C&P EXAM - HELP/Clarification Needed.

Cspence852

PEB Forum Regular Member
Registered Member
Hello all,
If anyone can help me decipher this exam, please do.... I put in for an increase of my back disability currently rated at 10% for degenerative arthritis, and not sure what take I get on this last P&C exam... Any opinions are appreciated on what you think this outcome will be... Thanks all fellow VETS in advance for your help... My examiner never tested me on weight bearing that I know of... some notes seem inconsistent to what I remember. PLEASE HELP!!!!

Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
REFERRAL CLINIC
---------------
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[ ] Yes [X] No
If no, how was the examination completed (check all that apply)?
[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:
[ ] 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
Diagnosis #1: Degenerative arthritis of the spine
ICD code: unknwon
Date of diagnosis: 2017
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Active duty service dates:
Branch: Army
EOD: 08/24/1989
RAD: 01/10/1990
DBQ MUSC Back (thoracolumbar spine):
The Veteran is service connected for degenerative arthritis of the spine
(previously claimed as lower back chronic pain secondary to left hip)
which
is currently evaluated at 10%. Please evaluate for the current level of
severity of the Veteran's service connected disability.
She continues to have lower back pain and feel the lower back warmth.
She takes ibuprohen for pain. She does not wear back brace.
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.
limited in prolong sitting
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 70 degrees
Extension (0 to 30): 0 to 20 degrees
Right Lateral Flexion (0 to 30): 0 to 25 degrees
Left Lateral Flexion (0 to 30): 0 to 20 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
? [ ] 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, Extension, Right Lateral Flexion, Left Lateral
Flexion, Right Lateral Rotation, Left Lateral Rotation
Is there evidence of pain with weight bearing? [ ] Yes [X] 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):
slight tendernes on low back
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:
not examined
d. Flare-ups
Not applicable
e. Guarding and muscle spasm
Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [X] Yes [ ] No
Muscle spasm:
[ ] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[X] Not resulting in abnormal gait or abnormal spinal contour
[ ] Unable to evaluate, describe below:
Guarding:
[X] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[ ] Not resulting in abnormal gait or abnormal spinal contour
[ ] Unable to evaluate, describe below:
f. Additional factors contributing to disability
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: 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 [ ] 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?
[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?
[ ] 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:
limited in prolong sitting aa legal assistance
and have stand a lot to walk while working.
17. Remarks, if any:
--------------------
correia questions
there is no contralateral joint on lumbar spine condition
there is no pain or change on passive range of motion
on lumbar spine on supine and nonweightbearing position.
 

chaplaincharlie

Super Moderator
Staff Member
PEB Forum Veteran
Lifetime Supporter
Registered Member
You will likely remain 10%.

Forward Flexion (0 to 90): 0 to 70 degrees
Extension (0 to 30): 0 to 20 degrees
Right Lateral Flexion (0 to 30): 0 to 25 degrees
Left Lateral Flexion (0 to 30): 0 to 20 degrees
Right Lateral Rotation (0 to 30): 0 to 20 degrees
Left Lateral Rotation (0 to 30): 0 to 20 degrees


Total = 175



1539805366048.png
 

SeniorMech

PEB Forum Regular Member
PEB Forum Veteran
Registered Member
Welcome to the Forum! I'll toss my 2 cents into the ring lol. I am currently in the IDES process and have been rated by both the VA and the PEB. I was diagnosed with DDD which I believe is the same as you. After reading the results from your exam and comparing them to the results from my exam, I don't see there being much of an increase if any.... It's actually pretty easy to take an educated guess as to what rating you will get by looking at the answers the C&P Doc gave and looking at the rating verbiage in the 38 CFR. Since you have flexion forward of 70 deg's, that's why you were rated at 10% (see picture)
 

Attachments

Cspence852

PEB Forum Regular Member
Registered Member
Welcome to the Forum! I'll toss my 2 cents into the ring lol. I am currently in the IDES process and have been rated by both the VA and the PEB. I was diagnosed with DDD which I believe is the same as you. After reading the results from your exam and comparing them to the results from my exam, I don't see there being much of an increase if any.... It's actually pretty easy to take an educated guess as to what rating you will get by looking at the answers the C&P Doc gave and looking at the rating verbiage in the 38 CFR. Since you have flexion forward of 70 deg's, that's why you were rated at 10% (see picture)
Thanks for your opinion on this C&P EXam. I also had an evaluation for my hip and knee which will probably be still rated at 10%. I did see some inconsisiencies in what the rated said i couldnt and could perform---- i was never tested on weight bearing and was in alot of pain. How can i contest what was in my exam???? I appreciated your feedback...
 

Cspence852

PEB Forum Regular Member
Registered Member
You will likely remain 10%.

Forward Flexion (0 to 90): 0 to 70 degrees
Extension (0 to 30): 0 to 20 degrees
Right Lateral Flexion (0 to 30): 0 to 25 degrees
Left Lateral Flexion (0 to 30): 0 to 20 degrees
Right Lateral Rotation (0 to 30): 0 to 20 degrees
Left Lateral Rotation (0 to 30): 0 to 20 degrees


Total = 175



View attachment 3316
T
 

Cspence852

PEB Forum Regular Member
Registered Member
Thanks for your opinioon and reply to my C&P Exam.. Where and how can i contest what the examiner put in my report? I do see alot of inconsistencies in the report of what I was testd on during the exam> Ialso where can I find the charts on my flexions and rotations for hip, knee, and spine? Thanks for your support to a fellow Vetera!!!!
 

chaplaincharlie

Super Moderator
Staff Member
PEB Forum Veteran
Lifetime Supporter
Registered Member
You can have your doctor complete a DBQ. You can file an appeal via e-benefits. Your doc's DBQ would support that the examination was does not reflect your condition. Best wishes to you. Mike
 

Cspence852

PEB Forum Regular Member
Registered Member
You can have your doctor complete a DBQ. You can file an appeal via e-benefits. Your doc's DBQ would support that the examination was does not reflect your condition. Best wishes to you. Mike
Thanks chaplaincharlie! My civilian docs gave me an opinion letter and medical reports whch are not consistent to wht the examiner had in C&P notes.
 

chaplaincharlie

Super Moderator
Staff Member
PEB Forum Veteran
Lifetime Supporter
Registered Member
That will be helpful, but a complete DBQ would be better. For some conditions; there are multiple factors that play into the rating. If your doc is willing to fill out a DBQ, the VA will have all the data they need to make a decision.

You can download the appropriate DBQ here:
https://www.benefits.va.gov/COMPENSATION/dbq_listbysymptom.asp

Hope things work well for you!
Mike
 

Cspence852

PEB Forum Regular Member
Registered Member
That will be helpful, but a complete DBQ would be better. For some conditions; there are multiple factors that play into the rating. If your doc is willing to fill out a DBQ, the VA will have all the data they need to make a decision.

You can download the appropriate DBQ here:
https://www.benefits.va.gov/COMPENSATION/dbq_listbysymptom.asp

Hope things work well for you!
Mike
Thanks again chaplaincharlie! So if two of my current disabilitiies are as follows, should I also be rated additional for degenerative arthitis of the disabilities as well?? Im new at all this and somewhat confused..... current disabilities are listed below....

patellofemoral pain syndrome w/ chondro
trochanteric pain syndrome (includes trochanteric bursitis) (previously claimed as left hip chronic pain secondary to left knee)
10%Service Connected

patellofemoral pain syndrome w/ chondromalacia patella left knee (previously rated as patellofemoral syndrome with lateral tilt, left knee with chondromalacia patella)10%Service Connected

.
 

Cspence852

PEB Forum Regular Member
Registered Member
Welcome to the Forum! I'll toss my 2 cents into the ring lol. I am currently in the IDES process and have been rated by both the VA and the PEB. I was diagnosed with DDD which I believe is the same as you. After reading the results from your exam and comparing them to the results from my exam, I don't see there being much of an increase if any.... It's actually pretty easy to take an educated guess as to what rating you will get by looking at the answers the C&P Doc gave and looking at the rating verbiage in the 38 CFR. Since you have flexion forward of 70 deg's, that's why you were rated at 10% (see picture)
Welcome to the Forum! I'll toss my 2 cents into the ring lol. I am currently in the IDES process and have been rated by both the VA and the PEB. I was diagnosed with DDD which I believe is the same as you. After reading the results from your exam and comparing them to the results from my exam, I don't see there being much of an increase if any.... It's actually pretty easy to take an educated guess as to what rating you will get by looking at the answers the C&P Doc gave and looking at the rating verbiage in the 38 CFR. Since you have flexion forward of 70 deg's, that's why you were rated at 10% (see picture)
Thanks SeniorMech!!! Were can i find charts like the one you attached? Need for knee, hip, and back!! I appreciate your feedback and opinions!!
 

Cspence852

PEB Forum Regular Member
Registered Member
Hello All, How can i get a repeat C&P exam if I didnt have a favorable outcome for my decision. Some notes in the exam was not consistent, and wording of what I said is not correct. Im sure i was denied but waiting for letter to come in the mail...
 

ctsusmc

PEB Forum Regular Member
Registered Member
That will be helpful, but a complete DBQ would be better. For some conditions; there are multiple factors that play into the rating. If your doc is willing to fill out a DBQ, the VA will have all the data they need to make a decision.

You can download the appropriate DBQ here:
List By Symptom - Compensation

Hope things work well for you!
Mike

I'm in a fairly similar situation. I'll write my own post in a little bit from home, but a quick question for you @chaplaincharlie , who will the VA/PEB accept a DBQ from? My Civ Physical Therapist (who is a DR) at the base clinic has been helping to mitigate pain from my neck and back issues for a few years with dry needling and stim. After I received my initial results from the IPEB/VA I requested a formal board. The Physical Therapist conducted a new AROM measurements yesterday and has entered the new (and much more accurate (and much smaller)) ROM into my record. Should I ask him to fill out the DBQ to take to the FPEB, or is that something that my PCM would have to do? I'll write up a full background and a few questions later tonight to further explain my case/reason for appeal. As of now I have a FPEB date scheduled for 29 Jan 2019 and am trying to get everything in order before then. My appointed disability attorney has not been very responsive... Thanks.
 

ctsusmc

PEB Forum Regular Member
Registered Member
The VA Dr who did my C&P exam made a lot of mistakes and never did a weight bearing ROM measurement/exam either.
 

chaplaincharlie

Super Moderator
Staff Member
PEB Forum Veteran
Lifetime Supporter
Registered Member
Once your rating comes back from the IPEB, you would request a VARR. The data you have should be supplied to the C&P examiner that completes the re-rating. You can also send the additional info to the DRO if the IPEB has not yet made a decision.
 

jayjays78

New Member
Registered Member
Hello all,
If anyone can help me decipher this exam, please do.... I put in for an increase of my back disability currently rated at 10% for degenerative arthritis, and not sure what take I get on this last P&C exam... Any opinions are appreciated on what you think this outcome will be... Thanks all fellow VETS in advance for your help... My examiner never tested me on weight bearing that I know of... some notes seem inconsistent to what I remember. PLEASE HELP!!!!

Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
REFERRAL CLINIC
---------------
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[ ] Yes [X] No
If no, how was the examination completed (check all that apply)?
[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:
[ ] 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
Diagnosis #1: Degenerative arthritis of the spine
ICD code: unknwon
Date of diagnosis: 2017
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Active duty service dates:
Branch: Army
EOD: 08/24/1989
RAD: 01/10/1990
DBQ MUSC Back (thoracolumbar spine):
The Veteran is service connected for degenerative arthritis of the spine
(previously claimed as lower back chronic pain secondary to left hip)
which
is currently evaluated at 10%. Please evaluate for the current level of
severity of the Veteran's service connected disability.
She continues to have lower back pain and feel the lower back warmth.
She takes ibuprohen for pain. She does not wear back brace.
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.
limited in prolong sitting
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 70 degrees
Extension (0 to 30): 0 to 20 degrees
Right Lateral Flexion (0 to 30): 0 to 25 degrees
Left Lateral Flexion (0 to 30): 0 to 20 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
? [ ] 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, Extension, Right Lateral Flexion, Left Lateral
Flexion, Right Lateral Rotation, Left Lateral Rotation
Is there evidence of pain with weight bearing? [ ] Yes [X] 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):
slight tendernes on low back
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:
not examined
d. Flare-ups
Not applicable
e. Guarding and muscle spasm
Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [X] Yes [ ] No
Muscle spasm:
[ ] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[X] Not resulting in abnormal gait or abnormal spinal contour
[ ] Unable to evaluate, describe below:
Guarding:
[X] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[ ] Not resulting in abnormal gait or abnormal spinal contour
[ ] Unable to evaluate, describe below:
f. Additional factors contributing to disability
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: 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 [ ] 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?
[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?
[ ] 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:
limited in prolong sitting aa legal assistance
and have stand a lot to walk while working.
17. Remarks, if any:
--------------------
correia questions
there is no contralateral joint on lumbar spine condition
there is no pain or change on passive range of motion
on lumbar spine on supine and nonweightbearing position.
 
data-matched-content-ui-type="image_stacked" data-matched-content-rows-num="3" data-matched-content-columns-num="1" data-ad-format="autorelaxed">
Top