What is everyone's opinion of this exam. I am currently 10% S/C for pes cavus. I had an exam in Jan. of this year and the left and right are practacially identical.
Is there objective evidence of painful motion? YES
Objective Evidence:
Wincing and pulling away from examiner during exam
Evidence of swelling: NO
Is there objective evidence of tenderness? YES
Objective Evidence:
Pulling away from examiner during exam.
Is ther objective evidence of weakness? YES
Objective Evidence:
Not able to pearform ROM actively; muscle strength 3/5
Is there other objective evidence? NO
Is there evidence of abnormal weight bearing: YES
Evidence of Abnormal weight bearing:
Unusual shoe wear pattern.
IS THIS EXAMINATION FOR PES CAVUS (CLAWFOOT) ? YES
STATUS OF PLANTAR FASCIA, WHETHER OR NOT THERE IS A DROPPED FOREFOOT, ABNORMAL POSITION OF ANY TOES AND ANY LIMITATION OF ANKLE DORSIFLEXION:
Plantar fascitis present; dropped forefoot; unable to perform dorsiflexion but able to obtain neurtal position with active ROM (not passive ROM).
TESTS
====
X-RAYS:
Bilateral feet xray results (weight bearing requested): The patient appears to a mild pes cavus deformity bilaterally. No fractures or dislocations are seen. No bone destruction or erosion is appreciated. Impression: 1. Mild pes cavus deformity.
WERE THE RESULTS OF ALL TESTS INCLUDED? YES
EMPLOYMENT HISTORY
__________________
IS VETERAN CURRENTLY EMPLOYED? No
IS VETERAN RETIRED? Yes
DATE OF RETIREMENT: 1990
CAUSE OF RETIREMENT:
Medical (physical problem)
MEDICAL/PHYSICAL PROBLEMS:
Back pain
Bilateral foot pain
IS THE DIAGNOSED CONDITION CONGENITAL OR DEVELOPMENTAL? Unable to answer.
SUMMARY OF ALL EFFECTS ON OCCUPATIONAL AND DAILY ACTIVITIES:
DIAGNOSIS OR ETIOLOGY OF PROBLEM: Pes cavus, bilateral
PROBLEM ASSOCIATED WITH DIAGNOSIS: bilateral pes cavus
GENERAL OCCUPATIONAL EFFECT: Significant Effects.
THIS DISABILITY'S IMPACT ON OCCUPATIONAL ACTIVITIES: Decreased Mobility,
Decreased Strength: Lower Extremity, Pain
IF NOT NOW WORKING, DATE LAST EMPLOYED: 1990
ARE THERE EFFECTS OF THE PROBLEM ON THE FOLLOWING DAILY ACTIVITIES: Yes
Question
Railroader
What is everyone's opinion of this exam. I am currently 10% S/C for pes cavus. I had an exam in Jan. of this year and the left and right are practacially identical.
Is there objective evidence of painful motion? YES
Objective Evidence:
Wincing and pulling away from examiner during exam
Evidence of swelling: NO
Is there objective evidence of tenderness? YES
Objective Evidence:
Pulling away from examiner during exam.
Is ther objective evidence of weakness? YES
Objective Evidence:
Not able to pearform ROM actively; muscle strength 3/5
Is there other objective evidence? NO
Is there evidence of abnormal weight bearing: YES
Evidence of Abnormal weight bearing:
Unusual shoe wear pattern.
IS THIS EXAMINATION FOR PES CAVUS (CLAWFOOT) ? YES
STATUS OF PLANTAR FASCIA, WHETHER OR NOT THERE IS A DROPPED FOREFOOT, ABNORMAL POSITION OF ANY TOES AND ANY LIMITATION OF ANKLE DORSIFLEXION:
Plantar fascitis present; dropped forefoot; unable to perform dorsiflexion but able to obtain neurtal position with active ROM (not passive ROM).
TESTS
====
X-RAYS:
Bilateral feet xray results (weight bearing requested): The patient appears to a mild pes cavus deformity bilaterally. No fractures or dislocations are seen. No bone destruction or erosion is appreciated. Impression: 1. Mild pes cavus deformity.
WERE THE RESULTS OF ALL TESTS INCLUDED? YES
EMPLOYMENT HISTORY
__________________
IS VETERAN CURRENTLY EMPLOYED? No
IS VETERAN RETIRED? Yes
DATE OF RETIREMENT: 1990
CAUSE OF RETIREMENT:
Medical (physical problem)
MEDICAL/PHYSICAL PROBLEMS:
Back pain
Bilateral foot pain
IS THE DIAGNOSED CONDITION CONGENITAL OR DEVELOPMENTAL? Unable to answer.
SUMMARY OF ALL EFFECTS ON OCCUPATIONAL AND DAILY ACTIVITIES:
DIAGNOSIS OR ETIOLOGY OF PROBLEM: Pes cavus, bilateral
PROBLEM ASSOCIATED WITH DIAGNOSIS: bilateral pes cavus
GENERAL OCCUPATIONAL EFFECT: Significant Effects.
THIS DISABILITY'S IMPACT ON OCCUPATIONAL ACTIVITIES: Decreased Mobility,
Decreased Strength: Lower Extremity, Pain
IF NOT NOW WORKING, DATE LAST EMPLOYED: 1990
ARE THERE EFFECTS OF THE PROBLEM ON THE FOLLOWING DAILY ACTIVITIES: Yes
CHORES: Moderate
SHOPPING: Moderate
EXERCISE: Severe
SPORTS: Prevents
RECREATION: Mild
TRAVELING: Mild
FEEDING: None
BATHING: None
DRESSING: None
TOILETING: None
GROOMING: None
DRIVING: Mild
**************************************************************************
WAS A MEDICAL OPINION REQUESTED? No
I forgot to note that I wear rigid orthotic devices in my shoes and use a cane for balance.
Do you think that I will get an increase or not? This C&P was done by a NP at the VA.
Thank You,
Railroader
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