Back condition as secondary, DBQ

Jeromy · May 21, 2018

All,

I had my C&P for my back the other day, here is my DBQ. Looking at the examiners notes, he is basically saying, "Yeah, since there is not a noted limp or impaired gait, the fact your were overweight but lost 100lbs., you're knee isn't the cause of your back problems." The doctor puts some medical articles to back up his own theory and opinion do actually persuade a coming denial for my claim. Take a look for yourself, would love the communities thoughts:

Note

LOCAL TITLE: C&P EXAMINATION NOTE

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: MAY 17, 2018@08:00 ENTRY DATE: MAY 17, 2018@14:32:21

AUTHOR: DYE,JAMES C EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Back (Thoracolumbar Spine) 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)

[X] CPRS

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: degenerative arthritis with facet arthropathy L4-L5,

L5-S1

ICD code: M47.817

Date of diagnosis: 8/01/2014

2. Medical history

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

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

thoracolumbar spine (back) condition (brief summary):

The Veteran states he developed back pain while in the military prior to

injuring his right knee. He provides a copy of his STR from 11/20/2003

which show acute onset of idiopathic (non-traumatic) low back pain. The

note states he had decreased ROM of the back with mild parapsinal

tenderness. He was treated medically and seen again on 12/01/2003, and

the medical information provided shows full resolution of a thoracic

muscle sprain which had occurred 10 days prior according to the records

provided. A normal exam was noted and the note states he was returned to

full duty with complete resolution of the injury.

The Veteran then injured right knee in 2005 which lead to a medical

discharge on 5/10/2006. The MEB does not mention a back condition at that

time. A review of the C&P examination performed on 7/24/2006 near the

time

of discharge noted the history of a thoracic muscle sprain, but notes the

spine was completely normal on exam and the veteran had NO complaint of

back pain. Thoracic and lumboscaral xrays of the spine performed on

7/20/2006 were compltely normal at that time. The Veteran's knee

condition was noted and his gait was noted to be normal.

The Veteran states today he continued with low back pain which he

self-treated and did not require addititonal medical attention until

2014.

The Veteran sought medical attention for his lower back during his first

PCP visit at the Hunter Holmes McGuire VAMC on 08/01/2014 stating the

back

pain worsened due to moving and lifting heavy boxes a few months prior.

At

that time the Veteran also weighed nearly 300 pounds and had a BMI of 40

on 8/01/2014.

His gait was noted to be normal.

Records multiple medical visits to the Castle Point VAMC for his ongoing

right knee pain years earlier, but no mention of a back condition. An

orthopedic evaluation on 2008 noted the ongoing right knee condition but

a

normal gait and no back condition was recorded.

The Veteran had a BMI of 40 on 08/01/2014. He went on a diet and lost

100

pounds over 2-3 years. His current BMI in approximately 30. He is a

non-smoker. He drinks alcohol about about 5-6 beers on about 3-4 times

weekly. He currently works at Fort Lee as a academic counselor, which is

a

seated non-stenous job, although prolonged sitting will aggravate his

lower back.

Currently, he is having a flair of low back pain which started 5/3/2018

and he was evaluated on 5/04/2018 by his PCP at the Hunter Holmes McGuire

VAMC. He had been physically acitve prior to the onset of worsening back

pain without any specific injury or changes in the activity before the

pain decveloped by his rpeort. The PCP noted he had been participating in

kick boxing according to the PCP note, but the Veteran states the kick

boxing is non-combative and does not involve hitting but is more of a

movement exercise, but states he did not injure himself.

The Veteran appears very stiff and guarded with his back and prefers to

stand during the interview. he has difficulty moving about the exam table

due to low back pain, however on exal the lumbosacral muscles are flaccid

without spasm or tension, although it is painful to gently palpate the

lower lumbar muscles. The thoracic muscles are neither tender not tight.

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:

The Veteran is currently have a flair with increased pain and

decreased movement of the lower back. He reports 2 such flairs over

the last year and will typically last 7-10 days, although currenlty

the symptoms have been present for 2 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.

The Veteran reports limiting his lifting to less than 15 pounds. He

does not sit longer than a few minutes before trying to change

position. He limits bending forward to pick up objects from the

floor. He states he limits his exercises to stretching and gentle

movements

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 18 degrees

Right Lateral Flexion (0 to 30): 0 to 14 degrees

Left Lateral Flexion (0 to 30): 0 to 12 degrees

Right Lateral Rotation (0 to 30): 0 to 24 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:

limited forward motion of lower back inhibit usual movments like

bending forward to pick up objects

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, Left Lateral Flexion, 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 join

ts or associated soft tissue of the thoracolumbar spine (back)?

[X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

tender lower lumbar muscle to light tough, but muscles without spasm

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? [X] Yes [ ] No

Select all factors that cause this functional loss:

Pain

ROM after 3 repetitions:

Forward Flexion (0 to 90): 0 to 15 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 24 degrees

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

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:

[ ] 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.

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

Able to describe in terms of range of motion: [ ] Yes [X] No

If no, please describe:

The Veteran states there is more pain and less function when the

joint is used over times repeatedly or during flair, but since

those conditions are not currently present to examine any further

estimation of ROM other than what is documented would be pure

estimation.

d. Flare-ups

Is the exam being conducted during a flare-up? [X] Yes [ ] No

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

Able to describe in terms of range of motion: [X] Yes [ ] No

Forward Flexion (0 to 90): 0 to 15 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 24 degrees

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

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

In addition to those addressed above, are there additional contributing

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

Less movement than normal due to ankylosis, adhesions, etc.,

Disturbance

of locomotion, Interference with sitting

Please describe additional contributing factors of disability:

prolonged sitting and walking will worsen lower back pain

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: