lumbosacral Quick C&P Exam Lumbarsacral Degenerative

[renee]

Good evening everyone,

I opened an increase for a SD on my lower back pain due to its worsening condition. I've been service connected since 1996 starting at 10% at mechanical lower back then it was increased to 20% in 2002 and changed to Lumbosacral Degenerative. I also have fibromyalgia which is not yet been service connected. My primary doctor treats me for this condition with muscle relaxers, tramadol and a very strong cream. He has recommended that the next stage be steroid shot and possibly back surgery since the pain is persistent and worsening.

The increase was opened on August 30th and on September 12th I received a letter to call the Hampton VA medical center to schedule and appoint for a C&P examination. They scheduled me for today September 17th and advised how important it was for me to make the appointment. I had to have someone drive me there because the pain was just unbearable. The pain has become more frequent and severe for several days at a time. I checked in at 11:55am and the doctor came to get me at exactly 12:12pm. She said hello and I said hello in return. She took me to the examination room and the first question she asked was for me to have a seat or to stand if I was too uncomfortable to sit. I stood. She asked me what type of job I had and if it was desk job and I said yes. She didn't ask me any questions about my condition but mentioned that she read my VA file and noted that I have a lot going on and was sorry I was having such a bad day. She also stated that the last X-rays and MRI show a degenerative condition and that no new x-rays or MRI would be done today. Next she asked if I could take off my shirt and when I tried to she saw that I was struggling she asked if she could raise my shirt to check my spine. Afterwards she did the standard ROM exercise (left, right, front) she asked if I could repeat them twice and said "I see you can't bend backwards" so there was no ROM conducted in this direction.

She asked if I took my shoes off could I feel the temperature of the floor and I could. She asked if the pain radiates to other places and I replied yes it does. Her entire examination took 17 minutes. I'm curious if I should have requested the x-ray and or MRI despite the fact that ones already exist in my records. In addition, I noticed that she didn't have the standard C&P worksheet and wondered if this was is normal for a C&P examination. In fact the sheet she worked from looked to have been 1 page and printed from the hospital system. I'm not so sure. I did ask her politely how long after would I be able to request a copy of her report and she stated that she didn't know. She further stated that my claim is a lawsuit against the United States for my service connected disability and that it's up to the regional office to provide me with copies. I'd never heard it put quite like that before. Maybe this information will be in the VA system since it was conducted at the VA hospital? Also is this normal for the examiner not use the standard worksheet?

Looking for you guys helpful insight as usual.