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C&p Exam Results

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Yawl,

If anyone can help me understand what this all means and/or where u think it may fall within the rating scale....please chime in!! I have looked at the ratings schedule but I don't know where I fit in (currently rated at 20% for cervical DDD). I do know that I'm having WAY more problems with my neck now, as compared to when I was originally rated 10yrs ago.

It is confusing to me cuz I was truly having a "bad day" when I went in for this exam. I could barely turn my neck, especially to the left, while at this exam (I actually had to call out from work for 2 days after this exam cuz I could not move). The doc also stated to me that he was supposed to have my records there to review but the VA had not sent them over to him at QTC. He actually made a call to get them sent over while I was in the room but had to leave a message.

Thanks in advance for ANY & ALL feedback cuz I NEVER type this much.... :blink:

Here's the results:

CERVICAL SPINE: No evidence of muscle spasm, guarding, weakness, loss of tone & atrophy of limbs. There is evidence of radiating pain on movement described as all movements. Tenderness described as posterior cervical region. No ankylosis of c-spine.

ROM Degree Repetitive

Flexion: 40 40 40

Extension: 41 41 41

Rt Lateral Flexion: 35 35 35

Lft Lateral Flexion: 35 35 35

Rt Rotation: 70 70 70

Lft Rotation: 70 70 70

Joint function of spine is additionally limited by the following after repetive use: pain & pain has the major functional impact. Not additionally limited by: fatigue, weakness, endurance & incoordination.

NEUROLOGICAL EXAM (SPINE): C-spine sensory function is impaired.

C7 = Sensory deficiet of left long finger.

C8 = Sensory deficiet of left ulnar side of the left ring finger & left little finger. Right biceps & triceps jerk 2+. Left biceps & triceps jerl 2+. Upper extremities show no signs of pathologic reflexes. Normal cutaneous reflexes. There are signs of Cervical IVDS. Most likely peripheral nerve is the Ulnar nerve.

DIAGNOSIS: For the VA diagnosis of Cervical Degenerative Disc Disease, the diagnosis is changed to Cervical Degenerative Disc Disease; Intervertebral Dis Syndrome, most likely affecting left Ulnar nerve (sensory component); cervical strain. This is a result of a progression of the previous diagnosis.

EXAM: Subjective factors are: pain, cervical LOM, abnormal sensation LUE. The objective factors are: established diagnosis, cervical LOM with TTP posterior cervical region, abnormal sensory findings LUE. Diagnosis is IVDS & most likely involved peripheral nerve is the left Ulnar nerve which affects the left side of the body. the IVDS does not cause any complications.

REMARKS: The effect of the conditions usual occupation is abnormal sensation left hand, cervical LOM. The effect of the condition on th eclaimant's daily activity is abnormal sensation left hand, cervical LOM.

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Newbie response (since I'm waiting for my own IVDS ROM-based ratings):

Your cervical total ROM seems to be 291, which rates at 10% ("combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees"), but I don't know how much they'll add for the neurological impact.

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Thad,

Thanks for takin the time to post a response!

This doc was obviously in a different room than I was.

Man I can't even explain how I feel right now....

I could not move my head AT ALL to the left side when I had this exam & ROM was limited MUCH more than this report states. I do walk with a limp (abnormal gait) but this doc (board certified in family practice) put that my ROM was equal for both right & left and NO abnormal gait. Also, my whole left side of my neck was in spasm & my muscles on top of my left shoulder & neck were twitching while in the exam. That's the reason why I put the results up here, cuz I was rated at 20% before for Cervical DDD & am much worse off now. After reading the results of this exam myself.....I felt that the doc just made up stuff to fill in the blanks or put someone else's exam in place of mine. The only part that is right was the nerve & pain part.

This doc was from QTC (atl). It's a shame that the VA pays QTC for exams of this calibur. I feel like a victim now and need to start figuring out how to appeal this....even though I have not recieved the official rating decision yet.

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I do believe that the VA coaches all NP's and physicians to down play the actual limitations noted in the exams. Hang in their and get all your records in order in case you need to file a NOD. Also keep all treatment records from all the medical professionals you see. Good luck.

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Yawl,

If anyone can help me understand what this all means and/or where u think it may fall within the rating scale....please chime in!! I have looked at the ratings schedule but I don't know where I fit in (currently rated at 20% for cervical DDD). I do know that I'm having WAY more problems with my neck now, as compared to when I was originally rated 10yrs ago.

It is confusing to me cuz I was truly having a "bad day" when I went in for this exam. I could barely turn my neck, especially to the left, while at this exam (I actually had to call out from work for 2 days after this exam cuz I could not move). The doc also stated to me that he was supposed to have my records there to review but the VA had not sent them over to him at QTC. He actually made a call to get them sent over while I was in the room but had to leave a message.

Thanks in advance for ANY & ALL feedback cuz I NEVER type this much.... :o

Here's the results:

CERVICAL SPINE: No evidence of muscle spasm, guarding, weakness, loss of tone & atrophy of limbs. There is evidence of radiating pain on movement described as all movements. Tenderness described as posterior cervical region. No ankylosis of c-spine.

ROM Degree Repetitive

Flexion: 40 40 40

Extension: 41 41 41

Rt Lateral Flexion: 35 35 35

Lft Lateral Flexion: 35 35 35

Rt Rotation: 70 70 70

Lft Rotation: 70 70 70

Joint function of spine is additionally limited by the following after repetive use: pain & pain has the major functional impact. Not additionally limited by: fatigue, weakness, endurance & incoordination.

NEUROLOGICAL EXAM (SPINE): C-spine sensory function is impaired.

C7 = Sensory deficiet of left long finger.

C8 = Sensory deficiet of left ulnar side of the left ring finger & left little finger. Right biceps & triceps jerk 2+. Left biceps & triceps jerl 2+. Upper extremities show no signs of pathologic reflexes. Normal cutaneous reflexes. There are signs of Cervical IVDS. Most likely peripheral nerve is the Ulnar nerve.

DIAGNOSIS: For the VA diagnosis of Cervical Degenerative Disc Disease, the diagnosis is changed to Cervical Degenerative Disc Disease; Intervertebral Dis Syndrome, most likely affecting left Ulnar nerve (sensory component); cervical strain. This is a result of a progression of the previous diagnosis.

EXAM: Subjective factors are: pain, cervical LOM, abnormal sensation LUE. The objective factors are: established diagnosis, cervical LOM with TTP posterior cervical region, abnormal sensory findings LUE. Diagnosis is IVDS & most likely involved peripheral nerve is the left Ulnar nerve which affects the left side of the body. the IVDS does not cause any complications.

REMARKS: The effect of the conditions usual occupation is abnormal sensation left hand, cervical LOM. The effect of the condition on th eclaimant's daily activity is abnormal sensation left hand, cervical LOM.

Hey Yawl, Two things; Since the doctor wasn't able to review your record prior to your exam, which they are suppose to do, you may be scheduled for another exam at a later date. Secondly, if you diagnoisis has changed to include intevertable disc syndrome you will probably get a increase. I went from 20% to 60% for change to Ivds in the lumbar area. I hope its the same for cervical.

Blackbird

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You need to get an IMO from a Neurosurgeon.

Always get a second opinion from a Doc who will carry more weight than a C and P doc.

J

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