Medical Rationale
cribbsjm
JohnDoesclaimSpecial.docxDate: 21 September 2018
Re: {John Doe, Jr.; SS# 123-45-6789; 4 November 1926}
To whom this may concern:
My name is Dr. James B. Moses and I am a board-certified interventional cardiologist. I’m writing this statement in support of Mr. John Doe’ medical claim of which I believe directly contributed to his heart condition.
I have personally reviewed his medical history; I have also noted the circumstances and events of his military service from October 15, 1976 to July 26, 1978. I also reviewed his medical records from the West Palm Beach VA Medical Center from 2007 to 2009, leading up to his first open heart surgery. For example:
While on active duty, Mr. Doe was transported by ambulance to the hospital Homestead Air Force Base on October 22, 1977 complaining of sharp grabbing pain on the upper left side of his chest. he had an x-ray done which demonstrated no findings. he was given Mylanta and discharged back to duty.
On December 2, 1977 Mr. Doe was transported by aeromedical evacuation to Keesler Air Force Base for further evaluation for narcolepsy. A cardiovascular workup was performed which demonstrated an I/VI early systolic ejection murmur at the left sternal border.
On February 15, 1978 Mr. Doe complained of a body rash condition on his back, legs, and arms for 2 weeks or more.
On March 15, 1978 Mr. Doe again, complained of a skin rash that were on his arms legs, back, and stomach accompanied with headaches for approximately 1 month or more.
Mr. Doe has been under my care since 2010 and is currently treating. He has undergone multiple testing in the form of labs, x-rays, EKGs, echocardiograms and stress tests. Since 2010, John Doe has been diagnosed and is actively receiving treatment for hypertension, cardiomyopathy, mitral valve disorder, mitral valve regurgitation, hyperlipidemia, and recurrent chest pain.
In 2007, Mr. Doe’s medical records from West Palm Beach VA noted from his echocardiogram that he had a rheumatic mitral valve and mitral valve regurgitation. On February 18, 2009, Mr. Doe underwent mitral valve replacement for severe mitral valve regurgitation and mitral stenosis. Upon removing the original mitral valve, it was described as rheumatic in nature. During his C&P examination notes indicated that the valve was suggestive of rheumatic in nature, as noted and agreed upon by both Dr. Smells, Chief of Cardio Thoracic Surgery and Dr. Kassey a Thoracic Heart Surgeon and his assistant from the Miami VA Medical Center.
I have also reviewed his military records and found no mention of any prior heart condition. And the findings of a I/VI early systolic murmur, found by his military service doctors
In summary, given all the conditions and complaints that were noted during Mr. Doe’s military service time, I am surprised that there were not a diagnoses present for strep throat, rheumatic fever or something that would have explained the rheumatic mitral valve. The symptoms are listed below:
Chest pains heart murmur sore throat headaches
Fatigued skin rash
Therefore; It is my professional opinion that Mr. Doe’s heart condition was a direct and connected to his military service.
