So I received my C&P for the general medicine part of the evaluation. I feel like everything that she put down makes it seem like I have no issues at all. Did anyone else encounter this? Did it cause any issues down the road?
Issues with VA Appt notes
- Thread starter fielding87
- Start date
I am good with what was written for my unfitting condition, which is PTSD, but for all the phsycial issues, such as my back, neck and shoulder pain and everything else it's worded saying no pain, while there are symptoms it doesn't constitute a diagnosis, things of that nature.
I encountered something similar in my C&P exams. There was a "general" portion and then a separate exam template for each of my physical issues (1 section entirely for feet, 1 for back etc). In many instances the "general" portion of the exam glossed over issues, but they were later covered correctly in their own specific exam. If you claimed a physical contention than they should have done a specific exam for that body part. If they did not you should talk to PEBLO. My PEBLO went line-by-line and checked off my claimed disabilities against the C&Ps to ensure everything that needed a specific exam got one.
Did you do ROM test for neck and shoulder? That's hold more weight than notes
I did do that and it was very painful and couldn't move it all the way, but she marked that I had normal functioning.
She did do the exam for each one. The problem is she marked things wrong. Is there pain? She marked no for that. Made it seem like there was nothing wrong with anything I was claiming, marked all my ROM as normal, things like that. The way I read it, it doesn't seem like I have any issues with any of the problems anymore, even thought I do.
if your ROM or other notes are wrong, the only option that I have seen so far is complain through the VA, however the va will not schedule you new exams etc. until after your out because your not in their jurisdiction. Do you know or do you have what ROM's she wrote down? are they all checked "WNL" etc.
What is WNL? And yes, I do have all them.
WNL=within normal limits.
What ROMS were listed and do you feel the percentage assigned that rom is accurate. What I am trying to say, is like in instance for my back, I know I cannot bend as far as she wrote down, BUT the percentage assigned to the number she did put down was still in the same rating range as I felt was fair. (I think I am past 30-but not the 50-60 she wrote down but the percentage is the same), Same with my neck, she did not even do the rotation measurements, but she put down she did, however my x-rays show contour changes that would equal 20%, which is the same as what ROM I feel I have.
I reaaaaly want a new exam, but with the numbers she made up/listed, the ratings should be close, and I do not want to start this process over, so will fight after I get out, or with my Physical therapist's ROM testing through the VA recon.
What ROMS were listed and do you feel the percentage assigned that rom is accurate. What I am trying to say, is like in instance for my back, I know I cannot bend as far as she wrote down, BUT the percentage assigned to the number she did put down was still in the same rating range as I felt was fair. (I think I am past 30-but not the 50-60 she wrote down but the percentage is the same), Same with my neck, she did not even do the rotation measurements, but she put down she did, however my x-rays show contour changes that would equal 20%, which is the same as what ROM I feel I have.
I reaaaaly want a new exam, but with the numbers she made up/listed, the ratings should be close, and I do not want to start this process over, so will fight after I get out, or with my Physical therapist's ROM testing through the VA recon.
Yes, they were all marked WNL
If you feel that is wrong, I would start barking up every tree available. I just do not know how many trees are available, besides, direct complaints to the VA, or congressional. We really need a sticky or something describing complaint/problem resolution with the VA C/P side of the house. maybe I can work something out over the holiday, since its frozen outside here at Tinker area, I will not be leaving my chair/heating pad much.
Beware, they watch you during your exam, not just during your ROM. If you bend to tye you shoes and such. If you have no MRI or x-ray for your neck and back showing problems, they will most likely put your pain in as part of your Fibro. If that is so, ROM doesn't matter, what matters is if your pain is constant or intermitent.
I as aware of that during my exam. The issue I have is that she tried to say I don't meet the criteria for fibro because I don't have pressure points but I do have them. She just didn't check.
Can you expound on this? Especially the difference between constant and intermittent pain.
Have you been diagnosed by a rheumatologist for Fibro? If so, I would think. Regardless of what she thinks, the VA should still rate it based on med records as long as they are current.
5025 Fibromyalgia (fibrositis, primary fibromyalgia syndrome)
With widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms:
That are constant, or nearly so, and refractory to therapy.......................... 40
That are episodic, with exacerbations often precipitated by
environmental or emotional stress or by overexertion, but that
are present more than one-third of the time............................................ 20
That require continuous medication for control.......................................... 10
Note: Widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities.
With widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms:
That are constant, or nearly so, and refractory to therapy.......................... 40
That are episodic, with exacerbations often precipitated by
environmental or emotional stress or by overexertion, but that
are present more than one-third of the time............................................ 20
That require continuous medication for control.......................................... 10
Note: Widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities.
Indeed, and as a direct result, I am still implementing my authorized rights under the DoD IDES appeal process at this point in time.
To that extent, never default acceptance to potential injustice; fight then continue to fight some more is my stance on any erroneous situation!
Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer."
Best Wishes!
Do you have her notes? Sounds like you're going to have a fight on your hands.
Did you have MRIs of you neck and back?
Sounds like she is trying to dismiss you fibro all together.