C&p Exam Notes Post Shoulder Surgery - Requested Increase

[Tampabud]

Hello all, finally was able to get my C&P exam notes from Myhealthevet. This is what I found. The VA closed my claim without ever deciding on my case. I went to the fed building in LA and talked to a representative at the VA offices, he said it was a clerical/administrative error, had me fill out a form, and told me to stand by for a response. I'm hoping (since they have a TON of evidence, just never decided) that I will hear something soonish. I am still rated 10% for shoulder sprain and bicep tendonitis, even though I had service-connected surgery that was a failure. You decide what they should do.

Name of patient/Veteran: tampabud :-)

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

Page 14 of 39

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?

[ ] Yes [X] No

If yes, list any records that were reviewed but were not

included in the

Veteran's VA claims file:

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

[X] 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 now have or has he/she ever had a shoulder

and/or arm

condition?

[X] Yes [ ] No

Diagnosis #1: TENDINITIS, LEFT SHOULDER

ICD code: 726.19

Date of diagnosis: 10/03/2012

Side affected: [ ] Right [X] Left [ ] Both

Diagnosis #2: LABRAL TEAR, LEFT SHOULDER

ICD code: 840.8

Page 15 of 39

Date of diagnosis: 10/03/2012

Side affected: [ ] Right [X] Left [ ] Both

Diagnosis #3: STRAIN OF SUPRASPINATUS TENDON

ICD code: 840.6

Date of diagnosis: 10/03/2012

Side affected: [ ] Right [X] Left [ ] Both

2. Medical history

------------------

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

Veteran's

shoulder and/or arm condition (brief summary):

Veteran was active duty in the U.S.A.F. from 1997

to 2007 and is 10 % service connected for tendon

inflammation and claims increase disability.

MRI Left shoulder 10/03/12 revealed posterior

superior labral tear and on 06/24/13 he had

L shoulder arthroscopy with anterior labral

repair and SLAP lesion debridement. The superior

labral tear was found to be "grossly unstable

and a type 3 SLAP tear which was not amendable

to repair."

Currently, veteran reports chronic increasing pain

and restricted range of motion in his left dominant

shoulder and is trying to get approved for PT near

his home. He has difficulty sleeping becuse of pain

and he awakes with throbbing pain in the left shoulder.

He is in law enforcement and is having difficulty

maintaing employment due to the nature of his job

duties. His job is trying to do reasonable accomondation.

Veteran is also s/p right shoulder surgery (work-related)

labral tear 10/2011 with full recovery but with residual

pain with full range of motion.

b. Dominant hand:

[ ] Right [X] Left [ ] Ambidextrous

3. Flare-ups

------------

Does the Veteran report that flare-ups impact the function of

the shoulder

and/or arm?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of

flare-ups in

his or her own words:

Veteran reports flare-ups

Page 16 of 39

ADDITIONAL LOSS OF ROM BILATERAL SHOULDERS DURING FLAREUPS:

DUE TO

PAIN.

(MITCHELL CRITERIA)

LEFT SHOULDER FLEXION: 0 - 85

LEFT SHOULDER ABDUCTION: 0 - 75

4. Initial range of motion (ROM) measurements

---------------------------------------------

a. Right shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [X] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [X] 180

b. Right shoulder abduction

Select where abduction ends (normal endpoint is 180

degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

Page 17 of 39

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [X] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [X] 180

c. Left shoulder flexion

Select where flexion ends (normal endpoint is 180 degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [X] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

Page 18 of 39

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [ ] 180

d. Left shoulder abduction

Select where abduction ends (normal endpoint is 180

degrees):

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [X] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [ ] 180

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[X] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [ ] 180

e. If ROM does not conform to the normal range of motion

identified above but

is normal for this Veteran (for reasons other than a shoulder

or arm

condition, such as age, body habitus, neurologic disease),

explain:

No response provided.

5. ROM measurements after repetitive use testing

------------------------------------------------

a. Is the Veteran able to perform repetitive-use testing with 3

repetitions?

[X] Yes [ ] No

b. Right shoulder post-test ROM

Page 19 of 39

Select where flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [X] 180

Select where abduction ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [X] 180

c. Left shoulder post-test ROM

Select where flexion ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [ ] 75 [ ] 80 [X] 85 [ ] 90 [ ] 95

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [ ] 180

Select where abduction ends:

[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25

[ ] 30

[ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60

[ ] 65

[ ] 70 [X] 75 [ ] 80 [ ] 85 [ ] 90 [ ] 95

Page 20 of 39

[ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130

[ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165

[ ] 170

[ ] 175 [ ] 180

6. Functional loss and additional limitation in ROM

---------------------------------------------------

a. Does the Veteran have additional limitation in ROM of the

shoulder and arm

following repetitive-use testing?

[X] Yes [ ] No

b. Does the Veteran have any functional loss and/or functional

impairment of

the shoulder and arm?

[X] Yes [ ] No

c. If the Veteran has functional loss, functional impairment

and/or

additional limitation of ROM of the shoulder and arm after

repetitive use,

indicate the contributing factors of disability below (check

all that

apply and indicate side affected):

[X] Less movement than normal [ ] Right [X]

Left [ ] Both

[X] Weakened movement [ ] Right [X]

Left [ ] Both

[X] Excess fatigability [ ] Right [X]

Left [ ] Both

[X] Pain on movement [ ] Right [ ]

Left [X] Both

7. Pain (pain on palpation)

---------------------------

a. Does the Veteran have localized tenderness or pain on

palpation of

joints/soft tissue/biceps tendon of either shoulder?

[X] Yes [ ] No

If yes, shoulder affected: [ ] Right [X] Left [ ]

Both

b. Does the Veteran have guarding of either shoulder?

[X] Yes [ ] No

If yes, shoulder affected: [ ] Right [X] Left [ ]

Both

Page 21 of 39

8. Muscle strength testing

--------------------------

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

Shoulder abduction:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Shoulder forward flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5

9. Ankylosis

------------

Does the Veteran have ankylosis of the glenohumeral articulation

(shoulder

joint)?

[ ] Yes [X] No

10. Specific tests for rotator cuff conditions

----------------------------------------------

a. Hawkins' Impingement Test (Forward flex the arm to 90 degrees

with the

elbow bent to 90 degrees. Internally rotate arm. Pain on

internal rotation

indicates a positive test; may signify rotator cuff

tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

If positive, side affected: [ ] Right [X] Left [ ]

Both

b. Empty-can test (Abduct arm to 90 degrees and forward flex 30

degrees.

Page 22 of 39

Patient turns thumbs down and resists downward force applied

by the

examiner. Weakness indicates a positive test; may indicate

rotator cuff

pathology, including supraspinatus tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

If positive, side affected: [ ] Right [X] Left [ ]

Both

c. External rotation/Infraspinatus strength test (Patient holds

arm at side

with elbow flexed 90 degrees. Patient externally rotates

against

resistance. Weakness indicates a positive test; may be

associated with

infraspinatus tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

If positive, side affected: [ ] Right [X] Left [ ]

Both

d. Lift-off subscapularis test (Patient internally rotates arm

behind lower

back, pushes against examiner's hand. Weakness indicates a

positive test;

may indicate subscapularis tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

If positive, side affected: [ ] Right [X] Left [ ]

Both

11. History and specific tests for

instability/dislocation/labral pathology

----------------------------------------------------------------

-----------

a. Is there a history of mechanical symptoms (clicking,

catching, etc.)?

[ ] Yes [X] No

b. Is there a history of recurrent dislocation (subluxation) of

the

glenohumeral (scapulohumeral) joint?

[ ] Yes [X] No

c. Crank apprehension and relocation test (With patient supine,

abduct

patient's arm to 90 degrees and flex elbow 90 degrees. Pain

and sense of

instability with further external rotation may indicate

shoulder

instability.)

Page 23 of 39

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

12. History and specific tests for clavicle, scapula,

acromioclavicular (AC)

joint, and sternoclavicular joint conditions

----------------------------------------------------------------

------------

a. Does the Veteran have an AC joint condition or any other

impairment of the

clavicle or scapula?

[ ] Yes [X] No

b. Is there tenderness on palpation of the AC joint?

[ ] Yes [X] No

c. Cross-body adduction test (Passively adduct arm across the

patient's body

toward the contralateral shoulder. Pain may indicate

acromioclavicular

joint pathology.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

13. Joint replacement and/or other surgical procedures

------------------------------------------------------

a. Has the Veteran had a total shoulder joint replacement?

[ ] Yes [X] No

b. Has the Veteran had arthroscopic or other shoulder surgery?

[X] Yes [ ] No

If yes, indicate side affected: [ ] Right [X] Left [ ]

Both

Date and type of surgery: 06/24/2013 Left shoulder

arthroscopy with

anterior labral repair and SLAP lesion debridement

c. Does the Veteran have any residual signs and/or symptoms due

to

arthroscopic or other shoulder surgery?

[X] Yes [ ] No

If yes, indicate side affected: [ ] Right [X] Left [ ]

Both

If yes, describe residuals:

Chronic pain left anterior shoulder with limited

flexion and abduction 80-90 degrees.

14. Other pertinent physical findings, complications,

conditions, signs

and/or symptoms

----------------------------------------------------------------

Page 24 of 39

-------

a. 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?

[X] Yes [ ] No

If yes, are any of the scars painful and/or unstable, or

is the total

area of all related scars greater than 39 square cm (6

square inches)?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to

any conditions

listed in the Diagnosis section above?

[X] Yes [ ] No

If yes, describe (brief summary):

Numbness and paresthesias left 4th and 5th fingers.

Sensation with monofilament wire deminished left 4th

and 5th fingers. Vibratory and position sense intact.

15. Remaining effective function of the extremities

---------------------------------------------------

Due to the Veteran's shoulder and/or arm conditions, 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)

[ ] Yes, functioning is so diminished that amputation with

prosthesis would

equally serve the Veteran.

[X] No

16. Diagnostic Testing

----------------------

a. Have imaging studies of the shoulder been performed and are

the results

available?

[X] Yes [ ] No

If yes, is degenerative or traumatic arthritis

documented?

[ ] Yes [X] No

Page 25 of 39

b. Are there any other significant diagnostic test findings

and/or results?

[X] Yes [ ] No

If yes, provide type of test or procedure, date and results

(brief

summary):

MRI SHOULDER: LEFT W/O CONTRAST

Exm Date: OCT 03, 2012@11:36

Req Phys: LEE,SAMUEL J

Impression:

1. POSTERIOR SUPERIOR LABRAL TEAR.

2. SMALL INTRASUBSTANCE TEAR AT THE MUSCULOTENDINOUS

JUNCTION OF THE SUPRASPINATUS.

3. MINIMAL IRREGULARITY OF THE GLENOHUMERAL CARTILAGE.

17. Functional impact

---------------------

Does the Veteran's shoulder condition impact his or her ability

to work?

[X] Yes [ ] No

If yes, describe the impact of each of the Veteran's shoulder

conditions

providing one or more examples:

Veteran's left shoulder condition impacts his ability to

lift, push or pull weight greater 5 lbs. He is also

unable to do reaching or overhead work with his left

arm.

18. Remarks, if any:

--------------------

No remarks provided.

[killemall]

What's 1151?

[Tampabud]

C&P exam was yesterday... again. I even had the same doctor as I did the first time around. Michael Harvey. He is a very nice person, and was very polite and professional with me. The exam results should reflect the same as they did the first time around. I will wait and see when they become available in myhealthevet blue button. He even gave me some recommendations regarding dealing with my physical therapy issues (over a year since surgery, still no PT because the VA sucks at their job). I am hoping they will finally rate my claim and close it. It has been a long and arduous journey to this point.

[killemall]

Are you hoping for 20%

[Tampabud]

My expectation is 40%, as my flexion/movement is severely limited to less than 90 degrees and it is my dominant arm. Your C&P exam results reflected a greater range at 170+, so that alone puts you in the 10% range.

[georgiapapa]

Tampa,

Just a guess. I believe you will get a minimum of 20% for your left shoulder based on your exam results and the comments by the examining doctor. Just my opinion.

Good luck to you.

[georgiapapa]

Tampa,

I hope you get 40%. Keep us posted.

Good luck