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....
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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MLR
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....
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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