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.

[BearGator56]

I was not happy with this doctor. He saw me for less than 30 minutes and hardly asked me any questions. I had a list with notes that I brought with and he just stuffed it in his file. None of which made it to my file from what I can see. He was in a rush to get me out of there. He was like, "thank you for your service" and waited for me to get up and leave. I brought up something else, barely got a reply, then got the "thank you for your service" again. He said it a total of 4 times as I was trying to bring up issues.

I may need to file a complaint on him, if there's a process for that. I'll reserve judgement until the results come back.

[free_spirit_etc]

I read somewhere that using the Healthevet system can be useful for documenting symptoms - and that anything the veteran puts on there becomes part of their medical history. I don't know much about it - but you might want to check it out. It could be useful to show reporting of symptoms.

[ntyler0341]

BearGator56:

That is a better exam write up than mine. I was rated 30% IBS GERD.

Dont put too much thought into prognosis notes.

[BearGator56]

You're correct. I did wind up with 30% for it. Although, they didn't rate me for the acid reflux stating that I wasn't diagnosed, even though they've had me on prescription meds for it for over 4 years now.

[john999]

Get more testing and get a doctor to opine that your condition meets a higher disability rating than 30%. You need a good IME and a private doctor who will send you out for tests to confirm you are worse than 30%. I would send in my NOD. Many of these VA lawyers who are also SSDI and SSI lawyers know doctors who actually know how to write reports to get benefits. If you could get 100% for your conditions it would be worth every penny of retro you shared with a lawyer and IME doctor. You are at war with the VA now so don't go to a gunfight with a knife.

[Guest]

You're correct. I did wind up with 30% for it. Although, they didn't rate me for the acid reflux stating that I wasn't diagnosed, even though they've had me on prescription meds for it for over 4 years now.

This is VA's way of awarding the highest rating possible. You need to be diagnosed with GERD and even then VA will say that the symptoms are more like IBS due to your description that you give.