Jump to content

Mo

Seaman
  • Content count

    19
  • Joined

  • Last visited

Community Reputation

7 Neutral

About Mo

  • Rank
    E-3 Seaman

Previous Fields

  • Service Connected Disability
    90IU
  • Branch of Service
    USA
  1. Congrats on making it thru the exam! I could usually see my results in about 3 business days on MyHealtheVet . I used the Blue Button download my data button, focused on the date of the exam, and selected "VA Notes" only.
  2. Thank you so much...not only for the congratulations but for this website! First thing I want to do once I get my retro is make a donation! I hope I can help someone as much as you and everyone else has helped me!
  3. Completed!!!!! Check my post in the "Success Stories" forum! Thank you all!
  4. Completed!!!!! Check my post in the "Success Stories" forum! Thank you all!
  5. First off...THANK YOU!!!! I love you guys and I appreciate all the knowledge I have gained. Second....I look forward to helping to helping those in need as the way I have been helped! This is my story: Claim Submission: 11/19/2015 Prep for Decision: 12/14/15 Prep for Notification:12/15/15 Completed: 12/17/15 Award Letter on E Benefits 12/17/15 Military InformationYour most recent, verified periods of service (up to three) include: Recent periods of military serviceBranch of ServiceCharacter of ServiceEntered Active DutyReleased/DischargedArmyHonorableMay 29, 2003December 01, 2004(There may be additional periods of service not listed above.) VA Benefit InformationSummary of benefit informationYou have one or more service-connected disabilities:YesYour combined service-connected evaluation is:90%Your current monthly award amount is:$XXXX.XXThe effective date of the last change to your current award was:October 01, 2015You are considered to be totally and permanently disabled due solely to your service-connected disabilities:Yes:
  6. I haven't gotten to see a surgeon yet. I'm already 40% for my back. I had a DBQ for radiculopathy. Just going crazy waiting
  7. **Update** Moved to Prep for notification stage....praying
  8. ptsd e benefits question?

    Hi Buck, Apparently E Benefits is having "tech and software issues" as they call it. I have been on the phone with Tech Support and VARO for the past 2 weeks trying to confirm they they got my paperwork. From what I have been told, the VAROs cannot access anything at the moment in the system because of "software issues" and that tech support is "aware of the problem and trying to fix it". Although you submitted everything via snail mail, they still scan and upload it electronically and THEN the VARO deciding your claim goes by your electronic folder. Hope they get it fixed for all of our sanity.
  9. PA-C did first exam. Scheduled for 12/18/15 with MD
  10. Ok....thanks for the advice. I read somewhere that I have to have either a diagnosis or symptoms connecting to service. I found something else as well in my service medical records: Dated Aug 11 2004 from Monroe Health Clinic in Ft Hood,Tx Diagnosis: Chronic Sciatica "SM with abnormal posture and gait, know lumbar disc disease pain radiating to right with bladder spasticity during exaceberation. Pain constant to right up and down rt leg with bladder urgency. Reflexes absent or depressed builaterally. No discoverable comfortable position unresolved with NSAID's and medication." I also have 3 different trips to Emergency Room while in service for the same thing. What else should I be looking for? I appreciate all the info and input since this is my first big claim I am filing by myself. The others were simple in proving. This is my first time putting in a claim for secondary disabilities...
  11. I think it is covered What are your thoughts? I have: 1. service medical records that state a diagnosis of acute sciatica in 2004 and radical symptoms 2. my MRI from this year states that I have a history of radiculapathy since 2004, 3.From this C&P exam: Nexus??? ----> "Diagnosis #2: Bilateral lower extremity radiculopathy due to IVDS/DDD of lumbar spine ICD code: M54Date of diagnosis: 2004 by hx"
  12. They told me on the phone that they have my medical records and C&P exams but they want another "medical opinion. I'm wonder if this is because my exam seems air tight maybe?
  13. Well I am representing myself but will get a rep after my decision if not happy. My C&P for my lower back was excellent I though. Here it is: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No [X] Other Diagnosis Diagnosis #1: IVDS/DEGENERATIVE DISC DISEASE (DDD), LUMBOSACRAL SPINE, L4- L5, L5-S1 ICD code: M51 Date of diagnosis: SC Diagnosis #2: Bilateral lower extremity radiculopathy due to IVDS/DDD of lumbar spine ICD code: M54 Date of diagnosis: 2004 by hx 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Veteran is being seen at his request in the DBQ referral clinic for the SC condition of DEGENERATIVE DISC DISEASE, LUMBOSACRAL SPINE, L5-S1. Veteran relates his condition is worse, and he is awaiting a pain clinic evaluation, however it is currently scheduled in December. Veteran relates that he had similar presenting symptoms when the condition occurred in 2004. Has had pain and radiation os symptoms since 2004 for short periods of time-a few days or weeks. He indicates that around May of this year had a worsening of low back pain with radiation into the legs (currently right > left), at time has body shaking as a response, numbness and tingling that begins in the lumbar spine, radiates to bilateral buttocks and continues along lateral hip/thigh area then to anterior calf down to great toe when sitting or standing, and pain and burning sensation of posterior thigh and calf when lying down. He indicates that it is just not getting better despite taking pain medications, having had steroid taper doses, and muscle relaxers. No loss of bowel control, urinary retention, or saddle anesthesia. Due to worsening symptoms, he underwent an MRI in Aug 2015 that revealed Degenerative changes at L4-5 and L5-S1 with right-sided discal cyst at L5-S1 resulting in moderate right lateral recess stenosis and impingement of the right S1 nerve root. Veteran is very tearful, has difficulty sitting still in the exam room, has "jerking" almost bouncing movements associated with his reported severe pain symptoms, or with various movements of legs or back. 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: Veteran reports an inability to walk or stand during flares 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. cannot stand, walk, run, climb stairs, etc 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) Right Lateral Flexion (0 to 30): 0 to 5 degrees Left Lateral Flexion (0 to 30): 0 to 20 degrees Right Lateral Rotation (0 to 30): 0 to 15 degrees Left Lateral Rotation (0 to 30): 0 to 10 degrees Unable to test forward flexion and extension formally due to veteran not being able to stand without risk of fall, due to his repeated jerking movements If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: unable to twist or bend adequately; although veteran cannot undergo formal testing of forward flexion, it is clear he cannot apply his own shoes, etc. due to low back pain and readicular pain Description of pain (select best response): Pain noted on exam on rest/non-movement 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): caused by SC DDD causing muscle spasms due to resisting movement b. Observed repetitive use Is the Veteran able to perfor m repetitive use testing with at least three repetitions? [ ] Yes [X] No If no, please provide reason: severe pain reported 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: [X] The examination is medically consistent 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 [ ] No [ ] 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: [ ] Yes [X] No If no, please describe: veteran is unable to complete movements after repeated movement over time due to severe pain, limitation cannot be described in degrees of motion, but would be severe in all planes of motion based on todays limited exam, 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: [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. [ ] 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 [ ] No [ ] 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: [ ] Yes [X] No If no, please describe: Veteran is not being examined during a flare, limitation cannot be described in degrees of motion, but would be severe in all planes of motion based on todays limited exam e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [ ] None [X] Resulting in abnormal gait or abnormal spinal contour Provide description and/or etiology: tenderness with light touch in anticipation of pain due to DDD of lumbar spine Localized tenderness: [ ] None [X] Resulting in abnormal gait or abnormal spinal contour Provide description and/or etiology: veteran is resistent to allow examination and if the wheelchair he is sitting in is going to hit a bump preparing for anticipated pain due to DDD of lumbar spine 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: Instability of station, Disturbance of locomotion, Interference with sitting, Interference with standing 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 Ankle plantar flexion: Right: [ ] 5/5 [X] 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 dorsiflexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [ ] 5/5 [X] 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? [ ] Yes [X] No 5. Reflex exam -------------- No response provided 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: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [ ] Negative [ ] Positive [X] Unable to perform Left: [ ] Negative [ ] Positive [X] 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: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] 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 [ ] Moderate [X] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] 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] Cane(s) [ ] Occasional [ ] Regular [X] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: single cane used for DDD of lumbar spine 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? [X] Yes [ ] No If yes, describe (brief summary): Reflexes and strength of hips and knees were NOT tested due to veteran's guarding on exam and jerking motions with any sort of spikes in pain. Minimal movements of veteran's lower extremities casued significant pain; 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? [ ] 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? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): MRI Lumbar spine 08/13/2015 Impression: 1. Negative for spinal canal stenosis. 2. Degenerative changes at L4-5 and L5-S1 with right-sided discal cyst at L5-S1 resulting in moderate right lateral recess stenosis and impingement of the right S1 nerve root. 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: Veteran has difficulty walking at this time, cannot stand for more than a few moments, needs to use a cane when ambulating, cannot walk more than a few feet, cannot sit for more than 10 minutes without needing to move. 17. Remarks, if any: -------------------- Veteran's condition is currently in the process of additional treatment with pain clinic evaluation scheduled in December 2015, possibly sooner; it is possible that this treatment could improve his overall physical functioning and symptoms related to the lumbar spine condition; Veteran's upadted diagnosis of IVDS/DDD of lumbar spine now inlcudes bilateral lower extrmeity radiculopathy, Right worse than left, as evidenced by physical examination and history; the updated diagnosis includes the findings due to progression of the condition over time
  14. Hello all. This is an update on my progress. 10/23- Review of PTSD C&P Exam 10/31 - Lower Back C&P Exam 11/19 - Claim Submitted FDC on EBenny (all DBQs, Med Records, Forms,and Sworn Declarations uploaded) 11/23 - "Gathering Evidence" Status 12/1 - Spoke to RO and VA had submitted a 'medical opinon request from outside dr" 12/3 - Received call from "Veterans Evaluation Services" in MN stating the VA is requesting a local medical provider to conduct the same 2 C&P Exams!!! Has this happening to anyone else? Could it be good or bad news? I filed for Depression secondary to IVDS, Bilateral Radiculapathy of lower extremities secondary to IVDS, IU, and increase in PTSD. Any input would be greatly appreciated. ~Mo~
  15. This is what I got from my C&P Exam...I'm hoping for 60% for my right side and maybe 30% for my left side. Currently my status is "Gathering Evidence" needing VA Form 21-4192 from my two previous employers. It seems I should be getting approved for TDIU as well since I lost my job due to my injuries. Thoughts anyone? 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No [X] Other Diagnosis Diagnosis #1: IVDS/DEGENERATIVE DISC DISEASE (DDD), LUMBOSACRAL SPINE, L4- L5, L5-S1 ICD code: M51 Date of diagnosis: SC Diagnosis #2: Bilateral lower extremity radiculopathy due to IVDS/DDD of lumbar spine ICD code: M54 Date of diagnosis: 2004 by hx 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Veteran is being seen at his request in the DBQ referral clinic for the SC condition of DEGENERATIVE DISC DISEASE, LUMBOSACRAL SPINE, L5-S1. Veteran relates his condition is worse, and he is awaiting a pain clinic evaluation, however it is currently scheduled in December. Veteran relates that he had similar presenting symptoms when the condition occurred in 2004. Has had pain and radiation os symptoms since 2004 for short periods of time-a few days or weeks. He indicates that around May of this year had a worsening of low back pain with radiation into the legs (currently right > left), at time has body shaking as a response, numbness and tingling that begins in the lumbar spine, radiates to bilateral buttocks and continues along lateral hip/thigh area then to anterior calf down to great toe when sitting or standing, and pain and burning sensation of posterior thigh and calf when lying down. He indicates that it is just not getting better despite taking pain medications, having had steroid taper doses, and muscle relaxers. No loss of bowel control, urinary retention, or saddle anesthesia. Due to worsening symptoms, he underwent an MRI in Aug 2015 that revealed Degenerative changes at L4-5 and L5-S1 with right-sided discal cyst at L5-S1 resulting in moderate right lateral recess stenosis and impingement of the right S1 nerve root. Veteran is very tearful, has difficulty sitting still in the exam room, has "jerking" almost bouncing movements associated with his reported severe pain symptoms, or with various movements of legs or back. 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: Veteran reports an inability to walk or stand during flares 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. cannot stand, walk, run, climb stairs, etc 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) Right Lateral Flexion (0 to 30): 0 to 5 degrees Left Lateral Flexion (0 to 30): 0 to 20 degrees Right Lateral Rotation (0 to 30): 0 to 15 degrees Left Lateral Rotation (0 to 30): 0 to 10 degrees Unable to test forward flexion and extension formally due to veteran not being able to stand without risk of fall, due to his repeated jerking movements If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: unable to twist or bend adequately; although veteran cannot undergo formal testing of forward flexion, it is clear he cannot apply his own shoes, etc. due to low back pain and readicular pain Description of pain (select best response): Pain noted on exam on rest/non-movement 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): caused by SC DDD causing muscle spasms due to resisting movement b. Observed repetitive use Is the Veteran able to perfor m repetitive use testing with at least three repetitions? [ ] Yes [X] No If no, please provide reason: severe pain reported 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: [X] The examination is medically consistent 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 [ ] No [ ] 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: [ ] Yes [X] No If no, please describe: veteran is unable to complete movements after repeated movement over time due to severe pain, limitation cannot be described in degrees of motion, but would be severe in all planes of motion based on todays limited exam, 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: [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. [ ] 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 [ ] No [ ] 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: [ ] Yes [X] No If no, please describe: Veteran is not being examined during a flare, limitation cannot be described in degrees of motion, but would be severe in all planes of motion based on todays limited exam e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [ ] None [X] Resulting in abnormal gait or abnormal spinal contour Provide description and/or etiology: tenderness with light touch in anticipation of pain due to DDD of lumbar spine Localized tenderness: [ ] None [X] Resulting in abnormal gait or abnormal spinal contour Provide description and/or etiology: veteran is resistent to allow examination and if the wheelchair he is sitting in is going to hit a bump preparing for anticipated pain due to DDD of lumbar spine 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: Instability of station, Disturbance of locomotion, Interference with sitting, Interference with standing 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 Ankle plantar flexion: Right: [ ] 5/5 [X] 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 dorsiflexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [ ] 5/5 [X] 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? [ ] Yes [X] No 5. Reflex exam -------------- No response provided 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: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [ ] Negative [ ] Positive [X] Unable to perform Left: [ ] Negative [ ] Positive [X] 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: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] 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 [ ] Moderate [X] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] 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] Cane(s) [ ] Occasional [ ] Regular [X] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: single cane used for DDD of lumbar spine 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? [X] Yes [ ] No If yes, describe (brief summary): Reflexes and strength of hips and knees were NOT tested due to veteran's guarding on exam and jerking motions with any sort of spikes in pain. Minimal movements of veteran's lower extremities casued significant pain; 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? [ ] 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? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): MRI Lumbar spine 08/13/2015 Impression: 1. Negative for spinal canal stenosis. 2. Degenerative changes at L4-5 and L5-S1 with right-sided discal cyst at L5-S1 resulting in moderate right lateral recess stenosis and impingement of the right S1 nerve root. 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: Veteran has difficulty walking at this time, cannot stand for more than a few moments, needs to use a cane when ambulating, cannot walk more than a few feet, cannot sit for more than 10 minutes without needing to move. 17. Remarks, if any: -------------------- Veteran's condition is currently in the process of additional treatment with pain clinic evaluation scheduled in December 2015, possibly sooner; it is possible that this treatment could improve his overall physical functioning and symptoms related to the lumbar spine condition; Veteran's upadted diagnosis of IVDS/DDD of lumbar spine now inlcudes bilateral lower extrmeity radiculopathy, Right worse than left, as evidenced by physical examination and history; the updated diagnosis includes the findings due to progression of the condition over time.
×