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Finally the last of my C and P results what do you all think?

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Muffin

Question

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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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 but expect the worst...Keep us updated please!

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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 rating on the rhinitis.

I have a claim pending for this same condition.

Edited by 63Charlie
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Hello my friends,

As you all know I was rated 30% for MDD; 0% for migranes; and 0% for skin rash.  I asked for increases in MDD, migranes, and skin rash.  I also asked to re-open sinusitis/rhinitis and then asked for PTSD and MDD to be reopened because I was originally denied for this in 2014.  Well the decision is final today on Ebenefits, and my AB8 states that I am now 70% and it looks like they will retro me back from Dec 2014. Here is the information below.  I really appreciate the help from the members and I will continue to stick with Hadit because the fight is never over.  I am one happy lady.:))))

 

 

sinusitis (also claimed as chronic allergies) 0% Service Connected   07/14/2014
rhinitis 0% Service Connected   07/14/2014
condition of the duodenum   Not Service Connected    
insomnia   Not Service Connected    
shin splints, left lower extremity (akso claimed as aching pain and cramps)   Not Service Connected    
post traumatic stress disorder with major depression 70% Service Connected

PTSD - Personal Trauma

07/14/2014
left hand condition (also claimed as tingling sensation and numbness in fingers)   Not Service Connected    
bilateral foot condition to include corns bunions, callouses, hammertoes, blisters, and pain)   Not Service Connected    
left shoulder pain and popping out of place   Not Service Connected    
rash on neck (now claimed as rash all over body) 0% Service Connected   10/05/2012
depression to include anxiety (also claimed as suicidal thoughts, nightmares, hallucinations, panic attacks, and short term memory loss) 30% Service Connected   08/15/2011
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