Gulf Ware: Ibs / Gastro Issues C&p

[BearGator56]

This is from my Gulf War C&P Exam. Any thoughts on possible rating are appreciated. I didn't feel as if the doctor was as thorough as he should have been, as he asked very few follow up questions and seemed in a hurry to get me out of there. He checked off "occasional" even though I told him this is an every day thing.

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: XXXX

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:

CPRS

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: 564.1

Date of diagnosis: 9/6/13

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

intestinal condition (brief summary):

The veteran stated that he always has diarrhea since gulf war;at times

he becomes constipated if occasional bubble comes he may have 4-5

loose

stools a day. No history of colonoscopy. No history of gallbladder

disease or surgery no loss of weight he had hemorrhoids he takes

Pepto-Bismol and Imodium.

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:

imodium,peptobismol

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:

as above

[X] Abdominal distension

If checked, describe:

occasionally

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:

[X] Occasional episodes

[ ] 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

9. Diagnostic testing

---------------------

a. Has laboratory testing been performed?

[X] Yes [ ] No

[X] CBC (if anemia due to any intestinal condition is suspected or

present)

Date of test: 1/1/13

Hemoglobin: 15.9

Hematocrit: 46

White blood cell count: 5.6

Platelets: 126

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?

[ ] Yes [X] No

11. Remarks, if any:

--------------------

The veterans irritable bowel syndrome is a diagnosable but medically

un-explained chronic gastrointestinal and multisystem disease of unknown

etiology.

[free_spirit_etc]

I am not an expert here - but I would say it looks like zero percent since he checked the occasional box.

7319 Irritable colon syndrome (spastic colitis, mucous colitis, etc.):

Severe; diarrhea, or alternating diarrhea and constipation, with more

or less constant abdominal distress..................................................................... 30

Moderate; frequent episodes of bowel disturbance with abdominal

distress................................................................................................................ 10

Mild, disturbances of bowel function with occasional episodes of

abdominal distress................................................................................................ 0

[free_spirit_etc]

Maybe you can put in for increased rating...

[BearGator56]

I had a feeling he screwed me. Would think if it says 4 or 5 movements a day that would be more than "occasional."

[free_spirit_etc]

Maybe you could use a commode and save it for them to weigh each week...

I might not even be right on the estimate -- I was just guessing based on the way these three seem to line up with each other.

I would think that every day should be either frequent or constant.

[X] Episodes of bowel disturbance with abdominal distress

If checked, indicate frequency:

[X] Occasional episodes

[ ] Frequent episodes

[ ] More or less constant abdominal distress

7319 Irritable colon syndrome (spastic colitis, mucous colitis, etc.):

Severe; diarrhea, or alternating diarrhea and constipation, with more

or less constant abdominal distress..................................................................... 30

Moderate; frequent episodes of bowel disturbance with abdominal

distress................................................................................................................ 10

Mild, disturbances of bowel function with occasional episodes of

abdominal distress................................................................................................ 0

Edited October 9, 2013 by free_spirit_etc

[BearGator56]

He contradicts how he filled it out. He put my statement in of 4-5 a day, but then put occasional. Makes sense.

[free_spirit_etc]

If he noted 4 to 5 a day that is good. You should be able to appeal for a higher rating based on that. I can't see how anyone could consider 4 to 5 episodes a day to be occasional.