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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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atd1972

C & P Exam results and feedback

Question

    Here is my C& P Exam results for Fibromyalgia, Chronic Bronchitis & Chronic Sinusitis: I put in a new claim for chronic fatigue/malaise. I put in for an increase based upon increased shortness of breath for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War) currently rated at 0%.  I put in new claims for chronic sinusitis (related to: Environmental Hazard in Gulf War) (New), chronic bronchitis (related to: Environmental Hazard in Gulf War) (New).

   What does all this mean as far as service connection/possible percentages?

      I am currently rated at 90% total: 70 % for eye condition bilateral CRVO (related to: Environmental Hazard in Gulf War), macular edema secondary to Bilateral CRVO (related to: Environmental Hazard in Gulf War); 50 % for post traumatic stress disorder (Non-Combat) with unspecified depressive disorder;10% for tinnitus; and 0% for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War).

   Two other new claims were not addressed at this C & P exam. Dont know why???? Trying to get to 100% combined disability. Any feedback would be appreciated. Sorry for long post. Did not know how to hide info, if in an attachment. Feel free to move this post, if in wrong section. 

 

 

LOCAL TITLE: C&P MD NOTE
STANDARD TITLE: PHYSICIAN NOTE
DATE OF NOTE: MAR 07, 2018@12:30 ENTRY DATE: MAR 07, 2018@14:02:03
 AUTHOR: XXXXXXXXXXX EXP COSIGNER:
 URGENCY: STATUS: COMPLETED
 Gulf War General Medical Examination
 Disability Benefits Questionnaire
 * Internal VA or DoD Use Only*
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXX

 1. Evidence Review
 ------------------
 Evidence reviewed (check all that apply):

 [X] VA e-folder (VBMS or Virtual VA)
 [X] CPRS
 2. Medical History
 ------------------

 a. No symptoms, abnormal findings or complaints: No answer provided

 b. Skin and scars: No answer provided

XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 38 of 139
 c. Hematologic/lymphatic: No answer provided

 d. Eye: No answer provided

 e. Hearing loss, tinnitus and ear: No answer provided

 f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other
 Conditions of the Nose, Throat, Larynx and Pharynx

 g. Breast: No answer provided

 h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep
 apnea)

 i. Cardiovascular: No answer provided

 j. Digestive and abdominal wall: No answer provided

 k. Kidney and urinary tract: No answer provided

 l. Reproductive: No answer provided

 m. Musculoskeletal: No answer provided

 n. Endocrine: No answer provided

 o. Neurologic: Fibromyalgia

 p. Psychiatric: No answer provided

 q. Infectious disease, immune disorder or nutritional deficiency: No
answer
 provided

 r. Miscellaneous conditions: No answer provided

 3. Diagnosed illnesses with no etiology
 ---------------------------------------

 From the conditions identified and for which Questionnaires were completed,
 are there any diagnosed illnesses for which no etiology was established?
 [ ] Yes [X] No

 4. Additional signs and/or symptoms that may represent an "undiagnosed
 illness" or "diagnosed medically unexplained chronic
multisymptom illness"

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

 Does the Veteran report any additional signs and/or symptoms not addressed
 through completion of DBQs identified in the above sections?
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 39 of 139
 [ ] Yes [X] No

 5. Physical Exam
 ----------------

 Normal PE, except as noted on additional Questionnaires included as part of
this
 report

 6. Functional impact of additional signs and/or symptoms that may represent
 an "undiagnosed illness" or "diagnosed medically
unexplained chronic
 multisymptom illness"

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

 [X] Yes [ ] No

 If yes, describe the impact of each additional sign and/or symptom that
impacts
 his or her ability to work, providing one or more examples: See
individual
 DBQS

 7. Remarks, if any:
 -------------------

 No answer provided

****************************************************************************
 Fibromyalgia
 Disability Benefits Questionnaire
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX

 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

XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 40 of 139
 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
 fibromyalgia? (This is the condition the Veteran is claiming or for which an
 exam has been requested)
 [X] Yes [ ] No

 [X] Fibromyalgia
 ICD code: M79.7
 Date of diagnosis: 1991
 2. Medical history
 ------------------
 a. Describe the history (including onset and course) of the Veteran's
 fibromyalgia condition:
 He reports of generalized and wide spread musculoskeletal pain with
 weakness, stiffness, chronic tiredness as well fatigue, multiple
 joints and body pain including lower back, mid back, upper back in
 between scapula, neck area, both hip, both pelvis, both thigh area,
 both knee joints, both ankle area, both shoulder, both wrists, both
 elbow area as well as both foot and hand area, while he was while he
 was in Gulf countries in 1991. His condition has been getting worse
 since then.
 He also reports of difficulty to fall in sleep and maintain sleep.
 He reports of headaches, and frequency of headaches 2 to 3 times in a
 month and it lasts for 8 to 12 hours. He reports of band like
 sensation of his head during headaches.


 b. Is continuous medication required for control of fibromyalgia symptoms?
 [X] Yes [ ] No

 If yes, list only those medications required for the Veteran's
 fibromyalgia condition:
 OTC Aleeve PRN


 c. Is the Veteran currently undergoing treatment for this condition?
 [ ] Yes [X] No

 d. Are the Veteran's fibromyalgia symptoms refractory to therapy?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 41 of 139
 [ ] Yes [X] No

 3. Findings, signs and symptoms
 -------------------------------
 Does the Veteran currently have any findings, signs or symptoms attributable
 to fibromyalgia?
 [X] Yes [ ] No

 a. Findings, signs and symptoms (check all that apply):

 [X] Widespread musculoskeletal pain
 [X] Stiffness
 [X] Muscle weakness
 If checked, describe:
 See my history part


 [X] Fatigue
 [X] Sleep disturbances
 [X] Paresthesias
 [X] Headache
 [X] Depression
 [X] Anxiety
 b. Frequency of fibromyalgia symptoms (check all that apply):

 [X] Episodic with exacerbations
 [X] Present more than one-third of the time
 c. Does the Veteran have tender points (trigger points) for pain present?
 [X] Yes [ ] No

 [X] All bilaterally
 4. 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

 5. Diagnostic testing
 ---------------------
 Are there any significant diagnostic test findings and/or results?
 [ ] Yes [X] No
XXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 42 of 139

 6. Functional impact
 ---------------------
 Does the Veteran&apos
;s fibromyalgia impact his or her ability to work?
 [ ] Yes [X] No

 7. Remarks, if any:
 -------------------
 Fibromyalgia: I reviewed his STR and he had no issue regarding his
 fibromyalgia condition before deployment. As per history from the
Veteran,
 he developed all the signs and symptoms of fibromyalgia symptoms while
he
 was in Gulf countries.
 As per CPRS, his CBC, BMP, LFT, UA and chest x-ray were negative. His HIV
 test, and hep C and hep B and ESR were negative.
 So his Fibromyalgia condition is at least as likely as not an
undiagnosed
 illness due VA statutes and regulations provide for service connecting
 certain chronic disability patterns based on exposure to environmental
 hazards experienced during military service in Southwest Asia. The
 environmental hazards may have included: exposure to smoke and
particles
 from oil well fires; exposure to pesticides and insecticides; exposure
to
 indigenous infectious diseases; exposure to solvent and fuel fumes;
 ingestion of pyridostigmine bromides tablets, as a nerve gas antidote;
 the combined effect of multiple vaccines administered upon deployment;
 and inhalation of ultra fine-grain san particles. In addition, there
may
 have been exposure to smoke and particles from military installation
 "burn pit" fires that incinerated a wide range of toxic waste
materials.
 Fibromyalgia is recognized as an undiagnosed illness. VA recognizes this
 is one of the presumptive diseases related to GULF War Exposure.
 Therefore, it does not need medical opinion.


****************************************************************************
 Respiratory Conditions
 (Other Than Tuberculosis and Sleep Apnea)
 Disability Benefits Questionnaire
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 43 of 139

 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: DIAGNOSES
 --------------------
 Does the Veteran now have or has he/she ever been diagnosed with a
 respiratory condition? (This is the condition the Veteran is claiming or for
 which an exam has been requested): Yes
 [X] Chronic bronchitis
 ICD code: J42 Date of diagnosis: SC
 SECTION II: MEDICAL HISTORY
 ---------------------------
 Describe the history (including onset and course) of the Veteran's
 respiratory condition (brief summary): The Veteran reports that he developed
 chronic cough and shortness of breath due to due to exposure to toxic fumes
 due to burn pit and other inorganic and organic environmental hazardous
 exposure while he was in Gulf countries in 1991 and his condition has been
 getting worse .

 Does the Veteran's respiratory condition require the use of oral or
 parenteral corticosteroid medications? No

 Does the Veteran's respiratory condition require the use of inhaled
 medications? Yes
 Check all that apply:
 [X] Inhalational bronchodilator therapy
 Indicate frequency: Daily
 Does the Veteran's respiratory condition require the use of oral
 bronchodilators? No

XXXXXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 44 of 139
 Does the Veteran's respiratory condition require the use of antibiotics?
No
 response provided

 Does the Veteran require outpatient oxygen therapy for his or her
respiratory
 condition? No
 SECTION III: Pulmonary conditions
 ---------------------------------
 Does the Veteran have any of the following pulmonary conditions? No
 Other pertinent physical findings, scars, complications, conditions, signs,
 symptoms and scars
 -----------------------------------------------------------------------
 Does the Veteran have any other pertinent physical findings, complications,
 conditions, signs or symptoms related to any conditions listed in the
 Diagnosis Section above? No

 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

 Comments, if any: No response provided

 SECTION IV: Diagnostic testing
 ------------------------------
 Have imaging studies or procedures been performed? Yes
 Has pulmonary function testing (PFT) been performed? Yes
 Do PFT results reported below accurately reflect the Veteran's
current
 pulmonary function? No
 PFT results
 Date: 09/02/2016

 Pre-bronchodilator: Post-bronchodilator, if indicated:
 FVC: 89% predicted FVC: 89% predicted
 FEV-1: 89% predicted FEV-1: 90% predicted
 FEV-1/FVC: 82% FEV-1/FVC: 104%
 DLCO: 122% predicted

 Which test result most accurately reflects the Veteran's level of
disability
 (based on the condition that is being evaluated for this report)? FEV-1%
 predicted
 Does the Veteran have multiple respiratory conditions? No
 Has exercise capacity testing been performed? No
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 45 of 139
 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 respiratory condition impact his or her ability to
work?
 No
 2. Remarks, if any:
 -------------------
 Chronic bronchitis: As per history from the Veteran, the developed
chronic
 cough and shortness of breath due to due to exposure to toxic fumes due
to
 burn pit and other inorganic and organic environmental hazardous exposure
 while he was in Gulf.
 So, his condition is at least as likely as not a diagnosable but
 medically unexplained chronic multisymptom illness of unknown etiology
due
 to VA statutes and regulations provide for service connecting certain
 chronic disability patterns based on exposure to environmental hazards
 experienced during military service in Southwest Asia. The environmental
 hazards may have included: exposure to smoke and particles from oil well
 fires; exposure to pesticides and insecticides; exposure to indigenous
 infectious diseases; exposure to solvent and fuel fumes; ingestion of
 pyridostigmine bromide tablets, as a nerve gas antidote; the combined
 effect of multiple vaccines administered upon deployment; and inhalation
 of ultra fine-grain sand particles. In addition, there may have been
 exposure to smoke and particles from military installation "burn
pit"
 fires that incinerated a wide range of toxic waste materials.
 Chronic bronchitis is a diagnosable but medically unexplained chronic
 multisymptom illness of unknown etiology. VA recognizes this is one of
the
 presumptive diseases related to GULF War Exposure. Therefore, it does
not
 need medical opinion.

 NOTE: VA may request additional medical information, including additional
 examinations if necessary to complete VA's review of the
Veteran's
 application.
****************************************************************************
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 46 of 139
 Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
 Larynx and Pharynx
 Disability Benefits Questionnaire
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXXX

 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: J32 Date of diagnosis: 1991
 SECTION II: Medical history
 ---------------------------

 The Veteran reports that he developed sinus congestion, runny nose due to
 exposure to toxic fumes due to burn pit and other inorganic and organic
 environmental hazardous exposure while he was in Gulf countries back in
1991.
 His condition has been getting worse.

 SECTION III: Nose, throat, larynx or pharynx conditions
 -------------------------------------------------------
 Does the Veteran have any of the following nose, throat, larynx or pharynx
 conditions?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 47 of 139
 [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 [X] Maxillary [X] Frontal
 [X] Ethmoid [ ] Sphenoid [ ] Pansinusitis

 b. Does the Veteran currently have any findings, signs or symptoms
 attributable to chronic sinusitis?
 [X] Yes [ ] No

 If yes, check all that apply:

 [ ] Chronic sinusitis detected only by imaging studies (see Diagnostic
 testing section)
 [X] Episodes of sinusitis
 [ ] Near constant sinusitis
 If checked, describe frequency:

 [X] Headaches
 [X] Pain of affected sinus
 [X] Tenderness of affected sinus
 [X] 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
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 48 of 139
 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

 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?: No answer provided

 e. Does the Veteran have loss of part of the nose or other scars causing
loss
 of part of one ala?: No answer provided

 f. 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?
 [ ] Yes[X] No
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 49 of 139

 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 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?
 [ ] Yes [X] No

 2. Remarks, if any:
 -------------------
 Chronic sinusitis : As per history from the Veteran, he developed sinus
 congestion, runny nose due to exposure to toxic fumes due to burn pit and
 other inorganic and organic environmental hazardous exposure.
 So, his condition is at least as likely as not a diagnosable but medically
 unexplained chronic multisymptom illness of unknown etiology due to VA
 statutes and regulations provide for service connecting certain chronic
 disability patterns based on exposure to environmental hazards experienced
 during military service in Southwest Asia. The environmental hazards may
 have included: exposure to smoke and particles from oil well fires;
exposure
 to pesticides and insecticides; exposure to indigenous infectious diseases;
 exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide
 tablets, as a nerve gas antidote; the combined effect of multiple vaccines
 administered upon deployment; and inhalation of ultra fine-grain sand
 particles. In addition, there may have been exposure to smoke and particles
 from military installation "burn pit" fires that incinerated a wide
range of
 toxic waste materials.
 Chronic sinusitis is a diagnosable but medically unexplained chronic
 multisymptom illness of unknown etiology. VA recognizes this is one of the
 presumptive diseases related to GULF War Exposure. Therefore, it does not
 need medical opinion.
 *****************************************************************
XXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 50 of 139
 The Veteran has no question and concern about my examination. He
understands
 me well.

/es/ XXXXXXXXXXXX
MD
Signed: 03/07/2018 14:02

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You are in the best position to answer this question.  To figure it out, check your medical records when you were awarded benefits, such as the c and p exam.   Then, check to see if this exam indicates that your symptoms increased.  Compare your symptoms with that of the schedule of rating disabilities (criteria) for your condition(s).  

Remember, to get to 100 percent from 90 percent (if the 90 percent were a single 90 percent) you have to have an increase of 50 percent or more to get to 100 because of the VA math.  

Note carefully the impact of your symptoms on work.  VA disability is to compensate you for your loss of ability to perform your job.  If you think you are unable to work because of your disabilities, then you can likely get to either 100 percent or TDIU.  

 

However, what I read, above, did not indicate that your sc condition impacted your work.  Are you currently working?  The C and P exam did not indicate you were "out of work" for any period of time due to your sc condition(s).  

That is the bad news.  The good news, as far as benefits goes is that your doctor indicated depression and fatigue, so your course of action may be to go that route.  

If you are unable to work due to sc conditions, then, yes, you should be able to get to 100 percent with/without tdiu.  

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Based on your post, you should get unemployability (TDIU) as you are unable to work due to SC conditions, provided that a doc has documented this.  

An award of Social security disability is also great evidence especially if the conditions to which the SSD decision says your award is based on, are also service connected.  

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 Broncovet,

Thanks for your feedback.

I been out of work since approx. 2006 because of my disabilities. I have received SSDI since 2008. The doctor only asked me what I did now, I told him I was unable to work because of my disabilities in which I suffer from. I submitted a statement in support of claim to refute functional impact and to let them know I have been out of work because of inability to sustain gainful employment because of my disabilities . I will see what happens when they make a decision one way or the other.

 

Edited by atd1972

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On 3/10/2018 at 2:28 PM, atd1972 said:

    Here is my C& P Exam results for Fibromyalgia, Chronic Bronchitis & Chronic Sinusitis: I put in a new claim for chronic fatigue/malaise. I put in for an increase based upon increased shortness of breath for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War) currently rated at 0%.  I put in new claims for chronic sinusitis (related to: Environmental Hazard in Gulf War) (New), chronic bronchitis (related to: Environmental Hazard in Gulf War) (New).

   What does all this mean as far as service connection/possible percentages?

      I am currently rated at 90% total: 70 % for eye condition bilateral CRVO (related to: Environmental Hazard in Gulf War), macular edema secondary to Bilateral CRVO (related to: Environmental Hazard in Gulf War); 50 % for post traumatic stress disorder (Non-Combat) with unspecified depressive disorder;10% for tinnitus; and 0% for lung condition Pulmonary Nodules (related to Environmental Hazard in Gulf War).

   Two other new claims were not addressed at this C & P exam. Dont know why???? Trying to get to 100% combined disability. Any feedback would be appreciated. Sorry for long post. Did not know how to hide info, if in an attachment. Feel free to move this post, if in wrong section. 

 

 

LOCAL TITLE: C&P MD NOTE
STANDARD TITLE: PHYSICIAN NOTE
DATE OF NOTE: MAR 07, 2018@12:30 ENTRY DATE: MAR 07, 2018@14:02:03
 AUTHOR: XXXXXXXXXXX EXP COSIGNER:
 URGENCY: STATUS: COMPLETED
 Gulf War General Medical Examination
 Disability Benefits Questionnaire
 * Internal VA or DoD Use Only*
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXX

 1. Evidence Review
 ------------------
 Evidence reviewed (check all that apply):

 [X] VA e-folder (VBMS or Virtual VA)
 [X] CPRS
 2. Medical History
 ------------------

 a. No symptoms, abnormal findings or complaints: No answer provided

 b. Skin and scars: No answer provided

XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 38 of 139
 c. Hematologic/lymphatic: No answer provided

 d. Eye: No answer provided

 e. Hearing loss, tinnitus and ear: No answer provided

 f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other
 Conditions of the Nose, Throat, Larynx and Pharynx

 g. Breast: No answer provided

 h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep
 apnea)

 i. Cardiovascular: No answer provided

 j. Digestive and abdominal wall: No answer provided

 k. Kidney and urinary tract: No answer provided

 l. Reproductive: No answer provided

 m. Musculoskeletal: No answer provided

 n. Endocrine: No answer provided

 o. Neurologic: Fibromyalgia

 p. Psychiatric: No answer provided

 q. Infectious disease, immune disorder or nutritional deficiency: No
answer
 provided

 r. Miscellaneous conditions: No answer provided

 3. Diagnosed illnesses with no etiology
 ---------------------------------------

 From the conditions identified and for which Questionnaires were completed,
 are there any diagnosed illnesses for which no etiology was established?
 [ ] Yes [X] No

 4. Additional signs and/or symptoms that may represent an "undiagnosed
 illness" or "diagnosed medically unexplained chronic
multisymptom illness"

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

 Does the Veteran report any additional signs and/or symptoms not addressed
 through completion of DBQs identified in the above sections?
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 39 of 139
 [ ] Yes [X] No

 5. Physical Exam
 ----------------

 Normal PE, except as noted on additional Questionnaires included as part of
this
 report

 6. Functional impact of additional signs and/or symptoms that may represent
 an "undiagnosed illness" or "diagnosed medically
unexplained chronic
 multisymptom illness"

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

 [X] Yes [ ] No

 If yes, describe the impact of each additional sign and/or symptom that
impacts
 his or her ability to work, providing one or more examples: See
individual
 DBQS

 7. Remarks, if any:
 -------------------

 No answer provided

****************************************************************************
 Fibromyalgia
 Disability Benefits Questionnaire
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX

 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

XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 40 of 139
 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
 fibromyalgia? (This is the condition the Veteran is claiming or for which an
 exam has been requested)
 [X] Yes [ ] No

 [X] Fibromyalgia
 ICD code: M79.7
 Date of diagnosis: 1991
 2. Medical history
 ------------------
 a. Describe the history (including onset and course) of the Veteran's
 fibromyalgia condition:
 He reports of generalized and wide spread musculoskeletal pain with
 weakness, stiffness, chronic tiredness as well fatigue, multiple
 joints and body pain including lower back, mid back, upper back in
 between scapula, neck area, both hip, both pelvis, both thigh area,
 both knee joints, both ankle area, both shoulder, both wrists, both
 elbow area as well as both foot and hand area, while he was while he
 was in Gulf countries in 1991. His condition has been getting worse
 since then.
 He also reports of difficulty to fall in sleep and maintain sleep.
 He reports of headaches, and frequency of headaches 2 to 3 times in a
 month and it lasts for 8 to 12 hours. He reports of band like
 sensation of his head during headaches.


 b. Is continuous medication required for control of fibromyalgia symptoms?
 [X] Yes [ ] No

 If yes, list only those medications required for the Veteran's
 fibromyalgia condition:
 OTC Aleeve PRN


 c. Is the Veteran currently undergoing treatment for this condition?
 [ ] Yes [X] No

 d. Are the Veteran's fibromyalgia symptoms refractory to therapy?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 41 of 139
 [ ] Yes [X] No

 3. Findings, signs and symptoms
 -------------------------------
 Does the Veteran currently have any findings, signs or symptoms attributable
 to fibromyalgia?
 [X] Yes [ ] No

 a. Findings, signs and symptoms (check all that apply):

 [X] Widespread musculoskeletal pain
 [X] Stiffness
 [X] Muscle weakness
 If checked, describe:
 See my history part


 [X] Fatigue
 [X] Sleep disturbances
 [X] Paresthesias
 [X] Headache
 [X] Depression
 [X] Anxiety
 b. Frequency of fibromyalgia symptoms (check all that apply):

 [X] Episodic with exacerbations
 [X] Present more than one-third of the time
 c. Does the Veteran have tender points (trigger points) for pain present?
 [X] Yes [ ] No

 [X] All bilaterally
 4. 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

 5. Diagnostic testing
 ---------------------
 Are there any significant diagnostic test findings and/or results?
 [ ] Yes [X] No
XXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 42 of 139

 6. Functional impact
 ---------------------
 Does the Veteran&apos
;s fibromyalgia impact his or her ability to work?
 [ ] Yes [X] No

 7. Remarks, if any:
 -------------------
 Fibromyalgia: I reviewed his STR and he had no issue regarding his
 fibromyalgia condition before deployment. As per history from the
Veteran,
 he developed all the signs and symptoms of fibromyalgia symptoms while
he
 was in Gulf countries.
 As per CPRS, his CBC, BMP, LFT, UA and chest x-ray were negative. His HIV
 test, and hep C and hep B and ESR were negative.
 So his Fibromyalgia condition is at least as likely as not an
undiagnosed
 illness due VA statutes and regulations provide for service connecting
 certain chronic disability patterns based on exposure to environmental
 hazards experienced during military service in Southwest Asia. The
 environmental hazards may have included: exposure to smoke and
particles
 from oil well fires; exposure to pesticides and insecticides; exposure
to
 indigenous infectious diseases; exposure to solvent and fuel fumes;
 ingestion of pyridostigmine bromides tablets, as a nerve gas antidote;
 the combined effect of multiple vaccines administered upon deployment;
 and inhalation of ultra fine-grain san particles. In addition, there
may
 have been exposure to smoke and particles from military installation
 "burn pit" fires that incinerated a wide range of toxic waste
materials.
 Fibromyalgia is recognized as an undiagnosed illness. VA recognizes this
 is one of the presumptive diseases related to GULF War Exposure.
 Therefore, it does not need medical opinion.


****************************************************************************
 Respiratory Conditions
 (Other Than Tuberculosis and Sleep Apnea)
 Disability Benefits Questionnaire
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 43 of 139

 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: DIAGNOSES
 --------------------
 Does the Veteran now have or has he/she ever been diagnosed with a
 respiratory condition? (This is the condition the Veteran is claiming or for
 which an exam has been requested): Yes
 [X] Chronic bronchitis
 ICD code: J42 Date of diagnosis: SC
 SECTION II: MEDICAL HISTORY
 ---------------------------
 Describe the history (including onset and course) of the Veteran's
 respiratory condition (brief summary): The Veteran reports that he developed
 chronic cough and shortness of breath due to due to exposure to toxic fumes
 due to burn pit and other inorganic and organic environmental hazardous
 exposure while he was in Gulf countries in 1991 and his condition has been
 getting worse .

 Does the Veteran's respiratory condition require the use of oral or
 parenteral corticosteroid medications? No

 Does the Veteran's respiratory condition require the use of inhaled
 medications? Yes
 Check all that apply:
 [X] Inhalational bronchodilator therapy
 Indicate frequency: Daily
 Does the Veteran's respiratory condition require the use of oral
 bronchodilators? No

XXXXXXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 44 of 139
 Does the Veteran's respiratory condition require the use of antibiotics?
No
 response provided

 Does the Veteran require outpatient oxygen therapy for his or her
respiratory
 condition? No
 SECTION III: Pulmonary conditions
 ---------------------------------
 Does the Veteran have any of the following pulmonary conditions? No
 Other pertinent physical findings, scars, complications, conditions, signs,
 symptoms and scars
 -----------------------------------------------------------------------
 Does the Veteran have any other pertinent physical findings, complications,
 conditions, signs or symptoms related to any conditions listed in the
 Diagnosis Section above? No

 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

 Comments, if any: No response provided

 SECTION IV: Diagnostic testing
 ------------------------------
 Have imaging studies or procedures been performed? Yes
 Has pulmonary function testing (PFT) been performed? Yes
 Do PFT results reported below accurately reflect the Veteran's
current
 pulmonary function? No
 PFT results
 Date: 09/02/2016

 Pre-bronchodilator: Post-bronchodilator, if indicated:
 FVC: 89% predicted FVC: 89% predicted
 FEV-1: 89% predicted FEV-1: 90% predicted
 FEV-1/FVC: 82% FEV-1/FVC: 104%
 DLCO: 122% predicted

 Which test result most accurately reflects the Veteran's level of
disability
 (based on the condition that is being evaluated for this report)? FEV-1%
 predicted
 Does the Veteran have multiple respiratory conditions? No
 Has exercise capacity testing been performed? No
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 45 of 139
 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 respiratory condition impact his or her ability to
work?
 No
 2. Remarks, if any:
 -------------------
 Chronic bronchitis: As per history from the Veteran, the developed
chronic
 cough and shortness of breath due to due to exposure to toxic fumes due
to
 burn pit and other inorganic and organic environmental hazardous exposure
 while he was in Gulf.
 So, his condition is at least as likely as not a diagnosable but
 medically unexplained chronic multisymptom illness of unknown etiology
due
 to VA statutes and regulations provide for service connecting certain
 chronic disability patterns based on exposure to environmental hazards
 experienced during military service in Southwest Asia. The environmental
 hazards may have included: exposure to smoke and particles from oil well
 fires; exposure to pesticides and insecticides; exposure to indigenous
 infectious diseases; exposure to solvent and fuel fumes; ingestion of
 pyridostigmine bromide tablets, as a nerve gas antidote; the combined
 effect of multiple vaccines administered upon deployment; and inhalation
 of ultra fine-grain sand particles. In addition, there may have been
 exposure to smoke and particles from military installation "burn
pit"
 fires that incinerated a wide range of toxic waste materials.
 Chronic bronchitis is a diagnosable but medically unexplained chronic
 multisymptom illness of unknown etiology. VA recognizes this is one of
the
 presumptive diseases related to GULF War Exposure. Therefore, it does
not
 need medical opinion.

 NOTE: VA may request additional medical information, including additional
 examinations if necessary to complete VA's review of the
Veteran's
 application.
****************************************************************************
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 46 of 139
 Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
 Larynx and Pharynx
 Disability Benefits Questionnaire
 Name of patient/Veteran: XXXXXXXXXXXXXXXXXXX

 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: J32 Date of diagnosis: 1991
 SECTION II: Medical history
 ---------------------------

 The Veteran reports that he developed sinus congestion, runny nose due to
 exposure to toxic fumes due to burn pit and other inorganic and organic
 environmental hazardous exposure while he was in Gulf countries back in
1991.
 His condition has been getting worse.

 SECTION III: Nose, throat, larynx or pharynx conditions
 -------------------------------------------------------
 Does the Veteran have any of the following nose, throat, larynx or pharynx
 conditions?
XXXXXXXXXXXXXXXXX CONFIDENTIAL Page 47 of 139
 [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 [X] Maxillary [X] Frontal
 [X] Ethmoid [ ] Sphenoid [ ] Pansinusitis

 b. Does the Veteran currently have any findings, signs or symptoms
 attributable to chronic sinusitis?
 [X] Yes [ ] No

 If yes, check all that apply:

 [ ] Chronic sinusitis detected only by imaging studies (see Diagnostic
 testing section)
 [X] Episodes of sinusitis
 [ ] Near constant sinusitis
 If checked, describe frequency:

 [X] Headaches
 [X] Pain of affected sinus
 [X] Tenderness of affected sinus
 [X] 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
XXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 48 of 139
 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

 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?: No answer provided

 e. Does the Veteran have loss of part of the nose or other scars causing
loss
 of part of one ala?: No answer provided

 f. 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?
 [ ] Yes[X] No
XXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 49 of 139

 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 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?
 [ ] Yes [X] No

 2. Remarks, if any:
 -------------------
 Chronic sinusitis : As per history from the Veteran, he developed sinus
 congestion, runny nose due to exposure to toxic fumes due to burn pit and
 other inorganic and organic environmental hazardous exposure.
 So, his condition is at least as likely as not a diagnosable but medically
 unexplained chronic multisymptom illness of unknown etiology due to VA
 statutes and regulations provide for service connecting certain chronic
 disability patterns based on exposure to environmental hazards experienced
 during military service in Southwest Asia. The environmental hazards may
 have included: exposure to smoke and particles from oil well fires;
exposure
 to pesticides and insecticides; exposure to indigenous infectious diseases;
 exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide
 tablets, as a nerve gas antidote; the combined effect of multiple vaccines
 administered upon deployment; and inhalation of ultra fine-grain sand
 particles. In addition, there may have been exposure to smoke and particles
 from military installation "burn pit" fires that incinerated a wide
range of
 toxic waste materials.
 Chronic sinusitis is a diagnosable but medically unexplained chronic
 multisymptom illness of unknown etiology. VA recognizes this is one of the
 presumptive diseases related to GULF War Exposure. Therefore, it does not
 need medical opinion.
 *****************************************************************
XXXXXXXXXXXXXXXXXXXX CONFIDENTIAL Page 50 of 139
 The Veteran has no question and concern about my examination. He
understands
 me well.

/es/ XXXXXXXXXXXX
MD
Signed: 03/07/2018 14:02

Whatever happened with this sinus claim due to environmental exposure??

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I filed my first compensation claim in August of 2018. I am still in the Gathering evidence stage. I had a C & P exam on December 14th 2018. My claim is also for fibromyalgia. I was hoping that you could tell me exactly how you were able to obtain your c&p exam results. I have been searching this website to try to get an answer for that and there's so many varying answers depending on the years of the post. I would really appreciate exact directions as to how to obtain the results to my c&p exam thank you for your time.

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