diabetes Peripheral Neuropathy C&p Exam -- Rating?

philusmc · December 14, 2014

_{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: