cervical strain Depressing C&p Examination Results. Any Ideas?

Ryguy · January 14, 2015

These are the results from my C and P Exam I had on Saturday. Any ideas, I was sent back to the local VARO, from a Remand, and this is the C and P Examination requested by the Veterans Law Judge. I'm assuming I will just get denied again from the way this is reading, any thoughts or ideas will be appreciated.

I was praying for secondary or aggravation disability because my neck problems are real!! Here goes my exam.....

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran:

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

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VA TREATMENT RECORDS

VISTA WEB

VBMS

MEDICAL OPINION SUMMARY

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

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: BASED ON THEW EVALUATION OF THE VETERAN AND

THE REVIEW OF THE MEDICAL HISTORY, THE EXAMINER MUST EXPRESS AN OPINION AS

TO

WHETHER IT AS AT LEAST AS LIKELY AS NOT THAT THE VETERAN HAS ANY CURRENT

CERVICAL SPINE DISABILITY THAT IS DUE TO THE MARCH 2001 MVA OR ANY OTHER

INCIDENT OF SERVICE. THIS INCLUDES WHETHER THE VETERAN'S CURRENT NECK

DISABILITY HAD IT'S ONSET DURING SRVICE AND /OR WHETHER IT IS LIKELY OR

NOT

THAT THE VETERAN'S CURRENT DEGENERATIVE ARTHRITIS OF THE CERVICAL SPINE/

IVD

SYNDROME IS A PROGRESSION OF THE VETERAN'S REPORTS THAT HIS NECK PAIN

BEGAN

AT E TIME OF THE MARCH 2001 MVA.

b. Indicate type of exam for which opinion has been requested: CERVICAL

SPINE

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

b. The condition claimed was less likely than not (less than 50%

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: ALL OF THIS VETERAN'S STRs AS WELL AS VA TREATMENT RECORDS

WERE

REVIEWED. UNFORTUNATELY, STRs ARE SILENT FOR A COMPLAINT OF NECK PAIN IN

SERVICE BY THIS VETERAN. IT WAS NOT UNTIL A PROGRESS NOTE WRITTEN BY

ATTENDING PHYSICIAN IN ATLANTA VA IS NECK PAIN MENTIONED. PROGRESS NOTE

8/2/2006:

"6 MONTHS OF NECK PAIN".

XRAYS PERFORMED AT THAT TIME WERE READ AS NORMAL

CONFIDENTIAL Page 32 of 161

REASON FOR XRAY NOTED IN XRAY REQUEST: "2 WEEKS OF NECK PAIN"

THE ETIOLOGY OF THIS VETERAN'S CURRENT CONDITION CANNOT BE DETERMINED IN

A

COMPENSATION AND PENSION EXAM.

REGARDING STATEMENT OF DR SCHEID 12/26/07 STATING VETERAN'S CONDITION

IS

"SERVICE CONNECTED", THIS IS STRICTLY HIS OPINION WITHOUT BASIS,

SINCE HIS

PROGRESS NOTE OF 8/26/06 STATES: VETERAN COMPLAINS OF NECK PAIN OF SIX

MONTHS

DURATION. IT IS NOT UNCOMMON FOR A PCP TO TAKE A VETERAN'S DESCRIPTION

OF AN

INJURY OR ILNESS AND USE THE TERMS "SERVICE CONNECTED" WITHOUT IT

ACTUALLY

BEING SERVICE CONNECTED.

AS TO DR GUTIERREZ NOTE AT HINES VA DATED 2/2011:

NOTE STATES: "1.Continues with this SC condition. On robaxin and

tramadol/naproxen.

Seems all issue started after MVA when he was in the service. More likely

than not that this is sequelae of injury. I referred him to appeal decision

by

C&P Board since they have access to all files and records."

AGAIN,THIS IS A CASE OF A PCP USING THE TERM "SERVICE CONNECTED"

WHEN IN FACT

THE CONDITION IS NOT YET SERVICE CONNECTED. DR GUTIERREZ ALSO NOTES THAT

C&P

HAS ACCESS TO ALL FILES AND RECORDS AND IMPLIED THAT HE, HIMSELF, DOES

NOT.HENCE,THEY WERE NOT REVIEWED BY HIM.

VETERAN WAS SEPERATED FROM SERVICE IN JULY 2001 AND MADE NO MENTION UNTIL

AUGUST 2006 OVER 5 YEARS LATER OF ANY NECK PAIN. THERE IS NO NEXUS FOR

SERVICE CONNECTION IN THIS EXAMINER'S OPINION. WHICH IS THE SAME

OPINION

REACHED ON PREVIOUS OCCASIONS REGARDING VETERAN'S NECK COMPLAINTS.

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

/es/ JOANNE H PA LATKO

PA-C ORTHO

Signed: 01/10/2015 12:30

Date/Time: 10 Jan 2015 @ 0900

Note Title: C&P ORTHO SPINE

Location: EDWARD J. HINES JR. HOSPITAL

Signed By: LATKO,JOANNE H PA

CONFIDENTIAL Page 33 of 161

Co-signed By: LATKO,JOANNE H PA

Date/Time Signed: 10 Jan 2015 @ 1227

Note

LOCAL TITLE: C&P ORTHO SPINE

STANDARD TITLE: ORTHOPEDIC SURGERY C & P EXAMINATION CONSULT

DATE OF NOTE: JAN 10, 2015@09:00 ENTRY DATE: JAN 10, 2015@12:27:44

AUTHOR: LATKO,JOANNE H PA EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Neck (Cervical Spine) Conditions

Disability Benefits Questionnaire

Name of patient/Veteran:

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 (hard copy paper C-file) reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VISTA WEB

ATLANTA VA TREATMENT RECORDS

HINES VA TREATMENT RECORDS

VBMS

CONFIDENTIAL Page 34 of 161

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

[ ] 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 a cervical

spine (neck) condition?

[X] Yes [ ] No

[ ] Ankylosing spondylitis

[ ] Cervical strain

[ ] Degenerative arthritis of the spine

[X] Intervertebral disc syndrome

[ ] Segmental instability

[ ] Spinal fusion

[X] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

[X] Other Diagnosis

Diagnosis #1: CHRONIC CERVICAL STRAIN

Date of diagnosis: 2012

Diagnosis #2: NECK PAIN PER VA TREATMENT RECORDS

Date of diagnosis: 8/2/2006

Diagnosis #3: SPINAL STENOSIS

Date of diagnosis: 2012

2. Medical history

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

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

cervical spine (neck) condition (brief summary):

VETERAN GIVES HISTORY OF BEING INVOLVRD IN A MOTOR VEHICLE ACCIDENT IN

MARCH OF 2001

JUST PRIOR TO BEING DISCHARGED. HE WAS TAKEN TO THE ED AND TREATED FOR

BACK PAIN. VETERAN STATES HE NEVER SPECIFICALLY SAID THAT HIS NECK HURT,

CONSIDERING EVERYTHING TO BE HIS "BACK". VETERAN STATES NECK

CONFIDENTIAL Page 35 of 161

PAIN BECAME

BOTHERSOME ABOUT 1-2 YEARS AFTER SEPERATION WITH PAIN AND STIFFNESS. HE

NOTED DIFFICULTY GETTING OUT OF BED AND RAISING HIS OFF OF THE PILLOW.

CURRENTLY VETERAN IS BEING TRATED AT HINES VA FOR NECK AND BACK PAIN. HE

WAS SEEN RECENTLY IN HINES ED FOR HIS NECK BECAUSE HIS HOME MEDICATIONS

WERE NOT HOLDING HIM. HE HAS TAKEN A LEAVE OF ABSENCE FROM HIS CUSTOMER

SERVICE POSITION ABOUT 65 MOS AGO AND DOEWS NOT ANTICIPATE RETURNING TO

WORK. VETERAN FEELS THAT HIS NECK CONDITION WAS EXACERBATED BY HIS WORK

AS

A COOK IN SERVICE, LIFTING HEAVY POTS AND PANS. VETERAN DESCRIBES

OCCASIONAL "ELECTRICAL SHORT" TYPE OF PAIN. HE ALSO NOTES

NUMBNESS AND

TINGLING DOWN HIS RIGHT ARM WITH TINGLING IN HIS RIGHT THUMB, ALING WITH

SHOOTING PAIN WITH SPASM IN HIS NECK.

VETERAN SELT TREATS WITH ICE PACKS AND OTHER MODALITIES TO INCREASE HIS

COMFORT LEVEL.

b. Dominant hand:

[ ] Right [X] Left [ ] Ambidextrous

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

cervical

spine (neck)?

[ ] Yes [X] No

d. Does the Veteran report having any functional loss or functional

impairment of the cervical spine (neck) (regardless of repetitive use)?

[X] Yes [ ] No

If yes, document the Veteran's description of functional loss or

functional impairment in his or her own words:

VETERAN NOTES THAT AT TIMES HIS NECK PAIN IS SEVERE ENOUGH TO

PREVENT HIM FROM COOKING. HE LIVES CLOSE BY TO HIS SSISTER AND HER

FAMILY AND AT THESE TIMES THEY ARE ABLE TO ASSIST HIM.

3. Range of motion (ROM) and functional limitations

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

a. Initial range of motion

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Forward Flexion (0-45): 0 to 20 degrees

Extension (0-45): 0 to 20 degrees

Right Lateral Flexion (0-45): 0 to 20 degrees

Left Lateral Flexion (0-45): 0 to 20 degrees

Right Lateral Rotation (0-80): 0 to 50 degrees

Left Lateral Rotation (0-80): 0 to 60 degrees

CONFIDENTIAL Page 36 of 161

If abnormal, does the range of motion itself contribute to a

functional loss? [X] Yes, (please explain) [ ] No

If yes, please explain:

DIFFICULTY DRIVING AN AUTO AS HE HAS DIFFICULTY TURNING HIS NECK

TO

SEE BEHIND AND ALONG SIDE OF HIM.

Description of pain (select best response):

Pain noted on examination and causes functional loss

If noted on examination, which ROM exhibited pain (select all that

apply)?

Forward flexion, Extension, Right lateral flexion, Left lateral

flexion, Right lateral rotation, Left lateral rotation

Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on palpation

of the joint or associated soft tissue of the cervical spine (neck)?

[X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

SPINAL AND PARASPINAL TENDERNESS ON PALPATION WORSE IN RIGHT

PARASPINAL

RE

b. Observed repetitive use

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [ ] Yes [X] No

If no, please provide reason:

TOO PAINFUL

c. Repeated use over time

Is the Veteran being examined immediately after repetitive use over time?

[ ] Yes [X] No

If the examination is not being cond

ucted immediately after repetitive

use over time:

[ ] The examination supports the Veteran?s statements describing

functional loss with repetitive use over time.

[ ] The examination contradicts the Veteran?s statements describing

functional loss with repetitive use over time. Please explain.

[X] The examination neither supports nor contradicts the Veteran?s

statements describing functional loss with repetitive use over

time.

CONFIDENTIAL Page 37 of 161

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

UNABLE TO PERFORM REPETITIVE MOTION TESTING TODAY

d. Flare-ups

Is the examination being conducted during a flare-up? [ ] Yes [X] No

If no, does the Veteran report flare-ups? [ ] Yes [X] No

If the examination is not being conducted during a flare-up:

[ ] The examination supports the Veteran?s statements describing

functional loss during flare-ups.

[ ] The examination contradicts the Veteran?s statements describing

functional loss during flare-ups. Please explain.

[X] The examination neither supports nor contradicts the Veteran?s

statements describing functional loss during flare-ups.

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with flare-ups?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

VETERAN DOES NOT DESCRIBE FLARE UPS

e. Guarding and muscle spasm

Does the Veteran have localized tenderness, guarding, or muscle spasm of

the cervical spine? [X] Yes [ ] No

Muscle spasm

[ ] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[X] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Localized tenderness

[ ] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[X] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Guarding

[ ] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[X] Not resulting in abnormal gait or abnormal spinal contour

CONFIDENTIAL Page 38 of 161

[ ] Unable to evaluate, describe below:

f. Additional factors contributing to disability

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe:

Less movement than normal due to ankylosis, adhesions, etc., Weakened

movement due to muscle or peripheral nerve injury, etc.

Please describe:

LESS MOVEMENT/SLOW MOVEMENT DUE TO PAIN

4. 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