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Hugh Blood pressure and GI C&P Results.
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sauerkraut1977
Hi all. Just got my exam result for Hugh Blood pressure and Gastero GI. Need help interperating these results as I have never know how SC Works for these. Thank you all on advance and I apperciate your Assistance.
LOCAL TITLE: COMP & PEN GENERAL MEDICAL EXAM
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: MAY 09, 2017@08:30 ENTRY DATE: MAY 15, 2017@10:33:59
AUTHOR: AZMABALANI,GITI E EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Hypertension
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
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: 03/2017
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
hypertension condition (brief summary):
Veteran reports diagnosis of high BP since March and taking
medication.
He denies stroke, hypertensive emergency.
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 10mg Daily
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 [X] No [ ] Unknown
Reading 1: 148 / 100 Date: 03/08/2017
Reading 1: 119 / 68 Date: 3/28/2017
Reading 1: 133 / 94 Date: 05/08/2017
d. Does the Veteran have a history of a diastolic BP elevation to
predominantly 100 or more?
No response provided.
3. Current blood pressure readings
----------------------------------
Systolic Diastolic
Blood pressure reading 1: 133 / 94 Date: 5/8/2017
Average Blood Pressure Reading: Calculating / Calculating
4. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
-----------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to the conditions
listed in the Diagnosis Section above?
[ ] Yes [X] No
b. 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
c. Comments, if any:
No response provided
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
------------------
No remarks provided.
****************************************************************************
Esophageal Conditions
(Including gastroesophageal reflux disease (GERD), hiatal hernia
and other esophageal disorders)
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
Diagnosis
---------
Does the Veteran now have or has he/she ever been diagnosed with an
esophageal condition? Yes
Gastroesophageal reflux disease (GERD)
ICD code: Date of diagnosis: 2017
Medical history
---------------
Description of the history (including onset and course) of the
Veteran's
esophageal conditions: Veteran was prescribed PPI for report of acid reflux
and chest discomfort in 2017.
Review of STRs shows several occasion of nausea nd gastroenteritis.
No H-Pylori test in records.
History of alcohol dependency
Does the Veteran's treatment plan include taking continuous medication
for
the diagnosed condition? Yes
Medications used for the diagnosed condition: Prilosec 40mg daily
Signs and symptoms
------------------
Does the Veteran have any of the following signs or symptoms due to any
esophageal conditions (including GERD)? Yes
Sign and Symptoms:
Reflux
Pain
Substernal
Shoulder
Sleep disturbance caused by esophageal reflux
Frequency of symptom recurrence per year: 4 or more
Average duration of episodes of symptoms: Less than 1 day
Nausea
Frequency of episodes of nausea per year: 4 or more
Average duration of episodes of nausea: Less than 1 day
Esophageal stricture, spasm and diverticula
-------------------------------------------
Does the Veteran have an esophageal stricture, spasm of esophagus
(cardiospasm or achalasia), or an acquired diverticulum of the esophagus? No
Other pertinent physical findings, complications, conditions, signs, symptoms
and
scars
-----------------------------------------------------------------------------
Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above? No
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? No
Diagnostic Testing
------------------
Have diagnostic imaging studies or other diagnostic procedures been
performed? Yes
Diagnostic Testing Preformed:
Esophagram (barium swallow) Date: Results: ordered
Has laboratory testing been performed? Yes
CBC Date of test: 03/28/2017
Hemoglobin: 14.3
Hematocrit: 41.9
White blood cell count: 9.2
Platelets: 375,000
Helicobacter pylori Date of test: 5/9/2017
Results: NEGATIVE
Are there any other significant diagnostic test findings and/or results? No
Functional impact
-----------------
Do any of the Veteran's esophageal conditions i
mpact on his or her ability to
work? No
Remarks, if any: No response provided
-----------------
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
MEDICAL OPINION SUMMARY
-----------------------
MEDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.
OPINION REQUESTED: Secondary Service Connection.
Is the Veteran's Gastrointestinal problems at least as likely as not (50
percent or greater probability) proximately due to or the result of
Unspecified anxiety disorder with features of obsessive compulsive disorder
and other trauma related disorder (also claimed as posttraumatic stress
disorder)?
Rationale must be provided in the appropriate section.
**OPINION:
It is at least as likley as not that the veteran's Acid reflux is
related to
Unspecified anxiety disorder with features of obsessive compulsive disorder
and other trauma related disorder (also claimed as posttraumatic stress
disorder).
-Review of medical literature supports a close correlation between anxiety
and symptoms of acid reflux.
" Anxiety and depression increase GERD-related symptoms reported in
population-based studies . Thus, it has been proposed that patients who did
not respond to PPI therapy are more likely to have psychosocial comorbidity
than those who were successfully treated with a PPI"
/es/ GITI E AZMABALANI, D.O.
Staff Physician, Compensation & Pension
Signed: 05/15/2017 10:34
Date/Time: 09 May 2017 @ 0830
Note Title: COMP & PEN GENERAL MEDICAL EXAM
LOCAL TITLE: COMP & PEN GENERAL MEDICAL EXAM
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: MAY 09, 2017@08:30 ENTRY DATE: MAY 15, 2017@10:30:14
AUTHOR: AZMABALANI,GITI E EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran:
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
MEDICAL OPINION SUMMARY
-----------------------
EDICAL OPINION REQUEST
TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.
OPINION REQUESTED: Secondary Service Connection.
Is the Veteran's Hypertension at least as likely as not (50 percent or
greater probability) proximately due to or the result of Unspecified anxiety
disorder with features of obsessive compulsive disorder and other trauma
related disorder (also claimed as posttraumatic stress disorder)?
OPINION:
It is less likley as not that the veteran's HTN diagnosed at age 39 is
related to or the result of Unspecified anxiety disorder with features of
obsessive compulsive disorder and other trauma related disorder (also
claimed
as posttraumatic stress disorder).
* Veteran has stage one HTN based on VA PCP findings of two occasions of
diastolic BP elevation of 90-100 from 3/2017 to 5/2017. Anxiety could cause
Edited by Tbirdsecondary HTN but the HTN is paroxysmal, abrupt elevation of blood pressure
(which can be greater than 200/110 mmHg). This veteran does not have any
report of paroxysmal elevation of BP.
Secondary causes of HTN should be performed only in patients with an unusual
presentation of hypertension (new onset at an especially young or especially
old age, presentation with stage 2 hypertension, abrupt onset of
hypertension
in a patient with previously normal blood pressure, resistant hypertension)
or in those with a clinical clue for a specific cause of hypertension, such
as an abdominal bruit (suggestive of renovascular hypertension) or low serum
potassium (suggestive of primary aldosteronism). This veteran does not have
any of the above indications.
/es/ GITI E AZMABALANI, D.O.
Staff Physician, Compensation & Pension
Removed Personal Identification Information
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