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Hugh Blood pressure and GI C&P Results.

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sauerkraut1977

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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
 secondary 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

Edited by Tbird
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