C&p Exam Gerd And Sciatic..... Questions

[bayfritz]

Hello ALL,

Recently had a C&P exam and have a few question about the underlined areas. I am service connected 0% for GERD and 10% right side sciatic nerve since 2003. I filed for increase on both and here is a synopsis from actual C&P report. This is directly from the form I retrieved from the VA. I have question related to the underlined portions.

1. My regular Gastro doctor filled out a DBQ, but the Va Doctor did also. I indicated my GERD impacted my work, but the VA doctor did not write it down, but my gastro doctor did document the work related issues on his DBQ. When I have nighttime GERD attacks (throw up), I can't go back to sleep and as a result I am constantly tired at work. Is this possible NOD?

2. The VA doctor is changing my diagnosis code from Sciatic to DDD after x-ray showed reduced disc space between L4 & L5 and L5 & S1. Is this a good thing or bad? Can I get SC for both Sciatic and DDD and award on both?

3. From experience does this look like 30% for GERD and 30% back/DDD/sciatic?

4. What does this mean? "per 2507 DM-PN ordered – no dx of DM evident"

GERD Reflux Questionaire

• Does the Veteran now have or has he/she ever been diagnosed with an esophageal condition
  • Yes
• If yes, indicate diagnoses.
  • GERD
    • ICD code 530.81, Date of Diagnosis 1998
• Describe the history of the Veterans esophagitis conditions:
  • Prior dx and rated HH/GERD complex – complex and often refractory in nature – reflux esophagitis well documented per EGD – will get day and HS symptoms – symptomatic daytime reflux 3-4 x weekly and HS regurgitation 2-3 x weekly – severe episodes of gagging and vomiting 1-2 x monthly- no surgical interventions.
• Does the Veteran’s treatment plan include taking medications for the diagnosed treatment
  • Yes
• If yes, list medications
  • Protonix 80 bid, Zantac 150 daily
• Does the Veteran have any conditions of the following or symptoms due to any esophageal conditions (including GERD)?
  • Yes
• If yes check all that apply
  • [x] Persistently recurrent epigastric distress
  • [x] Dysphagia
  • [x] Pyrosis (heartburn)
  • [x] Reflux
  • [x] Regurgitation
  • [x] Substernal arm or shoulder pain
  • [x] Sleep disturbances caused by esophageal reflux
    • Recurrent, 4 or more episode per year
  • [x] Nausea
    • Recurrent, 4 or more episode per year
  • [x] Vomiting
    • Recurrent, 4 or more episode per year, duration of episodes (less than1 day)
• Have diagnostic imaging studies or other diagnostic procedure been performed?
  • Yes, Upper endoscopy
  • Date: 5/11/12
  • Results: reflux esophagitis
• Functional impact
• Do any of the veterans esophageal conditions impact on his or her ability to work?
  • [x] No

Thoracolumbar Spine Questionnaire

• Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back condition)
  • [x] Yes
• If yes, provide only diagnoses that pertains to thoracolumbar spine conditions.
  • Diagnosis #1, ICD code 722.52, date of diagnosis 1998
• Describe the history of the Veterans thoracolumbar spine condition.
  • Well documented L/S back pain associated with service duties – OP eval confirms DDD with episodic severe sciatic radiculopathy – tx with conservative tx no interventions – the veteran will have episodic symptoms with intervals of symptom relief.
• Does the Veteran report that flare-ups impact the function of the thoracolumbar spine (back)
  • [x] Yes
• If yes, document the Veterans description
  • 3-4 flairs per year described – no inciting incidents – currently symptomatic – this can be considered “flair” findings.
• ROM readings
  • Forward flexion ends [35]
    • Objective evidence of painful motion begins [35]
    • Select where extension ends [15]
  • Right lateral flexion ends [30]
    • Select where objective evidence of painful motion begins [30]
  • Left lateral flexion ends [20]
    • Select where objective evidence of painful motion begins [20]
  • right lateral rotation ends [30]
    • No objective evidence of pain
  • left lateral rotation ends [25]
    • No objective evidence of pain
• ROM measurements after repetitive use testing
• Select where post-test forward flexion ends [35]
• Select where post-test extension ends [20]
• Select where post-test right lateral flexion ends [30]
• Select where post-test left lateral flexion ends [20]
• Select where post-test right rotational ends [30]
• Select where post-test left rotational ends [30]
• Does the veteran have any functional loss and/or functional impairment of the thoracolumbar spine
  • [Yes]
    • [x] less movement than normal
    • [x] pain on movement
• Does the veteran have localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine?
  • [Yes] , pain to L/S palpation L3-L5 bilaterally
• Does the veteran have guarding or muscle spasm of the thoracolumbar spine?
  • [Yes], abnormal spinal contour, such as scoliosis, reversed lordosis or abnormal kyphosis.
• Rate deep tendon reflexes (DTR’s)
  • Knee, Right 1+, Left 1+
  • Ankle, Right 1+, Left 1+
• Provide straight leg raising test result
  • Right, positive
  • Left, negative
• Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
  • [YES]
• Symptoms
  • Intermittent pain (usually dull)
    • Right lower extremity- [x] Severe
  • Numbness
    • Right lower extremity- [x] Moderate
• Indicate nerve roots involved:
  • Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
  • [X] Right
• Indicate severity of radiculopathy and side affected
  • Right [x] Severe
• Does the veteran have IVDS of the thoracolumbar spine?
  • [x] Yes
• If yes, has the veteran had any incapacity episodes over the past 12 months due to IVDS?
  • [x] Yes
• If yes, provide the total duration of all incapacitating episodes over the past 12 months
  • [x] At least 4 weeks but less than 6 weeks
• Does the veteran use any assistance devices
  • [x] Yes
  • If yes, identify [x] cane [x] occasional
• If veteran uses any assistance devices, specify
  • With L/S and sciatic flairs- cane used
• Have imaging studies of the thoracolumbar spine been performed and are the results available?
  • [x] Yes
  • If yes, is arthritis documented?
  • [x] Yes
  • Are there any other significant diagnostic test findings and or results?
  • [x] Yes
  • Verified via report xxxxxxxx
• REPORT FINDINGS
  • Study shows mild posterior subluxation of L4 on L5. Remaining vertebrae are normally aligned. Disc spaces are reduced at L4-L5 and L5-S1 levels consistent with degenerative changes.
• Impression
  • Degenerative discs L4-L5 and L5-S1. Mild posterior subluxation of L4 on L5. Spondylosis multiple lumbar vertebral bodies.
• Functional Impact
  • Does the veteran’s thoracolumbar spine condition impact on his or her ability to work?
  • [X] Yes
  • If yes, describe the impact of each of the veterans thoracolumbar spine conditions
    • - on average of 4 weeks of bed rest yearly due to IVDS
• Remarks
  • The veteran is service connected for PN-Sciatic – in actuality this is DDD with sciatic radiculopathy – confirmed in private records and confirmed in STR review – I did discuss this with the veteran and completed Spine DBQ which more accurately defines pathology – call placed to rater to discuss – per 2507 DM-PN ordered – no dx of DM evident
    • Doctor name

[Navy04]

Just to give you an idea on the GERD, I have a 30% for Crohn's Disease which is so severe the Navy retired me in Feb after 9 years active duty. My GERD is also so bad that I have been tested twice and will be on Tuesday next week to make sure that I don't have throat Cancer, due to tearing and holes in my Esophagus. I wish you the best, but I will be surprised if you get 10% for GERD.