ptsd Verbally denied GWI

[DocC03]

This is what an highly regarded environmental specialist had to say in my medical records. Since then I keep getting told that gulf war illness in not a real diagnosis. What do I do to get my docs to take this seriously? What can I do?

 

We talked about your exposures during your military service including your deployment(s) to Iraq You indicated that you were exposed to Burn pits, chemicals from industrial plant, exposure to organophosphates and unknown chemicals from manufacturing facility and Uranium. You would like to know whether your exposure(s)are related to development, migraines, fatigue, joint pain, PTSD, and DJD. The remainder of this discussion focuses on exposure concerns and their possible relationship to current health issues.

GULF WAR ILLNESS- Based on your description of your health issues and your exposures during your military service, your current symptoms and medical condition are consistent with, and meet the criteria for the VA case definition for Gulf War Illness/Syndrome. The VA case definition for Gulf War Syndrome is as follows: A medical condition affecting some veterans of the Gulf War, characterized by fatigue, headache, joint pain, skin rashes, nausea, dizziness, and respiratory disorders, and attributed to reactions to prophylactic drugs and vaccines, infectious diseases, or exposure to pesticides and other chemicals, radiation, and smoke from oil fires. For more information, please see - Research Advisory Committee on Gulf War Veterans' Illnesses. Gulf War Illness and the Health of Gulf War Veterans

[DocC03]

Does the Veteran now have or has/she ever been diagnosed with chronic fatigue syndrome? [X] Yes [ ] No [X] Chronic fatigue syndrome ICD code: R53.82 Date of diagnosis: Feb 2016 (General Malaise 2006)

a. Describe the history (including onset and course) of the Veteran's chronic fatigue syndrome: veteran has reported chronic fatigue since approx 2006- his CPRS records clearly show that his complaints of fatigue have continued and severity of his fatigue has worsened over the years, the veteran reports that he is tired all the time, worse in the mornings and worse after a day of increased activity. over time the symptoms are getting worse, he has had a sleep study which was negative, thyroid testing is normal, he was officially diagnosed in Palo Alto VAMC at "war related Illness and injury Study center".

c. Have other clinical conditions that may produce similar symptoms been excluded by history, physical examination and/or laboratory tests to the extent possible? [X] Yes [ ] No d. Did the Veteran have an acute onset of chronic fatigue syndrome? [X] Yes [ ] No e. Has debilitating fatigue reduced daily activity level to less than 50% of pre-illness level? [X] Yes [ ] No

If yes, specify length of time daily activity level has been reduced to less than 50% of pre-illness level: [ ] Less than 6 months [X] 6 months or longer

Does the Veteran now have or has the Veteran had any findings, signs and symptoms attributable to chronic fatigue syndrome? [X] Yes [ ] No If yes, check all that apply: [X] Debilitating fatigue [X] Palpable or tender cervical or axillary lymph nodes [X] Generalized muscle aches or weakness [X] Fatigue lasting 24 hours or longer after exercise [X] Headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state) [X] Migratory joint pains [X] Sleep disturbance

For all checked conditions, describe: please see VBMS for detailed description of the above complaints. DBQ's included in this exam are also detailing above complaints, he has swollen anterior cervical lymph nodes now, and records show this is a common finding for this veteran.

Does the Veteran now have or has the Veteran had any cognitive impairment attributable to chronic fatigue syndrome? [X] Yes [ ] No If yes, check all that apply: [X] Poor attention [X] Forgetfulness c. Specify frequency of symptoms: [X] Symptoms are nearly constant

For checked conditions, describe: he reports daily fatigue, daily muscle aches which migrate, daily headaches,daily lymph node enlargement.

Do the Veteran's symptoms due to chronic fatigue syndrome restrict routine daily activities as compared to the pre-illness level? [X] Yes [ ] No If yes, specify % of restriction (check all that apply): [X] Symptoms restrict routine daily activities to less than 50% of the pre-illness level

Does the Veteran's chronic fatigue syndrome impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's chronic fatigue syndrome, providing one or more examples: it is unlikely he could work a full time job, the more activity he does the worse he feels, aside form his debilitating headaches the fatigue is also causing him to be unemployable. he needs frequent breaks, and he gets unnaturally tired after minimal physical activity.

[DocC03]

There are a couple things that I don't agree...

1. I do have a diagnosis of Fibro from a Rheumatologist. 

2. I have complained for years of stomach issues including IBS symptoms. I reviewed my records and it is true that it has never made it in my records. I have always brought it up when I am there for other stuff. He used the generic notes that the docs put in that state "pt denies everything under the sun"... i am sure everyone is aware of the generic form notes that docs use all the time. 

But I digress. This is not the point of this. So please just base responses on what has been provided in the C&P. Thanks

[Buck52]

Did you get a denied?

About the only thing you can do is Appeal this and let them know why  with your records & statements from Dr's and from this C&P Examiner .

looks like to me you should have been SC & rated at 70%   which your already at 90% that would have put you in the SMC-S  And that is a statutory rating at 100% plus other benefits.

jmo

...................Buck

[DocC03]

Buck,

Thank you my friend. I jumped the gun on the title of the post. The V.A. C&P P.A. told me that he would not discuss most of my claims with me. He made it sound like I had no diagnosis and he was not interested in conversating about these issue.

My guess after reading my C&P notes it looks like he figured that there was enough evidence to support my claim and he did not need any additional info.

I have not received the answer yet from my claim so I am not sure if it will be approved or not.

The way I read the notes I thought that I should have a rating of 60% for CFS. Where are you getting the 70%?? What am I missing?

Also I have been 100% TDIU for 2 years. I will post in the SMC section the details to see if maybe I have qualified this whole time for SMC-S.

 

Thanks in advance.

Edited April 7, 2016 by DocC03