Here is my C& P Exam results for Fibromyalgia, Chronic Bronchitis & Chronic Sinusitis: I put in a new claim for chronic fatigue/malaise. I put in for an increase based upon increased shortness of breath for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War) currently rated at 0%. I put in new claims for chronic sinusitis (related to: Environmental Hazard in Gulf War) (New), chronic bronchitis (related to: Environmental Hazard in Gulf War) (New).
What does all this mean as far as service connection/possible percentages?
I am currently rated at 90% total: 70 % for eye condition bilateral CRVO (related to: Environmental Hazard in Gulf War), macular edema secondary to Bilateral CRVO (related to: Environmental Hazard in Gulf War); 50 % for post traumatic stress disorder (Non-Combat) with unspecified depressive disorder;10% for tinnitus; and 0% for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War).
Two other new claims were not addressed at this C & P exam. Dont know why???? Trying to get to 100% combined disability. Any feedback would be appreciated. Sorry for long post. Did not know how to hide info, if in an attachment. Feel free to move this post, if in wrong section.
LOCAL TITLE: C&P MD NOTE
STANDARD TITLE: PHYSICIAN NOTE
DATE OF NOTE: MAR 07, 2018@12:30 ENTRY DATE: MAR 07, 2018@14:02:03
AUTHOR: XXXXXXXXXXX EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Gulf War General Medical Examination
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Name of patient/Veteran: XXXXXXXXXXXXXXXXXX
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
2. Medical History
------------------
a. No symptoms, abnormal findings or complaints: No answer provided
b. Skin and scars: No answer provided
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 38 of 139
c. Hematologic/lymphatic: No answer provided
d. Eye: No answer provided
e. Hearing loss, tinnitus and ear: No answer provided
f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other
Conditions of the Nose, Throat, Larynx and Pharynx
g. Breast: No answer provided
h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep
apnea)
i. Cardiovascular: No answer provided
j. Digestive and abdominal wall: No answer provided
k. Kidney and urinary tract: No answer provided
l. Reproductive: No answer provided
m. Musculoskeletal: No answer provided
n. Endocrine: No answer provided
o. Neurologic: Fibromyalgia
p. Psychiatric: No answer provided
q. Infectious disease, immune disorder or nutritional deficiency: No
answer
provided
r. Miscellaneous conditions: No answer provided
3. Diagnosed illnesses with no etiology
---------------------------------------
From the conditions identified and for which Questionnaires were completed,
are there any diagnosed illnesses for which no etiology was established?
[ ] Yes [X] No
4. Additional signs and/or symptoms that may represent an "undiagnosed
illness" or "diagnosed medically unexplained chronic
multisymptom illness"
Does the Veteran report any additional signs and/or symptoms not addressed
through completion of DBQs identified in the above sections?
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 39 of 139
[ ] Yes [X] No
5. Physical Exam
----------------
Normal PE, except as noted on additional Questionnaires included as part of
this
report
6. Functional impact of additional signs and/or symptoms that may represent
an "undiagnosed illness" or "diagnosed medically
unexplained chronic
multisymptom illness"
If yes, describe the impact of each additional sign and/or symptom that
impacts
his or her ability to work, providing one or more examples: See
individual
DBQS
7. Remarks, if any:
-------------------
No answer provided
****************************************************************************
Fibromyalgia
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX
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
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 40 of 139
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
fibromyalgia? (This is the condition the Veteran is claiming or for which an
exam has been requested)
[X] Yes [ ] No
[X] Fibromyalgia
ICD code: M79.7
Date of diagnosis: 1991
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
fibromyalgia condition:
He reports of generalized and wide spread musculoskeletal pain with
weakness, stiffness, chronic tiredness as well fatigue, multiple
joints and body pain including lower back, mid back, upper back in
between scapula, neck area, both hip, both pelvis, both thigh area,
both knee joints, both ankle area, both shoulder, both wrists, both
elbow area as well as both foot and hand area, while he was while he
was in Gulf countries in 1991. His condition has been getting worse
since then.
He also reports of difficulty to fall in sleep and maintain sleep.
He reports of headaches, and frequency of headaches 2 to 3 times in a
month and it lasts for 8 to 12 hours. He reports of band like
sensation of his head during headaches.
b. Is continuous medication required for control of fibromyalgia symptoms?
[X] Yes [ ] No
If yes, list only those medications required for the Veteran's
fibromyalgia condition:
OTC Aleeve PRN
c. Is the Veteran currently undergoing treatment for this condition?
[ ] Yes [X] No
d. Are the Veteran's fibromyalgia symptoms refractory to therapy?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 41 of 139
[ ] Yes [X] No
3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to fibromyalgia?
[X] Yes [ ] No
a. Findings, signs and symptoms (check all that apply):
[X] Widespread musculoskeletal pain
[X] Stiffness
[X] Muscle weakness
If checked, describe:
See my history part
[X] Fatigue
[X] Sleep disturbances
[X] Paresthesias
[X] Headache
[X] Depression
[X] Anxiety
b. Frequency of fibromyalgia symptoms (check all that apply):
[X] Episodic with exacerbations
[X] Present more than one-third of the time
c. Does the Veteran have tender points (trigger points) for pain present?
[X] Yes [ ] No
[X] All bilaterally
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 any 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
5. Diagnostic testing
---------------------
Are there any significant diagnostic test findings and/or results?
[ ] Yes [X] No
XXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 42 of 139
6. Functional impact
---------------------
Does the Veteran&apos
;s fibromyalgia impact his or her ability to work?
[ ] Yes [X] No
7. Remarks, if any:
-------------------
Fibromyalgia: I reviewed his STR and he had no issue regarding his
fibromyalgia condition before deployment. As per history from the
Veteran,
he developed all the signs and symptoms of fibromyalgia symptoms while
he
was in Gulf countries.
As per CPRS, his CBC, BMP, LFT, UA and chest x-ray were negative. His HIV
test, and hep C and hep B and ESR were negative.
So his Fibromyalgia condition is at least as likely as not an
undiagnosed
illness due VA statutes and regulations provide for service connecting
certain chronic disability patterns based on exposure to environmental
hazards experienced during military service in Southwest Asia. The
environmental hazards may have included: exposure to smoke and
particles
from oil well fires; exposure to pesticides and insecticides; exposure
to
indigenous infectious diseases; exposure to solvent and fuel fumes;
ingestion of pyridostigmine bromides tablets, as a nerve gas antidote;
the combined effect of multiple vaccines administered upon deployment;
and inhalation of ultra fine-grain san particles. In addition, there
may
have been exposure to smoke and particles from military installation
"burn pit" fires that incinerated a wide range of toxic waste
materials.
Fibromyalgia is recognized as an undiagnosed illness. VA recognizes this
is one of the presumptive diseases related to GULF War Exposure.
Therefore, it does not need medical opinion.
****************************************************************************
Respiratory Conditions
(Other Than Tuberculosis and Sleep Apnea)
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 43 of 139
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
SECTION I: DIAGNOSES
--------------------
Does the Veteran now have or has he/she ever been diagnosed with a
respiratory condition? (This is the condition the Veteran is claiming or for
which an exam has been requested): Yes
[X] Chronic bronchitis
ICD code: J42 Date of diagnosis: SC
SECTION II: MEDICAL HISTORY
---------------------------
Describe the history (including onset and course) of the Veteran's
respiratory condition (brief summary): The Veteran reports that he developed
chronic cough and shortness of breath due to due to exposure to toxic fumes
due to burn pit and other inorganic and organic environmental hazardous
exposure while he was in Gulf countries in 1991 and his condition has been
getting worse .
Does the Veteran's respiratory condition require the use of oral or
parenteral corticosteroid medications? No
Does the Veteran's respiratory condition require the use of inhaled
medications? Yes
Check all that apply:
[X] Inhalational bronchodilator therapy
Indicate frequency: Daily
Does the Veteran's respiratory condition require the use of oral
bronchodilators? No
XXXXXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 44 of 139
Does the Veteran's respiratory condition require the use of antibiotics?
No
response provided
Does the Veteran require outpatient oxygen therapy for his or her
respiratory
condition? No
SECTION III: Pulmonary conditions
---------------------------------
Does the Veteran have any of the following pulmonary conditions? No
Other pertinent physical findings, scars, 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
Comments, if any: No response provided
SECTION IV: Diagnostic testing
------------------------------
Have imaging studies or procedures been performed? Yes
Has pulmonary function testing (PFT) been performed? Yes
Do PFT results reported below accurately reflect the Veteran's
current
pulmonary function? No
PFT results
Date: 09/02/2016
Which test result most accurately reflects the Veteran's level of
disability
(based on the condition that is being evaluated for this report)? FEV-1%
predicted
Does the Veteran have multiple respiratory conditions? No
Has exercise capacity testing been performed? No
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 45 of 139
Are there any other significant diagnostic test findings and/or results? No
SECTION V: Functional impact and remarks
----------------------------------------
1. Functional impact
--------------------
Does the Veteran's respiratory condition impact his or her ability to
work?
No
2. Remarks, if any:
-------------------
Chronic bronchitis: As per history from the Veteran, the developed
chronic
cough and shortness of breath due to due to exposure to toxic fumes due
to
burn pit and other inorganic and organic environmental hazardous exposure
while he was in Gulf.
So, his condition is at least as likely as not a diagnosable but
medically unexplained chronic multisymptom illness of unknown etiology
due
to VA statutes and regulations provide for service connecting certain
chronic disability patterns based on exposure to environmental hazards
experienced during military service in Southwest Asia. The environmental
hazards may have included: exposure to smoke and particles from oil well
fires; exposure to pesticides and insecticides; exposure to indigenous
infectious diseases; exposure to solvent and fuel fumes; ingestion of
pyridostigmine bromide tablets, as a nerve gas antidote; the combined
effect of multiple vaccines administered upon deployment; and inhalation
of ultra fine-grain sand particles. In addition, there may have been
exposure to smoke and particles from military installation "burn
pit"
fires that incinerated a wide range of toxic waste materials.
Chronic bronchitis is a diagnosable but medically unexplained chronic
multisymptom illness of unknown etiology. VA recognizes this is one of
the
presumptive diseases related to GULF War Exposure. Therefore, it does
not
need medical opinion.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
****************************************************************************
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 46 of 139
Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
Larynx and Pharynx
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXX
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
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 Date of diagnosis: 1991
SECTION II: Medical history
---------------------------
The Veteran reports that he developed sinus congestion, runny nose due to
exposure to toxic fumes due to burn pit and other inorganic and organic
environmental hazardous exposure while he was in Gulf countries back in
1991.
His condition has been getting worse.
SECTION III: Nose, throat, larynx or pharynx conditions
-------------------------------------------------------
Does the Veteran have any of the following nose, throat, larynx or pharynx
conditions?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 47 of 139
[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 [X] Maxillary [X] Frontal
[X] Ethmoid [ ] Sphenoid [ ] Pansinusitis
b. 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)
[X] Episodes of sinusitis
[ ] Near constant sinusitis
If checked, describe frequency:
[X] Headaches
[X] Pain of affected sinus
[X] Tenderness of affected sinus
[X] 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?
[ ] Yes [X] No
If yes, provide the total number of non-incapacitating episodes over the
past 12 months:
[ ] 1 [ ] 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 [X] 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
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 48 of 139
months:
[ ] 1 [ ] 2 [ ] 3 or more
e. Has the Veteran had sinus surgery?
[ ] Yes [X] 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[X] No
6. 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 answer provided
d. Does the Veteran have loss of part of the nose or other scars of the nose
exposing both nasal passages?: No answer provided
e. Does the Veteran have loss of part of the nose or other scars causing
loss
of part of one ala?: No answer provided
f. 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?
[ ] Yes[X] No
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 49 of 139
b. Has endoscopy been performed?: No
c. Has the Veteran had a biopsy of the larynx or pharynx?: No
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?
[ ] Yes [X] No
2. Remarks, if any:
-------------------
Chronic sinusitis : As per history from the Veteran, he developed sinus
congestion, runny nose due to exposure to toxic fumes due to burn pit and
other inorganic and organic environmental hazardous exposure.
So, his condition is at least as likely as not a diagnosable but medically
unexplained chronic multisymptom illness of unknown etiology due to VA
statutes and regulations provide for service connecting certain chronic
disability patterns based on exposure to environmental hazards experienced
during military service in Southwest Asia. The environmental hazards may
have included: exposure to smoke and particles from oil well fires;
exposure
to pesticides and insecticides; exposure to indigenous infectious diseases;
exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide
tablets, as a nerve gas antidote; the combined effect of multiple vaccines
administered upon deployment; and inhalation of ultra fine-grain sand
particles. In addition, there may have been exposure to smoke and particles
from military installation "burn pit" fires that incinerated a wide
range of
toxic waste materials.
Chronic sinusitis is a diagnosable but medically unexplained chronic
multisymptom illness of unknown etiology. VA recognizes this is one of the
presumptive diseases related to GULF War Exposure. Therefore, it does not
need medical opinion.
*****************************************************************
XXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 50 of 139
The Veteran has no question and concern about my examination. He
understands
me well.
Question
atd1972
Here is my C& P Exam results for Fibromyalgia, Chronic Bronchitis & Chronic Sinusitis: I put in a new claim for chronic fatigue/malaise. I put in for an increase based upon increased shortness of breath for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War) currently rated at 0%. I put in new claims for chronic sinusitis (related to: Environmental Hazard in Gulf War) (New), chronic bronchitis (related to: Environmental Hazard in Gulf War) (New).
What does all this mean as far as service connection/possible percentages?
I am currently rated at 90% total: 70 % for eye condition bilateral CRVO (related to: Environmental Hazard in Gulf War), macular edema secondary to Bilateral CRVO (related to: Environmental Hazard in Gulf War); 50 % for post traumatic stress disorder (Non-Combat) with unspecified depressive disorder;10% for tinnitus; and 0% for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War).
Two other new claims were not addressed at this C & P exam. Dont know why???? Trying to get to 100% combined disability. Any feedback would be appreciated. Sorry for long post. Did not know how to hide info, if in an attachment. Feel free to move this post, if in wrong section.
LOCAL TITLE: C&P MD NOTE
STANDARD TITLE: PHYSICIAN NOTE
DATE OF NOTE: MAR 07, 2018@12:30 ENTRY DATE: MAR 07, 2018@14:02:03
AUTHOR: XXXXXXXXXXX EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Gulf War General Medical Examination
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Name of patient/Veteran: XXXXXXXXXXXXXXXXXX
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
2. Medical History
------------------
a. No symptoms, abnormal findings or complaints: No answer provided
b. Skin and scars: No answer provided
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 38 of 139
c. Hematologic/lymphatic: No answer provided
d. Eye: No answer provided
e. Hearing loss, tinnitus and ear: No answer provided
f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other
Conditions of the Nose, Throat, Larynx and Pharynx
g. Breast: No answer provided
h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep
apnea)
i. Cardiovascular: No answer provided
j. Digestive and abdominal wall: No answer provided
k. Kidney and urinary tract: No answer provided
l. Reproductive: No answer provided
m. Musculoskeletal: No answer provided
n. Endocrine: No answer provided
o. Neurologic: Fibromyalgia
p. Psychiatric: No answer provided
q. Infectious disease, immune disorder or nutritional deficiency: No
answer
provided
r. Miscellaneous conditions: No answer provided
3. Diagnosed illnesses with no etiology
---------------------------------------
From the conditions identified and for which Questionnaires were completed,
are there any diagnosed illnesses for which no etiology was established?
[ ] Yes [X] No
4. Additional signs and/or symptoms that may represent an "undiagnosed
illness" or "diagnosed medically unexplained chronic
multisymptom illness"
-----------------------------------------------------------------------------
Does the Veteran report any additional signs and/or symptoms not addressed
through completion of DBQs identified in the above sections?
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 39 of 139
[ ] Yes [X] No
5. Physical Exam
----------------
Normal PE, except as noted on additional Questionnaires included as part of
this
report
6. Functional impact of additional signs and/or symptoms that may represent
an "undiagnosed illness" or "diagnosed medically
unexplained chronic
multisymptom illness"
-----------------------------------------------------------------------------
[X] Yes [ ] No
If yes, describe the impact of each additional sign and/or symptom that
impacts
his or her ability to work, providing one or more examples: See
individual
DBQS
7. Remarks, if any:
-------------------
No answer provided
****************************************************************************
Fibromyalgia
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX
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
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 40 of 139
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
fibromyalgia? (This is the condition the Veteran is claiming or for which an
exam has been requested)
[X] Yes [ ] No
[X] Fibromyalgia
ICD code: M79.7
Date of diagnosis: 1991
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
fibromyalgia condition:
He reports of generalized and wide spread musculoskeletal pain with
weakness, stiffness, chronic tiredness as well fatigue, multiple
joints and body pain including lower back, mid back, upper back in
between scapula, neck area, both hip, both pelvis, both thigh area,
both knee joints, both ankle area, both shoulder, both wrists, both
elbow area as well as both foot and hand area, while he was while he
was in Gulf countries in 1991. His condition has been getting worse
since then.
He also reports of difficulty to fall in sleep and maintain sleep.
He reports of headaches, and frequency of headaches 2 to 3 times in a
month and it lasts for 8 to 12 hours. He reports of band like
sensation of his head during headaches.
b. Is continuous medication required for control of fibromyalgia symptoms?
[X] Yes [ ] No
If yes, list only those medications required for the Veteran's
fibromyalgia condition:
OTC Aleeve PRN
c. Is the Veteran currently undergoing treatment for this condition?
[ ] Yes [X] No
d. Are the Veteran's fibromyalgia symptoms refractory to therapy?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 41 of 139
[ ] Yes [X] No
3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to fibromyalgia?
[X] Yes [ ] No
a. Findings, signs and symptoms (check all that apply):
[X] Widespread musculoskeletal pain
[X] Stiffness
[X] Muscle weakness
If checked, describe:
See my history part
[X] Fatigue
[X] Sleep disturbances
[X] Paresthesias
[X] Headache
[X] Depression
[X] Anxiety
b. Frequency of fibromyalgia symptoms (check all that apply):
[X] Episodic with exacerbations
[X] Present more than one-third of the time
c. Does the Veteran have tender points (trigger points) for pain present?
[X] Yes [ ] No
[X] All bilaterally
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 any 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
5. Diagnostic testing
---------------------
Are there any significant diagnostic test findings and/or results?
[ ] Yes [X] No
XXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 42 of 139
6. Functional impact
---------------------
Does the Veteran&apos
;s fibromyalgia impact his or her ability to work?
[ ] Yes [X] No
7. Remarks, if any:
-------------------
Fibromyalgia: I reviewed his STR and he had no issue regarding his
fibromyalgia condition before deployment. As per history from the
Veteran,
he developed all the signs and symptoms of fibromyalgia symptoms while
he
was in Gulf countries.
As per CPRS, his CBC, BMP, LFT, UA and chest x-ray were negative. His HIV
test, and hep C and hep B and ESR were negative.
So his Fibromyalgia condition is at least as likely as not an
undiagnosed
illness due VA statutes and regulations provide for service connecting
certain chronic disability patterns based on exposure to environmental
hazards experienced during military service in Southwest Asia. The
environmental hazards may have included: exposure to smoke and
particles
from oil well fires; exposure to pesticides and insecticides; exposure
to
indigenous infectious diseases; exposure to solvent and fuel fumes;
ingestion of pyridostigmine bromides tablets, as a nerve gas antidote;
the combined effect of multiple vaccines administered upon deployment;
and inhalation of ultra fine-grain san particles. In addition, there
may
have been exposure to smoke and particles from military installation
"burn pit" fires that incinerated a wide range of toxic waste
materials.
Fibromyalgia is recognized as an undiagnosed illness. VA recognizes this
is one of the presumptive diseases related to GULF War Exposure.
Therefore, it does not need medical opinion.
****************************************************************************
Respiratory Conditions
(Other Than Tuberculosis and Sleep Apnea)
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 43 of 139
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
SECTION I: DIAGNOSES
--------------------
Does the Veteran now have or has he/she ever been diagnosed with a
respiratory condition? (This is the condition the Veteran is claiming or for
which an exam has been requested): Yes
[X] Chronic bronchitis
ICD code: J42 Date of diagnosis: SC
SECTION II: MEDICAL HISTORY
---------------------------
Describe the history (including onset and course) of the Veteran's
respiratory condition (brief summary): The Veteran reports that he developed
chronic cough and shortness of breath due to due to exposure to toxic fumes
due to burn pit and other inorganic and organic environmental hazardous
exposure while he was in Gulf countries in 1991 and his condition has been
getting worse .
Does the Veteran's respiratory condition require the use of oral or
parenteral corticosteroid medications? No
Does the Veteran's respiratory condition require the use of inhaled
medications? Yes
Check all that apply:
[X] Inhalational bronchodilator therapy
Indicate frequency: Daily
Does the Veteran's respiratory condition require the use of oral
bronchodilators? No
XXXXXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 44 of 139
Does the Veteran's respiratory condition require the use of antibiotics?
No
response provided
Does the Veteran require outpatient oxygen therapy for his or her
respiratory
condition? No
SECTION III: Pulmonary conditions
---------------------------------
Does the Veteran have any of the following pulmonary conditions? No
Other pertinent physical findings, scars, 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
Comments, if any: No response provided
SECTION IV: Diagnostic testing
------------------------------
Have imaging studies or procedures been performed? Yes
Has pulmonary function testing (PFT) been performed? Yes
Do PFT results reported below accurately reflect the Veteran's
current
pulmonary function? No
PFT results
Date: 09/02/2016
Pre-bronchodilator: Post-bronchodilator, if indicated:
FVC: 89% predicted FVC: 89% predicted
FEV-1: 89% predicted FEV-1: 90% predicted
FEV-1/FVC: 82% FEV-1/FVC: 104%
DLCO: 122% predicted
Which test result most accurately reflects the Veteran's level of
disability
(based on the condition that is being evaluated for this report)? FEV-1%
predicted
Does the Veteran have multiple respiratory conditions? No
Has exercise capacity testing been performed? No
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 45 of 139
Are there any other significant diagnostic test findings and/or results? No
SECTION V: Functional impact and remarks
----------------------------------------
1. Functional impact
--------------------
Does the Veteran's respiratory condition impact his or her ability to
work?
No
2. Remarks, if any:
-------------------
Chronic bronchitis: As per history from the Veteran, the developed
chronic
cough and shortness of breath due to due to exposure to toxic fumes due
to
burn pit and other inorganic and organic environmental hazardous exposure
while he was in Gulf.
So, his condition is at least as likely as not a diagnosable but
medically unexplained chronic multisymptom illness of unknown etiology
due
to VA statutes and regulations provide for service connecting certain
chronic disability patterns based on exposure to environmental hazards
experienced during military service in Southwest Asia. The environmental
hazards may have included: exposure to smoke and particles from oil well
fires; exposure to pesticides and insecticides; exposure to indigenous
infectious diseases; exposure to solvent and fuel fumes; ingestion of
pyridostigmine bromide tablets, as a nerve gas antidote; the combined
effect of multiple vaccines administered upon deployment; and inhalation
of ultra fine-grain sand particles. In addition, there may have been
exposure to smoke and particles from military installation "burn
pit"
fires that incinerated a wide range of toxic waste materials.
Chronic bronchitis is a diagnosable but medically unexplained chronic
multisymptom illness of unknown etiology. VA recognizes this is one of
the
presumptive diseases related to GULF War Exposure. Therefore, it does
not
need medical opinion.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
****************************************************************************
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 46 of 139
Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
Larynx and Pharynx
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXX
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
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 Date of diagnosis: 1991
SECTION II: Medical history
---------------------------
The Veteran reports that he developed sinus congestion, runny nose due to
exposure to toxic fumes due to burn pit and other inorganic and organic
environmental hazardous exposure while he was in Gulf countries back in
1991.
His condition has been getting worse.
SECTION III: Nose, throat, larynx or pharynx conditions
-------------------------------------------------------
Does the Veteran have any of the following nose, throat, larynx or pharynx
conditions?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 47 of 139
[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 [X] Maxillary [X] Frontal
[X] Ethmoid [ ] Sphenoid [ ] Pansinusitis
b. 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)
[X] Episodes of sinusitis
[ ] Near constant sinusitis
If checked, describe frequency:
[X] Headaches
[X] Pain of affected sinus
[X] Tenderness of affected sinus
[X] 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?
[ ] Yes [X] No
If yes, provide the total number of non-incapacitating episodes over the
past 12 months:
[ ] 1 [ ] 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 [X] 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
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 48 of 139
months:
[ ] 1 [ ] 2 [ ] 3 or more
e. Has the Veteran had sinus surgery?
[ ] Yes [X] 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[X] No
6. 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 answer provided
d. Does the Veteran have loss of part of the nose or other scars of the nose
exposing both nasal passages?: No answer provided
e. Does the Veteran have loss of part of the nose or other scars causing
loss
of part of one ala?: No answer provided
f. 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?
[ ] Yes[X] No
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 49 of 139
b. Has endoscopy been performed?: No
c. Has the Veteran had a biopsy of the larynx or pharynx?: No
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?
[ ] Yes [X] No
2. Remarks, if any:
-------------------
Chronic sinusitis : As per history from the Veteran, he developed sinus
congestion, runny nose due to exposure to toxic fumes due to burn pit and
other inorganic and organic environmental hazardous exposure.
So, his condition is at least as likely as not a diagnosable but medically
unexplained chronic multisymptom illness of unknown etiology due to VA
statutes and regulations provide for service connecting certain chronic
disability patterns based on exposure to environmental hazards experienced
during military service in Southwest Asia. The environmental hazards may
have included: exposure to smoke and particles from oil well fires;
exposure
to pesticides and insecticides; exposure to indigenous infectious diseases;
exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide
tablets, as a nerve gas antidote; the combined effect of multiple vaccines
administered upon deployment; and inhalation of ultra fine-grain sand
particles. In addition, there may have been exposure to smoke and particles
from military installation "burn pit" fires that incinerated a wide
range of
toxic waste materials.
Chronic sinusitis is a diagnosable but medically unexplained chronic
multisymptom illness of unknown etiology. VA recognizes this is one of the
presumptive diseases related to GULF War Exposure. Therefore, it does not
need medical opinion.
*****************************************************************
XXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 50 of 139
The Veteran has no question and concern about my examination. He
understands
me well.
/es/ XXXXXXXXXXXX
MD
Signed: 03/07/2018 14:02
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