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Question
COOL BREEZE
With a current claim pending at the decision stage in Phoenix, I am trying to contemplate my chances of going from a current rating of 70% to 100%.
Last time I had a claim, I noticed that there was a statement saying "Veteran spoke of chronic fatigue, drowsiness and tiredness. However he didn't make it clear if he was seeking service connection. So, I put in a claim for chronic fatigue caused by all the service connected medications I am on.
Also, I have a claim for my cervical fusion in July with medical evidence that I was off for over 7 months for incapacitating Episodes( rating doctor stated I had IDS, however no episode having a total duration of 6 weeks or more which is 60%. I had faxed and mailed this info to the VA with proof I had 3 months off for bed rest from the surgery plus the other 4 months that would give me the 60 % or possible 100%. Also, I was just admitted to the hospital again because of the neck pain that returned.
Also-Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition?
X Yes
Degenerative arthritis of the spine
X Other Diagnosis
Diagnosis #1: C5-C6 and C6-C7 Degenerative disc disease with C7 radiculopathy,
S/P C5-6 and C6-C-7 antercervial discectomy and fusion with PEEK cages.
Veteran states that he injured his neck after a helicopter crash in 1990. Since this injury, Veteran states he has "many other" neck injuries and was diagnosed with "chronic cervical strain." He had "extremely severe pain" radiating to both arms. After failure of epidural steroid injections, he had and anterior cervical fusion of the C5-C^ and C6-C7 at Tucson Medical Center, Tucson, Arizona on 7/17-13. Since his surgery, Veteran continued with constant 9-10/10 pain aggravated by neck movement. He has recurrence of with radicular pain to both hands 1 month after surgery.
Initial range of motion (ROM) measurements
forward flexion ends
X 15 degrees
objective evidence of painful motion begins
X 10 degrees
Extension ends
X 5 degrees
Objective evidence of painful motion begins:
X 5 degrees
Right lateral flexion ends
X 10 degrees
evidence of painful motion begins
X 10 degrees
left lateral flexion ends
X 5 degrees
objective evidence of painful motion begins
X 5 degrees
right lateral rotation ends
X 10 degrees
objective evidence of painful motion begins
X 10 degrees
left lateral rotation ends
X 10 degrees
objective evidence of painful motion begins
X 10 degrees
If ROM does not conform to the normal range of motion listed above but is normal for this Veteran ( for reasons other than a cervical spine (neck) condition, such as age, body habitus, neurologic disease) explain:
Veteran had guarded movement of his neck. He appeared to demonstrate greater mobility, but still limited movement of neck that measure with active range of motion measurements.
5. ROM measurements after repetitive use testing
a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
X Yes
Select where post-test forward flexion ends
X 15 degrees
Post-test extension ends:
X 5 degrees
post-test right lateral flexion ends:
X 10 degrees
post -test left lateral flexion ends
X 5 degrees
post test right lateral flexion ends:
X 10 degrees
post test left lateral rotation ends:
X 10 degrees
Does the Veteran have any functional loss and/ or functional impairment of the cervical spine (neck)
X Yes
If the Veteran has functional loss, functional impairment and/or additional limitation of ROM of the cervical spine (neck) after repetitive use, indicate the contributing factures of disability below
X Less movement than normal
X Pian on movement
Muscle strength testing
Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
X Yes
Indicate location and severity of symptoms
Constant pain(may be excruciating at times
Intermittent pain (usually dull)
Right & left upper extremity
X Mild
Indicate nerve roots involved: (Check all that apply)
X Involvement pf C5/C6 nerve roots (upper radicular group)
Indicate severity of radiculopathy and side affected:
Right & left
X Mild
Intervertebral disc syndrome (IVDS) and incapaciting episodes
A. Does the Veteran have IVDS of the cervical spine?
X Yes
****Note- I submitted proof for this claim that I had 181 days off from work with Incapacitating episodes with signed copies from doctor who prescribed each ocurrance. I l also provided a copy from rating manual that showed 6 weeks or more of bed rest were entitled to a 60% rating and that per guide lines I should be rated at the minimum of 60-100%!!!
Veteran had guarded movements of his neck. Left anterior 7.5 cm x 0.5cm healed, non tender, surgical, cervical scar. No cervical paraspinous muscle tenderness. O'Donohue's maneuver considered not reliable due to diminished effort. Breakaway weakness noted at triceps and biceps. Diminished effort for grip testing. Normal sensory exam of bilateral upper extrmeties. Phalen's and Tinnnel's negative bilaterally
At C4-5 there is mild relative disc space narrowing and small ventral osteophyte formation. At C5-C6 an anterior plate, interbody screws, and intervertebral disc spacers are present. No lucencies about the screws are noted to suggest loosening.
Does the Veterans cervical spine (neck) condition impact on his ability to work?
X Yes
If yes, describe the impact of each of the Veteran's cervical spine (neck)conditions, providing one or more examples:
Cannot reach above shoulder level or perform overhead work.
Seen for cervical spine and lumbar spine pain. Report indicated EMG showing "evidence of C7 nerve root irritation as well as carpal tunnel and cubital tunnel."
Also the doctor has stated if I had a pain from my shoulders arms from the spine-I stated severe. Then I have carpal tunnel per EMG
I think they only give like 20% for arms including hands, not sure about the nerves,
"MRI of the cervical spine, dated 511/1 3/ reveals degenerative disc disease of the cervical of the cervical spine. Patient has a disc osteo-right complex at C5-6 with left greater than right foraminal narrowing. Patient has foraminal narrowing bilaterally at C6-7.
Assessment
1. Cervical Radiculopathy 723.4
2. Cervical Disc Degeneration 722.4
3. Cervical Spine Stenosis 723.0
4. Cervical Spondylosis 721.0"
X Foot injuries- Fracture left & right 5th toes***Note this is a change in diagnosis and more accurately reflects the Veterans service connected bilateral foot conditions
Other foot conditions (specify): Degenerative Joint disease, left great MTP joint **Note this is a separate condition, and is not a progression of the Veteran's service connected bilateral foot condition
Veteran fractured right toe in 1989
left 5th toe
Callus formation lateral aspect of MTP right 5th toe No motion loss.
Right 5th toe
Callus formation lateral aspect of MTP right 5th toe No motion loss
Assistive device
X-Cane X occasional
Degenerative or traumatic arthritis -left foot
There is a bunion deformity of the great toe. There is some metatarsus adductus of the 2nd through the 4th toes as well. There are mild degenerative findings of the great toe MTP joint
.
There is an Achilles insertion site ethesophyte.
Mild Degenerative findings of the great toe MTP joint
3 weight bearing views of the right foot were obtained. Comparison 12/14/2011
There is a bunion deformity of the great toe. There is some metatarsus adductus of the 2nd through the 4th toes as well.
Calcaneal pitch is normal. There is an Achilles insertion site ethesophyte.
There are atherosclerotic vascular calcifications. Correlate clinically in regards to any evidence for diabetes.
Deformity of the small toe proximal phalanx head and nek is compatible with a healed fracture site.
Does the Veterans foot condition impact his or her ability to work?
X Yes
Cannot continously stand/walk>30 minutes at a time
Seen for blister R foot
Assessment "Fx small toe L foot
x ray report-left foot "Comminuted fracture of proxima 5th phalanx
Assessment: Resolving Fx of 5th digit l foot.
Evaluated for "Plantar Fasiciitis"
Seen for pes planus, calcaneal pain, and plantar fascittis
Seen for bilateral heel pain. Given bilateral heel support and "adjust arch supports
***Statement of individual Unemployability
9. Functional impact
Does the Veteran's flatfoot condition impact his or her ability to work?
X Yes
If yes describe the impact of each of the Veteran's flatfoot conditions providing one or more example's:
Cannot stand/walk continuously>30 minutes at a time.
There is minimal spurring about the great toe MTP joint.
There are flexion deformities of 2nd through fifth toes. There is a healed small toe proximal head and neck fracture.
There are minimal degenerative findings of the small toe proximal interphalangeal joint.
There is an Achilles insertion site enthesophyte.
Right Foot:
No deformities, redness, warmth, or swelling. Subjective pain to palpation over calcaneus and lateral aspect of MTP right toe and calcaneus.
Does the veteran use any assistive devices(other than corrective shoes or orthotic inserts) as a normal mode of locomotion, although occasional locomotion by other methods may be possible?
X Yes
If yes, identify assistive devices used(check all that apply and indicate frequency)
Assistive device:
X Cane
Keep in mind I had written a statement that the VA needed to Cue themselves back to 96 for deliberately stating I didn't have any feet issues-gave a 0%, and a 0% for spine as they said I didn't have any medical info stating I had any accidents such as the helicopter crash in the service as well as all the other injuries. This doctor clearly saw them. So far, I'm thinking it will be close-perhaps 90%. I also submitted the IU for as well. For one issue for the unemployabilty Doctor wrote I can't reach over my shoulders, and on the feet I can't walk or stand more than 30 minutes. Not sure if that will sway the rating board as I never saw a response if that is favorable. Currently still not working, employer has me on FMLA. Only worked 2 weeks out of the last 7 months.
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