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GERD exam. Did dr. mess up? possible rating


*******It seems my examiner filled it out with symptoms for 30 percent, but then checked no if it disturbs my works.  Any guesses?  Does her putting "doesn't impact my ability to work" going to hurt my claim?

Esophageal Conditions (Including gastroesophageal reflux disease (GERD), hiatal hernia and other esophageal disorders)
Disability Benefits Questionnaire 
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No

ACE and Evidence Review -----------------------
Indicate method used to obtain medical information to complete this document: [X] In-person examination
Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Diagnosis ---------

Does the Veteran now have or has he/she ever been diagnosed with an esophageal condition? Yes
Gastroesophageal reflux disease (GERD) ICD code: R69 Date of diagnosis: IN SERVICE
Hernia hiatal ICD code: R69 Date of diagnosis: 2011

Medical history ---------------
Description of the history (including onset and course) of the Veteran's esophageal conditions: SEEKING INCREASE IN SC GERD CURRENTLY, WAKES UP WITH BURNING ACID IN THROAT AND HAS REFLUX THROUGHOUT THE DAY ON DAILY BASIS. WAKES UP SEVERAL TIMES A WEEK. GREASY FOODS MAKES SYMPTOMS WORSE. OMEPRAZOLE 20 MG DAILY TUMS THROUGHOUT THE DAY Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition? Yes Medications used for the diagnosed condition: OMEPRAZOLE 20 MG QD 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
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, symptoms and scars ---------------------------------------------------------------- -------------

Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? No

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

Diagnostic Testing ------------------
Have diagnostic imaging studies or other diagnostic procedures been performed? No
Has laboratory testing been performed? No
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: ---------------- 07/28/2011 UPPER GI AIR CONT W/O KUB Thoracic esophageal, gastric, proximal small bowel motility morphology were notable only for small variably reducing hiatal hernia documentation of gastroesophageal reflux into the distal third thoracic esophagus.07/28/2011 08:32

Edited by marinevet1987

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