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C&p Notes Review

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Spanman

Question

So I went to the VA yesterday to get access to MyHealtheVet and was asking for my records from my C&P exam, the tech told me they had direction NOT to give Vets the notes unless they were 5 years or older. The beauty was that because the notes were already uploaded to the system "By law I have to give them to you" his words excatly. So I got my notes and I am wondering if anyone could extrapolate if they are helpful in getting an increase? I guess if anyone can help I can send it via email, not sure I can attach or want to cut and paste the entire 7 pages here...PM member

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MEDICAL RECORD

NOTE DATED: 04/07/2015 09:30

LOCAL TITLE: C&P REPORT

STANDARD TITLE: C & P EXAMINATION NOTE

VISIT: 04/07/2015 09:30 ANC CP GEN MED

Foot Conditions, including Flatfoot (Pes Planus)

Disability Benefits Questionnaire

Name of patient/Veteran:

ACE and Evidence Review

Progress Notes

Indicate method used to obtain medical information to complete this document:

[ J 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.

[ J 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.

[ J Examination via approved video telehealth

[XJ In-person examination

a. Evidence Review

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?

[X] Yes [ J No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed?

[ J Yes [XJ No

If no, check all records reviewed:

[ J Military service treatment records

[ J Military service personnel records

[ J Military enlistment examination

[ J Military separation examination

[ J Military post-deployment questionnaire

[ J Department of Defense Form 214 Separation Documents

[ J Veterans Health Administration medical records (VA treatment

records)

[ J Civilian medical records

[ J Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

[ J Other:

[XJ No records were reviewed

b. Was pertinent information from collateral sources reviewed?

[ J Yes [XJ No

1. Diagnosis

a. List the claimed condition(s) that pertain to this DBQ:

Bilateral Plantar Fasciitis

b. Select diagnoses associated with the claimed condition(s):

[X] Hammer toes

Side affected: Both

Date of diagnosis: Right 2015

Date of diagnosis: Left 2015

[X] Hallux valgus

Side affected: Both

Date of diagnosis: Right 2015

Date of diagnosis: Left 2015

[X] Plantar fasciitis

Side affected: Both

Date of diagnosis: Right 2012

Date of diagnosis: Left 2012

c. Comments (if any):

No response provided

Progress Notes

d. Was an opinion requested about this condition (internal VA only)?

[ ] Yes [X] No [ ] N/A

2. Medical history

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

condition (brief summary):

Chronic foot pain prevents even moderate walking or standing.

b. Does the Veteran report pain of the foot being evaluated on this DBQ?

[X] Yes [ J No

If yes, document the Veteran's description of pain in his or her own

words:

Burning pain after even moderate day of "normal" activity. Pain poorly

relieved by orthotics or injections.

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

[ J Yes [X] No

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

of the foot being evaluated on this DBQ (regardless of repetitive use)?

[XJ Yes [ J No

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

functional impairment in his or her own words:

Unable to walk without pain. Must use orthotics full time, even at

night if he must get up to use the bathroom.

3. Flatfoot (pes planus)

a. Does the Veteran have pain on use of the feet? [XJ Yes [ J No

If yes, indicate side affected: [ J Right [ J Left [XJ Both

If yes, is the pain accentuated on use? [XJ Yes [ J No

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

b. Does the Veteran have pain on manipulation of the feet? [X] Yes [ J No

If yes, indicate side affected: [ J Right [ J Left [XJ Both

If yes, is the pain accentuated on manipulation? [XJ Yes [ J No

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

c. Is there indication of swelling on use? [ J Yes [XJ No

d. Does the Veteran have characteristic callouses? [X] Yes [ J No

If yes, indicate side affected: [ J Right [ J Left [XJ Both

e. Effects of use of arch supports, built-up shoes or orthotics:

Tried But Remains Symptomatic

Device Side Not Relieved:

[X] Orthotics [ J Right [ J Left [X] Both

f. Does the Veteran have extreme tenderness of plantar surfaces on one or both

feet? [XJ Yes [ J No

If yes, indicate side affected: [ J Right [ J Left [XJ Both

Is the tenderness improved by orthopedic shoes or appliances?

RIGHT - [X] Yes [ J No [ J N/A

LEFT - [X] Yes [ ] No [ ] N/A

g. Does the Veteran have decreased Longitudinal arch height of one or both feet

on weight-bearing? [ J Yes [XJ No

h. Is there objective evidence of marked deformity of one or both feet

(pronation, abduction etc.)? [ J Yes [X] No

i. Is there marked pronation of one or both feet? [ J Yes [XJ No

j. For one or both feet, does the weight-bearing Line fall over or medial to

the great toe? [ J Yes [XJ No

k. Is there a Lower extremity deformity other than pes planus, causing

alteration of the weight-bearing Line? [ J Yes [XJ No

L. Does the Veteran have "inward" bowing of the Achilles tendon (i.e., hindfoot

valgus, with Lateral deviation of the heel) of one or both feet?

[X] Yes [ J No

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

m. Does the Veteran have marked inward displacement and severe spasm of the

Achilles tendon (rigid hindfoot) on manipulation of one or both feet?

[ J Yes [XJ No

n. Comments: No comments provided

4. Morton's neuroma (Morton's disease) and metatarsalgia

No response provided

5. Hammer toe

a. Which toes are affected on each side?

RIGHT:

[X] Fourth toe

LEFT:

[X] Fourth toe

b. Comments: Asymptomatic, very slight and Likely is congenital.

6. Hallux valgus

a. Does the Veteran have symptoms due to a hallux valgus condition?

[X] Yes [ J No

If yes, indicate severity:

[X] Mild or moderate symptoms

Side affected: [ J Right [ J Left [XJ Both

b. Has the Veteran had surgery for hallux valgus?

[ J Yes [XJ No

c. Comments: No comments provided

7. Hallux rigidus

No response provided

8. Acquired pes cavus (clawfoot)

No response provided

9. Malunion or nonunion of tarsal or metatarsal bones

No response provided

10. Foot injuries and other conditions

a. Does the Veteran have any foot injuries or other foot conditions not already

described?

[XJ Yes [ J No

If yes, describe the foot injury or other conditions (including

frequency and physical exam findings) and complete question b. (severity

and side affected).

Carry of heavy equipment while wearing steel toe boots resulted in foot

pain in service. Was seen multiple time with diagnosis of plantar

fascial tear syndrome bilaterally. Worsened over the years.

b. Indicate severity and side affected:

[XJ Moderately severe [ J Right [ J Left [XJ Both

c. Does the foot condition chronically compromise weight bearing?

[X] Yes [ J No

d. Does the foot condition require arch supports, custom orthotic inserts or

shoe modifications?

[X] Yes [ J No

e. Comments: Custom orthotics help some what but still has pain with walking

over 1/2 mile and unable to stand for more than 15 minutes without severe

and Lasting pain in feet bilaterally.

11. Surgical procedures

a. Has the Veteran had foot surgery (arthroscopic or open)?

[X] Yes [ J No

If yes, indicate side affected, type of procedure and date of surgery:

[X] Right foot procedure: Plantar fascial release- failed

Date of surgery: 2000

b. Does the Veteran have any residual signs or symptoms due to arthroscopic or

other foot surgery?

[ J Yes [XJ No

12. Pain

RIGHT FOOT:

Is there pain on physical exam?

[XJ Yes [ J No

If yes, (there is pain on physical exam), does the pain contribute to

functional Loss?

[XJ Yes [ J No

(Further description of Limitations requested in Section XIII below.)

LEFT FOOT:

Is there pain on physical exam?

[XJ Yes [ J No

If yes, (there is pain on physical exam), does the pain contribute to

functional Loss?

[X] Yes [ J No

(Further description of Limitations requested in Section XIII below.)

13. Functional Loss and Limitation of motion

a. Contributing factors of disability (check all that apply and indicate side

affected):

[X] Excess fatigability

Side affected:

[ ] Right [ J Left [X] Both

[X] Pain on movement

Side affected:

[ J Right [ J Left [X] Both

[X] Pain on weight-bearing

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

[X] Pain on non weight-bearing

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

[X] Disturbance of Locomotion

Side affected: [ J Right [ J Left [XJ Both

[X] Interference with standing

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

Contributing factors of disability associated with Limitation of motion:

b. Is there pain, weakness, fatigability, or incoordination that significantly

Limits functional ability during flare-ups or when the foot is used

repeatedly over a period of time?

RIGHT FOOT: [X] Yes [ J No

If yes, (there is a functional Loss due to pain, during flare-ups

and/or when the joint is used repeatedly over a period of time) please

describe the functional Loss:

Foot pain with standing, walking, steps, or Ladders Lead to veteran

being transferred to a desk job for 80% of his duties with the Corps of

Engineers.

LEFT FOOT: [X] Yes [ J No

If yes, (there is a functional Loss due to pain, during flare-ups

andfor when the joint is used repeatedly over a period of time) please

describe the functional Loss:

Foot pain with standing, walking, steps, or Ladders Lead to veteran

being transferred to a desk job for 80% of his duties with the Corps of

Engineers.

c. Is there any other functional Loss during flare-ups or when the foot is used

repeatedly over a period of time?

RIGHT FOOT: [ J Yes [X] No

LEFT FOOT: [ ] Yes [X] No

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

symptoms and scars

a. Does the Veteran have any other pertinent physical findings, complications,

conditions, signs or symptoms related to any conditions Listed in the

Diagnosis section above?

[XJ Yes [ J No

If yes, describe (brief summary):

Very early hallux valgus and DJD of 1st metatarsal head is now noted.

b. 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?

[XJ Yes [ J No

If yes, are any of these scars painful or unstable; have a total area

equal to or greater than 39 square em (6 square inches); or are Located

on the head, face or neck? (An "unstable scar" is one where, for any

reason, there is frequent Loss of covering of the skin over the scar.)

[ J Yes [X] No

If no, provide Location and measurements of scar in centimeters.

Location: Plantar right foot

Measurements: Length 7cm X width 0.2cm

c. Comments: No comments provided

15. Assistive devices

a. Does the Veteran use any assistive device as a normal mode of Locomotion,

although occasional Locomotion by other methods may be possible?

[XJ Yes [ J No

If yes, identify assistive devices used (check all that apply and

indicate frequency):

Assistive Device:

[XJ Cane(s)

[X] Other:

Orthotics

Frequency of use:

[X] Occasional

[ J Occasional

[ J Regular

[ J Regular

Progress Notes

[ J Constant

[XJ Constant

b. If the Veteran uses any assistive devices, specify the condition and

identify the assistive device used for each condition:

Cane is used when traveling or on requirements to walk more than usual.

16. Remaining effective function of the extremities

Due to the Veteran's foot 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., while functions for the

Lower extremity include balance and propulsion, etc.)

[ J Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

17. Diagnostic testing

a. Have imaging studies of the foot been performed and are the results

available?

[X] Yes [ J No

If yes, is degenerative or traumatic arthritis documented?

[XJ Yes [ J No

If yes, indicate foot: [ J Right [ J Left [X] Both

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

[ J Yes [X] No

c. If any test results are other than normal, indicate relationship of abnormal

findings to diagnosed condition:

No response provided

18. Functional impact

Regardless of the Veteran's current employment status, do the condition(s)

Listed in the Diagnosis section impact his or her ability to perform any type

of occupational task (such as standing, walking, Lifting, sitting, etc.)?

[XJ Yes [ J No

If yes, describe the functional impact of each condition, providing one or

more examples:

Walking more than 1/2 mile or standing over 10-15 minutes had such an

effect, he was transferred to a desk job for 80% of his duties to

accomondate him.

19. Remarks, if any:

Very early callus is noted on medial great toes, compatible with early bunion

as noted on x-rays. A slight achilles bowing of 7 degrees on right and 5

degrees on Left also was noted at todays examination. Clinically these are

very minimal findings today.

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Not sure why it posted the "J" in lieu of the "]" end bracket. Anyway, I had a spinal stimulator installed in Feb due to my feet (and lower back) becoming more of a problem and no relief except for more Morphine. I had DAV do an request for an increase from 30% to 50% or at least a re-evaluation. Not sure what's written will help support that, but Hallux valgus is new as well as Hammer Toe (described as possible genetic)

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In the remarks section the C/P examiner indicates there are very minimal findings...I don't know what your % is for your feet but not sure if will get an increase based on the above C/P exam.

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