Hello,
First time poster but I've been around a while.
I've recently been denied a claim for IBS. I've included my information below. I feel they have made a CUE in processing my claim. Any thought on how I should move forward? I have diagnosis for IBS(presumptive) was in the Gulf War what else is needed?
Thanks
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:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
[X] Other (please identify other evidence reviewed):
VistaWeb.
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: XXXXX
Date of diagnosis: 11/20/2017
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
intestinal condition (brief summary):
Veteran has claimed irregular bowel patterns since service in The
Gulf.
Veteran reports no problems with his bowels until returning from
service in The Gulf. Over the years, he reports developing a pattern
of constipation alternating with diarrhea. He reports that if he takes
medication for constipation, then he has diarrhea for weeks and admits
he is glad for constipation. Veteran reports bloating with
constipation
and diarrhea. He denies seeing any blood in stools and there is no FH
of colon cancer. Veteran denies any nausea or vomiting, or
hemorrhoids.
He denies any abnormal weight loss. Veteran does report frequent
cramping and gas. He admits he is afraid not to ber in the restroom
to
pass gas as he has soiled himself at work and at home on several
occasions. He reports his diarrhea is explosive and uncontrolled.
Veteran denies any food that triggers his diarrhea or constipation and
reports he eats "normal". He does have prescribed Miralax for his
constipation. Veteran does see a Gastroenterologist through the VAMC.
He has never had a colonoscopy.
b. Is continuous medication required for control of the Veteran's intestinal
condition?
[X] Yes [ ] No
If yes, list only those medications required for the intestinal
condition:
Miralax for constipation
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] Alternating diarrhea and constipation
If checked, describe:
Veteran reports more diarrhea than constipation (most days
5-6 loose stools)with occasional constipation that quickly
turns back into diarrhea.
[X] Abdominal distension
If checked, describe:
Veteran reports daily bloating and excessive gas.
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
[ ] Frequent episodes
[X] 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,
symptoms and scars
-----------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to any conditions
listed in the Diagnosis Section above?
[X] Yes [ ] No
If yes, describe (brief summary):
On exam, Veteran has hyperactive bowel sounds with tender abdomen
to palpation.
b. 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
c. Comments, if any:
9. Diagnostic testing
---------------------
a. Has laboratory testing been performed?
[X] Yes [ ] No
If yes, check all that apply:
[X] CBC (if anemia due to any intestinal condition is suspected or
present)
Date of test: 11/19/2016
Hemoglobin: 14.3
Hematocrit: 42.5
White blood cell count: 9.13
Platelets: 246
[X] Other, specify: Ova and Parasites, Giardia, Culture
Date of test: 01/05/2017
Results: Negative, Negative, No Salmonella, Shigella,
Campylobacter, Shiga-toxin E. coli isolated
b. Have imaging studies or diagnostic procedures been performed and are the
results available?
[ ] Yes [X] No
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:
Veteran reports he would have difficulty with performing occupational
tasks that would require him to work away from a rest room or that
would not allow him to go to the rest room as needed.
11. Remarks, if any:
--------------------
10. Veteran reports he works at a desk in finance and reports he is
allowed to go to the rest room as needed.
****************************************************
VBMS, CPRS, VistaWeb were reviewed by this examiner for this claim.
Veteran was given a diagnosis of IBS (Irritable Bowel Syndrome)
11/20/2017. There is specific etiology stated and there is no mention
on
the GI consultation notes of when the symptoms started or reference to
him serving in The Gulf. Veteran give an account of bowel problems
being
present since returning from The Gulf in 1991. Veteran has only been
seen by the VAMC providers since 2016 with no records discovered to
support IBS symptoms being present since returning to the USA from The
Gulf in 1991 (25 years later). This Veteran's claimed IBS is less
likely
than no due to his service in The Gulf.
Rated Disabilities
Table of Rated Disabilities
Disability
Rating
Decision
Related To
Effective Date
tinnitus
10%
Service Connected
11/24/2016
Sensori-neural hearing loss
Not Service Connected
obstructive sleep apnea
Not Service Connected
Environmental Hazard in Gulf War
chronic fatigue syndrome
Not Service Connected
Environmental Hazard in Gulf War
esophageal stricture
0%
Service Connected
Burn Pit Exposure
01/25/2017
eosinophilic esophagitis by biopsy with GERD
10%
Service Connected
Burn Pit Exposure
01/25/2017
allergic rhinitis
Not Service Connected
Environmental Hazard in Gulf War
headaches, unexplained chronic multi-symptom illness
10%
Service Connected
Environmental Hazard in Gulf War
11/24/2016
post traumatic stress disorder (also claimed as memory loss)
30%
Service Connected
PTSD - Combat
11/24/2016
erectile dysfunction
0%
Service Connected
06/28/2017
fibromyalgia (to include joint and muscle pain)
40%
Service Connected
Environmental Hazard in Gulf War
07/09/2017
hypertension
Not Service Connected
Environmental Hazard in Gulf War
irritable bowel syndrome
Not Service Connected
Environmental Hazard in Gulf War