C&p For Gerd Have A Few Questions

[John99GSX]

Hello,

Below is the part of my C&P related to GERD:

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Esophageal Conditions
(Including gastroesophageal reflux disease (GERD), hiatal hernia
and other esophageal disorders)
Disability Benefits Questionnaire
Indicate method used to obtain medical information to complete this
document:
In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed: No
Check all records reviewed:
[X] Other: cprs,vbms, electronic c file
Diagnosis
---------
Does the Veteran now have or has he/she ever been diagnosed with an
esophageal condition? Yes
Gastroesophageal reflux disease (GERD)
ICD code: 530.81 Date of diagnosis: 2012
Medical history
---------------
Description of the history (including onset and course) of the
Veteran's
esophageal conditions: Vet diagnosed with gerd in 2012. he has been taking
for gerd.he still gets sore throat daily,regurgitatation 2-3 times a
month,&
heartburn several times a month.he also gets stomach pain 1-2 times per
month. Some times left upper chest pain , he had stress test done it was
normal.
Does the Veteran's treatment plan include taking continuous medication
for
the diagnosed condition: Yes
Medications used for the diagnosed condition: pantoparazole 40 mg daily
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:
Reflux
Regurgitation
Pain
Substernal
Vomiting
Frequency of episodes of vomiting per year: 1
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? No
Diagnostic Testing
------------------
Have diagnostic imaging studies or other diagnostic procedures been
performed? Yes
Diagnostic Testing Preformed:
Upper endoscopy Date: july 2012 Results: normal
Has laboratory testing been performed? Yes
CBC Date of test: april 2015
Hemoglobin: 15.1
Hematocrit: 44.0
White blood cell count: 5.12
Platelets: 176
Are there any other significant diagnostic test findings and/or results? No
Functional impact
-----------------
Do any of the Veteran's esophageal conditions impact on his or her
ability to
work? No
Remarks, if any: No response provided
-----------------
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.

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I have already recieved my decision and was awarded GERD 10%

SC for GERD was established (seconday to NSAIDS for SC Knee pain)

10% based on Regurgitation, Substernal pain, Vomiting

30% is not warrented unless the evidence shows persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health.

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My questions are it appears they several boxes were not checked on the C&P / DBQ paperwork, but are clearly noted in the history notes.

recurrent epigastric distress with dysphagia > Inhistory as sore throat daily, gets stomach pain 1-2 times per month

pyrosis > In history as heartburn several times a month

What are my best options here? It appears he missed/skipped the entire signs and symptoms section on page 1 of the DBQ?

I have a GI follow up at the VA today, I will attempt to get them to complete a DBQ as well.

I have seen a private DR for the GERD, and he will complete one as well if needed.

Thanks,

John

[Navy04]

It is hard to get higher then 10% for Gerd, that is what I got when they combined it with my Crohns, and that is with Scarring of the Esophagus and tested for Throat Cancer Twice, due to severity of damage to throat and mouth, and now my teeth will have to come out, and I am only 33. Remember that you can always put in for an increase, or NOD if you feel you should have been granted Higher. Good luck

[Vync]

The problem with DBQ's is that they require the examiners to actually examine your records.

This is straight out of the rating criteria:

30% is not warrented unless the evidence shows persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health.

There are a lot of commas and and's in there. It is not enough just to have it just a few times a month, but you basically have to have symptoms mirroring most, if not all, of what they stated.

It took several unwanted VAMC emergency room visits and being admitted for cardiac observation before they granted my 30%. My chest was in so much pain, but I was not having a heart attack - it was severe GERD. I never knew that could happen.

[John99GSX]

Yes I had the chest pain that would put me on the floor. My primary sent me for EKG, and stress test to rule out the heart. Follow up with gastro yesterday added another med for the evening and scheduled for another upper GI scope. I do have all the symptoms in the list for the 30%.

My major concern on the C&P is that it shows in the history\notes all of the "missing" symptoms listed on the 30% requirements. He didnt seem to check any of the symptoms on the page 1 of the DBQ and they are all in my medical notes at the VA as well. Im not sure if he skipped over it or didnt know what the terms were. I always make sure to use both the generic and medical terms when talking to the VA.

When the examiner states: heartburn several times a month and then the symptom of pyrosis (heartburn) isnt on the symptoms list it is a bit onfusing to me.