3Rd Bad C & P Exam Out Of 5 Exams....what Do You Think?

[cragwex]

These are my notes that I wrote immediately after my C & P Exam. Please feel free to make any constructive comments. I applied for three New Items, Right Hip Osteoarthritis (NEW), Left hip Osteoarthritis (NEW), and IBS (NEW). I am a Gulf War Vet. I have knee and back issues. I am actually rated for both knees for instability, laxity, sprain/strain, and meniscus tear of right knee, and left knee needs TKR within the summer and fall. I also have right ankle issues. The way the directions were written the people reviewing the case were to look at only the papers I submitted and (a. Evidence review , Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?[X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed:[ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)[ ] Other:[ ] No records were reviewed b. Was pertinent information from collateral sources reviewed?[X] Yes [ ] No) So no one ever looked at my C-File to line up what all correlates to my case......figures. I know this is long but please stay with me. I am going to file a NOD on monday when my VSO comes back from leave. The following is the Notes from the MD VA Notes Source: VA Last Updated: 28 May 2015 @ 0717 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Date/Time: 18 May 2015 @ 1000 Note Title: C&P EXAM Location: CONNECTICUT HEALTH CARE SYSTEM - WEST HAVEN DIVISION Signed By: Co-signed By: B Date/Time Signed: 18 May 2015 @ 1050 Note LOCAL TITLE: C&P EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAY 18, 2015@10:00 ENTRY DATE: MAY 18, 2015@10:50:09 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Hip and Thigh Conditions Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the CONFIDENTIAL Page 24 of 122 ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination a. Evidence review ------------------ Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] Other: [ ] No records were reviewed b. Was pertinent information from collateral sources reviewed? [X] Yes [ ] No If yes, describe: remote data 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: No response provided b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Osteoarthritis, hip Side affected: [ ] Right [ ] Left [X] Both ICD Code: 715.9 Date of diagnosis: Right 2014 Date of diagnosis: Left 2014 c. Comments (if any): No response provided CONFIDENTIAL Page 25 of 122 d. Was an opinion requested about this condition (internal VA only)? Yes 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's hip or thigh condition: DOS: October 28, 1985 to December 31, 2007 exit exam dated 12/2007: reported h/o right hip bursitis listed as NCD 7/07 normal hip films 2/2008 seen for right lateral hip pain and popping from walking dx trochanteric bursitis 1/08 normal right hip films 3/08 note seen for c/o right hip pain and right LE radiculaopthy Dx with greater trochanteric buursitis and given steroid injections with ortho note 4/2013 states Thoracic car accident at age 19 This would explain shooting /neuropathic pain into his hips hip films 4/2014- mild bilateral djd done for 1 year of intermittent sharp bilateral hip pain 8/2014 films read as normal 12/2014 note sates R>L bilateral hip pain for last 7 years pain worse with prolonged sitting or standing occasional popping. Films unchanged from 4/2014 which show mild djd. DX mild R>L djd but no joint space narrowing or ROM limitations. hip films 12/2014 djd not changed from 4/2014 Veteran says after discharge he worked as a crane rigger from 2009-2012 and then did crane surveillance ( more managerial type work) Now works doing QA. States that his knee and back condition more so affected his ability to perform physical work. Vetan reports daily bilateral hip pain of varying intensity. Says that it bothers him if he sits too long and says it helps to move around but then bothers him if he stands too long. Says his hips pop and ache R>L. Veteran also has significant knee disorder and a total left knee replacment is being planned for this summer. SMRS do not document the diagnosis of bilateral DJD or a chronic bilateral hip condition in service. He was treated only for a right hip bursistis in service with exit exam stating " h/o right hip films bursitis listed NCD". Film request in 2014 states "1 year of intermittent sharp bilateral hip pain ". Given above this examiner Page 26 of 122 opines his current bilateral hip condition is less likley as not due to service and at least as likely as not due to post service events b. Does the Veteran report flare-ups of the hip or thigh? [ ] Yes [X] No c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [ ] Yes [X] No 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right hip --------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0-125): 0 to 90 degrees Extension (0-30): 0 to 30 degrees Abduction (0-45): 0 to 45 degrees Adduction (0-25): 0 to 25 degrees Is adduction limited such that the Veteran cannot cross legs? [ ] Yes [X] No External Rotation (0-60): 0 to 60 degrees Internal Rotation (0-40): 0 to 40 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes, (please explain) [X] No Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Flexion, Abduction, Adduction, Internal rotation Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): right hip CONFIDENTIAL Page 27 of 122 Is there objective evidence of crepitus? [ ] Yes [X] No Left hip -------- [ ] All Normal [ ] Abnormal or outside of normal range [X] Unable to test (please explain) [ ] Not indicated (please explain) If unable to test or not indicated please explain: unable to test due to his left knee condition Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right hip --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No Left hip -------- c. Repeated use over time Right hip --------- Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? CONFIDENTIAL Page 28 of 122 [ ] Yes [X] No [ ] Unable to say w/o mere speculation Left hip -------- d. Flare-ups: No response provided e. Additional factors contributing to disability Right hip --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Right Hip Rate Strength: Flexion: 5/5 Extension: 5/5 Abduction: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No Left Hip: No response provided b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the hip. a. Indicate severity of ankylosis and side affected Right side: Left side: [ ] Favorable, in flexion at [ ] Favorable, in flexion at CONFIDENTIAL Page 29 of 122 an angle between 20 and an angle between 20 and 40 degrees, and slight 40 degrees, and slight abduction or adduction abduction or adduction [ ] Intermediate, between [ ] Intermediate, between favorable and unfavorable favorable and unfavorable [ ] Unfavorable, extremely [ ] Unfavorable, extremely unfavorable ankylosis, unfavorable ankylosis, foot not reaching ground, foot not reaching ground, crutches needed crutches needed [X] No ankylosis [X] No ankylosis b. Comments, if any: No response provided 6. Additional conditions ------------------------ a. Does the Veteran have malunion or nonunion of femur, flail hip joint or leg length discrepancy? [ ] Yes [X] No b. Comments, if any: No response provided 7. Surgical procedures ---------------------- No response provided 8. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any condition listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 9. Assistive devices -------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response CONFIDENTIAL Page 30 of 122 provided 10. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's hip or thigh conditions, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 11. Diagnostic testing ---------------------- a. Have imaging studies of the hip or thigh been performed and are the results available? [X] Yes [ ] No If yes, is degenerative or traumatic arthritis documented? [X] Yes [ ] No If yes, indicate hip: [ ] Right [ ] Left [X] Both b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 12. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [ ] Yes [X] No 13. Remarks, if any: -------------------- No response provided **************************************************************************** COMPENSATION AND PENSION EXAMINATION REPORT (FREE TEXT) ======================================================= CONFIDENTIAL Page 31 of 122 colon done for colon cancer sreen and h/o IBS 7/2013 negative dx with irritable bowel 5/2013 exit exam 12/2007 marked off not to any stomach intestinal trouble. There is no objective documentation for the diagnosis of or treatment for IBS in service or withing 1 year of discharge from service. As such his current IBS is less likely as not due to service. /es/ MD medical attending Signed: 05/18/2015 10:50 Then my notes right after the Exam and then forwarded to my VSO and two other e-mails of mine to ensure all saw that this was written ASAP. My notes from my 18th of May 2015 C & P Exam This female doctor is the same one I had in 2009. From the start of the whole appt it was quick, to what point she wanted, interrupted and she not only gave her opinions on my x-rays but on my future ratings. She told me a lot of film will not show arthritis. She told me that I had no x-rays showing arthritis and that they were normal. I agreed that I did not know what the 2007/08 x-rays showed. She also stated that the one done by the VA was unremarkable showing a normal hip. I replied by saying that I had the Naval Ambulatory Clinic New London also take x-rays two separate times within the last year. Both showed evidence of arthritis with the right being worse and advised to get an MRI. She claimed not to have them. She said MRIs are only for soft tissue and that they wouldnt show anything either. I brought these with me to the exam and when she said she didnt have them I showed them to her. Upon seeing them and while trying to hand those over to her, she said oh I see them here now. The screen had never moved as I watched it through this back and forth conversation. She told me that x-rays really dont show arthritis and are open for interpretation by who ever read them, and that everybody reads them differently. She them asked me how long I was in the service to which I replied, 22 years. During our conversation she asked about other things going on with me and I told her about my left knee which I am scheduled to get replaced this summer. She then asked me what I did in the Navy to which I replied I was a Navy Deep Sea Diver and that I had a VA Training letter that dealt with my rate in the Navy. She said she was not allowed to take any paper and that if I wanted it in my record I should write the VA. She then said lets take a look, please have a seat on the exam table and lie back on your back. She then asked me to bring my left knee to my chest. I refused for the simple fact that I cannot bend my left knee that far and that its the one that I need to get replaced. She says oh yeah thats right I forgot that was your bad knee! She then had me bend my right knee as far as I can towards my chest. I also have issues with this knee. After not bending it all the way up, she asked if that was as far as I could bend it, to which I replied yes. She then tried to help it further at which point I protested and said thats enough stop it hurts to go further. I physically put my hands up to stop her from doing it again, she reacted by bringing both hands up and out to her sides at shoulder height while displaying a surprised look on her face. After this she stopped. She then asked me to cross my right foot over my left and then outwards while telling her when it hurt. I told her I felt pain during the initial movement and the end rotation. But during the middle I didnt feel a lot of pain. During no time did she have any angle indicator or similar device out and present. The last test she did while I was on the bench was a strength test for adduction and abduction of the thigh and up and down. While she conducted this test it was very quick and she barely even did the left thigh strength motion test while saying well we know this one is weak. She had me stand facing the wall with my hands against the wall she wanted me to stand on one leg while extending the other leg back and up behind me. I told her I could not stand on my left leg and do that but did do the right. She told me that they would most likely have me come in again after my knee replacement because I could not do the test. She never asked me when the pain started and or ended during this motion. I asked her what if I had the same issues with bending it happened. She did not answer. She asked me what I took for the pain to which I replied 30mg oxycodone and 30mg oxycontin. She then asked me about my jobs and what they were and how long I had them. I told her I was a rigger in 2009 until 2012 when I became a crane surveillance specialist. I then told her I was now since June of 2014 a quality assurance specialist. I explained that since my progression in limits of physical activity and increase in pain I have had to find less and less physical work. I also told her once my wife went back to school for her masters in nursing I would be quitting/retiring as it has been getting harder and harder to work. She said she saw little if any at all arthritis on the x-rays. In concluding the exam she stated that my both my hips will most likely stand as is. She asked me if I wanted talk to Mr. Seally which was an office manager for temporary ratings when going for knee surgery such as mine. We talked to him and he said because of my present rating it would do no good. During the exam she asked me on three different occasions what my occupations was and when I was in them. On one occasion she asked me when I was a crane operator, to which I replied I wasnt. She was short with me and interrupted throughout the exam and gave opinions on how she thought the rating was going to be, which was negative. I hand wrote these notes on the 18th of May in my vehicle immediately after my examination at 10:35. I signed in at 09:55 and was taken back to the exam room by the doctor at 09:59. I compiled this word document on the 19th of May 2015. I e-mailed this to myself at two different addresses and ccd Rob Lewis my Veteran Service Officer as well. This was added on the 20th of May 2015; I also forgot to mention that the Doctor neglected to do or ask me to bend at the hip or with me laying flat on my back with her holding all the weightrotate my legs in a frog leg kick fashion. After thoughts: Entered on 21 May 2015, The Doctor also neglected to do any x-rays or MRI either the day of my exam or after, as this could potentially clear up or enforce any already stated comments. After thoughts 6 Jun 2015, She commented on an entry that my pain clinic had said I had a car accident (note 4/2013) where the office took liberty to comment as to this could have been the origin of my thoracic spinal issues. The reason I entered that paper into evidence was because of my IBS. I am corresponding with the office to get this amended. Only after I received a VA Training Letter detailing the adverse affects of Navy Deep Sea Diving had on the body did we think we knew where my issues stemmed. She speculates on issues from 30 years ago without reviewing my C-file or anything else. At no time did she ask about my time in the Persian Gulf, malaria pills or symptoms of my IBS.

[Berta]

"Given above this examiner Page 26 of 122 opines his current bilateral hip condition is less likley as not due to service and at least as likely as not due to post service events"

I assume you claimed the hip condition as secondary.
Veteran also has significant knee disorder and a total left knee replacment is being planned for this summer.

Do you have osteo arthritus in the knees? HAs VA ever ruled that out?

In this BVA remand ,for similar disabilities another orthopedic C & P was ordered:
http://www.va.gov/vetapp04/files4/0434406.txt


As this case shows, a knee disability can certainly cause a secondary hip disability:
http://www.va.gov/vetapp02/files01/0201428.txt

This is also a grant for secondary, knee to hip.

The biomechanics from feet, knees, hip and back are all related.

Was the recent C & P signed and if so what is the doctor's name...Can you find out and then see what they actually have a medical degree in?

If the claim is denied you might need to obtain an IMO from a real ortho professional but maybe you can stop this at the pass, by immediately questioning the C & P examiner's credentials.

I do not believe you got a professional C & P exam for your issues.

I would hate to see any claim like this be denied and go all the way to the BVA, for a reamand because they want an orthopedic spcialist to re do the C & P.

This concerns me:
"She said she saw little if any at all arthritis on the x-rays." That might not be a fact.
" In concluding the exam she stated that my both my hips will most likely stand as is." Meaning no SC rating?
" She asked me if I wanted talk to Mr. Seally which was an office manager for temporary ratings when going for knee surgery such as mine. We talked to him and he said because of my present rating it would do no good."

These people are not qualified benefits counselors or VA raters.I think the C & P examiner acted inappropriately, because a lack of a possible rating per Mr. Seally , made it easier for her to render a bogus exam result.,hoping you wont even question it.

You could possibly become eligible for TDIU and/or SMC at some point....you do have a potential secondary claim.for SC but I think you will need an IMO unless you can challenge this exam and ask for a new exam, right away.

Maybe Mr Seally would know her name and medical background.

I got the most ridiculous posthumous C & P report I ever got, a few months ago and have had plenty over the past 20 years.

It was for a 1151 HBP claim regarding my deceased husband.

I couldnt believe how awful it was and I was convinced that it was prepared by the guy who refills the cup dispenser at my ROs water cooler thing.

Even worse is that they never considered a report from a top Cardio doc at VA Central.Although the report was generated in 1997 for my FTCA case, it still was binding on the VA.

Once they finally read that evidence, they reversed their denial right away.

I even had a www.healthgrades report on this VA doc and it was outstanding.

I had to knock down a PA C & P in 2009 . BVA ordered a Cardio report for that claim but I got a PA and he didnt have a clue and I rebutted that his report was mere speculation and he was not qualified to opine on Cardio disease. BVA agree and shit canned his C & P. That left 2 C & P s against and I had 3 IMOs for, so they awarded that claim.

I hope you can can turn this around fast. Do you have a ret rep?

others will chime in here too.

[cragwex]

Yes I did claim as secondary but from what I know this is not necessary since they are the Medical Professionals. She is a MD. I have osteo arthritis in both knees, ankles and DJD in various places throughout my Spine. I was denied for all and will file a NOD and probably ask for DRO. I had her for another C & P in 2009 and she was totally a different person. She actually contradicts herself by saying x-rays are subjective to whoever reads them. Then says she did not see any arthritis but its marked that I do in fact have it. When she stated that she did not see any evidence on the x-rays and how she opines that my rating would not change, she is not there to judge. She is there to write down what she sees and observes, not to rate me. Thats not her job, and she is not a radiologist. I am at 100% right now just not P & T. That is what I am seeking. I am doing this for my wife and sons education and future financial stability. None of my disabilities will get better. In fact if I was so inclined I could go back for a psychological exam which with all of my disabilities could easily get an increase in my rating. I am so sorry for the bad C & P reports you had to put up with in a time like that. On another C & P for my low testosterone which I won the claim, the Dr (female), claimed that I had an erection during the exam and that I was circumcised. When I told my VSO at the time she asked if I had an erection and laughed and told her no. She asked why I was laughing. I said sally..I am not circumcised! She said since we won the claim dont make a fuss. However she said if I ever was scheduled for any exam with her to call and cancel right away and that if they had an issue with it, that it was time to sue and that I would easily win the law suit. Its almost like they dont read everything in your claim. I do have a VSO in Newington CT. I will be filling with him Next Week when he comes back from his vacation. Thanks Berta, I appreciate it.

[Berta]

Thanks for that Very descriptive information.......I was able to help a vet prove inservice diabetes, in part due to spending a lot of time studying his penis (that is studying the SMRs he gave me about his many bouts with VD.

I found he not only was not circumcised but had a condition that could be prevalent in uncircumcised men, and he probably did not have VD in service.at all.,,more than likely he had this other condition....

It was a condition not only possible due to lack of circumcision but also highly likely due to his inservice undiagnosed diabetes.

Forget what it was called and he had lots more evidence too, that 2 lawyers ,the BVA, and the CAVC twice ,never looked at carefully.

He got an IMO and he finally won.

He was so happy he did not want to file a NOD and I felt he should have as it seemed to be a lowball rating..

[Navy04]

Sorry to hear of your troubles bud. Good advice given above bud, but remember try not to rock the boat, unless you absolutely feel you have to. As you all know on here, I have been put thru a lot of Crap the last few months due to submitting and FDC last Nov 2014. Good luck and God Bless