Jump to content
VA Disability Community via Hadit.com

VA Disability Claims Articles

Ask Your VA Claims Question | Current Forum Posts Search | Rules | View All Forums
VA Disability Articles | Chats and Other Events | Donate | Blogs | New Users

  • hohomepage-banner-2024-2.png

  • 27-year-anniversary-leaderboard.png

    advice-disclaimer.jpg

  • donate-be-a-hero.png

  • 0

C&p Exams All Done

Rate this question


ssgtob1

Question

Hi all,

I am new here and have a quick question about my C&P exams. I have many, and can copy and paste them all here if need be, but they all state: Does the Veteran's wrist condition impact his or her ability to work? [] Yes [x ] No

Does that mean that I wont be rated for any of these conditions?

Link to comment
Share on other sites

  • Answers 22
  • Created
  • Last Reply

Top Posters For This Question

Top Posters For This Question

Recommended Posts

  • 0

1. Diagnosis

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

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

spine (neck) condition?

[X] Yes [ ] No

Cervical Spine Common Diagnoses:

[ ] Ankylosing spondylitis

[X] Cervical strain

[X] Degenerative arthritis of the spine

[ ] Intervertebral disc syndrome

[ ] Segmental instability

[ ] Spinal fusion

[X] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

Diagnosis #1: Cervical sprain

ICD code: 847.0

Date of diagnosis: 2005

Diagnosis #2: Cervical disc degeneration

ICD code: 722.4

Date of diagnosis: 2014

Diagnosis #3: Cervical spinal stenosis

ICD code: 723.0

Date of diagnosis: 2014

2. Medical history

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

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

spine (neck) condition (brief summary):

The Veteran has a history of a head injury in 2005. He reports that while

on a F 16 he was knocked out by a piece of equipment. He reports that he

fell to the ground and has had neck pain intermittently since this time.

The Veteran reports that he was treated with medication and then referred

for physical therapy. He continues to have neck pain. X rays done for this

exam show degenerative changes and stenosis of the C spine.

3. Flare-ups

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

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

spine (neck)?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact of flare-ups in

his or her own words:

The Veteran reports that his neck pain will flare up with sitting and

turning his neck to much.

The Veteran's neck pain will flare up with reamining in once position

for a prolonged period of time.

4. Initial range of motion (ROM) measurements

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

a. Select where forward flexion ends (normal endpoint is 45 degrees):

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

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

b. Select where extension ends (normal endpoint is 45 degrees):

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

c. Select where right lateral flexion ends (normal endpoint is 45 degrees):

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

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

d. Select where left lateral flexion ends (normal endpoint is 45 degrees):

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

[X] Other: 60

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

[X] Other: 60

e. Select where right lateral rotation ends (normal endpoint is 80 degrees):

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

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

f. Select where left lateral rotation ends (normal endpoint is 80 degrees):

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

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

Select where objective evidence of painful motion begins:

[ ] No objective evidence of painful motion

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

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

g. If ROM does not conform to the normal range of motion identified above

but

is normal for this Veteran (for reasons other than a cervical spine

(neck)

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. Select where post-test forward flexion ends:

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

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

c. Select where post-test extension ends:

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45 or greater

d. Select where post-test right lateral flexion ends:

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

[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45 or greater

e. Select where post-test left lateral flexion ends:

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

[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45 or greater

[X] Other: 60

f. Select where post-test right lateral rotation ends:

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

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

g. Select where post-test left lateral rotation ends:

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

[X] 30 [ ] 35 [ ] 40 [ ] 45 [ ] 50 [ ] 55

[ ] 60 [ ] 65 [ ] 70 [ ] 75 [ ] 80 or greater

6. Functional loss and additional limitation in ROM

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

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

(neck) following repetitive-use testing?

[ ] Yes [X] No

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

the cervical spine (neck)?

[X] Yes [ ] No

c. 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 factors of disability below:

[X] Less movement than normal

[X] Excess fatigability

[X] Pain on movement

7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)

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

a. Does the Veteran have localized tenderness or pain to palpation for

joints/soft tissue of the cervical spine (neck)?

[X] Yes [ ] No

b. Does the Veteran have muscle spasm of the cervical spine resulting in

abnormal gait or abnormal spinal countour?

[ ] Yes [X] No

c. Does the Veteran have muscle spasms of the cervical spine not resulting

in

abnormal gait or abnormal spinal countour?

[X] Yes [ ] No

d. Does the Veteran have guarding of the cervical spine resulting in

abnormal

gait or abnormal spinal countour?

[ ] Yes [X] No

e. Does the Veteran have guarding of the cervical spine not resulting in

abnormal gait or abnormal spinal countour?

[ ] Yes [X] No

8. Muscle strength testing

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

a. 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

Elbow flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Elbow extension

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Wrist flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Wrist extension:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Finger Flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Finger Abduction

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

b. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

9. Reflex exam

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

Rate deep tendon reflexes (DTRs) according to the following scale:

0 Absent

1+ Hypoactive

2+ Normal

3+ Hyperactive without clonus

4+ Hyperactive with clonus

Biceps:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Triceps:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Brachioradialis:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

10. Sensory exam

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

Provide results for sensation to light touch (dermatomes) testing:

Shoulder area (C5):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Inner/outer forearm (C6/T1):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Hand/fingers (C6-8):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

11. Radiculopathy

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

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

radiculopathy?

[X] Yes [ ] No

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: [X] None [ ] 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)

d. Indicate severity of radiculopathy and side affected:

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

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

12. Ankylosis

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

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

13. 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

14. Intervertebral disc syndrome (IVDS) and incapacitating episodes

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

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

[ ] Yes [X] No

15. 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?

[ ] Yes [X] No

16. 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

17. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

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

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?

[ ] Yes [X] No

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

complications, conditions, signs or symptoms?

[ ] Yes [X] No

18. 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?

[ ] Yes [X] No

19. Functional impact

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

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

ability to work?

[ ] Yes [X] No

20. REMARKS

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Neck strain

Diagnosis: Cervical strain, Cervical disc degeneration, Cervical spinal

stenosis

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

Link to comment
Share on other sites

  • 0

1. Diagnosis

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

Does the Veteran now have or has he/she ever had a shoulder and/or arm

condition?

[X] Yes [ ] No

Diagnosis #1: Shoulder impingement

ICD code: 726.2

Date of diagnosis: 2008

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

Diagnosis #2: Right shoulder tendonitis

ICD code: 726.11

Date of diagnosis: 2008

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

2. Medical history

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

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

shoulder and/or arm condition (brief summary):

The Veteran reports a history of right shoulder pain starting in 2008.

He states that his shoulder was injured while lifting. He was seen

and

diagnosed with tendonitis in his right shoulder and treated with

physical therapy. He reports that since his injury he continues to

have right shoulder pain that is aggravated by lifting raising his

arms

above his head.

The Veteran's left shoulder pain started in 2008. He denies any

specific injury to his shoulder reports that his left shoulder pain is

less painful that his right. He was diagnosed with an impingement on

his left shoulder and treated with medications as need. He has not

had

any further treatment for this condition.

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:

The Veteran reports that his bilateral shoulder pain will flare-up

with raising his arms above his head and doing arm circles which he

tries to avoid.

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 [X] 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 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 180

b. Right 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 [ ] 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 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 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 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 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 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 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 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [X] 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 [ ] 80 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [X] 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

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 [X] 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 [ ] 75 [ ] 80 [ ] 85 [X] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [ ] 170

[ ] 175 [ ] 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 [ ] 85 [ ] 90 [ ] 95 [ ] 100

[ ] 105 [ ] 110 [ ] 115 [ ] 120 [ ] 125 [ ] 130 [ ] 135

[ ] 140 [ ] 145 [ ] 150 [ ] 155 [ ] 160 [ ] 165 [X] 170

[ ] 175 [ ] 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 [X] 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?

[ ] Yes [X] 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 [ ] Left [X] Both

[X] Excess fatigability [ ] Right [ ] Left [X] 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 [ ] Left [X] Both

b. Does the Veteran have guarding of either shoulder?

[X] Yes [ ] No

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

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: [X] 5/5 [ ] 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: [X] 5/5 [ ] 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.)

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

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

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.)

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

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.)

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

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.)

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

11. History and specific tests for instability/dislocation/labral pathology

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

a. Is there a history of mechanical symptoms (clicking, catching, etc.)?

[X] Yes [ ] No

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

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.)

[ ] 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?

[ ] Yes [X] No

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

arthroscopic or other shoulder surgery?

[ ] Yes [X] No

14. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

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

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?

[ ] 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?

[ ] Yes [X] No

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

b. Are there any other significant diagnostic test findings and/or results?

[ ] Yes [X] No

17. Functional impact

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

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

[ ] Yes [X] No

18. REMARKS

-----------

a. Remarks, if any:

The V file was reviewed.

Claimed condition: Left shoulder impingement, Right shoulder tendonitis

Diagnosis: Left shoulder impingement, Right shoulder tendonitis

Prognosis: This is a stable chronic condition

Evidence: STRs, Clinical history

External rotation 75 degrees right shoulder 80 degrees left shoulder

Internal rotation 80 degrees bilateral shoulders.

Link to comment
Share on other sites

  • 0

SECTION I: Diagnosis:

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

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

nose, throat, larynx, or pharynx condition? (This is the condition the

Veteran is claiming or for which an exam has been requested)

[X] Yes [ ] No

[X] Chronic sinusitis ICD code: 473.9 Date of diagnosis: 2007

[X] Deviated nasal septum (traumatic)

ICD code: 470 Date of diagnosis: 2007

SECTION III: Nose, throat, larynx or pharynx conditions

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

Does the Veteran have any of the following nose, throat, larynx or pharynx

conditions?

[X] Yes [ ] No

[X] Sinusitis

[X] Deviated nasal septum (traumatic)

1. Sinusitis

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

a. Indicate the sinuses/type of sinusitis currently affected by the

Veteran's

chronic sinusitis (check all that apply):

[ ] None [ ] Maxillary [ ] Frontal

[ ] Ethmoid [ ] Sphenoid [X] Pansinusitis

b. Does the Veteran currently have any findings, signs or symptoms

attributable to chronic sinusitis?

[X] Yes [ ] No

If yes, check all that apply:

[ ] Chronic sinusitis detected only by imaging studies (see Diagnostic

testing section)

[X] Episodes of sinusitis

[X] Near constant sinusitis

If checked, describe frequency:

Daily symptoms with exacerbation of infections every 2-3 months.

[X] Headaches

[X] Pain of affecte

d sinus

[X] Tenderness of affected sinus

[ ] Purulent discharge

[ ] Crusting

[X] Other

For all checked conditions, describe:

Constant frontal hedaches with tenderness & pain and tenderness over

all

sinuses,increased with bending head foreward.Also difficulty breathing

through both nares.The veteran relates that when he experiences a

recurrence of exacerbation of his chronic sinus infections,he is

incapacitated for a few days and not able to work.

c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis

characterized

by headaches, pain and purulent discharge or crusting in the past 12

months?

[X] Yes [ ] No

If yes, provide the total number of non-incapacitating episodes over the

past 12 months:

[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [X] 7 or more

d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring

prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months?

[ ] Yes [X] No

NOTE: For VA purposes, an incapacitating episode of sinusitis means one

that requires bed rest and treatment prescribed by a physician.

If yes, provide the total number of incapacitating episodes of sinusitis

requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12

months:

[ ] 1 [ ] 2 [ ] 3 or more

e. Has the Veteran had sinus surgery?

[X] Yes [ ] No

If yes, specify type of surgery:

[ ] Radical (open sinus surgery) [X] Endoscopic [X] Other: Nasal

septoplasty X 2

Type of procedure, sinuses operated on and side(s):

Bilateral sinus surgery to open all sinus passagways to nasal

turbinates.Also nasal septoplasty.Surgeries in 2008 and 2009.Surgical

reports not available at this time.

Date(s) of surgery (if repeated sinus surgery, provide all dates of

surgery):

2008 and 2009

If Veteran has had radical sinus surgery, did chronic osteomyelitis

follow

the surgery?

[ ] Yes [ ] No

f. Has the Veteran had repeated sinus-related surgical procedures performed?

[X] Yes[ ] No

4. Deviated nasal septum (traumatic)

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

a. Is there at least 50% obstruction of the nasal passage on both sides due

to traumatic septal deviation?

[ ] Yes [X] No

b. Is the Veteran's deviated septum traumatic?

[X] Yes [ ] No

c. Is there complete obstruction on left side due to traumatic septal

deviation?

[ ] Yes [X] No

d. Is there complete obstruction on right side due to traumatic septal

deviation?

[ ] Yes [X] No

6. Other pertinent physical findings, scars, complications, conditions,

signs

and/or symptoms

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

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?

[ ] 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?

[ ] Yes[X] No

c. Does the Veteran have loss of part of the nose or other scars of the nose

exposing both nasal passages?

[ ] Yes[X] No

d. Does the Veteran have loss of part of the nose or other scars causing

loss

of part of one ala?

[ ] Yes[X] No

e. Does the Veteran have loss of part of the nose or other scars causing

other obvious disfigurement?

[ ] Yes[X] No

SECTION IV: Diagnostic testing

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

a. Have imaging studies of the sinuses or other areas been performed?

[X] Yes[ ] No

[ ] Magnetic resonance imaging (MRI) Date:

Results:

[X] Computed tomography (CT) Date: Multiple 2004-2010

Results:

Frontal and Left Maxillary sinusitis.Last CAT scan suggestive of a

pansinusitis.

[ ] X-rays:

Date:

Results:

[ ] Other:

Date:

Results:

b. Has endoscopy been performed?: Yes

If yes, complete the following:

If yes, check all that apply:

[X] Nasal endoscopy Date: 2007,2008 & 2010

Results:

Not available,but resulted in Functional Endoscopic Surgeries.

[ ] Laryngeal endoscopy Date:

Results:

[ ] Bronchoscopy Date:

Results:

[ ] Other endoscopy Date:

Results:

c. Has the Veteran had a biopsy of the larynx or pharynx?: No

d. Has the Veteran had pulmonary function testing to assess for upper airway

obstruction due to laryngeal stenosis?: No

e. Are there any other significant diagnostic test findings and/or results?:

No

SECTION V: Functional impact and remarks

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

1. Functional impact

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

Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact

his or her ability to work?

[ ] Yes [X] No

2. Remarks, if any:

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

Current Case. VBMS available and was reviewed.The veteran was noted to have

a deviated nasal septum on ENT examination in 2007.The etiology of the

deviated nasal septum has not been established but is considered in most

cases to be traumatic.The veteran denies any clinical history of allergies.

CC: Sinusitis,Allergies,Status Post Septoplasty,Deviated septum, Sinusitus

DX:Chronic Sinusitis, Deviated Septum

RAT:Documented with CAT scans of the sinuses,and Functional Endoscopic Sinus

Surgeries x 2 .The veteran denies any clinical history of allergies.

PROG:Chronic not resolved with Rx and sinus surgeries

Link to comment
Share on other sites

  • 0

I can only give an opinion on the conditions I am familiar with.

TBI service connection but at 0%.

Migraine service connection at 30%

Mental health 0 or 10%.

If you have other records in your medical file that would support a higher rating for any of those then it's possible the rater may go with that evidence, but those are the numbers I see based on the C&P.

Link to comment
Share on other sites

  • 0

Ive never seen so c@ps...

My moneys on an total of 90% rating

Did you mean that you have never seen so many C&P's? Did you arrive at 90% based off of the amount of the claims or what they actually are?

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...

Important Information

Guidelines and Terms of Use