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Sorry i can not figure out how to format this better… But long story short i am posting this for a friend since both her and I are confused on how this either of these 2 DBQS read. on one hand the examiner seems say yes and then later on says no but maybe so but then probably not but mostly yes, so if any one can translate all this that would be awesome since this is a 10 year old claim that was remand to the AMC for further development.
Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXX Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No
ACE and Evidence Review ———————- Indicate method used to obtain medical information to complete this document: [X] In-person examination
Evidence Review ————–
Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS
1. Diagnosis ———– Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No
Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture
2. Medical history —————– a. Describe the history (including onset and course) of the Veteran’s thoracolumbar spine (back) condition (brief summary): veteran is SC for a lumbosacral strain
veteran reports during the last mission, was in C-130 aircraft, landed hard felt something pop in my back, onset of back pain, approx 2003.
veteran reports dx with sprynix of the thoracic spine, in 2005 follows with VA neurology butler, PA. aqua therapy, no benefit with chiropractor, ADVSIED AGAINTS INJECTIONS TO SPINE. pain and radicular symproms progressively worse.
veteran reports back pain from thoracic spine to lumbosacral region with radicular symptoms down both legs, veteran reports foot drop both feet, documented by neurologist. back pain constant back pain 8/10. flares – with any bending and twisting, any lifting, standing more than 10 minutes, sitting more than 30 minutes, walking more than 30 minutes, walking up down stairs with radicular symptoms. alleviated: moist heat, tens unit
b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran’s description of the flare-ups in his or her own words: see above
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. pain with prolonges standind/sitting 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 30 degrees Extension (0 to 30): 0 to 5 degrees Right Lateral Flexion (0 to 30): 0 to 10 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 30 degrees
If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No
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? [ ] 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): ttp paraspinal muscles throacic, lumbar sacral region 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: