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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
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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