hypertension Dr. Ime

[marinejay]

This is an Independent Medical Opinion that i got. I would like to know what the experts think and how it can be better. I've been lurking on the board for about 9mts and was finally able to join. I would also like to get an idea of how the va might try to find ways on not connecting me.

I am opening a claim for an increase for my left shoulder and a new claim for right shoulder secondary. Also i am opening a claim for my right knee pain due to service. He also diagnosed me with Hypertension due to my medical records and after service records. I just need your opinion an my chances for service connection for:

R-shoulder (secondary to Left)

L-Shoulder (Increase eval)

Hypertension (new diagnosis due to records)

Sciatica (diagnosis due to records)

Thanks

Jay

INDEPENDENT MEDICAL EVALUATION

To: VA

Re: Patient (myself)

C# (va #)

In 1998

Out 2 Nov 2002

I have reviewed this patient’s medical records for the purpose of making a medical opinion concerning his knees and back as it relates to his service time. He is currently rated 10% for his right ankle and left shoulder, respectively, as of 11/3/2002. In order to make my evaluation, I have carefully reviewed the following information:

Service Medical Records;

Post service Medical records;

Imaging reports;

Patients lay statements dated 2006 (attached).

Other medical opinions;

Medical literature review

OPINIONS:

See below.

Expertise-Special Knowledge:

I have special knowledge in the area of spine disease as I am double board certified sub specialist, am a Senior Member of the American Society of Neuro-Radiology (ASNR) and am an attending level school of medicine associate professor. I have completed a three fellowship in neuroradiology (2 years of which was at the NIH), which is a field, which specializes in spine/orthopedic medical problems. I have performed and/or interpreted plain x-rays, CT scans, nuclear medicine scans, and MRI (basic and research/experimental) scans on thousands of patients with this patient’s type of disorder/s and I have correlated my findings with the clinical record. This patient’s case includes several of the above imaging studies. (Please see my attached C.V.) .

Competency:

I am highly competent to make the above opinion/s because I am a licensed physician with extensive specialized training and experience in the areas of interest (as above described), have performed several hundred VA IMEs, am familiar with the VA rating schedule as published in the CFRs/U.S. Codes, have reviewed the medical record, have reviewed the patients lay statements, have spoken to the patient on the phone, have referenced current applicable publications (explained how they apply to this patient’s medical data set), have examined the patient by way of reviewing his pivotal imaging study reports, have reviewed pertinent positive and negative medical data and have reviewed/reference other physicians professional medical opinions1.

Facts:

Patient entered service fit for duty.

Patient has hypertension of 138/79 as of July 13, 2002.

July 13, 2002 “Patient complained of low back pain for a month, low back injury two years ago…increase pain in lower back…”signed, Dr. Step*****.

August 9, 2002 “…low back pain….decrease sensation L5-S1 on the right…decrease strength rate right great toe … assessment/plan rule out herniated L5-S1 on the right…MRI scheduled…” signed, Dr. Step****.

October 11, 2002 “ …patient has history of low back pain today…increase pain in low back … increase pain …positive low back pain when straight leg raises about 3 degrees… “ signed, Dr. Ras*****.

October 29, 2002 “…one to two year history of low back pain, usually wakes up with pain…assessment mild low back pain with paraspinal muscle spasms…” signed, Dr. unreadable

August 16, 2005 “…patient presents with low back pain…” signed, Lun*****, Physical Therapist.

August 16, 2005 “…patient originally injured his back as result of his service ….patient gets pain with bending forward and arching back….tingling shooting down front of thighs with certain movements especially arching spine…” signed, Lun****.

October 13, 2005 “…patient reports low back pain 3 to 4 out of 10, upper back 0/10…” signed, Judith.

October 12, 2005 “…excessive ….chronic low back pain and right lower extremity paresthesias… point tender midline S1… and right side sciatic notch…lower extremity motor right hamstrings 4/5, right extensor hallius longus 3/5… sensation 4/5 right L5 distribution…”signed, Dr. Fu.

October 12, 2005 “…chronic low back pain with some radicular pain…complains of electric shocks…running down both legs bilaterally, previous MRI does show bilateral foraminal narrowing at NL4-5…” signed, Dr. May***.

Discussion:

It is clear this patient has had a severe back injury in service. It is currently not rated for this back injury but he has sciatica with measured muscle strength 4/5 in both the lower extremities[/b].(i think the va may try to b.s me on this even though it was diagnosed based on miltary and va records) It is known that spine injuries early in life precipitate and/or accelerate the onset of the degenerative process of the spine, Turek, beginning at page 1512 (and elsewhere):

As a result, the facets become sclerosed, and the same changes are observed in the notches. The facet articulations themselves develop degenerative changes, including narrowing of the joint space, loss of articular cartilage, scelrosis, irregularity, and osteophyte formation. These changes take place over a number of years.

Anything that suddenly or continually increases the superincumbent pressure stresses, will eventually cause the posterior fibers of the annulus to give way [producing a ruptured intervertebral disc]...

The most common history is that of severe low back pain coming immediately after or within a few hours of an injury. The pain is associated with muscle spasms and flattening of the lumbar area. The acute attack subsides within a few days. Many such attacks are the rule, each one coming on with a lesser amount of trauma...The course is essentially repeated acute strains of the lumbosacral junction.

It is well known that the resultant chronic ligament laxity and spine instability leads to degenerative arthritis as one author states the following:

“...At the onset, tearing of ligaments and subluxation are manifest by local symptoms of low back pain accentuated by the motion which stretches the ligaments…Eventually, symptoms of localized degenerative arthritis are superimposed…” (Turik page 853)

It is my opinion that this patient current spine problem is the result of his service time spine injuries

For the following reasons:

He entered fit for duty.

He had a spine injury in service.

He had a 1-2 year history of back pain, associated with muscle spasms and decreased strength, while in service as is documented in his medical record by my physician colleagues.

The literature supports an association between early in life spine injuries and the development of advanced degenerative arthritis.

The patient has advanced degenerative arthritis without another more plausible medical etiology.

It is also clear that this patient has had a chronically injured right knee, which he initial injured in service on August 30, 2002 “complained of left knee …right ankle pain chronic worsened in the last two days… left knee pain secondary trauma …”signed Dr. Tham*****.

This patient’s knee is still problematic and he should therefore be service connected for it since his record does not contain a more likely etiology.

He had hypertension while in service based on my diagnosis in accordance with the following definition of Cecil (page 253)

“ Diastolic Blood Pressure 90-104 mmhg Mild hypertension

Systolic Blood Pressure 140-159 Borderline isolated systolic hypertension

Systolic Blood Pressure > 160 Isolated systolic hypertension”

Long standing hypertension is a well known cause of cardiac disease and this disease can be asymptomatic “ …for the first 15-20 years even as it progressively damages the cardiovascular system…” (Braumwald page 807).

It is my opinion that he should be assigned a medical diagnostic rating for his hypertension, which clearly began during service time.

It is also my opinion that his rating of 10% for his left shoulder is incorrect as he has a left shoulder rotator cuff injury which according to recent C and P exam by Dr. Gillick is causes him to awaken at night, have numbness/pain at night, limit his arm motion, have pain with overhead work. He should be assigned at least 20% for this problem.

He also now has new right shoulder pain according to lay statements, which has been diagnosed as supraspinatous tendenitis. He gets tingling and numbness in his right arm associated with a limited range of motion and grinding. This is likely a result if overuse of this arm in compensation for his service connected left arm as his record do not show another antecedent injury. It is my opinion that he should be assigned a medical diagnostic rating for his right shoulder due to secondary overuse resulting from his service connected limited use of his left shoulder.

It is medically plausible that he also injured his neck during his service time accident however his service records do not contain corroborating data and Dr. Gillick feels that this problem is due to an accident after discharge. I am uncertain as to the cause of his current neck pathology and would review any new medical documentation if available. X-rays at the time of the post service accident would be useful as an antecedent old c-spine injury might be visible and this finding would likely not be due toe his acute post service injury.

Respectfully submitted,

He pretty much told then i should be service connected, but as always the va like to play games. Thanks for the help

[Guest jangrin]

Is hypertension a secondary condition of diabetes? This diabetes thing seems to be a can of worms. Except for cancer the DMII is probably the worst thing that can happen to you from AO exposure since there are so many secondary conditions from blindess to heart disease.

John999,

Hypertension is a secondary condition to DMII. In the claim we filed, we filed for this as secondary. Hopefully we will be hearing something soon. We got a "we are working on your claim" letter from the new VARO in Waco. So with any luck at all we will find out if they SC to the DMII.

Jangrin