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    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
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bhoward422

C&p Exam Findings

Question

Back (Thoracolumbar Spine) Conditions

Disability Benefits Questionnaire

Name of patient/Veteran: Self

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to

prepare the DBQ and such an examination will likely provide no

additional

relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[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:

Charleston CPRS record reviewed

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

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] Other Diagnosis

Diagnosis #1: lumbar spine disc disease

ICD code: 799.9

Date of diagnosis: 9/7/12

2. Medical history

------------------

Describe the history (including onset and course) of the Veteran's

thoracolumbar spine (back) condition (brief summary):

Onset back pain many years ago with injury during parachute jump during

service and went on sick call and had medication treatment for back. No

surgery to the back, had steroid injections to the back which helps a

little. Pain in the back is constant and radiates to the left knee and

right foot.Has numbness and weakness in the legs with the pain.

Medications for the back: naproxen, cyclobenzaprine, and tramadol which

help a little. Uses tens unit for back condition.

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:

flares occur 4-5 times lasting up to 1 hour and he has to stand with

the flare

4. Initial range of motion (ROM) measurement

--------------------------------------------

a. Select where forward flexion ends (normal endpoint is 90):

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45

[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70

[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45

[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70

[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater

b. Select where extension ends (normal endpoint is 30):

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 or greater

c. Select where right lateral flexion ends (normal endpoint is 30):

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 or greater

d. Select where left lateral flexion ends (normal endpoint is 30):

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20

[ ] 25 [ ] 30 or greater

e. Select where right lateral rotation ends (normal endpoint is 30):

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 or greater

f. Select where left lateral rotation ends (normal endpoint is 30):

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 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:

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater

c. Select where post-test extension ends:

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or

greater

d. Select where post-test right lateral flexion ends:

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or

greater

e. Select where post-test left lateral flexion ends:

[ ] 0 [ ] 5 [X] 10 [ ] 15

[ ] 20 [ ] 25 [ ] 30 or

greater

f. Select where post-test right lateral rotation ends:

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or

greater

g. Select where post-test left lateral rotation ends:

[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 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] Incoordination, impaired ability to execute skilled movements

smoothly

[X] Pain on movement

[X] Disturbance of locomotion

[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:

pain to palpation lower lumbar spine paraspinal muscles

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

in

abnormal gait or abnormal spinal countour?

[X] Yes [ ] 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?

[X] Yes [ ] 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 [ ] 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

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: [ ] 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+

10. Sensory exam

----------------

Provide results for sensation to light touch (dermatome) testing:

Upper anterior thigh (L2):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Thigh/knee (L3/4):

Right: [ ] Normal [X] 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

11. Straight leg raising test

-----------------------------

Provide straight leg raising test results:

Right: [X] Negative [ ] 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?

[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: [ ] None [ ] Mild [ ] Moderate [X] Severe

Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe

Paresthesias and/or dysesthesias

Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe

Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe

Numbness

Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe

Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe

b. Does the Veteran have any other signs or symptoms of radiculopathy?

[X] Yes [ ] No

If yes, describe: decreased sensation right lower extremity

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 [X] Moderate [ ] Severe

Left: [ ] Not affected [X] 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?

[X] Yes [ ] No

The total duration over the past 12 months: With incapacitating

episodes having a total duration of at least one week but less than

two

weeks during the past 12 months.

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?

[X] Yes [ ] No

Identify assistive device(s) used:

Assistive Device: Frequency of use:

----------------- -----------------

[X] Brace(s) [ ] Occasional [X] Regular [ ] Constant

[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:

cane and brace for back condition

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?

[X] Yes [ ] No

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

summary):

MRI, LUMBAR SPINE WITHOUT CONTRAST

Exm Date: SEP 07, 2012@10:35

Req Phys: TORRES,ALBERTO LUIS Pat Loc: ZZZBPCC TEAM 03

TORRES (Req'g

Img Loc: MRI

Service: Unknown

(Case 1599 COMPLETE) MRI, LUMBAR SPINE WITHOUT CONTRAS(MRI

Detailed) CPT:72148

Reason for Study: severe chronic low back pain

Clinical History:

Clinical History:A 54 y/o male veteran that presents severe

low

back pain. Lumbosacral spine X-Rays are normal.

No data available

CREATININE,SERUM/PLASMA 3/29/12 12:46 1.07

2/6/12 08:20 1.02

12/10/10 07:55 1.10

EGFR 3/29/12 12:46 87.5

2/6/12 08:20 92.4

12/10/10 07:55 85.1

No Is patient weight greater than 300 lbs? Weight: 180.8 lb

[82.2 kg] (08/07/2012 08:13)

No Cardiac Pacemaker or wires left after pacemaker removal?

No Automatic inplanted defibrillator?

No Cochlear(ear) implant or stapes?

No Metal in your eyes or history of being a metalworker?

No Surgery or intravascular stent in past 6 wks?

No Implanted nerve or bone growth stimulator?

No Implanted infusion pump for drug delivery?

No Aneurysm clips in brain?

No Penile implant?

No Heart valve?

No Eye implant / band?

No History of shrapnel,gunshot wound?

No History of any Cancer? Type?

No Known allergies or prior reaction to constrast/dye?

No Skin patch medication?

No First trimester pregnancy?

No Lactating (breastfeeding)?

No Is patient on dialysis or in renal failure?

Name of Interviewing Medical Personnel?

No Patient has claustrophobia?

No Rides a shuttle bus?

No Does the patient have sleep apnea and/or on home oxygen?

No Uses prescription pain medication regularly?

No Has patient received surgery on the same locations to be

imaged? If Yes to surgery; What year?

Report Status: Verified Date Reported: SEP

07, 2012

Date Verified: SEP

07, 2012

Verifier E-Sig:/ES/BRADLEY AMERSON, MD

Report:

MR lumbar spine without contrast

Indication:severe chronic low back pain

Comparison:Lumbosacral radiographs 5/24/2012

Technique:Standard adult HNP spine protocol MR images of the

lumbar spine were performed without the use of gadolinium

based

contrast.

Findings: There are 5 non rib bearing lumbar-type vertebrae

(lowermost referred to as L5) with visualization from T11 to

the

sacrum.

There is normal height and alignment of the vertebral

bodies.

Normal bone marrow signal. T1/T2 hyperintense signal within

as to

is compatible with an osseous hemangiomata. Conus

demonstrates

normal course, caliber, morpholgy, signal and terminates at

L1.

Visualized lower thoracic spine is within normal limits.

Small

bilateral renal cysts are present.

There is disk desiccation at L3/L4, L4/L5 and L5/S1.

T12-L1: No signifigant neuroforaminal or spinal canal

narrowing.

No signifigant facet disease. Sagittal images only.

L1-L2: No signifigant neuroforaminal or spinal canal

narrowing.

No signifigant facet disease. Sagittal images only.

L2-L3: No signifigant neuroforaminal or spinal canal

narrrowing.

No signifigant facet disease.

L3-L4: There is a broad-based posterior disc protrusion

causing

mild bilateral neural foraminal stenosis. There is mild

bilateral facet arthrosis.

L4-L5: There is a broad-based posterior disc protrusion and

bilateral facet arthrosis causing moderate bilateral neural

foraminal stenosis. No significant spinal canal stenosis.

L5-S1: There is a broad-based posterior disc protrusion

without

significant neuroforaminal or spinal canal stenosis. The

disc

protrusion contacts the traversing S1 nerve roots.

Impression:

1. Degenerative disc disease described above, worse at

L4-L5

where there is a broad-based posterior disc protrusion and

bilateral facet arthrosis causing moderate bilateral

neuroforaminal stenosis. No significant spinal canal

stenosis.

2. Broad-based posterior disc protrusion at L5-S1 contacting

the

traversing S1 nerve roots.

Primary Diagnostic Code:

Primary Interpreting Staff:

BRADLEY AMERSON, MD, ATTENDING (Verifier)

/BA

SPINE LUMBOSACRAL MIN 2 VIEWS

Exm Date: FEB 03, 2014@13:12

Req Phys: OCONNOR,CATHERINE C Pat Loc: CHS C&P

O'CONNOR

(Req'g Loc)

Img Loc: VAMC RADIOLOGY,

CHARS

Service: Unknown

*** THIS IS AN AMENDED REPORT ***

(Case 452 COMPLETE) SPINE LUMBOSACRAL MIN 2 VIEWS (RAD

Detailed) CPT:72100

Reason for Study: C&P evaluation

Clinical History:

 

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Brother, you are really F-up but Based on the above you WILL NOT get service connected for your back. The Examiner stated that your condition was less likely (<50%) than not related to your service. Based on what was written, you never went and got your back checked out while you were in the military. You will need an IME or IMO (Independent Medical Exam/Opinion) stating that your injury was related to your service. Good Luck and sorry bout the bad news.

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MarineJay,

Is on the money bud. The Doc well documented that your back is screwed, but again your records must have not indicated that this medical issue is service connected. Good luck and keep us posted

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The exam doctor is saying you have no evidence in your SMR's that your injuries happened in the military? How did you get hurt and what evidence of any kind do you have that it happened in the military? Were you ever treated for a back injury in the military? Did you tell anyone you had injured yourself? Did a buddy see you get hurt? Were you hurt in a combat zone/situation?

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Did you receive a separation physical prior to discharge and if so, did it indicate disease or injury regarding your back?

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yes but my smr sick call documents are missing but i have a IMO nexus showing I was in the airborne and states on my dd214 that i was assigned in the airborne and my duty was air movement operation and parachuting also showed I re-enlisted for paratrooper duty. yes a nexus was done on my back. by a IMO.

Edited by bhoward422

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