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  1. Disabilities include degenerative arthritis, lumbar spine 10% and sciatica, right lower extremity 10%, both with November 2011 effective dates. Back pain and function got progressively worse over the years, developed extreme pain and left foot drop in December 2019, had lumbar discectomy with spinal fusion L5-S1 in April 2020. I also have documented sciatica in the left lower extremity now. X-rays and other diagnostics taken before my retirement Nov 2011 showed all sorts of misaligned vertebrae and narrowed disk spaces. I had been planning on requesting a re-evaluation last winter but COVID pandemic put a hold on that. Should I file for a re-evaluation of the degenerative arthritis or file a new claim for the issues pre and post lumbar fusion. When I do searches I usually see fusions with their own category. I have x-rays and such while i was on active duty that show misalignment of disks and irregular disk spaces and plenty of medical notes for back pain the last 3 years of active duty. I was basically on activity restrictions the last 3 years of my service. Hadn't completed a fitness test in 4 years before retirement, Also wondering if a decision on a new issue would nullify one or both of the existing back condition ratings. My current total rating is 91.1 % and I'd hate to come out of all this with a lower rating appreciate any advice, ty
  2. Hello All, I am a 41yr old disabled vet (70%) Degenerative Arthritus of the left Knee 20%Degenerative Arthritus of the Right knee 20%Degenerative Disc Disease of the Lumbar Spine 10%Radiculopathy Right Lower Extremity 10%Radiculopathy Left Lower Extremity 10%Degenerative Tears, Bilateral Knees 20%Tinnitus 10% This exam was scheduled 1 week after my back surgery (Fusion of L4/L5). Hip and Thigh 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 (VBMS or Virtual VA) 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: B/L HIP STRAIN DX 9-16 SECONDARY TO LUMBAR SPINE COND. b. Select diagnoses associated with the claimed condition(s) (Check all that apply): c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? Yes 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hip or thigh condition: 16 W/U DX AS ABOVE PAIN STANDING B/L MRI WNL. TX MEDS. b. Does the Veteran report flare-ups of the hip or thigh? [ ] Yes [X] No c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [ ] Yes [X] No 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right hip --------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): 0 to 90 degrees Extension (0-30): 0 to 30 degrees Abduction (0-45): 0 to 45 degrees Adduction (0-25): 0 to 25 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 60 degrees Internal Rotation (0-40): 0 to 40 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes, (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No Is there objective evidence of crepitus? [ ] Yes [X] No Left hip -------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): 0 to 90 degrees Extension (0-30): 0 to 30 degrees Abduction (0-45): 0 to 45 degrees Adduction (0-25): 0 to 25 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 60 degrees Internal Rotation (0-40): 0 to 40 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes, (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [ ] Yes [X] No Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right hip --------- 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 Left hip -------- 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 Right hip --------- 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. Left hip -------- 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. d. Flare-ups: Not applicable e. Additional factors contributing to disability Right hip --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None Left hip -------- 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. Muscle strength - 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 so me resistance 5/5 Normal strength Right Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No b. Does the Veteran have muscle atrophy? No response provided c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the hip. a. Indicate severity of ankylosis and side affected Right side: Left side: [ ] Favorable, in flexion at [ ] Favorable, in flexion at an angle between 20 and an angle between 20 and 40 degrees, and slight 40 degrees, and slight abduction or adduction abduction or adduction [ ] Intermediate, between [ ] Intermediate, between favorable and unfavorable favorable and unfavorable [ ] Unfavorable, extremely [ ] Unfavorable, extremely unfavorable ankylosis, unfavorable ankylosis, foot not reaching ground, foot not reaching ground, crutches needed crutches needed [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Additional conditions ------------------------ No response provided 7. Surgical procedures ---------------------- No response provided 8. 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 9. 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 10. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's hip or thigh conditions, is there functional impairment of an extremity such that no effective functions remain 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 11. Diagnostic testing ---------------------- a. Have imaging studies of the hip or thigh been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? No response provided c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 12. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [ ] Yes [X] No 13. Remarks, if any: -------------------- No response provided !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: PUGH 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) 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 [ ] 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: PO DISC FUSION LUMBAR 2-17 Date of diagnosis: 2-17 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): AS ABOVE, DONE DUE TO R SCIATICA ,DROP R FOOT. 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: PAIN 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. LESS MOTION 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 20 degrees Extension (0 to 30): 0 to 10 degrees Right Lateral Flexion (0 to 30): 0 to 10 degrees Left Lateral Flexion (0 to 30): 0 to 10 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees 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): LUMBAR PAIN 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 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 Is the exam being conducted during a flare-up? [ ] Yes [X] No e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: 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: 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 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? No response provided. 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 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 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: [ ] Normal [X] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [X] 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 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): Intermittent pain (usually dull) Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right 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: [X] Right [ ] Left [ ] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities ---------------------------------- No response provided 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? [X] Yes [ ] No If yes, select the total duration over the past 12 months: PO SURGERY c. If yes to question 11b above, provide the following documentation that supports the Yes response: [X] Medical history as described by the Veteran only, without documentation: AS ABOVE [ ] Medical history as shown and documented in the Veteran's file: [ ] Other, describe: 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) [ ] Occasional [X] Regular [ ] Constant 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? [ ] 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? [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: NEW DRESSING NOT REMOVED Measurements: length cm X width cm 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? [ ] Yes [X] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? No response provided. c. Are there any other significant diagnostic test findings and/or results? No response provided. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [ ] Yes [X] No
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