degenerative arthritis Hip and Lumbar Back C&P Exam, would someone review and give me their thoughts?

mytime34 · March 14, 2017

Hello All,

I am a 41yr old disabled vet (70%)

Degenerative Arthritus of the left Knee 20%
Degenerative Arthritus of the Right knee 20%
Degenerative Disc Disease of the Lumbar Spine 10%
Radiculopathy Right Lower Extremity 10%
Radiculopathy Left Lower Extremity 10%
Degenerative Tears, Bilateral Knees 20%
Tinnitus 10%

This exam was scheduled 1 week after my back surgery (Fusion of L4/L5).

Hip and Thigh Conditions

Disability Benefits Questionnaire

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)

1. Diagnosis

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

a. List the claimed condition(s) that pertain to this DBQ: B/L HIP STRAIN

DX 9-16 SECONDARY TO LUMBAR SPINE COND.

b. Select diagnoses associated with the claimed condition(s) (Check all that

apply):

c. Comments (if any): No response provided

d. Was an opinion requested about this condition (internal VA only)? Yes

2. Medical history

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

a. Describe the history (including onset and course) of the Veteran's

hip or

thigh condition:

16 W/U DX AS ABOVE PAIN STANDING B/L MRI WNL. TX MEDS.

b. Does the Veteran report flare-ups of the hip or thigh? [ ] Yes [X] No

c. Does the Veteran report having any functional loss or functional

impairment of the joint or extremity being evaluated on this DBQ

(regardless of repetitive use)? [ ] Yes [X] No

3. Range of motion (ROM) and functional limitations

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

a. Initial range of motion

Right hip

---------

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Flexion (0-125): 0 to 90 degrees

Extension (0-30): 0 to 30 degrees

Abduction (0-45): 0 to 45 degrees

Adduction (0-25): 0 to 25 degrees

Is adduction limited such that the Veteran cannot cross legs?

[ ] Yes [X] No

External Rotation (0-60): 0 to 60 degrees

Internal Rotation (0-40): 0 to 40 degrees

If abnormal, does the range of motion itself contribute to a

functional

loss? [ ] Yes, (please explain) [X] No

Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on examination, which ROM exhibited pain (select all that

apply)?

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 joint or associated soft tissue? [X] Yes [ ] No

Is there objective evidence of crepitus? [ ] Yes [X] No

Left hip

--------

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Flexion (0-125): 0 to 90 degrees

Extension (0-30): 0 to 30 degrees

Abduction (0-45): 0 to 45 degrees

Adduction (0-25): 0 to 25 degrees

Is adduction limited such that the Veteran cannot cross legs?

[ ] Yes [X] No

External Rotation (0-60): 0 to 60 degrees

Internal Rotation (0-40): 0 to 40 degrees

If abnormal, does the range of motion itself contribute to a

functional

loss? [ ] Yes, (please explain) [X] No

Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on examination, which ROM exhibited pain (select all that

apply)?

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 joint or associated soft tissue? [ ] Yes [X] No

Is there objective evidence of crepitus? [ ] Yes [X] No

b. Observed repetitive use

Right hip

---------

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

Left hip

--------

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

Right hip

---------

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:

[ ] 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.

[X] The examination is neither medically consistent or inconsistent

with the Veteran?s statements describing functional loss with

repetitive use over time.

Left hip

--------

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:

[ ] 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.

[X] The examination is neither medically consistent or inconsistent

with the Veteran?s statements describing functional loss with

repetitive use over time.

d. Flare-ups: Not applicable

e. Additional factors contributing to disability

Right hip

---------

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe:

None

Left hip

--------

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe:

None

4. Muscle strength testing

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

a. Muscle strength - 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 so

me resistance

5/5 Normal strength

Right Hip

Rate Strength: Flexion: 5/5

Extension: 5/5

Abduction: 5/5

Is there a reduction in muscle strength? [ ] Yes [X] No

Left Hip

Rate Strength: Flexion: 5/5

Extension: 5/5

Abduction: 5/5

Is there a reduction in muscle strength? [ ] Yes [X] No

b. Does the Veteran have muscle atrophy? No response provided

c. Comments, if any: No response provided

5. Ankylosis

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

Complete this section if the Veteran has ankylosis of the hip.

a. Indicate severity of ankylosis and side affected

Right side: Left side:

[ ] Favorable, in flexion at [ ] Favorable, in flexion at

an angle between 20 and an angle between 20 and

40 degrees, and slight 40 degrees, and slight

abduction or adduction abduction or adduction

[ ] Intermediate, between [ ] Intermediate, between

favorable and unfavorable favorable and unfavorable

[ ] Unfavorable, extremely [ ] Unfavorable, extremely

unfavorable ankylosis, unfavorable ankylosis,

foot not reaching ground, foot not reaching ground,

crutches needed crutches needed

[X] No ankylosis [X] No ankylosis

b. Comments, if any: No response provided

6. Additional conditions

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

No response provided

7. Surgical procedures

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

No response provided

8. 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

9. Assistive devices

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

a. Does the Veteran use any assistive devices 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

10. Remaining effective function of the extremities

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

Due to the Veteran's hip or thigh conditions, 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

11. Diagnostic testing

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

a. Have imaging studies of the hip or thigh been performed and are the

results available? [ ] Yes [X] No

b. Are there any other significant diagnostic test findings or results? No

response provided

c. If any test results are other than normal, indicate relationship of

abnormal findings to diagnosed conditions: No response provided

12. 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.)?

[ ] Yes [X] No

13. Remarks, if any:

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

No response provided

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Back (Thoracolumbar Spine) Conditions

Disability Benefits Questionnaire

Name of patient/Veteran: PUGH

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)

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

[ ] Degenerative arthritis of the spine

[X] Intervertebral disc syndrome

[ ] Sacroiliac injury

[ ] Sacroiliac weakness

[ ] Segmental instability

[ ] Spinal fusion

[ ] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

Diagnosis #1: PO DISC FUSION LUMBAR 2-17

Date of diagnosis: 2-17

2. Medical history

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

a. Describe the history (including onset and course) of the Veteran's

thoracolumbar spine (back) condition (brief summary):

AS ABOVE, DONE DUE TO R SCIATICA ,DROP R FOOT.

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:

PAIN

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.

LESS MOTION

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 20 degrees

Extension (0 to 30): 0 to 10 degrees

Right Lateral Flexion (0 to 30): 0 to 10 degrees

Left Lateral Flexion (0 to 30): 0 to 10 degrees

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

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

Description of pain (select best response):

Pain noted on exam and causes functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Forward Flexion, Extension, Right Lateral Flexion, Left Lateral

Flexion, Right Lateral Rotation, Left Lateral Rotation

Is there evidence of pain with weight bearing? [X] Yes [ ] 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):

LUMBAR PAIN

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

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

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:

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

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: