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What Is This Letter Missing? Hysterectomy Secondary To Anemia

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Hysterectomy,

Service connect for anemia

TO WHOM THIS MAY CONCERN;

Ms. xxxxxx, has been a patient of Dr. zzzzzzzz for many years. She was first seen in my office approximately, November 1983 for a physical to enter college. Through the next few years I treated Ms. Xxxxx for various conditions such as: pregnancy and annual Pap smear. I treated her prior to her enlistment in UNITED STATES NAVY, was approximately April 1988.

She returned back to my office in 1997 after she had been discharge from the Navy. She was in for a routine Pap smear and abdomen pain. She gave me her medical history which was chronic migraine headaches, chronic anemia, abdomen pain and chronic sinus. She stated that she took the following medicine midrin, DARVOCET-N and florinal, and Ferrous sulfate tablets daily for anemia.

She stated that the only surgeries she had was bilateral tubal ligation and (1992) and reduction mammoplasty (1997).

I performed an hysterectomy on Ms.xxxxxx on April 2004.

It is my medical opinion that iron deficiency anemia and her hysterectomy is related to each other.

I believed that it is more likely than not (greater than 50%) that this condition first manifest on active duty/military.

The reason for this medical opinion is that:

  1. Due to the size of the mass on ovaries and the condition of her uterus and cervix, it is my opinion that more likely than not (greater than 50%) that these disability was first manifest during active duty.

  1. Ms. xxxxxxx had been taking Ferrous sulfate tablet(iron tablets) three times a day 65mg since 1989 and hemoglobin and hematocrit was still low.

  1. Fibroids do grow slowly initially, but over time, the fibroids will get worse and will reach a critical mass and become severe, which is what happened to Ms. xxxxxx.

Diagnosis from post-operative report:

Her postoperative diagnosis was :

  1. Chronic nonspecific pain
  2. Iron deficiency anemia associated menorrhagia with associated dysmenorrheal
  3. Status post previous bilateral tubal ligation
  4. Large left adnexal mass, persistent consistent with probable adult cystic teratoma
  5. Slight uterine enlargement, rule out adenomyosis.
  6. 2 cm hemorrhagic corpus luteum cyst, ruptured.

Ovary and about 1.5 cm to 2.0 cm cystic teratoma of right ovary

What is missing, are is this to much information.

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  • HadIt.com Elder

I'd suggest that the doctor should state the exact reasons for the decision to do the hysterectomy, and directly relate it to the symptoms that occurred in service. The general wording need to be more in line with what the VA "likes".

"The reason for this medical opinion is that:"

I'd rather see - -

It is my professional medical opinion that:

The Doctors qualifications to render the opinion can be important as well, and should be added.

Such things as license to practice, specialty(preferably board certified) also lend authority to the opinion.

Edited by Chuck75
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Thanks you Chuck, yes I will add that and yes the physcian nurse will put the qualification. I had to type up something because they didn't know what to put on the letter. The VARO in Atlanta, said i need a letter that said that it was least as likely as not related to my military service. The exact reason is on the operative report Pre-Operative and Post Operative report.

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  • HadIt.com Elder

"The physician nurse will put the qualification" Who actually writes the opinion is not the point.

The qualified and licensed doctor involved is the one to sign the opinion, and the listed qualification, license, etc. are the doctors.

This is often a problem with VA medical practitioners that are a veteran's PCP, but may be a nurse practitioner or a physician's assistant.

(And may not be licensed to practice in the state with the VA facility.)

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