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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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My Response To C & P Exam, Heart And Unclaimed Disabilities


vern2

Question

This is my response to recent C & P exam conducted on 10 April 2015. Went over the exam word by word and discovered many, many errors and statements that were not true.

Note: I tried to attach this as word document, but hadit system would not accept it. File was only 42kb in size. i used M/S Word 10, as have Word 13, but did not use it.

Please note examiners terminology and his omission of key facts, as usual. I did not correct the misspelling by the examiner. Hope this helps someone. I am somewhat meticulous in my critique of the exam, as a decision can turn on one key word or phrase. :unsure:

UPDATED RESPONSE TO C & P Exam on 10 April 2015

Date: 11 May 2015

Sent to:

DVA Claims Intake Center

P.O. Box 5235

Newnan, Ga. 30721-0020

USPS CERTIFIED MAIL # xxx

Heart Conditions: (Including Ischemic & Non-ischemic Heart

Disease, Arrhythmias, Valvular Disease and Cardiac Surgery)

Disability Benefits Questionnaire

Name of patient/Veteran:

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 (hard copy paper C-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, CPRS, and CPRS remote data, for data from DOD and other

locations.

Comment: Dr. Kittle did not review my hard copy C-file, just the VBMS per his comments. My VBMS file is incomplete as is the C-file. Over 200+ pages of data uploaded in 2013 are not in either file. I have a CUE in for this omission.

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] Atherosclerotic cardiovascular disease

[X] Congestive heart failure

Date of diagnosis: 4/8/2013

Comment:

The comment above is not correct; as original diagnosis of heart disease was October 2003 by Dr. Ayoubi- see his tests already submitted many times.

Heart changes as noted in October 2003 by Doctor Maher Ayoubi

  1. Left atrium mildly dilated
  2. Right heart is mildly dilated
  3. Left ventricular systolic function revealed distal septal hyperkinesia with an ejection fraction of about 50%
  4. Mild tricuspid regurgitation with mild pulmonary hypertension
  5. Left internal carotid artery has slightly increased velocity at the origin at 130cm/s, consistent with moderate carotid artery disease, grade 40-59% stenosis.
  6. Moderate disease involving the origin of the left common carotid artery.
  7. Reversible anteroapical and fixed inferior defect with normal ejection fraction

Heart changes as noted in 2012-2014, by Navy Hospital Pensacola and also Baptist Hospital Pensacola and tests performed at each facility, including ECG, cardio version, TEE, and Cardiac Ablation.

  1. Carotid Ultrasound on 8 September 2013, revealed mild focal calcific plaque in right bulb. (BHC)
  2. Mild atherosclerotic calcifications in the aorta (abdomen) (Woodlands , 9 September 2012)
  3. “Diagnosis of hypertensive heart disease with concentric LVH which is directly correlated to the development of diastolic dysfunction. This in turn leads to atrial dilation that leads to an increase in pulmonary venous pressure> pulmonary artery pressure with resulting impact on right ventricular function which can lead to lower extremity edemaDoctor Chandler in statement on 4 October 2012.
  4. “Atrial dysrhythmia in particular multifocal tachycardia is a causative factor in pulmonary disease (pulmonary hypertension).” Doctor Chandler letter in 27 June 2012.
  5. VA 21-0960A-3, DBQ from Dr. Chandler on hypertension dated 10 January 2014 states 2A: “the patient chronic progressive long standing hypertension now requiring 4 (now 7) drugs to control c/w stage II HTN. This lead to progressive LVH and associated diastolic dysfunction. The elevated LV filling pressure leads to Type II pulmonary hypertension and RV dilatation.”
  6. VA 21-0960a-3, Section, IV, “patient to avoid significant exertion sustained above 7 METS as this is shown to produce a hypertensive response of 204/101”.
  7. Letter by Dr. Chandler dated 10 January 2014, “His long standing hypertension has resulted in the development of concentric left ventricular hypertrophy with associated diastolic dysfunction, Stage II. The increased LV filling pressures subsequently lead to mild LA dilation and associated Type II pulmonary HTN with elevated PAPS and associated mild RV dilation”.
  8. Stress test on 5 September 2013 was stopped due to significant increase in blood pressure beyond anticipated. (This is third time that a stress test had to be stopped due to hypertensive BP response.)
  9. Letter by Dr. Chandler on 10 January 2014 also states: the presence of elevated right sided cardiac pressures and mild dilation increase the likelihood of clinical signs and symptoms of right heart failure which can be associated with peripheral edema.” (I have had pedal edema since 2005.)
  10. See VA 21-0960A-4 (heart) by Dr. Chandler on 10 January 2004. Hypertensive heart disease secondary to hypertension (section II, 2C).
  11. See VA 21-0960A-4, (heart) by Dr. Chandler on 10 January 2014, Section VI, 6C, “mild mitral regurgitation on Echo on 08/26/2013, moderate tricuspid regurgitation on Echo on 08/26/2003.”
  12. Chest x-ray noted on VA 21-0960A-4, Section XIII, 13C, “borderline enlarged cardiac silhouette.”
  13. VA 21-0960A-4, DBQ by Dr. Chandler on 10 January 2014, Section XV, “patient due to degree of hypertension is unable to perform sustained intense physical activity >7 METS without dangerous elevation in blood pressure. Patient is able to perform modest activity and not to exceed PRs.” I had exercise stress test on 1 April 2015 that was stopped after 3.4 minutes due to extreme chest pain- Premature Ventricular contraction and SvT in Recovery. Copy of this test was submitted via eBenefits and also faxed to Newnan, Georgia Intake Center.

There is a clear link between the hypertension and changes to my heart, increased heart size, enlarged left atrium, and right heart and hypertensive reaction to stress tests in 2003, 2012, and 2013. The pedal edema caused by the structural changes to the heart and hypertension has also worsened. My pedal edema diuretic (Lasix) was doubled by Doctor Chandler, after exam on 10 July 2014.

My analysis supported by medical evidence already submitted contradicts much of what Dr. Kittle states in his opinion. What facts does he have to support his opinion?

INCORRECT DATE: I was also diagnosed with hypertensive heart disease in 2003 by Dr. Ayoubi- see his tests from October-December 2003, as well as diastolic dysfunction stage I.

[X] Hypertensive heart disease

Date of diagnosis: service-connected

[X] Other heart condition, specify below

Other diagnosis #1: atrial fibrillation (resolved)

Date of diagnosis: 4/8/2013

Comment: Not correct date, PAF was first noted in January 2013 during EKG at NHP by Dr. Chandler, see his heart DBQ for 10 January 2014, AND changed to permanent Afib on 8 April 2013.

Other diagnosis #2: atrial flutter (resolved)

Date of diagnosis: 4/8/2013

2. Medical History

------------------

a. Describe the history (including onset and course) of the Veteran's heart condition(s) (brief summary):

veteran reports that he has heart disease, including cardiomegally/cardiomyopthy, CAD, structural heart disease, atrial fibrillation, atrial flutter, chf. He reports he was admitted to

Baptist Hospital ER 4/8/03.

Comment: Actual date of admission at BHC ER was 8 April 2013, not 2003.

His 10/2003 medical records report heart problems

noted less than 6 months after seperation which was on 5/9/2003. 2002

sleep apnea. 2013 CHF. No h/o MI. He had a cardiac catheterization in

2003. No stents. No bypass. In April, 2013 he had a cardiac ablation.

Prognosis is fair to good.

Comment: this is first time a VA C & P examiner has made an accurate statement on my heart problems, as noted began or noted in October 2003, less than 6 months after I came off Active Duty. I AM SERVICE CONNECTED FOR THE HEART CONDITIONS AS NOTED ABOVE. I have Sleep Apnea dating back to 2002 when complained of sleep problems and was told to “Follow the Laws of Sleep”.

How can he state my prognosis is “fair to good”, when both my cardiologists have not made a similar statement? Is this more speculation? Show me the proof!

Reviewing the medical record shows that he had a positive nuclear

Stress test in 2003 but records indicate that he had a negative

Catheterization which is the more accurate test.

Comment: not exactly true as the catheterization resolved the blockage in carotid artery which is why the procedure was done. The stenosis which was at 59% has since returned.

He had atrial fibrillation and atrial

flutter which were successfully treated and have resolved. He had congestive heart failure which was probably secondary to his atrial fibrillation and atrial flutter and his echocardiogram shows an excellent ejection fraction at the current time and no further evidence

of congestive heart failure. There is no record of any myocardial infarction.

Stress echocardiogram was negative for ischemia.

Comment: Not true. Positive in 2003 and again in 2013 at Baptist Hospital ER on 8 April 2013. And also in 2012 at Woodlands CT. Does Doctor Kittle intend to ignore the CHF symptoms, severe pedal edema that go so bad in July 2014 that my medication to treat this condition was DOUBLED and still another hypertension medication was added?

b. Do any of the Veteran's heart conditions qualify within the

generally accepted medical definition of ischemic heart disease (IHD)?

[X] Yes [ ] No

If yes, list the conditions that qualify:

Atherosclerotic cardiovascular disease

Comment: I have had CAD since 2003 tests as noted by Dr. Ayoubi and noted again by Dr. Chandler in 2012, 2013 and 2014 (on his DDBQ of 10 January 2014).

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

Buildup of cholesterol and arteries

Comment: see my numerous lab tests from 2003-2015 and also CT scan by Woodlands Medical Center in 2011 and 2012.

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):

Hyzaar, verapamil, amlodipine, furosemide, aspirin.

Comment: list is incomplete as also take pravastatin for high cholesterol. First prescribed Simvastatin in 2007 by VA for this condition and changed in 2013 after VA nurse (Linda Hixon) at xxx, noted it contraindicated the Verapamil. This is in my Health eVet records.

3. Myocardial infarction (MI)

-----------------------------

Has the Veteran had a myocardial infarction (MI)?

[ ] Yes [X] No

4. Congestive Heart Failure (CHF)

---------------------------------

Has the Veteran had congestive heart failure (CHF)?

[X] Yes [ ] No

a. Does the Veteran have chronic CHF?

[ ] Yes [X] No

Comment: not a true statement, WHERE IS THE EVIDENCE? I have evidence that proves I have chronic CHF.

Letter by Dr. Chandler on 10 January 2014 also states: “the presence of elevated right sided cardiac pressures and mild dilation increase the likelihood of clinical signs and symptoms of right heart failure which can be associated with peripheral edema.” (I have had pedal edema since 2005.)

b. Has the Veteran had any episodes of acute CHF in the past year?

[ ] Yes [X] No

Comment: I had three instances in 2013, April 8, 16 and 27. Documented by Event Monitor.

5. Arrhythmia

-------------

Has the Veteran had a cardiac arrhythmia?

[X] Yes [ ] No

Type of arrhythmia (check all that apply):

[X] Atrial fibrillation

If checked, indicate frequency:

[ ] Constant [X] Intermittent (paroxysmal)

Comment: Not correct, had PAF for one year in 2012 and then in January 2013 changed to constant Afib. Then on 8 April 2013 went into Atrial Flutter and CHF. Documented by BHC ER.

If intermittent, indicate number of episodes in the past 12 months:

[X] 0 [ ] 1-4 [ ] More than 4

Indicate how these episodes were documented (check all that apply)

[X] EKG

[X] Other, specify:

Resolved after radiofrequency ablation.

[X] Atrial flutter

If checked, indicate frequency:

[ ] Constant [X] Intermittent (paroxysmal)

If intermittent, indicate number of episodes in the past 12 months:

[X] 0 [ ] 1-4 [ ] More than 4

Indicate how these episodes were documented (check all that apply)

[X] EKG

[X] Other, specify:

Resolved after radiofrequency ablation.

6. Heart valve conditions

-------------------------

Has the Veteran had a heart valve condition?

[X] Yes [ ] No

a. Valves affected (check all that apply):

[X] Mitral

b. Describe type of valve condition for each checked valve:

Normal mitral valve without significant stenosis with mild insufficiency

Comment: not exactly true, as have backflow and heart murmur. My mitral valve is not “normal”. Define normal?

See: See VA 21-0960A-4, (heart) by Dr. Chandler on 10 January 2014, Section VI, 6C, “mild mitral regurgitation on Echo on 08/26/2013, moderate tricuspid regurgitation on Echo on 08/26/2003.”

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?

[X] Yes [ ] No

If yes, indicate the non-surgical or surgical procedures the Veteran has had for the treatment of heart conditions (check all that apply):

[X] Other surgical and/or non-surgical procedures for the treatment of a

heart condition, describe:

Radiofrequency ablation for atrial fibrillation and atrial flutter in 2013.

Indicate date of admission for treatment and treatment facility:

Navy Hospital, April 10, 2013.

Comment: incorrect, as the procedure was done at Baptist Hospital in xxx, on this date.

Indicate the condition that resulted in the need for this

procedure/treatment:

Atrial fibrillation and atrial flutter

Comment: I was admitted to BHC ER for congestive Heart Failure, build-up of fluid around heart and head problems breathing as well as Atrial Flutter. See the BHC ER report for 8 April 2013.

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

Comment: I was hospitalized via Emergency Room admission at Baptist Hospital xxx on 8 April-11 April 2013 when did cardio version, which was not successful. This is in the available records.

11. Physical exam

-----------------

a. Heart rate: 67

b. Rhythm: [X] Regular [ ] Irregular

c. Point of maximal impact: [X] Not palpable [ ] 4th intercostal space

[ ] 5th intercostal space

[ ] Other, specify:

d. Heart sounds: [X] Normal [ ] Abnormal, specify:

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+

Comment: NOT TRUE, My lower extremities swell each day even though I take two different medications to reduce pedal edema. I have submitted numerous pictures taken since 2012-to 2015 to show the swelling. It gets so bad I have fluid oozing from legs, as noted in pictures submitted via eBenefits and via PC-FAX this year. The pictures do not lie, pedal edema and CHF are still present even though taking 7 HTN medications and both loop and thiazide diuretics to reduce fluid build-up in lower extremities.

Letter by Dr. Chandler on 10 January 2014 also states: “the presence of elevated right sided cardiac pressures and mild dilation increase the likelihood of clinical signs and symptoms of right heart failure which can be associated with peripheral edema.” (I have had pedal edema since 2005.)

i. Blood pressure: 133/65

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?

[ ] Yes [X] No

Comment: what about the numerous pictures of both legs showing the pedal edema that have submitted via eBenefits and also via fax (PC-FAX) to Newnan, Ga. Intake Center? Did Dr. Kittle even look at these pictures before rendering his opinion? It appears that he did not as he did not make any comments about the pictures of my pedal edema, nor any other favorable pedal edema information from my cardiologists.

13. Diagnostic Testing

----------------------

a. Is there evidence of cardiac hypertrophy?

[ ] Yes [X] No

Comment: Incorrect statement. I have had numerous ECG that show cardiac hypertrophy beginning in 2003 to present time. The evidence is in the VBMS and some in C-file. It appears that Dr. Kittle ignored the available evidence. Did Dr. Kittle review the DBQ on my heart that was filled out by hand by Dr. Jerry Chandler, my Navy cardiologist for past 3 years, on 10 January 2014? It appears that he did not, as he would have stated YES!

See: “Diagnosis of hypertensive heart disease with concentric LVH which is directly correlated to the development of diastolic dysfunction. This in turn leads to atrial dilation that leads to an increase in pulmonary venous pressure> pulmonary artery pressure with resulting impact on right ventricular function which can lead to lower extremity edema” Doctor Chandler in statement on 4 October 2012.

b. Is there evidence of cardiac dilatation?

[X] Yes [ ] No

If yes, indicate how this condition was documented:

[ ] EKG [ ] Chest x-ray [X] Echocardiogram

Date of test: 4/6/15

Comment: actually this was noted in 2003 tests by Dr. Ayoubi and forward in tests by NHP and BHC. (2012-2015)

c. Diagnostic tests

Indicate all testing completed; provide only most recent results which

reflect the Veteran's current functional status (check all that apply):

[X] Echocardiogram Date of echocardiogram: 4/6/15

Comment: this ECG was suboptimal in view and does not meet the standard for ECG. I had the ECG repeated at Baptist Hospital on 21 April, results are drastically different!

Left ventricular ejection fraction (LVEF): 60 %

Wall motion:

[X] Normal [ ] Abnormal, describe:

Wall thickness:

[X] Normal [ ] Abnormal, describe:

[X] Coronary artery angiogram Date of angiogram: 2003

Result:

[X] Normal [ ] Abnormal, describe:

Comment: NOT TRUE! Coronary artery angiogram indicated left internal coronary artery stenosis of 40-59% in 2003 in test by Dr. Ayoubi. It appears that this test result was overlooked. The test result was NOT NORMAL!

14. METs Testing

----------------

Indicate all testing completed; provide only most recent results which

reflect the Veteran's current functional status (check all that apply):

a. [X] Exercise stress test

Date of most recent exercise stress test: 4/1/2015

Results: positive

Comment: test was stopped after 3.4 minutes when I experienced severe heart pain due to PVC and also SvT in recovery. Test results are in my c-file.

I had a NUCLEAR STRESS TEST ON 4 AND 7 MAY 2015 at the Navy Hospital Pensacola (NHP). I am still waiting on results for these test and will fax/upload them as soon as I get them.

METs level the Veteran performed, if provided: 5.6

Did the test show ischemia?

[X] Yes [ ] No

b. If an exercise stress test was not performed, provide reason:

No response provided.

Comment: My exercise stress test was stopped after 3.4 minutes due to heart pain and PVC and SvT. A nuclear stress test was performed on 5 and 7 May 2015. I do not have results as of 11 May 2015.

c. [X] Interview-based METs test

Date of interview-based METs test: 4/10/15

Symptoms during activity:

The METs level checked below reflects the lowest activity level at

which the Veteran reports any of the following symptoms attributable

to a cardiac condition (check all symptoms that the Veteran reports at the indicated METs level of activity):

[X] Dyspnea

Comment: I also had severe chest pain, documented as PVC and also some kind of SvT in recovery on stress test on 1 April 2015 at NHP. I also had trouble breathing as felt like someone squeezing my heart. Test was stopped and Nuclear stress test was conducted on 5 and 7 May 2015. I do not have results of this test as of 11 May 2015.

Results of interview-based METs test

METs level on most recent interview-based METs test:

[X] (>3-5 METs) This METs level has been found to be consistent

with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph)

Comment: There is no way I can walk 4 mph, more like 2.5 mph.

( tried this on tread mill, 4 mph is jogging and get hypertensive reaction every time I try this, see stress test on 1 April 2015.) No longer cut grass or use weed eater due to heart and hypertension. Dr. MacDonald and Dr. Chandler as well as Dr. Kittle have all stated that my METS level is 3-5 METS. I experienced severe chest pain when my METS level was 5.6 on the 1 April 2015 exercise stress test at NHP. It appears that anything above 5 METS is dangerous for me!

d. Has the Veteran had both an exercise stress test and an interview-based

METs test?

[ ] Yes [X] No

Comment: INCORRECT. I have had both tests, beginning in 2003, 2012, 2013, 2014, and 2015. The results of all these tests are in my medical records. Dr. Ayoubi in 2003, NHP IN 2012, 2013, 2015 and BHC in 2013, 2014 and 2015. Please see comments by Dr. MacDonald in C & P exam in 2013 and comments on DBQ (Heart) by my cardiologist, Dr. Chandler on 10 January 2014. Both stated my METS level was 3-5 inclusive. In fact Dr. Chandler warned that I was not to engage in strenuous exercise above 7 METS as very dangerous to me.

e. Is the METs level limitation provided above due solely to the heart condition(s) that the Veteran is claiming in the Diagnosis Section?

[X] Yes [ ] No

If yes, skip Section 14f.

f. What is the estimated METs level due solely to the cardiac condition(s)

listed above? (If this is different than METs reported above because of

co-morbid conditions, provide METs level and Rationale below.)

No response provided.

g. Comments, if any:

OVERALL IMPRESSION:

Normal wall thicknesses and dilated LA/RV, 4.6/3.5 cm

Normal left ventricular systolic function with 60 % LVEF

No discrete segmental wall motion abnormalities

Normal mitral valve without significant stenosis with mild insufficiency

Sclerotic aortic valve without significant stenosis or insufficiency

Comment: This is from the ECG that was not meeting the standard and suboptimal in quality at Pensacola JACC per Dr. Schang the VA cardiologist who read the test results. I had it repeated at Baptist Hospital and results were similar to ECG done on 26 August 2013 at Baptist Hospital. Compare the two ECG and then the one at JACC and note the great differences!

Normal left ventricular diastolic function

Comment: I have Diastolic Dysfunction, Stage II, so this statement is just not TRUE! Again, where is the proof? I have proof of the exact opposite:

VA 21-0960A-3, DBQ from Dr. Chandler on hypertension dated 10 January 2014 states 2A: “the patient chronic progressive long standing hypertension now requiring 4 (now 7) drugs to control c/w stage II HTN. This lead to progressive LVH and associated diastolic dysfunction. The elevated LV filling pressure leads to Type II pulmonary hypertension and RV dilatation.”

“Diagnosis of hypertensive heart disease with concentric LVH which is directly correlated to the development of diastolic dysfunction. This in turn leads to atrial dilation that leads to an increase in pulmonary venous pressure> pulmonary artery pressure with resulting impact on right ventricular function which can lead to lower extremity edema” Doctor Chandler in statement on 4 October 2012.

Increased RVSP, estimated at 39 mmHg, i.e., mild PA hypertension

No pericardial effusion or intracardiac masses or thrombi obvious

NB: This study is compared to one in our records done August 23, 2013, and

left atrial size was also increased on that study as well as RVSP

estimated at 49 mmHg.

Comment: What about the ECG that showed enlarged left atrium way back in 2003 by Dr. Ayoubi and again in 2013, 2015 by NHP and BHC?

/es/ STEVEN J SCHANG

CARDIOLOGIST

Signed: 04/06/2015

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:

cannot do fast walk. Can climb a flight of stairs but must do it slowly.

Comment: I do not climb stairs as passed out and fell on 8 April 2014 while climbing stairs at son’s house. I also passed out and fell in my driveway on 4 April 2014, as witnessed by my neighbor. I told Dr. Kittle that I had climbed stairs at NHP on 27 July 2013 and ended up in NHP ER due to chest pain- see the ER records for that date. This is after the Cardiac Ablation was done on 10 May 2013. I still had extremely high and uncontrolled hypertension and shortly after this, another drug (Norvasc) as well as Lasix was doubled to try and bring the BP down.

16. Remarks, if any

-------------------

DBQ CARDIO Heart:

MEDICAL OPINION REQUEST

TYPE OF MEDICAL OPINION REQUESTED: Aggravation of a nonservice

Connected disability by a service connected disability.

OPINION REQUESTED: Aggravation of a nonservice connected disability

by a service connected disability.

Was the Veteran's atrial fibrillation and ischemic heart disease

At least as likely as not aggravated beyond its natural progression by his/her

Service connected hypertension with pulmonary hypertension?

Discussion of above question: The above question requires that the

atrial fibrillation and ischemic heart disease exist prior to military

service and be aggravated by his hypertension. His atrial fibrillation

did not occur until 2013 and proof of ischemic heart disease until

2015, occurring long after his military service, and therefore this

does not seem to be the appropriate question. If we stay with the

above question the opinion is that his atrial fibrillation and ischemic

heart diseease were not aggravated by his hypertension and pulmonary heypertension.

Comment: the VARO is ignoring the simple fact that I was shown to have heart disease in tests done by Dr. Ayoubi beginning less than 6 months after I came off Active Duty. The question is improper and ignores this fact. My claim is that the heart disease as noted on tests less than 6 months after came off Active Duty should be considered service connected, not the opposite! Is the VARO ignoring this simple fact?

What about the email from Dr. Weisberg where he stated that my cardiac arrhythmia more than likely had its onset during this time frame due to hypertension and heart disease as evidenced by these tests in 2003 by Dr. Ayoubi?

Comment: I had proof of Ischemic heart disease, early stages in tests done in 2003 by Dr. Ayoubi.

The more appropriate question is whether the atrial fibrillation and atrial flutter are secondary to the hypertension with pulmonary hypertension.

Opinion: It is at least as likely as not that the atrial fibrillation/atrial flutter/ischemic heart disease are secondary to his hypertension and pulmonary hypertension.

Rationale: The veteran had long-standing hypertension that began

During his military service. He is service connected for hypertensive heart

disease. Hypertensive heart disease damages the muscle and electrical

system of the heart which can lead to atrial fibrillation and atrial

flutter. Hypertension also damages the arteries which causes the cholesterol to adhere and cause ischemic heart disease. It is therefore logical and in agreement with his cardiologist's opinion that the hypertensive heart disease caused his atrial fibrillation/atrial flutter and also his ischemic heart disease.

Comment:

Dr. Weisberg commented in email response to me : “ your tests in 2003 represent the effect of hypertension on your heart (enlarged left atrium and left ventricular hypertrophy) and some of the early signs of peripheral artery disease (carotid stenosis). These effects on the heart are likely what led to your atrial fibrillation and atrial flutter which as of last time I saw was still successfully ablated.” This email was received by me on 28 July 2014 and was uploaded via eBenefits and also mailed via certified mail to VARO.

Note: this statement contradicts what Dr. Kittle stated that did not have ventricular hypertrophy, when the tests in 2003 and again in 2013 showed that did have left ventricular hypertrophy.

Hypertension

Disability Benefits Questionnaire

Name of patient/Veteran: xxx

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 (hard copy paper C-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, CPRS, and CPRS remote data, for data from DOD and other

locations.

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

Date of diagnosis: 1995

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

hypertension condition (brief summary):

Veteran did not have any high blood pressure prior to his military

service. He reports that he is on pressure was noted to be high enough

in the mid 1990s to start him on Hyzaar 50?12 and Covera 120 mg while

in the reserves and became severe when he was on active duty.

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:

Hyzaar, verapamil, amlodipine, furosemide,

Comment: this is an incomplete list as does not include Aspirin (81mg) that take 2 X day and also Pravastatin that take for CAD. It appears that Dr. Kittle did not examine my most recent list of medications, or he ignored it.

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?

[ ] Yes [ ] No [X] Unknown

d. Does the Veteran have a history of a diastolic BP elevation to

predominantly 100 or more?

[X] Yes [ ] No

If yes, describe frequency and severity of diastolic BP elevation:

180/100-110.

3. Current blood pressure readings

----------------------------------

Systolic Diastolic

Blood pressure reading 1: 143 / 67 Date: 4/10/15

Blood pressure reading 2: 142 / 66 Date: 4/10/15

Blood pressure reading 3: 133 / 65 Date: 4/10/15

Comment: the third reading was 143/65, as I noted. Not sure where this different figure came from. Trestin, the VA person who took the readings did not have me stand or move or anything, just did three readings on right arm. This is not per protocol.

Average Blood Pressure Reading: 139 / 66

Comment: My AMP BP monitor which I wore AFTER this exam showed no readings in a 24 hour period less than 142 Systolic! Copy of this test was submitted via eBenefits and also PC-FAX to Newnan, Ga. Intake Center.

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

Does the Veteran's hypertension or isolated systolic hypertension impact

His or her ability to work?

[ ] Yes [X] No

6. Remarks, if any

------------------

No remarks provided.

****************************************************************************

Intestinal Conditions (other than surgical or infectious),

including irritable bowel syndrome, Crohn's disease, ulcerative

colitis and diverticulitis

Disability Benefits Questionnaire

Name of patient/Veteran: Horton, Kenneth Vernon

Indicate method used to obtain medical information to complete this

document:

[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, CPRS, and CPRS remote data, for data from DOD and other locations.

1. Diagnosis

------------

Does the Veteran now have or has he/she ever been diagnosed with an

intestinal condition (other than surgical or infectious)?

[X] Yes [ ] No

[X] Diverticulitis

Date of diagnosis: 2008

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

intestinal condition (brief summary):

Veteran did not have any gastrointestinal problems prior to joining

service. He reports that he was put on spironolactone in November 2008

and became very constipated over a two-month period. He reports that he

went to his physician and had a test done which showed that he had

diverticulitis. He was started on multiple antibiotics and was treated

for about a month. The spironolactone was discontinued. The

diverticulitis cleared up and has not caused him any problems since.

He states that he is not putting in a claim for this issue. Prognosis is

fair.

Comment: NOT TRUE. It is my intent to continue the claim for this as caused by the VA prescribed Spirolactone.

b. Is continuous medication required for control of the Veteran's

intestinal condition?

[ ] Yes [X] No

Comment: NOT TRUE, I have to take Miralax for the rest of my life due to the aggravation of my pouches in colon by the VA prescribed Spirolactone!

c. Has the Veteran had surgical treatment for an intestinal condition?

[ ] Yes [X] No

3. Signs and symptoms

---------------------

Does the Veteran have any signs or symptoms attributable to any non-surgical

non-infectious intestinal conditions?

[ ] Yes [X] No

4. Symptom episodes, attacks and exacerbations

----------------------------------------------

Does the Veteran have episodes of bowel disturbance with abdominal distress,

or exacerbations or attacks of the intestinal condition?

[ ] Yes [X] No

5. Weight loss

--------------

Does the Veteran have weight loss attributable to an intestinal condition

(other than surgical or infectious condition)?

[ ] Yes [X] No

6. Malnutrition, complications and other general health effects

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I have some other contentions as well, ED, non-allergic rhinitis, but heart and HTN are the two major contentions. The C& P doc in my recent exam opined that my ED was caused by my HTN. Been claiming this all along! SMC-K is not much, but better than 0%.

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