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lfredrick123

Continued Exams- Please review for details

Question

Here is the most recent CT Exam 

GOOD SAMARITAN MEDICAL CENTER

 

 

 

 

Adm: 6/6/2017, D/C: 6/6/2017

CT Chest Abdomen And Pelvis Wo Contrast]

Resulted: 06/06/17 1617, Result status: Final

result

Ordering provider:

Resulted by: MD

Performed: 06/06/17 1522 - 06/06/17 1539 Resulting lab: SVB STRESS SERVICES

Narrative:

CT OF THE CHEST, ABDOMEN AND PELVIS WITHOUT INTRAVENOUS CONTRAST

EXAM DATE AND TIME: 6/6/2017 3:22 PM

INDICATION: Lung mass. Vascular disorder of the kidneys.

TECHNIQUE: Routine CT of the chest, abdomen and pelvis without IV

contrast. Dose reduction techniques were employed.

COMPARISON: None available.

FINDINGS:

CHEST:

Lungs: Evaluation lung bases is hindered by extensive respiratory

motion artifact. There is patchy left greater than right bilateral

lower lobe consolidations, consistent with pneumonia and/or

atelectasis. The upper lobes appear clear.

Mediastinum/Hila: There is mild cardiomegaly. Aortic valvular

calcifications are noted. Calcified plaque is seen in the aortic arch.

No mediastinal or hilar adenopathy. Tracheostomy tube appears in

satisfactory position.

Pleura: Tiny left pleural effusion.

Chest Wall: Right-sided VP shunt catheter is seen in the subcutaneous

right anterior chest wall, terminating in the right upper quadrant of

the abdomen.

ABDOMEN:

Liver: Normal size and homogeneous, without focal suspicious

parenchymal lesion.

Gallbladder/Bile Ducts: Few tiny calcified gallstones are seen

layering in the gallbladder, which otherwise appears unremarkable.

There is no biliary dilation.

Pancreas: The pancreas appears normal.

Spleen: The spleen appears normal.

Adrenals: The adrenal glands appear normal.

Kidneys: 3.3 cm simple left upper pole renal cyst. No hydronephrosis

or nephrolithiasis.

Bowel: Numerous colonic diverticuli are noted, without CT evidence of

acute diverticulitis.

Mesentery/Omentum/Peritoneum: The mesentery, omentum and peritoneum

appear normal.

Lymph Nodes: Lymph nodes appear normal. No adenopathy.

Vessels: Calcified plaque in the abdominal aorta, without evidence of

aneurysm.

Abdominal Wall: The abdominal wall appears normal.

PELVIS: Unremarkable urinary bladder. Unremarkable prostate gland. No

free air. No free fluid.

Printed on 6/8/2017 9:37 AM Page 1

GOOD SAMARITAN MEDICAL CENTER

200 Exempla Cir

Lafayette CO 80026

FREDRICK,GERALD W

MRN: S0406306

DOB: 2/28/1940, Sex: M

Adm: 6/6/2017, D/C: 6/6/2017

CT Chest Abdomen And Pelvis Wo Contrast [213904399]

(continued)

Resulted: 06/06/17 1617, Result status: Final

result

BONES: Multilevel degenerative changes in the lumbar spine are noted.

No destructive bony lytic or sclerotic osseous lesion.

IMPRESSION:

1. Patchy bilateral lower lobe left greater than right

consolidations, possibly representing atelectasis and/or pneumonia.

Evaluation of these regions are hindered by extensive respiratory

motion artifacts. Underlying mass, while considered less likely cannot

entirely be excluded. Follow-up chest CT suggested after resolution of

acute symptoms.

2. Right-sided VP shunt apparently in satisfactory position, tip

terminating right upper quadrant.

3. Cholelithiasis, without CT evidence of acute cholecystitis.

4. Diverticulosis, without CT evidence of acute diverticulitis.

THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED:

 MD

6/6/2017 4:17 PM

Contributed By:

Printed

What do you see in this report? 

as compared to the initial finding in February?

 

02/19/2017 6:16 PM

Ordered By:

, MD

Result Status:

Final result

 

CT ABDOMEN AND PELVIS WO CONTRAST - Details

 

About This Test

The My Chart portal may not provide a complete representation of the laboratory test results in your medical record. 
If you have questions, please contact your physician. If the report is not complete, you may contact Health Information Management for a complete report.

·        Details

Narrative

HISTORY:
76M. Diarrhea. Noncontrast CT abdomen and pelvis with coronal
and sagittal reformats.
FINDINGS:
Mild basilar atelectasis.
Mild cardiomegaly.
Right abdominal ventriculoperitoneal shunt partially seen
extending along the liver.
Dependent cholelithiasis without pericholecystic inflammation.
Unremarkable spleen, adrenals, pancreas.
Retroperitoneal lipomatosis with mildly atretic kidneys.
Left renal 3.3 cm hypodense lesion with indeterminate density.
Diffuse fluid-filled stomach, small bowel, and large bowel
without evidence of obstruction compatible with infectious
gastroenteritis/enterocolitis and diarrhea.
Normal appendix, axial image 64.
Distal colonic diverticulosis without diverticulitis.
Central mesenteric misty appearance with subcentimeter lymph
nodes.
Unremarkable bladder.
No free fluid or free air.
Small fat-containing inguinal hernia is without inflammation.
Bowel seen immediately deep to the umbilicus.
No acute osseous finding.
IMPRESSION:
1. Diffuse fluid-filled stomach and bowel compatible with
infectious gastroenteritis or enterocolitis.
2. Indeterminate left renal 3.3 cm lesion, most, a hyperdense
cyst. Recommend all sound further evaluate if not stable on
prior exams.
3. Cholelithiasis.
4. Central mesenteric misty appearance with subcentimeter lymph
nodes most commonly associated with mesenteric panniculitis or
sclerosing mesenteritis. Consider 6 month follow-up CT abdomen.

 

Component Results

There is no component information for this result.

General Information

Collected:

02/19/2017 7:02 PM

Resulted:

02/19/2017 7:02 PM

Ordered By:

 MD

Result Status:

Final result

Help Please!!!!

Blood Testing

KAPPA/LAMBDA LIGHT CHAINS FREE WITH RATIO, SERUM
KAPPA LIGHT CHAIN, FREE, SERUM Reference Range: 3.3-19.4 (mg/L)     Actual  41.3 H


LAMBDA LIGHT CHAIN, FREE, SERUM Reference Range: 5.7-26.3 (mg/L)  Actual   24.2
KAPPA/LAMBDA LIGHT CHAINS FREE WITH RATIO, SERUM Reference Range: 0.26-1.65  Actual   1.71 H

 

DOB: 02/28/1940
Sex: M
Phone: 
Patient ID: 
Age: 77
Fasting:
Specimen: KS400824A
Requisition: 7737005
Report Status: FINAL / SEE REPORT
Collected: 05/31/2017 17:19
Received: 06/02/2017 06:23
Reported: 06/09/2017 05:21
Client #: 70300946

Quest, Quest Diagnostics, the associated logo, Nichols Institute, Interactive Insights and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. All third party marks - '®' and '™' - are the
property of their respective owners. Privacy policy can be found at: http://questdiagnostics.com/home/privacy-policy/online-privacy.html. © 2017 Quest Diagnostics Incorporated. All rights reserved.

These results have been sent to the person that ordered the tests. Your receipt of these results should not be viewed as medical advice and is not meant to
replace discussion with your doctor or other healthcare professional.
Performing Sites
AMD Quest Diagnostics/Nichols Chantilly-Chantilly VA, 14225 Newbrook Drive, Chantilly, VA 20151-2228 Laboratory Director: Patrick W Mason M.D.,PhD
EZ Quest Diagnostics/Nichols SJC-San Juan Capistrano,, 33608 Ortega Hwy, San Juan Capistrano, CA 92675-2042 Laboratory Director: Jon Nakamoto
MD,PhD
THYROGLOBULIN
THYROGLOBULIN Reference Range: <0.1 (ng/mL)
Reference range applies to differentiated thyroid
cancer patients following treatment. The presence of
measurable thyroglobulin indicates the presence of
thyroglobulin-producing thyroid tissue. Clinical
correlation is advised.
This test was performed using the Beckman Coulter
Chemiluminescent method. Values obtained from
different assay methods cannot be used interchangeably.
Thyroglobulin levels, regardless
of value, should not be interpreted as absolute
evidence of the presence or absence of disease.
THYROID CANCER (THYROGLOBULIN) MONITOR
THYROGLOBULIN ANTIBODY Reference Range: <=1 (IU/mL)
This Thyroglobulin antibody test was performed
using the Beckman Coulter Immunoenzymatic method.
Values obtained from different assay methods cannot be
used interchangeably. Thyroglobulin antibody levels,
regardless of value, should not be interpreted as
absolute evidence of the presence or absence of
disease.
If the sample contains anti-thyroglobulin antibodies
of greater than 1 IU/mL, the presence of these
autoantibodies may cause falsely low thyroglobulin
values.
SEROTONIN, SERUM
SEROTONIN, SERUM Reference Range: 56-244 (ng/mL)
This test was developed and its analytical performance
characteristics have been determined by Quest Diagnostics
Nichols Institute San Juan Capistrano. It has not been
cleared or approved by FDA. This assay has been validated
pursuant to the CLIA regulations and is used for clinical
purposes.
10.4 H


 


 

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Ok.  It looks like you will have to speak for him at the hearing, unless you have a representative.  I think the number 1 thing you need to accomplish at the hearing is to view the records, and compare it with YOUR records, to see if VA is "dealing with a full deck".  

If the VA is missing stuff, then request they add the records, hopefully you can just hand them to them.  

     If stuff is missing from your file at VA, then you are getting a "bad" deal, that is, they are dealing from the bottom of the deck.  

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Unfortunately,  the portions of the  exam  you posted does not say anything about your caluza elements, and you need those for Service connection for any of these disorders.  Look for these 3 things for service connection:

1.  Current diagnosis.  

2.  In service event or aggravation.

3.  Nexus, or docs statement that your (diagnosis) is "at least as likely as not due to (in service event) while in military service".  

After you get the caluza elements, you can look at "symptoms" to try to determine a rating.  

     These elements may well be in your Cfile.  You need to order a copy of your cfile to see if you have the above documented.     To get your "lung mass" or "kidney disorder" service connected you need the above.  Exception:  Secondary conditions.  If the doc says your "lung mass" or kidney disorder is a result of an already service connected ;condition, you wont need to AGAIN fulfill requirement number 2 above.  That is, if a condition is secondary to a SC condition, you dont need to again document an in service event or aggravation.  

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Bronco Vet thank you.   Here are the DBQ's done recently showing the diagnosis, also the IME, and I have affidavits signed by other vets attesting to seeing and breathing the heavy spraying, and a letter from the Col who was in charge of the Public Works Department that says they were using 2,4,5,T,Chlordane, Lindane,Malathion, Diasinon, DDT,DDE, and Nicotine Sulfate, throughout the base, and a fellow soldier in the same  unit in Germany on the HIDAL Subkit spraying at the border DBQ's for VA review.docx we were stationed. The Industrial Hygiene Survey that was done at the exact time I was there, that showed extensive levels of carbon monoxide and diesel fumes (benezene and other particulates), as well as noise levels all without protection and inexcess of limits,

This coupled with the above

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The documents state that you "are unable to speak", and confined to a wheelchair with a stroke, that is, unless I read this incorrectly.  You also have CAD.   However, still missing from the documents you posted are at least 2 of the Caluza Elements necessary for service connection.  

The 3 Caluza elements are:

1.  Current diagnosis.  You apparently have that.  

2.  In service event or aggravation.  This is not documented in the documents you posted. 

3.  Nexus, or medical opinion that your diagnosis is "at least as likely as not" due to an in service event.  Again, I did not see a nexus in the documents you posted.  It could be in other parts of your file.  

     You need to order your cfile and see if all of the above are documented.  Im also more than a little disappointed your doctor seemed to suggest it does not affect your working.  How many people do you see out there working who are confined to a wheel chair and unable to speak???  Not many.  

      My opinion is that if you have, or can get documented all of these caluza elements you should be rated at 100%, and probably with SMC S or even SMC L.  (aid and attendance).  If you are confined to a wheel chair and cant speak, then you need some help, and probably can not leave your house alone.  

Edited by broncovet

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I believe the DBQ's show the diagnosis. As well as the private records. There were error in the PA statements that I have already asked VA to ammend. First he is on continuous oxygen, and he has proxyimal a fib, and he has private ekg that showed a  AV Block on its readings twice, that they dont want to address. And because of the recurring infections, the damage to his lungs f rom exposures well documented and statements from many others about them. I believe we have all three. I have a nexus as well from IME , that states the stroke was caused due to hypertension that was shown in his service medical records. He also has arteriosclerosis, and he had a rupture due to weakened vessels due to hypertension. He also had a huge clot removed from the cerebellum as well as hemorrhaging. I am just wondering what else can be given or angle of attack here.

 

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