Questions About My Peripheral Neuropathy C & P Exam Report

[georgiapapa]

I apologize for the long post but I felt all of the info was needed in order to get the best input from fellow hadit forum members.

Yesterday I received a copy of my recent C & P exam report for my claims for AO Multiple Myeloma and PN secondary to Multiple Myeloma. I have no complaints with the part of the C & P exam findings on my Multiple Myeloma which mirror those of my private oncologists. The C & P examiner also concluded "The claimed condition (peripheral neuropathy of lower extremities) is at least as likely as not proximately due to or the result of the Veteran's service connected condition (multiple myeloma). This statement is in agreement with my neurologist's IMO conclusion so I have no problem with this part of the report. My problem with the report deals with the responses in the section concerning severity of the peripheral neuropathy.

Keep in mind that my entire C & P exam was performed by a nurse practitioner and lasted a total of about 15 minutes. The examiner did not perform any exams or tests in regards to my multiple myeloma. I had made copies of my oncologist reports and lab reports and brought them to the C & P exam for the examiner. She took the copies and it appears she used the reports to fill in the responses for her C & P report. She asked how my multiple myeloma was first diagnosed and I told her it was discovered by my neurologist who performed blood tests when I went to him about problems with neuropathy and the neurologist referred me to an oncologist after one of my blood tests indicated myeloma protein in my blood. In regards to my peripheral neuropathy, the only test she performed was when she broke what appeared to be a large Q tip in half, had me close my eyes while she touched my legs with the ends of the broken Q tip. As she would touch my leg, she would ask if I knew whether she was touching me with the dull end or the sharp end. No other tests were performed and no other questions were asked. I also provided her with a copies of the EMG and nerve studies on my lower extremities and my upper extremities from my private doctor. She also kept these and cited them in her C & P report.

In her report the examiner indicated that I had moderate intermittent pain in both of my lower extremities, moderate paresthesias and/or dysesthesias in both of my lower extremities, and moderate numbness in both of my lower extremities. She also indicated that I had mild intermittent pain in both of my upper extremities, mild paresthesias and/or dysesthesias in both of my upper extremities, and mild numbness in both of my upper extremities. NOTE: I did not file a claim for peripheral neuropathy in my upper extremities and the examiner never checked my upper extremities.

In the part of C & P report regarding the affected nerves and severity of condition, the following instructions are given to the examiner by the VA: "For VA purposes, the term incomplete paralysis indicates a degree of lost or impaired function substantially less than the description of complete paralysis that is given with each nerve." The instructions further state "If the nerve is completely paralyzed, check the box for complete paralysis." "If the nerve is not completely paralyzed, check the box for incomplete paralysis and indicate severity." "For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild, or at most moderate."

Each nerve is listed on the C & P report just like on the DBQs and the following choices are given: ( )normal, ( )incomplete paralysis, ( ) complete paralysis. Under each nerve section, the report's instructions states "if incomplete paralysis is checked, indicate severity." The following choices are given to indicate severity: ( )mild, ( )moderate, ( )severe.

Despite her findings that I had pain, paresthesias and numbness in my extremitites, on every nerve listed she checked the normal blocks rather than incomplete paralysis and she did not check any blocks showing severity. NOTE: Keep in mind again, she never performed any tests to check the functioning of my lower extremities or asked me about the functioning.

The EMG & NCV reports I provided to the VA examiner were reports prepared and signed by the private doctor who performed the tests. This doctor specializes in performing electrodiagnostic studies for diagnosing nerve root disorders as well as various peripheral nerve disorders. This doctor's findings were also referred to by my private neurologist in his IMO letter to the VA. The private doctor performing the EMG & NCV tests stated: "This is an abnormal study." "There is evidence of severe, axonal and demyelinating tibial neuropathy in both lower extremities affecting the motor component." "There is evidence of prolonged H-reflex response in both lower extremities." Evaluation of the left tibial nerve motor nerve showed reduced amplitude (1.0mV). The right tibial motor nerve showed prolonged distal onset latency (7.5 ms) and reduced amplitude (2.2mV)." "H-reflex studies indicate that the left tibial H-reflex has prolonged latency (37.34 ms)." "The right tibial H-reflex has prolonged latency (37.50 ms)."

My private neurologist stated in his IMO letter, "I have diagnosed the patient with symmetrical distal polyneuropathy in his lower extremities that is primarily sensory." "He has slight proprioception problems and a positive romberg which is effecting his gait." He also stated in his IMO letter that my peripheral neuropathy in my lower extremities was more than likely secondary to my multiple myeloma disease.

I feel that by checking the box "normal" rather than "incomplete paralysis", I will be rated at 0%. I believe the examiner should have checked incomplete paralysis because my feet and lower legs are totally numb and I have lost some motor function in them. I have difficulty walking on uneven or rough terrain because I have a tendancy to stumble or trip. I recently had multiple ant bites on one of my feet because I did not know my foot was in an ant bed.

Please give me your thoughts and suggestions concerning the C & P exam report and possible ratings. Also, let me know if you think the VA might possibly service connect peripheral neuropathy in my upper extremities based on the VA examiner's report of my upper extremities.

Thanks...Georgiapapa

[SP4RVN1971]

GeorgiaPapa, PN is a hard to judge, but when I went into my first C&P" it was a Joke" , but they gave me 20% both legs. Then I to a Neurologist for EMG and nerve study and sent that directly to VA with a letter from the Doctor of my condition. The Neurologist doctor test upper and lower body. The VA follew up with another C&P test and this test was basic a test like yours. The person had no clue on what they were doing, but they did notice my left leg was smaller and and shorter. VA came back with 60% left side and 40% right called Paraylsis of the Sciatic nerve or PN, with 10% for both hands. I think making sure that my Neruologist report got to VA direct was that got the job done.

You need to go back and NOT give up. I live in pain all the time, so I feel your pain. It sound like with your walking condition is the same as mind, dragging your feet, tripping, I trip twice last week and me and concrete don't work!

I'm pretty sure that PN can only secondary to another condition and not primary YET. It should be primary because I had this the PN along time before my DMII.

[deanbrt]

appeal. i have the same thing. peripheral neuropathy.. no feeling at all in my feet.

[georgiapapa]

deanbrt & SP4RVN1971,

I will wait and see how I am actually rated for PN before I have further contact with the VARO. I just can not understand how the C & P examiner could show that all my nerves are normal yet state that I have moderate intermittent pain, moderate paresesthias, and moderate numbness in my lower extremities. This is not logical. Hopefully the person doing the rating will have enough sense to understand this also.

The statements from my two private doctors should also put to rest any notions that my nerves are normal, especially the statement contained in the EMG & NCV test report where the doctor stated "There is evidence of severe, axonal and demyelinating tibial neuropathy in both lower extremities affecting the motor component." Based on this statement and other info in the report and the IMO letter from my neurologist, I believe I am entitled to 20% for each lower extremity based on the criteria in the VA disability ratings schedule.

Any additional thoughts or suggestions would certainly be appreciated.

Georgiapapa...

[71M10]

I don't believe she checked normal. The dirty little secret about VA's EMR (Electronic Medical Record)is that it will provide default responses. I imagine your NP did her thing, filled out what she wanted to be bothered with and closed the record. Anything she didn't put an entry into shows up with the default value which is "normal".

You would think, with an EMR, and a computer generated exam sheet, that any intelligent organization would require an entry in each field. The VA apparently is quite comfortable with default answers representing medical facts. Why doesn't it say NE or No Entry or NULL?

I have actually had more complete physical exams conducted by NP's than some of the VA's "doctors"! Clearly there are some exams that should never be assigned to an NP.