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tdiu THINK IM HEADED FOR NOD
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Question
harrysday
LOCAL TITLE: C&P INTESTINES
STANDARD TITLE: C & P EXAMINATION NOTE
AUTHOR: EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Gulf War General Medical Examination
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Name of patient/Veteran:
1. Medical record review
------------------------
[X] C-file (VA only)
[X] Other, describe: The c-file(VBMS and Virtual VA), service treatment
records and VA CPRS electronic medical records are
reviewed.
2. Medical history
------------------
a. No symptoms, abnormal findings or complaints: No answer provided
b. Skin and scars: No answer provided
c. Hematologic/lymphatic: No answer provided
d. Eye: No answer provided
e. Hearing loss, tinnitus and ear: No answer provided
f. Sinus, nose, throat, dental and oral: No answer provided
g. Breast: No answer provided
h. Respiratory: No answer provided
i. Cardiovascular: No answer provided
j. Digestive and abdominal wall: Esophageal Disorders (GERD and Hiatal
Hernia), Intestinal Conditions (other than Surgical and Infectious)
k. Kidney and urinary tract: No answer provided
l. Reproductive: No answer provided
m. Musculoskeletal: No answer provided
n. Endocrine: No answer provided
o. Neurologic: No answer provided
p. Psychiatric: No answer provided
q. Infectious disease, immune disorder or nutritional deficiency: No
answer
provided
r. Miscellaneous conditions: No answer provided
3. Diagnosed illnesses with no etiology
---------------------------------------
From the conditions identified and for which Questionnaires were completed,
are there any diagnosed illnesses for which no etiology was established?
[X] Yes [ ] No
Diagnosis #1: Irritable Bowel Syndrome
ICD code: K59.9
Date of diagnosis: 1992
Name of Questionnaire: DBQ GI INTESTINES (OTHER THAN SURGICAL OR
INFECTIOUS)
4. Additional signs and/or symptoms that may represent an "undiagnosed
illness" or "diagnosed medically unexplained chronic
multisymptom illness"
-----------------------------------------------------------------------------
Does the Veteran report any additional signs and/or symptoms not addressed
through completion of DBQs identified in the above sections?
[ ] Yes [X] No
5. Physical Exam
----------------
Normal PE, except as noted on additional Questionnaires included as part of
this
report
6. Functional impact of additional signs and/or symptoms that may represent
an "undiagnosed illness" or "diagnosed medically
unexplained chronic
multisymptom illness"
-----------------------------------------------------------------------------
[ ] Yes [X] No
7. Remarks, if any:
-------------------
Veteran is aware that evaluation is for C&P purposes. Advised to follow
up
with primary care provider for further evaluation and treatment.
****************************************************************************
Esophageal Conditions
(Including gastroesophageal reflux disease (GERD), hiatal hernia
and other esophageal disorders)
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed: Yes
List any records that were reviewed but were not included in the
Veteran's
VA claims file: The c-file(VBMS and Virtual VA), service treatment records
and VA CPRS electronic medical records are reviewed.
Diagnosis
---------
Does the Veteran now have or has he/she ever been diagnosed with an
esophageal condition? Yes
Gastroesophageal reflux disease (GERD)
ICD code: K21.9 Date of diagnosis: 1998
Hernia hiatal
ICD code: K44.9 Date of diagnosis: 2008
Medical history
---------------
Description of the history (including onset and course) of the
Veteran's
esophageal conditions: C-File(VBMS and Virtual VA) reviewed. VA CPRS
reviewed.
47 year old male states he has GERD symptoms since 1991. Upper GI on 8/20/98
indicated GERD. Uses Protonix (pantoprazole). No surgery.
Does the Veteran's treatment plan include taking continuous medication
for
the diagnosed condition: Yes
Medications used for the diagnosed condition: Protonix (pantoprazole)
Signs and symptoms
------------------
Does the Veteran have any of the following signs or symptoms due to any
esophageal conditions (including GERD)? Yes
Sign and Symptoms:
Persistently recurrent epigastric distress
Pyrosis
Reflux
Regurgitation
Pain
Substernal
Sleep disturbance caused by esophageal reflux
Frequency of symptom recurrence per year: 4 or more
Average duration of episodes of symptoms: Less than 1 day
Nausea
Frequency of episodes of nausea per year: 4 or more
Average duration of episodes of nausea: Less than 1 day
Vomiting
Frequency of episodes of vomiting per year: 4 or more
Average duration of episodes of vomiting: Less than 1 day
Esophageal stricture, spasm and diverticula
-------------------------------------------
Does the Veteran have an esophageal stricture, spasm of esophagus
(cardiospasm or achalasia), or an acquired diverticulum of the esophagus? No
Other pertinent physical findings, complications, conditions, signs and/or
symptoms
-----------------------------------------------------------------------------
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? No
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs and/or symptoms related to any conditions listed in the
Diagnosis section above? No
Diagnostic Testing
------------------
Have diagnostic imaging studies or other diagnostic procedures been
performed? Yes
Diagnostic Testing Preformed:
Upper endoscopy Date: 10/1/08 Results: Normal
esophagus. Moderate Hiatal Hernia. Gastric Polyps.
Has laboratory testing been performed? No
Are there any other significant diagnostic test findings and/or results? No
Functional impact
-----------------
Do any of the Veteran's esophageal conditions impact on his or her
ability to
work? No
Remarks, if any:
----------------
Veteran is aware that evaluation is for C&P purposes. Advised to
follow up
with primary
care provider for further evaluation and treatment.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
****************************************************************************
Intestinal Conditions (other than surgical or infectious),
including irritable bowel syndrome, Crohn's disease, ulcerative
colitis and diverticulitis
Disability Benefits Questionnaire
Name of patient/Veteran:
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
The c-file(VBMS and Virtual VA), service treatment records and VA CPRS
electronic medical records are reviewed.
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with an
intestinal condition (other than surgical or infectious)?
[X] Yes [ ] No
[X] Irritable bowel syndrome
ICD code: K59.9
Date of diagnosis: 1992
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
intestinal condition (brief summary):
C-File(VBMS and Virtual VA) reviewed. VA CPRS reviewed.
47 year old male states he has irritable bowel symptoms since 1992.
Diarrhea only. States he has liquid/loose stool bowel movements twelve
times per day.
b. Is continuous medication required for control of the Veteran's
intestinal
condition?
[ ] Yes [X] No
c. Has the Veteran had surgical treatment for an intestinal condition?
[ ] Yes [X] No
3. Signs and symptoms
---------------------
Does the Veteran have any signs or symptoms attributable to any non-surgical
non-infectious intestinal conditions?
[X] Yes [ ] No
If yes, check all that apply:
[X] Diarrhea
If checked, describe:
States he has liquid/loose stool bowel movements twelve
times per day.
[X] Abdominal distension
If checked, describe:
Recurrent episodes of abdominal distension.
4. Symptom episodes, attacks and exacerbations
----------------------------------------------
Does the Veteran have episodes of bowel disturbance with abdominal distress,
or exacerbations or attacks of the intestinal condition?
[X] Yes [ ] No
If yes, indicate severity and frequency: (check all that apply)
[X] Episodes of bowel disturbance with abdominal distress
If checked, indicate frequency:
[ ] Occasional episodes
[X] Frequent episodes
[ ] More or less constant abdominal distress
5. Weight loss
--------------
Does the Veteran have weight loss attributable to an intestinal condition
(other than surgical or infectious condition)?
[ ] Yes [X] No
6. Malnutrition, complications and other general health effects
---------------------------------------------------------------
Does the Veteran have malnutrition, serious complications or other general
health effects attributable to the intestinal condition?
[ ] Yes [X] No
7. Tumors and neoplasms
-----------------------
a. Does the Veteran have a benign or malignant neoplasm or metastases
related
to any of the diagnoses in the Diagnosis section?
[ ] Yes [X] No
8. 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 and/or symptoms?
[ ] Yes [X] No
9. Diagnostic testing
---------------------
a. Has laboratory testing been performed?
[ ] Yes [X] No
b. Have imaging studies or diagnostic procedures been performed and are the
results available?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
8/20/98 Colonoscopy: Rectal bleeding secondary to hemorrhoids.
c. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
10. Functional impact
---------------------
Does the Veteran's intestinal condition impact his or her ability to
work?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's intestinal
conditions, providing one or more examples:
Frequency of bowel movements requires access to bathroom
facilities.
11. Remarks, if any:
--------------------
Veteran is aware that evaluation is for C&P purposes. Advised to
follow
up with primary care provider for further evaluation and treatment.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
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
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
The c-file(VBMS and Virtual VA), service treatment records and VA CPRS
electronic medical records are reviewed.
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Medical Opinion Needed:
1. Type of medical opinion requested: Direct service connection
Contention: Claimed Condition: GERD
Opinion Requested:
Is the veteran's current diagnosis of GERD at least as likely as not (50
percent or greater probability) evidenced to have begun in service and left
undiagnosed?
b. Indicate type of exam for which opinion has been requested: DBQ GI
ESOPHAGUS (INCLUDING GERD & HIATAL HERNIA)
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
b. The condition claimed was less likely than not (less than 50%
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: The c-file(VBMS and Virtual VA), service treatment records and
VA CPRS electronic medical records are reviewed. The Veteran is diagnosed
with Gastroesophageal Reflux Disease(GERD). The service treatment records
contain a 1/12/89 military entrance exam and a 3/9/93 military separation
exam. Neither exam references GERD symptoms. There are no references to GERD
symptoms in the in-service clinical notes. Based on a review of the
available
service treatment records, it is difficult to find an association between
the
Veteran's current GERD diagnosis and military service.
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Type of medical opinion requested: Direct
service connection
Contention: Claimed Condition: IBS
Opinion Requested:
Is the veteran's current diagnosis of IBS at least as likely as not (50
percent or greater probability) evidenced to have begun in service and left
undiagnosed?
b. Indicate type of exam for which opinion has been requested: DBQ GI
INTESTINES (OTHER THAN SURGICAL OR INFECTIOUS)
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
b. The condition claimed was less likely than not (less than 50%
probability) incurred in or caused by the claimed in-service injury, event
or
illness.
c. Rationale: The c-file(VBMS and Virtual VA), service treatment records and
VA CPRS electronic medical records are reviewed. The Veteran is diagnosed
with Irritable Bowel Syndrome. The service treatment records contain a
1/12/89 military entrance exam and a 3/9/93 military separation exam.
Neither
exam references IBS symptoms. There is an 11/23/92 clinical note referencing
diarrhea and nausea. However, there are no further clinical notes regarding
the condition. This includes the 3/9/93 military separation exam. This would
indicate the condition was acute and self-limited without recurrence during
military service. Based on a review of the available service treatment
records, it is difficult to find an association between the Veteran's
current
IBS diagnosis and military service.
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Opinion Requested:
Is the veteran's current diagnosis of Gulf War Illness at least as
likely as
not (50 percent or greater probability) evidenced to have begun in service
and left undiagnosed?
GULF WAR
Please provide a medical statement explaining whether the Veteran's
disability pattern is: (1) an undiagnosed illness, (2) a diagnosable but
medically unexplained chronic multisymptom illness of unknown etiology,
(3)
a diagnosable chronic multisymptom illness with a partially explained
etiology, or (4) a disease with a clear and specific etiology and
diagnosis.
If, after examining the Veteran and reviewing the claims file, you
determine
that the Veteran's disability pattern is either (3) a diagnosable
chronic
multi-symptom illness with a partially explained etiology, or (4) a
disease
with a clear and specific etiology and diagnosis, then please provide a
medical opinion, with supporting rational, as to whether it is "at
least
as
likely as not" that the disability pattern or diagnosed disease is
related
to a specific exposure event experienced by the Veteran during service in
Southwest Asia.
b. Indicate type of exam for which opinion has been requested: DBQ GENERAL
MEDICAL GULF WAR; DBQ GI ESOPHAGUS (INCLUDING GERD & HIATAL HERNIA);DBQ
GI
INTESTINES (OTHER THAN SURGICAL OR INFECTIOUS)
c. STATEMENT/OPINION: The Veteran served in Southwest Asia. He is diagnosed
with Irritable Bowel Syndrome(IBS) and Gastroesophageal Reflux
Disease(GERD).
The Irritable Bowel Syndrome does not have a known cause and would represent
a disability pattern that is a diagnosable but medically unexplained chronic
multisymptom illness of unknown etiology.
Gastroesophageal Reflux Disease (GERD) is caused by frequent acid reflux
(the
backup of stomach acid or bile into the esophagus). This is usually caused
by
a physiologic or anatomic defect at the junction of the esophagus and
stomach. It is not known to be caused by enviornmental exposures or
contacts.
It represents a disease with a clear and specific etiology and diagnosis.
The
GERD is less likely than not (less than 50 percent probability) related to a
specific exposure event experienced by the Veteran during service in
Southwest Asia.
*************************************************************************
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Type of medical opinion requested: Direct
service connection
Contention: Claimed Condition: Individual Unemployability
Opinion Requested: INDIVIDUAL UNEMPLOYABILITY
Please opine as to whether or not the veteran's service connected
conditions
preclude him from obtaining and maintaining gain full employment.
b. Indicate type of exam for which opinion has been requested: DBQ GI
ESOPHAGUS (INCLUDING GERD & HIATAL HERNIA); DBQ GI INTESTINES (OTHER
THAN
SURGICAL OR INFECTIOUS)
c. STATEMENT/OPINION: The c-file(VBMS and Virtual VA), service treatment
records and VA CPRS electronic medical records are reviewed. The Veteran is
diagnosed with Gastroesophageal Reflux Disease(GERD) and Irritable Bowel
Disease(IBS). The Veteran has minimal symptoms with the GERD. The related
symptoms would not impair the performance of physical or sedentary
occupational/employment activities. The Veteran has frequent bowel movements
related to his IBS. This would not impair the performance of physical or
sedentary occupational/employment activities in a setting that provided
ready
access to restroom facilities.
AM I HEADED FOR NOD PLEASE CHIME IN THANKS AHEAD
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R3dneck
I wouldn't get a lawyer until/if it goes to an appeal but it's your choice bud. I found this for you just edit to fit your needs: Remember that your NOD needs to be on the new form VA FORM 21-0958Th
broncovet
Ok, we would like to see the R and B. Its usually not a good idea to go to the Board of Veterans Appeals without a nexus, UNLESS you are claiming the presumptive. I am guessing you feel you meet the
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