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Received C&p Exam Results


Bound4heaven

Question

Greetings,

we just got the results from the C&P exam for Veteran in question.

Veteran is currently rated at 100% for loss of use of both feet

40% lumbar

40% Right shoulder

30 % Left myofascial strain

20% Right median inpairment

Uses a cane to walk, and cannot walk without the use of cane due to feet, back

I do not agree with all of the exam results, because I was there with him at the exam.

Doctors Diagnosis

1)Myofascial strain of both shoulders

2) Myofascial back strain. There is decrease disc height at L5/S1

4) Central Neurological Syndrome of unclear etiology

Examination of the lumbar spine revealed that there is a scoliosis with a convexity to the left. There is also a thoracic Kyphosis. Formal range-of-motion testing of the lumbar spine was limited due to the multiple other medical issues. Difficult to do any objective testing of the spine. He is unable to flex or extend or laterally bend due to his need to support his feet, He uses a cane. At the exam table he had 70 degrees of foward flexion in a seated position. he was unable to do rotation testing due to his instability and the need to support himself. The spine was diffusely tender as noted in the previous exam.

Exam of the lower extremity function revealed he was able to come to stand and sit independently. I did not dectect marked weakness in the legs. However, he had pain which prevented formal manual muscle testing. Good bulk in both legs (Veteran is 320 lbs. There should be good bulk Bound4heaven) sensory exam revealed defused complete loss of pinprick with only occasional area whereas able to elicit some discomfort. Overall it was marked diminishment of sensation. The patient was unbale to walk with out his shoues dut to discomfort. With his shoes on he was able to walk independently out of the clinic (I had my arm inside of his to help him walk Bound4heaven. This statement was incorrect by this Dr.)

On the 1st page of th exam he states, "There is addtional request to assess the patient's functional impairment of the lower extriminites and need for assistive devices as well as ability to do acvtivities of daily living secondary to shoulder conditions" What is this statement for.

I know he applied for AA and his primary doctor from the VA wrote a letter on his behalf stating his need for AA in all aspects of his daily living and had a big list of issues that he needed help doing.

Functional capabilities:

The patient functional capabilities are affected by the service connected conditions as well and the neurological findings. The neurological syndrome contributes to his functional impairment. The following function capabilities will include only the current service connected conditions.

The patient has limited use of right shoulder, however with his left shoulder he was able to help remove his shoe (That did not happen I removed his shoes) he appeared to have adquate function in his left shoulder to allow him to perform his own self cares. This doesn't include the upper extremity weakness and sensory loss. (What does this last statement mean???????????)

Mobility:

The patient was able to come to stand independently in the clinic (Not with out his cane or me holding his arm Bound4heaven) he uses a cane to assist with ambulation. He should be able to walk undepently around his house. Home modifications are being done to allow him to use a downstaires room. With the downstairs living space, he should be able to live independently within that space. (What does this Dr. Mean by independtly. This veteran cannot even wipe his own fical matter bound4Heaven) He is able to go up the stairs once a day.These functional capabilities don't include any loss of neurological function (What does this last statement mean?)

Presently the patients reports spending most of his time in his house. He only gets out on infrequent basis. He is now walking 1 block and able to do this 3 times per week. Other tines he spends most of the time in his room. He does come downstairs once a day. He is able to go to the bathroom indepently for urination. He needs some help cleaning up with his bowel movements.

Some of the this report does not spell out the truth. We did address those issues and sent them off today to the VARO.

His issues on appeal he requested an increase on his lumbar spine (currently 40%)

Increase right shoulder issues (Currently 40%)

Wanted the VARO to use the bi-lateral rating factor.

Applied for AA

On his last C&P exam results 6 months ago the 2 neurolgists results connected his left shoulder and myofacial straim to his right arm condition. NOw that this DR. Gave him Myofacial stran bi-lateral shoulders and back and increase lumbar pain. What will the DRO do with all of this?

Please note the Dr did not do ROM on this lumbar area. Will that hurt this vet. We will be going to my Doctor outside the VA system to get this completed, or do you all feel it is not necesssary?

Thank you all so much for your help.

God bless you all,

Bound4Heaven

One last issue the C&P exam Dr addressed. I do not know how to take his finding:

Unspecified neurlogical syndrome

Patient demonstrates a unspecific central neurological syndrome. He has had a decline in function over the past few years. The finding on todays exam includes loss of sensation starting at the back of the skull and extending down into all four extremies. In addition to the sensory changes, he also has significant weakness of both upper extremities including the previously reported bilateral hand weakness. His loss of function has presented over the past couple of years. Since this neurological exam was not focus of today's exam. I did not pursue futher diagnostic studies. Based on the information available on today's exam, it is less likely than not that the multiple service connected condition bcaused or aggrevated the neurological condition.

I am clueless on what this means as far as ratings. Any advice??????????????????????

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  • HadIt.com Elder

This doctor is saying that your service connected conditions are not affecting your neurological condition. Less likely than not. Just keep appealing if you don't get what you are seeking.

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"Based on the information available on today's exam, it is less likely than not that the multiple service connected condition bcaused or aggrevated the neurological condition."

I agree with John and the doctor provided no medical rationale for this statement- it is just a "guess".

I would state that the doctor gave no medical rationale for this statement nor any clear medical finding as to why that the unspecified neurological syndrome is not aggravated by- nor even caused by- the service connected conditions.

This is a good case of why a veteran must question each part of any exam like this that they disagree with.

VA doctors have to give a medical rationale to their findings.

In the 2nd IMO I got from Dr. Bash, he pounced on the VA doctor's lack of stating any medical rationale in her opinion.

The "more than likely or less than likely" is more than guesswork and has to be supported by a medical statement that makes sense.

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Dear Berta,

Thank you both for your response. I will get a letter out to the VARO (DRO) and question this issue and use your advice.

What do you think in regards to the rest of the exam results? Thank you for your opinion. God bless.

Bound4Heaven

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Greetings,

You are correct. Thank you for your response. This exam was for a veteran friend of mine who is 74. He and I are rated almost the same. I would appriciate anyone's opinions on the entire exam listed. Thank you all. God bless.

Bound4Heaven

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