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C&p Exam Resuts Rating?


charlest27

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Hear is my C&P exams just want to know what rating the VA should give me? Thanks for the help.

Heart Conditions: (Including Ischemic & Non-ischemic Heart
Disease, Arrhythmias, Valvular Disease and Cardiac Surgery)
Disability Benefits Questionnaire

Name of patient/Veteran: xxxxxxxxxxxxx

Indicate method used to obtain medical information to complete this
document:

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

A] VMBS
1. Chronological Record of Medical Record
Date: 06 April 2010
Facility: NH Jacksonville
Problems:
hypertension
Murmur heard
Active medications:
Lisinopril/Hydrochlorothiazide
A/P
Hypertension [systemic]

2. Chronological Record of Medical Record
Date: 14 Dec 2009
Facility: NBHC Kings Bay
Problems:
Murmur heard
Benign essential hypertension
Active medications:
Lisinopril/Hydrochlorothiazide
A/P
Hypertension [systemic]

3. Facility: Naval Medical Center Portsmouth
Date: 13 March 2012
Procedure: ECG
Results:
Normal sinus rhythm
Incomplete right bundle branch block
Borderline ECG
Diagnosis: Headache,Fever,Altered Mental status,Neurologic abnormality
Lumbar puncture was done

B] No other medical records available for review other than the VBMS.


If no, check all records reviewed:

[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a heart
condition?
[X] Yes [ ] No

[X] Hypertensive heart disease
ICD code: ICD.9.CM 402.90Date of diagnosis: 2013

2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's heart
condition(s) (brief summary):
39 y/o,male.
VBMS reviewed.
USN Feb 1994 to Sept 30,2013; worked as a first class builder.
Informations provided by the Veteran.
Accompanied by his wife,Erlinda Booth.
No employment since discharge from service.


"CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER.
Date of Claim: September 30, 2013
30 days pending
This is a VBMS case.
Service personnel records are still with VA Manila. STRs are loaded in
VBMS.
Please have the examiner review these records as well as the VBMS
records.
The Veteran was recently discharged on September 30, 2013. He is
currently
claiming service-connection for the following conditions:
-
- Hypertension
-
- Heart murmur
- ...
Please conduct a general medical exam with attention to these
conditions.
Veteran's claimed conditions were taggeded in his STRs in VBMS.
If current diagnosis is related to symptoms found in service, please
provide
an opinion as to whether the symptoms in service are at least as
likely
as
not related to the current diagnosis.
...
Note to the Examiner for the heart condition: If Veteran's METS level
due
to cardiovascular limitations cannot be reasonably determined due to the

effects of NSC conditions upon the METS level and that LVEF testing
renders
a more accurate measure of cardiovascular manifestations alone, please
specifically state so.
ACE process must not be used to complete the DBQ for Hearing Loss and
Tinnitus and Mental Disorders.
To the Clinician:
If using the ACE process to complete the DBQ, please
- explain the basis for the decision not to examine the Veteran, and
- identify the specific materials reviewed to complete the DBQ.
In addition, the Veteran has a power of attorney. Please send a
courtesy
copy of the exam notice letter to Georgia Department of Veteran
Service.
Any questions can be directed to Ruphee Ornedo at Ext 3868.
Thank you."

VBMS reviewed.
2009 & 2010 - noted to have murmur and hypertension;given Lisinopril
and
HCTZ which he took regularly.
March 2012 - treated for headache;ECG was done also and showed
Incomplete right bundle branch block & borderline ECG.
No hospitalization.
No surgery related to heart disease.
Currently,he complains of occasional chest pain,dizziness and
difficulty
in breathing.


b. Do any of the Veteran's heart conditions qualify within the generally
accepted medical definition of ischemic heart disease (IHD)?
[ ] Yes [X] No

c. Provide the etiology, if known, of each of the Veteran's heart
conditions,
including the relationship/causality to other heart conditions,
particularly the relationship/causality to the Veteran's IHD conditions,
if any:

Heart condition #1: Provide etiology
hypertension


d. Is continuous medication required for control of the Veteran's heart
condition?
[X] Yes [ ] No

If yes, list medications required for the Veteran's heart condition
(include name of medication and heart condition it is used for, such
as
atenolol for myocardial infarction or atrial fibrillation):
Lisinopril 20mg one tab daly.
HCTZ 25 mg one tab daily.



3. Myocardial infarction (MI)
-----------------------------
Has the Veteran had a myocardial infar
ction (MI)?
[ ] Yes [X] No

4. Congestive Heart Failure (CHF)
---------------------------------
Has the Veteran had congestive heart failure (CHF)?
[ ] Yes [X] No

5. Arrhythmia
-------------
Has the Veteran had a cardiac arrhythmia?
[ ] Yes [X] No

If checked, indicate frequency:
[ ] Constant [ ] Intermittent (paroxysmal)

6. Heart valve conditions
-------------------------
Has the Veteran had a heart valve condition?
[ ] Yes [X] No

7. Infectious heart conditions
------------------------------
Has the Veteran had any infectious cardiac conditions, including active
valvular infection (including rheumatic heart disease), endocarditis,
pericarditis or syphilitic heart disease?
[ ] Yes [X] No

8. Pericardial adhesions
------------------------
Has the Veteran had pericardial adhesions?
[ ] Yes [X] No

9. Procedures
-------------
Has the Veteran had any non-surgical or surgical procedures for the
treatment
of a heart condition?
[ ] Yes [X] No

10. Hospitalizations
--------------------
Has the Veteran had any other hospitalizations for the treatment of heart
conditions (other than for non-surgical and surgical procedures described
above)?
[ ] Yes [X] No

11. Physical exam
-----------------
a. Heart rate: 78/min

b. Rhythm: [X] Regular [ ] Irregular

c. Point of maximal impact: [X] Not palpable [ ] 4th intercostal space
[ ] 5th intercostal space
[ ] Other, specify:
d. Heart sounds: [ ] Normal [X] Abnormal, specify:
? systolic murmur at the apex

e. Jugular-venous distension: [ ] Yes [X] No

f. Auscultation of the lungs: [X] Clear [ ] Bibasilar rales
[ ] Other, describe:
g. Peripheral pulses:
Dorsalis pedis: [X] Normal [ ] Diminished [ ] Absent
Posterior tibial: [X] Normal [ ] Diminished [ ] Absent

h. Peripheral edema:
Right lower extremity: [X] None [ ] Trace
[ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+

Left lower extremity: [X] None [ ] Trace
[ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+

i. Blood pressure: 100/70

12. Other pertinent physical findings, complications, conditions, signs
and/or symptoms
-----------------------------------------------------------------------
a. 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

b. 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?
[X] Yes [ ] No

If yes, describe (brief summary):
Refer to DBQ CARDIO Hypertension template.


13. Diagnostic Testing
----------------------
a. Is there evidence of cardiac hypertrophy?
[X] Yes [ ] No

If yes, indicate how this condition was documented:
[ ] EKG [ ] Chest x-ray [X] Echocardiogram

Date of test: 12-5-13

b. Is there evidence of cardiac dilatation?
[ ] Yes [X] No

c. Diagnostic tests

[X] EKG Date of EKG: 11-26-13 [Refer to Vista Imaging Display]

Result:
[X] Other, describe: Sinus bradycardia.

[X] Chest x-ray Date of CXR: 11-25-13

Result:
[X] Normal [ ] Abnormal, describe:
[X] Echocardiogram Date of echocardiogram: 12-5-13.[Refer to Vista
Imaging Display]
Left ventricular ejection fraction (LVEF): 68 %

[X] Other test, specify:
1. Procedure: 2d-echo [Refer to Vista Imaging Display]
Facility: UST Hospital

2. Procedure: Stress test [Refer to Vista Imaging Display]
Facility: Manila VA OPC


Date: 1. 12-5-13 2. Nov. 26,2013

Result:

1. Conclusion:
Concentric left ventricular remodelling with good wall motion and
contractility and normal resting systolic function.
Thickened tip of anterior mitral valve leaflet with no restriction
of motion.


2. Bruce Total Exercise Time 09:01
Max HR: 125bpm 69% of max predicted 181bpm
Max BP: 140/90 Max Workload: 10.00 METS
Reason for termination: Uninterpretable tracing at peak exercise
due
to multiple artifacts
Interpretation.
Summary:
Resting ECG: Normal
Functional Capacity: Normal
HR Response to exercise: attenuated secondary to medication
BP Response to Exercise: normal resting BP - appropriate response
Chest pain: none
Arrhythmias: none
ST changes : none
Overall impression: normal stress test
Conclusion: Functional Class I




14. METs Testing
----------------
a. [X] Exercise stress test

Date of most recent exercise stress test: 11-26-13

Results: [Refer to Vista Imaging Display]

METs level the Veteran performed, if provided: 10 METS

b. [X] Interview-based METs test

Date of interview-based METs test: 11-26-13

Symptoms during activity:
The METs level checked below reflects the lowest activity level at
which the Veteran reports any of the following symptoms (check all
symptoms that the Veteran reports at the indicated METs level of
activity):

[X] Dyspnea
[X] Angina
[X] Dizziness
Results:
METs level on most recent interview-based METs test:

[X] (>7-10 METs) This METs level has been found to be
consistent
with activities such as climbing stairs quickly,
moderate bicycling, sawing wood, jogging (6 mph)

c. If the Veteran has had both an exercise stress test and an
interview-based
METs test, indicate which results most accurately reflect the Veteran's
current cardiac functional level:

[X] Exercise stress test [ ] Interview-based METs test [ ] N/A

d. Is the METs level limitation due solely to the heart condition(s)?
[X] Yes [ ] No

e. In addition to the heart condition(s), does the Veteran have other
non-cardiac medical conditions (such as musculoskeletal or pulmonary
conditions) limiting the METs level?
[ ] Yes [X] No

If yes, identify each condition and describe how each non-cardiac
medical condition limits the Veteran's METs level:

15. Functional impact
---------------------
Does the Veteran's heart condition(s) impact his or her ability to work?
[X] Yes [ ] No

If yes, describe impact of each of the Veteran's heart conditions,
providing one or more examples:


Mild/moderate restriction


16. Remarks, if any
-------------------
39 y/o,male.
VBMS reviewed.
USN Feb 1994 to Sept 30,2013; worked as a first class builder.
Informations provided by the Veteran.
Accompanied by his wife,Erlinda Booth.
No employment since discharge from service.

Refer to DBQ GM-Comp template,11-26-13.
Refer to DBQ CARDIO Hypertension VAE,11-25-13.
Notes:
The hypertensive heart disease is,at least as likely as not,related to
his hypertension noted in servicce.It is likely a progression of the
disease.The murmur could be a manifestation of the heart disease.

Hypertension
Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXXX

Indicate method used to obtain medical information to complete this
document:

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

VBMS and CPRS reviewed.

If no, check all records reviewed:

[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:

1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with
hypertension
or isolated systolic hypertension based on the following criteria:
[X] Yes [ ] No

[X] Hypertension
ICD code: 401.9 Date of diagnosis: 2008

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
hypertension condition (brief summary):
The veteran claims that during a routine eye examintation in 2008, he
was noted to have "bulging blood vesssels" hence blood pressure was
checked and was told to be elevated. He underwent 2-day hypertension
screening and was diagnosed to have hypertension. He was started on
Lisinopril 10mg once a day and Hydrochlorthiazide 12.5mg daily.
Adjustment of the antihypertensive medication was done in 2010 with
increase in the dose with better control of BP.

b. Does the Veteran's treatment plan include taking continuous medication
for
hypertension or isolated systolic hypertension?
[X] Yes [ ] No

If yes, list only those medications used for the diagnosed conditions:
Lisinopril 20mg/tablet 1 tablet once a day.
Hydrochlorthiazide 25mg/tablet 1 tablet once a day.

c. Was the Veteran's initial diagnosis of hypertension or isolated systolic
hypertension confirmed by blood pressure (BP) readings taken 2 or more
times on at least 3 different days?
[X] Yes [ ] No [ ] Unknown

If yes, provide BP readings used to establish initial diagnosis, if
known:

Reading 1: 146 / 90 Date: Feb. 29,
2008
Reading 1: 144 / 96 Date: April 7,
2008
Reading 1: 153 / 104 Date: Oct. 28,
2008


d. Does the Veteran have a history of a diastolic BP elevation to
predominantly 100 or more?
[ ] Yes [X] No

3. Current blood pressure readings
----------------------------------
Blood pressure reading 1: 110 / 60 Date: Nov. 25, 2013
Blood pressure reading 2: 110 / 60 Date: Nov. 25, 2013
Blood pressure reading 3: 120 / 60 Date: Nov. 25, 2013

4. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms

-----------------------------------------------------------------------------
a. 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

b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to the condition
listed in the Diagnosis section above?
[ ] Yes [X] No

5. Functional impact
--------------------
Does the Veteran's hypertension or isolated systolic hypertension impact his
or her ability to work?
[ ] Yes [X] No


6. Remarks, if any
------------------
Repeat blood pressure readings:
Sitting : 100/60mmHg
Standing: 110/60mmHg
Lying : 110/60mmHg



/es/ MA FLORDELIZA AQUINO CRISTOBAL, MD
Contract Physician
Signed: 11/26/2013 15:21
-------------------------------------------------------------------------

=========================================================================
Date/Time: 25 Nov 2013 @ 1300
Note Title: COMPENSATION & PENSION PHYSICIAN ENCOUNTER NOTE
Location: MANILA RO
Signed By: CRISTOBAL,MA FLORDELIZA AQUINO
Co-signed By: CRISTOBAL,MA FLORDELIZA AQUINO
Date/Time Signed: 26 Nov 2013 @ 1528
-------------------------------------------------------------------------

LOCAL TITLE: COMPENSATION & PENSION PHYSICIAN ENCOUNTER NOTE
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: NOV 25, 2013@13:00 ENTRY DATE: NOV 26, 2013@15:28:33
AUTHOR: CRISTOBAL,MA FLORDE EXP COSIGNER:
URGENCY: STATUS: COMPLETED

Take care

Charles T

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