MoparFin

Nothing?

Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire 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 [X] CPRS [X] Other (please identify other evidence reviewed): office notes from civilain pain management and EMG results 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 [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture [X] Other Diagnosis Diagnosis #1: DDD lumbar spine ICD code: M51.06 Date of diagnosis: already SC'd Diagnosis #2: DJD lumbar spine ICD code: M47.016 Date of diagnosis: at least 2017 Diagnosis #3: left lower extremity lumbar radiculopathy ICD code: M54.16 Date of diagnosis: already Sc'd If there are additional diagnoses pertaining to thoracolumbar spine (back) conditions, list using above format: Diagnosis #4: s/p lumbar laminotomy L5-S1 IDC code: Z98.1 Date of Diagnosis: 2014 2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Veteran is SC'd for DDD, s/p lumbar lamintomy and left lower extremity radiculopathy to include restless leg syndrome. Please note that the original restless leg syndrome C&P exam was done by a neurologist and was listed as a central nervous system DBQ; not a peripheral nerve DBQ since restless leg syndrome does not occur at the peripheral nerve level. Last C&P exam from 2/23/2017 was reviewed. Veteran had ER visit on 9/20/2018 for his back. No new surgeries since 2014. He has tried epidural injections, physical therapy and aqua therapy all with no relief. He has an H-wave at home which gives some relief while it is on and for a half hour afterwards. He just takes Motrin for pain. He reports the back pain with worse and constant and that "everything" hurts his back. He does continue to work and sits and stands/walk about 50/50 for each. He has constant tingling in bilateral lower extremities. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [ ] Yes [X] No 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. The pain is constat. Everything hurts it like sitting, standing and walking. 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 25 degrees Extension (0 to 30): 0 to 15 degrees Right Lateral Flexion (0 to 30): 0 to 15 degrees Left Lateral Flexion (0 to 30): 0 to 20 degrees Right Lateral Rotation (0 to 30): 0 to 10 degrees Left Lateral Rotation (0 to 30): 0 to 10 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain and decreased ROM 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): midly tender lower lumbar spine at midline 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 [X] No [ ] Unable to say w/o mere speculation d. Flare-ups Not applicable 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: None 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: [X] 5/5 [ ] 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: [X] 5/5 [ ] 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: [X] 5/5 [ ] 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: [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 ------------- 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 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 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: [X] Negative [ ] Positive [ ] Unable to perform Left: [X] Negative [ ] 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: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] 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 [X] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] 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? [ ] 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? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 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): CORREIA: Pain with non-weight bearing lumbar spine. Not medically feasible to do passive ROM on a lumbar spine. 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? [X] Yes [ ] No If yes, is there objective evidence that any of these scars are painful, unstable, have a total area equal to or greater than 39 square cm (6 square inches), or are located on the head, face or neck? (An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.) [ ] Yes [X] No If no, provide location and measurements of scar in centimeters. Location: midline lumbar spine scar from previous surgery Measurements: length 2.5cm X width 0.3cm c. Comments, if any: scar is non-tender, no instability 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): Report Status: Verified Date Reported: JAN 15, 2019 Date Verified: JAN 15, 2019 Report: Exam: MRI of lumbar spine, without and with contrast Clinical history: Low back pain and lumbar radiculopathy. Technique: Routine unenhanced and enhanced MRI of the lumbar spine was performed. Results: Correlation is to a prior exam from 6/30/2017. Alignment of the lumbar spine vertebrae is maintained, without spondylolisthesis. The lumbar vertebral body heights and marrow signal are maintained. Again noted is desiccation and reduction in height of the L5-S1 disc. The conus medullaris is at the level of L1 and is unremarkable. Incidentally noted is a small perineural cyst in the right T11-T12 neural foramen. At L1-L2, L2-L3 and L3-L4 levels, there is no significant disc herniation and there is no significant central canal or foraminal stenosis. At L4-L5 level, there is no significant disc herniation. There is mild bilateral facet arthropathy and ligamentous hypertrophy. There is no significant central canal or foraminal stenosis. At L5-S1 level, again noted are postoperative changes of left-sided laminotomy. There is a small broad-based posterior central and left paracentral disc protrusion, which likely impinges on the traversing left S1 nerve root. There is bilateral facet arthropathy. There is no significant central canal stenosis. There is mild to moderate left foraminal stenosis. The right neural foramen is patent. Following intravenous contrast, there is no evidence of enhancing epidural or perineural scar. There is a small left lower pole renal cyst. Otherwise, the visualized paravertebral soft tissues are grossly unremarkable. Impression: Small broad-based posterior central and left paracentral protrusion of the L5-S1 disc, which likely impinges on the left S1 nerve root. Stable postoperative changes of left-sided laminotomy at L5-S1 level, without evidence of enhancing epidural or perineural scarring. 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 intolerant of prolonged periods of walking, sitting or standing and no heavy lifting. A light duty job with the accomodation of changing positions as needed for comfort would be feasible and no heavy lifting. 17. Remarks, if any: ------------------- Not an ACE exam. Veteran reports constant pain in his back no matter what position or use so repetitive motion over time does not cause any pain, fatigability or incordination that would significantly reduce veteran's function since he continues to work and at this time has no job restrictions. After examination of the veteran, listening to his complete history and current subjective complaints, combined with a review of the available records, I have no basis to offer additional losses of function or motion when it comes to repetitive use over time. Notes from pain management also report difficulty illicting bilateral lower extremity reflexes even with distraction which is consistent with exam today so more then likely normal for veteran to have decreased reflexes. Veteran has decreased ROM today, note from pain management 10/2018 noted forward flexion to 45 so some limitation of motion may be from pain. EMG 12/10/2018: acute/subacute nerve root lesion at or about the left L4-L5 nerve root. Acute/subacute nerve root lesion or lesions at or about the right L4 nerve root. EMG shows right and left lower extremity radiculopathy; right leg is a new diagnosis from last exam and is mild bilaterally. Current level of severity of lumbar spine DDD with DJD, s/p laminotomy is moderate. The DJD which has been noted on previous xrays was noted as a diagnosis from last C&P exam as well and is related to the DDD lumbar spine. ============================================================================= == Report Status: Verified Date Reported: FEB 02, 2017 Date Verified: FEB 02, 2017 Report: Exam: Lumbar spine, 5 views. Clinical History: Pain. Rule out arthritis. Results: There are no comparison studies. Alignment of the lumbar spine vertebrae is maintained, without spondylolisthesis. The lumbar vertebral body heights are maintained. There is mild narrowing of the L5-S1 disc space with minimal marginal osteophytic spurring. There is mild facet arthropathy at this level as well. Remainder of the lumbar disc spaces are grossly preserved. There are no definite pars defects identified on the oblique views. Bony mineralization is maintained. The sacroiliac joints are unremarkable. The visualized paravertebral soft tissues are grossly unremarkable. **************************************************************************** Peripheral Nerves Conditions (not including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire 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): office notes from civilain pain management and EMG results 1. Diagnosis ----------- Does the Veteran have a peripheral nerve condition or peripheral neuropathy? [X] Yes [ ] No Diagnosis #1: Bilateral lower extremity radiculopathy ICD code: M54.16 Date of diagnosis: already SC'd 2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's peripheral nerve condition (brief summary): Veteran is SC'd for left lower extremity radiculopathy to include restless leg syndrome. Please note that the original restless leg syndrome C&P exam was done by a neurologist and was listed as a central nervous system DBQ; not a peripheral nerve DBQ since restless leg syndrome does not occur at the peripheral nerve level. Veteran does still report his legs feels restless if he doesn't move them. Veteran reports bilateral lower extremity tingling which is constant. EMG done in 12/2018. No upper extremity exam requested nor deemed necessary so not performed. b. Dominant hand [X] Right [ ] Left [ ] Ambidextrous 3. Symptoms ---------- a. Does the Veteran have any symptoms attributable to any peripheral nerve conditions? [X] Yes [ ] No 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: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe 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 Knee extension: 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 Ankle plantar 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 Ankle dorsiflexion: 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 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 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam -------------- Indicate results for sensation testing for light touch: 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. Trophic changes ----------------- Does the Veteran have trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy? [ ] Yes [X] No 8. Gait ------ Is the Veteran's gait normal? [ ] Yes [X] No If no, describe abnormal gait: mild limp Provide etiology of abnormal gait: more then likely from back 9. Special tests for median nerve -------------------------------- Were special tests indicated and performed for median nerve evaluation? [ ] Yes [X] No 10. Nerves Affected: Severity evaluation for upper extremity nerves and radicular groups ---------------------------------------------------------------------- No response provided. 11. Nerves Affected: Severity evaluation for lower extremity nerves ------------------------------------------------------------------ a. Sciatic nerve Right: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [X] Mild [ ] Moderate [ ] Moderately Severe [ ] Severe, with marked muscular atrophy Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis If Incomplete paralysis is checked, indicate severity: [X] Mild [ ] Moderate [ ] Moderately Severe [ ] Severe, with marked muscular atrophy b. External popliteal (common peroneal) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis c. Musculocutaneous (superficial peroneal) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis d. Anterior tibial (deep peroneal) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis e. Internal popliteal (tibial) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis f. Posterior tibial nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis g. Anterior crural (femoral) nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis h. Internal saphenous nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis i. Obturator nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis j. External cutaneous nerve of the thigh Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis k. Ilio-inguinal nerve Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis 12. Assistive devices -------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities -------------------------------------------------- Due to peripheral nerve conditions, 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., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [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 EMG studies been performed? [X] Yes [ ] No Extremities tested: [X] Right lower extremity Results: [ ] Normal [X] Abnormal Date: 12/10/2018 [X] Left lower extremity Results: [ ] Normal [X] Abnormal Date: 12/10/2018 If abnormal, describe: acute/subacute nerve root lesion at or about the left L4-L5 nerve root. Acute/subacute nerve root lesion or lesions at or about the right L4 nerve root. b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact -------------------- Does the Veteran's peripheral nerve condition and/or peripheral neuropathy impact his or her ability to work? [ ] Yes [X] No 17. Remarks, if any: ------------------- Not an ACE exam. Restless leg syndrome is NOT a peripheral nerve condition, it is a central nervous system condition and as such was done as a CNS DBQ by the neurologist with the original claim; therefore no specific nerve can be listed for restless leg syndrome and peripheral nerve DBQ in appropriate DBQ for this condition; unsure why it is listed with the radiculopathy as they are two separate conditions. According to UpToDate, restless leg sydrome is, "Restless legs syndrome (RLS), also called Willis-Ekbom disease (WED), is a common sleep-related movement disorder characterized by an often unpleasant or uncomfortable urge to move the legs that occurs during periods of inactivity, particularly in the evenings, and is transiently relieved by movement." EMG shows right and left lower extremity radiculopathy; right leg is a new diagnosis from last exam and is mild bilaterally. Notes from pain management also report difficulty illicting bilateral lower extremity reflexes even with distraction which is consistent with exam today so more then likely normal for veteran to have decreased reflexes. Current level of severity for bilateral lower extremity lumbar radiculopathy is mild. EXP COSIGNER: URGENCY: STATUS: COMPLETED Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: --------- 1. Diagnosis ----------- a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes [ ] No ICD code: F32.9 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Major Depressive Disorder, unspecified ICD code: F32.9 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Lumbar Radiculopathy 2. Differentiation of symptoms ----------------------------- a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 3. Occupational and social impairment ------------------------------------ a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [ ] Yes [ ] No [X] Not Applicable (N/A) c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ---------- Clinical Findings: ----------------- 1. Evidence Review ----------------- Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS [X] Other (please identify other evidence reviewed): The claimant's responses on the PHQ-9, a self report measure of sx of Depression 2. History --------- a. Relevant Social/Marital/Family history (pre military, military, and post-military): He is a 37 y.old Vet, a husband and father, lives with the family, works as a safety manager. He was medically discharged in 2015 due to his spine problems. He states that since he had a surgery for a herniated disc in 2014 his medical condition went worse and he has been suffering from pain and inability to perform his duties as husband and father. He has been upset with his difficulties, shows irritability and anger in the family, feels guilty for that. He spends weekends trying to do some house and yard work but then feels very tired and stays in bed for the rest of the day. He is upset that due to his pain and decreased physical abilities he cannot participate in his children's sport activities and other family events. b. Relevant Occupational and Educational history (pre-military, military, and post-military): He served from 2003-2015, medically discharged ( cervical and back problems), since that he has been working as a security manager, changed companies, has reprimands from his supervisors for his "harsh" treatment of others- he agrees with the critique but states that he feels irritable and angry due to the pain and physical limits and cannot adequately control his reactions and responses. He was fired from one his jobs - in Nov 2017- for disrespecting his direct supervisor and the next level supervisor (reportedly, called each of them an "idiot" or something to that effect) c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): He has developed depression since his surgery in 2014, as per his report. He started feeling irritable, angry and guilty due to his medical issues and physical incapacities imposed by his conditions (radiculopathy, cervical strain) For the last 6 months he has been in tx with a VA Psychologist on the DX-es of Depressive Disorder and Adjustment Disorder - see CPRS. d. Relevant Legal and Behavioral history (pre military, military, and post-military): no issues reported e. Relevant Substance abuse history (pre-military, military, and post-military): drinks once a week, has 5-6 drinks then f. Other, if any: No response provided. 3. Symptoms ---------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Chronic sleep impairment [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Impaired impulse control, such as unprovoked irritability with periods of violence 4. Behavioral observations ------------------------- A 37 y.old male, looks older than his chronological age, appears irritable and upset, no other issues in his MS, no avh, no S/H/D 5. Other symptoms ---------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [ ] Yes [X] No 6. Competency ------------ Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 7. Remarks (including any testing results), if any: -------------------------------------------------- The claimant's responses on the PHQ-9 produced a score of 16 - in the "Moderately - Severe" range A a 37 y.old Vet, a husband and father, lives with the family, works as a safety manager. He was medically discharged in 2015 due to his spine problems. He states that since he had a surgery for a herniated disc in 2014 his medical condition went worse and he has been suffering from pain and inability to perform his duties as husband and father. HE reports being irritable, angry, dysphoric, having problems dealing with others, becoming secluded, also suffering from guilt and shame. He reports continuous issues at his work places - was fired in 2017 for being rude to the supervisors, now has verbal reprimands for 'harsh" treatment of the staff. Since Sept 2018 he has been evaluated and then treated for the DX of Depressive Disorder and also the DX of Adjustment Disorder at the VA system - the tx is ongoing - see the CPRS. ____________________________________________________ _________________________ _ Given the claimant's presentation and history, and considering his records, the undersigned opines: The claimant meets criteria for Major Depressive Disorder unspecified and it is more likely than not that the claimant's condition diagnosed as above has developed in response to his struggle with Lumbar Radiculopathy .