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degenerative arthritis C/p Exam Complete For Back Increase
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Navy4life
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
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VA
Last Updated:
18 Mar 2015 @ 0431
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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
Co-signed By:
Date/Time Signed: 14 Mar 2015 @ 0940
LOCAL TITLE: COMP & PEN GENERAL MEDICAL EXAM STANDARD TITLE: C & P EXAMINATION NOTE
URGENCY: STATUS: COMPLETED
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:
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
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
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?
[ ] 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 Navy4lifeLink to comment
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