whoami? Posted May 21, 2014 Share Posted May 21, 2014 (edited) Please let me know what you guys think my rating will be based on this C&P exam. Thanks. Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: 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: VBMS 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: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: ICD code: 847 Date of diagnosis: Already connected 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): He states that he has constant pain in the lower back that radiates down his legs at times. He states that he has pain with bending. He states that the pain is severe. He is currently on Lortab and Toradol for a knee surgery that he had yesterday, so the pain is not as bad today. 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: The veteran states that pain flares up with excessive use. Pain, weakness, fatigability or incoordination could significantly limit functional ability during flare ups of after repeated use. However to specify to the amount of limited functional ability would be resorting to mere speculation as I can not exam the veteran under these conditions. 4. Initial range of motion (ROM) measurement -------------------------------------------- a. Select where forward flexion ends (normal endpoint is 90): [ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 [X] 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 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 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 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 or greater d. Select where left lateral flexion ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 or greater e. Select where right lateral rotation ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 or greater f. Select where left lateral rotation ends (normal endpoint is 30): [ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25 [ ] 30 or greater Select where objective evidence of painful motion begins: [ ] No objective evidence of painful motion [ ] 0 [ ] 5 [ ] 10 [X] 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? [ ] Yes [X] No If unable, provide reason: Too painful. 6. Functional loss and additional limitation in ROM --------------------------------------------------- a. Does the Veteran have additional limitation in ROM of the thoraco lumbar 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] 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)? [ ] Yes [X] No 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 [ ] 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: [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: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 11. Straight leg raising test ----------------------------- Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] 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 [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] 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 [ ] Mild [X] 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? [ ] 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? [X] Yes [ ] No Identify assistive device(s) used: Assistive Device: Frequency of use: ----------------- ----------------- [X] Walker [ ] Occasional [ ] Regular [X] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: Walker is due to knee surgery that he had yesterday. 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? [ ] 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: He would be unable to walk or stand for extended periods. 21. REMARKS ----------- a. Remarks, if any: No comments provided. b. Mitchell criteria: The veteran states that pain flares up with excessive use. Pain, weakness, fatigability or incoordination could significantly limit functional ability during flare ups of after repeated use. However to specify to the amount of limited functional ability would be resorting to mere speculation as I can not exam the veteran under these conditions. Edited May 21, 2014 by whoami? Link to comment Share on other sites More sharing options...
0 NYNurse1124 Posted May 27, 2014 Share Posted May 27, 2014 Wish I could offer you some insight however, we just went through the same exam and are also looking for some input. Link to comment Share on other sites More sharing options...
0 whoami? Posted May 28, 2014 Author Share Posted May 28, 2014 Thanks for your response NYNurse. I will keep you informed as to the findings in my case for this issue. Please keep me informed with you guys' progresss also. Thanks. Link to comment Share on other sites More sharing options...
0 NYNurse1124 Posted June 11, 2014 Share Posted June 11, 2014 Whoami? I wish you lots of luck, I do know that this process is VERY Frusterating! Hang in there! Link to comment Share on other sites More sharing options...
0 Content Curator/HadIt.com Elder Vync Posted June 12, 2014 Content Curator/HadIt.com Elder Share Posted June 12, 2014 (edited) This is my first time trying to interpret the results of a DBQ against rating criteria, so don't flame me if I get it totally wrong. The DBQ showed you had forward flexion 45 degree range of motion with pain. Next, look at the schedule of ratings for the spine to see what it says. §4.71a Schedule of ratings—musculoskeletal system. 20% rating section Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis I bolded the section that might apply to your situation because your range of forward flexion motion was 45 degrees. There was also some indications about mild to moderate levels of radiculopathy in each leg. I am not familiar with that rating table, but it could be worth a shot to look at it, too... I didn't see any indications of whether they thought you could become SC or not. Hopefully someone else can follow up and verify this. It looks to me like if you do get awarded SC for your back, you could get 20%, possibly with an unknown radiculopathy rating. Edited June 12, 2014 by Vync Link to comment Share on other sites More sharing options...
0 killemall Posted June 12, 2014 Share Posted June 12, 2014 Good luck Link to comment Share on other sites More sharing options...
0 HadIt.com Elder john999 Posted June 12, 2014 HadIt.com Elder Share Posted June 12, 2014 I think before vets go for these subjective exams they should consult with Hadit. Vync 1 Link to comment Share on other sites More sharing options...
Question
whoami?
Link to comment
Share on other sites
Top Posters For This Question
5
3
2
1
Popular Days
Jun 12
3
Jun 24
2
Jun 20
2
Jun 26
1
Top Posters For This Question
whoami? 5 posts
NYNurse1124 3 posts
john999 2 posts
Vync 1 post
Popular Days
Jun 12 2014
3 posts
Jun 24 2014
2 posts
Jun 20 2014
2 posts
Jun 26 2014
1 post
Popular Posts
john999
I think before vets go for these subjective exams they should consult with Hadit.
12 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now