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Confusing C&P
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gs106
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: 11/16/19993. Symptoms
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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 [ ] Severe11. 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 [ ] Severe17. 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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