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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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MOMO68

C & P Help

Question

Hello Hadit. This site is so helpful and gives great advice. I recently received a copy of my C & P and need some advice on if or not I will receive a SC rating based on the Medical Opinion given below.

RATIONALE FOR OPINION GIVEN:
Based on examination and all available documentation, veteran has a
NORMAL THROAT/PHARYNX EXAMINATION (claimed as pharyngitis). A
pharyngitis/throat condition is corroborated as having occurred during
service with complaint of neck pain, elevated temperature, nasal
congestion, examination showed neck to be supple with positive
tenderness
over trapezius, erythema pharyngeal without exudate or tender
adenopathy,
positive tenderness over maxillary, lungs bibasilar, complain of
headache without aura, diagnosed with ARDS 07/19/1999). Military
findings
are inconsistent with current clinical presentation of a normal
throat/pharynx examination. Examiner also stated my condition impact my ability to work.
.

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4 answers to this question

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Welcome,

I moved your post to the Claims / Benefits forum.

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MOMO68, Welcome to the Hadit forum. We really need to see the entire DBQ examination, to be able to help you with this claim. Specifically, we need the examiner’s opinions in their entirety and the name of the DBQ used. If the entire exam is available to review, thenwe can tell you if it is a positive or negative exam, for your claim. Your post as it is, does not provide enough information. - Harleyman

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Here is the DBQ from my C and P

Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
Larynx and Pharynx
DBQ

Indicate Indicate method 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) process
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?
[X] Yes[ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

c-file reviewed.

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] Other, specify:

Other diagnosis #1: NORMAL THROAT EXAMINATION
ICD code: --
Date of diagnosis: 08/2013

SECTION II: Medical history
---------------------------

--Army, 1987-1991, honorable discharge, PERSIAN GULF WAR.
--Stationed at Fort Gordon. In 1991, evaluated in sick call for vomiting,
etc, was diagnosed with dehydration, stomach and pharyngitis, hospitalized
at
Eisenhower Hospital in Augusta, GA.

SINCE POST MILITARY DISCHARGE, the veteran stated that her throat
condition has worsen.

--CURRENT SYMPTOMS: throat is irritated (burns) alot, scratchy, with flareups

(1-2 times months) difficulty with swallowing. Don't know whether it is her
acid reflux bothering her or not.
--Has followed up with Dr. Taube in Warner Robins, GA and was treated twice
for throat infections, last treated 01/2013.

--SURGERY: None.

--CURRENT MEDICATIONS/THERAPY:
--Treat over the counter Mouth Rinse (Listerine) or cough drops.
--RANITIDINE HCL 150MG TAB
TAKE ONE TABLET BY MOUTH EVERY DAY AS NEEDED FOR STOMACH
OMEPRAZOLE 20MG EC CAP
TAKE ONE CAPSULE BY MOUTH TWICE A DAY, BEFORE MEALS FOR STOMACH


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] Larynx or pharynx condition

3. Larynx and pharynx conditions
--------------------------------
a. Does the Veteran have chronic laryngitis?
[ ] Yes [X] No

If yes, does the Veteran have any of the following symptoms due to
chronic
laryngitis?
[ ] Yes [ ] No

If yes, check all that apply:

[ ] Hoarseness
If checked, describe frequency:

[ ] Inflammation of vocal cords or mucous membrane
[ ] Thickening or nodules of vocal cords
[ ] Submucous infiltration of vocal cords
[ ] Vocal cord polyps
[ ] Other, describe:

b. Has the Veteran had a laryngectomy?
[ ] Yes [X] No

If yes, specify:

[ ] Total laryngectomy
[ ] Partial
laryngectomy
If checked, does the Veteran have any residuals of the partial
laryngectomy?
[ ] Yes [ ] No

If yes, describe:

c. Does the Veteran have laryngeal stenosis, including residuals of
laryngeal
trauma (unilateral or bilateral)?
[ ] Yes [ ] No

If yes, assess for upper airway obstruction with pulmonary function
testing, to include Flow-Volume Loop, and provide results in Diagnostic
testing section.

d. Does the Veteran have complete organic aphonia?
[ ] Yes [ ] No

If yes, check all that apply:

[ ] Constant inability to speak above a whisper
[ ] Constant inability to communicate by speech
[ ] Other, describe:

e. Does veteran have incomplete organic aphonia?
[ ] Yes [ ] No

If yes, check all that apply:

[ ] Hoarseness
If checked, describe frequency:

[ ] Inflammation of vocal cords or mucous membrane
[ ] Thickening or nodules of vocal cords
[ ] Submucous infiltration of vocal cords
[ ] Vocal cord polyps
[ ] Other, describe:

f. Has the Veteran had a permanent tracheostomy?
[ ] Yes [ ] No

If yes, describe reason for tracheostomy and potential for decannulation:

g. Has the Veteran had an injury to the pharynx?
[ ] Yes [ ] No

If yes, check all findings, signs and symptoms that apply:

[ ] Stricture or obstruction of the pharynx or nasopharynx
[ ] Absence of the soft palate secondary to trauma
[ ] Absence of the soft palate secondary to chemical burn
[ ] Absence of the soft palate secondary to granulomatous disease
[ ] Paralysis of the soft palate with swallowing difficulty (nasal
regurgitation) and speech impairment
[ ] Other, describe:

h. Does the Veteran have vocal cord paralysis or any other pharyngeal or
laryngeal conditions?
[ ] Yes [X] No

If yes, describe:

6. Other pertinent physical findings, scars, complications, conditions,
signs
and/or symptoms

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

RATIONALE FOR OPINION GIVEN:
Based on examination and all available documentation, veteran has a
NORMAL THROAT/PHARYNX EXAMINATION (claimed as pharyngitis). A
pharyngitis/throat condition is corroborated as having occurred during
service with complaint of neck pain, elevated temperature, nasal
congestion, examination showed neck to be supple with positive
tenderness
over trapezius, erythema pharyngeal without exudate or tender
adenopathy,
positive tenderness over maxillary, lungs bibasilar, complain of
headache without aura, diagnosed with ARDS 07/19/1999). Military
findings
are inconsistent with current clinical presentation of a normal
throat/pharynx examination. Examiner also stated my condition impact my ability to work

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The examiner is stating you have a history of an in-service throat condition, but the current examination shows you have a normal throat, and he did not give you a current diagnosis of a throat condition. Remember you need the follwing:

1. in service condition or injury

2. a current diagnosis

3. a nexus linking the two

You have the in service condition/event, and you have an examiner who acknowledges the records indicate a condition while in service; However, examination did not show you have a current diagnosis of this condition, the examiner stated you have a "Normal throat". This can go two ways, You could get Service connected at "0" (non-compensable) because the examiner confirmed you suffered from episodes while in service and you currently have no symptoms, OR the condition will be denied because you do not have a current diagnosis. I suspect it is more likely to be denied for lack of a diagnosis. - IMO

Edited by harleyman

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