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What % For Crohn's And Gerd C&p Exam Do You Think I Will Get?
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Navy04
I was medically retired last year for Crohn's Disease. I am SC 30%. Below is my results from recent C&P exam to have Crohn's Disease and GERD increase. Can you please assist with info as to whether I will get an increase. Thanks
Indicate method used to obtain medical information to complete this
document:
In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed: Yes
List any records that were reviewed but were not included in the
Veteran's
VA claims file: PAPER C-FILE REVIEWED.
VIRTUAL VA REVIEW.
VBMS CHECK. NO DATA AVAILABLE IN TABLE.
CPRS CHECK.
VETERAN ALSO GAVE HISTORY.
Diagnosis
---------
Does the Veteran now have or has he/she ever been diagnosed with an
esophageal condition? Yes
GERD ICD code: UNKNOWN Date of diagnosis: 2009
Medical history
---------------
Description of the history (including onset and course) of the
Veteran's
esophageal conditions: VETERAN SERVED ACTIVE DUTY U.S. NAVY 2004-2013.
2507 INDICATES SC FOR GERD. EVALUATION FOR INCREASE REQUESTED
VETERAN STATES HAS FREQUENT HEARTBURN, ESPECIALLY AT NIGHT, ALONG WITH
RELFLUX SYMPTOMS. THIS IS A DAILY EVENT. HE AWAKENS AT NIGHT WITH SUCH
SYMPTOMS FREQUENTLY. HE IS TAKING PANTOPRAZOLE BID AS PER RX, SUPPLEMENTING
THIS WITH TUMS AND OTHER OTC ANTACIDS. NOT YET CONTROLLED. HE PLANS
FOLLOW-UP WITH HIS PROVIDERS ON THIS SOON HE STATES.
Does the Veteran's treatment plan include taking continuous medication
for
the diagnosed condition: Yes
Medications used for the diagnosed condition: SEE ABOVE.
Signs and symptoms
------------------
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
Pyrosis (heartburn)
Reflux
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
Esophageal stricture, spasm and diverticula
-------------------------------------------
Does the Veteran have an esophageal stricture, spasm of esophagus
(cardiospasm or achalasia) , or an acquired diverticulum of the esophagus?
No
Other pertinent physical findings, complications, conditions, signs and/or
symptoms
-----------------------------------------------------------------------------
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? No
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs and/or symptoms related to any conditions listed in the
Diagnosis section above? Yes
Description: DIRECTED EXAMINATION AS PERMITTED BY VETERAN.
ABDOMEN WITHOUT ACUTE FINDINGS.
NO HEPATOSPLENOMEGALY.
NL. BOWEL
TONES.
RECTAL DEFERRED.
MILD LOWER ABDOMINAL SORENESS TO PALPATION.
NO EPIGASTRIC TENDERNESS TO PALPATION.
Diagnostic Testing
------------------
Have diagnostic imaging studies or other diagnostic procedures been
performed? Yes
Diagnostic Testing Preformed:
Upper endoscopy Date: SEE ABOVE Results: SEE ABOVE.
Biopsy, specify site: SEE ABOVE.
Date: SEE ABOVE Results: SEE ABOVE
Functional impact
-----------------
Do any of the Veteran's esophageal conditions impact on his or her
ability to
work? Yes
Impact of each of the Veteran's esophageal conditions, providing one
or
more examples: VETERAN STATES FREQUENT GERD SYMPTOMS INTERFERE WITH
WORK/COGNITIVE TASK FOCUS FOR DUTY.
Remarks, if any:
----------------
PAPER C-FILE REVIEWED.
VIRTUAL VA REVIEW.
VBMS CHECK. NO DATA AVAILABLE IN TABLE.
CPRS CHECK.
VETERAN ALSO GAVE HISTORY.
2507 REQUESTS DBQ ESOPHAGEAL CONDITIONS.
SEE ABOVE FORM.
SEE OTHER
FORMS THIS DATE ALSO.
2507 ALSO INDICATES AS FOLLOWS:
"...1. Veteran seeks increased evaluation for service connected
conditions:
A. crohns disease with acid reflux ..."
SEE ABOVE FO
RM.
Intestinal Conditions (other than surgical or infectious),
including irritable bowel syndrome, Crohn's disease, ulcerative
colitis and diverticulitis
Disability Benefits Questionnaire
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:
PAPER C-FILE REVIEWED.
VIRTUAL VA REVIEW.
VBMS CHECK. NO DATA AVAILABLE IN TABLE.
CPRS CHECK.
VETERAN ALSO GAVE HISTORY.
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] Crohn's disease
ICD code: UNKNOWN
Date of diagnosis: 2009 (APPROX.)
2. Medical history
------------------
b. Is continuous medication required for control of the Veteran's
intestinal
condition?
[X] Yes [ ] 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:
VETERAN STATES HAS EPISODES OF LOOSE STOOLS FOR A DAY OR
SO,
FOLLOWED BY CONSTIPATION. THIS OCCURS USUALLY TWO OR MORE
TIMES PER WEEK. STOOLS CAN BE DARK AND ARE SOMETIMES
BLOODY.
[X] Abdominal distension
If checked, describe:
VETERAN NOTES ABDOMINAL "BLOATING" AT TIMES.
[X] Nausea
If checked, describe:
VETERAN NOTES SOME NAUSEA WHEN CRAMPING BECOMES MORE
UNCOMFORTABLE.
[X] Other, describe:
VETERAN DESCRIBES OCCASIONAL BLOODY STOOLS, DARK.
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
[X] Episodes of exacerbations and/or attacks of the intestinal
condition
If checked, describe typical exacerbation or attack:
SEE ABOVE.
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
--------------
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?
[X] Yes [ ] No
If yes, describe (brief summary):
DIRECTED EXAMINATION AS PERMITTED BY VETERAN.
ABDOMEN WITHOUT ACUTE FINDINGS.
NO HEPATOSPLENOMEGALY.
NL. BOWEL TONES.
RECTAL DEFERRED.
MILD LOWER ABDOMINAL SORENESS TO PALPATION.
NO EPIGASTRIC TENDERNESS TO PALPATION.
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: 10/15/13
Hemoglobin: 15.9
Hematocrit: 44
White blood cell count: 5.1
Platelets: 192K
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):
SEE ABOVE.
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?
[X] Yes [ ] No
If yes, describe the impact of each of the Veteran's intestinal
conditions, providing one or more examples:
VETERAN STATES MUST GO FREQUENTLY TO NEARBY RESTROOM. THIS MAKES
DRIVING OR TRAVEL DUTIES IN LAW ENFORCEMENT VERY DIFFICULT.
VETERAN STATES WITH FLARE-UPS OF ABDOMINAL PAIN/BLOATING/CRAMPING
HE HAS DIFFICULY IN FOCUSING FOR WORK/COGNITIVE TASKS
PAPER C-FILE REVIEWED.
VIRTUAL VA REVIEW.
VBMS CHECK. NO DATA AVAILABLE IN TABLE.
CPRS CHECK.
VETERAN ALSO GAVE HISTORY.
2507 REQUESTS DBQ INTESTINAL CONDITIONS.
SEE ABOVE FORM.
SEE OTHER FORMS THIS DATE ALSO.
2507 ALSO INDICATES AS FOLLOWS:
"...1. Veteran seeks increased evaluation for service connected
con
ditions:
A. crohns disease ..."
SEE ABOVE FORM.
VETERAN
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