Navy04 Posted February 16, 2015 Share Posted February 16, 2015 Below is C&P results for back exam. Can you please help me with figuring on what % I might get. Thanks so much and God Bless!!! Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire 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 (hard copy paper C-file) reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VA medical records. 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: LS strain Date of diagnosis: 2000s 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): The Veteran states that he initially injured his lower back during military service in 2005 secondary to heavy liftingl then it was re-injured in 2007 and 2010. He was treated conservatively at those times. Since military service discharge in early 2013, the Veteran states that he has experienced daily lower back pain, along with RLE radiuclar symptoms. He has been seeing a chiropractor of late, which has helped somewhat. He has a TENS unit which he uses as needed. He denies bowel or bladder dysfunction secondary to his lower back. He also has ED, for which he is prescribed Viagra, and for which he is service connected as well, secondary to his chronic epididymitis and varicocele surgery. He also ambulates with a cane for lower back and bilateral knee support and stabilization. X-rays of his lower back in October 2013 were read as normal. MRI of the LS spine on 2/15/2014 at Red River Regional Hospital revealed the following: L2-3: Mild facet DJD L3-4: Mild facet DJD L4-5: Bulging annulus L5-S1: Mild facet DJD b. 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: Stiffness/weakness 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. See (b) above 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 55 degrees Extension (0 to 30): 0 to 20 degrees Right Lateral Flexion (0 to 30): 0 to 20 degrees Left Lateral Flexion (0 to 30): 0 to 20 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 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 on rest/non-movement 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 Does the Veteran have localized tenderness or pain on palpation of joints and/or soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): There is localized tenderness over the bilateral paralumbar muscles and SI joints, as well as the right mid buttock and right sciatic notch. 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 If the examination is not being conducted immediately after repetitive use over time: [ ] The examination supports the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination contradicts the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination neither supports nor contradicts the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not currently flared up. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If no, does the Veteran report flare-ups? [X] Yes [ ] No Frequency: Weekly Severity: Moderate Duration: 1-2 days If the examination is not being conducted during a flareup: [ ] The examination supports the Veteran's statements describing functional loss during flare-ups. [ ] The examination contradicts the Veteran's statements describing functional loss during flare-ups. Please explain [X] The examination neither supports nor contradicts the Veteran's statements describing functional loss during flare Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not currently flared up. 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: Provide description and/or etiology: Diffuse spasm on the right side Localized tenderness: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: See above. Guarding: [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] 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: None 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: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 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 Other sensory findings, if any: There is normal perianal sensation and normal anal sphincter tone. 7. Straight leg raising test Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [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): 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: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] 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 Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. 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 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ---------------------------------------------------------------- ------- a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] Yes [X] No 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 Identify assistive device(s) used Assistive Device: Frequency of use: ----------------- ----------------- [X] Cane(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: See above. 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? [ ] Yes [X] No 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? [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): Lumbar MRI has been ordered and is currently pending; when completed and reported, I will review it and add any additional comments as indicated. Labs today: Testosterone 3.1 ng/ml (normal; this is therefore not the cause of his ED problem.) 16. 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: The Veteran's current lower back condition would limit his ability to perform repetitive heavy lifting, pushing or pulling. 17. Remarks, if any: -------------------- The Veteran is claiming service connection for a lower back condition. Opinion: It is as least as likely as not that the Veteran's current lower back condition is proximately due to or caused by military service. Rationale: The C file was reviewed. The STRs do contain documentation with regard to treatment for the lower back beginning in 2005, and again in 2007 as well. Separation exam also comments on the lower back problems. VA chiropractor notes in 2014 also describe chronic low back pain since 2007. **************************************************************************** Link to comment Share on other sites More sharing options...
0 TiredCoastie Posted February 16, 2015 Share Posted February 16, 2015 Hey Shipmate! Looks like you made it to your C&Ps. Seems from your postings that you got some reasonable outcomes but you're in a better position to know if the docs got it right. I'm a lot less severe and have 10%, so you're going to exceed that percentage. Link to comment Share on other sites More sharing options...
0 Navy04 Posted February 16, 2015 Author Share Posted February 16, 2015 Thanks for the support bud. I have to do a few tests along with a brain scan but I made it thru thanks to you guys on Hadit. Link to comment Share on other sites More sharing options...
0 TiredCoastie Posted February 17, 2015 Share Posted February 17, 2015 PTL! Keep up the fight, Navy! Link to comment Share on other sites More sharing options...
0 iceturkee Posted February 17, 2015 Share Posted February 17, 2015 Hey Shipmate! Looks like you made it to your C&Ps. Seems from your postings that you got some reasonable outcomes but you're in a better position to know if the docs got it right. I'm a lot less severe and have 10%, so you're going to exceed that percentage. i disagree. compared to my lumbar mri, his is a cake walk. my guess is maybe 20 percent but probably 10. for the record, i have 5 herniated discs, spinal and foraminal stenosis, a slipped vertabrae, arthritis and 2 torn discs. i'm 40 percent for my back. Link to comment Share on other sites More sharing options...
0 Navy04 Posted February 17, 2015 Author Share Posted February 17, 2015 I forgot to mention that due to the VA waiting to long to refer to Ortho Surgeon I developed a whole in the spine near L3 Plate caused by the pressure of the spine compression. That is what brought this claim to light when the VA back Dr caught this severe issue, but too late for surgery in my case. The C&P doc ordered another MRI of the Neck as it appears that the back issues brought on problems with the Neck and nerve damage. I guess we will see. I am 100% already just want it all documented. Heck I have a ton of other issues that I have not even submitted for, one being Sleep Apnea which is an automatic 50%. Just too much going on for now. I have multiple procedures over the next month to include Colonoscopy, Endoscopy, Brain Scan, Chest xrays and some kind of other Neuro Test. Thanks again Link to comment Share on other sites More sharing options...
Question
Navy04
Below is C&P results for back exam. Can you please help me with figuring on what % I might get. Thanks so much and God Bless!!!
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
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 (hard copy paper C-file)
reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not
included in the
Veteran's VA claims file:
VA medical records.
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: LS strain
Date of diagnosis: 2000s
2. Medical history
------------------
a. Describe the history (including onset and course) of the
Veteran's
thoracolumbar spine (back) condition (brief summary):
The Veteran states that he initially injured his lower back
during
military service in 2005 secondary to heavy liftingl then it
was
re-injured in 2007 and 2010.
He was treated conservatively at those times.
Since military service discharge in early 2013, the Veteran
states that he
has experienced daily lower back pain, along with RLE
radiuclar symptoms.
He has been seeing a chiropractor of late, which has helped
somewhat.
He has a TENS unit which he uses as needed.
He denies bowel or bladder dysfunction secondary to his lower
back.
He also has ED, for which he is prescribed Viagra, and for
which he is
service connected as well, secondary to his chronic
epididymitis and
varicocele surgery.
He also ambulates with a cane for lower back and bilateral
knee support
and stabilization.
X-rays of his lower back in October 2013 were read as normal.
MRI of the LS spine on 2/15/2014 at Red River Regional
Hospital revealed
the following:
L2-3: Mild facet DJD
L3-4: Mild facet DJD
L4-5: Bulging annulus
L5-S1: Mild facet DJD
b. 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:
Stiffness/weakness
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.
See (b) above
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 55 degrees
Extension (0 to 30): 0 to 20 degrees
Right Lateral Flexion (0 to 30): 0 to 20 degrees
Left Lateral Flexion (0 to 30): 0 to 20 degrees
Right Lateral Rotation (0 to 30): 0 to 30 degrees
Left Lateral Rotation (0 to 30): 0 to 30 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 on rest/non-movement
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
Does the Veteran have localized tenderness or pain on
palpation of joints
and/or soft tissue of the thoracolumbar spine (back)? [X] Yes
[ ] No
If yes, describe including location, severity and
relationship to
condition(s):
There is localized tenderness over the bilateral
paralumbar muscles and
SI joints, as well as the right mid buttock and right
sciatic notch.
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
If the examination is not being conducted immediately
after repetitive
use over time:
[ ] The examination supports the Veteran's statements
describing
functional loss with repetitive use over time.
[ ] The examination contradicts the Veteran's statements
describing
functional loss with repetitive use over time. Please
explain.
[X] The examination neither supports nor contradicts the
Veteran's
statements describing functional loss with repetitive
use over
time.
Does pain, weakness, fatigability or incoordination
significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
Not currently flared up.
d. Flare-ups
Is the exam being conducted during a flare-up? [ ] Yes [X]
No
If no, does the Veteran report flare-ups? [X] Yes [ ]
No
Frequency: Weekly
Severity: Moderate
Duration: 1-2 days
If the examination is not being conducted during a flareup:
[ ] The examination supports the Veteran's statements
describing
functional loss during flare-ups.
[ ] The examination contradicts the Veteran's statements
describing
functional loss during flare-ups. Please explain
[X] The examination neither supports nor contradicts the
Veteran's
statements describing functional loss during flare
Does pain, weakness, fatigability or incoordination
significantly limit
functional ability with flare-ups?
[ ] Yes [ ] No [X] Unable to say w/o mere speculation
If unable to say w/o mere speculation, please explain:
Not currently flared up.
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:
Provide description and/or etiology:
Diffuse spasm on the right side
Localized tenderness:
[ ] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[X] Not resulting in abnormal gait or abnormal spinal
contour
[ ] Unable to evaluate, describe below:
Provide description and/or etiology:
See above.
Guarding:
[X] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[ ] 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: None
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: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Knee extension:
Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Ankle plantar flexion:
Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Ankle dorsiflexion:
Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Great toe extension:
Right: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
Left: [ ] 5/5 [ ] 4/5 [X] 3/5 [ ] 2/5 [ ] 1/5
[ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
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
Other sensory findings, if any: There is normal perianal
sensation and
normal anal sphincter tone.
7. Straight leg raising test
Provide straight leg raising test results:
Right: [ ] Negative [X] Positive [ ] Unable to perform
Left: [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):
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: [X] None [ ] Mild [ ] Moderate
[ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [X] Mild [ ] Moderate
[ ] Severe
Left lower extremity: [X] None [ ] 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
Left: [X] Not affected [ ] Mild [ ] Moderate [ ]
Severe
9. Ankylosis
------------
Is
there ankylosis of the spine? [ ] Yes [X] No
10. 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
11. Intervertebral disc syndrome (IVDS) and episodes requiring
bed rest
----------------------------------------------------------------
-------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[ ] Yes [X] No
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
Identify assistive device(s) used
Assistive Device: Frequency of use:
----------------- -----------------
[X] Cane(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:
See above.
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?
[ ] Yes [X] No
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?
[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):
Lumbar MRI has been ordered and is currently pending;
when
completed and reported, I will review it and add any
additional
comments as indicated.
Labs today: Testosterone 3.1 ng/ml (normal; this is
therefore not
the cause of his ED problem.)
16. 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:
The Veteran's current lower back condition would limit
his ability
to perform repetitive heavy lifting, pushing or
pulling.
17. Remarks, if any:
--------------------
The Veteran is claiming service connection for a lower back
condition.
Opinion: It is as least as likely as not that the Veteran's
current lower
back condition is proximately due to or caused by military
service.
Rationale: The C file was reviewed.
The STRs do contain documentation with regard to treatment for
the lower back
beginning in 2005, and again in 2007 as well.
Separation exam also comments on the lower back problems.
VA chiropractor notes in 2014 also describe chronic low back
pain since 2007.
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