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BearGator56

Gulf War Exam C&p: Peripheral Nerves Conditions

2 posts in this topic

This was part of my Gulf War Exam, and it doesn't look like it should be rated from the GW. But, the wrist injury received while I was in the Marines does have nerve issues. Would they continue the rating on it's own, or would I have to re-file again on a claim not under Gulf War? I'm currently rated for the wrist, but nothing to do with the nerve issues.
Peripheral Nerves Conditions
(not including Diabetic Sensory-Motor Peripheral Neuropathy)
Disability Benefits Questionnaire
Name of patient/Veteran: XXXX
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
CPRS
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran have a peripheral nerve condition or peripheral neuropathy?
[X] Yes [ ] No
Diagnosis #1: lt ulnar neuropathy
ICD code: (354.2)
Date of diagnosis: 9/6/13
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
peripheral nerve condition (brief summary):
He stated that he developed tingling in the left arm for a long time
started while on active duty his left wrist was injured while on active
duty no history of neck pain or surgery; no history of elbow injury or
surgery. He takes Neurontin; he has mild weakness of the left hand with
no history of diabetes mellitus. He has mild wasting of his left hand.
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 upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Intermittent pain (usually dull)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Numbness
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
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
Elbow 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
Elbow 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
Wrist 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
Wrist 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
Grip:
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
Pinch (thumb to index finger):
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
b. Does the Veteran have muscle atrophy?
[X] Yes [ ] No
If muscle atrophy is present, indicate location:
lt 1st dorsal interossei
Normal side: not measured cm. Atrophied side: not measured
cm.
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
Biceps:
Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+
Triceps:
Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+
Brachioradialis:
Right: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+
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:
Shoulder area (C5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Inner/outer forearm (C6/T1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Hand/fingers (C6-8):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
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?
[X] Yes [ ] No
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
-----------------------------------------------------------------------
a. Radial nerve (musculospiral nerve)
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
b. Median nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
c. Ulnar nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis
If Incomplete paralysis is checked, indicate severity:
[ ] Mild [X] Moderate [ ] Severe
d. Musculocutaneous nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
e. Circumflex nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
f. Long thoracic nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
g. Upper radicular group (5th & 6th cervicals)
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
h. Middle radicular group
Right [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
i. Lower radicular group
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
11. Nerves Affected: Severity evaluation for lower extremity nerves
-------------------------------------------------------------------
Not applicable
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
and/or symptoms
-----------------------------------------------------------------------
a. 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
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms?
[ ] Yes [X] No
15. Diagnostic testing
----------------------
a. Have EMG studies been performed?
[X] Yes [ ] No
Extremities tested:
[X] Left upper extremity
Results: [ ] Normal [X] Abnormal
Date: 1/15/13
b. 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):
Findings:
The left median sensory nerve conduction study (NCS) showed normal
peak
latency and amplitude.
The left ulnar sensory NCS showed normal peak latency and amplitude.
The left median motor NCS showed normal distal latency, amplitudes,
and conduction velocity.
The left ulnar motor NCS was ABNORMAL and showed normal distal
latency,
normal
amplitudes, and DIMINISHED conduction velocities across the ELBOW.
The right ulnar motor NCS showed normal distal latency, amplitudes,
and conduction velocities.
The left median-to-ulnar comparison mixed nerve study showed no
significant
difference in latencies.
Electromyography (EMG) of selected muscles representing the ulnar
innervations showed normal insertional activity, no spontaneous
activity, and
normal voluntary MUAP's.
IMPRESSION:
1) Abnormal study.
2) Electrophysiological evidence of LEFT ulnar neuropathy across the
elbow
consistent with a focal demyelinating process. No evidence of axonal
loss.
3) NO electrophysiological evidence of a left median neuropathy at the
wrist.
PLAN:
1) Prosthetics consult to issue a LEFT elbow brace to the patient
2) Advised patient to protect the elbows with gel pads or towels
anytime they
are on a hard surface and to limit sleeping with hands overhead
3) Please consider obtaining a LEFT elbow xray given hx of remote
injury
4) Can consider hand surgery consult in the future for possible
surgical
interventions if above conservative measures fail.
5) Thank you the consult.
/es/ AMAR G PATEL
PM&R PGY 3
Signed: 04/18/2013 14:21
16. Functional impact
---------------------
Does the Veteran's peripheral nerve condition and/or peripheral neuropathy
impact his or her ability to work?
[X] Yes [ ] No
If yes, describe impact of each of the Veteran's peripheral nerve and/or
peripheral neuropathy condition(s), providing one or more examples:
Left ulnar neuropathy condition will limit repetitive moderately
strenuous physical activity with his left hand.
17. Remarks, if any:
--------------------
the veterans ulnar neuropathy is a disease with a clear and specific
etiology and diagnosis.
Medical opinion-it is less likely is not, less than 50% probability,
that
the above condition is related to any specific exposure event
experienced
by the veteran during service in Southeast Asia;
rationale-current medical literature review does not correlate ulnar
neuropathy with Gulf War exposure.
Edited by BearGator56

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This was also added in the commentary:

2. Restatement of requested opinion
-----------------------------------
a. Insert requested opinion from general remarks:
ALSO,
The Veteran is claiming service connection for low back pain and left
wrist pain. Please review the medical opinion requests below regarding
these two issues:
MED OPINION #1:
A. Requested DBQ: Peripheral Nerves
" Claimed conditions: nerve damage left wrist
" Claimed nexus: secondary or related to the in-service left wrist
fracture
" Opinion requested: Is there a diagnosis of nerve damage in the
left wrist? If yes, is it at least as likely as not related to the
left
wrist fracture in service?
B. Available pertinent evidence:
" Military Service: Marines from March 14, 1990 to June 28, 1994
" Service Treatment Records (STRs): These records show the left
wrist fracture
" Private Treatment Records: none
" VA Treatment Records: the Atlanta VAMC treatment records
(available for your review in CPRS) show that the Veteran has
complained
of pain in the left wrist. There are images available for your review
as
well.

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