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marinejay

Back C&p Exam: Need To Know What Write Up Saying In Eng...

Question

I need some help deciphering this C&P exam, I am currently at 20% and I would like to know what this is saying in plain english

my take is I will get 10% for sciatica or radicopothy and maybe get an increase, but I think i'll be able to keep my current rating of 20%. any input would greatly be appreciated.

I took out all of the gargable and just left the docs answers bolded...

____________________________________________________________________________________________________

Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire

Name of patient/Veteran:

Indicate method used to obtain medical information to complete this document:

[X] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed? [X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

current VA studies


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:


[X] Intervertebral disc syndrome

2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):

The veteran states that his back condition has worsened since he was first
rated for it in 2003. He states that the radiation of the
pain into the right leg is more frequent and more intense, and sometimes goes into the
left leg as well. Does not like taking narcotic pain medication but finds he has to do it more often now. No bladder or bowel dysfunction.

3. Flare-ups
------------
Does the Veteran report that flare-ups impact the function of the
thoracolumbar spine (back)?
[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in
his or her own words:

States that if he does something too physically demanding his pain will
increase for 1-2 days, but is unable to quantify any changes in ROM.

Not having a flare up at the time of this exam.

4. Initial range of motion (ROM) measurement --------------------------------------------
a. Select where forward flexion ends (normal endpoint is 90):

[ x] 70

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 60

b. Select where extension ends (normal endpoint is 30):]
[X] 25

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 20

c. Select where right lateral flexion ends (normal endpoint is 30): [X] 30 or greater

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 30 or greater

d. Select where left lateral flexion ends (normal endpoint is 30): [X] 30 or greater

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [X] 30 or greater

e. Select where right lateral rotation ends (normal endpoint is 30): [X] 30 or greater

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion
[X] 30 or greater

f. Select where left lateral rotation ends (normal endpoint is 30): [X] 30 or greater

Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion
[X] 30 or greater

g. If ROM for this Veteran does not conform to the normal range of motion

identified above but is normal for this Veteran (for reasons other than a
back condition, such as age, body habitus, neurologic disease), explain:

No response provided.

5. ROM measurement after repetitive use testing -----------------------------------------------
a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?

[X] Yes [ ] No
b. Select where post-test forward flexion ends: [X] 75

c. Select where post-test extension ends:
 [X] 20

d. Select where post-test right lateral flexion ends: X] 30 or
greater

e. Select where post-test left lateral flexion ends: 
[X] 30 or
greater

f. Select where post-test right lateral rotation ends: 
[X] 30 or
greater

g. Select where post-test left lateral rotation ends: 
[X] 30 or
greater

6. Functional loss and additional limitation in ROM ---------------------------------------------------
a. Does the Veteran have additional limitation in ROM of the thoracolumbar

spine (back) following repetitive-use testing? [ ] Yes [X] No

b. Does the Veteran have any functional loss and/or functional impairment of the thoracolumbar spine (back)? [X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment and/or

additional limitation of ROM of the thoracolumbar spine (back) after
repetitive use, indicate the contributing factors of disability below:

[X] Less movement than normal

[X] Weakened movement


[X] Pain on movement


[X] Interference with sitting, standing and/or weight-bearing

7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait) ----------------------------------------------------------------
------------

a. Does the Veteran have localized tenderness or pain to palpation for joints

and/or soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No

If yes, describe:
lumbar paravertebral tenderness

b. Does the Veteran have muscle spasm of the thoracolumbar spine resulting in

abnormal gait or abnormal spinal countour? [ ] Yes [X] No

c. Does the Veteran have muscle spasms of the thoracolumbar spine not

resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No

d. Does the Veteran have guarding of the thoracolumbar spine resulting in

abnormal gait or abnormal spinal countour? [ ] Yes [X] No

e. Does the Veteran have guarding of the thoracolumbar spine not resulting in abnormal gait or abnormal spinal countour? [ ] Yes [X] No

8. Muscle strength testing
--------------------------
a. Rate strength according to the following scale:

0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength

Hip flexion:
Right: [X] 5/5 
Left: [X] 5/5

Knee extension: Right: [X] 5/5 5
Left: [X] 5/5

Ankle plantar flexion: Right: [X] 5/5 5
Left: [X] 5/5

Ankle dorsiflexion: Right: [X] 5/5 
Left: [X] 5/5

Great toe extension: Right: [X] 5/5 
Left: [X] 5/5

b. Does the Veteran have muscle atrophy? [ ] Yes [X] No

9. 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: [x ] 2+ Left: [x ] 2+

Ankle: Right: [x ] 2+ Left: [ x] 2+

10. Sensory exam
----------------
Provide results for sensation to light touch (dermatome) testing:

Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased

Thigh/knee (L3/4):
Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased

Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased

Foot/toes (L5):
Right: [X] Normal [ ] Decreased Left: [X] Normal [ ] Decreased

11. Straight leg raising test -----------------------------
Provide straight leg raising test results:

Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform

12. Radiculopathy
-----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[ ] Yes [X] No

a. Indicate symptoms' location and severity (check all that apply):

No response provided.

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 THIS SEEMS VERY CONFUSING WHAT LOOKING AT QUESTION #12 SAYING NO.. NEED HELP HERE

d. Indicate severity of radiculopathy and side affected:

Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe

13. Ankylosis
-------------
Is there ankylosis of the spine? [ ] Yes [X] No

14. 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

15. Intervertebral disc syndrome (IVDS) and incapacitating episodes
----------------------------------------------------------------
---

a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No

b. If yes, has the Veteran had any incapacitating episodes over the past

12 months due to IVDS? [ ] Yes [X] No

16. 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

17. 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

18. Other pertinent physical findings, complications, conditions, signs

and/or symptoms ----------------------------------------------------------------
-------
a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms?
[ ] Yes [X] No

19. 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?

[ ] Yes [X] No

20. 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:

interferes with prolonged sitting

21. Remarks, if any: --------------------
No remarks provided.

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4 answers to this question

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I could see 20% bud, but just try to wait and see what the BBE says. Good luck and try not to stress too much, the hardest part is past you know.

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me tinks 30.

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Yea that's what I kinda figured. I am thinking they will keep me at 20 or raise me to 30. I am not familar with the back DBQ's. THANKS again.

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Just wait it out bud, and good luck

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