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C&P Exam. Opinions please


sgtdjusmc

Question

I am thinking 20, 20, 20. Anyone see anything else?

 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):          JOINT L
    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       [X] Intervertebral disc syndrome       [ ] Sacroiliac injury       [ ] Sacroiliac weakness       [ ] Segmental instability       [ ] Spinal fusion       [ ] Spinal stenosis       [ ] Spondylolisthesis       [ ] Vertebral dislocation       [ ] Vertebral fracture


          Diagnosis #1:  LUMBAR DDD          Date of diagnosis:  2015 BY MRI                  

  Diagnosis #2:  THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION          Date of diagnosis:  SERVICE CONNECTED                 

   Diagnosis #3:  BILATERAL RADICULOPATHY          Date of diagnosis:  2018              2. Medical history    -----------------    a. Describe the history (including onset and course) of the Veteran's    thoracolumbar spine (back) condition (brief summary):    

   THE VETERAN IS A 42 YO MALE WHO SERVED IN THE MARINE CORP FROM 1995 TO       1999, THE MARINE CORP RESERVE FROM 1999 - 2001, AND THE NATIONAL GUARD       FROM 2001 TO 2003 AND AGAIN FROM 2016 TO PRESENT DAY WITH DEPLOYMENT TO       AFRICA FROM 2017 TO 2018.  HE IS HERE FOR A CURRENT LEVEL OF DISABILITY       EXAM FOR THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION.  HE REPORTS SINCE HIS       LAST COMP AND PEN EVALUATION AROUND 2013 HE HAS WORSENING PAIN WITH ONSET       OF RADICULOPATHY IN BOTH LEGS.  HIS PAIN LEVEL RANGE IS FROM A 5-9/10 WITH       A THROBBING CHARACTER HAVING OVERLYING SHARP JABS.  HE IS STIFF AFTER       SITTINIG AND IN THE MORNING. HIS MORNING STIFFNESS WILL LAST 1-2 HOURS.       HE STATES IN REGARDS TO HIS RADICULOPATHY HIS LEFT IS WORSE THAN HIS RIGHT       AND EXTEND TO HIS FEET BILATERALLY.  HE PREVIOUS TREATMENT INCLUDES       PHYSICAL THERAPY, CHIROPRACTIC CARE.  HE DENIES ANY SURGERY.  HE JUST       ANOTHER ROUND OF PHYSICAL THERAPY.           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:           HIS PAIN WILL ELEVATE TO A 9/10 TWICE A WEEK LASTING A FEW HOURS           TRIGGERED BY OVERACTIVITY. HE WILL REST AND USE PAIN CONTROL.
    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 REPORTS HE DIFFICULTY WALKING FOR LONG DISTANCES, CANNOT SIT IN A           HARD CHAIR, HAS PROBLEM SOCIAL FUNCTION ACTIVITIES AND PLYAING WITH           HIS CHILDREN. HE CANNOT LIFT OVER 15 POUNDS OR STAND MORE THAN 30           MINTUES.  HE HAS PROBLEMS WITH ANY MOVEMENT THAT REQUIRES BENDING,           LIKE PUTTING ON HIS SHOES. HE HAS DIFFICULTY CONCENTRATING WHEN HIS           PAIN ELEVATES.           HE HAS DIFFICULTY DRIVING OVER AN HOUR.
    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 35 degrees         

  Extension (0 to 30):                 0 to 10 degrees        

   Right Lateral Flexion (0 to 30):     0 to 15 degrees        

   Left Lateral Flexion (0 to 30):      0 to 15 degrees         

  Right Lateral Rotation (0 to 30):    0 to 20 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:              HE WOULD NOT BE ABLE TO RETREIVE AN ITEM FROM THE FLOOR
       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):           TENDERNESS OVER THE LUMBAR VERTEBRAE, PARASPINOUS MUSCLES, BILATERAL           SI JOINTS AND BILATERAL SCIATIC NERVES.               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:           HE HAS NOT USED HIS BACK REPEATEDLY.          
    d. Flare-ups           Is the exam being conducted during a flare-up? [ ] Yes   [X] No                  If the examination is not being conducted during a flare-up:           [ ] 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.

           [X] 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?       [ ] Yes   [ ] No   [X] Unable to say w/o mere speculation           If unable to say w/o mere speculation, please explain:           HE WAS NOT HAVING A FLARE.          
    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, Interference with standing,         Other (please describe)                    Please describe additional contributing factors of disability:           INTERFERENCE WITH LIFTING.       

        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:  [ ] 5/5   [X] 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:  [ ] 5/5   [X] 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:  [ ] 5/5   [X] 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:  [ ] 5/5   [X] 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   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+         Left:  [ ] 0   [X] 1+   [ ] 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: [ ] Negative   [X] Positive   [ ] Unable to perform       Left:  [ ] Negative   [X] Positive   [ ] Unable to perform
    8. Radiculopathy    ---------------    Does the Veteran have radicular pain or any other signs or symptoms due to    radiculopathy?    [X] Yes   [ ] No      

  a. Indicate symptoms' location and severity (check all that apply):           Constant pain (may be excruciating at times)    

     Right lower extremity: [X] None   [ ] Mild   [ ] Moderate   [ ] Severe         Left lower extremity:  [X] None   [ ] Mild   [ ] Moderate   [ ] Severe


       Intermittent pain (usually dull)         Right lower extremity: [ ] None   [ ] Mild   [X] Moderate   [ ] Severe         Left lower extremity:  [ ] None   [ ] Mild   [ ] Moderate   [X] Severe


       Paresthesias and/or dysesthesias         Right lower extremity: [ ] None   [ ] Mild   [X] Moderate   [ ] Severe         Left lower extremity:  [ ] None   [ ] Mild   [ ] Moderate   [X] Severe


       Numbness         Right lower extremity: [ ] None   [X] Mild   [ ] Moderate   [ ] Severe         Left lower extremity:  [ ] None   [X] Mild   [ ] Moderate   [ ] Severe


    b. Does the Veteran have any other signs or symptoms of radiculopathy?       [ ] Yes   [X] No           c. Indicate nerve roots involved: (check all that apply)         

  [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)                    If checked, indicate:  [ ] Right   [ ] Left   [X] Both               

  d. Indicate severity of radiculopathy and side affected:             Right: [ ] Not affected   [ ] Mild   [X] Moderate   [ ] Severe                  Left:  [ ] Not affected   [ ] Mild   [X] Moderate   [ ] Severe    

         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?       [X] Yes   [ ] No          

b. If yes to question 11a above, has the Veteran had any episodes of acute       signs and symptoms due to IVDS that required bed rest prescribed by a       physician and treatment by a physician in the past 12 months?       [ ] 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?       [X] Yes   [ ] No                  If yes, identify assistive device(s) used (check all that apply and           indicate frequency):                      Assistive Device:                Frequency of use:           -----------------                ----------------           [X] Brace(s)           [X] Occasional   [ ] Regular   [ ] Constant
    b. If the Veteran uses any assistive devices, specify the condition and       identify the assistive device used for each condition:          BACK BRACE FOR SUPPORT              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?       [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):              For Official Use Only             
              Click image to open viewer              Priority:                      MRI LUMBAR SPINE WO CONTRAST
                              
                            Proc Ord: MRI LUMBAR SPINE WWO CONTRAST
                            Exm Date: NOV 07, 2015@11:21
                            Req Phys:                       Pat Loc: DAL PACT              CL10-I2NURSE (Req'g L
                                                                     Img Loc: MRI
                                                                     Service: Unknown

                           
                            
                           
                            (Case 7346 COMPLETE) MRI LUMBAR SPINE WO CONTRAST     (MRI              Detailed) CPT:72148
                                 Reason for Study: low back pain chronic
                           
                                Clinical History:
                                  as above
                           
                            Report Status: Verified                   Date Reported: NOV              07, 2015
                            Date Verified: NOV              07, 2015
                                Verifier E-Sig:/ES/LENA A OMAR, M.D.
                           
                                Report:
                                  MRI Lumbar Spine without contrast dated 11/7/2015
                                  
                            Clinical History: 38-year-old male with history of low back              pain
                                  chronic
                                  
                                  Comparison: Radiograph 8/28/2015
                                  
                            Technique:  Sagittal and axial T1 and T2, as well as axial              PD
                                  sequences were obtained of the lumbar spine.
                                  
                                  Findings: 
                                  
                            Vertebral body height, alignment, and marrow signal are              preserved
                                  throughout the lumbar spine. There is either focal fat or
                                  hemangioma in the L1 vertebral body. Vertebral bodies are
                                  unremarkable. The conus terminates at L1-L2. 
                                  
                            There is no significant canal or neural foraminal stenosis.              No


                            areas of abnormal signal within the cord are seen. There is              a
                            tiny central disc protrusion at L5-S1 without any              significant
                            narrowing of the thecal sac or neural foramen. Small amount              of
                                  fluid is present in the facet joints in the lumbar spine. 
                                  
                                  Visualized paraspinal soft tissues are unremarkable. 
                                  
                                 
                           
                                Impression:
                            1. Essentially unremarkable MRI of the lumbar spine except              for a
                            tiny central disc protrusion at L5-S1 without any              significant
                                  narrowing of the thecal sac or neural foramen. 
                           
                                Primary Diagnostic Code: ABNORMAL
                           

                            /LAO
                           
                              
                                              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:             

THE VETERAN WORKS AS AN ACCOUNTANT. HE SITS FOR LONG PERIODS AT              WORK WHICH ELEVATES HIS BACK PAIN AND DECREASES HIS CONCENTRATION              AND WORK CAPACITY.              HE WOULD NOT BE ABLE TO WORK A PHYSICALLY DEMANDING JOB REQUIRING              PROLONGED WALKING, STANDING OR REPEATED HEAVY LIFTING.  HE ALSO              WOULD REQUIRE THE ABILITY TO MOVE FROM SITTING TO STANDING POSTIONS              WITH A SEDENTARY JOB SUCH AS THE ONE HIS IS CURRENTLY WORKING.             

     17. Remarks, if any:    -------------------    1.      Is there evidence of pain on passive range of motion testing?     (Yes/No/Cannot be performed or is not medically appropriate)
    YES
    2.      Is there evidence of pain when the joint is used in non-weight     bearing? (Yes/No/Cannot be performed or is not medically appropriate)
    YES
    3.      If yes, is the opposing joint undamaged (i.e. no abnormalities)?     NA


    If yes, conduct range of motion testing for the opposing joint and provide     ROM measurements.
    PASSIVE AND ACTIVE RANGE OF MOTION ARE THE SAME.    *****************************************************************************    **********
    THE VETERAN HAS A SERVICE CONNECTION FOR THORACOLUMBAR SPINE SEGMENTAL    DYSFUNCTION. THIS IS A CHRIOPRACTIC DIAGNOSIS \:  "segmental dysfunction, a    motion theory concept that states that two articulating joint surfaces cannot    interact optimally if they are misaligned. Basis of vertebral subluxation and    theory of illness.
    SYNONUMS FOR SEGMENTAL DYSFUNCTION OF THE LUMBAR SPINE ARE:  LOW BACK PAIN,    LUMBAGO, LUMBALGIA.
    GIVEN THE SERVICE CONNECTED DIAGNOSIS IS BROAD BASED AND GENERAL BY    DEFINITION, THE VETERANS CONFIRMED DIAGNOSIS OF LUBMAR DDD WITH COMPLICATIONS    OF BILATERAL LEG RADICULOPATHY WOULD BE INCLUDING AND THEREFORE ALSO SERVICE    CONNECTED.
    OF NOTE THE VETERAN COMPLAINED OF BACK PAIN, PAIN IN ARMS, LEGA NAD JOINTS    DURING HIS DEPLOYMENT IN 2017 TO 2018 WHICH MORE THAN LIKELY WAS DUE TO HIS    LUMBAR DDD WITH RADICULOPATHY.   
 

 

Edited by sgtdjusmc (see edit history)
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3 hours ago, shrekthetank1 said:

I think you are right.

thanks. I see she did check hypoactive reflex for the left ankle so maybe it will go to 40% 

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