So I went to my C&P exam for my back a couple weeks back. I injured my back in two spots (upper back around my chest and lower back with pain radiating down the leg) in Iraq March 2009 moving a Mk19 off of a gun truck, was seen at the TMC with a vague diagnosis of "backache." I was on a small FOB without MRI or diagnostic machines so I was on profile for a couple weeks then returned to duty. I initially put a claim in for my back in 2009 after returning home from Iraq but missed my exam so I tried to claim it again in 2011 but the va didn't schedule a C&P exam for my back and then denied me saying there was no evidence of my back having any problems; I appealed it until it somehow disappeared off ebenefits so I put a new claim in earlier this year. I went to the C&P exam and the rater focused on specific points and completely ignored other points, including my chief complaint. She totally ignored the lower back pain and radiation down my legs and said my injury was solely to the middle back, and said that I had only complained about this since 2012 after I got my MRI (had to beg my PCP for 3 years, he kept ordering xrays which showed nothing), despite several primary care, physical therapy, MRI's showing degenerative changes visits specifically for my lower back from 2009 to current. This is what it showed in the blue button, some edits for privacy and key points are bolded:
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXX
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?
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[X] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[X] Other:
lay note from XXXXXXXXXXXX
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:
No response provided.
Diagnosis #1: lumbar strain
ICD code: 847.9
Date of diagnosis: 2009
Diagnosis #2: lumbar djd
ICD code: 847.2
Date of diagnosis: 2012
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
The veteran is here for evaluation for possible compensation for his
lumbar condition. He has some new information since the last time that he
was in for this same condition. He injured his mid-back in service in
2009, while deployed. He was lifting a machine gun system into a truck,
when he suddenly felt sharp, intense pain in his mid-back and around to
the front of his chest (she totally ignored my explanation of the lower back pain occurring at the same time). He found that it was hard to breathe. He was able
to finish his work duty, but then was seen for these symptoms a short
time
later. There is a note from 3/19/09, which is a copy of a note stating
that this veteran has back and chest pain and needs to be on light duty.
The veteran states that he was on light duty for 2-3 weeks. He was given
some flexeril for muscle spasms. There are no other notes in this
veteran's STRs concerning this incident. He does now have a note from a
friend, SGT xxxxxxxxxxxx, stating that he was there when this veteran
lifted the machine gun into the truck and he could see how much the
veteran was in pain at the time. The veteran was not seen again for his
back pain during his deployment. He went back to Guard duty and then back
to school. He states that he has continued to have constant back pain,
but
now describes it as lumbar pain. He was seen by his private provider in
2012 for this condition and had an MRI lumbar done in 2012 (I was seen by the VA primary care provider several times from 2009 until 2012 and several times after and she states it was just in 2012). This MRI
lumbar showed mild DJD changes and mild bilaeral neruoforaminal
stenosis.
He was treated with physical therapy, which didn't help much. He states
that he has flare ups about once a year (I said I had flare ups at least once a year, generally going several times for the condition to the VA), depending on his activities. He
has a baseline of pain at a level of 4-5 out of 10. He had left
testicular
pain in 2012 (I had testicular pain from sciatica in november 2009, just a couple days after returning home from Iraq, and she incorrectly put it as occurring in 2012), which is when he had the MRI lumbar done and this pain was
attributed to sciatica. The testicular pain has not continued, but he
does
have some pain in the buttocks at times, with numbness going into the
great toes, right greater than left. He also noted that he can't lift his
right leg up as far as he can the left leg, when standing. He takes
medication every day for his back pain.
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:
about once a year, sudden increase in pain, in bed for 3 days and
lighter activities for up to two weeks
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.
He states that he can't lift as much as he used to and he can't bend
forward as far as he used to.
3. Range of motion (ROM) and functional limitation
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?
[X] Yes [ ] 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):
MRI lumbar 2012
mild degenerative changes, especially at L4-5, and mild bilateral
neuroforaminal stenoses
16. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or her
ability to work?
[ ] Yes [X] No
17. Remarks, if any:
--------------------
The veteran had back pain during his deployment in March, 2009, but this
pain
is described by the veteran as mid-back and wrapping around the chest,
causing difficulty breathing. This is a different pain than what he has had
since that time and for which he has been seen for and received physical
therapy. (again, totally ignored what I said or the years of being seen at the VA for lower back pain starting just days after returning home from deployment)
(not including Diabetic Sensory-Motor Peripheral Neuropathy)
Disability Benefits Questionnaire
Name of patient/Veteran: Lars Gerhardt Reichenbach
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?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
If no, check all records reviewed:
[X] Military service treatment records
[X] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[X] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[X] Other:
lay note from SGT Curtis Bortle
1. Diagnosis
------------
Does the Veteran have a peripheral nerve condition or peripheral neuropathy?
[X] Yes [ ] No
Diagnosis #1: sciatica
ICD code: 353.9
Date of diagnosis: 2012
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
peripheral nerve condition (brief summary):
The veteran is here for evaluation for possible compensation for his
sciatica. He is also here at this time for evaluation for possible
compensation for his lumbar back condition. He has had some pain, which
came on suddenly in 2012, in which his left side of his testicle was
very painful. (Again, this occurred in 2009 about a week after returning home from Iraq and she put the wrong date) He was evaluated and this pain was attributable to
sciatica. He had an MRI lumbar done in 2012, which showed mild
degenerative changes in L4-5 and mild bilateral neruoforaminal
stenoses.
He was treated with physical therapy in 2012, which he states did not
help much. He no longer has any testicular pain, but has had buttock
pain and numbness in his great toes, greater on the right than on the
left. He has no loss of strength in his legs or feet.
b. Dominant hand
[X] Right [ ] Left [ ] Ambidextrous
3. Symptoms
-----------
a. Does the Veteran have any symptoms attributable to any peripheral nerve
conditions?
[X] Yes [ ] No
Constant pain (may be excruciating at times)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Intermittent pain (usually dull)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Numbness
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
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
Question
docbach
So I went to my C&P exam for my back a couple weeks back. I injured my back in two spots (upper back around my chest and lower back with pain radiating down the leg) in Iraq March 2009 moving a Mk19 off of a gun truck, was seen at the TMC with a vague diagnosis of "backache." I was on a small FOB without MRI or diagnostic machines so I was on profile for a couple weeks then returned to duty. I initially put a claim in for my back in 2009 after returning home from Iraq but missed my exam so I tried to claim it again in 2011 but the va didn't schedule a C&P exam for my back and then denied me saying there was no evidence of my back having any problems; I appealed it until it somehow disappeared off ebenefits so I put a new claim in earlier this year. I went to the C&P exam and the rater focused on specific points and completely ignored other points, including my chief complaint. She totally ignored the lower back pain and radiation down my legs and said my injury was solely to the middle back, and said that I had only complained about this since 2012 after I got my MRI (had to beg my PCP for 3 years, he kept ordering xrays which showed nothing), despite several primary care, physical therapy, MRI's showing degenerative changes visits specifically for my lower back from 2009 to current. This is what it showed in the blue button, some edits for privacy and key points are bolded:
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