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C&p Exam Clinicians Guide 9.4


ztecman

Question

Would there be a CUE if the following is not followed in a C&P Exam of this type? Only one doctor did my exam back in 1981. Very little information was entered by the Doctor. He did not note any my complaints in the exam report. This is what the guide states must happen at the exam please see bolded item.

Thanks in advance

ztecman

C&P Exam Clinicians Guide 9.4

What needs to be reported about anatomical loss or loss of use of a creative organ and why?

The examination must include the following information:

a. The details of loss of a creative organ may be in the medical records, but the examiner should still describe lost and remaining portions of the penis, scrotum, and testes.

b. Impotence, sterility, or retrograde ejaculation should always be described and the cause named (e.g., Peyronie's disease causing impotence or TURP for BPH causing retrograde ejaculation). If a vasectomy was performed, the examiner should report when it was done and the reason.

c. With impotence, the report should indicate whether it is constant, whether it is permanent, what treatment is used, and the effectiveness of treatment in allowing intercourse.

d. With penile deformity, whether erectile function is wholly or partially lost should be reported.

e. Examination for testicular atrophy must be conducted by at least two examiners. The size and consistency of the testis should be recorded. Reduction in size should be described as reduction to one-third or one-half normal size, or even less, for example. If only one testis is affected, the size of the unaffected testis should be recorded. The etiology of the atrophy should be reported.

Worksheet - GENITOURINARY EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Lethargy, weakness, anorexia, weight loss or gain.

2. Frequency (day or night, indicate voiding intervals), hesitancy, stream, dysuria.

3. Incontinence - if present, describe required frequency of absorbent material and

whether an appliance is needed.

4. Provide details of any history of:

a. Surgery on any part of the urinary tract. Residuals? Impotence?

b. Recurrent urinary tract infections.

c. Renal colic or bladder stones.

d. Acute nephritis.

e. Hospitalization for urinary tract disease, if so, how many in the past year?

f. Treatment for malignancy, including type and date of last treatment.

5. Treatments.

a. Is catheterization needed? Intermittent or continuous?

b. Frequency of dilations?

c. Drainage procedures.

d. Diet therapy - specify.

e. Medications.

f. Frequency per year of invasive and noninvasive procedures.

6. Describe the effects of the condition(s) on the veteran's usual occupation and daily

activities.

For Male Loss of Use of a Creative Organ

Comment on:

1. Trauma/surgery affecting penis/testicles (e.g. vasectomy?)

2. Local and/or systemic diseases affecting sexual function.

a. Endocrine.

b. Neurologic.

c. Infections.

d. Vascular.

e. Psychological.

3. Symptoms: Vaginal penetration with ejaculation possible?

4. Past treatment:

a. Medications, injections, implants, pump, counseling

b. Effectiveness in allowing intercourse.

C. Physical Examination (Objective Findings):

Address each of the following, as appropriate, to the condition being examined and fully

describe current findings:

1. Blood pressure, cardiovascular examination, if indicated, describe edema, to include

persistence.

2. If on dialysis, type, where done, and how often?

3. Inspection and palpation of penis, testicles, epididymis, and spermatic cord. If there is

penis deformity, state whether there is loss of erectile power. Inspection of anus and

digital exam of rectal walls, prostate, and seminal vesicles.

4. Fistula.

5. Specific residuals of genitourinary disease, including post-treatment residuals of

malignancy.

6. Testicular atrophy - size and consistency.

7. Sensation and reflexes

8. Peripheral pulses

D. Diagnostic and Clinical Tests:

1. CBC.

2. UA.

3. Creatinine, BUN, albumin, electrolytes.

4. Uroflowmetry, if indicated.

5. Measurement of post-void residual, if indicated.

6. Semen analysis, including sperm count and interpretation of results, if applicable.

7. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH, prolactin), if applicable.

8. Psychiatric evaluation, if applicable.

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

E. Diagnosis:

Signature: Date:

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In short the answer is no. No Cue would exist in this case. The only argument you would have is inadequate exam which should have been approached shortly after the exam.

Keep in mind a guide is a guide and not law. Cue only exist when there is a failure to comply with law (as cue is a legal issue). Although there is no CUE successful arguments of inadequate exams have been resulted in re-exams and the award of a claim. However, such an argument would have to had been made at the time or shortly after the exam.

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