degenerative arthritis C&p Notes, Guesses On Ratings?

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Hello everyone, I am finally able to see notes regarding my recent exams. I am hoping that someone can give me a guestimate of what my ratings might be. Seems odd that my neck issues are simply "cervical strain" when it has been called degenerative disc disease, spondylosis and spinal stenosis.

1st my neck, and this is why the MEB began.The ROM part bothers me so much because it was eyeballed and I did not turn my head left, right or up much at all, because I cant!

1. Diagnosis

‐‐‐‐‐‐‐‐‐‐‐‐

Does the Veteran now have or has he/she ever been diagnosed with a cervical

spine (neck) condition?

[X] Yes [ ] No

[ ] Ankylosing spondylitis

[X] Cervical strain

[ ] Degenerative arthritis of the spine

[ ] Intervertebral disc syndrome

[ ] Segmental instability

[ ] Spinal fusion

[ ] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

Diagnosis #1: Cervical spondylosis with radiculopathy

ICD code: 721.1

Date of diagnosis: 2010

2. Medical history

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

a. Describe the history (including onset and course) of the Veteran's

cervical spine (neck) condition (brief summary):

He developed neck pain in 2001 or so. He was deployed and was seen in

clinic for neck pain. His neck pain has continued through the years and

he has had multiple MRIs. He has had physical therapy, steroid and facet

injections and RFA. His radio frequency ablation was in 2014. His

symptoms

worsened after that and he is on daily narcotics and uses his TENs daily.

His neck pain is constant, aching/sharp and severe. About 2‐3 days a

week

he has more severe flare ups of pain. His pain is worse with

lifting/carrying, any movement of the head and cold weather. He has not

had surgery on the neck. His pain radiates into both shoulders as a

stabbing pain. It is worse on the right. It does not radiate into the

left

arm. It radiates as a sharp stabbing pain down the right arm to the

fingers. The stabbing pain will taper off when he goes back to his normal

positions. He takse narcotic pain medications, ice, TENs unit, and rest

daily. He does yoga stretches also to help. He also gets chiropractic

care and massage. He goes off base to get these and it is helpful.

b. Dominant hand:

[X] Right [ ] Left [ ] Ambidextrous

c. Does the Veteran report flare‐ups of the cervical spine (neck)?

[X] Yes [ ] No

If yes, document the Veteran's description of the flare‐ups in his or

her own words:

He has even more limited ROM with flare ups.4/23/2015 My HealtheVet

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d. Does the Veteran report having any functional loss or functional

impairment of the cervical spine (neck) (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:

He has limited ROM on a daily basis.

3. Range of motion (ROM) and functional limitations

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

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 (0‐45): 0 to 45 degrees

Extension (0‐45): 0 to 30 degrees

Right Lateral Flexion (0‐45): 0 to 45 degrees

Left Lateral Flexion (0‐45): 0 to 30 degrees

Right Lateral Rotation (0‐80): 0 to 45 degrees

Left Lateral Rotation (0‐80): 0 to 45 degrees

If abnormal, does the range of motion itself contribute to a

functional loss? [X] Yes, (please explain) [ ] No

If yes, please explain:

Pt is unable to have normal ROM. He is limited in turning his head

Description of pain (select best response):

Pain noted on examination and causes functional loss

If noted on examination, 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 joint or associated soft tissue of the cervical spine (neck)?

[X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

Pain with palpation over the trapezius muscle. Pain with palpation

over

the cervical paraspinous processes.

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

Does the Veteran have radicular pain or any other signs or symptoms due to

radiculopathy?

[X] Yes [ ] No

If yes, complete the following section:

a. Indicate location and severity of symptoms (check all that apply):

Constant pain (may be excruciating at times)

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Left upper 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

Paresthesias and/or dysesthesias

Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ]

Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe

Numbness

Right upper extremity: [ ] None [X] Mild [ ] Moderate [ ]

Severe

Left upper 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 C5/C6 nerve roots (upper radicular group)

[X] Involvement of C7 nerve roots (middle radicular group)

[X] Involvement of C8/T1 nerve roots (lower radicular group)

d. Indicate severity of radiculopathy and side affected:

Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe

Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe

8. Ankylosis

‐‐‐‐‐‐‐‐‐‐‐‐

Is there ankylosis of the spine? [ ] Yes [X] No

9. Other neurologic abnormalities

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Does the Veteran have any other neurologic abnormalities related to a

cervical spine (neck) condition (such as bowel or bladder problems due to

cervical myelopathy)?

[ ] Yes [X] No

10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

a. Does the Veteran have IVDS of the cervical spine?

[ ] Yes [X] No

11. 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?

[X] Yes [ ] No

If yes, identify assistive device(s) used (check all that apply and

indicate frequency):

Assistive Device: Frequency of use:

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

[X] Brace(s) [ ] Occasional [X] Regular [ ] Constant4/23/2015 My HealtheVet

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b. If the Veteran uses any assistive devices, specify the condition and

identify the assistive device used for each condition:

He uses a neck brace at home several days a week.

12. Remaining effective function of the extremities

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Due to a cervical spine (neck) 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.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

13. 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

14. Diagnostic testing

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

a. Have imaging studies of the cervical spine been performed and are the

results available?

[X] Yes [ ] No

If yes, is arthritis (degenerative joint disease) documented?

[X] Yes [ ] No

b. Does the Veteran have a 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?

15. Functional impact

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Does the Veteran's cervical spine (neck) condition impact on his or her

ability to work?

[X] Yes [ ] No

If yes, describe the impact of each of the Veteran's cervical spine

(neck) conditions, providing one or more examples:

He has missed about 1/3 to 1/2 of his work days due to his neck and

back pain in the last year.

I have many other ailments that were reviewed, I can post those as well. However the DOD is only looking at my neck as unfitting.