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Sinusitis C&P
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ShuMan
Team,
I'm thinking this is a 0%, What do you think?
-Thank You!!
---------------------------------------------
Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
Disability Benefits Questionnaire
========================================================
Indicate method used 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) p
rocess 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?
[ ] Yes[X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Veterans Health Administration medical records (VA treatment
records)
========================================================
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: J32.2 Date of diagnosis: 2015
SECTION II: Medical history
---------------------------
The Veteran reports intermittent symptoms of URI and sinusitis while in
service (so noted in STR's). He denies pre-service episodes. He has
been
evaluated at the VA and treated. He reports several episodes per year that
require antibiotic treatment.
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
1. Sinusitis
------------
a. Indicate the sinuses/type of sinusitis currently affected by the
Veteran's
chronic sinusitis (check all that apply):
[ ] None [ ] Maxillary [ ] Frontal
[X] 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?
[X] Yes [ ] No
If yes, provide the total number of non-incapacitating episodes over the
past 12 months:
[ ] 1 [X] 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 [ ] 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 [ ] 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[ ] No
6. Other pertinent physical findings, scars, complications, conditions,
signs
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
========================================================
section above? : No answer provided
b. 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?: No answer provided
c. Does the Veteran have loss of part of the nose or other scars of the nose
exposing both nasal passages?: No answer provided
d. Does the Veteran have loss of part of the nose or other scars causing
loss
of part of one ala?: No answer provided
e. 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?
No answer provided
b. Has endoscopy been performed?
No answer provided
c. Has the Veteran had a biopsy of the larynx or pharynx?
No answer provided
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?
No answer provided
2. Remarks, if any:
-------------------
========================================================
VBMS P. 1 dated 07/02/2015 STR's P. 4-5 Sinusitis.
STR's P. 4/7 pseudoephedrine RX for ALLERGY symptoms.
STR's dated 05/26/2005 P. 4-5/93 noted 6 simultaneous diagnosis: URI,
allergic rhinitis, viral syndrome, sinusitis, bronchitis and acute
bronchitis.
Rhinitis noted on STR's P 58/93. Being treated with medications for
allergies
and nasal congestion, however in the past medical history of 04/07/2009 NO
allergy or hayfever was entered in the note
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Reddit
In the future if you can, every time you think that you are coming down with a sinus infection get to a doctor, whether it is VA or private, and get it on records, then when you have your prescription
Vync
It's not uncommon for you to verbally indicate having 5-6 non-incapacitating episodes, but not all docs write everything down. If you have medical visits showing this, it can help to counter it. Even
Vync
Andyman, The 30% rating for "more than six non-incapacitating episodes per year of sinusitis" needs to be "characterized by headaches, pain, and purulent discharge or crusting." If you see a doc for t
18 answers to this question
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