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Finally the last of my C and P results what do you all think?
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Muffin
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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Buck52
Not sure what all your claiming ? but this C&P don't look very favorable to me this is just my opinion if your lucky and get some of these S.C. you might get a 10% rating but from what I rea
Navy4life
Muffin; Okay I remember now! You supplied your C&P for the PTSD/MST and I remember thinking that was favorable. The ones today are "iffy" so fingers crossed and toes and hope for the best b
63Charlie
The allergic rhinitis requires a 50% blockage to get a 10% disability rating. A 50% blockage with polyps rates 30% disability. You will most likely get service connection but no disability r
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