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Found 1 result

  1. Skin Diseases Disability Benefits Questionnaire Name of patient/Vete 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 1. Diagnosis: ------------- Does the Veteran now have or has he/she ever had a skin condition? [X] Yes [ ] No [X] Other skin condition Other diagnosis #1: RASH ICD code: 271807003 Date of diagnosis: SC 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's skin conditions (brief summary): Veteran is service connected for rash on neck (now claimed as rash all over body) as noted on VA Form 21 2507. Veteran states the rash to her neck continues to come and go. Veteran states she also has a rash that appears all over her body that comes and goes. Veteran states she was bothered with this rash while in-service. Veteran states currently she has no visible rash. b. Do any of the Veteran's skin conditions cause scarring (regardless of location), or disfigurement of the head, face or neck? [ ] Yes [X] No c. Does the Veteran have any benign or malignant skin neoplasms (including malignant melanoma)? [ ] Yes [X] No d. Does the Veteran have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma)? [ ] Yes [X] No e. Comments, if any: No response provided. 3. Treatment ------------ a. Has the Veteran been treated with oral or topical medications in the past 12 months for any skin condition? [X] Yes [ ] No [X] Topical corticosteroids If checked, list medication(s): Triamcinolone cream Specify condition medication used for: itching and rash Total duration of medication use in past 12 months: [ ] < 6 weeks [ ] 6 weeks or more, but not constant [X] Constant/near-constant b. Has the Veteran had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders? [ ] Yes [X] No 4. Debilitating and non-debilitating episodes --------------------------------------------- a. Has the Veteran had any debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis? [ ] Yes [X] No b. Has the Veteran had any non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months? [ ] Yes [X] No 5. Physical exam ---------------- a. Indicate the Veteran's visible skin conditions; indicate the approximate total body area and approximate total EXPOSED body area (face, neck and hands) affected on current examination (check all that apply): [X] The Veteran does not have any of the above listed visible skin conditions 6. Specific Skin Conditions --------------------------- Indicate the Veteran's specific skin conditions and complete all applicable subsequent questions (check all that apply): [X] Veteran does not have any of the specific skin conditions listed above 7. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 8. Other pertinent physical findings, complications, conditions, signs or symptoms ----------------------------------------------------------------------------- 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. Comments, if any: No response provided. 9. Functional impact -------------------- Do any of the Veteran's skin conditions impact his or her ability to work? [ ] Yes [X] No 10. Remarks, if any: -------------------- Active Outpatient Medications (excluding Supplies): Issue Date Status Last Fill Active Outpatient Medications Refills Expiration ========================================================================= 2) KETOCONAZOLE 2% CREAM Qty: 30 for 30 ACTIVE Issu:01-16-15 days Sig: APPLY THIN FILM TOPICALLY Refills: 5 Last:07-01-15 THREE TIMES A DAY FOR FUNGAL INFECTION Expr:01-17-16 APPLY TO CHEST THREE TIMES A DAY 3) TRIAMCINOLONE ACETONIDE 0.1% CREAM Qty: ACTIVE Issu:08-15-14 60 for 90 days Sig: APPLY THIN FILM Refills: 1 Last:07-01-15 TOPICALLY TWICE A DAY FOR ITCHING/RASH Expr:08-16-15 Issue Date Status Last Fill Pending Outpatient Medications Refills Expiration **************************************************************************** Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire Name of patient/Veteran: 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: 36971009Date of diagnosis: UNCERTAIN [X] Allergic rhinitis ICD code: 86094006Date of diagnosis: UNCERTAIN SECTION II: Medical history --------------------------- Veteran seeks service connection for sinusitis and rhinitis as stated on VA Form 21 2507. Veteran states while on active duty stationed in Washington DC in a climate different from her home state Alabama, she began to have nasal drainage and suffered from episodes of sinusitis. States she was evaluated and treated with antibiotics and underwent nasal endoscopy & laryngoscopy. Veteran states after service she contined to have runny nose with post nasal drainage and sinsus infections. Currently condition unchanged. --Medications: Drug Name FLUTICASONE 50MCF/120D NASAL SPRAY 16GM Issue Date 11/30/2015 SIG USE 2 SPRAYS IN EACH NOSTRIL ONCE DAILY Facility: DUBLIN VAMC ============================================================================= == 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 1. Sinusitis ------------ a. Indicate the sinuses/type of sinusitis currently affected by the Veteran's chronic sinusitis (check all that apply): [ ] None [X] Maxillary [ ] Frontal [ ] 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? [ ] 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 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 2. Rhinitis ----------- a. Is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis? [ ] Yes [X] No b. Is there complete obstruction on the left side due to rhinitis? [ ] Yes [X] No c. Is there complete obstruction on the right side due to rhinitis? [ ] Yes [X] No d. Is there permanent hypertrophy of the nasal turbinates? [ ] Yes [X] No e. Are there nasal polyps? [ ] Yes [X] No f. 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: 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? [ ] Yes[X] No e. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala? [ ] Yes[X] No f. 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? [X] Yes[ ] No [ ] Magnetic resonance imaging (MRI) Date: Results: [ ] Computed tomography (CT) Date: Results: [X] X-rays: Procedure Name: SINUSES 3 OR MORE VIEWS Date: 06/30/2016 13:24 Results: Exam Date/Time: 06/30/2016 13:24 Procedure Name: SINUSES 3 OR MORE VIEWS Reason for Study: C&P EXAMINATION Clinical History: C&P EXAMINATION C/O SINUS PRESSURE Impression: Multiple views of the paranasal sinuses are submitted. No comparison. No mucoperiosteal thickening or air fluid level within visualized paranasal sinuses. Hypoplasia of the frontal sinuses. Nasal septum is slightly deviated to the left. Middle and inferior nasal turbinates are normal. No bony dehiscence. IMPRESSION: No radiographic evidence of inflammatory changes. CT scan is imaging modality for evaluation of paranasal sinuses. DIAGNOSTIC CODE: 1 D: 06/30/2016 T: 06/30/2016 15:21:52EDT Job number: 1634290 CMTS Primary Diagnostic Code: NORMAL Secondary Diagnostic Codes: NONE Report: Facility: DUBLIN VAMC [ ] Other: Date: Results: 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 e. 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 sinus, nose, throat, larynx or pharynx condition impact his or her ability to work? [ ] Yes [X] No 2. Remarks, if any: ------------------- None **************************************************************************** Headaches (including Migraine Headaches) Disability Benefits Questionnaire Name of patient/Veteran: 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 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a headache condition? [X] Yes [ ] No [X] Migraine including migraine variants ICD code: 445322004 Date of diagnosis: SC 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): Veteran isservie conencted for migraine headaches as stated on VA Form 21 2507. Veteran states the frequency of the ehadaches have increased. States currently on leave from work due to the headaches. b. Does the Veteran's treatment plan include taking medication for the diagnosed condition? [X] Yes [ ] No If yes, describe treatment (list only those medications used for the diagnosed condition): Drug Name IBUPROFEN 800MG TAB Issue Date 06/30/2015 SIG TAKE ONE TABLET BY MOUTH THREE TIMES A DAY Facility: DUBLIN VAMC ======================================================================== ======= 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pulsating or throbbing head pain [X] Pain on both sides of the head b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain) [X] Yes [ ] No [X] Nausea [X] Sensitivity to light [X] Sensitivity to sound c. Indicate duration of typical head pain [X] Less than 1 day d. Indicate location of typical head pain [X] Both sides of head 4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [ ] Yes [X] No 5. 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 c. Comments, if any: No response provided. 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: Veteran will have missed days from work during times of headaches. 8. Remarks, if any: ------------------- None **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: 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 MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Whether the Veteran have a diagnosis of (a) Rhinitis that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) irritants during service? b. Indicate type of exam for which opinion has been requested: RHINITIS TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: I have reviewed the electronic folder in VBMS. I have examined the veteran. Veteran has a well documented history of Chronic Rhinitis. STRs are positive for treatment of Rhinitis. --VBMS: Allertic Rhinitis p. 18 of 28. 11/20/1991 Upper Respiratory Infection p. 23 of 28. Rash all over body. --CPRs 06/27/2014 Sinusitis. Zpack 02/28/2014 Sinusitis Augmentin 875mg Chronic Rhihnitis - Flonase ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Whether the Veteran have a diagnosis of (a) Skin condition that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) rash during service? b. Indicate type of exam for which opinion has been requested: SKIN TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: I have reviewed the electronic folder in VBMS. I have examined the veteran. Veteran has a history of rash of the neck for which she is service connected as stated on VA Form 21 2507. Veteran is now claiming to have a rash "all over body." Although the STRs were positive for treatment of rash, "all over body", unfortunately, review of the treatment records did not show any treatment for rash "all over body." --VBMS: Rash all over body. P. 19 OF 28. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Whether the Veteran have a diagnosis of (a) Sinusitis (also claimed as chronic allergies) that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) irritants during service? b. Indicate type of exam for which opinion has been requested: SINUSITIS TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: I have reviewed the electronic folder in VBMS. I have examined the veteran. Veteran has a well documented history of treatment for sinusitis. STRs are positive for treatment of sinus problems. --VBMS: Allertic Rhinitis p. 18 of 28. 11/20/1991 Upper Respiratory Infection p. 23 of 28. Allergies and sinus problems. p. 14 of 28. --CPRs 06/27/2014 Sinusitis. Zpack 02/28/2014 Sinusitis Augmentin 875mg Chronic Rhihnitis - Flonase ************************************************************************
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