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What % For Crohn's And Gerd C&p Exam Do You Think I Will Get?

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Navy04

Question

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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They combined my GERD with my colon resection - no change in rating because they said they wouldn't rate parts of the same system separately.

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I was bumped up from 80 to 100%, but my Crohn's and GERD stayed the same at 30%. It is so crazy because I was Medically Retired last year from the Navy due to my Crohn's being so bad, I have had two blood Transfusions, and the VA is going to remove almost 9 feet of my Intestine this year. Also my GERD is so bad that I have Barretts Disease, and have been tested twice in the last year for throat cancer. I am 100% now and just don't have the strength to fight with the Govt anymore. I will deal with the VA down the road.

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