C&P Exam Notes for IBS--Any guess how an RO will view it?

[bcnandprn]

I just had my C&P for IBS last week and this is what the notes in ebenefits say, but I'm not exactly sure what it means in regard to how an RO may look at it.  The notes do state that the condition is at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event, or illness.  I know that there are no guarantees, but I was hoping for a few opinions.

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: K58.0

 

Date of diagnosis: 2005

 

 

2. Medical history

 

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a. Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary):

 

Private MD ----Veteran started seeing this doctor in January of 2010-noted headache, diarrhea (gastroenteritis) given Imodium, IBS.  The bowel issues started in Iraq ---the conditions were very poor-wooden box with 5 LB (the examiner wrote LB instead of gallon) bucket that was burned when full---she started experiencing abdominal cramps and diarrhea---gradual it gotten worse -she was embarrassed to talk about and never reported ---Veteran reports she developed frequency -after every meal-and urgency so she stop going out -she was self-treating with tums (intermittently helped)-After separation she was given Imodium, told to try gluten free food-non had helped ----Presently she is taking tum's

 

 

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:

 

Takes tums OTC product--reports helps as much as Imodium, just taste better, so she has decided to continue with tums—this reduces her bloating, but does not change the characteristics of the stool

 

c. Has the Veteran had surgical treatment for an intestinal condition?

 

[ ] Yes [X] No

 

 

3. Signs and symptoms

 

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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 5 times a week type 7 stool, on occasion type 2 abut 2 x a week and seldom type 1

 

Bristol Stool Chart

 

Type 1-2 indicate constipation

 

Type 3-4 are ideal stools as they are easier to pass, and

 

Type 5-7 may indicate diarrhea and urgency.

 

[X] Abdominal distension

 

If checked, describe: most of the time

 

[X] Nausea

 

[X] Other, describe: sharp and intense cramps

 

 

 

4. Symptom episodes, attacks and exacerbations

 

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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

 

 

[X] Episodes of exacerbations and/or attacks of the intestinal condition

 

If checked, describe typical exacerbation or attack:

 

75 % are reported to be severe abdominal cramping with severe urgency

 

 

 

Indicate number of exacerbations and/or attacks in past 12 months:

 

[ ] 0 [ ] 1 [ ] 2 [ ] 3

 

[ ] 4 [ ] 5 [ ] 6 [X] 7 or more

 

 

5. Weight loss

 

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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

 

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Does the Veteran have malnutrition, serious complications or other general health effects attributable to the intestinal condition?

 

[ ] Yes [X] No

 

 

7. Tumors and neoplasms

 

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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

 

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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

 

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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: Dec. 03, 2015

 

Hemoglobin: 13.3

 

Hematocrit: 40.2

 

White blood cell count: 9.9

 

Platelets: 273

 

[X] Other, specify: electrolytes

 

Date of [X] Other, specify: electrolytes

 

Date of test: 12/02/2015

 

Results: normal

 

b. Have imaging studies or diagnostic procedures been performed and are the results available?

 

[X] Yes [ ] No

 

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

 

Report Status: Verified Date Reported: DEC 03,

 

2015

 

Date Verified: DEC

 

03, 2015

 

Report:

 

Supine and erect abdomen:

 

No free air in the abdomen is seen on the erect view. The stomach is filled with ingested food. Retained fecal material throughout the colon is identified. Some mild gaseous congenital the transverse colon is seen with a small air-fluid level seen on the erect view. No significant small bowel gas is present. No mass or abnormal calcification is seen. The renal and psoas margins are well-defined.

 

Impression:

 

No acute change.

 

Primary Diagnostic Code: NORMAL

 

 

 

 

 

10. Functional impact

 

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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:

 

Conscious of her surroundings-need to know where bathrooms are, avoiding going out or dining out , feel embers by her bowel condition

 

11. Remarks, if any:

 

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No remarks provided.

 

 

Edited December 8, 2015 by bcnandprn

[Navy4life]

Hi there!  I am S/C for IBS (30%) and from what I am reading above and if the statement says "s at least as likely as not (50% or greater probability)  you should get the max of 30%.....