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Imo For Sleep Apnea


Ricky

Question

Hi guys, the below is a draft of a IMO that my sleep doctor provided to me for review. It looks good to me but I would like for the experts to take a look at it and comment on it before I tell him it is ok.

Thanks Ricky.

LETTER HEAD

Date:

Subject: Medical Diagnosis, Treatment and Opinion

Reference: Patient: xxxxx Ricky ssn DOB:

Subjective Complaints: Mr. XXXX was seen in this office on __________ for sleep related problems. Mr. XXXX presented with complaints of inability to fall asleep accompanied with snoring and waking three to four times per night gasping for breath. Other symptoms included excessive day time somnolence, frequent day time napping, general fatigue due to lack of sleep and irritability. Mr. XXXX stated that these symptoms first occurred in 1998 while in military service. He stated that he sought treatment and was diagnosed with sleep difficulties at which time he was told to treat the symptoms with good sleep hygiene to include additional exercise and diet. After retirement from the military Mr. XXXXXX continued to complain of the above symptoms and was diagnosed with poor sleep and treated with Elvail on a trial basis without any success. After the lack of success with the Elvail, Mr. XXXXX was told to practice good sleep hygiene in and attempt to resolve his sleep issues. Mr. XXXX' symptoms continued and were worsened in early 2005 after he suffered a Cerebral Vascular Accident from a Right Thalamic Infarct. Mr. XXXXXX also presented with complaints of Hypertension, Diabetes Mellitus-Type II, and Central Post Stroke Pain Syndrome (Dejerine-Roussy) of the left side and Gastroesophageal Reflux Disease

Objective Observations: Mr. XXXXXX is a 50 year old male. A review of his service medical records and post service medical records confirmed: that he was diagnosed with a “sleep disorder” in 1998 by military physicians, however, no treatment notes were provided. In late 2000 during his military retirement medical examination he continued to complain of sleep problems, which was diagnosed as questionable Gulf War Syndrome. In a January 2003 Veterans Health Administration Progress Note a diagnosis of Insomnia was provided. His post service medical records provide that in late 2002 Mr. XXXXXX once again complained of sleep difficulties. He was diagnosed with and treated for “poor sleep” with Elvail on a trial basis. In late 2006 Mr. XXXXX continued to complain of the inability to go to sleep and waking during the night gasping for breath which had increased since his January 2005 Cerebral Vascular Accident . At this point he was referred to this office for examination, diagnoses and treatment. The review of Mr. XXXXX service medical and post service medical records also disclosed that he has been diagnosed with and is currently being treated for severe Hypertension, Diabetes Mellitus-Type II, Gastroesophageal Reflux Disease , Cerebral Vascular Accident and Post Stroke Pain Syndrome.

Based upon Mr.XXXXX diagnoses of sleep difficulties in 1998, his continued complaints of sleep difficulties and his Epworth Scale Score he was scheduled for a Polysomnography. The Polysomnography disclosed that Mr. XXXX suffers from moderate Sleep Apnea and Periodic Limb Movement Disorder. Based upon the result of the initial Polysomnography Mr. XXXX was scheduled for a follow-on Polysomnography with Continuous Positive Airway Pressure treatment. During the second Polysomnography with Continuous Positive Airway Pressure treatment his Apnea events were reduced to an acceptable level.

Diagnosis and Treatment: Mr. XXXXX suffers from Chronic Insomnia, Sleep Apnea and Periodic Limb Movement Disorder. Continuous Positive Airway Pressure treatment appears to be an effective treatment in this case, therefore, Mr. XXX has been prescribed and issued a Continuous Positive Airway Pressure device for nightly home use.

Medical Opinion: Based upon my experience in providing medical treatment in patients with Sleep Apnea, Insomnia and Periodic Limb Movement Disorders, my review of his pertinent in service and post service medical records, Mr. XXXXX' current symptoms, the results of the Polysomnography and his other related medical conditions of Diabetes, Hypertension, Gastroesophageal Reflux Disease and Cerebral Vascular Accident it is my professional medical opinion that his Sleep Apnea and Insomnia more likely than not existed at the time of the diagnosis of sleep difficulties in 1998 by military doctors. It has continued without treatment since then and has increased in severity as a result of his January 2005 Cerebral Vascular Accident. It is also my opinion that his Periodic Limb Movement Disorder is at least as likely as not a result of his January 2005 Cerebral Vascular Accident and its associated Dejerine-Roussy Syndrome.

My Opinion is based upon my experience, published medical literature and recent studies conducted by organizations such as the American Heart Association (AHA), the National Stroke Association (NSA), The National Institute of Health (NIH), The American Diabetes Association (ADA), the National Institute of Sleep Disorders and various Medical Research and Training Universities. Each of these organizations has conducted studies which concluded that a profound association exists between Sleep Apnea and Hypertension, Diabetes, and Gastroesophageal Reflux Disease. Mr. XXXXX had been diagnosed with Hypertension, Gastroesophageal Reflux Disease and elevated Glucose readings in 1998 coinciding with the 1998 in service diagnosis of sleep difficulties. Mr. XXXX also suffered a Cerebral Vascular Accident in January 2005. Although the most relevant risk factors for Cerebral Vascular Accident are Hypertension and Diabetes, recent NIH studies have provided that Sleep Apnea is more likely than not a risk factor for Cerebral Vascular Accident. Their studies have also shown that Sleep Apnea is present in approximately 90 percent of all post Cerebral Vascular Accident patients indicating that Cerebral Vascular Accident is at least as likely as not the cause of Sleep Apnea in such patients.

The basis of my opinion concerning Mr. XXXX’ Period Limb Movement Disorder is the fact that he suffers from Dejerine-Roussy Syndrome and the medical research and published literature of the National Institute of Neurological Disorders and Stroke and the American Pain Foundation. Both organizations describe Dejerine-Roussy Syndrome as an intolerable continuous pain due to damage to the Central Nervous System resulting from Cerebral Vascular Accident. They also provide that Pain may be moderate to severe in intensity, and is often made worse by light touch such as that presented by a patient attempting to sleep under bed covers. In this situation Mr. XXXX’ Periodic Limb Movement is an attempt to re-position his limbs to alleviate the pain.

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Yes- Excellent- and I liked the way he referenced how it tied into the Cerebral vascular accident- which is either due to this or due to the diabetes.

It seems that he is saying the CVA is due to the sleep apnea- which is supported here for service connection-

and the CVA would be secondary when they SC the sleep apnea.-

Ricky do you see it this way?

Great IMO -very professional-

Is he strictly a "sleep" doctor? Does he do other types of IMO claims?

I might not need another IMO but I am thinking of getting another one anyhow.

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Thanks guys for the comments. Berta he is a Plum guy who is in charge of a very large sleep clinic here. The CVA and Dejerine-Roussy is already service connected. What he is trying to show is that diabetes and hypertension are tied together at the hip with sleep apena. So if both of them were present in 1998 then it is more than likely that the sleep apena was present also since the military doctors diagnosed me with "sleep difficulties". However, he understands the VA line of thinking so he also wanted to introduce the fact that although sleep apnea is also believed to cause CVA, there are also just as many studies and and other medical opinions out there that also believe that CVA can and does cause sleep apena. That way is VA shoots down the fact that military diagnosis of Sleep Difficulties in 1998 is in no way associated with sleep apnea, then the attack will be that the 2005 CVA must be the cause of the sleep apnea. He is a pretty good guy who is trying to win the battle by cutting them off at the pass while still planning his next move which will be a flanking move. My tricare doc is also preparing a medical opinion agreeing with the sleep doc and including that sleep apnea was still a strange thing to the Army in 1998 and the diagnosis of sleep difficulties with a treatment of sleep hygeine was common during that time. My Neuro will also provide a medical opinion but I am saving that for the NOD. I know it will be a long road but I can drive it hopefully without falling asleep at the wheel.

Ricky

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Thanks guys for the comments. Berta he is a Plum guy who is in charge of a very large sleep clinic here. The CVA and Dejerine-Roussy is already service connected. What he is trying to show is that diabetes and hypertension are tied together at the hip with sleep apena. So if both of them were present in 1998 then it is more than likely that the sleep apena was present also since the military doctors diagnosed me with "sleep difficulties". However, he understands the VA line of thinking so he also wanted to introduce the fact that although sleep apnea is also believed to cause CVA, there are also just as many studies and and other medical opinions out there that also believe that CVA can and does cause sleep apena. That way is VA shoots down the fact that military diagnosis of Sleep Difficulties in 1998 is in no way associated with sleep apnea, then the attack will be that the 2005 CVA must be the cause of the sleep apnea. He is a pretty good guy who is trying to win the battle by cutting them off at the pass while still planning his next move which will be a flanking move. My tricare doc is also preparing a medical opinion agreeing with the sleep doc and including that sleep apnea was still a strange thing to the Army in 1998 and the diagnosis of sleep difficulties with a treatment of sleep hygeine was common during that time. My Neuro will also provide a medical opinion but I am saving that for the NOD. I know it will be a long road but I can drive it hopefully without falling asleep at the wheel.

Ricky

hello friend i am suffering with diabetes obstructive sleep apnea and hypertension if he ties all of these things together ina way that the va understands thats a great thing alot of docs dont care or dont want to get involved what is this doctors name if you dont mind me asking and is it possible to get a copy of the documentation where he actually ties these illnesses together this info will aid alot of vets who are suffering with the very same problem and cant find a reputable doc to actually put these things together or has the knowledge to do so

thanks for posting that info will do alot of vets alot of good god bless

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Ricky- he sure sounds like a great doctor-

with a very good take on what the VA needs-

and he is -like you are- anticipating the land mines.

I have 3 IMos -2 from Dr. Bash and a freeby brief one from a former VA doctor-

I also found a pathologist last week-who will prepare an additional one too if I need it-

What I have is excellent already but if I need another way of looking at the evidence- this pathologist has different evidence to focus on, unlike what the other IMOs consider.

Then again I don't know how they can go against what I have- but I don't trust them to consider it all properly.Since submitting the initial IMOs in Nov 2004 (2 years ago)no SOC from the VA ever mentioned them at all or ay additional medical evidence I sent-from the med recs-even after a DRO-POA conference to bring them up-

I think when I filed a FTCA claim in Sept. for destruction of them,(they must be gone if they were not considered) it helped trigger the VA to read them.

I "talked" to Dr. Bash the other day by email- he thinks I should send these IMOs to my Congressman and Senator- but yet I am waiting to see if they are actually considered this time.His concern is that in Feb it will be four years without resolve of this claim.The claims have had continuous movement since their return from the BVA so I can only wait and see.

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As soon as I get the final product I will post the results. He does not want his name published on the net as an IMO guy. He will only provide IMO's for his patients. I will also look up the links and post them. The American Heart Association, American Sleep Association,American Diabietes Association, National Institute of Health etc.... all have published articles on this tie. The problem is there is still a lot of discussion on which came first the chicken or the egg. In that I mean they are about equally divided on what disease came first - some say hypertension is the cause of SA, some say SA is the cause of hypertension. The same goes for the rest of the connections. You will just have to hope your doctor supports your theory. Regardless of the well written IMO that I have I expect an uphill battle with the VA just like on all claims.

By the way my private Tricare Doc also supports this position and will issue his own IMO. So that will be two in favor

ricky

Edited by Ricky (see edit history)
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