ptsd Verbally denied GWI

[DocC03]

This is what an highly regarded environmental specialist had to say in my medical records. Since then I keep getting told that gulf war illness in not a real diagnosis. What do I do to get my docs to take this seriously? What can I do?

 

We talked about your exposures during your military service including your deployment(s) to Iraq You indicated that you were exposed to Burn pits, chemicals from industrial plant, exposure to organophosphates and unknown chemicals from manufacturing facility and Uranium. You would like to know whether your exposure(s)are related to development, migraines, fatigue, joint pain, PTSD, and DJD. The remainder of this discussion focuses on exposure concerns and their possible relationship to current health issues.

GULF WAR ILLNESS- Based on your description of your health issues and your exposures during your military service, your current symptoms and medical condition are consistent with, and meet the criteria for the VA case definition for Gulf War Illness/Syndrome. The VA case definition for Gulf War Syndrome is as follows: A medical condition affecting some veterans of the Gulf War, characterized by fatigue, headache, joint pain, skin rashes, nausea, dizziness, and respiratory disorders, and attributed to reactions to prophylactic drugs and vaccines, infectious diseases, or exposure to pesticides and other chemicals, radiation, and smoke from oil fires. For more information, please see - Research Advisory Committee on Gulf War Veterans' Illnesses. Gulf War Illness and the Health of Gulf War Veterans

[DocC03]

Veteran was seen by the Palo Alto VA "war related Illness and injury Study center" seen recently Feb 2016. The conclusion of this study was that the veteran has chronic fatigue syndrome, GERD, migratory muscle pain, and chronic skin infections are all related to his gulf war exposures. he has ankle and back pain which are considered likely due to his wear and tear related to occupations, and past injuries. I agree with the opinion of the PAlo Alto VA "war related Illness and injury Study center", I feel clearly that sufficient medical examination has been done to confidently diagnose the above conditions, He does not have fibromyalgia, there is not evidence to support this as a known diagnosis at this time.

He is already service connected for migraines and these continue, he reports 5-6 migraines a week still. last evaluated by me in Aug 2014, his description today of his headache condition is consistant with reported symptoms in 2014, esssentially no change reported.

[DocC03]

Does the Veteran now have or has he/she ever had a skin condition? [X] Yes [ ] No [X] Infectious skin conditions (including bacterial, fungal, viral, treponemal and parasitic skin conditions) Diagnosis: MRSA skin infection ICD code: L08.9 Date of diagnosis: 2004- in Iraq

veteran has had MRSA skin infections frequently since service, his first MRSA infection was noted in service while deployed to Iraq. diagnosed upon return as MRSA. he continues to have frequent skin infections. His records show frequent skin infections still last one he was treated for was on his lip, he was treated with PO clindamycin and it did not help, then he was treated with IM rocephen and it resolved. HE reports that he has a small skin infection to his left axilla, he reports it has nearly resolved. His exam is negative for current skin infections.

b. Do any of the Veteran's skin conditions cause scarring (regardless of location), or disfigurement of the head, face or neck? [X] Yes [ ] No If yes, indicate skin condition and describe scarring and/or disfigurement: he has a smal 1.5cm x 0.2 scar to his left elbow, this was a skin infection wich required antibiotics

Do any of the Veteran's skin conditions impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's skin conditions, providing one or more examples: he should use precautions when working with active infections, as they are contagious. should not work in food preperation.

[DocC03]

Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary): veteran reports he has IBS, i do not see records which confirm this. Veteran reports left lower quadrant pain for years, he reports he had this pain in the military. I do not see records from his multiple visits to doctors that really address any GI complaints aside from mild hemmorhoids, which was present before he went to Iraq. Every record I reviewed showed that the veteran denied Nausea, diarrhea, constipation. Veteran describes constant left lower quadrant pain. he reports that this has been present for years. He reports normal stool pattern and generally he has formed stool, no chronic diarrhea, and no chronic constipation.

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

[X] Episodes of exacerbations and/or attacks of the intestinal condition If checked, describe typical exacerbation or attack: veteran reports constant chronic left lower quadrant discomfort, worse if area is palpated. he reports this is a daily continuous problem.

Date of test: Feb 2 2016 Hemoglobin: 15.6 Hematocrit: 46.2 White blood cell count: 6.7 Platelets: 223

 

[DocC03]

Does the Veteran now have or has he/she ever been diagnosed with an esophageal condition? Yes Gastroesophageal reflux disease (GERD) ICD code: K21.9 Date of diagnosis: Feb 2014

Description of the history (including onset and course) of the Veteran's esophageal conditions: veteran diagnosed with GERD in 2014, started taking Ranitidine in 2014. he reports the GERD symptoms were present for approx 1 yr prior to the diagnosis. he cannot tolerate spicy food any longer, he used to eat it all the time. he reports the he avoids spicy foods. he still gets GERD symptoms generally at night, he reports he gets woke up at night several times a week due to GERD symptoms. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition? Yes Medications used for the diagnosed condition: zantac 150 mg 1- 2 tabs daily.

Does the Veteran have any of the following signs or symptoms due to any esophageal conditions (including GERD)? Yes Sign and Symptoms: Persistently recurrent epigastric distress Reflux Regurgitation Pain Substernal Sleep disturbance caused by esophageal reflux Frequency of symptom recurrence per year: 4 or more Average duration of episodes of symptoms: Less than 1 day

he reports his symptoms are almost always at night and generally wake him from sleep.

 

[DocC03]

List the claimed condition(s) that pertain to this DBQ: Right ankle sprain, ankle instability

Lateral collateral ligament sprain (chronic/recurrent) Side affected: [X] Right [ ] Left [ ] Both ICD Code: M25.37 Date of diagnosis: Right sc

The veteran had a severe sprain to the right ankle in Iraq 2003, and he reports he frequently rolls the ankle to the outside when walking on uneven surfaces. Veterans CPRS records show continued complaints of right ankle pain and instability. his 2009 MRI showed significant evidence for old sprain, as well as talofibular ligament tears.

Does the Veteran report flare-ups of the ankle? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: he reports tha ankle pain is always worse in the mornings, he states that prolonged standing will lead to flare-up as well. he reports the ankle pain in the mornings returns to baseline in less than 45 minutes after being up and walking.

 document the Veteran's description of functional loss or functional impairment in his or her own words: he reports increased pain and decreased ROM with flare-ups.

a. Initial range of motion Right ankle ----------- [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 10 degrees Plantar Flexion (0-45): 0 to 45 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: his reduced ROM is decreased due to pain with this movement.

If yes, describe including location, severity and relationship to condition(s): anterior talofibular ligament is tender to palpation, swelling in this area noted as well. CPRS records show that he is always a bit swollen in this area.

Is there objective evidence of crepitus? [X] Yes [ ] No

If the examination is not being conducted during a flare-up: [X] The examination is medically consistent with the Veteran?s statements describing functional loss during flare-ups

Right ankle Is ankle instability or dislocation suspected? [X] Yes [ ] No If yes, complete the following: Anterior Drawer Test Is there laxity compared with opposite side? [X] Yes [ ] No [ ] Unable to test Talar Tilt Test Is there laxity compared with opposite side? [X] Yes [ ] No

Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: he should avoid working on uneven surfaces, and avoid prolonged standing as well.

Left ankle normal

 

 

[DocC03]

Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: lumbar strain ICD code: M54,8 Date of diagnosis: sc

a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): veteran reports mild low back, on a daily basis. He denies significant injury to his back.

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: veteran reports his back pain flares up with sleeping, and when is it cold outside. he is unsure of any other causes of flare- ups, he reports of the low back pain occurs a couple times a week.

c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. during flare ups he reports increased back pain.

a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 70 degrees Extension (0 to 30): 0 to 30 degrees Right Lateral Flexion (0 to 30): 0 to 30 degrees Left Lateral Flexion (0 to 30): 0 to 30 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: mild discomfort with forwar flexion, otherwise no pain complaints with ROM testing