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  • 14 Questions about VA Disability Compensation Benefits Claims

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    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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Take a look at these DBQs, what do you think I will get?

Question

                      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    [X] CPRS

    [X] Other (please identify other evidence reviewed):          office notes from civilain pain management and EMG results

    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       [X] Other Diagnosis

          Diagnosis #1:  DDD lumbar spine          ICD code:  M51.06          Date of diagnosis:  already SC'd                    Diagnosis #2:  DJD lumbar spine          ICD code:  M47.016          Date of diagnosis:  at least 2017                    Diagnosis #3:  left lower extremity lumbar radiculopathy          ICD code:  M54.16          Date of diagnosis:  already Sc'd                    If there are additional diagnoses pertaining to thoracolumbar spine          (back) conditions, list using above format:             Diagnosis #4: s/p lumbar laminotomy L5-S1             IDC code: Z98.1             Date of Diagnosis: 2014                 2. Medical history    -----------------    a. Describe the history (including onset and course) of the Veteran's    thoracolumbar spine (back) condition (brief summary):       Veteran is SC'd for DDD, s/p lumbar lamintomy and left lower extremity       radiculopathy to include restless leg syndrome. Please note that the       original restless leg syndrome C&P exam was done by a neurologist and was

       listed as a central nervous system DBQ; not a peripheral nerve DBQ since       restless leg syndrome does not occur at the peripheral nerve level.

       Last C&P exam from 2/23/2017 was reviewed. Veteran had ER visit on       9/20/2018 for his back. No new surgeries since 2014. He has tried epidural       injections, physical therapy and aqua therapy all with no relief. He has       an H-wave at home which gives some relief while it is on and for a half       hour afterwards. He just takes Motrin for pain. He reports the back pain       with worse and constant and that "everything" hurts his back. He does       continue to work and sits and stands/walk about 50/50 for each. He has       constant tingling in bilateral lower extremities.           b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?    [ ] Yes   [X] No

    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 pain is constat. Everything hurts it like sitting, standing and           walking.

    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 25 degrees           Extension (0 to 30):                 0 to 15 degrees           Right Lateral Flexion (0 to 30):     0 to 15 degrees           Left Lateral Flexion (0 to 30):      0 to 20 degrees           Right Lateral Rotation (0 to 30):    0 to 10 degrees           Left Lateral Rotation (0 to 30):     0 to 10 degrees

           If abnormal, does the range of motion itself contribute to a           functional loss? [X] Yes (please explain)   [ ] No              If yes, please explain:              pain and decreased ROM

       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):           midly tender lower lumbar spine at midline               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   [X] No   [ ] Unable to say w/o mere speculation

    d. Flare-ups       Not applicable           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: None           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   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+         Left:  [ ] 0   [X] 1+   [ ] 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: [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?    [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: [X] None   [ ] Mild   [ ] Moderate   [ ] Severe         Left lower extremity:  [X] None   [ ] Mild   [ ] Moderate   [ ] Severe

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

       Numbness

         Right lower extremity: [X] None   [ ] Mild   [ ] Moderate   [ ] Severe         Left lower extremity:  [X] None   [ ] 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   [X] Mild   [ ] Moderate   [ ] Severe                  Left:  [ ] Not affected   [X] Mild   [ ] 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?       [ ] 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?       [X] Yes   [ ] No                  If yes, describe (brief summary):              CORREIA: Pain with non-weight bearing lumbar spine. Not medically              feasible to do passive ROM on a lumbar spine.                  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?       [X] Yes   [ ] No                  If yes, is there objective evidence that any of these scars are           painful, unstable, have a total area equal to or greater than 39           square cm (6 square inches), or are located on the head, face or neck?           (An "unstable scar" is one where, for any reason, there is frequent           loss of covering of the skin over the scar.)           [ ] Yes   [X] No                          If no, provide location and measurements of scar in centimeters.                  Location: midline lumbar spine scar from previous surgery                  Measurements:  length 2.5cm  X  width 0.3cm                      c. Comments, if any:       scar is non-tender, no instability           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):              Report Status: Verified                   Date Reported: JAN              15, 2019              Date Verified: JAN              15, 2019

                  Report:                    Exam: MRI of lumbar spine, without and with contrast                                          Clinical history: Low back pain and lumbar radiculopathy.                                           Technique: Routine unenhanced and enhanced MRI of the lumbar

                    spine was performed.                                           Results: Correlation is to a prior exam from 6/30/2017.                                     Alignment of the lumbar spine vertebrae is maintained,              without               spondylolisthesis. The lumbar vertebral body heights and              marrow               signal are maintained. Again noted is desiccation and              reduction               in height of the L5-S1 disc. The conus medullaris is at the              level                     of L1 and is unremarkable. Incidentally noted is a small                     perineural cyst in the right T11-T12 neural foramen.                                     At L1-L2, L2-L3 and L3-L4 levels, there is no significant              disc               herniation and there is no significant central canal or              foraminal                     stenosis.                                     At L4-L5 level, there is no significant disc herniation.              There is               mild bilateral facet arthropathy and ligamentous hypertrophy.                                   There is no significant central canal or foraminal stenosis. 

                                         At L5-S1 level, again noted are postoperative changes of                     left-sided laminotomy. There is a small broad-based posterior                  central and left paracentral disc protrusion, which likely               impinges on the traversing left S1 nerve root. There is              bilateral                     facet arthropathy. There is no significant central canal               stenosis. There is mild to moderate left foraminal stenosis.              The               right neural foramen is patent. Following intravenous              contrast,               there is no evidence of enhancing epidural or perineural              scar.                                           There is a small left lower pole renal cyst. Otherwise, the               visualized paravertebral soft tissues are grossly              unremarkable.                                          

                  Impression:                    Small broad-based posterior central and left paracentral              protrusion of the L5-S1 disc, which likely impinges on the              left                    S1 nerve root. Stable postoperative changes of left-sided              laminotomy at L5-S1 level, without evidence of enhancing              epidural                    or perineural scarring.                                  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 intolerant of prolonged periods of walking, sitting or              standing and no heavy lifting. A light duty job with the              accomodation of changing positions as needed for comfort would be              feasible and no heavy lifting.                  17. Remarks, if any:    -------------------    Not an ACE exam.

    Veteran reports constant pain in his back no matter what position or use so    repetitive motion over time does not cause any pain, fatigability or    incordination that would significantly reduce veteran's function since he    continues to work and at this time has no job restrictions. After

examination    of the veteran, listening to his complete history and current subjective    complaints, combined with a review of the available records, I have no basis    to offer additional losses of function or motion when it comes to repetitive    use over time.

    Notes from pain management also report difficulty illicting bilateral lower    extremity reflexes even with distraction which is consistent with exam today    so more then likely normal for veteran to have decreased reflexes.

    Veteran has decreased ROM today, note from pain management 10/2018 noted    forward flexion to 45 so some limitation of motion may be from pain.

    EMG 12/10/2018: acute/subacute nerve root lesion at or about the left L4-L5    nerve root. Acute/subacute nerve root lesion or lesions at or about the right    L4 nerve root.

    EMG shows right and left lower extremity radiculopathy; right leg is a new    diagnosis from last exam and is mild bilaterally.

    Current level of severity of lumbar spine DDD with DJD, s/p laminotomy is    moderate. The DJD which has been noted on previous xrays was noted as a    diagnosis from last C&P exam as well and is related to the DDD lumbar spine.

    =============================================================================    ==

        Report Status: Verified                   Date Reported: FEB 02, 2017                                                  Date Verified: FEB 02, 2017      

        Report:          Exam: Lumbar spine, 5 views.                       Clinical History: Pain. Rule out arthritis.                       Results: There are no comparison studies.                       Alignment of the lumbar spine vertebrae is maintained, without           spondylolisthesis. The lumbar vertebral body heights are           maintained. There is mild narrowing of the L5-S1 disc space with           minimal marginal osteophytic spurring. There is mild facet           arthropathy at this level as well. Remainder of the lumbar disc           spaces are grossly preserved. There are no definite pars defects           identified on the oblique views. Bony mineralization is           maintained.                      The sacroiliac joints are unremarkable. The visualized

    paravertebral soft tissues are grossly unremarkable.   

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

                          Peripheral Nerves Conditions          (not including Diabetic Sensory-Motor Peripheral Neuropathy)                        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    [X] Other (please identify other evidence reviewed):          office notes from civilain pain management and EMG results

    1. Diagnosis    -----------    Does the Veteran have a peripheral nerve condition or peripheral neuropathy?    [X] Yes   [ ] No           Diagnosis #1:  Bilateral lower extremity radiculopathy       ICD code:  M54.16

       Date of diagnosis:  already SC'd           2. Medical history    -----------------    a. Describe the history (including onset and course) of the Veteran's       peripheral nerve condition (brief summary):

         Veteran is SC'd for left lower extremity radiculopathy to include         restless leg syndrome. Please note that the original restless leg         syndrome C&P exam was done by a neurologist and was listed as a central         nervous system DBQ; not a peripheral nerve DBQ since restless leg         syndrome does not occur at the peripheral nerve level. Veteran does         still report his legs feels restless if he doesn't move them.

         Veteran reports bilateral lower extremity tingling which is constant.         EMG done in 12/2018.

         No upper extremity exam requested nor deemed necessary so not performed.             b. Dominant hand       [X] Right   [ ] Left   [ ] Ambidextrous           3. Symptoms    ----------    a. Does the Veteran have any symptoms attributable to any peripheral nerve       conditions?       [X] Yes   [ ] No              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: [X] None   [ ] Mild   [ ] Moderate   [ ] Severe         Left lower extremity:  [X] None   [ ] Mild   [ ] Moderate   [ ] Severe

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

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

                     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              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

    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   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+         Left:  [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+

       Ankle:         Right: [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+         Left:  [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+

    6. Sensory exam    --------------       Indicate results for sensation testing for light touch:              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. Trophic changes    -----------------    Does the Veteran have trophic changes (characterized by loss of extremity    hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy?    [ ] Yes   [X] No        8. Gait    ------    Is the Veteran's gait normal?    [ ] Yes   [X] No            If no, describe abnormal gait:           mild limp                   Provide etiology of abnormal gait:           more then likely from back               9. Special tests for median nerve    --------------------------------    Were special tests indicated and performed for median nerve evaluation?    [ ] Yes   [X] No        10. Nerves Affected: Severity evaluation for upper extremity nerves and        radicular groups    ----------------------------------------------------------------------        No response provided.            11. Nerves Affected: Severity evaluation for lower extremity nerves    ------------------------------------------------------------------    a. Sciatic nerve       Right: [ ] Normal   [X] Incomplete paralysis   [ ] Complete paralysis                         If Incomplete paralysis is checked, indicate severity:                  [X] Mild                  [ ] Moderate                  [ ] Moderately Severe                  [ ] Severe, with marked muscular atrophy

       Left:  [ ] Normal   [X] Incomplete paralysis   [ ] Complete paralysis                         If Incomplete paralysis is checked, indicate severity:                  [X] Mild                  [ ] Moderate                  [ ] Moderately Severe                  [ ] Severe, with marked muscular atrophy

    b. External popliteal (common peroneal) nerve       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           c. Musculocutaneous (superficial peroneal) nerve

       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           d. Anterior tibial (deep peroneal) nerve       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           e. Internal popliteal (tibial) nerve       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           f. Posterior tibial nerve       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           g. Anterior crural (femoral) nerve       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           h. Internal saphenous nerve       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           i. Obturator nerve       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           j. External cutaneous nerve of the thigh       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           k. Ilio-inguinal nerve

       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis              Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis           12. 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.             13. Remaining effective function of the extremities    --------------------------------------------------    Due to peripheral nerve conditions, 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., 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

    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 EMG studies been performed?       [X] Yes   [ ] No                  Extremities tested:                      [X] Right lower extremity               Results: [ ] Normal   [X] Abnormal               Date:  12/10/2018                          [X] Left lower extremity               Results: [ ] Normal   [X] Abnormal               Date:  12/10/2018              

               If abnormal, describe:

                 acute/subacute nerve root lesion at or about the left L4-L5                 nerve root. Acute/subacute nerve root lesion or lesions at or                 about the right L4 nerve root.                     b. Are there any other significant diagnostic test findings and/or results?       [ ] Yes   [X] No                     16. Functional impact    --------------------    Does the Veteran's peripheral nerve condition and/or peripheral neuropathy    impact his or her ability to work?    [ ] Yes   [X] No                  17. Remarks, if any:    -------------------        Not an ACE exam.

        Restless leg syndrome is NOT a peripheral nerve condition, it is a        central nervous system condition and as such was done as a CNS DBQ by the        neurologist with the original claim; therefore no specific nerve can be        listed for restless leg syndrome and peripheral nerve DBQ in appropriate        DBQ for this condition; unsure why it is listed with the radiculopathy as        they are two separate conditions. According to UpToDate, restless leg        sydrome is, "Restless legs syndrome (RLS), also called Willis-Ekbom        disease (WED), is a common sleep-related movement disorder characterized        by an often unpleasant or uncomfortable urge to move the legs that occurs        during periods of inactivity, particularly in the evenings, and is        transiently relieved by movement."

        EMG shows right and left lower extremity radiculopathy; right leg is a        new diagnosis from last exam and is mild bilaterally.

        Notes from pain management also report difficulty illicting bilateral        lower extremity reflexes even with distraction which is consistent with        exam today so more then likely normal for veteran to have decreased        reflexes.

        Current level of severity for bilateral lower extremity lumbar        radiculopathy is mild.       

 

EXP COSIGNER:                                URGENCY:                            STATUS: COMPLETED                    

                                Mental Disorders                     (other than PTSD and Eating Disorders)                        Disability Benefits Questionnaire

    Is this DBQ being completed in conjunction with a VA     21-2507, C&P Examination    Request?    [X] Yes  [ ] No   

                                   SECTION I:                                   ---------    1. Diagnosis    -----------    a. Does the Veteran now have or has he/she ever been     diagnosed with a mental       disorder(s)?       [X] Yes  [ ] No              ICD code: F32.9              If the Veteran currently has one or more mental        disorders that conform to       DSM-5 criteria, provide all diagnoses:              Mental Disorder Diagnosis #1: Major Depressive        Disorder, unspecified       ICD code: F32.9

    b. Medical diagnoses relevant to the understanding     or management of the

       Mental Health Disorder (to include TBI): Lumbar        Radiculopathy      

    2. Differentiation of symptoms    -----------------------------    a. Does the Veteran have more than one mental     disorder diagnosed?       [ ] Yes  [X] No           c. Does the Veteran have a diagnosed traumatic brain     injury (TBI)?       [ ] Yes  [ ] No  [X] Not shown in records reviewed           3. Occupational and social impairment    ------------------------------------    a. Which of the following best summarizes the     Veteran's level of occupational       and social impairment with regards to all mental        diagnoses? (Check only       one)              [X] Occupational and social impairment with        occasional decrease in work           efficiency and intermittent periods of            inability to perform           occupational tasks, although generally            functioning satisfactorily,           with normal routine behavior, self-care and            conversation

    b. For the indicated occupational and social     impairment, is it possible to       differentiate which impairment is caused by each        mental disorder?       [ ] Yes  [ ] No  [X] Not Applicable (N/A)           c. If a diagnosis of TBI exists, is it possible to     differentiate which       occupational and social impairment indicated above        is caused by the TBI?       [ ] Yes  [ ] No  [X] Not Applicable (N/A)                                          SECTION II:                                   ----------                               Clinical Findings:                               -----------------    1. Evidence Review    -----------------    Evidence reviewed (check all that apply):        [X] VA e-folder

    [X] CPRS    [X] Other (please identify other evidence reviewed):          The claimant's responses on the PHQ-9, a self          report measure of sx of          Depression

         

    2. History    ---------    a. Relevant Social/Marital/Family history (pre    military, military, and       post-military):                He is   a 37     y.old  Vet,  a husband and          father, lives with the         family, works as a safety manager. He was          medically discharged in 2015         due to his spine problems. He states that since          he had a surgery for a         herniated disc  in 2014 his medical condition          went worse and he has been         suffering from pain and inability  to perform          his duties as husband and         father. He has been upset with his difficulties,          shows irritability and         anger in the family, feels guilty for that. He          spends weekends trying to         do some house and yard work but then feels very          tired and stays in bed         for the rest of the day. He is upset that due to          his pain and decreased         physical abilities he cannot participate in his          children's sport         activities and other family events.

                      b. Relevant Occupational and Educational history     (pre-military, military, and       post-military):                He served from 2003-2015, medically discharged          ( cervical and back         problems), since that he has been working as a          security manager, changed         companies, has reprimands from  his supervisors          for his "harsh"         treatment of others- he agrees with the critique          but states that he

         feels irritable and angry due to the pain and          physical limits  and         cannot adequately control his reactions and          responses. He was fired from         one his jobs - in Nov 2017- for disrespecting          his direct  supervisor and         the next level supervisor (reportedly, called          each of them an "idiot" or         something to that effect)

                      c. Relevant Mental Health history, to include     prescribed medications and       family mental health (pre-military, military, and        post-military):                He has developed depression since his surgery in          2014, as per his         report. He started feeling irritable, angry and          guilty due to his         medical issues and physical incapacities imposed          by his conditions         (radiculopathy, cervical strain)  For the last 6          months he has been in         tx with a VA Psychologist on the DX-es of            Depressive Disorder and         Adjustment Disorder  - see CPRS.                        d. Relevant Legal and Behavioral history (pre    military, military, and       post-military):                no issues reported             e. Relevant Substance abuse history (pre-military,     military, and       post-military):                drinks once a week, has  5-6 drinks then             f. Other, if any:       No response provided.           3. Symptoms    ----------    For VA rating purposes, check all symptoms that     actively apply to the    Veteran's diagnoses:           [X] Depressed mood

       [X] Anxiety       [X] Chronic sleep impairment       [X] Difficulty in establishing and maintaining        effective work and social           relationships       [X] Difficulty in adapting to stressful        circumstances, including work or a           worklike setting       [X] Impaired impulse control, such as unprovoked        irritability with periods           of violence

    4. Behavioral observations    -------------------------    A 37   y.old male, looks older than his     chronological age, appears irritable    and upset, no other  issues in his MS, no avh, no     S/H/D             5. Other symptoms    ----------------    Does the Veteran have any other symptoms     attributable to mental disorders    that are not listed above?    [ ] Yes  [X] No        6. Competency    ------------    Is the Veteran capable of managing his or her     financial affairs?    [X] Yes  [ ] No        7. Remarks (including any testing results), if any:    --------------------------------------------------    The claimant's responses on the PHQ-9  produced a     score of 16 - in the    "Moderately - Severe" range    A  a 37     y.old  Vet,  a husband and father, lives     with the family, works    as a safety manager. He was medically discharged in     2015 due to his spine    problems. He states that since he had a surgery for     a herniated disc  in 2014    his medical condition went worse and he has been     suffering from pain and    inability  to perform his duties as husband and     father. HE reports being    irritable, angry, dysphoric, having problems dealing     with others, becoming    secluded, also suffering from guilt and shame.   He

    reports continuous issues    at his work places - was fired in 2017 for being     rude to the supervisors, now    has verbal reprimands for 'harsh" treatment of the      staff. Since Sept 2018    he has been evaluated and then  treated  for  the DX     of Depressive Disorder    and also the DX of Adjustment Disorder at the VA system - the tx is    ongoing - see the CPRS.

    ____________________________________________________    _________________________    _

    Given the claimant's presentation and  history, and considering his records, the undersigned opines:     The  claimant meets criteria for  Major Depressive     Disorder unspecified  and    it is more likely than not that the claimant's     condition diagnosed as above    has developed in response to his struggle with     Lumbar Radiculopathy .   

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Not knowing if you are Service connected for anthing else

Reading these DBQ's This examiner didn't do you an favor's and contradicted his/her self.

I would say you should get a 100% rating or a high % rating and IU infrred. under the CFR 4.15 Extra scheduler rating system

but what  will happen on that is if your still working  then that will go out the window (jmo) but if they rate you I'd say 50% to 70% over all combined rating

If your still working  that will sure hinder a 100% or IU rating

My guess is a  over all 70% rating. 

Just my opinion , you should get a 100% rating due to your Back problems alone...and then there are the smaller ratings with ROM AND SCARES ect,,ect,,   you might look into possible secondary ratings also.

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