Second C&P looking for SWAG

[Tomahawk]

Any guesses on to how this will be rated?

 

                         Stomach and Duodenal Conditions
                  (Not including GERD or 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 Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS

    1. Diagnosis
    ------------
    Does the Veteran now have or has he/she ever had any stomach or 
    duodenum
    conditions? [ ] Yes   [X] No
    
    2. Medical History
    ------------------
    a. Describe the history (including onset and course) of the 
    Veteran's stomach
       or duodenum conditions (brief summary):
          The veteran presents today with the following requested: 
          "The examiner
          is asked to provide the following opinions:a. Is it at 
          least as likely
          as not (a 50 percent probability or greater) that any 
          current stomach
          disability, including GERD, was incurred during the 
          Veterans period of
          active service? Discuss the Veterans reports of frequent 
          indigestion
          and heartburn on his Report of Medical History in 
          September 1998.b.
          Is it at least as likely as not (a 50 percent probability 
          or greater)
          that any current stomach disability, including GERD, was 
          caused by or
          aggravated by his service-connected left foot disability, 
          to include
          his treatment for the condition? Please specifically 
          discuss the
          comments of the August 2010 VA examiner that the use of 
          nonsteroidal
          anti-inflammatoriesin individuals with known GERD may 
          contribute to the
          severity.

          "The veteran reports that he started to develop symptoms 
          of pyrosis
          during his military enlistment in the 1990s and was 
          medicated with
          over-the-counter antacids. Review of the veteran's C-file 
          shows on his
          separation exam he 
          checked indigestion as a symptom. There are no medical 
          reports of
          symptoms of pyrosis or indigestion noted in his service 
          medical
          records. Review of his CPRS electronic charting notes on a 
          consult that
          was placed, that he started to develop symptoms of 
          gastroesophageal
          reflux disease between 2002 and 2003. His first endoscopy 
          procedure was
          completed earlier this year which documented mild 
          esophagitis, and
          further testing at University Hospitals on an outpatient 
          basis
          diagnosed him with gastroesophageal reflux disease. He had 
          a treatment
          course of 
          proton pump inhibitors that he failed, and as recently as 
          May 2010
          underwent fundoplication surgery at the Wade Park VA 
          facility. The
          veteran states that since the surgery he has had a very 
          significant
          improvement in the episodes of pyrosis. He states if 
          eating spicy foods
          such as Mexican foods with hot sauce,he will still 
          experience an
          episode of pyrosis, but the frequency is drastically 
          reduced, and as
          long as he maintains lifestyle modifications such as 
          avoiding those
          foods, that he does not experience pyrosis. He does also 
          complain of an 
          occasional sharp pain noted after swallowing either large 
          amounts of
          food or liquid, which only lasts for a few minutes and 
          then resolves
          since the surgery."

          Today the veteran reports that his GERD has become worse 
          and he is
          taking additional medications that now include Omeprazole 
          40mg daily,
          Ranitidine 300mg QHS and Lactobacilus. He reports 
          increased pyrosis,
          more pronounced reflux and some pain in left upper 
          abdominal area.
          Increased belching. Occasional symptoms wake the veteran 
          at night.  

          
          
    b. Does the Veteran's treatment plan include taking continuous 
    medication for
       the diagnosed condition?
       [X] Yes   [ ] No
       
           If yes, list only those medications used for the 
           diagnosed condition:
              Omeprazole 20mg
              Lactobacillus
              
              
    3. Signs and symptoms
    ---------------------
    Does the Veteran have any of the following signs or symptoms due 
    to any
    stomach or duodenum conditions? [ ] Yes   [X] No
    
    4. Incapacitating episodes
    --------------------------
    Does the Veteran have incapacitating episodes due to signs or 
    symptoms of any
    stomach or duodenum condition? [ ] Yes   [X] No
    
    5. Other conditions
    -------------------
    Does the Veteran have any of the following conditions? [ ] Yes   
    [X] No
    
    6. Other pertinent physical findings, complications, conditions, 
    signs,
       symptoms and scars
    ----------------------------------------------------------------
    -------
    a. Does the Veteran have any other pertinent physical findings,
       complications, conditions, signs or symptoms related to the 
       conditions
       listed in the Diagnosis Section above?
       [X] Yes   [ ] No
       
           If yes, describe (brief summary):
              Veteran has GERD
              
              
    b. 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
       
    c. Comments, if any:
       No answer provided
       
    7. Diagnostic testing
    ---------------------
    a. Have diagnostic imaging studies or other diagnostic 
    procedures been
       performed?
       [X] Yes   [ ] No
       
           If yes, check all that apply:
           
           [X] Upper endoscopy
                  Date:  2009
                  Results:  see below

    b. Has laboratory testing been performed?
       [ ] Yes   [X] No
       
    c. Are there any other significant diagnostic test findings 
    and/or results?
       [X] Yes   [ ] No
       
           If yes, provide type of test or procedure, date and 
           results (brief
           summary):
              Endoscopic reports confirms mild esophagitis, and other 
              testing
              confirms gastroesophageal reflux disease, and the 
              veteran is status post fundoplication surgery. 
              
              
    8. Functional impact
    --------------------
    Do any of the Veteran's stomach or duodenum conditions impact 
    his or her
    ability to work? [ ] Yes   [X] No
    
    9. Remarks, if any:
    -------------------
       The examiner is asked to provide the following opinion
s:

       a. Is it at least as likely as not (a 50 percent probability 
       or greater)
       that any current stomach disability, including GERD, was 
       incurred during
       the Veterans period of active service? Discuss the Veterans 
       reports of
       frequent indigestion and heartburn on his Report of Medical 
       History in
       September 1998.

       b. Is it at least as likely as not (a 50 percent probability 
       or greater)
       that any current stomach disability, including GERD, was 
       caused by or
       aggravated by his service-connected left foot disability, to 
       include his
       treatment for the condition? Please specifically discuss the 
       comments of
       the August 2010 VA examiner that the use of nonsteroidal
       anti-inflammatoriesin individuals with known GERD may 
       contribute to the
       severity.

       2507 requested opinion:

       a. After a review of the veteran's available medical records 
       he does not
       have a "stomach" condition. The veteran has gastroesophageal 
       reflux
       disease. Although he reported symptoms on his "Report of 
       Medical History"
       in September of 1998 there is no other documentation found in 
       his service
       treatment records that represents objective evidence to 
       support the
       diagnosis. Therefore this examiner would have to resort to 
       speculation to
       determine that his complaints as listed above were the first
       manifestations of his gastroesophageal reflux disease.

       b. Although the use of anti-inflammatory pain medications can 
       increase the
       severity of symptoms and GERD itself there is no baseline
       Esophagogastroduodenoscopy to document findings either prior 
       to his use of
       chronic NSAIDs or early in his development of symptoms of 
       GERD to
       establish a baseline. Therefore it would be at least as 
       likely as not that
       the veteran's GERD was aggravated beyond it's normal 
       progression however
       this examiner cannot provide a degree of aggravation because 
       of the above
       rationale.   
       
       

[jfrei]

Was this service connected already I’m confused it sounds like the rationale was that you don’t have a stomach condition for a denial but I’m know nothiing about GERD.. if it is connected I would say 30% 

Edited May 14, 2018 by jfrei