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Sinusitis, Rhinitis and Other Conditions C/P exam Any Ideals what do you think I get?

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Army man 2

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Sinusitis, Rhinitis and Other Conditions C/P exam Any Ideals what do you think I get?

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:
Date of diagnosis: 2011 [X] Allergic rhinitis ICD code: Date of diagnosis:

SECTION II: Medical history Veteran is here claiming SC for sinus and rhinitis condition. He reports h/o chronic sinusitis, allergic rhinitis, while he was in the military.

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 [X] Rhinitis 

Sinusitis
-
a. Indicate the sinuses/type of sinusitis currently affected by the=16.0ptVeteran's
chronic sinusitis (check all that apply):
[ ] None [X] Maxillary [X] Frontal
[ ] Ethmoid [ ] Sphenoid [ ] Pansinusitis

 Does the Veteran currently have any findings, signs or symptoms attributable to chronic sinusitis?
[X] Yes [ ] No  

If yes, check all that apply:[ ] Chronic sinusitis detected only by imaging studies (see Diagnostic testing section)  ] Episodes of sinusitis
[ ] Near constant sinusitis tIf checked, describe frequency:[X] Headaches
 [X] Pain of affected sinus
[ ] Tenderness of affected sinus [ ] Purulent discharge
[ ] Crusting
[ ] Other For all checked conditions, describe: Left side headaches
Pain in left sided forehead and maxillary

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 tIf yes, provide the total number of non-incapacitating episodes over the past 12 months:
[X] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or more

Has the Veteran had INCAPACITATING episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months? [X] Yes [ ] No NOTE: For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician.=16.0ptIf 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 [X] 3 or more

Has the Veteran had sinus surgery? [ ] Yes [X] No tIf 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):=16.0ptIf Veteran has had radical sinus surgery, did chronic osteomyelitis follow=16.0ptthe surgery? [ ] Yes [ ] No

Has the Veteran had repeated sinus-related surgical procedures performed? [ ] Yes[X] No
2. Rhinitis
-a. Is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis? [ ] Yes [X] No
Is there complete obstruction on the left side due to rhinitis? [ ] Yes [X] No
Is there complete obstruction on the right side due to rhinitis? [ ] Yes [X] No
Is there permanent hypertrophy of the nasal turbinates? [ ] Yes [X] No
Are there nasal polyps? [ ] Yes [X] No

Does the Veteran have any of the following granulomatous conditions? [ ] Yes [X] No
If yes, check all that apply:
[ ] Granulomatous rhinitis [ ] Rhinoscleroma
[ ] Wegener's granulomatosis [ ] Lethal midline granuloma [ ] Other granulomatous infection, describe:Other pertinent physical findings, scars, complications, conditions,=16.0ptsigns
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=16.0ptsection above? [ ] Yes[X] No=16.0ptb. 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? [ ] Yes[X] No

Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages?
[ ] Yes[X] No
Does the Veteran have loss of part of the nose or other scars causing loss part of one ala? [ ] Yes[X] No
Does the Veteran have loss of part of the nose or other scars causing other obvious disfigurement?
[ ] Yes[X] No

SECTION IV: Diagnostic testing
 
a. Have imaging studies of the sinuses or other areas been performed? t[X] Yes[ ] No=[ ] Magnetic resonance imaging (
MRI) Date: Results:[X] Computed tomography (CT) Date: 2011
Results:Except left frontal sinuses opacification otherwise normal sinus series. However, sphenoid sinus cannot be evaluated due to the technique.[ ] X-rays Date:=Results: [ ] Other: Date: Has endoscopy been performed?: No
c. Has the Veteran had a biopsy of the larynx or pharynx?: No
.

Has the Veteran had pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis?: Yes   If yes, indicate results:
[ ] FEV-1 of 71 to 80% predicted [ ] FEV-1 of 56 to 70% predicted [ ] FEV-1 of 40 to 55% predicted [ ] FEV-1 less than 40% predicted Is the Flow-Volume Loop compatible with upper airway obstruction? [ ] Yes [X] No

FEV-1 % predicted: 63

Are there any other significant diagnostic test findings and/or results?: Yes= If yes, provide type of test or procedure, date and results (brief summary):
Mild-moderate restrictive lung disease

tSECTION V: Functional impact and remarks
1. Functional impact
-
Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact this or her ability to work? [ ] Yes [X] No
2. Remarks, if any: -------------------
No answer provided

RESTATEMENT OF REQUESTED OPINION:

Opinion from general remarks: Does the Veteran have a diagnosis of a sinusitis that is at least as likely as not incurred in or caused by
sinusitis, headaches symptoms during service?

Indicate type of exam for which opinion has been requested: Sinusitis condition

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
The condition claimed was at least as likely as not (50% or greate probability) incurred in or caused by the claimed in-service injury, event or
illness.

c. Rationale: Veteran's chronic sinusitis started in the Military  
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I will post my second DBQ later when I have time, so you can compare.  My first was contracted so I don't have it until I get my c-file..  I received 50% sinusitis and 0% rhinitis but the rhinitis should have been 30% (NOT pyramiding, separately ratable, multiple surgeries w/ polyps, should have been a clean kill) and, objectively, the argument could be made either way for the sinusitis, 50% or 30%.  You do need to understand though that I have near-constant sinus infections, a weakened immune system and had a multiple surgeries including a surgery which removed most of my sinus cavities completely.

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"1. Functional impact - Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact this or her ability to work? [ ] Yes [X] No"

This SCREAMS 0%, not what you want to hear, but...

 

 

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Review VA Pyramiding regs. May or may-not apply.

I recently got an increase of a 50% SA SC to 100%, because of a New Secondary issue that came back as SC Secondary to SA @ 0%. Just so happens it was listed as (1) of the "OR's" listed  in the 100% SA SC, if present.

Semper Fi

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