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VA Disability Claims: 5 Game-Changing Precedential Decisions You Need to Know
Tbird posted a record in VA Claims and Benefits Information,
These decisions have made a big impact on how VA disability claims are handled, giving veterans more chances to get benefits and clearing up important issues.
Service Connection
Frost v. Shulkin (2017)
This case established that for secondary service connection claims, the primary service-connected disability does not need to be service-connected or diagnosed at the time the secondary condition is incurred 1. This allows veterans to potentially receive secondary service connection for conditions that developed before their primary condition was officially service-connected.
Saunders v. Wilkie (2018)
The Federal Circuit ruled that pain alone, without an accompanying diagnosed condition, can constitute a disability for VA compensation purposes if it results in functional impairment 1. This overturned previous precedent that required an underlying pathology for pain to be considered a disability.
Effective Dates
Martinez v. McDonough (2023)
This case dealt with the denial of an earlier effective date for a total disability rating based on individual unemployability (TDIU) 2. It addressed issues around the validity of appeal withdrawals and the consideration of cognitive impairment in such decisions.
Rating Issues
Continue Reading on HadIt.com-
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Tbird, -
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Are all military medical records on file at the VA?
RichardZ posted a topic in How to's on filing a Claim,
I met with a VSO today at my VA Hospital who was very knowledgeable and very helpful. We decided I should submit a few new claims which we did. He told me that he didn't need copies of my military records that showed my sick call notations related to any of the claims. He said that the VA now has entire military medical record on file and would find the record(s) in their own file. It seemed odd to me as my service dates back to 1981 and spans 34 years through my retirement in 2015. It sure seemed to make more sense for me to give him copies of my military medical record pages that document the injuries as I'd already had them with me. He didn't want my copies. Anyone have any information on this. Much thanks in advance.-
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Picked By
RichardZ, -
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Caluza Triangle defines what is necessary for service connection
Tbird posted a record in VA Claims and Benefits Information,
Caluza Triangle – Caluza vs Brown defined what is necessary for service connection. See COVA– CALUZA V. BROWN–TOTAL RECALL
This has to be MEDICALLY Documented in your records:
Current Diagnosis. (No diagnosis, no Service Connection.)
In-Service Event or Aggravation.
Nexus (link- cause and effect- connection) or Doctor’s Statement close to: “The Veteran’s (current diagnosis) is at least as likely due to x Event in military service”-
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Tbird, -
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Post in ICD Codes and SCT CODES?WHAT THEY MEAN?
Timothy cawthorn posted an answer to a question,
Do the sct codes help or hurt my disability ratingPicked By
yellowrose, -
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Post in Chevron Deference overruled by Supreme Court
broncovet posted a post in a topic,
VA has gotten away with (mis) interpreting their ambigious, , vague regulations, then enforcing them willy nilly never in Veterans favor.
They justify all this to congress by calling themselves a "pro claimant Veteran friendly organization" who grants the benefit of the doubt to Veterans.
This is not true,
Proof:
About 80-90 percent of Veterans are initially denied by VA, pushing us into a massive backlog of appeals, or worse, sending impoverished Veterans "to the homeless streets" because when they cant work, they can not keep their home. I was one of those Veterans who they denied for a bogus reason: "Its been too long since military service". This is bogus because its not one of the criteria for service connection, but simply made up by VA. And, I was a homeless Vet, albeit a short time, mostly due to the kindness of strangers and friends.
Hadit would not be necessary if, indeed, VA gave Veterans the benefit of the doubt, and processed our claims efficiently and paid us promptly. The VA is broken.
A huge percentage (nearly 100 percent) of Veterans who do get 100 percent, do so only after lengthy appeals. I have answered questions for thousands of Veterans, and can only name ONE person who got their benefits correct on the first Regional Office decision. All of the rest of us pretty much had lengthy frustrating appeals, mostly having to appeal multiple multiple times like I did.
I wish I know how VA gets away with lying to congress about how "VA is a claimant friendly system, where the Veteran is given the benefit of the doubt". Then how come so many Veterans are homeless, and how come 22 Veterans take their life each day? Va likes to blame the Veterans, not their system.Picked By
Lemuel, -
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Question
Grumpbox
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
100% P&T (and some)
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There are 2 Five year rules but one is for survivors-----I am sure it is in the DIC forum-if not I wil post that info there. I think you mean this five year rule: In part: "Once a veter
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