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Tbi Exam

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TNengland

Question

Here is my TBI exam that was ordered in a remand from the BVA. Now I will sit and wait for the decision to be made.

Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Name of patient/Veteran: England, Larry Adam
Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes[X] No
If no, check all records reviewed:
[X] Veterans Health Administration medical records (VA treatment
records)
[X] Other:
VA rating documents as this is a review tbi
SECTION I: Diagnosis and medical history
----------------------------------------
1. Diagnosis
------------
Does the Veteran now have or has he/she ever had a traumatic brain injury
(TBI) or any residuals of a TBI?
[X] Yes [ ] No
[X] Traumatic brain injury (TBI)
ICD code: 000 Date of diagnosis: 3/2005
[X] Other diagnosed residuals attributable to TBI, specify:
Other diagnosis #1: headaches
ICD code: 000
Date of diagnosis: 2005
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's TBI
and
residuals attributable to TBI (brief summary):
from neuropsych hx 2012:
According to medical records intake note from 2nd Medical Group,
Barksdale
AFB,
LA, on 5 MAR 2005, "25-year-old male hit right side of head near
temple
while
cleaning pool on base. Patient hit side of concrete pool. + blurred
vision,
patient unsure if LOC, + neck and shoulder soreness, - EtOH, + headache
at
the
moment with nausea." Subsequent evaluation that same day by
physician
revealed:
"Mr. England was noted to be in no acute distress, laughing,
smiling,
alert and
oriented x 3, cranial nerves grossly intact, strength 5 x 5." He was
diagnosed
with a minor head trauma and ordered to return on 7 March 05 for f/u eval
prior
to being returned to duty. A subsequent medical technician note from 7
March
2005 indicates "patient here for f/ head injury f/u Patient states
he's
very
much better. Still has occ. HA." The subsequent physician note of
that
same day
stated: "?not any worse than any other ou headache. RTD, f/u
prn." He
was
discharged to follow up as needed. There are no other medical records
pertaining
to this injury. He reported no cognitive difficulties or other residual
effects
at the time. He also reported an episode of brief loss of consciousness
from a
MVA during the 9th grade.
A CT of the head on MAR 20, 2009 revealed:
Study was performed with intravenous contrast. The brain is of
normal attenuation. The ventricular system is midline and
symmetric. There is no edema or normal enhancement. The globes
and orbits appear normal.
Impression:
Normal brain.
rated by neuropsychologist Dr Hughes on 2/8/12
1 memory: mild c/o memory loss without objective findings on testing
2 judgment: normal
3 social interaction: routinely appropriate but with multiple firings
from
jobs
4 orientation: normal
5 Motor: normal
6 visual-spacial:normal
7 subjective: c/o 3 or more symptoms that mildly affect work or social
interactions
8 neurobehavioral: one or more that frequently interfere with work
9 communication: normal
10 Consciousness: normal
In summary, based upon this interview, history, and testing, it is clear
that
the veteran manifests normal organic cognitive capacities but that he has
significant emotional/motivational/behavioral difficulties. He likely
suffered
a mild concussion when he hit his head on the side of the pool; but
organic
cognitive factors do NOT appear to be involved in a current clinical
picture.
Indeed, psychiatric factors seem to play an exacerbating role in his
symptom
picture and are likely responsible for the veteran's reported
cognitive and functional difficulties.
Diagnostic Impression:
Axis I 311 Depression NOS
309.81 PTSD
Axis II: 301.83 Borderline personality disorder
Axis III: Please see medical record
Axis IV: History of volatile interpersonal relationships,lack of
coping
skills, marital and family problems, unemployment, financial
problems
Axis V: GAF = 49
Finally, in my professional opinion, the veteran is able to manage his own
financial affairs for VA purposes. Please contact me if you have
questions
concerning this evaluation.
states hit head on empty bottom of pool while
cleaning it in the service, felt nauseous and vision off, and had
headaches without loss of conciousness
SECTION II: Assessment of facets of TBI-related cognitive impairment and
subjective symptoms of TBI
-----------------------------------------------------------------------------
1. Memory, attention, concentration, executive functions
--------------------------------------------------------
[X] A complaint of mild memory loss (such as having difficulty following a
conversation, recalling recent conversations, remembering names of new
acquaintances, or finding words, or often misplacing items), attention,
concentration, or executive functions, but without objective evidence on
testing
If the Veteran has complaints of impairment of memory, attention,
concentration or executive functions, describe (brief summary):
see previous testing and note that this is as least likely as not
related
to ptsd, he recalled three things, and oriented to day and year
2. Judgment
-----------
[X] Normal
3. Social interaction
---------------------
[X] Social interaction is occasionally inappropriate
If the Veteran's social interaction is not routinely appropriate,
describe (brief summary):
he feels uncomfortable in group settings and doesn't leave house
much not
related to tbi
4. Orientation
--------------
[X] Always oriented to person, time, place, and situation
5. Motor activity (with intact motor and sensory system)
--------------------------------------------------------
[X] Motor activity is normal most of the time, but mildly slowed at times
due
to apraxia (inability to perform previously learned motor activities,
despite normal motor function)
If the Veteran has any abnormal motor activity, describe (brief
summary):
states baseball not as easy
as was in past. However had mild tbi and is
not as least as likely related to tbi
6. Visual spatial orientation
-----------------------------
[X] Normal
7. Subjective symptoms
----------------------
[X] Three or more subjective symptoms that moderately interfere with work;
instrumental activities of daily living; or work, family or other close
relationships. Examples of findings that might be seen at this level of
impairment are: marked fatigability, blurred or double vision, headaches
requiring rest periods during most days
If the Veteran has subjective symptoms, describe (brief summary):
veteran states occ dizzy, ringing in ears for which is sc,
headaches,states completely stop from working. only symptom related to
tbi is headaches see headaches exam included
8. Neurobehavioral effects
--------------------------
[X] One or more neurobehavioral effects that interfere with or preclude
workplace interaction, social interaction, or both on most days or that
occasionally require supervision for safety of self or others
If the Veteran has any neurobehavioral effects, describe (brief
summary):
veteran states unable to work due to social interaction difficults which
have precluded work for 3 years and he has ssdi for this but please see
headache rating exam included
9. Communication
----------------
[X] Able to communicate by spoken and written language (expressive
communication) and to comprehend spoken and written language.
10. Consciousness
-----------------
[X] Normal
SECTION III: Additional residuals, other findings, diagnostic testing,
functional impact and remarks
-----------------------------------------------------------------------------
1. Residuals
------------
Does the Veteran have any subjective symptoms or any mental, physical or
neurological conditions or residuals attributable to a TBI (such as migraine
headaches or Meniere's disease)?
[X] Yes [ ] No
[X] Hearing loss and/or tinnitus
[X] Erectile dysfunction
[X] Headaches, including Migraine headaches
[X] Mental disorder (including emotional, behavioral, or cognitive)
[X] Other, describe:
tinnitus see previous rating exam, mental heal issues see previous
rating exams, erectile dysfunction not related to tbi
2. 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?
[X] Yes [ ] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms?
[X] Yes [ ] No
If yes, describe (brief summary):
cn grossly intact, dtrs = and 2+ bilateral, sensation and movement
intact,
able to heel and toe stand, rhomberg neg, moves all extemities, sensation
intact upper and lower extremities. no dysdiadokinisis
3. Diagnostic testing
---------------------
a. Has neuropsychological testing been performed?
[X] Yes [ ] No
If yes, provide date: 2/8/12
Results:
I. Memory, attention, concentration, executive functions
The veteran has a complaint of mild memory loss (such as having difficulty
following a conversation, recalling recent conversations, remembering
names of
new acquaintances, or finding words, or often misplacing items, attention,
concentration, or executive functions, but without objective evidence on
testing.
II. Judgment
The veteran exhibits normal organic judgment capacity but mildly
impaired judgment overall as a result of emotional dysfunction. "I
get
impulsive without worrying about the consequences. I just react to
stimuli."
For some decision making, he is occasionally unwilling to identify,
understand
or weigh the alternatives, understand the consequences of choices, or
make
a
reasonable decision due to emotional reasoning. Concerning his judgment,
the
veteran stated: "On a stable day I have good judgment but on a
depressed
day I
don't. I get impulsive without worrying about the consequences. I
just
react
to stimuli."
III. Social interaction
The veteran stated his social interaction is routinely appropriate
"because I stay reserved." However, he also notes inappropriate
reaction
to
authority resulting in multiple firings from jobs.
IV. Orientation
The veteran is always oriented to person, time, place, and
situation.
V. Motor Activity (with intact motor and sensory system)
The veteran's motor activity is normal.
VI. Visual-Spatial Orientation
The veteran's visual-spatial orientation is normal.
VII. Subjective symptoms
The veteran complains of 3 or more subjective (emotional or pain
related) symptoms that mildly interfere with work; instrumental
activities
of
daily living; or work, family, or other close relationships. Examples of
findings that might be seen at this level of impairment or: Intermittent
dizziness, daily mild-to-moderate headaches, and frequent insomnia.
VIII. Neurobehavioral effects
The veteran complains of one or more emotional/behavioral symptoms
that
frequently interfere with work place interaction, social interaction, or
both
but did not preclude them. "I have had over 15 jobs since I left
the
military;
and I lost them for arguing with coworkers and customers. I'm on
Social
Security
disability for bipolar disorder, PTSD, and depression since May of
2010."
IX. Communication
The veteran is able to communicate by spoken and written language
(expressive communication), and to comprehend spoken and written
language.
X. Consciousness
The veteran's level of consciousness is normal.
In summary, based upon this interview, history, and testing, it is clear
that
the veteran manifests normal organic cognitive capacities but that he has
significant emotional/motivational/behavioral difficulties. He likely
suffered
a mild concussion when he hit his head on the side of the pool; but
organic
cognitive factors do NOT appear to be involved in a current clinical
picture.
Indeed, psychiatric factors seem to play an exacerbating role in his
symptom
picture and are likely responsible for the veteran's reported
cognitive
and
functional difficulties.
Diagnostic Impression:
Axis I 311 Depression NOS
309.81 PTSD
Axis II: 301.83 Borderline personality disorder
Axis III: Please see medical record
Axis IV: History of volatile interpersonal relationships,lack of
coping
skills, marital and family problems, unemployment, financial
problems
Axis V: GAF = 49
Finally, in my professional opinion, the veteran is able to manage his own
financial affairs for VA purposes. Please contact me if you have
questions
concerning this evaluation.
b. Have diagnostic imaging studies or other diagnostic procedures been
performed?
[X] Yes [ ] No
If yes, check all that apply:
[X] Computed tomography (CT)
Date: 3/20/2009
Results:
normal
c. Has laboratory testing been performed?
[ ] Yes [X] No
d. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
4. Functional impact
--------------------
Do any of the Veteran's residual conditions attributable to a traumatic
brain
injury impact his or her ability to work?
[X] Yes [ ] No
If yes, describe impact of each of the Veteran's residual conditions
attributable to a traumatic brain injury, providing one or more examples:
see included headache exam
5. Remarks, if any:
-------------------
none
****************************************************************************
Headaches (including Migraine Headaches)
Disability Benefits Questionnaire
Name of patient/Veteran:
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) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[X] Other:
VA rating documents as this is a review tbi
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a headache
condition?
[X] Yes [ ] No
[X] Other (specify type of headache): unknown type
ICD code: 000 Date of diagnosis: 2005
2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's
headache conditions (brief summary):
developed headaches at time of tbi in 2005. Had neurologic consult
3/2009 and diagnosed with headaches of unknown type inially treated
with
ibuprofen
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):
ibuprofen
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
[X] Pain worsens with physical activity
[X] Other, describe:
stress worsens and tinitis increases during headache
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] Vomiting
[X] Sensitivity to light
[X] Sensitivity to sound
[X] Changes in vision (such as scotoma, flashes of light, tunnel vision)
[X] Sensory changes (such as feeling of pins and needles in extremities)
[X] Other, describe:
headaches vary intensity, frontal headaches on 1-10 7-8 and
severe
posterior headache 8-9
c. Indicate duration of typical head pain
[X] Less than 1 day
d. Indicate location of typical head pain
[X] Both sides of head
[X] Other, describe:
both sides of head and back 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?
[X] Yes [ ] No
If yes, indicate frequency, on average, of prostrating attacks over the
last several months:
[X] Once every month
b. Does the veteran have very prostrating and prolonged attacks of
migraines/non-migraine pain productive of severe economic inadatability?
[X] Yes [ ] No
5. Other pertinent physical findings, 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?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
ENGLAND, LARRY ADAM CONFIDENTIAL Page 16 of 17conditions
listed in the Diagnosis section above?
[X] Yes [ ] No
If yes, describe (brief summary):
see included tbi physical
6. Diagnostic testing
---------------------
Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
ct normal see attached tbi exam
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 states headaches cause him to be unable to function in a job
seting due to need for no sensory input during headaches. He states
that
he has up 5 severe headaches a week lasting up to 2 hours that would
prevent him from having full or part time work.
8. Remarks, if any:
-------------------
none
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