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Confusing C&P

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gs106

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 I just had a C&P exam for fractured foot, deviated septum and bilateral lower extremity radiculopathy secondary to LOWER BACK.  I couldn't believe what the doctor wrote in the DBQ.  I'm not including the entire DBQ but enough to show what I believe to be incorrect information. I sent copies of my civilian doctors’ notes (sciatica), MRI results showing multiple nerve impingement, and the examination results from my first visit to the pain clinic with my claim but the VA doctor says it is due to a fractured foot.  The date of diagnosis of the peripheral neuropathy below is the date I fractured my foot.   Will the rater ask for clarification from the doctor doing the DBQ or decide the claim based this information?

1. Diagnosis
------------
Does the Veteran have a peripheral nerve condition or peripheral neuropathy?
[X] Yes [ ] No
Diagnosis #1: Peripheral neuropathy
ICD code: 302226006
Date of diagnosis: 11/16/1999
3. Symptoms
-----------
a. Does the Veteran have any symptoms attributable to any peripheral nerve
conditions?
[X] Yes [ ] No
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
11. Nerves Affected: Severity evaluation for lower extremity nerves
-------------------------------------------------------------------
a. Sciatic nerve
No response provided.
b. External popliteal (common peroneal) nerve
Right: [ ] Normal [X] Incomplete paralysis [ ] Complete paralysis
If Incomplete paralysis is checked, indicate severity:
[X] Mild [ ] Moderate [ ] Severe
17. Remarks, if any:
--------------------
VBMS reviewed.
Medical opinion: veteran peripheral neuropathy CONDITION is at mild
severity and is least as likely as not due to injury incurred in from
Jones fracture in service as evidenced by numerous STR for same
complaints.

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I'm not sure what your question is.  It appears to me the examiner is suggesting the condition is mild and that "it is at least as likely as not".  So... looks like the exam went in your favor.  You could always disagree with the assessment of severity but would need evidence to dispute.  This is why I went to see a private neurologist prior to submitting my claim.  I also had nerve conduction studies and an EMG completed.  It's difficult for the VA to disagree with diagnostic proof.  By the way, for peripheral neuropathy categorized as subjective (lacking objective proof), they rate it as mild.

Edited by green
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Looks like you will be service connected to me.

Now if you were SC'd for it already and were looking for an increase, well would have to know where you are starting from.

If this is a initial claim for this ailment, you may have been lowballed, but that just goes with the territory.

You'll have to wait for the rating and see what they say, but,

looks good to me,

Hamslice.

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Notes that sciatic nerve is "incomplete paralysis" would show that you have neuropathy related to your spine. 

He indicated the popliteal nerve, so that would give you 10%.  This is defined as sensory only, and not very bad.  If you get a LOT of pain, numbness, maybe some shooting zaps up your leg to your knee it can get rated as 20%.  There must be symptoms like weakness, inability to move your ankle, drop foot etc...to get a higher rating.

The problem you have now is that the examiner ignored existing medical records which indicate that the condition originates in the lumbar region (I am assuming that's what your non VA records show).  Unless there is a NCV and EMG test showing the exact source of the issue, neither one of the exam's can be called conclusive (yet, the MRI does carry a lot of weight toward the probability and should rule the day).  Consider if the C&P didn't order the NCV/EMG then his opinion is worthless because he didnt site the MRI results or explain why the records he was supposed to review were in error.

 

 

Edited by pwrslm
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Your last paragraph nailed it PWRSLM.  My question was how can the doctor tie the neuropathy to a foot fracture when the claim was secondary to lumbar spine with medical evidence included with the claim.  Perhaps part of it can be related to the fracture, I certainly don't have enough medical knowledge to know that.  Maybe they will SC both the peroneal and sciatic nerves :lol:  I know....I'm dreaming.

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