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megajunk

Please help me decipher this DBQ for Back (Thoracolumbar Spine) Conditions

Question

I recently (October 2018) made my first claim and was examined and rated @ 10% for Tinnitus.  Immediately afterwards, I received a letter from the VA stating that they had made an appointment for me for back pain that was from a claim in March of 2000.  (I left the USAF in January, 2000).  This is the result of that C&P exam.

I was also sent a letter about foot pain that I had claimed in 2000.  I ended up filling out more paperwork to explain condition, and sending in medical records from private doctors.  I believe that they combined the foot pain, and the back pain into one claim.

I cannot see anything on eBenefits regarding the status these claims since they are so old (that's what they told me). 

I am also soliciting opinions as to what the effective date for these claims would be.  

Please let me know what you think regarding this DBQ from a C&P exam:

Thank you VERY much!

    *************************************************************************
 LOCAL TITLE: COMPENSATION & PENSION EXAM                        
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE: DEC 21, 2018@09:30     ENTRY DATE: DEC 21, 2018@16:02:11                      
     URGENCY:                            STATUS: COMPLETED                     


                      Back (Thoracolumbar Spine) Conditions
                        Disability Benefits Questionnaire

    Name of patient/Veteran:   Xxxxxxxx XXXX
    
    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:  THORACOLUMBAR STRAIN.
          ICD code:  48532005
          Date of diagnosis:  Uncertain
          
    2. Medical history
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
    thoracolumbar spine (back) condition (brief summary):
       -- relates -- "I had to change really heavy parts in the bottom load of
       the air craft while I was in the military. They had these monorails but
       they didn't always work so we had to pick them up a lot of times. I can
       remember having back pain and having physical therapy in the Air Force 
and
       having to go to traction but that's all I can remember about what they
       did.  Since then I have always had back pain, upper and lower back. I 
have
       pain all the time, especially if I try to stand up for ten or more
       minutes. I can try to lean against something and put pressure and that
       seems to help. At night when I am sleeping it will wake me up with pain
       and I have to roll out of bed and walk around for a minute. I have just
       been living with the 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:
           see History
           

    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.
           see History
           

    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 60 degrees
           Extension (0 to 30):                 0 to 30 degrees
           Right Lateral Flexion (0 to 30):     0 to 30 degrees
           Left Lateral Flexion (0 to 30):      0 to 30 degrees
           Right Lateral Rotation (0 to 30):    0 to 30 degrees
           Left Lateral Rotation (0 to 30):     0 to 30 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 exam, which ROM exhibited pain (select all that apply)?
           Forward Flexion
           
       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)?
       [ ] 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?
       [ ] 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?
       [ ] Yes   [ ] No   [X] Unable to say w/o mere speculation
           If unable to say w/o mere speculation, please explain:

           Exam was not conducted under stated condition
           
           

    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: [ ] Yes   [X] No
              If no, please describe:
              No change in ROM
              
              

    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:
         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:
         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: [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
    ----------------------------------
    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
       
    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:
              unable to do strenuous activities
              
              
    17. Remarks, if any:
    --------------------
     -- "Correia" 
       
     -- Is there evidence of pain on passive ROM testing? No 
     -- Is there evidence of pain when the joint is used in 
        non-weight bearing? No 
     -- If yes, is the opposing joint undamaged?
    
    


****************************************************************************


                                 Medical Opinion
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Xxxxxxxx XXXX
    
    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


    MEDICAL OPINION SUMMARY
    -----------------------
    RESTATEMENT OF REQUESTED OPINION: 

    a. Opinion from general remarks: 
    -- Does the Veteran have a diagnosis of (a) back pain 1995 that is at least
    as 
    likely as not (50 percent or greater probability) incurred in or caused by 
    (the) motor vehicle accident and complaints of back pain during service?

    b. Indicate type of exam for which opinion has been requested: Back

    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: 
    -- C-file review:
    -- no date on note; c/o right upper back pain x 10 days; dx MS strain, right
    upper back/shoulder; tx provided
    -- 04/10/1996 c/o severe back pain x two weeks; dx recurrent musculoskeletal
    pain
    -- 05/03/1995 s/p MVA; activated airbag; dx negative exam, no injuries 
noted,
    minor MS aches
    -- 05/01/1995 c/o right upper back pain x 10 days; dx MS strain right upper
    back/shoulder' tx provided

    -- condition was first noted in the military as documented;
    noted condition is still present during C&P Exam

    *************************************************************************

Thanks!

 

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I recently received a phone call from the VA to schedule a C&P for my foot pain.  Scheduled for tomorrow morning.

Edited by megajunk

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On 2/13/2019 at 3:22 PM, Buck52 said:

Thanks broncovet   Roger that!

 

On 2/14/2019 at 7:33 AM, megajunk said:

Yep, except it is 19 years, not 9.

I seen your DBQ from the VA C&P exam. What I did was find a private doctor who will do EMG's on your back and legs. This will help your claim to a proper rating for your injuries. If I can be of service to you at  no cost to help you I am here. What one gives to a VSO will help them for ones claims. They can only put in what you give them, so help yourself and get the info you need.

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