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C&p Notes Are Grossly Misstated

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docbach

Question

So I went to my C&P exam for my back a couple weeks back. I injured my back in two spots (upper back around my chest and lower back with pain radiating down the leg) in Iraq March 2009 moving a Mk19 off of a gun truck, was seen at the TMC with a vague diagnosis of "backache." I was on a small FOB without MRI or diagnostic machines so I was on profile for a couple weeks then returned to duty. I initially put a claim in for my back in 2009 after returning home from Iraq but missed my exam so I tried to claim it again in 2011 but the va didn't schedule a C&P exam for my back and then denied me saying there was no evidence of my back having any problems; I appealed it until it somehow disappeared off ebenefits so I put a new claim in earlier this year. I went to the C&P exam and the rater focused on specific points and completely ignored other points, including my chief complaint. She totally ignored the lower back pain and radiation down my legs and said my injury was solely to the middle back, and said that I had only complained about this since 2012 after I got my MRI (had to beg my PCP for 3 years, he kept ordering xrays which showed nothing), despite several primary care, physical therapy, MRI's showing degenerative changes visits specifically for my lower back from 2009 to current. This is what it showed in the blue button, some edits for privacy and key points are bolded:

Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXX
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
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
Evidence review
---------------
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[X] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[X] Other:
lay note from XXXXXXXXXXXX
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
Thoracolumbar Common Diagnoses:
No response provided.
Diagnosis #1: lumbar strain
ICD code: 847.9
Date of diagnosis: 2009
Diagnosis #2: lumbar djd
ICD code: 847.2
Date of diagnosis: 2012
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
The veteran is here for evaluation for possible compensation for his
lumbar condition. He has some new information since the last time that he
was in for this same condition. He injured his mid-back in service in
2009, while deployed. He was lifting a machine gun system into a truck,
when he suddenly felt sharp, intense pain in his mid-back and around to
the front of his chest (she totally ignored my explanation of the lower back pain occurring at the same time). He found that it was hard to breathe. He was able
to finish his work duty, but then was seen for these symptoms a short
time
later. There is a note from 3/19/09, which is a copy of a note stating
that this veteran has back and chest pain and needs to be on light duty.
The veteran states that he was on light duty for 2-3 weeks. He was given
some flexeril for muscle spasms. There are no other notes in this
veteran's STRs concerning this incident. He does now have a note from a
friend, SGT xxxxxxxxxxxx, stating that he was there when this veteran
lifted the machine gun into the truck and he could see how much the
veteran was in pain at the time. The veteran was not seen again for his
back pain during his deployment. He went back to Guard duty and then back
to school. He states that he has continued to have constant back pain,
but
now describes it as lumbar pain. He was seen by his private provider in
2012 for this condition and had an MRI lumbar done in 2012 (I was seen by the VA primary care provider several times from 2009 until 2012 and several times after and she states it was just in 2012). This MRI
lumbar showed mild DJD changes and mild bilaeral neruoforaminal
stenosis.
He was treated with physical therapy, which didn't help much. He states
that he has flare ups about once a year (I said I had flare ups at least once a year, generally going several times for the condition to the VA), depending on his activities. He
has a baseline of pain at a level of 4-5 out of 10. He had left
testicular
pain in 2012 (I had testicular pain from sciatica in november 2009, just a couple days after returning home from Iraq, and she incorrectly put it as occurring in 2012), which is when he had the MRI lumbar done and this pain was
attributed to sciatica. The testicular pain has not continued, but he
does
have some pain in the buttocks at times, with numbness going into the
great toes, right greater than left. He also noted that he can't lift his
right leg up as far as he can the left leg, when standing. He takes
medication every day for his back pain.
b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or
her
own words:
about once a year, sudden increase in pain, in bed for 3 days and
lighter activities for up to two weeks
c. Does the Veteran report having any functional loss or functional
impairment of the thoracolumbar spine (back) (regardless of repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words.
He states that he can't lift as much as he used to and he can't bend
forward as far as he used to.
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
[ ] All normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Forward Flexion (0 to 90): 0 to 90 degrees
Extension (0 to 30): 0 to 20 degrees
Right Lateral Flexion (0 to 30): 0 to 30 degrees
Left Lateral Flexion (0 to 30): 0 to 30 degrees
Right Lateral Rotation (0 to 30): 0 to 30 degrees
Left Lateral Rotation (0 to 30): 0 to 30 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):
No pain noted on exam
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation
of the joints or associated soft tissue of the thoracolumbar spine
(back)?
[ ] Yes [X] No
b. Observed repetitive use
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
c. Repeated use over time
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?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
Is the exam being conducted during a flare-up? [ ] Yes [X] No
If the examination is not being conducted during a flare-up:
[X] The examination is medically consistent with the Veteran's
statements describing functional loss during flare-ups.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss during flare-ups. Please
explain.
[ ] The examination is neither medically consistent or inconsistent
with the Veteran's statements describing functional loss during
flare-ups.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain, Lack of endurance
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
no further change in range of motion
e. Guarding and muscle spasm
Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [ ] Yes [X] No
f. Additional factors contributing to disability
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. 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
Hip flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Great toe extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
5. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Knee:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
6. Sensory exam
---------------
Provide results for sensation to light touch (dermatome) testing:
Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Thigh/knee (L3/4):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Lower leg/ankle (L4/L5/S1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [ ] Normal [X] Decreased [ ] Absent
Left: [ ] Normal [X] Decreased [ ] Absent
7. Straight leg raising test
----------------------------
Provide straight leg raising test results:
Right: [ ] Negative [X] Positive [ ] Unable to perform
Left: [X] Negative [ ] Positive [ ] Unable to perform
8. Radiculopathy
----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[X] Yes [ ] No
a. Indicate symptoms' location and severity (check all that apply):
Constant pain (may be excruciating at times)
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Intermittent pain (usually dull)
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Numbness
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
b. Does the Veteran have any other signs or symptoms of radiculopathy?
[ ] Yes [X] No
c. Indicate nerve roots involved: (check all that apply)
[X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
If checked, indicate: [ ] Right [ ] Left [X] Both
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
9. Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No
10. Other neurologic abnormalities
----------------------------------
Does the Veteran have any other neurologic abnormalities or findings related
to a thoracolumbar spine (back) condition (such as bowel or bladder
problems/pathologic reflexes)?
[ ] Yes [X] No
11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
-----------------------------------------------------------------------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[ ] Yes [X] No
12. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion, although occasional locomotion by other methods may be
possible?
[ ] Yes [X] No
13. Remaining effective function of the extremities
---------------------------------------------------
Due to a thoracolumbar spine (back) condition, is there functional
impairment
of an extremity such that no effective function remains other than that
which
would be equally well served by an amputation with prosthesis? (Functions of
the upper extremity include grasping, manipulation, etc.; functions of the
lower extremity include balance and propulsion, etc.)
[X] No
14. 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 conditions listed in the Diagnosis
Section above?
[ ] Yes [X] No
c. Comments, if any:
No response provided
15. Diagnostic testing
----------------------
a. Have imaging studies of the thoracolumbar spine been performed and are
the
results available?
[X] Yes [ ] No
If yes, is arthritis documented?
[X] Yes [ ] No
b. Does the Veteran have a thoracic vertebral fracture with loss of 50
percent or more of height?
[ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
MRI lumbar 2012
mild degenerative changes, especially at L4-5, and mild bilateral
neuroforaminal stenoses
16. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or her
ability to work?
[ ] Yes [X] No
17. Remarks, if any:
--------------------
The veteran had back pain during his deployment in March, 2009, but this
pain
is described by the veteran as mid-back and wrapping around the chest,
causing difficulty breathing. This is a different pain than what he has had
since that time and for which he has been seen for and received physical
therapy. (again, totally ignored what I said or the years of being seen at the VA for lower back pain starting just days after returning home from deployment)
****************************************************************************
Peripheral Nerves Conditions
(not including Diabetic Sensory-Motor Peripheral Neuropathy)
Disability Benefits Questionnaire
Name of patient/Veteran: Lars Gerhardt Reichenbach
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
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
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
If no, check all records reviewed:
[X] Military service treatment records
[X] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[X] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[X] Other:
lay note from SGT Curtis Bortle
1. Diagnosis
------------
Does the Veteran have a peripheral nerve condition or peripheral neuropathy?
[X] Yes [ ] No
Diagnosis #1: sciatica
ICD code: 353.9
Date of diagnosis: 2012
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
peripheral nerve condition (brief summary):
The veteran is here for evaluation for possible compensation for his
sciatica. He is also here at this time for evaluation for possible
compensation for his lumbar back condition. He has had some pain, which
came on suddenly in 2012, in which his left side of his testicle was
very painful. (Again, this occurred in 2009 about a week after returning home from Iraq and she put the wrong date) He was evaluated and this pain was attributable to
sciatica. He had an MRI lumbar done in 2012, which showed mild
degenerative changes in L4-5 and mild bilateral neruoforaminal
stenoses.
He was treated with physical therapy in 2012, which he states did not
help much. He no longer has any testicular pain, but has had buttock
pain and numbness in his great toes, greater on the right than on the
left. He has no loss of strength in his legs or feet.
b. Dominant hand
[X] Right [ ] Left [ ] Ambidextrous
3. Symptoms
-----------
a. Does the Veteran have any symptoms attributable to any peripheral nerve
conditions?
[X] Yes [ ] No
Constant pain (may be excruciating at times)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Intermittent pain (usually dull)
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Numbness
Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
4. Muscle strength testing
--------------------------
a. 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
Elbow flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Elbow extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Wrist extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Grip:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Pinch (thumb to index finger):
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
5. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Biceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Triceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Brachioradialis:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Knee:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
6. Sensory exam
---------------
Indicate results for sensation testing for light touch:
Shoulder area (C5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Inner/outer forearm (C6/T1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Hand/fingers (C6-8):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Thigh/knee (L3/4):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Lower leg/ankle (L4/L5/S1):
Right: [ ] Normal [X] Decreased [ ] Absent
Left: [ ] Normal [X] Decreased [ ] Absent
Foot/toes (L5):
Right: [ ] Normal [X] Decreased [ ] Absent
Left: [ ] Normal [X] Decreased [ ] Absent
7. Trophic changes
------------------
Does the Veteran have trophic changes (characterized by loss of extremity
hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy?
[ ] Yes [X] No
8. Gait
-------
Is the Veteran's gait normal?
[X] Yes [ ] No
9. Special tests for median nerve
---------------------------------
Were special tests indicated and performed for median nerve evaluation?
[ ] Yes [X] No
10. Nerves Affected: Severity evaluation for upper extremity nerves and
radicular groups
-----------------------------------------------------------------------
a. Radial nerve (musculospiral nerve)
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
b. Median nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
c. Ulnar nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
d. Musculocutaneous nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
e. Circumflex nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
f. Long thoracic nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
g. Upper radicular group (5th & 6th cervicals)
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
h. Middle radicular group
Right [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
i. Lower radicular group
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
11. Nerves Affected: Severity evaluation for lower extremity nerves
-------------------------------------------------------------------
a. Sciatic nerve
Right: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis
If Incomplete paralysis is checked, indicate severity:
[X] Mild
[ ] Moderate
[ ] Moderately Severe
[ ] Severe, with marked muscular atrophy
Left: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis
If Incomplete paralysis is checked, indicate severity:
[X] Mild
[ ] Moderate
[ ] Moderately Severe
[ ] Severe, with marked muscular atrophy
b. External popliteal (common peroneal) nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
c. Musculocutaneous (superficial peroneal) nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
d. Anterior tibial (deep peroneal) nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
e. Internal popliteal (tibial) nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
f. Posterior tibial nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
g. Anterior crural (femoral) nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
h. Internal saphenous nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
i. Obturator nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
j. External cutaneous nerve of the thigh
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
k. Ilio-inguinal nerve
Right: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
Left: [X] Normal [ ] Incomplete paralysis [ ] Complete paralysis
12. 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
13. Remaining effective function of the extremities
---------------------------------------------------
Due to peripheral nerve conditions, is there functional impairment of an
extremity such that no effective function remains 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
14. Other pertinent physical findings, complications, conditions, signs
and/or symptoms
-----------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms?
[ ] Yes [X] No
15. Diagnostic testing
----------------------
a. Have EMG studies been performed?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
16. Functional impact
---------------------
Does the Veteran's peripheral nerve condition and/or peripheral neuropathy
impact his or her ability to work?
[ ] Yes [X] No
17. Remarks, if any:
--------------------
No remarks provided.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
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You need to see a private orthopedic back surgeon and have a Independent Medical Evaluation.

Refute the report with your medical evidence and get the issue to the VBA.

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You can also do a request to correct your medical records. If they refuse, they must allow you to put a short statement into the medical file noticing your disagreement with what the examiner put into the DBQ.

Go to the ROI/privacy office and they should get you started on this. If there is any error in the record, it is your right to challenge it and request it is amended.

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I just noticed that she actually contradicted herself in her notes, she says I was diagnosed with a lumbar strain in 2009, but then later on says that this didn't occur until 2012 so it can't be related to service.

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