lumbosacral Back (Thoracolumbar Spine) Conditions C&p Progress Notes

[mekon1971]

1. Diagnosis:

Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? YES

If yes, provide only diagnoses that pertain to thoracolumbar spine (back) conditions:

Diagnosis #1: Low back strain and degenerative disc disease

Date of Diagnosis: UNKNOWN

2. Medical history:

The veteran stated during his military service in the Army, he was playing football when he injured his head, low back, and his left shoulder. He was tackled and he was knocked out for about 30 min. He was transferred to the hospital. He said that his first memory was woke up in the field. He had x-rays on his back and his shoulder. Since then, he has been complaining recurrent low back pain due to suspected pinch nerve and osteoarthritis. He has been seen or ER at VAMC because of his back. He also recalled that he had Physical Therapy during his Army time. He also recalled that during his Desert Storm, he was hit in the head but had no LOC. He denies any other accident or trauma, he still having cognitive problem and memory issues. From his left shoulder, he is having pop all the time, some weakness and LOM. He is having a constant 4/10 on pain intensity but its depend on activities. Sometimes is a zero but sometimes is an 8/10. From his lower back, he is having a constant back pain about 4/10 on pain intensity. His worse pain is a 10/10 on pain intensity once a year.

He is on Naproxen with fair response.

4. Initial range of motion (ROM) measurement:

a. forward flexion ends: 60

Select where objective evidence of painful motion begins: 40

b. Select where extension ends: 15

Select where objective evidence of painful motion begins: 10

c. Select here right lateral flexion ends: 20

Select where objective evidence of painful motion begins: 20

d. Select where left lateral flexion ends: 20

Select where objective evidence of painful motion begins: 20

e. Select where right lateral rotation ends: 20

Select where objective evidence of painful motion begins: 20

f. Select where left lateral rotation ends: 30

Select where objective evidence of painful motion begins: <X) No objective evidence of painful motion

5. ROM measurment after repetitive use testing

a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? YES

b. post test forward flexion ends: 60

c. post test extension ends: 15

d. post test right lateral flexion ends: 20

e. post test left lateral flexion ends: 20

f. post test right latereral rotation ends: 20

g. post test left lateral rotation ends: 30 or greater

6. Functional loss and additional limitation in ROM

b. Does the Veteran h ave any funtional loss and/or functional impairment of the thoracolumbar spine (back)? YES

c. If the Veteran has a functional loss, functional impairment and/or additional limitations of ROM of the thoracolumbar spine (back) after repetitive use, indicate the contributing factors of disability below:

<X> Pain on movement

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 teh thoracolumbar spine (back)? YES

If yes, describe: thoracolumbar paraspinal muscle

b. Does the Veteran have guarding ofr muscle spasm of the thoracolumbar spine (back)? YES

If yes, is it severe enough to result in:

<X> Guarding and/or muscle spasm is present, but do not result in abnormal gait or spinal countour

10. Sensory exam

Foot/toes (L5): Right and left Decreased

14. Intervertebral disc syndrome (IVDS) and incapacitating episodes

a. Does the Veteran have IVDS of the thoracolumbar spine? YES

b. If yes, has the veteran had any incapacitating episodes over past 12 months? NO

18. Diagnostic testing

a. Have imaging studies of the thoracolumbar spine been performed and are the results available? YES

If yes, is arthritis documented? YES

c. Are there any other significant diagnostic test findings and/or results? YES

If yes, provide type of test or procedure, date and results (brief summary):

Report status: Verified Date Reported: Nov 10, 2011 Date Verified: Nov10, 2011

Impression: Frontal and Lateral Lumbar Spine 11/9/2011: No comparison lumbar spine. Preserved lumbar column alignment, vertebral body heights and disc spaces. Multilevel anterior osteophytic lipping. Normal sacroiliac joints. Posterior fusion anomaly at lumbosacral transition. Nonobstructive bowel gas pattern. Indeterminate renal outlines. No opacities to suggest biliary, pancreatic, or urinary tract stones.

19. Function Impact

YES, He is on SSDI due to Mental and Physical condition.

20. Remarks, if any:

C-File was reviewed. No evidence of back injury during service.

[harleyman]

the examiner said: " C-File was reviewed. No evidence of back injury during service."

This very last sentence on your exmination is problematic, for two reasons.

#1. If you had no records of back injury in service you are missing one side of the triangle. Remember you have to have:

a disease/illness/ injury in service

a current diagnosed condition or illness

and a nexus that links the two

according tothe exminer, you are missing the medical records that show you had a back injury/treatment during service.

#2. In your exmaination for your injury to your shoulder the examiner list the "history" portion as the same as the "history" portion of your back. Given the History is the same for both conditions it is likely neither will be service connected. You need to find those hospital records from when you were knock unconscience as you need to have medical treatment during your active duty servce to get these service connected.

Sorry, but what I am seeing on this exam is a denial on the back condition and a (? I don't know) , on the shoulder as I did not see an opinion on the shoulder in the shoulder exam. The examiner may have given an opinion and the end of the report but I can only go by what I am reading here. If there is more information of course that could diffinately change the outcome of whether or not you are ultimately sevice connected.