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.

[ghost14d]

My exam looks similar to yours but my doctor check frequently.

[ghost14d]

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

Date of diagnosis: 1990s

2. Medical history

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

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

intestinal condition (brief summary):

37-year-old African-American veteran who had normal stool pattern until

deployed to the Gulf in 1999. Patient was given malaria pills and one

to two

weeks after this he as well as several of his colleagues developed

watery non-

bloody diarrhea 2-5 times a day and occasionally at night. They were

informed

that diarrhea was from the malaria pill. However, after stopping this

medication

the diarrhea has persisted. Patient redeployed to the Gulf 2004 where

the

diarrhea again worsened. Patient indicates one of his major duties in

the Gulf

was burning human waste and other toxins with jet fuel on a regular

basis.

Patient currently has several watery to soft stools preceded by a

couple minutes

by bilateral lower abdominal cramping. He also notes increased

borborygmi

without distention. The cramps gradually dissipate within an hour

after

each

tool. Patient has urgency for stool, occasional tenesmus, occasional

incontinence for liquid stool. Patient denies fevers, chills, nausea,

vomiting,

anorexia, early satiety, arthritis, skin, ocular, liver related

symptoms. Has

tried Imodium which he took 3 to 4 times a day with initial marginal

benefit but

became less effective and discontinued this. Metamucil marginal help

with some

stool formation. Patient was placed on metformin but this was

discontinued

immediately due to severe diarrhea. Some benefit by discontinuing milk

and soda.

Started Wal-Mart Spring Valley probiotic two days ago with significant

improvement in borborygmi but not with diarrhea as of yet. Patient

states that

several of his colleagues in the Gulf War have similar chronic

diarrheal

symptoms without diagnoses.

Continues with above-described symptoms-recent upper and lower

endoscopy negative consistent with diagnosis

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

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:

See above

[X] Nausea

If checked, describe:

Associated with frequent bowel movements

[X] Vomiting

If checked, describe:

Occasional/infrequent

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?

[ ] Yes [X] No

c. Are there any other significant diagnostic test findings and/or results?

[X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief

summary):

Upper and lower endoscopy February 2014 negative-consistent with

diagnosis

10. Functional impact

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

Does the Veteran's intestinal condition impact his or her ability to work?

[ ] Yes [X] No

11. Remarks, if any:

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

No remarks provided

What you guys think I might get rated