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Question
fiasco2g
Hello. I went for my fibromyalgia C&P exam and just got the results from myhealthvet. It looks like it was several DBQ's including my back now. Can someone explain these results. I only see one error which is my pain is refractory to medicine. They have my pain is constant but then state NO to the refractory to medicine question. But anyways what do you guys think. IT IS LONG. Sorry. Attached & pasted
MHV Fibro.docx
CONFIDENTIAL Page 4 of 31
VA Notes
Source:
VA
Last Updated:
30 Jan 2017 @ 1321
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:
18 Jan 2017 @ 0800
Note Title:
C&P GENERAL MEDICAL - AMIE/CAPRI
Location:
Fayetteville NC VAMC
Signed By:
Co-signed By:
Date/Time Signed:
25 Jan 2017 @ 1740
Note
LOCAL TITLE: C&P GENERAL MEDICAL - AMIE/CAPRI STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JAN 18, 2017@08:00 ENTRY DATE: JAN 25, 2017@17:40:38 AUTHOR: EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Gulf War General Medical Examination Disability Benefits Questionnaire
* Internal VA or DoD Use Only* Name of patient/Veteran:
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA) [X] CPRS
[X] Other (please identify other evidence reviewed): JLV
Evidence Comments: Branch Army
DD214 EAD 6//3/98 RAD 9/5/2005
CONFIDENTIAL Page 5 of 31
Rank SGT E5
Served in Iraq 06/18/04-05/28/05
Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport.
6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and
low
back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia
2. Medical History
------------------
a. No symptoms, abnormal findings or complaints: No answer provided
b. Skin and scars: No answer provided
c. Hematologic/lymphatic: No answer provided
d. Eye: No answer provided
e. Hearing loss, tinnitus and ear: No answer provided
f. Sinus, nose, throat, dental and oral: No answer provided
g. Breast: No answer provided
h. Respiratory: No answer provided
i. Cardiovascular: No answer provided
j. Digestive and abdominal wall: No answer provided
k. Kidney and urinary tract: No answer provided
l. Reproductive: No answer provided
m. Musculoskeletal: The following conditions have been reported Spine: Back (Thoracolumbar Spine) Conditions
Miscellaneous musculoskeletal: Fibromyalgia
CONFIDENTIAL Page 6 of 31
n. Endocrine: No answer provided
o. Neurologic: No answer provided
p. Psychiatric: No answer provided
q. Infectious disease, immune disorder or nutritional deficiency: No answer
provided
r. Miscellaneous conditions: No answer provided
3. Diagnosed illnesses with no etiology
---------------------------------------
From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established?
[X] Yes [ ] No
Diagnosis #1: Fibromyalgia ICD code: M79.7
Date of diagnosis: approx. 2007
Name of Questionnaire: DBQ Neuro Fibromyalgia
4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic
multisymptom illness"
-----------------------------------------------------------------------------
Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections?
[ ] Yes [X] No
5. Physical Exam
----------------
Normal PE, except as noted on additional Questionnaires included as part of this
report
6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically
unexplained chronic multisymptom illness"
----------------------------------------------------------------------------- [ ] Yes [X] No
7. Remarks, if any:
-------------------
CONFIDENTIAL Page 7 of 31
The E-VBMs, CPRS, JlV, Veteran's history and documents carried in by the
patient were all reviewed and carefully considered during this exam.
Diagnosis: 1. Fibromyalgia, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology.
**************************************************************************
The examination was initiated and completed by provider Debra Barton FNP, and
administratively reviewed and closed by clinical lead Dr. June Roberts.
**************************************************************************** Fibromyalgia
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA) [X] CPRS
[X] Other (please identify other evidence reviewed): JLV
CONFIDENTIAL Page 8 of 31
Evidence Comments: Branch Army
DD214 EAD 6//3/98 RAD 9/5/2005
Rank SGT E5
Served in Iraq 06/18/04-05/28/05
Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport.
6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and
low
back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested)
[X] Yes [ ] No
[X] Fibromyalgia
ICD code: M79.7
Date of diagnosis: approx. 2007
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition:
The Veteran has a history of active military service in the United States Army highest rank E5 and a
Admits to service in Iraq 6/18/04-5/28/05. He presents for
Gulf War Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire.
He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness).
Veteran reports he has had diffuse pain throughout his
"joints" and
CONFIDENTIAL Page 9 of 31
other locations since he got out of the military. He has had X-rays of the wrist, ankle, knees and back to evaluate for degenerative an
inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia.
b. Is continuous medication required for control of fibr omyalgia symptoms?
[X] Yes [ ] No
If yes, list only those medications required for the Veteran's fibromyalgia condition:
Gabapentin
c. Is the Veteran currently undergoing treatment for this condition? [X] Yes [ ] No
If yes, describe:
He has been advised on a exercise program and search into a biofeedback program.
d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [ ] Yes [X] No
3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia?
[X] Yes [ ] No
a. Findings, signs and symptoms (check all that apply): [X] Widespread musculoskeletal pain
[X] Stiffness
[X] Sleep disturbances [X] Paresthesias
[X] Headache [X] Depression
For all checked conditions, describe:
Veteran has had a sleep study and has milds OSA, sleep efficiency was 70%. He has headaches bitemporal that may be associated with his
sinus
issues. He has parathesias when he tries to sleep. He has been diagnosed with PTSD.
b. Frequency of fibromyalgia symptoms (check all that apply): [X] Constant or nearly constant
CONFIDENTIAL Page 10 of 31
[X] Often precipitated by environmental or emotional stress or overexertion
If checked, describe:
Overexertion and extreme cold will exacerbate his symptoms.
c. Does the Veteran have tender points (trigger points) for pain present? [X] Yes [ ] No
[X] All bilaterally
[X] Low cervical region: at anterior aspect of the interspaces between transverse processes of C5-C7
If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Second rib: at second costochondral junction If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Occiput: at suboccipital muscle insertion If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Trapezius muscle: midpoint of upper border If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Supraspinatus muscle: above medial border of the scapular spine If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Lateral epicondyle: 2 cm distal to lateral epicondyle If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Gluteal: at upper outer quadrant of buttocks If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Greater trochanter: posterior to greater trochanteric prominence If checked, indicate side:
[ ] Right [ ] Left [X] Both
[X] Knee: medial joint line
If checked, indicate side:
[ ] Right [ ] Left [X] Both
4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars
CONFIDENTIAL Page 11 of 31
-----------------------------------------------------------------------
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
5. Diagnostic testing
---------------------
Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No
6. Functional impact
---------------------
Does the Veteran's fibromyalgia impact his or her ability to work? [X] Yes [ ] No
If yes, describe impact of the Veteran's fibromyalgia, providing one
or
more examples:
Veteran is not able to climb stairs, descend stairs or bend (squat) repeatedly and has to ask others to cover those tasks for him. He is not able to do repetitive task or he starts hurting and has to stop.
The Veteran is unable to participate in heavy physical prolonged labor. The Fibromyalgia does not preclude participation in sedentary employment.
7. Remarks, if any:
-------------------
The examination was initiated and completed by provider DEBRA BARTON AND REVIEWED BY DESL LEAD AND CLOSED.
****************************************************************************
Non-degenerative Arthritis (including inflammatory, autoimmune crystalline and infectious arthritis) and dysbaric osteonecrosis
Disability Benefits Questionnaire Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination
Request?
[X] Yes [ ] No
CONFIDENTIAL Page 12 of 31
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA) [X] CPRS
[X] Other (please identify other evidence reviewed): JLV
Evidence Comments: Branch Army
DD214 EAD 6//3/98 RAD 9/5/2005
Rank SGT E5
Served in Iraq 06/18/04-05/28/05
Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport.
6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and
low
back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia
1. Diagnosis
------------
a. List the claimed condition(s) that pertain to this DBQ: chronic multi-symptom illness(pain throughout his body)
b. Select diagnoses associated with the claimed condition(s): No response provided
CONFIDENTIAL Page 13 of 31
c. Comments (if any):
Diagnosis Degenerative Disc Disease Lumbar Spine L5/S1 date of diagnosis 6/6/2016 ICD 10 M43.06
d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's inflammatory, autoimmune, crystalline or infectious arthritis or Dysbaric Osteonecrosis. (brief summary)
The Veteran has a history of active military service in the United States Army highest rank E5 Admits to service in Iraq 6/18/04-5/28/05. He presents for a Gulf War
Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire.
He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness).
Veteran reports he has had diffuse pain throughout his "joints" and other
locations since he got out of the military. He has had X-rays of the
wrist, ankle, knees and back to evaluate for degenerative an inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia. Review of the radiographs of the wrist,
ankle, and knees showed no osseus abnormality. The lumbar spine showe mild
L5-S1 disc disease.
b. Does the Veteran require continuous use of medication for the arthritis condition?
[ ] Yes [X] No
c. Has the Veteran lost weight due to arthritis condition? [ ] Yes [X] No
d. Does the Veteran have anemia due to the arthritis condition? [ ] Yes [X] No
3. Joint Involvement
--------------------
a. Does the Veteran have pain (with or without joint movement) attributable to this arthritis condition? [X] Yes [ ] No
If yes, indicate affected joints
[ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint
CONFIDENTIAL Page 14 of 31
For all checked joints, describe involvement: Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He
started
complaining of low back pain and pain in some of his other joints. In 2007
he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC.
b. Does the Veteran have any limitation of joint movement attributable to the arthritis condition? [X] Yes [ ] No
If yes, indicate affected joints
[ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint
For all checked joints describe limitation of movement: The Veteran has problems with back flexion, extension, RL bending and LL bending.
c. Does the Veteran have any joint deformities attributable to the arthritis condition? [ ] Yes [X] No
d. Comments No response provided
4. Systemic involvement other than joints
-----------------------------------------
a. Does the Veteran have any involvement of any systems, other than joints, attributable to this arthritis condition? [ ] Yes [X] No
b. Comments: No response provided
5. Incapacitating and non-incapacitating exacerbations
------------------------------------------------------
a. Due to the arthritis condition, does the Veteran have exacerbations which are not incapacitating? [ ] Yes [X] No
b. Due to the arthritis condition, does the Veteran have exacerbations which are incapacitating? [X] Yes [ ] No
If yes, indicate frequency of incapacitating exacerbations per year (on average):
[ ] 0 [ ] 1 [X] 2 [ ] 3 [ ] 4 or more
Indicate the total duration of incapacitation over the past 12 months: [X] < 1 week
[ ] 1 week to < 2 weeks [ ] 2 weeks to < 4 weeks [ ] 4 weeks to < 6 weeks [ ] 6 weeks or more
Date of most recent incapacitating exacerbation: approx. 11/2016
CONFIDENTIAL Page 15 of 31
Duration of most recent incapacitating exacerbation: less than one day
Describe incapacitating exacerbation:
Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10 on a 0-10 scale.
c. Is the Veteran's arthritis manifested by constitutional manifestations associated with active joint involvement which are totally incapacitating? [ ] Yes [X] No
d. Is the Veteran's arthritis manifested by weight loss and anemia productive
of severe impairment of health? [ ] Yes [X] No
e. Is the Veteran's arthritis manifested by severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods? [ ] Yes [X] No
f. Is the Veteran's arthritis manifested by symptoms combinations productive of
definite impairment of health objectively supported by examination findings?
[ ] Yes [X] No
g. Comments: No response provided
6. 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
7. 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? [ ] Yes [X] No
b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response
provided
CONFIDENTIAL Page 16 of 31
8. Remaining effective function of the extremities
--------------------------------------------------
Due to the Veteran's arthritis condition, is there functional impairment
of
an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions
for
the lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran.
[X] No
9. Diagnostic testing
---------------------
a. Have imaging studies been performed and are the results available? [X] Yes [ ] No
[X] X-ray
Area(s) imaged: Lumbar spine Date: 6/6/2016
Results: L5-S1 degenerative disc diseae
b. Have laboratory studies been performed? [X] Yes [ ] No If yes, check all that apply:
[X] Erythrocyte sedimentation rate (ESR) Date of test: 6/2/16
Results: 3
[X] C-reactive protein Date of test: 6/2/16 Results: < 2.9
[X] Rheumatoid factor (RF) Date of test: 9/19/13 Results: <10
[X] CBC
Date of test: 6/2/16 Hemoglobin: 14.5
Hematocrit: 41.2
White blood cell count: 5.69 Platelets: 243
[X] Other, specify: CCP IgG Ab Date of test: 6/2/16 Results: <16
c. Has the Veteran had a joint aspiration or synovial fluid analysis? [ ] Yes [X] No
d. Has the Veteran had a biopsy (e.g., skin, nerve, fat, rectum, kidney)? [ ] Yes [X] No
CONFIDENTIAL Page 17 of 31
e. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No
f. If any test results are other than normal, indicate relationship of abnormal
findings to diagnosed conditions:
Report: Lumbosacral spine
Clinical data: pain Comparison: none.
Findings: Alignment: Normal. Vertebral bodies: Normal. Intervertebral disc spaces: Mild narrowing L5-S1. Facet Joints: Normal. Soft Tissues: Normal. Other:
Impression:
1. Mild L5-S1 disc disease.
Veteran has Degenerative disc disease, not a Rheumatic disease. The Veteran has palpable spasms of the lumbar spine which correlates to the degenerative changes on the lumbar spine x-ray.
10. 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
If yes, describe the functional impact of each condition, providing one or more examples:
Veteran is unable to lift more than 30 lbs. He can't sit or stand
for
extended periods of time. He is unable to participate in prolonge heavy physical labor. The diagnosed lumbar spine condition does not preclude participation in sedentary employment.
11. Remarks, if any:
--------------------
Veteran has degenerative arthritic conditions and Fibromyalgia; not inflammatory arthritic conditions.
**************************************************************************** Back (Thoracolumbar Spine) Conditions
CONFIDENTIAL Page 18 of 31
Disability Benefits Questionnaire Name of patient/Veteran
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA) [X] CPRS
[X] Other (please identify other evidence reviewed): JLV
Evidence Comments: Branch Army
DD214 EAD 6//3/98 RAD 9/5/2005
Rank SGT E5
Served in Iraq 06/18/04-05/28/05
Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport.
6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and
low
back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia
CONFIDENTIAL Page 19 of 31
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: Degenerative disc disease L5-S1 ICD code: M43.06
Date of diagnosis: 6/6/2016
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary):
Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He started complaining of low back pain and pain in some of his other joints.
In 2007 he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC. There he was evaluated and diagnosed with fibromyalgia and degenerative joint/disc disease of the low back and it was opined that it was related
to his service experience. However, the Veteran does not recall the diagnosis or any follow-up. He has complained of the low back pain and chronic polyarthralgias since enrolling at the FVAMC in September of 2013.
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:
Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10
CONFIDENTIAL Page 20 of 31
on a 0-10 scale.
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 does not lift over 30 pounds. He does not play sports or enjoy things with his children as his back will act up. He is unable to ride in a car for a long period of time without his back flaring up.
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 70 degrees
Extension (0 to 30): 0 to 25 degrees
Right Lateral Flexion (0 to 30): 0 to 25 degrees
Left Lateral Flexion (0 to 30): 0 to 25 degrees
Right Lateral Rotation (0 to 30): 0 to 30 degrees
Left Lateral Rotation (0 to 30): 0 to 25 degrees
If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No
If yes, please explain:
Veteran is unable to lift more than 30 lbs.
Description of pain (select best response):
Pain noted on exam but does not result in/cause functional loss
If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion
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)?
[X] Yes [ ] No
If yes, describe including location, severity and relationship to condition(s):
Veteran has spasm in the lumbosacral area that is tender.
CONFIDENTIAL Page 21 of 31
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:
[X] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time.
[ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain.
[ ] The examination is neither medically consistent or inconsistent with 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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
ability over
Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe:
Pain and or endurance are limiting the Veteran's functional
without repeated use over time. Based on the clinical exam today and the Veteran's statements it is plausible to concur that
time he would be more limited. I am not able to determine actual degrees of decreased ROM however.
d. Flare-ups
Is the exam being conducted during a flare-up? [ ] Yes [X] No
CONFIDENTIAL Page 22 of 31
If the examination is not being conducted during a flare-up: [X] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain.
[ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss
during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Weakness, Lack of endurance
Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe:
Pain, weakness and or endurance are limiting the Veteran's functional ability without being in a flare-up. Based on the clinical exam today and the Veteran's statements it is
plausible to
concur that during a flare-up he would be more limited. I am not able to determine actual degrees of decreased ROM however.
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:
Musle spasm present in the lumbosacral paraspinals related to the way the Veteran hols his back.
Guarding: [ ] 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:
Guarding of the lower back that results in muscle spasm.
CONFIDENTIAL Page 23 of 31
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: Interference with sitting, Interference with standing
Please describe additional contributing factors of disability: Veteran is not able to sit or stand for extended periods of time without experiencing more pain and spasms.
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
CONFIDENTIAL Page 24 of 31
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: [X] Negative [ ] 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?
[ ] Yes [X] No
9. Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No
10. Other neurologic abnormalities
CONFIDENTIAL Page 25 of 31
----------------------------------
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?
[ ] Yes [X] No
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, 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
CONFIDENTIAL Page 26 of 31
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? [ ] 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: Veteran is unable to lift more than 30 lbs. He can't sit or
stand
for extended periods of time. He can otherwise perform his job duties.
17. Remarks, if any:
--------------------
There was a thorough review of E-BVMs, CPRS and JLV as well as a focused history from the Veteran regarding his Southwest Asia Service. The Veteran claimed an unexplained chronic multi-symptom illness of pain throughout his body which included low back pain. The low back bain is diagnosed as 1.
Degenerative Arthritis of the Spine. M43.06. It is a disease with a clear and specific etiology and diagnosis that is separate from the Fibromyalgia.
The Degenerative Arthritis of The Spine is at least as likely as not (50 % probability) that it is related to the Veteran's Military Service.
Rationale: The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by a Rehab specialist who opined the back problems were related to his military service. The Veteran did have negative x-rays at
that time, however in June of 2016 his X-ray is indicating degenerative changes of the lumbar spine. The Veteran reports job duty changes while
CONFIDENTIAL Page 27 of 31
serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details.
**************************************************************************** Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA) [X] CPRS
[X] Other (please identify other evidence reviewed): JLV
Evidence Comments: Branch Army
DD214 EAD 6//3/98 RAD 9/5/2005
Rank SGT E5
Served in Iraq 06/18/04-05/28/05
Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport.
6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and
low
back pain, examiner was of the opinion it was related to military service.
CONFIDENTIAL Page 28 of 31
10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: DBQ General Medical Gulf War:
Please review the Veteran's electronic folder in VBMS and state that it was
reviewed in your report.
Please examine and evaluate this Veteran with Southwest Asia service for any
chronic disability pattern. Please review the claims file as part of your evaluation and state that it was reviewed. The Veteran has claimed a disability pattern related to Medically unexplained chronic multi-symptom illness (pain throughout his body).
Please provide a medical statement explaining whether the Veteran's disability pattern is:
(1) an undiagnosed illness
(2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology
(3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or
(4) a disease with a clear and specific etiology and diagnosis.
If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (1) an undiagnosed
illness;
or (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, then no medical opinion or rationale is required as these conditions are presumed to be caused by service in the Southwest Asia theater of operations.
If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (3) a diagnosable
chronic
multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a
CONFIDENTIAL Page 29 of 31
medical opinion, with supporting rational, as to whether it is "at least as
likely as not" that the disability pattern or diagnosed disease is related
to a specific exposure event experienced by the Veteran during service in Southwest Asia.
POTENTIALLY RELEVANT EVIDENCE:
NOTE: Your (examiner) review of the record is NOT restricted to the evidence listed below. This list is provided in an effort to assist the examiner in locating potentially relevant evidence.
Tab D (Federal treatment record in VBMS): VETERAN PROVIDED HIS COPY OF TREATMENT FROM THE VA dated 12/04/2016
Tab B (Veteran's statement in VBMS): Veteran provided statement on how his
pain is reflected throughout his entire body. dated 12/04/2016
Tab A (DD Form 214 in VBMS): DD 214, Iraqi Campaign Medal noted dated 12/04/2016
Tab C (Federal treatment record in VBMS): CAPRI MEDICAL FROM THE DURHAM, FAYETTEVILLE, AND WILKES-BARRE VAMC dated 12/16/2016
Please direct any questions regarding this request to: Mike Theriot
8810 Rio San Diego Dr San Diego, CA 92108
Phone number: 6194005515 Email: mike.theriot@va.gov
b. Indicate type of exam for which opinion has been requested: DBQ FIBRO
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: The Veteran was diagnosed with Fibromyalgia in approximately 2007 after serving in SWA in 6/18/04-5/28/05. He underwent an extensive evaluation and inflammatory/other rheumatological disorders were ruled out. He meets the diagnostic criteria for fibromyalgia. It is not an undiagnosed illness. It is not a disease with a clear and specific etiology. However, it
CONFIDENTIAL Page 30 of 31
is a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. I am unable to state with any degree of certainty which environmental hazards could have caused the disease.
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Contention: medically unexplained chronic multisymptom illness ( pain through out his body)
b. Indicate type of exam for which opinion has been requested: DBQ ARTH/BACK
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: The contention of medically unexplained chronic multisymptom
illness ( pain through out his body) diagnosed as degenerative arthritis of the lumbar spine(also see fibromyalgia template).
The diagnosis of djd lumbar spine is not an undiagnosed illness, and is not a diagnosable but medically unexplained chronic multi-symptom illness of
unknown etiology, and did not result from exposure to environmental hazard due to service in SWA. The degerative arthritis of the lumbar spine has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of
helicopters. All of which could put increased stress on the lumbar spine, and
many of the exercises are carried out with rucks on you back. Thus opined as above.
************************************************************************* Contention: Lumbar Spine Condition due to active military service.
Medical Opinion:
It is as least as likely as not a 50/50% probability that the Veteran claimed
medically unexplained chronic multisymptom illness ( pain through out his body), diagnosed as degenerative disc disease lumbar spine was incurred in
or
resulted from active military service. Rationale:
The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by
CONFIDENTIAL Page 31 of 31
a Rehab specialist who opined the back problems were related to his military service. The Veteran reports job duty changes while serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details. The degerative arthritis of the lumbar spine
has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of helicopters. All of which could put increased stress on the lumbar spine,
and
many of the exercises are carried out with rucks on you back. Thus opined as above.
THIS DOCUMENT WAS ORIGINALLY INITIATED BY: BARTON,DEBRA A
/es/ June L ROBERTS MD
Signed: 01/25/2017 17:40
END OF MY HEALTHEVET PERSONAL INFORMATION REPORT
Edited by fiasco2gLink to comment
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Berta
The fibro seems to have 2 conflicting VA opinions. I hope others chime in on that. However this should trigger an award: "The Degenerative Arthritis of The Spine is at least as likely as not
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