Jump to content
Using an Ad Blocker? Consider adding HadIt.com as an exception. Hadit.com is funded through advertising, ad free memberships, contributions and out of pocket. ×
  • 0

Peripheral Neuropathy C&p Exam -- Rating?


philusmc
This thread is over 365 days old and has been closed.

Please post your question as a New Topic by clicking this link and choosing which forum to post in.

For almost everything you are going to want to post in VA Claims Research.

If this is your first time posting. Take a moment and read our Guidelines. It will inform you of what is and isn't acceptable and tips on getting your questions answered. 

 

Remember, everyone who comes here is a volunteer. At one point, they went to the forums looking for information. They liked it here and decided to stay and help other veterans. They share their personal experience, providing links to the law and reference materials and support because working on your claim can be exhausting and beyond frustrating. 

 

This thread may still provide value to you and is worth at least skimming through the responses to see if any of them answer your question. Knowledge Is Power, and there is a lot of knowledge in older threads.

 

spacer.png

Question

I Had My C&p Exam Last Week And I'd Appreciate Any Feedback On My Exam Summary. Semper Fi

Diabetic Sensory-Motor Peripheral Neuropathy

Disability Benefits Questionnaire

Name of patient/Veteran: HOLLOWAY, Phillip Lamar

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 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 been diagnosed with diabetic

peripheral neuropathy?

[X] Yes [ ] No

Diagnosis #1: Diabetic neuropathy

ICD code: 357.2

Date of diagnosis: 2011

2. Medical history

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

a. Does the Veteran have diabetes mellitus type I or type II?

[X] Yes [ ] No

b. Describe the history (including cause, onset and course) of the Veteran's

diabetic peripheral neuropathy:

The veteran states he was diagnosed with Diabetes about 10 years ago. He

states he started getting numbness, tingling and burning sensations in his

bilateral forefeet about 2011. He states this is worse at night and often it

will wake him up while sleeping. He states he is now on Gabapentin daily for

his symptoms.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

c. Dominant hand

[X] Right [ ] Left [ ] Ambidextrous

3. Symptoms

-----------

a. Does the Veteran have any symptoms attributable to diabetic peripheral

neuropathy?

[X] Yes [ ] No

If yes, indicate symptoms' location and severity (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

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower 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

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower 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

Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Numbness

Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe

b. [ ] Other symptoms (describe symptoms, location and severity):

No response provided.

4. Neurologic exam

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

a. Strength

Rate strength according to the following scale:

0/5 No muscle movement

1/5 Visible muscle movement, but no joint movement

2/5 No movement against gravity

3/5 No movement against resistance

4/5 Less than normal strength

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

Grip:

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

Pinch (thumb to index finger):

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

Knee 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

Knee 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

Ankle plantar 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

Ankle dorsiflexion:

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. Deep tendon reflexes (DTRs)

Rate reflexes according to the following scale:

0 Absent

1+ Decreased

2+ Normal

3+ Increased without clonus

4+ Increased 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+

Lef

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

Brachioradialis:

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

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

Knee:

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

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

Ankle:

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

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

c. Light touch/monofilament testing results:

Shoulder area:

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

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

Inner/outer forearm:

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

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

Hand/fingers:

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

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

Knee/thigh:

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

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

Ankle/lower leg:

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

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

Foot/toes:

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

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

d. Position sense (grasp index finger/great toe on sides and ask patient to

identify up and down movement)

[X] Not tested

e. Vibration sensation (place low-pitched tuning fork over DIP joint of

index

finger/IP joint of great toe)

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

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

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

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

f. Cold sensation (test distal extremities for cold sensation with side of

tuning fork)

[X] Not tested

g. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

h. Does the Veteran have trophic changes (characterized by loss of extremity

hair, smooth, shiny skin, etc.) attributable to diabetic peripheral

neuropathy?

[X] Yes [ ] No

If yes, describe:

1.) Dystrophic toe-nails.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

5. Severity

-----------

a. Does the Veteran have an upper extremity diabetic peripheral neuropathy?

[ ] Yes [X] No

b. Does the Veteran have a lower extremity diabetic peripheral neuropathy?

[X] Yes [ ] No

If yes, indicate nerve affected, severity and side affected:

Sciatic nerve

Right: [ ] Normal [X] Incomplete paralysis [ ] Complete

paralysis

If Incomplete paralysis is checked, indicate severity:

[X] Mild [ ] Moderate [ ] Moderately Severe

[ ] Severe, with marked muscular atrophy

Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis

If Incomplete paralysis is checked, indicate severity:

[X] Mild [ ] Moderate [ ] Moderately Severe

[ ] Severe, with marked muscular atrophy

Femoral nerve (anterior crural)

Right: [X] Normal [ ] Incomplete paralysis [ ] Complete

paralysis

Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis

6. 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

7. Diagnostic testing

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

a. Have EMG studies been performed?

[ ] Yes [X] No

b. If there are other significant findings or diagnostic test results,

provide dates and describe:

HgA1c

6.5% - 06/14/2012

6.5% - 02/04/2013

7.4% - 08/22/2013

6.4% - 07/28/2014

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

8. Functional impact

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

Does the Veteran's diabetic peripheral neuropathy impact his or her ability

to work?

[ ] Yes [X] No

9. Remarks, if any:

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

1.) Mild diabetic peripheral neuropathy of the distal bilateral lower

extremities.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

****************************************************************************

COMPENSATION AND PENSION EXAMINATION

MEDICAL OPINION

====================================

A STANDARD MEDICAL OPINION WAS REQUESTED.

PROVIDERS RESTATEMENT OF REQUESTED MEDICAL OPINION.

THIS IS NOT THE MEDICAL OPINION ITSELF:

Is it as likely as not that the veteran's Neuropathy of the lower

extremities

was caused by his Service Connected Diabetes.

Is it due to or a result of Service Connected Diabetes?

WERE PRIVATE MEDICAL RECORDS REVIEWED: No

WERE SERVICE MEDICAL RECORDS REVIEWED: No

WERE VETERANS ADMINISTRATION RECORDS REVIEWED: Yes

WERE OTHER RECORDS REVIEWED: No

(STANDARD EXAMINERS MEDICAL OPINION)

THE CONDITION/DISABILITY

Is it as likely as not that the veteran's Neuropathy of the lower

extremities

was caused by his Service Connected Diabetes.

IT IS AS LEAST AS LIKELY AS NOT (50/50 PROBABILITY) CAUSED BY OR A RESULT OF

Service Connected Diabetes.

RATIONALE FOR OPINION GIVEN:

The veteran has had diabetes for approximately 10 years. His Hga1c levels

show spikes indicating less than optimal control. His current complaint of

neuropathic like symptoms to the distal feet is consistent with early onset

mild diabetic neuropathy.

It is as least as likely as not (50/50 probability) that the veteran's

Neuropathy of the lower extremities was caused by or is related to his

Service Connected Diabetes.

Link to comment
Share on other sites

  • Answers 1
  • Created
  • Last Reply

Top Posters For This Question

Popular Days

Top Posters For This Question

1 answer to this question

Recommended Posts

  • 0
  • HadIt.com Elder

I think I see 10% probably both feet. The VA rated my PN for each limb. I got 10% due to pain and some numbness. I had some problems because my upper PN was DX'ed

before I actually had DX for DMII. I got 10% in each limb but actually my upper is some kind of neuropathy probably more related to my neck. It is ten times worse than my feet and they hurt. Do your feet ever feel like blocks of painful wood? You know the PN starts in feet and hands and then works towards the center. The worst danger is that you get a cut or abrasion on your foot and you don't feel it until it gets infected. I got a staff infection and because of the PN it took forever to heal. Regardless of your rating take care of your feet. I let some quack podiatrist do something invasive to my left foot which was very "minor". I got an infection so bad I had an operation and my foot is still not normal 3-4 years later. There was a guy at the post office where I worked who had DMII. He just would not attempt to control his eating. He got his foot cut off and then died later on about 2 years. When they give you 10% it does not compensate you at all compared to the pain and danger you are in of losing a foot. We have a vet here who drops by named Terry. He has 40% in each lower limb. That must be hell, but he soldiers on somehow. I can't even stand in line at the airport or sometimes grocery shopping. I am riding around in a scooter because my feet hurt so bad.

John

Link to comment
Share on other sites

  • veterans-crisis-line.jpg
    The Veterans Crisis Line can help even if you’re not enrolled in VA benefits or health care.

    CHAT NOW

  • Advertisemnt

  • question-001.jpegLooking for Answers? Here are tips for finding the answers you seek.

     

    All VA Claims questions should be posted on our forums. To post, you must register. Registration is free. You can register for a free account here.

     

    You can read the forums without registering.

     

    Tips on posting on the forums.
     

    1. Post a clear title like ‘Need help preparing PTSD claim’ or “VA med center won’t schedule my surgery” instead of ‘I have a question.
    2. Knowledgeable people who don’t have time to read all posts may skip yours if your need isn’t clear in the title. I don’t read all posts every login and will gravitate towards those I have more info on.
    3. Use paragraphs instead of one massive, rambling introduction or story. Again – You want to make it easy for others to help. If your question is buried in a monster paragraph, there are fewer who will investigate to dig it out.

     

    Leading to:

     

    Post straightforward questions and then post background information.

     

    Examples:
     
    • A. I was previously denied for apnea – Should I refile a claim?
      • Adding Background information in your post will help members understand what information you are looking for so they can assist you in finding it.
    • I was diagnosed with apnea in service and received a CPAP machine, but the claim was denied in 2008. Should I refile?
       
    • B. I may have PTSD- how can I be sure?
      • See how the details below give us a better understanding of what you’re claiming.
        • I was involved in a traumatic incident on base in 1974 and have had nightmares ever since, but I did not go to mental health while enlisted. How can I get help?

     

    This gives members a starting point to ask clarifying questions like “Can you post the Reasons for Denial from your claim?” etc.

     

    Note:

     

    • Your first posts on the board may be delayed before they appear as they are reviewed.
    • This process does not take long.
    • Your first posts on the board may be delayed before they appear as they are reviewed. The review requirement will usually be removed by the 6th post. However, we reserve the right to keep anyone on moderator preview.
    • This process allows us to remove spam and other junk posts before hitting the board. We want to keep the focus on VA Claims, and this helps us do that.
  • Most Common VA Disabilities Claimed for Compensation:   

    tinnitus-005.pngptsd-005.pnglumbosacral-005.pngscars-005.pnglimitation-flexion-knee-005.pngdiabetes-005.pnglimitation-motion-ankle-005.pngparalysis-005.pngdegenerative-arthitis-spine-005.pngtbi-traumatic-brain-injury-005.png

  • Advertisemnt

  • VA Watchdog

  • Advertisemnt

  • Ads

  • Can a 100 percent Disabled Veteran Work and Earn an Income?

    employment 2.jpeg

    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

×
×
  • Create New...

Important Information

{terms] and Guidelines

<——>