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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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RMurr

IBS C&P - No note of sevice connecction.

Question

I just completed a C&P exam foe IBS. See below. I was wondering why there was no statement from the doctor saying, it was or was not connected to my service. All medical records from my first term of service are missing including hospital records form what I am being told. (Had four different times I was admitted to the Hospital during that time). There is a comment on a reenlistment psychical where I said I had parasites in South America. The C&P Doctor noted that. 

 

I also have a question on a bone fracture, but not sure if I should post it here or somewhere else. Thanks for any help that you can provide.

 

 

 

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: 

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination   

Request?    [X] Yes   [ ] No   

 ACE and Evidenc e Review    ----------------------    Indicate method used to obtain medical information to complete this document:       

 [X] In-person examination   

 Evidence Review    --------------    Evidence reviewed (check all that apply):       

[X] VA e-folder (VBMS or Virtual VA)   

[X] 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: K58             

Date of diagnosis:  per history 1985

   

2. Medical history    -----------------   

a. Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary):  53 yo Army Veteran states he was in hospital in Panama for 2 months with a presumed parasitic infection (he states it was never identified though he states he was told he had a parasitic infection). Since that time he's have urgency for BMs. It has been unchanged since that time.  He has seen doctors over the years and no improvement in symptoms.

Current bowel pattern: diarrhea x 2 days (watery stools, 4-5 per day), then 1-2 weeks constipated and cycle repeats. no blood in stool. He states he had another colonoscopy 1 yr ago and had 2 polyps that  were benign. These records are not available for review.

He is on no meds for his bowels currently. Tried fiber which didn't help, other otc medicines.

review of str: records from his hospitalization in Panama/lab results are not available for review. Non of his records from first period of service are found in vbms.  At time of his re-entry exam in 1990, he          reported "parasites" in 1988. Examiner's notes are difficult to read and it's unclear it this was commented on. 

b. Is continuous medication required for control of the Veteran's intestinal condition?     

 [ ] Yes   [X] No         

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] Alternating diarrhea and constipation If checked, describe:                  

 per above                                                    

 

[X] Abdominal distensionIf checked, describe:                   

 gassy                                          

  

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,       symptoms and scars    ----------------------------------------------------------------------------    a. Does the Veteran have any other pertinent physical findings,       complications, conditions, signs or symptoms related to any conditions       listed in the Diagnosis Section above?

 [ ] Yes   [X] No          

b. 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           c. Comments, if any:            

 

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?      

[ ] 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:    -------------------        This examiner introduced herself to Veteran and ensured that 2  identifiers were correctly answered.  Veteran was thanked for their military service.  The purpose of this specific exam was reviewed. Veteran was informed that the VBA makes determinations on claims, and that all questions regarding claims should be directed toward the Regional Office.  Limitations of confidentiality were reviewed.  Veteran agreed to proceed with this examination.

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Congratulations!   You just figured out one of the VA's first "gotcha's"....no nexus statement.  Sometimes, with VSO's they will send you through years of appeals with what I call a "naked" claim...missing the nexus.  Now, here is what to do about it.  

1.  Check the rest of your medical records to see if another doc opined favorably on your nexus..that is, your condition is at least as likely as not related to an event in service.  

2.  Get those missing records.  They could be a deal maker/deal breaker.

3.  IF you have an "in service event" then you may need an IMO if you do not have a nexus.  

Make no mistake:  You have to have all 3 Caluza elements for SC.  Diagnosis, in service event or aggravation, and nexus.  

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My systems worsened after my deployment to the golf. I told the Dr about that, but there is no note of it in my C&P How do I get that in my record?

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Take the medical records that state this and have your VSO send this to the VA.  It should be listed as evidence considered in your RO decision, if not then you have reason to appeal.

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Thank you for the help.

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Rmurr,  I had some of my medical recording missing from Iraq.  Luckily I had a good VSO who cared.  My medical records were gone, but this gives an opportunity in a way as they can't prove or disprove as the event did happen.  So just my 2 cents that worked for me.  Get your lay statements (you-battle buddy-anyone who can support your claim) for some reason these give that extra boost you might need.

good luck!

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