Sinusitis C&P

[ShuMan]

Team, 

I'm thinking this is a 0%, What do you think?

-Thank You!!

 

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Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,

Disability Benefits Questionnaire

========================================================

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) p

rocess 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 reviewed?

[ ] Yes[X] No

If no, check all records reviewed:

[X] Military service treatment records

[X] Veterans Health Administration medical records (VA treatment

records)

========================================================

 

SECTION I: Diagnosis:

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

Does the Veteran now have or has he/she ever been diagnosed with a sinus,

nose, throat, larynx, or pharynx condition? (This is the condition the

Veteran is claiming or for which an exam has been requested)

[X] Yes [ ] No

[X] Chronic sinusitis ICD code: J32.2 Date of diagnosis: 2015

SECTION II: Medical history

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

The Veteran reports intermittent symptoms of URI and sinusitis while in

service (so noted in STR's). He denies pre-service episodes. He has

been

evaluated at the VA and treated. He reports several episodes per year that

require antibiotic treatment.

SECTION III: Nose, throat, larynx or pharynx conditions

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

Does the Veteran have any of the following nose, throat, larynx or pharynx

conditions?

[X] Yes [ ] No

[X] Sinusitis

1. Sinusitis

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

a. Indicate the sinuses/type of sinusitis currently affected by the

Veteran's

chronic sinusitis (check all that apply):

[ ] None [ ] Maxillary [ ] Frontal

[X] Ethmoid [ ] Sphenoid [ ] Pansinusitis

b. Does the Veteran currently have any findings, signs or symptoms

attributable to chronic sinusitis?

[ ] Yes [X] No

If yes, check all that apply:

[ ] Chronic sinusitis detected only by imaging studies (see Diagnostic

testing section)

[ ] Episodes of sinusitis

[ ] Near constant sinusitis

If checked, describe frequency:

[ ] Headaches

[ ] Pain of affected sinus

[ ] Tenderness of affected sinus

[ ] Purulent discharge

[ ] Crusting

========================================================

 [ ] Other

For all checked conditions, describe:

c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis

characterized

by headaches, pain and purulent discharge or crusting in the past 12

months?

[X] Yes [ ] No

If yes, provide the total number of non-incapacitating episodes over the

past 12 months:

[ ] 1 [X] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or more

d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring

prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months?

[ ] Yes [ ] No

NOTE: For VA purposes, an incapacitating episode of sinusitis means one

that requires bed rest and treatment prescribed by a physician.

If yes, provide the total number of incapacitating episodes of sinusitis

requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12

months:

[ ] 1 [ ] 2 [ ] 3 or more

e. Has the Veteran had sinus surgery?

[ ] Yes [ ] No

If yes, specify type of surgery:

[ ] Radical (open sinus surgery) [ ] Endoscopic [ ] Other:

Type of procedure, sinuses operated on and side(s):

Date(s) of surgery (if repeated sinus surgery, provide all dates of

surgery):

If Veteran has had radical sinus surgery, did chronic osteomyelitis

follow

the surgery?

[ ] Yes [ ] No

f. Has the Veteran had repeated sinus-related surgical procedures performed?

[ ] Yes[ ] No

6. Other pertinent physical findings, scars, 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? : No answer provided

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?: No answer provided

c. Does the Veteran have loss of part of the nose or other scars of the nose

exposing both nasal passages?: No answer provided

d. Does the Veteran have loss of part of the nose or other scars causing

loss

of part of one ala?: No answer provided

e. Does the Veteran have loss of part of the nose or other scars causing

other obvious disfigurement?: No answer provided

SECTION IV: Diagnostic testing

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

a. Have imaging studies of the sinuses or other areas been performed?

No answer provided

b. Has endoscopy been performed?

No answer provided

c. Has the Veteran had a biopsy of the larynx or pharynx?

No answer provided

d. Has the Veteran had pulmonary function testing to assess for upper airway

obstruction due to laryngeal stenosis?

No answer provided

e. Are there any other significant diagnostic test findings and/or results?

No answer provided

SECTION V: Functional impact and remarks

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

1. Functional impact

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

Does the Veteran's sinus, nose, throat, larynx or pharynx condition

impact

his or her ability to work?

No answer provided

2. Remarks, if any:

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

========================================================

VBMS P. 1 dated 07/02/2015 STR's P. 4-5 Sinusitis.

STR's P. 4/7 pseudoephedrine RX for ALLERGY symptoms.

STR's dated 05/26/2005 P. 4-5/93 noted 6 simultaneous diagnosis: URI,

allergic rhinitis, viral syndrome, sinusitis, bronchitis and acute

bronchitis.

Rhinitis noted on STR's P 58/93. Being treated with medications for

allergies

and nasal congestion, however in the past medical history of 04/07/2009 NO

allergy or hayfever was entered in the note

[Reddit]

No, you have an honest chance with this.  Just remember to answer the questions right, and described everything that happens when your sinus flairs up.  Va examiner should have request an x-rays.

[Andyman73]

Reddit,

Thanks for your input,  again, Shuman, I appreciate you posting this thread about sinusitis.  I do suffer, and have while on AD.  If not for you I probably would still be in the dark about filing a claim for that.  I wish you complete success with your sinus claim.

Semper Fi.

Andyman

[ShuMan]

Reddit,

Good thinking on the DBQ, I did that for my back and migraines. I have some extra evidence and will fight this one. What should be the next step when they come back with a SC 0%?

Andyman73,

Good luck Brother!

[Vync]

Shuman and Vync,

Forgive me, I know it's not my thread, but this is same topic, and I don't want to forget that I saw this topic...cuz I will.

I noticed that the chart says 6 or more non-incapacitating episodes per year.  I have 9-12 episodes per year, and mostly treat with otc meds.  I do have a few strs where antibiotics were prescribed.  Do I have an honest chance with this?  Or is this something that needs to be tied in with my sleep issues, and such?

Andyman,
The 30% rating for "more than six non-incapacitating episodes per year of sinusitis" needs to be "characterized by headaches, pain, and purulent discharge or crusting." If you see a doc for them, you might consider not taking the OTC meds before you go to the doc. It would be better to have the actual symptoms on record, not the reduced symptoms after you take OTC meds. Also, keep a "sinusitis diary" which describes when it started, symptoms, what you took, saw doc, duration, etc... I did this for migraines and it was helpful.

[Vync]

Reddit,

Good thinking on the DBQ, I did that for my back and migraines. I have some extra evidence and will fight this one. What should be the next step when they come back with a SC 0%?

Andyman73,

Good luck Brother!

Reddit will probably answer separately, but if they come back with 0%, collect your evidence and (preferable) a strong IMO in your favor, and file a reconsideration. The raters are supposed to take another look. It is not an appeal, but I believe you have a year to file a formal appeal. If they don't approve you, then make sure you file an appeal/NOD before your time runs out. This will preserve your original effective date and any retro you might receive for initial or an increased combined rating. Read the documentation they send you if you are not satisfied with their decision.

[ShuMan]

Thanks Vync,

I just started the process of gathering my military health records. Once I have those, I'll combine those with my VA records and go search for an IMO.