C&P TBI Results are in!

Grumpbox · February 1, 2018

ALL - This post is extremely long, because in order for me to ask specific questions, I have to explain my past.

Current disabilities right from Ebenefits follow:

PTSD-Combat posttraumatic stress disorder and anxiety disorder, NOS (claimed with insomnia) with traumatic brain injury and vertigo (claimed with memory loss)	100%	Service Connected	Disability Evaluation System (DES)	08/28/2012
heart murmur		Not Service Connected	Disability Evaluation System (DES)
left Bell's Palsy		Not Service Connected	Disability Evaluation System (DES)
Hypertension	0%	Service Connected	Disability Evaluation System (DES)	11/23/2011
bilateral plantar fasciitis		Not Service Connected	Disability Evaluation System (DES)
Tinnitus	10%	Service Connected	Disability Evaluation System (DES)	11/23/2011
obstructive sleep apnea	50%	Service Connected	Disability Evaluation System (DES)	11/23/2011
degenerative disc disease with L5/S1 disc protrusion, lumbar spine	20%	Service Connected	Disability Evaluation System (DES)	11/23/2011
left knee strain		Not Service Connected	Disability Evaluation System (DES)
right hip degenerative arthritis	10%	Service Connected	Disability Evaluation System (DES)	11/23/2011
left ankle strain		Not Service Connected	Disability Evaluation System (DES)
right basal thumb arthritis	10%	Service Connected	Disability Evaluation System (DES)	11/23/2011
status post, right shoulder labral tear repair	10%	Service Connected	Disability Evaluation System (DES)	11/23/2011
bilateral high frequency sensorineural hearing loss	0%	Service Connected	Disability Evaluation System (DES)	11/23/2011
left hip degenerative arthritis	10%	Service Connected	Disability Evaluation System (DES)	11/23/2011
post concussive headaches	30%	Service Connected	Disability Evaluation System (DES)	11/23/2011
right renal cyst	0%	Service Connected	Disability Evaluation System (DES)	11/23/2011
erectile dysfunction	0%	Service Connected	Disability Evaluation System (DES)	11/23/2011

NOTICE!!! Above you will see that my PTSD and TBI are linked together. However, for VA rating purposes, TBI (mainly residuals) are rated separately. Also, note, I was MEDICALLY RETIRED from the US Army, 21 Nov 2011.

Currently (nor have I ever), I receive NO VA DISABILITY for TBI....

I am not P&T, IU, or anythings else, except 100% with disabilities listed service connected.

The only change to my ratings since retirement was my PTSD, which ONE year from retirement, the VA called me in for a PTSD C&P Exam, which was increased from 50% to 100%. The date for this increase is seen above for an "Effective Date."

Last Oct 2017, I was called to attend my FIVE YEAR C&P Exam for PTSD. The exam (C&P) results are posted on Hadit under the PTSD Forum. The PTSD C&P Exam prompted the most recent C&P TBI Exam, Jan 2018. The lady from the VA that called me to schedule the TBI C&P even told me this, how it was a, "Supplement Request" from my PTSD C&P.

I had no real issues with the TBI C&P Exam. The Lady was a Neurologist...she was professional, direct, and did not attempt to manipulate my input or answers. When she needed clarification, she did so without being rude and without being impatient. My exam took about 40mins.

Some of the main areas she addressed were:

Headaches

Vertigo

Hearing

Memory

Mood

One thing that caught me off-guard was that when we discussed areas where I already receive VA disabilities (vertigo, headaches, tinnitus), she would say, "Hold on...I see you already are receiving disability for that." I thought this was very strange, but I did not try to question her thought process or motives. But it did make me wonder this: If I am already receiving disability for these things, then why am at a TBI C&P Exam? Furthermore, in her comments it clearly says I have a mTBI; however, the doctor for my PTSD C&P shows I DO NOT. TO add, DOD never awarded me ratings for TBI when I was medically retired.....

As mentioned, this post is long. The results for the TBI Exam follow. However, one note: its mainly in three-four sections, and there are some repetitive entries so if it seems like a re-run of data, well, it is.

All feedback from anyone is always greatly appreciated and an honor from other Vets!!

LOCAL TITLE: C&P EXAMINATION

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: JAN 29, 2018@10:30 ENTRY DATE: JAN 29, 2018@11:17:39

AUTHOR: Xxxx, Xxxx, X. 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: Name Redacted

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

Evidence Comments:

2/10/11 TBI EXAM reviewed--Per a neurologist, Dr. Xxxxx. TBI diagnosed,

listed as date of onset 12/10/05. History states, "40 year old man who

states he had multiple lED blast exposures. The worst was in Dec. 2005,

while in Iraq. He was stunned, and had brief LOC. He was taken to a

local clinic. He felt he was OK and did not stay long at the clinic but

later he felt sick with nausea and headaches. He continued with his patrol that afternoon. He was also involved in other lED blasts." Did report vertigo.

7/20/11 CT of the brain without contrast

Impression: no acute intracranial abnormalities.

5/1/08 CT of the head

Reason for order: dizziness ha, imbalance this past wewek, after similar sx every other month since blast trauma in OIF in 2006. Current sc occur every day and ha last v8-10 yrs.

Impression: normal exam

4/14/09 MRI IAC

Impression: Normal bilateral internal auditory canals with no evidence of

left facial nerve abnormal enhancement or mass.

3/20/08 Problem list includes concussion with brief loss of

consciousness(under 1 hour) and postconcussion syndrome

10/14/10 Medical Evaluation Board

"PAST MEI)ICAL HISTC.RY: 1. History of Anxiety and possible Attention

Deficit Hyperactivity Disorder.

He has been, evaluated by Dr Xxxx on 21 September 2010 and it was

felt to' have significant Andety. 2. Veteran endorses some memory

difficulty. He has tO Write down most things that he does duting the day

or he wIll forget them. During: 1s deployment to Iraq he was Stunned many

timesby close proximity of blasts from improvised explosive devices TED's) and other explosions. He hadloss of consciousness very, briefly (seconds)

a few times during this deployment. The soldier does iOtthitik he has

traumatic brain injury and has been screened for this in the past and does

not have it. 3.Vet haS history of difficulty with sleep, espeially

since 2007 When, his wife noted he had increased snoring and his sleep was not restful On 29 October 2009 a sleep study was consistent with obstructive Sleep apnea and a repeat study to titrate the continuOus positive airway pressure (cPAP) was on 4 December 2009 and shows that the best CPAP pressure for this soldief is 8 cth of Water.With this therapy he does obtain reasonably good sleep..."

5/12/11 Medical evalution board proceedings

"..."VA DX": Concussions, medically acceptable..."

8 Jul 2010 A/P "1. DELAYED POSTTRAUMATIC STRESSDISORDER: Cyrnbalta-6Omg

but

discontinue Wlibutrin SR 450rng

2. DEPRESSION: Same-as #1

3. ATTENTION-DEFICIT HYPERACTIVITY DISORDER: Concerta..."

18 Sept 2007 PHYSICAL MEDICINE TBI

History-of present -illness. -

The Patient-is a 36 year old male. Source of patient information was

patient Pt here for memory robIems -since lED blast in Dec 2005 in Iraq.

Pt

statesmemory-.problems havebeen getting worse since Dec 2005. Pt states h

doesn't handle stress very well and he gets worked up really easy. Had

full

cardiac work up last month due to chest pain. Cardiac test were NL and pt

was told tht sxs were due to anxiety. Pt states he is an all or nothing

person and3 weeks has been a nothing person on the job because he decided to not allow things to get to him,

Date of Suspected Head Injury: Dec 2005

Period of loss of consciousness after injury: NO

[]Alteration in mental state (dazed, confused, disoriented) at time of

accident/injury [)Loss of memory for events immediately before or after

accident/injury..."

"...Neurological symptoms: No lightheadedness, no dizziness recently but

had 3 ocurrences since blast in Dec 2005, and no vertigo.

No convulsions and no fainting. No decrease in concentrating ability.

Slowed rate of thinking, racing thoughts, and thinking

two thoughts at the same time with alotof stress. No confusion or

disorientation. Memory lapses or loss has had problems

remembering ST information since lED blast in 2005. No speech

difficulties,

no difficulty writing, no motor disturbances, and

no ataxia. Good coordination.

Psychological symptoms: Anxiety..."

"...A/P 1. Concussion with brief LOSS OF cONscIOuSNESS (UNDER 1-

HOUR):.Although Veteran likely experienced a concussive injury-in an lED blast in Dec.2005, it does not--appear likely that he sustained brain injujy of sufficiCnt severity to produce residual symptoms as seen in the-current evaluation,[irritability and memory lapse]. Given-the severity of his psychiatric symptoms at the current: time, it appears likely that his. Cognitive difficufties are the result of, or in the very -least exac-erbated by, .his psychiatric disorder. Mental health counseling randSSRI RX is

strongly-recommended to ensure that his symptoms of Anxiety are optimally

managed. Pt-was given an appt-With speech pathologist to work on memory

strategies. F/ U by TBI team is not warranted..."

3/16/09 ENT note indicates pt had vacation to Disney World last week, with prodromic sx (abnl tasts in mouth, oral incontinence, and left crocodile

tears) then on 9 Mar had flushing overheated feeling followed by LOC and left complete facial paralysis...A/P 1. Bell's palsy..."

12 Sep 2007

"...POSTCONCUSSION SYNDROME

Consult(s): -Referred To: TBI TEAM (Routine) Specialty: PHYSICAL MEDICINE

&

REHABILITATION Clinic:PHYSICAL MEDICINE TBI Primary Diagnosis:

POSTCONCUSSION SYNDROME Ordered By:

- Xxxxx, Xxxxx..."

9/17/07 Physical Medicine TBI

Initial visit for TBI program.

"The Patient is a 36 year old male. Source of patient information w as

patient Pt here for memory problems since IED blast in Dec 2005 in Iraq.

Pt states memory problems have been getting w orse since Dec 2005. Pt states

he doesn't handle stress very well and he gets worked up really easy.

Had full cardiac work up last month due to chest pain. Cardiac test w ere NL

and pt was told that sxs were due to anxiety. Pt states he is an all or

nothing person and in the past 3 wks has been a nothing person on the job

because he decided to not allow things get to him..."

"...no dizziness recently but had 3 ocurrences since blast in Dec 2005,

And no vertigo. No convulsions and no fainting. No decrease in concentrating

ability. Slowed rate of thinking, racing thoughts, and thinking two

thoughts at the same time with alot of stress. No confusion or disorientation. Memory lapses or loss has had problems remembering ST information since IED blast in 2005. No speech difficulties, no difficulty

writing, no motor disturbances, and no ataxia. Good coordination..."

"...A/P

1. Concussion with brief loss of consciousness (under 1 hour). Although

Veteran likely experienced a concussive injury in an IED blast in Dec 2005, it does not appear likely that he sustained a brain injury of sufficient severity to produce residual symptoms as seen in the current evaluation,[ irritability and memory lapse]. Given the severity of his psychiatric symptoms at the current time, it appears likely that his cognitive difficulties are the result of, or in the very least exacerbated by, his psychiatric disorder. Mental health counseling and SSRI RX is strongly recommended to ensure that his symptoms of Anxiety are optimally managed. Pt was given an appt with speech pathologist to work on memory strategies. F/ U by TBI team is not warranted..."

27 May 2008 "c/c feeling dizzy off and on since 2006,and ringing of

both ears"

"FOR ABOUT A YEAR FEELING ANXIOUS, NOW HATES HIS JOB, LOSS OF INTEREST IN

USUAL

THINGS, MARRAGE APATHY, SYMPTOMS RARELY OF PANIC ATTACKS. INC ETOH-NOW BY

SELF REPORT 6

BEERS/NITE. NOT SUICIDAL UNDERGOING WIU FOR TBI -HX OF SIG BLAST EXPOSURES

RARE LOSS OF BALANCE BRIEF EPISODES ("DIZZINESS")-USUALLY PRECEDED BY

FEELING PANIC SENSATION..."

SECTION I: Diagnosis and medical history

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

If you are making the initial diagnosis of TBI or if you are stating that

The claimant does not meet the criteria for a diagnosis of TBI, please indicate your specialty:

[X] Neurologist

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: mTBI

[X] Other diagnosed residuals attributable to TBI, specify:

Other diagnosis #1: vertigo

Other diagnosis #2: headache

2. Medical history

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

Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary):

Veteran was exposed to multiple blasts, the most significant was in

2005 while in Iraq. He has "spotty memory" of the event. He knows that the battalion commander said it was the largest IED to date. He recalls it was

cold that morning and they were rolling down a hill susceptible to being hit. He does not recall if he was outside the stryker vehicle or not. He

has no memory of the explosion and next memory was having mixed emotions and rage, scared, and lots of screaming in the area about which security

had already been established. He felt like he wanted to cry and that he had been blessed but didn't want to do that in front of his soldiers. This

was a few minutes after the blast. He does not know if he had LOC or not.

He was told that his helmet was knocked off and he was yanked inside the

vehicle when it stopped. He was confused after the blast which lasted an

an unclear period of time that day. He recalls going to sleep and having a

very bad dream, awakening w nausea. His squad leader made him go to see

the medics. He did not want to go because they were "handing out purple

hearts" and he didn't want that. Since this event, he has had headaches at times. He also reports having difficulty with his memory.

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):

He has difficulty with short and long term memory. He recalls an

incident after the blast during the deployment he had to report a head count,

and had to start writing on his hand the numbers that he previously could

recall without writing it down. He has to write things down to remember

to get them at the store. Sometimes even if he writes it down he forgets

it anyway. He is not seeing anyone about this at this point.

Standardized cognitive screening was within normal limits at 28/30. The

effects of PTSD and TBI cannot be fully differenitated without resorting

to speculation with respect to these symptoms.

2. Judgment

-----------

[X] Normal

3. Social interaction

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

[X] Social interaction is frequently inappropriate

If the Veteran's social interaction is not routinely appropriate,

describe (brief summary):

He reports half of the time his interactions would be inappropriate

related to his irritability. He is "short" with others and lacks

patience. He may say things or give others a look which seem in anger.

The effects of PTSD and TBI cannot be fully differenitated without

resorting to speculation with respect to these symptoms.

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] Moderately 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)

If the Veteran has impaired visual spatial orientation, describe (brief

summary):

He sometimes has trouble with maps and directions. He has used a GPS

but

has trouble with it at times. The effects of PTSD and TBI cannot be

fully differenitated without resorting to speculation with respect to

these symptoms.

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):

headache with assoc light and noise sensitivity and nausea

memory loss

vertigo

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):

He endorses irritability, poor frustration tolerance, and mood swings.

He

will sometimes get into verbal arguments with others. He states that he

has been fired in the past related to this. The effects of PTSD and TBI

cannot be fully differenitated without resorting to speculation with

respect to these symptoms.

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] Headaches, including Migraine headaches

[X] Dizziness/vertigo

2. Other pertinent physical findings, scars, complications, conditions,

signs, symptoms and scars

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

a. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms related to any conditions

listed in the Diagnosis Section above?

[ ] Yes [X] No

b. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

Section above?

[ ] Yes [X] No

c. Comments, if any:

No response provided

3. Diagnostic testing

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

a. Has neuropsychological testing been performed?

[ ] Yes [X] No

b. 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:

His headaches would cause him to have frequent absences from work in

either a physical or sedentary occupation. His vertigo would negatively

impact his ability to do work at heights.

His reported memory loss would reduce his work efficiency and

productivity. His neurobehavioral symptoms would have a negative impact

on his relationships and interactions with others in an occupational

setting. The effects of his PTSD and TBI on his behavioral and cognitive

symptoms cannot be fully differentiated without resorting to

speculation.

5. Remarks, if any:

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

No remarks provided.

****************************************************************************

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran:

ACE and Evidence Review

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

Indicate method used to obtain medical information to complete this

document:

[X] In-person examination

Evidence Review

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

Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA)

[X] CPRS

Evidence Comments:

2/10/11 TBI EXAM reviewed--Per a neurologist, Dr. Xxxxx. TBI diagnosed,

listed as date of onset 12/10/05. History states, "40 year old man who

states he had multiple lED blast exposures. The worst was in Dec. 2005,

wwhile in Iraq. He was stunned, and had brief LOC. He was taken to a local

clinic. He felt he was OK and did not stay long at the clinic but later he

felt sick with nausea and headaches. He continued with his patrol that

afternoon. He was also involved in other lED blasts." Did report vertigo.

7/20/11 CT of the brain without contrast

Impression: no acute intracranial abnormalities.

5/1/08 CT of the head

Reason for order: dizziness ha, imbalance this past wewek, after similar

sx

every other month since blast trauma in OIF in 2006. Current sc occur

every

day and ha last v8-10 yrs.

Impression: normal exam

4/14/09 MRI IAC

Impression: Normal bilateral internal auditory canals with no evidence of

left facial nerve abnormal enhancement or mass.

3/20/08 Problem list includes concussion with brief loss of consciousness

(under 1 hour) and postconcussion syndrome

10/14/10 Medical Evaluation Board

"PAST MEI)ICAL HISTC.RY: 1. History of Anxiety and possible Attention

Deficit Hyperactivity

Disorder. He has been, evaluated by Dr Xxxxx on 21 September 2010 and it was

felt to' have significant Andety. 2. Veteran endorses some memory

difficulty. He has tO Write down most things that he does duting the day

or

he wIll forget them. During: 1s deployment to Iraq he was Stunned many

timesby close proximity of blasts from improvised explosive devices

(TED's)

and other explosions. He had loss of consciousness very, briefly (seconds)

a

few times during this deployment. The soldier does iOtthitik he has

traumatic brain injury and has been screened for this in the past and does

not have it. 3.Veteran haS hlstori of difficulty with sleep, espeially

since 2007 When, his wife noted he had

increased snoring and his sleep was not restful On 29 October 2009 a sleep

study was consistent with obstructive Sleep apnea and a repeat study to

titrate the continuOus positive airway pressure (cPAP) was on 4 December

2009 and shows that the best CPAP pressure for this soldief is 8 cth of

Water.With this therapy he does obtain reasonably good sleep..."

5/12/11 Medical evalution board proceedings

"..."VA DX": Concussions, medically acceptable..."

8 Jul 2010 A/P "1. DELAYED POSTTRAUMATIC STRESSDISORDER: Cyrnbalta-6Omg

but

discontinue Wlibutrin SR 450rng

2. DEPRESSION: Same-as #1

3. ATTENTION-DEFICIT HYPERACTIVITY DISORDER: Concerta..."

18 Sept 2007 PHYSICAL MEDICINE TBI

History-of present -illness. -

The Patient-is a 36 year old male. Source of patient information was

patient Pt here for memory robIems -since lED blast in Dec 2005 in Iraq.

Pt

statesmemory-.problems havebeen getting worse since Dec 2005. Pt states h

doesn't handle stress very well and he gets worked up really easy. Had

full

cardiac work up last month due to chest pain. Cardiac test were NL and pt

was told tht sxs were due to anxiety. Pt states he is an all or nothing

person and3 weeks hasbeen a nothing person on the job because he decided

to

not allow things to get to him,

Date of Suspected Head Injury: Dec 2005

Period of loss of consciousness after injury: NO

[]Alteration in mental state (dazed, confused, disoriented) at time of

accident/injury

[)Loss of memory for events immediately before or after

accident/injury..."

"...Neurological symptoms: No lightheadedness, no dizziness recently but

had 3 ocurrences since blast in Dec 2005, and no vertigo.

No convulsions and no fainting. No decrease in concentrating ability.

Slowed rate of thinking, racing thoughts, and thinking

two thoughts at the same time with alotof stress. No confusion or

disorientation. Memory lapses or loss has had problems

remembering ST information since lED blast in 2005. No speech

difficulties,

no difficulty writing, no motor disturbances, and

no ataxia. Good coordination.

Psychological symptoms: Anxiety..."

"...A/P 1. Concussion with brief LOSS OF cONscIOuSNESS (UNDER 1-

HOUR):.Although Veteran likely xperienced a concussive injury-in an lED blast in

Dec.2005, it does not--appear likely that he sustained brain injujy of

sufficiCnt severity to

produce residual symptoms as seen in the-current evaluation,[irritablity

and memory lapse]. Given-the severity of his psychiatric symptoms at the

current: time, it appears likely that his. cognitivedifficufties are the

resultof, or in the very -least exac-erbated by, .his

psychiatric disorder. Mental health counseling randSSRI RX is

strongly-recommended to ensure that his symptoms of Anxiety are optimally

managed. Pt-was given an appt-With speech pathologist to work on memory

strategies. F/ U by TBI team is not warranted..."

3/16/09 ENT note indicates pt had vacation to Disney World last week, with

prodromic sx (abnl tasts in mouth, oral incontinence, and left crocodile

tears) then on 9 Mar had flushing overheated feeling followed by LOC and

left complete facial paralysis...A/P 1. Bell's palsy..."

12 Sep 2007

"...POSTCONCUSSION SYNDROME

Consult(s): -Referred To: TBI TEAM (Routine) Specialty: PHYSICAL MEDICINE

&

REHABILITATION Clinic:PHYSICAL MEDICINE TBI Primary Diagnosis:

POSTCONCUSSION SYNDROME Ordered By:

- Xxxxxx, Xxxxx..."

9/17/07 Physical Medicine TBI

Initial visit for TBI program.

"The Patient is a 36 year old male. Source of patient information w as

patient Pt here for memory problems since IED blast in Dec 2005 in Iraq.

Pt

states memory problems have been getting worse since Dec 2005. Pt states

he doesn't handle stress very w ell and he gets w orked up really easy.

Had

full cardiac w ork up last month due to chest pain. Cardiac test w ere NL

and pt w as told that sxs w ere due to anxiety. Pt states he is an all or

nothing person and in the past 3 w ks has been a nothing person on the job

because he decided to not allow things get to him..."

"...no dizziness recently but had 3 ocurrences since blast in Dec 2005,

and

no

vertigo. No convulsions and no fainting. No decrease in concentrating

ability. Slow ed rate of thinking, racing thoughts, and thinking tw o

thoughts at the same time w ith alot of stress. No confusion or

disorientation. Memory lapses or loss has had problems remembering ST

information since IED blast in 2005. No speech difficulties, no difficulty

w riting, no motor disturbances, and no ataxia. Good coordination..."

"...A/P

1. Concussion with brief loss of consciousness (under 1 hour). Although

Veteran likely experienced a

concussive injury in an IED blast in Dec 2005, it does not appear likely

that he sustained a brain injury of sufficient severity to produce

residual

symptoms as seen in the current evaluation,[ irritability and memory

lapse]. Given the severity of his psychiatric

symptoms at the current time, it appears likely that his cognitive

difficulties are the result of, or in the very least exacerbated by,his

psychiatric disorder. Mental health counseling and SSRI RX is strongly

recommended to ensure that his symptoms of Anxiety

are optimally managed. Pt w as given an appt w ith speech pathologist to w

ork on memory strategies. F/ U by TBI team is not warranted..."

27 May 2008 "c/c feeling dizzy off and on since 2006,and ringing of

both ears"

"FOR ABOUT A YEAR FEELING ANXIOUS, NOW HATES HIS JOB, LOSS OF INTEREST IN

USUAL

THINGS, MARRAGE APATHY, SYMPTOMS RARELY OF PANIC ATTACKS. INC ETOH-NOW BY

SELF REPORT 6

BEERS/NITE. NOT SUICIDAL UNDERGOING WIU FOR TBI -HX OF SIG BLAST EXPOSURES

RARE LOSS OF BALANCE BRIEF EPISODES ("DIZZINESS")-USUALLY PRECEDED BY

FEELING PANIC SENSATION..."

(RIGHT HERE IS WHERE I NEED SOME REAL INPUT IN THE COMMENTS THE TBI DOCTOR PENNED)

MEDICAL OPINION SUMMARY

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

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: DBQ NEURO TBI Initial:

Please review the Veteran's electronic folder in VBMS and state that it was

reviewed in your report.

MEDICAL OPINION REQUEST

TYPE OF MEDICAL OPINION REQUESTED: Direct service connection

OPINION: Direct service connection

Does the Veteran have a diagnosis of (a) TBI/Vertigo that is at least as

likely as not (50 percent or greater probability) incurred in or caused by

(the) TBI/Vertigo during service?

(WHAT DOES THIS MEAN ABOVE???????)

Rationale must be provided in the appropriate section.

If the Veteran has a co-existing psychiatric condition, please state, to the

extent possible, which emotional/behavioral signs and symptoms are part of

a co-morbid mental disorder and which represent residuals of TBI. If it is

impossible to make such a determination without speculation, please state

so.

Additional remarks for the examiner:

Opinion Evidence and Evaluation is needed to see if separate rating is

needed for TBI/Vertigo

b. Indicate type of exam for which opinion has been requested: TBI INITIAL

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

a. The condition claimed was at least as likely as not (50% or greater

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: The STR's and prior compensation and pension examination are

supportive of the claimed TBI related to service. His problem list in the

STR's contains the diagnoses of concussion and postconcussion syndrome. In

2007 he reported having had dizziness for a year. Prior TBI Initial exam

performed by a neurologist in 2010 reflects diagnosis of TBI. Vertigo is

also

listed as one of the symptoms.

*************************************************************************

****************************************************************************

Ear Conditions

(including Vestibular and Infectious Conditions)

Disability Benefits Questionnaire

Name of patient/Veteran:

Is this DBQ being completed in conjunction with a VA 21-2507, C&P

Examination

Request?

[X] Yes[ ] No

ACE and Evidence Review

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

Indicate method used to obtain medical information to complete this

document:

[X] In-person examination

Evidence Review

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

Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA)

[X] CPRS

Evidence Comments:

2/10/11 TBI EXAM reviewed--Per a neurologist, Dr. Xxxxx. TBI diagnosed,

listed as date of onset 12/10/05. History states, "40 year old man who

states he had multiple lED blast exposures. The worst was in Dec. 2005,

wwhile in Iraq. He was stunned, and had brief LOC. He was taken to a local

clinic. He felt he was OK and did not stay long at the clinic but later

he

felt sick with nausea and headaches. He continued with his patrol that

afternoon. He was also involved in other lED blasts." Did report vertigo.

7/20/11 CT of the brain without contrast

Impression: no acute intracranial abnormalities.

5/1/08 CT of the head

Reason for order: dizziness ha, imbalance this past wewek, after similar

sx

every other month since blast trauma in OIF in 2006. Current sc occur

every

day and ha last v8-10 yrs.

Impression: normal exam

4/14/09 MRI IAC

Impression: Normal bilateral internal auditory canals with no evidence of

left facial nerve abnormal enhancement or mass.

3/20/08 Problem list includes concussion with brief loss of consciousness

(under 1 hour) and postconcussion syndrome

10/14/10 Medical Evaluation Board

"PAST MEI)ICAL HISTC.RY: 1. History of Anxiety and possible Attention

Deficit Hyperactivity

Disorder. He has been, evaluated by Dr Xxxxx on 21 September 2010 and it was

felt to' have significant Andety. 2. Veteran endorses some memory

difficulty. He has tO Write down most things that he does duting the day

or

he wIll forget them. During: 1s deployment to Iraq he was Stunned many

timesby close proximity of blasts from improvised explosive devices

(TED's)

and other explosions. He hadloss of consciousness very, briefly (seconds)

a

few times during this deployment. The soldier does iOtthitik he has

traumatic brain injury and has been screened for this in the past and does

not have it. 3.Veteran haS hlstori of difficulty with sleep, espeially

since 2007 When, his wife noted he had

increased snoring and his sleep was not restful On 29 October 2009 a sleep

study was consistent with obstructive Sleep apnea and a repeat study to

titrate the continuOus positive airway pressure (cPAP) was on 4 December

2009 and shows that the best CPAP pressure for this soldief is 8 cth of

Water.With this therapy he does obtain reasonably good sleep..."

5/12/11 Medical evalution board proceedings

"..."VA DX": Concussions, medically acceptable..."

8 Jul 2010 A/P "1. DELAYED POSTTRAUMATIC STRESSDISORDER: Cyrnbalta-6Omg

but

discontinue Wlibutrin SR 450rng

2. DEPRESSION: Same-as #1

3. ATTENTION-DEFICIT HYPERACTIVITY DISORDER: Concerta..."

18 Sept 2007 PHYSICAL MEDICINE TBI

History-of present -illness. -

The Patient-is a 36 year old male. Source of patient information was

patient Pt here for memory robIems -since lED blast in Dec 2005 in Iraq.

Pt

statesmemory-.problems havebeen getting worse since Dec 2005. Pt states h

doesn't handle stress very well and he gets worked up really easy. Had

full

cardiac work up last month due to chest pain. Cardiac test were NL and pt

was told tht sxs were due to anxiety. Pt states he is an all or nothing

person and3 weeks hasbeen a nothing person on the job because he decided

to

not allow things to get to him,

Date of Suspected Head Injury: Dec 2005

Period of loss of consciousness after injury: NO

[]Alteration in mental state (dazed, confused, disoriented) at time of

accident/injury

[)Loss of memory for events immediately before or after

accident/injury..."

"...Neurological symptoms: No lightheadedness, no dizziness recently but

had 3 ocurrences since blast in Dec 2005, and no vertigo.

No convulsions and no fainting. No decrease in concentrating ability.

Slowed rate of thinking, racing thoughts, and thinking

two thoughts at the same time with alotof stress. No confusion or

disorientation. Memory lapses or loss has had problems

remembering ST information since lED blast in 2005. No speech

difficulties,

no difficulty writing, no motor disturbances, and

no ataxia. Good coordination.

Psychological symptoms: Anxiety..."

"...A/P 1. Concussion with brief LOSS OF cONscIOuSNESS (UNDER 1-

HOUR):.Although Veteran likely xperienced a concussive injury-in an lED blast in

Dec.2005, it does not--appear likely that he sustained brain injujy of

sufficiCnt severity to

produce residual symptoms as seen in the-current evaluation,[irritablity

and memory lapse]. Given-the severity of his psychiatric symptoms at the

current: time, it appears likely that his. cognitivedifficufties are the

resultof, or in the very -least exac-erbated by, .his

psychiatric disorder. Mental health counseling randSSRI RX is

strongly-recommended to ensure that his symptoms of Anxiety are optimally

managed. Pt-was given an appt-With speech pathologist to work on memory

strategies. F/ U by TBI team is not warranted..."

3/16/09 ENT note indicates pt had vacation to Disney World last week, with

prodromic sx (abnl tasts in mouth, oral incontinence, and left crocodile

tears) then on 9 Mar had flushing overheated feeling followed by LOC and

left complete facial paralysis...A/P 1. Bell's palsy..."

12 Sep 2007

"...POSTCONCUSSION SYNDROME

Consult(s): -Referred To: TBI TEAM (Routine) Specialty: PHYSICAL MEDICINE

&

REHABILITATION Clinic:PHYSICAL MEDICINE TBI Primary Diagnosis:

POSTCONCUSSION SYNDROME Ordered By:

- Xxxxx, Xxxxx..."

9/17/07 Physical Medicine TBI

Initial visit for TBI program.

"The Patient is a 36 year old male. Source of patient information w as

patient Pt here for memory problems since IED blast in Dec 2005 in Iraq.

Pt

states memory problems have been getting w orse since Dec 2005. Pt states

he doesn't handle stress very w ell and he gets w orked up really easy.

Had

full cardiac w ork up last month due to chest pain. Cardiac test w ere NL

and pt w as told that sxs w ere due to anxiety. Pt states he is an all or

nothing person and in the past 3 w ks has been a nothing person on the job

because he decided to not allow things get to him..."

"...no dizziness recently but had 3 ocurrences since blast in Dec 2005,

and

no

vertigo. No convulsions and no fainting. No decrease in concentrating

ability. Slow ed rate of thinking, racing thoughts, and thinking tw o

thoughts at the same time w ith alot of stress. No confusion or

disorientation. Memory lapses or loss has had problems remembering ST

information since IED blast in 2005. No speech difficulties, no difficulty

w riting, no motor disturbances, and no ataxia. Good coordination..."

"...A/P

1. Concussion with brief loss of consciousness (under 1 hour). Although

Veteran likely experienced a

concussive injury in an IED blast in Dec 2005, it does not appear likely

that he sustained a brain injury of sufficient severity to produce

residual

symptoms as seen in the current evaluation,[ irritability and memory

lapse]. Given the severity of his psychiatric

symptoms at the current time, it appears likely that his cognitive

difficulties are the result of, or in the very least exacerbated by,his

psychiatric disorder. Mental health counseling and SSRI RX is strongly

recommended to ensure that his symptoms of Anxiety

are optimally managed. Pt w as given an appt w ith speech pathologist to work on memory strategies. F/ U by TBI team is not warranted..."

27 May 2008 "c/c feeling dizzy off and on since 2006,and ringing of

both ears"

"FOR ABOUT A YEAR FEELING ANXIOUS, NOW HATES HIS JOB, LOSS OF INTEREST IN

USUAL

THINGS, MARRAGE APATHY, SYMPTOMS RARELY OF PANIC ATTACKS. INC ETOH-NOW BY

SELF REPORT 6

BEERS/NITE. NOT SUICIDAL UNDERGOING WIU FOR TBI -HX OF SIG BLAST EXPOSURES

RARE LOSS OF BALANCE BRIEF EPISODES ("DIZZINESS")-USUALLY PRECEDED BY

FEELING PANIC SENSATION..."

1. Diagnosis

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

Does the Veteran now have or has he/she ever been diagnosed with an ear or peripheral vestibular condition? Yes

Benign Paroxysmal Positional Vertigo (BPPV)

2. Medical history

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

Description of the history (including onset and course) of the Veteran's ear

or peripheral vestibular condition: He describes having occ episodes where

his surroundings appear to be spinning. He recalls having these in the

middle

of the day when they were leaving AK and it scared him. There were a couple

of times that he had it "back to back" and the last one was 6-9 months ago

when he was on the back porch and went to walk to his car. They last for

seconds at a time. He has not seen a provider about these. He may have some

dizziness briefly triggered by turning fast or looking up to a high shelf.

Does the Veteran's treatment plan include taking continuous medication for

the diagnosed condition: No

3. Vestibular conditions

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

Does the Veteran have any of the following findings, signs or symptoms

attributable to Meniere's syndrome (endolymphatic hydrops), a peripheral

vestibular condition or another diagnosed condition from Section 1: Yes

Vertigo

Frequency: 1 to 4 times per month Duration of episodes: <1 hour

Staggering

Frequency: 1 to 4 times per month Duration of episodes: <1 hour

4. Infectious, inflammatory and other ear conditions

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

Does the Veteran have any of the following findings, signs or symptoms

attributable to chronic ear infection, inflammation, cholesteatoma or any of

the diagnoses in Section 1: No

5. Surgical treatment

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

Has the Veteran had surgical treatment for any ear condition: No

6. Physical exam

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

External ear:

Normal

Ear canal:

Normal

Tympanic membrane:

Normal

Gait:

Normal

Romberg test:

Normal or negative

Dix Hallpike test (Nylen-Barany test) for vertigo:

Exam using this test not indicated

Limb coordination test (finger-nose-finger):

Normal

7. Tumors and neoplasms

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

Does the Veteran have a benign or malignant neoplasm or metastases related

to any of the diagnoses in the Diagnosis section: No

8. 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 response provided

9. Diagnostic testing

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

Have diagnostic imaging studies or other diagnostic procedures been

performed: No

Has the Veteran had an audiogram: Yes

Attach or provide results: He has had a separate evalaution for tinnitus

and impaired hearing.

Are there any other significant diagnostic test findings and/or results: No

10. Functional impact

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

Do any of the Veteran's ear or peripheral vestibular conditions impact his

or

her ability to work? Yes

Describe impact of each of the Veteran's ear or peripheral vestibular

conditions, providing one or more examples: His vertigo would

negatively

impact his ability to do work at heights.

11. Remarks, if any: No response provided

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

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran's

application.

****************************************************************************

Headaches (including Migraine Headaches)

Disability Benefits Questionnaire

Name of patient/Veteran:

Is this DBQ being completed in conjunction with a VA 21-2507, C&P

Examination

Request?

[X] Yes [ ] No

ACE and Evidence Review

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

Indicate method used to obtain medical information to complete this

document:

[X] In-person examination

Evidence Review

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

Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA)

[X] CPRS

Evidence Comments:

2/10/11 TBI EXAM reviewed--Per a neurologist, Dr. Xxxxx. TBI diagnosed,

listed as date of onset 12/10/05. History states, "40 year old man who

states he had multiple lED blast exposures. The worst was in Dec. 2005,

wwhile in Iraq. He was stunned, and had brief LOC. He was taken to a local

clinic. He felt he was OK and did not stay long at the clinic but later he

felt sick with nausea and headaches. He continued with his patrol that

afternoon. He was also involved in other lED blasts." Did report vertigo.

7/20/11 CT of the brain without contrast

Impression: no acute intracranial abnormalities.

5/1/08 CT of the head

Reason for order: dizziness ha, imbalance this past wewek, after similar

sx

every other month since blast trauma in OIF in 2006. Current sc occur

every

day and ha last v8-10 yrs.

Impression: normal exam

4/14/09 MRI IAC

Impression: Normal bilateral internal auditory canals with no evidence of

left facial nerve abnormal enhancement or mass.

3/20/08 Problem list includes concussion with brief loss of consciousness

(under 1 hour) and postconcussion syndrome

10/14/10 Medical Evaluation Board

"PAST MEI)ICAL HISTC.RY: 1. History of Anxiety and possible Attention

Deficit Hyperactivity

Disorder. He has been, evaluated by Dr Xxxxx on 21 September 2010 and it was

felt to' have significant Andety. 2. Veteran endorses some memory

difficulty. He has tO Write down most things that he does duting the day

or

he wIll forget them. During: 1s deployment to Iraq he was Stunned many

timesby close proximity of blasts from improvised explosive devices

(TED's)

and other explosions. He hadloss of consciousness very, briefly (seconds)

a

few times during this deployment. The soldier does iOtthitik he has

traumatic brain injury and has been screened for this in the past and does

not have it. 3.Veteran haS hlstori of difficulty with sleep, espeially

since 2007 When, his wife noted he had

increased snoring and his sleep was not restful On 29 October 2009 a sleep

study was consistent with obstructive Sleep apnea and a repeat study to

titrate the continuOus positive airway pressure (cPAP) was on 4 December

2009 and shows that the best CPAP pressure for this soldief is 8 cth of

Water.With this therapy he does obtain reasonably good sleep..."

5/12/11 Medical evalution board proceedings

"..."VA DX": Concussions, medically acceptable..."

8 Jul 2010 A/P "1. DELAYED POSTTRAUMATIC STRESSDISORDER: Cyrnbalta-6Omg

but

discontinue Wlibutrin SR 450rng

2. DEPRESSION: Same-as #1

3. ATTENTION-DEFICIT HYPERACTIVITY DISORDER: Concerta..."

18 Sept 2007 PHYSICAL MEDICINE TBI

History-of present -illness. -

The Patient-is a 36 year old male. Source of patient information was

patient Pt here for memory robIems -since lED blast in Dec 2005 in Iraq.

Pt

statesmemory-.problems havebeen getting worse since Dec 2005. Pt states h

doesn't handle stress very well and he gets worked up really easy. Had

full

cardiac work up last month due to chest pain. Cardiac test were NL and pt

was told tht sxs were due to anxiety. Pt states he is an all or nothing

person and3 weeks hasbeen a nothing person on the job because he decided

to

not allow things to get to him,

Date of Suspected Head Injury: Dec 2005

Period of loss of consciousness after injury: NO

[]Alteration in mental state (dazed, confused, disoriented) at time of

accident/injury

[)Loss of memory for events immediately before or after

accident/injury..."

"...Neurological symptoms: No lightheadedness, no dizziness recently but

had 3 ocurrences since blast in Dec 2005, and no vertigo.

No convulsions and no fainting. No decrease in concentrating ability.

Slowed rate of thinking, racing thoughts, and thinking

two thoughts at the same time with alotof stress. No confusion or

disorientation. Memory lapses or loss has had problems

remembering ST information since lED blast in 2005. No speech

difficulties,

no difficulty writing, no motor disturbances, and

no ataxia. Good coordination.

Psychological symptoms: Anxiety..."

"...A/P 1. Concussion with brief LOSS OF cONscIOuSNESS (UNDER 1-

HOUR):.Although Veteran likely xperienced a concussive injury-in an lED blast in

Dec.2005, it does not--appear likely that he sustained brain injujy of

sufficiCnt severity to

produce residual symptoms as seen in the-current evaluation,[irritablity

and memory lapse]. Given-the severity of his psychiatric symptoms at the

current: time, it appears likely that his. cognitivedifficufties are the

resultof, or in the very -least exac-erbated by, .his

psychiatric disorder. Mental health counseling randSSRI RX is

strongly-recommended to ensure that his symptoms of Anxiety are optimally

managed. Pt-was given an appt-With speech pathologist to work on memory

strategies. F/ U by TBI team is not warranted..."

3/16/09 ENT note indicates pt had vacation to Disney World last week, with

prodromic sx (abnl tasts in mouth, oral incontinence, and left crocodile

tears) then on 9 Mar had flushing overheated feeling followed by LOC and

left complete facial paralysis...A/P 1. Bell's palsy..."

12 Sep 2007

"...POSTCONCUSSION SYNDROME

Consult(s): -Referred To: TBI TEAM (Routine) Specialty: PHYSICAL MEDICINE

&

REHABILITATION Clinic:PHYSICAL MEDICINE TBI Primary Diagnosis:

POSTCONCUSSION SYNDROME Ordered By:

- Xxxxx, Xxxxx..."

9/17/07 Physical Medicine TBI

Initial visit for TBI program.

"The Patient is a 36 year old male. Source of patient information w as

patient Pt here for memory problems since IED blast in Dec 2005 in Iraq.

Pt

states memory problems have been getting w orse since Dec 2005. Pt states

he doesn't handle stress very w ell and he gets w orked up really easy.

Had

full cardiac w ork up last month due to chest pain. Cardiac test w ere NL

and pt w as told that sxs w ere due to anxiety. Pt states he is an all or

nothing person and in the past 3 w ks has been a nothing person on the job

because he decided to not allow things get to him..."

"...no dizziness recently but had 3 ocurrences since blast in Dec 2005,

and

no

vertigo. No convulsions and no fainting. No decrease in concentrating

ability. Slow ed rate of thinking, racing thoughts, and thinking tw o

thoughts at the same time w ith alot of stress. No confusion or

disorientation. Memory lapses or loss has had problems remembering ST

information since IED blast in 2005. No speech difficulties, no difficulty

w riting, no motor disturbances, and no ataxia. Good coordination..."

"...A/P

1. Concussion with brief loss of consciousness (under 1 hour). Although

Veteran likely experienced a

concussive injury in an IED blast in Dec 2005, it does not appear likely

that he sustained a brain injury of sufficient severity to produce

residual

symptoms as seen in the current evaluation,[ irritability and memory

lapse]. Given the severity of his psychiatric

symptoms at the current time, it appears likely that his cognitive

difficulties are the result of, or in the very least exacerbated by,his

psychiatric disorder. Mental health counseling and SSRI RX is strongly

recommended to ensure that his symptoms of Anxiety

are optimally managed. Pt w as given an appt w ith speech pathologist to w

ork on memory strategies. F/ U by TBI team is not warranted..."

27 May 2008 "c/c feeling dizzy off and on since 2006,and ringing of

both ears"

"FOR ABOUT A YEAR FEELING ANXIOUS, NOW HATES HIS JOB, LOSS OF INTEREST IN

USUAL

THINGS, MARRAGE APATHY, SYMPTOMS RARELY OF PANIC ATTACKS. INC ETOH-NOW BY

SELF REPORT 6

BEERS/NITE. NOT SUICIDAL UNDERGOING WIU FOR TBI -HX OF SIG BLAST EXPOSURES

RARE LOSS OF BALANCE BRIEF EPISODES ("DIZZINESS")-USUALLY PRECEDED BY

FEELING PANIC SENSATION..."

1. Diagnosis

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

Does the Veteran now have or has he/she ever been diagnosed with a headache

condition?

[X] Yes [ ] No

[X] Migraine including migraine variants

2. Medical History

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

a. Describe the history (including onset and course) of the Veteran's

headache conditions (brief summary):

He reports having had headaches which can be severe, and assoc with

light sensitivity. He is SC for migraines. When they are bad he wants

to

lie in a dark room. He takes OTC medication for them when they occur.

They are severe and makes him want to lie down and "disconnect" at

least

once or twice a week.

b. Does the Veteran's treatment plan include taking medication for the

diagnosed condition?

[ ] Yes [X] No

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

b. Does the Veteran experience non-headache symptoms associated with

headaches? (including symptoms associated with an aura prior to headache

pain)

[X] Yes [ ] No

[X] Nausea

[X] Sensitivity to light

[X] Sensitivity to sound

c. Indicate duration of typical head pain

[X] Less than 1 day

d. Indicate location of typical head pain

[X] Both sides of head

4. Prostrating attacks of headache pain

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

a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating

attacks of migraine / non-migraine headache pain?

[X] Yes [ ] No

b. Does the Veteran have very prostrating and prolonged attacks of

migraines/non-migraine pain productive of severe economic inadaptability?

[X] Yes [ ] No

5. Other pertinent physical findings, complications, conditions, signs,

symptoms and scars

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

a. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms related to any conditions

listed in the Diagnosis Section above?

[ ] Yes [X] No

b. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

Section above?

[ ] Yes [X] No

c. Comments, if any:

No response provided.

6. Diagnostic testing

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

Are there any other significant diagnostic test findings and/or results?

[ ] Yes [X] No

7. Functional impact

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

Does the Veteran's headache condition impact his or her ability to work?

[X] Yes [ ] No

If yes, describe the impact of the Veteran's headache condition, providing

one or more examples:

His headaches would cause him to have frequent absences from work in

either a physical or sedentary occupation.

8. Remarks, if any:

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

No remarks provided.

/es/ Xxxx,Xxxx MD

VHA Neurologist, Diplomate ABPN, DMA certification

Signed: 01/29/2018 11:17

Edited February 1, 2018 by Grumpbox

Berta · February 1, 2018

WOW -it is a lot- maybe best bet is to wait to see how VA actually rates all this- as I am looking for a SMC statement. ( 100% plus 60 or Housebound)

"The only change to my ratings since retirement was my PTSD, which ONE year from retirement, the VA called me in for a PTSD C&P Exam, which was increased from 50% to 100%. The date for this increase is seen above for an "Effective Date."

So they lumped the TB I into the already established PTSD 100% rating??????

It seeems this might be their rationle:

"Given the severity of his psychiatric

symptoms at the current time, it appears likely that his cognitive

difficulties are the result of, or in the very least exacerbated by,his

psychiatric disorder. Mental health counseling and SSRI RX is strongly." etc etc .

Possible but they might be wrong

Are you employed?

"post concussive headaches

30%

Service Connected

Disability Evaluation System (DES)

11/23/2011" I copied this so not to forget it when you get the actual rating info in the award letter.

This is a physical disability from the TBI-yet PTSD is a mental disability, and can be exaserbated by a TBI but they might have not done this right.

C & P exams really do not reflect the way the VA will rate this stuff.

I hope the RO rates you 100% P & T with SMC......but it is really too hard to even take a guess yet what they will do.

Buck52 · February 3, 2018

Grumpbox,

Direct Service-Connection: If you file your VA Disability claim within one year of active-duty discharge, your effective date will be the first day after your separation.

''Moving on''

If you file your VA Disability claim after one year of separation, your effective date is the day the VA receives the claim or whenever the service-connected condition first appears in medical evidence, whichever is later.

If you filed the PTSD claim back in ''11-23-11 that should be the EED & Not the 8-28-12 you can disagree with that decision date. via CUE because this is a compensable claim and the out come would determine the EED would be greater amount $$ wise.

However if a Veteran files a claim (ptsd) in say 2005 and is denied and refiles a claim for ptsd years later in 2017 and Submits new & material Evidence his EED will be for 2017 date.

Also an EED can go back to when the condition first arose but you will need medical Dr's and examination reports for evidence to prove the ''when the condition first arose'' much more difficult to prove but it can be proven.

Also you should check the possibility's of secondary conditions b/c both these conditions can be related to ''secondary conditions'' from PTSD/TBI , Just because they ''lump'' them together don't necessarily mean they don't have secondary conditions, the VA try's to throw veterans off with the verbage they use.

Grumpbox · February 1, 2018

@Berta Thank you so for being the first to reply!! I always enjoy your sage advice and lady-like approach to things!

Yes ma'am! The VA has my TBI and PTSD lumped currently for a 100% rating.

No employment. Since my retirement (Nov 2011), I've held two jobs, both of the total time incurring a total of maybe six months in all.

Miles Davis can play some real jazz, also!!!

Thanks!

GB

Grumpbox · February 1, 2018

@Berta and others....

I would also like to point out that if you look at my disabilities listed above....specifically, the dates, you can see where my PTSD has a different date from all the other disabilities. For the longest, all my disabilities had a date of 11/23/2011. However, once I started the C&P Exam for my PTSD (back in October 2017), my date on Ebenefits for PTSD changed from 11/23/2011 TO the date it is now: 08/28/2012.

I'm still within the 5 year rule for disabilities, but unsure if this applies or if the VA will honor such date/reg.

Berta · February 1, 2018

I need to look up the "five year rule"

Grumpbox · February 3, 2018

On 2/1/2018 at 1:37 PM, Berta said:

I need to look up the "five year rule"

@Berta

I'd love to hear about what you discovered, Berta!!

Also, if any other Vet would like to comment on the results of my TBI C&P, that too would be great!!

@Gastone

@Vync

@Buck52

I put a few of the Vet's that in the past helped me gain some insight on their take.

Please, anyone else feel free to chime in and respond!!

Ebenefits says I should receive a verdict this coming week!!

GB

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