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dgraham82    0

Hello I recently had a C&P for TBI. I just received the DBQ from the exam and have a few questions. I was wondering if anyone could help me decipher this?


 LOCAL TITLE: C&P NEUROLOGY 16258                               
STANDARD TITLE: NEUROLOGY C & P EXAMINATION CONSULT            
DATE OF NOTE: AUG 18, 2015@08:30     ENTRY DATE: AUG 18, 2015@13:24:15     
      AUTHOR: PETERSON,KENDRA      EXP COSIGNER:                          
     URGENCY:                            STATUS: COMPLETED                  


       Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI)
                       Disability Benefits Questionnaire
                         * Internal VA or DoD Use Only*

    Name of patient/Veteran:   
   
    Indicate method used to obtain medical information to complete this
document:
   
    [X] In-person examination
 

    Evidence review
    ---------------
    Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
    [ ] Yes[X] No
   
      If no, check all records reviewed:
     
        [X] Military service treatment records
        [X] Military post-deployment questionnaire
        [X] Veterans Health Administration medical records (VA treatment
records)
        [X] Other:
              vbms and cprs records reviewed electronically
           

    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? (This is the condition the Veteran is
    claiming or for which an exam has been requested)
    [X] Yes    [ ] No
   
       [X] Traumatic brain injury (TBI)
             ICD code:     v15.52
             Date of diagnosis:    2007

       [X] Other diagnosed residuals attributable to TBI, specify:
             Other diagnosis #1:    Cognitive disorder NOS
                       ICD code:    294.9
              Date of diagnosis:    2007

             Other diagnosis #2:    Post-traumatic headaches
                       ICD code:    339.2
              Date of diagnosis:    2007

      
      
      
    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 summ
ary):
       
        Alert, oriented, flat affect, good eye contact. Please see full
        Neuropsychological testing from 7/23/2015.
       
       
    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):
       
        Tends to isolate himself and avoid interactions.
       
       
    4. Orientation
    --------------
    [X] Always oriented to person, time, place, and situation
   
    5. Motor activity (with intact motor and sensory system)
    --------------------------------------------------------
    [X] Motor activity normal
   
    6. Visual spatial orientation
    -----------------------------
    [X] Normal
   
    7. Subjective symptoms
    ----------------------
    [X] Three or more subjective 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 are: intermittent dizziness, daily mild to moderate
headaches,
        tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity
        to light
       
        If the Veteran has subjective symptoms, describe (brief summary):
       
        Insomnia, headaches, anxiety
       
       
    8. Neurobehavioral effects
    --------------------------
    [X] One or more neurobehavioral effects that frequently interfere with
        workplace interaction, social interaction, or both but do not preclude
        them
       
        If the Veteran has any neurobehavioral effects, describe (brief
summary):
       
        Apathy, depression, social isolation
       
       
    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
   
       If yes, check all that apply:
      
       [X] Hearing loss and/or tinnitus
       [X] Headaches, including Migraine headaches
       [X] Mental disorder (including emotional, behavioral, or cognitive)
       [X] Other, describe:

           Scheduled for Audiology Evaluation and Mental Health Evaluation.
           Neuropsychological Testing completed 7/2015. Please see attached DBQ
           headaches.
          
          
    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?
       [ ] Yes   [X] 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):
       Neurological Examination: Mental status as described above and in
       Neuropsych Testing. CN intact without nystagmus. MOTOR normal
       bulk/tone/strength throughout. DTRs 2 and symmetric throughout. COORD and
       GAIT normal. Able to tandem. Romberg not present.
      
      
    3. Diagnostic testing
    ---------------------
    a. Has neuropsychological testing been performed?
       [X] Yes    [ ] No
      
       If yes, provide date:  7/23/2015
       Results:
       Full result in cprs. Mild cognitive inefficiency and slowing of
processing
       speed; no frank cognitive impairment. Dx: PTSD, R/O Alcohol use disorder.
       PTSD/depression/ and frequent headaches might all contribute to his
       cognitive inefficiency. Also noted sleep disorder.
      
      
    b. Are there any other significant diagnostic test findings and/or results?
       No response provided.
      
    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:
        Although cognitive inefficiencies do not preclude him from working, it
        has made academic achievement difficult and could interfere with him
        working in highly intellectually- demanding jobs.
       
       
    5. Remarks, if any:
    -------------------
    Based on review of records, condition of service, and history from veteran,
    it is my opinion that it is at least as likely as not that the veteran
    sustained a traumatic brain injury while serving in the military. The
    severity of the TBI is difficult to determine with certainty due to lack of
    documentation but based on his account would be considered mild to moderate.

    In regard to any residual symptoms of TBI, his main complaint is of memory
    and concentration problems. In addition to TBI he has comorbid psychological
    symptoms of PTSD and depression, as well as chronic sleep deprivation. While
    the Neuropsychological Testing performed in July 2015 did not show frank
    cognitive impairment, it did show mild cognitive inefficiency and slowing of
    processing speed. Given the nature of the TBI described and the duration
    since the event, as well as the presence of co-morbid conditions, it is my
    opinion that TBI sustained during military is less likely than not the
    predominant cause of the mild cognitive symptoms or the subjective and
    neurobehavioral facets that he is experiencing, although I cannot exclude
    that residuals from TBI are a minor contributing cause without resorting to
    speculation.

    See attached DBQ Headaches.

    Kendra Peterson, MD
    C&P Examiner (Board Certified Neurologist)
 

Edited by dgraham82

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USMC_VET    350

Pardon for the long post, but below are how they rate TBI...

8045   Residuals of traumatic brain injury (TBI): 
There are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 
Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” 
Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table 
Evaluate emotional/behavioral dysfunction under §4.130 (Schedule of ratings—mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” 
Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. 
The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under §4.25 the evaluations for each separately rated condition. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations 
Consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc 
Evaluation of Cognitive Impairment and Subjective Symptoms 
The table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled “total.” However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than “total,” since any level of impaired consciousness would be totally disabling. Assign a 100-percent evaluation if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. 
Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified” with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. 
Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. 
Note (3): “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. 
Note (4): The terms “mild,” “moderate,” and “severe” TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under diagnostic code 8045. 
Note (5): A veteran whose residuals of TBI are rated under a version of §4.124a, diagnostic code 8045, in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic code 8045. A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008. For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 CFR 3.114, if applicable. 
8046   Cerebral arteriosclerosis: 
Purely neurological disabilities, such as hemiplegia, cranial nerve paralysis, etc., due to cerebral arteriosclerosis will be rated under the diagnostic codes dealing with such specific disabilities, with citation of a hyphenated diagnostic code (e.g., 8046-8207). 
Purely subjective complaints such as headache, dizziness, tinnitus, insomnia and irritability, recognized as symptomatic of a properly diagnosed cerebral arteriosclerosis, will be rated 10 percent and no more under diagnostic code 9305. This 10 percent rating will not be combined with any other rating for a disability due to cerebral or generalized arteriosclerosis. Ratings in excess of 10 percent for cerebral arteriosclerosis under diagnostic code 9305 are not assignable in the absence of a diagnosis of multi-infarct dementia with cerebral arteriosclerosis. 
Note: The ratings under code 8046 apply only when the diagnosis of cerebral arteriosclerosis is substantiated by the entire clinical picture and not solely on findings of retinal arteriosclerosis. 

Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified

Facets of cognitive
impairment and other
residuals of TBI not
otherwise classified
Level of
impairment
Criteria
Memory, attention, concentration, executive functions0No complaints of impairment of memory, attention, concentration, or executive functions.
   1A complaint of mild loss of memory (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.
   2Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment.
   3Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment.
   TotalObjective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment.
Judgment0Normal.
   1Mildly impaired judgment. For complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.
   2Moderately impaired judgment. For complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions.
   3Moderately severely impaired judgment. For even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.
   TotalSeverely impaired judgment. For even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. For example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities.
Social interaction0Social interaction is routinely appropriate.
   1Social interaction is occasionally inappropriate.
   2Social interaction is frequently inappropriate.
   3Social interaction is inappropriate most or all of the time.
Orientation0Always oriented to person, time, place, and situation.
   1Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation.
   2Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation.
   3Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation.
   TotalConsistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation.
Motor activity (with intact motor and sensory system)0Motor activity normal.
   1Motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function).
   2Motor activity mildly decreased or with moderate slowing due to apraxia.
   3Motor activity moderately decreased due to apraxia.
   TotalMotor activity severely decreased due to apraxia.
Visual spatial orientation0Normal.
   1Mildly impaired. Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system).
   2Moderately impaired. Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS (global positioning system).
   3Moderately severely impaired. Gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system).
   TotalSeverely impaired. May be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment.
Subjective symptoms0Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples are: mild or occasional headaches, mild anxiety.
   1Three or more subjective 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 are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light.
   2Three 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.
Neurobehavioral effects0One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. Examples of neurobehavioral effects are: Irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects.
   1One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them.
   2One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them.
   3One 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.
Communication0Able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language.
   1Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas.
   2Inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time. Can generally communicate complex ideas.
   3Inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time. May rely on gestures or other alternative modes of communication. Able to communicate basic needs.
   TotalComplete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both. Unable to communicate basic needs.
ConsciousnessTotalPersistently altered state of consciousness, such as vegetative state, minimally responsive state, coma.

 

Basically what htey do is they go through all the different aspects of TBI and they rate you a 0-3 in each area, ie, communication, spatial orientation etc.

 

From what i can see in yours is that you are.

Memory - 1

Judgement - 0

Social interaction - 1

Orientation - 0

Motor activity - 0

Visual Spatial - 0

Subjective symptoms - 2

neurobehavioral - 1

communicaiton - 1

consciousness - 0

 

Residuals are rated at the highest number being what your residuals are rated as.  1= 10%, 2=40%, so roughly you should be rated at 40% for TBI residuals from what i can read.

However you have comorbid symptoms of PTSD and depression. 

They might try and shove of your TBI residuals in the terms of psychological or cognitive as already rated under PTSD and rate you at 0% TBI and keep your PTSD the same.  It is always hard when you get cases of TBI and PTSD together as often they show similar effects in terms of psychological and cognitive issues and its hard to seperate them (which is ridiculous as they are often the cause of each other, etc.).

I think you are good to go, but it will probably depend on how the decision ends up.  at best you will keep PTSD the same and get rated at 40% for TBI on top of it, at worst you could be same PTSD and 0% TBI, or they could giv eyou 40% tbi and reduce PTSD if they decide that TBI is the main cause of it.

I wish i could give you a better more black and white answer.  its hard to determine how the rater will read this.

 

 

 

 

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WhyMista    8

Where are people finding their C&P results because I looked for mine on myhealthevet and its not there and my C&P for TBI was done back in may or june.

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USMC_VET    350

Where are people finding their C&P results because I looked for mine on myhealthevet and its not there and my C&P for TBI was done back in may or june.

 

i have had this issue as well mine was in 06 and i am trying to find it to show that my level II screening was not valid (was not conducted by a doctor but civilian employees). 

It SHOULD be under my health e vet blue button, however if it is not and was done that far back make a records request through the hospital you went to.

 

Also was yours conducted at the VA by the VA or by a outside doctor?

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dgraham82    0

Where are people finding their C&P results because I looked for mine on myhealthevet and its not there and my C&P for TBI was done back in may or june.

I found my on myhealthevet under blue button

 

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WhyMista    8

 

 

i have had this issue as well mine was in 06 and i am trying to find it to show that my level II screening was not valid (was not conducted by a doctor but civilian employees). 

It SHOULD be under my health e vet blue button, however if it is not and was done that far back make a records request through the hospital you went to.

 

Also was yours conducted at the VA by the VA or by a outside doctor?

Mine was conducted through VES who handles the C&P exams down here.  Now right after I was hit by an IED we just got towed back to fallujah and then seen at Bn BAS by the corpsman.  I've also requested my c-file because they denied me based on the fact that there wasn't any evidence I was ever in an explosion...

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USMC_VET    350

Hey Brother, Fallujah was a shithole, sorry you got hit.

As far as evidenc eof being in a IED, i am in the same boat. 

I have requested from HQUSMC via FOIA the unit reports and records surrounding my incident, going on 3 months now.  I would FOIA for your unit records for the incident as well as reports from you units BN BAS regarding injuries in that 3 day window.  might take awhile.

I would also get buddy statements from a bunch of guys that were there especially your platoon corpsman that yes you got hit.  if you can remember the bn corpsman names that wer ein BAS and try and track them down as well.  get sworn declarations stating that hte incident occured and you were involved and you got seen by BAS.  this COULD and should be enough for the VA, but it may not, but could be enough for right now to submit as evidence and proof of inservice event.

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