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
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
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
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
US Navy Desert Storm Veteran Proudly served my Country!!!
Caluza Triangle – Caluza vs Brown defined what is necessary for service connection. See COVA– CALUZA V. BROWN–TOTAL RECALL
This has to be MEDICALLY Documented in your records:
Current Diagnosis. (No diagnosis, no Service Connection.)
In-Service Event or Aggravation.
Nexus (link- cause and effect- connection) or Doctor’s Statement close to: “The Veteran’s (current diagnosis) is at least as likely due to x Event in military service”
VA has gotten away with (mis) interpreting their ambigious, , vague regulations, then enforcing them willy nilly never in Veterans favor.
They justify all this to congress by calling themselves a "pro claimant Veteran friendly organization" who grants the benefit of the doubt to Veterans.
This is not true,
Proof:
About 80-90 percent of Veterans are initially denied by VA, pushing us into a massive backlog of appeals, or worse, sending impoverished Veterans "to the homeless streets" because when they cant work, they can not keep their home. I was one of those Veterans who they denied for a bogus reason: "Its been too long since military service". This is bogus because its not one of the criteria for service connection, but simply made up by VA. And, I was a homeless Vet, albeit a short time, mostly due to the kindness of strangers and friends.
Hadit would not be necessary if, indeed, VA gave Veterans the benefit of the doubt, and processed our claims efficiently and paid us promptly. The VA is broken.
A huge percentage (nearly 100 percent) of Veterans who do get 100 percent, do so only after lengthy appeals. I have answered questions for thousands of Veterans, and can only name ONE person who got their benefits correct on the first Regional Office decision. All of the rest of us pretty much had lengthy frustrating appeals, mostly having to appeal multiple multiple times like I did.
I wish I know how VA gets away with lying to congress about how "VA is a claimant friendly system, where the Veteran is given the benefit of the doubt". Then how come so many Veterans are homeless, and how come 22 Veterans take their life each day? Va likes to blame the Veterans, not their system.
However, (and I have no idea of knowing whether or not you would likely succeed) Im unsure of why you seem to be so adamant against getting an increase in disability compensation.
When I buy stuff, say at Kroger, or pay bills, I have never had anyone say, "Wait! Is this money from disability compensation, or did you earn it working at a regular job?" Not once. Thus, if you did get an increase, likely you would have no trouble paying this with the increase compensation.
However, there are many false rumors out there that suggest if you apply for an increase, the VA will reduce your benefits instead.
That rumor is false but I do hear people tell Veterans that a lot. There are strict rules VA has to reduce you and, NOT ONE of those rules have anything to do with applying for an increase.
Yes, the VA can reduce your benefits, but generally only when your condition has "actually improved" under ordinary conditions of life.
Unless you contacted the VA within 72 hours of your medical treatment, you may not be eligible for reimbursement, or at least that is how I read the link, I posted above. Here are SOME of the rules the VA must comply with in order to reduce your compensation benefits:
NOTE: TO PROVE CAUSE OF DEATH WILL LIKELY REQUIRE AN AUTOPSY. This means if you die of a SC condtion, your spouse would need to do an autopsy to prove cause of death to be from a SC condtiond. If you were P and T for 10 full years, then the cause of death may not matter so much.
Question
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
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
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 Navy4lifeUS Navy Desert Storm Veteran
Proudly served my Country!!!
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