C&p

[roadking]

Can anyone give me any info on what to expect at my annual C&P exam for my 100%IU rating. This is my first one, are they any different than the others that I have been through.

[rentalguy1]

Welcome to hadit! The TDIU C&P isn't a annual event, but you will be asked to complete a VA Form 21-4140 every year. There has been a lot of trouble with this form this year and a lot of vets didn't receive them when they were supposed to. Since the response time on this form is only 60 days, that put many IU vet's in jeapordy of losing their compensation. THe best way to approach this is to go to the VA's web site and print the form off yourself when your rating decision anniversary month is coming up. Then fill it out and send it into your VA Regional Office (VARO) via certified mail, return receipt requested. The C&P that you will have will be a general medical exam. If there are any special exams needed, the C&P examiner will request them. Here is the C&P worksheet for the general medical exam:

Worksheet - GENERAL MEDICAL EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: This is a comprehensive base-line or screening examination for all body systems, not just specific conditions claimed by the veteran. It is often the initial post-discharge examination of a veteran requested by the Compensation and Pension Service for disability compensation purposes. As a screening examination, it is not meant to elicit the detailed information about specific conditions that is necessary for rating purposes. Therefore, all claimed conditions, and any found or suspected conditions that were not claimed, should be addressed by referring to and following all appropriate worksheets, in addition to this one, to assure that the examination for each condition provides information adequate for rating purposes. This does not require that a medical specialist conduct examinations based on other worksheets, except in the case of vision and hearing problems, mental disorders, or especially complex or unusual problems. Vision, hearing, and mental disorder examinations must be conducted by a specialist. The examiner may request any additional studies or examinations needed for proper diagnosis and evaluation (see other worksheets for guidance). All important negatives should be reported. The regional office may also request a general medical examination as evidence for nonservice-connected disability pension claims or for claimed entitlement to individual unemployability benefits in service-connected disability compensation claims. Barring unusual problems, examinations for pension should generally be adequate if only this general worksheet is followed.

A. Review of Medical Records: Indicate whether the C-file was reviewed.

B. Medical History (Subjective Complaints):

Discuss: Whether an injury or disease that is found occurred during active service, before active service, or after active service. To the extent possible, describe the circumstances, dates, specific injury or disease that occurred, treatment, follow-up, and residuals. If the injury or disease occurred before active service, describe any worsening of residuals due to being in military service. Describe current symptoms and treatment.

1. Occupational history (for pension and individual unemployability claims): Obtain the name and address of employers (list most current first), type of occupation, employment dates, and wages for last 12 months. If any time was lost from work in the past 12-month period, please describe the reason and extent of time lost.

2. Describe details of current treatment, conditions being treated, and side effects of treatment.

3. Describe all surgery and hospitalizations in and after service with approximate dates.

4. If a malignant neoplasm is or was present, provide:

a. Date of confirmed diagnosis.

b. Date of the last surgical, X-ray, antineoplastic chemotherapy, radiation, or other therapeutic procedure.

c. State expected date treatment regimen is to be completed.

d. If treatment is already completed, provide date of last treatment.

e. If treatment is already completed, fully describe residuals.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings: The examiner should incorporate results of all ancillary studies into the final diagnoses.

1. VS: Heart rate, blood pressure (see #13 below), respirations, height, weight, maximum weight in past year, weight change in past year, body build, and state of nutrition.

2. Dominant hand: Indicate the dominant hand and how this was determined, e.g., writes, eats, combs hair with that hand.

3. Posture and gait: Describe abnormality and reason for it. Describe any ambulatory aids.

4. Skin, including appendages: If abnormal, describe appearance, location, extent of lesions. If there are laceration or burn scars, describe the location, exact measurements (cm. x cm.), shape, depression, type of tissue loss, adherence, and tenderness. For each burn scar, state if due to a 2nd or 3rd degree burn. Describe any limitation of activity or limitation of motion due to scarring or other skin lesions.

NOTE: If there are disfiguring scars (of face, head, or neck), obtain color photographs of the affected area(s) to submit with the examination report.

5. Hemic and Lymphatic: Describe adenopathy, tenderness, suppuration, edema, pallor, etc.

6. Head and face: Describe scars, skin lesions, deformities, etc., as discussed under item #4.

7. Eyes: Describe external eye, pupil reaction, eye movements.

8. Ears: Describe canals, drums, perforations, discharge.

9. Nose, sinuses, mouth and throat: Include gross dental findings. For sinusitis, describe headaches, pain, episodes of incapacitation, frequency and duration of antibiotic treatment.

10. Neck: Describe lymph nodes, thyroid, etc.

11. Chest: Inspection, palpation, percussion, auscultation. Describe respiratory symptoms and effect on daily activities, e.g., how far the veteran can walk, how many flights of stairs veterans can climb. If a respiratory condition is claimed or suspected, refer to appropriate worksheet(s). Most respiratory conditions will require PFT’s, including post-bronchodilation studies. Describe in detail any treatment for pulmonary disease.

12. Breast: Describe masses, scars, nipple discharge, skin abnormalities. Give date of last mammogram, if any. Describe any breast surgery (with approximate date) and residuals.

13. Cardiovascular : NOTE: If there is evidence of a cardiovascular disease, or one is claimed, refer to appropriate worksheet(s).

a. Record pulse, quality of heart sounds, abnormal heart sounds, arrhythmias. Describe symptoms and treatment for any cardiovascular condition, including peripheral arterial and venous disease. Give NYHA classification of heart disease. A determination of METs by exercise testing may be required for certain cardiovascular conditions, and an estimation of METS may be required if exercise testing cannot be conducted for medical reasons. (See the cardiovascular worksheets for further guidance.)

b. Describe the status of peripheral vessels and pulses. Describe edema, stasis pigmentation or eczema, ulcers, or other skin or nail abnormalities. Describe varicose veins, including extent to which any resulting edema is relieved by elevation of extremity. Examine for evidence of residuals of cold injury when indicated. See and follow special cold injury examination worksheet if there is a history of cold exposure in service and the special cold injury examination has not been previously done.

c. Blood pressure: (Per the rating schedule, hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm.)

1. If the diagnosis of hypertension has not been previously established, and it is a claimed issue, B.P. readings must be taken two or more times on each of at least three different days.

2. If hypertension has been previously diagnosed and is claimed, but the claimant is not on treatment, B.P. readings must be taken two or more times on at least three different days.

3. If hypertension has been previously diagnosed, and the claimant is on treatment, take three blood pressure readings on the day of the examination.

4. If hypertension has not been claimed, take three blood pressure readings on the day of the examination. If they are suggestive of hypertension or are borderline, readings must be taken two or more times on at least two additional days to rule hypertension in or out.

5. In the diagnostic summary, state whether hypertension is ruled in or out after completing these B.P. measurements. Describe treatment for hypertension and side effects. If hypertensive heart disease is suspected or found, follow worksheet for Heart.

14. Abdomen: Inspection, auscultation, palpation, percussion. Describe any organ enlargement, ventral hernia, mass, tenderness, etc.

15. Genital/rectal (male): Inspection and palpation of penis, testicles, epididymis, and spermatic cord. If there is a hernia, describe type, location, size, whether complete, reducible, recurrent, supported by truss or belt, and whether or not operable. Describe anal fissures, hemorrhoids, ulcerations, etc. Include digital exam of rectal walls and prostate.

16. Genital/rectal (female): Pelvic exam, including inspection of introitus, vagina, and cervix, palpation of labia, vagina, cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear if none within past year. If unable to conduct an examination and Pap smear, or if there is a severe or complex problem, refer to a specialist.

17. Musculoskeletal:

a. For all joint or muscle disorders, state each muscle and joint affected.

b. Separately examine and describe in detail each affected joint. Measure active and passive range of motion in degrees using a goniometer. In addition, provide an assessment of the effect on range of motion and joint function of pain, weakness, fatigue, or incoordination following repetitive use or during flare-ups. (See the appropriate musculoskeletal worksheet for more detail.) NOTE: The diagnosis of degenerative or traumatic arthritis of any joint requires X-ray confirmation, but once confirmed by X-ray, either in service or after service, no further X-rays of that joint are required for disability evaluation purposes.

c. Describe swelling, effusion, tenderness, muscle spasm, joint laxity, muscle atrophy, fibrous or bony residual of fracture. If joint is ankylosed, describe the position and angle of fixation.

d. Describe any mechanical aids used by veteran.

e. If foot problems exist, also describe objective evidence of pain at rest and on manipulation, rigidity, spasm, circulatory disturbance, swelling, callus, loss of strength, and whether condition is acquired or congenital.

f. If there is amputation of a part, see the appropriate worksheet.

g. With disc disease, also describe any neurological findings.

18. Endocrine: Describe signs and symptoms of any endocrine disease, effects on other body systems, and current and past treatment. See endocrine worksheets for further guidance.

19. Neurological: Assess orientation and memory, gait, stance, and coordination, cranial nerve functions. Assess deep tendon reflexes, pain, touch, temperature, vibration, and position, motor and sensory status of peripheral nerves. If neurological abnormalities are found on examination, or there is a history of seizures, refer to appropriate worksheet.

20. Psychiatric: Describe behavior, comprehension, coherence of response, emotional reaction, signs of tension and effects on social and occupational functioning. (This is meant to be a brief screening examination. If a mental disorder is claimed, or suspected based on the screening, an examination for diagnosis and assessment should be conducted by a psychiatrist or psychologist.) State whether the veteran is capable of managing his or her benefit payments in his or her own best interests without restriction. (A physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs.)

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

2. Review all test results before providing the summary and diagnosis.

3. Follow additional worksheets, as appropriate.

E. Diagnosis: Provide a summary list of all disabilities diagnosed. Include an interpretation of the results of all diagnostic and other tests conducted in the final summary and diagnosis. For each condition diagnosed, describe its effect on the veteran's usual occupation and daily activities.

Signature: Date:

Good luck and keep us updated on how it went!