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Gulf War Exam C&p: Peripheral Nerves Conditions

nerves nerve damage

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#1 BearGator56

 
BearGator56

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Posted 09 October 2013 - 09:24 AM

This was part of my Gulf War Exam, and it doesn't look like it should be rated from the GW.  But, the wrist injury received while I was in the Marines does have nerve issues.  Would they continue the rating on it's own, or would I have to re-file again on a claim not under Gulf War?  I'm currently rated for the wrist, but nothing to do with the nerve issues.
 
 
Peripheral Nerves Conditions
          (not including Diabetic Sensory-Motor Peripheral Neuropathy)
                        Disability Benefits Questionnaire
 
    Name of patient/Veteran:  XXXX
    
    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?
    [X] Yes   [ ] No
    
      If yes, list any records that were reviewed but were not included in the
      Veteran's VA claims file:
      
        CPRS
        
      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 have a peripheral nerve condition or peripheral neuropathy?
    [X] Yes   [ ] No
    
       Diagnosis #1:  lt ulnar neuropathy
       ICD code:  (354.2)
       Date of diagnosis:  9/6/13
       
    2. Medical history
    ------------------
 
 
    a. Describe the history (including onset and course) of the Veteran's
       peripheral nerve condition (brief summary):
         He stated that he developed  tingling in the left arm for a long time
         started while on active duty his left wrist was injured while on active
         duty no history of  neck pain or surgery; no history of elbow injury or
         surgery. He takes Neurontin; he has mild weakness of the left hand with
         no history of diabetes mellitus. He has mild wasting of his left hand.
         
    b. Dominant hand
       [X] Right   [ ] Left   [ ] Ambidextrous
       
    3. Symptoms
    -----------
    a. Does the Veteran have any symptoms attributable to any peripheral nerve
       conditions?
       [X] Yes   [ ] No
       
       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:  [ ] None   [X] Mild   [ ] Moderate   [ ] Severe
         Right lower extremity: [X] None   [ ] Mild   [ ] Moderate   [ ] Severe
         Left lower extremity:  [X] None   [ ] Mild   [ ] Moderate   [ ] Severe
 
       Numbness
         Right upper extremity: [X] None   [ ] Mild   [ ] Moderate   [ ] Severe
         Left upper extremity:  [ ] None   [X] Mild   [ ] Moderate   [ ] Severe
         Right lower extremity: [X] None   [ ] Mild   [ ] Moderate   [ ] Severe
         Left lower extremity:  [X] None   [ ] Mild   [ ] Moderate   [ ] Severe
 
                 
    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
         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:  [ ] 5/5   [X] 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
 
       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. Does the Veteran have muscle atrophy?
       [X] Yes   [ ] No
       
           If muscle atrophy is present, indicate location:
              lt  1st dorsal  interossei
              
              Normal side: not measured cm.        Atrophied side: not measured
              cm.
              
    5. Reflex exam
    --------------
    Rate deep tendon reflexes (DTRs) according to the following scale:
    
       0  Absent
       1+ Hypoactive
       2+ Normal
       3+ Hyperactive without  clonus
       4+ Hyperactive with clonus
       
       Biceps:
         Right: [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
 
       Triceps:
         Right: [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
 
       Brachioradialis:
         Right: [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
 
       Knee:
         Right: [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
 
       Ankle:
         Right: [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [X] 1+   [ ] 2+   [ ] 3+   [ ] 4+
 
    6. Sensory exam
    ---------------
       Indicate results for sensation testing for light touch:
       
       Shoulder area (C5):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
 
       Inner/outer forearm (C6/T1):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
 
       Hand/fingers (C6-8):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
 
       Upper anterior thigh (L2):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
 
       Thigh/knee (L3/4):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
 
       Lower leg/ankle (L4/L5/S1):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
 
       Foot/toes (L5):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
 
    7. Trophic changes
    ------------------
    Does the Veteran have trophic changes (characterized by loss of extremity
    hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy?
    [ ] Yes   [X] No
    
    8. Gait
    -------
    Is the Veteran's gait normal?
    [X] Yes   [ ] No
    
    9. Special tests for median nerve
    ---------------------------------
    Were special tests indicated and performed for median nerve evaluation?
    [ ] Yes   [X] No
    
    10. Nerves Affected: Severity evaluation for upper extremity nerves and
        radicular groups
    -----------------------------------------------------------------------
    a. Radial nerve (musculospiral nerve)
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    b. Median nerve
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    c. Ulnar nerve
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left:  [ ] Normal   [X] Incomplete paralysis   [ ] Complete paralysis
       
 
 
                  If Incomplete paralysis is checked, indicate severity:
                  [ ] Mild   [X] Moderate   [ ] Severe
                  
 
    d. Musculocutaneous nerve
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    e. Circumflex nerve
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    f. Long thoracic nerve
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    g. Upper radicular group (5th & 6th cervicals)
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    h. Middle radicular group
       Right  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    i. Lower radicular group
       Right: [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
       Left:  [X] Normal   [ ] Incomplete paralysis   [ ] Complete paralysis
       
 
    11. Nerves Affected: Severity evaluation for lower extremity nerves
    -------------------------------------------------------------------
        Not applicable
        
    12. Assistive devices
    ---------------------
    a. Does the Veteran use any assistive devices as a normal mode of 
locomotion,
       although occasional locomotion by other methods may be possible?
       [ ] Yes   [X] No
       
         
    b. If the Veteran uses any assistive devices, specify the condition and
       identify the assistive device used for each condition:
         No response provided.
         
    13. Remaining effective function of the extremities
    ---------------------------------------------------
    Due to peripheral nerve conditions, 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.)
    
    [ ] Yes, functioning is so diminished that amputation with prosthesis would
        equally serve the Veteran.
    [X] No
 
    14. 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 or symptoms?
       [ ] Yes   [X] No
       
             
    15. Diagnostic testing
    ----------------------
    a. Have EMG studies been performed?
       [X] Yes   [ ] No
       
           Extremities tested:
           
           [X] Left upper extremity
               Results: [ ] Normal   [X] Abnormal
               Date:  1/15/13
               
 
                 
    b. Are there any other significant diagnostic test findings and/or results?
       [X] Yes   [ ] No
       
        If yes, provide type of test or procedure, date and results (brief
        summary):
          Findings:
          The left median sensory nerve conduction study (NCS) showed normal 
peak
          latency and amplitude.
          The left ulnar sensory NCS showed normal peak latency and amplitude.
 
          The left median motor NCS showed normal distal latency, amplitudes,
          and conduction velocity.
          The left ulnar motor NCS was ABNORMAL and showed normal distal 
latency,
          normal 
          amplitudes, and DIMINISHED conduction velocities across the ELBOW.
          The right ulnar motor NCS showed normal distal latency, amplitudes,
          and conduction velocities.
 
          The left median-to-ulnar comparison mixed nerve study showed no
          significant 
          difference in latencies.
 
          Electromyography (EMG) of selected muscles representing the ulnar
          innervations showed normal insertional activity, no spontaneous
          activity, and 
          normal voluntary MUAP's.
 
          IMPRESSION:
          1) Abnormal study.
          2) Electrophysiological evidence of LEFT ulnar neuropathy across the
          elbow 
          consistent with a focal demyelinating process. No evidence of axonal
          loss. 
          3) NO electrophysiological evidence of a left median neuropathy at the
          wrist. 
 
          PLAN:
          1) Prosthetics consult to issue a LEFT elbow brace to the patient 
          2) Advised patient to protect the elbows with gel pads or towels
          anytime they 
          are on a hard surface and to limit sleeping with hands overhead
          3) Please consider obtaining a LEFT elbow xray given hx of remote
          injury 
          4) Can consider hand surgery consult in the future for possible
          surgical 
          interventions if above conservative measures fail. 
          5) Thank you the consult. 
 
 
           
          /es/ AMAR G PATEL
          PM&R PGY 3
          Signed: 04/18/2013 14:21
          
          
    16. Functional impact
    ---------------------
    Does the Veteran's peripheral nerve condition and/or peripheral neuropathy
    impact his or her ability to work?
    [X] Yes   [ ] No
    
        If yes, describe impact of each of the Veteran's peripheral nerve and/or
        peripheral neuropathy condition(s), providing one or more examples:
          Left ulnar neuropathy condition will limit repetitive moderately
          strenuous physical activity with his left hand.
          
    17. Remarks, if any:
    --------------------
        the veterans ulnar neuropathy is a  disease with a clear and specific
        etiology and diagnosis.
        Medical opinion-it is less likely is not, less than 50% probability, 
that
        the above condition is related to any specific exposure event 
experienced
        by the veteran during service in Southeast Asia;
        rationale-current medical literature review does not correlate ulnar
        neuropathy with Gulf War exposure.

Edited by BearGator56, 09 October 2013 - 09:25 AM.


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#2 BearGator56

 
BearGator56

    E-3 Seaman

  • Seaman
  • PipPipPip
  • 19 posts
  • Service Connected Disability: 80%
  • Branch of Service: USMC
 

Posted 09 October 2013 - 09:29 AM

This was also added in the commentary:

 

 

 

    2. Restatement of requested opinion
    -----------------------------------
    a. Insert requested opinion from general remarks:
       ALSO,
 
          The Veteran is claiming service connection for low back pain and left 
          wrist pain.  Please review the medical opinion requests below regarding 
 
          these two issues:
 
          MED OPINION #1:
          A.  Requested DBQ:   Peripheral Nerves
          " Claimed conditions:  nerve damage left wrist
          " Claimed nexus:  secondary or related to the in-service left wrist 
          fracture
          " Opinion requested:  Is there a diagnosis of nerve damage in the 
          left wrist?  If yes, is it at least as likely as not related to the
          left 
          wrist fracture in service?
          B.  Available pertinent evidence:
          " Military Service:  Marines from March 14, 1990 to June 28, 1994
          " Service Treatment Records (STRs):  These records show the left 
          wrist fracture
          " Private Treatment Records:  none
          " VA Treatment Records:  the Atlanta VAMC treatment records 
          (available for your review in CPRS) show that the Veteran has
          complained 
          of pain in the left wrist.  There are images available for your review
          as 
          well.





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