diabetes Gulf War Exam C&p: Peripheral Nerves Conditions

BearGator56 · October 9, 2013

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: