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C/p Exam Complete For Back Increase


Navy4life

Question

Hi everyone! Hope all is well! My boyfriend has his C/P on Saturday for his increase request that he put in back in November. Can you give your opinions on the results of the C/P?

VA Notes

Source:

VA

Last Updated:

18 Mar 2015 @ 0431

Sorted By:

Date/Time (Descending)

VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team.

Date/Time: 14 Mar 2015 @ 0930

Note Title: COMP & PEN GENERAL MEDICAL EXAM

NORTH TEXAS HEALTH CARE SYSTEM - DALLAS DIVISION

KOKEL,JIM S KOKEL,JIM S

Location: Signed By:

Co-signed By:

Date/Time Signed: 14 Mar 2015 @ 0940

LOCAL TITLE: COMP & PEN GENERAL MEDICAL EXAM STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: MAR 14, 2015@09:30 ENTRY DATE: MAR 14, 2015@09:40:43 AUTHOR: EXP COSIGNER:

URGENCY: STATUS: COMPLETED

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

CONFIDENTIAL Page 5 of 134

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:

vbms

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

[ ] Lumbosacral strain

[X] 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: lDDD and facet DJD Date of diagnosis: increase sc

2. Medical history

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

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

initiall hurt l-s on patrol in afganistan in a fire fight. he has had 2 facet injections and helped x 2 weeks only. sch for ablation 3-27-15. chiropractic therapy did not help.

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No

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

own words:

lbp every day and constant. pains are usually sharp, averages 7,

can

CONFIDENTIAL Page 6 of 134

go higher earlier in am and cant put on socks. agggrevated by sitting

long periods, walking, standing, sex. no pains in legs, no numbnes in legs. wears a back brace. no surgery. compared to military to now

it

is now about 60 % worse. pains are alot more freq/worse, cant do things like he used to do. affects his sleep.

c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [ ] Yes [X] No

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 40 degrees

Extension (0 to 30): 0 to 5 degrees

Right Lateral Flexion (0 to 30): 0 to 15 degrees

Left Lateral Flexion (0 to 30): 0 to 15 degrees

Right Lateral Rotation (0 to 30): 0 to 20 degrees

Left Lateral Rotation (0 to 30): 0 to 20 degrees

If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No

If yes, please explain: pains with rom

Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine

(back)?

[ ] Yes [X] No

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? [X] Yes [ ] No

CONFIDENTIAL Page 7 of 134

Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

d. Flare-ups

Is the exam being conducted during a flare-up? [ ] Yes [X] No

Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [ ] Yes [X] No

f. Additional factors contributing to disability No response provided

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: [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

CONFIDENTIAL Page 8 of 134

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

Foot/toes (L5):

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

7. Straight leg raising test

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

Provide straight leg raising test results:

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

8. Radiculopathy

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

Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?

CONFIDENTIAL Page 9 of 134

[ ] Yes [X] No

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

If yes, identify assistive device(s) used (check all that apply and indicate frequency):

Assistive Device: Frequency of use:

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

[X] Brace(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:

No response provided.

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,

CONFIDENTIAL Page 10 of 134

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? [ ] 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

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: manual

17. Remarks, if any:

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

No remarks provided.

Thanks!

Edited by Navy4life (see edit history)
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115 is total range of motion combined which equals a 20% rating per regulation. Also exam states that back disability effects employment which is good evidence for tdiu consideration. JMHO..

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Hi everyone :biggrin: I requested for a increase in about 8 contentions that are currently service connected from 0% to 30% per, a couple of weeks ago i had a C&P that i thought was the best i ever had by far.. I also asked for TDIU, the C&P exam notes were on ebene's for the past weeks and i have tried my best to pick it apart but i am a Rookie Monster and would like some help. Special inquiry to my TDIU? The Dr. per C&P Medical opinion section makes a statement that after all the comments made in my favor per condition. :ohmy: For example i will put a bit of the exam notes that show impact, its not all, but some conditions

14. Functional impact
---------------------
Regardless of the Veteran's current employment status, do the condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[X] Yes [ ] No
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:
"I can not lift and stand up or sit down for prolonged period of
time". On top of it he has major issues with significant chronic
headache condition.
Now here is my question .. for TDIU.. i think it does not look good, but why after several "yes it impacts employability"
His primarily condition for which he decided to quit working 28 months ago
as a Computer Technician is chronic frequent headaches which he states also
affected his ability to concentrate. His chronic constant back and chronic
bilateral knees have affected his ability on weight bearing activitiees
including prolonged standing/walking and sometimes driving due to pain on
his
left knee.
The current headache frequency although is relatively is still frequent
2-3X/week from 3-5X/week with current medications his headache seems to be
easily alleviated by the prescribed acute medication of
Bultalbital/Naproxen.
He is also bothered by the decreased concentration on the job due to
headaches.
His musculoskeletal joint conditions which include lower back and bilateral
knee pains affects his ability to travel, prolonged standing and walking.
Although still chronic, he has regular medications of Motrin 800mg BID to
decreased its intensity.
Without question at this time, that his impairment affects his ability to do
any job which requires a lot of physical activities.
At this time, with all his current conditions mentioned & considered above,
it doesn't preclude him from doing any sedentary type of work.
I will be willing to post the whole:
LOCAL TITLE: COMPENSATION AND PENSION EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
Just let me know everyone that views this
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Valhalla0321

Not that my opinion is worth spit, but it seems to me that the examiner thinks that inspite of near daily headaches, and back pain/knee pain, you can do a sitdown job. Hmmm, I can't ever recall having a headache that felt better the more I concentrated on paperwork or computer screens. Seems the examiner is shortshifting your claim.

Semper Fi.

Andy

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