathy –normal x-ray from 10/12/2013, and normal sensations/reflexes. 13. 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 If yes, describe condition and howit is related: If there are neurological abnormalities other than radiculopathy, also complete appropriate Questionnaire for each condition identified. 14. Intervertebral disc syndrome (IVDS) and incapacitating episodes a. Does the Veteran have IVDS of the thoracolumbar spine? []Yes[X]No b. If yes, has the Veteran had any incapacitating episodes over the past 12 months due to IVDS? []Yes[]No NOTE: For VA purposes, an incapacitating episode is a periodof acute symptoms severe enough to require prescribed bed rest and treatment by a physician. DBQBack (Thoracolumbar Spine) Conditions Page6of12 COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION If yes, provide the total duration of all incapacitating episodes over the past 12 months: [] Less than 1 week [] At least 1 week but less than 2 weeks [] At least 2 weeks but less than 4 weeks [] At least 4 weeks but less than 6 weeks [] At least 6 weeks 15. 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 [] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): [] WheelchairFrequency of use:[] Occasional[]Regular[]Constant [X] Brace(s)Frequency of use:[]Occasional[X]Regular[]Constant [] Crutch(es)Frequency of use:[]Occasional[]Regular[]Constant [] Cane(s)Frequency of use:[]Occasional[]Regular[]Constant [] WalkerFrequency of use:[]Occasional[]Regular[] Constant [] Other:Frequency of use:[]Occasional[]Regular[]Constant b. If the Veteranuses any assistive devices, specify the condition and identify the assistive device used for eachcondition: Regular use of back brace while working–not used on weekends. 16. Remaining effective function of the extremities Dueto 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.) [] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No If yes, indicate extremity(ies) (check all extremities for which this applies): [] Right lower [] Left lower 17. 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? [X] Yes []No If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)? [] Yes [X]No If yes, also completea Scars Questionnaire. b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms? [] Yes [X]No If yes, describe (brief summary): 18. Diagnostic testing The diagnosis of arthritis must be confirmed by imaging studies. Once arthritis has been documented, no further imaging studies are required by VA, even if arthritis has worsened. Imaging studies are not required to make the diagnosis of IVDS; Electromyography (EMG) studies are rarely required to diagnose radiculopathy in the appropriate clinical setting. DBQBack (Thoracolumbar Spine) Conditions Page7of12 COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION For purposes of this examination, the diagnosis of IVDS and/or radiculopathy can be made by a history of characteristic radiating pain and/or sensory changes in the arms, and objective clinical findings, which may include the asymmetrical loss or decrease of reflexes, decreased strength and/or abnormal sensation. 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. If diagnostics were performed, does the Veteran have a vertebral fracture? [] Yes [X] No [] No diagnostics were performed If yes, provide percent of loss of vertebral body: c. Are there any other significant diagnostic test findings and/or results? [X] Yes []No If yes, provide type of test or procedure, date and results (brief summary): According to medical records, lumbar spine x-rayfrom 10/12/2013 is unremarkable. 19. Functional impact Does the Veteran’s thoracolumbar spine (back) condition impacton his or her ability to work? [X] Yes [] No 20. Remarks, if any: There is not enough objective evidence to support a diagnosis for the claimed left lower extremity radiculopathy –normal x-ray from 10/12/2013, and normal sensations/reflexes. Additionalremarks on the flare-ups reported: Flare-up symptom (i.e. pain, How many times does the weakness, stiffness, etc.)flare-up occur per year? Increased pain, weakness, and stiffness Additional remarks on functional impairment: DBQBack (Thoracolumbar Spine) Conditions Page8of12 How long does the flare-up last? How much does the flare-up limit the Veteran compared to when he does not have a flare-up? 4 times per year1 dayUnable to sit or stand Additional remarks on functional loss and additional limitation in ROM: d. State whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. [X] Pain[X] Weakness[] Fatigability[] Incoordination[] None of these factors significantly limit functional ability e. Describe any such additional limitation due to pain, weakness, fatigability or incoordination, and if feasible, this opinion should be expressed in terms of the degrees of additional ROM loss due to “pain on use or during flare-ups.” Estimated degrees of additional ROM loss: Additional pain on use, but no additional loss of rom. Plane of ROM (flexion, extension, etc.): COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION Due to the Veteran’s condition, how much can the Veteran lift and how often? (or state “Unlimited”) Can lift at least 50 pounds intermittently as tolerance allows. DBQBack (Thoracolumbar Spine) Conditions Page9of12 Due to the Veteran’s condition, how far can the Veteran walk at one time? (or state “Unlimited”) 1 block1blockCan sit for at least 1 hour with adjusting and stretching as needed. Due to the Veteran’s condition, how much can the Veteran walk during an 8 hour day? (or state “Unlimited”) Due to the Veteran’s condition, how long can the Veteran sit/stand at one time? (or state “Unlimited”) Can stand for at least 15 minutes with breaks as needed. VES Clinician signature: VES Clinician prin VES Clinician VES Clinician specialty:Family Medicine Date:09/14/2015Medical license #: VESClinician address:5301 W LOVERS LANE STE 109,DALLAS,TX75209 Phone:1-877-637-8387Fax:1-800-320-3908 COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION Due to the Veteran’s condition, how long can the Veteran sit/stand during an 8 hour day? (or state “Unlimited”) Unlimited sitting and standing as long as allowed to adjust, stretch, or take breaks as needed, every 15 to 30 minutes. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA’s review of the Veteran’s application. Name of Veteran/Service Member: Date: Contractor: DBQBack (Thoracolumbar Spine) Conditions For the Claimed Compensation Condition of -LOW BACK CONDITION Medical Opinion (Complete) Disability Benefits Questionnaire 3. 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: COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION SSN: VA Claim Number: VES Number: The Veteran is applying to the U.S. Department of Veterans Affairs(VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim. Aggravation of nonservice-connected disabilities.Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. If no, check all records reviewed: [] Military service treatment records [] Military service personnel records [] Military enlistment examination []Military separation examination [] Military post-deployment questionnaire [] Department of Defense Form 214 Separation Documents [] Veterans Health Administration medical records (VA treatment records) [] Civilian medical records [] Interviews with collateral witnesses (family and others who have known the veteran before and after military service) [] No records were reviewed [] Other: 1. Definitions Aggravation of preexisting nonservice-connected disabilities.A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific findingthat the increase in disability is due to the natural progress of the disease. 2. Restatement of requested opinion a. Insert requested opinion from general remarks: MEDICAL OPINION 1 OF 1: PLEASE COMPLETE SECTION FOUR AND STATE WHETHER THE VETERAN’S MILITARY SERVICE MEDICAL RECORDS SUPPORT THAT THE CLAIMED LOW BACK CONDITION, IF FOUND, WAS AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) INCURRED IN OR CAUSED BY THE CAR ACCIDENT THAT OCCURRED 12/16/96 THAT OCCURRED WHILE ON ACTIVE DUTY. b. Indicate which, if any, DBQ forms were performed in conjunction with this medical opinion request (e.g. Scar, Knee and Lower Leg, Skin Diseases): DBQ Back Complete only the sections below that you are asked to complete in the Medical Opinion DBQ request. 4. Medical opinion for direct service connection Choose the statement that most closely approximates the etiology of the claimed condition. a. [X] The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rationale in section c. b. [] The claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rationale in section c. c. Rationale: The veteran’s thoracolumbar spine segmental dysfunction is at least as likely as not proximately due to the MVA on 12/16/1996. There are no back conditions prior to the MVA in 1996 (enlistment exam from 06/1994) and therehave been no interim spinal injuries since then. According to affidavit dated 09/12/2013 from a First Sergeant Duane Dishon, the veteran was involved in a MVA that had totaled the vehicle and the veteran did not seek evaluation for the residual back pain due to the resulting heckling from other service members. There are no other conditions present to account for the current symptoms. 5. Medical opinion for secondary service connection a. [] The claimed condition is at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran’s service connected condition. Provide rationale in section c. b. [] The claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result ofthe Veteran’s service connected condition. Provide rationale in section c. c. Rationale: 6. Medical opinion for aggravation of a condition that existed prior to service a. [] The claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. Provide rationale in section c. b. [] The claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakable not aggravated beyond its natural progression by an in-service injury, event, or illness. Provide rationale in section c. c. Rationale: 7. Medical opinion for aggravation of a nonservice connected condition by a service connected condition a. Can you determine a baselinelevel of severity of (claimed condition/diagnosis) based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by (service connected condition)? [] Yes [] No If “Yes” to question 7a, answer the following: i.Describe the baseline level of severity of (claimed condition/diagnosis) based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by (service connected condition): ii.Provide the date and nature of the medical evidence used to provide the baseline: iii.Is the current severity of the (claimed condition/diagnosis) greater than the baseline? [] Yes [] No DBQBack (Thoracolumbar Spine) Conditions Pa COPY MADE BY VARMC, ST.LOUIS FROM A RECORD IN V.A. POSSESION If yes, was the Veteran’s (claimed condition/diagnosis) at least as likely as not aggravated beyond its natural progression by (insert “service connected condition”)? [] Yes (provide rationale in section b.) [] No (provide rationale in section b.) If “No” to question 7a, answer the following: i.Provide rationale as to why a baseline cannot be established (e.g. medical evidence is not sufficient to support a determination of baseline level of severity): ii.Regardless of an established baseline, was the Veteran’s (claimed condition/diagnosis) at least as likely as not aggravated beyond its natural progression by (insert “service connected condition”)? [] Yes (provide rationale in section b.) [] No (provide rationale in section b.) b. Provide rationale: 8. Opinion regarding conflicting medical evidence I have reviewed the conflicting medical evidence and am providing the following opinion: Remarks, if any: VES Clinician signature: VES Clinician VES Clinician VES Clinician specialty:Family Medicine Date:09/14/201  VESClinicianaddress:5301 W LOVERS LANE STE 109,DALLAS, TX 75209 Phone:1-877-637-8387Fax:1-800-320-3908 NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA’s review of the Veteran’s application. DBQBack (Thoracolumbar Spine) Condi COPY MADE BY V
  14. meanwhile there is a claim backlog a mile long
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