tdiu THINK IM HEADED FOR NOD

[harrysday]

LOCAL TITLE: C&P INTESTINES

STANDARD TITLE: C & P EXAMINATION NOTE

• DATE OF NOTE: OCT 19, 2015@

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

[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 presumptive criteria for IBS/Gerd, and, you may well meet that criteria.  You can show service connection with either "direct", "presumptive" or "secondary" criteria, and VA should look for all 3 if you have the applicable evidence.  

[k5one]

It would be a good idea to see a private physician, who is not part of the VA.  Get a diagnosis and an opinion about the IBS.  Ask the physician to complete a DBQ.  Submit all of that, and see what happens.