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 anintestinal 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 thatwere 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, hereported "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-surgicalnon-infectious intestinal conditions?
[X] Yes[ ] NoIf 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 [ ] NoIf 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 generalhealth 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 relatedto 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 conditionslisted 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 DiagnosisSection above?
[ ] Yes[X] Noc. 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 2identifiers were correctly answered.Veteran was thanked for theirmilitary 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.
Question
RMurr
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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