C&P TBI Results are in!

[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

 

Edited February 1, 2018 by Grumpbox

[Buck52]

Yes I agree grumpbox yes if they S.C.  TBI, the 11 2011 date should be your EED on that  BUT NOT AS FOR BACK AS 2008

If your S.C. and Rated for PTSD AT 100% The depends on how much your rated for the TBI...If you get 70% for the TBI this opens up the SMC Doors  However , you can't get a rating for the same mental conditions   so they will need to break down the condition for TBI  B/C most if not all TBI Symptoms are evaluated from conditions that are in your Head  including vision and other conditions TBI can cause or be related to.

With your PTSD Rating I am not sure how they will rate your TBI?  IDK?

Without a PTSD Rating here is how they rate the TBI.

The VA evaluates the residuals of traumatic brain injury and their effect on the veteran’s current level of cognitive function, emotional/behavioral function, and physical function in order to assign a disability impairment rating.  Cognitive functions are defined as memory, concentration, attention, and executive functions of the brain.  Executive functions include abilities for goal setting, speed of information, judgment, and decision making.  Emotional and behavioral functions are evaluated based on a diagnosis of a mental disorder.  These may include inability to control anger, impulsiveness, and lack of initiative, inappropriate sexual activity, poor social judgment, and changes in personality.  Physical functions are evaluated under the appropriate diagnosis, which may include a neurological disorder.  The severity of symptoms may fluctuate in severity from day to day and from person to person.  Because brain function is temporarily or permanently impaired following a TBI, and structural damage may or may not be detectable with current technology, the VA has the duty to evaluate subjective symptoms as well.

It is noteworthy to mention that if you were originally diagnosed with mild, moderate, or severe TBI at, or close to, the time of injury, the VA will not rate your disability based on those classifications while you were in service.  Your disability rate is based on the current level of functioning at the time the claim is filed.

VA evaluates TBI at 0, 10, 40, 70, and 100 percent.  Recognizing that the schedule for rating brain disease due to trauma was outdated, the VA revised the rating schedule criteria which became effective October 23, 2008.  [Schedule for Rating Disabilities; Evaluation of Residuals of Traumatic Brain Injury (TBI), 73 Fed. Reg. 54693-54705 (Sept. 23, 2008)] A veteran whose residuals of TBI were rated under the old version of the code may request review under the new code irrespective of whether his or her disability has worsened since the last review.  VA will review that veteran’s disability rating to determine whether the veteran may be entitled to a higher disability rating under the new diagnostic code.  The claim will be treated as a claim for an increased rating.  The effective date, however, cannot be effective before October 23, 2008.

you will more likely be called up for a C&P for the TBI. this is when they will assign a rating.   jmo

I am not sure how they rate the PTSD AND TBI together?..but as I understand it they do....but I also understand they don't rate for the same condition twice  so I think they give certain conditions for the TBI And rate the severity of the TBI Symptoms.

Other Hadit elder members can help you better than I   because I am not up to date on TBI's (sorry)

[Grumpbox]

On 2/1/2018 at 9:40 AM, Grumpbox said:

  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

@Buck52  I just reread this for about my fifth time and saw the quote above!!  This is in my favor...finally, I get some recognition for these awful headaches!!  See below:

§4.124a Schedule of ratings—neurological conditions and convulsive disorders

8100 Migraine:

With very frequent completely prostrating and prolonged attacks
productive of severe economic inadaptability… 50
With characteristic prostrating attacks occurring on an average once
a month over last several months…………… 30
With characteristic prostrating attacks averaging one in 2 months over
last several months………………………. 10
With less frequent attacks……………………….. 0

 

[Buck52]

Roger that.

Beings you have a TBI do not take it lightly , I do hope you get a fare rating but Veterans that have TBI should always stay in treatment and keep yourself updated to this terrible Injury.

  stay on top of any improvements of treatments for TBI if and when they find them?  for your on sake.

[Grumpbox]

6 minutes ago, Buck52 said:

 

 

 

@Buck52 THANKS FOR ALL YOUR INPUT!!  See my comments within.

Yes I agree grumpbox yes if they S.C.  TBI, the 11 2011 date should be your EED on that  BUT NOT AS FOR BACK AS 2008 

Yeah, I remember reading about this.

If your S.C. and Rated for PTSD AT 100% The depends on how much your rated for the TBI (I currently get 30% for Postconcussion Headaches)...If you get 70% for the TBI this opens up the SMC Doors  However , you can't get a rating for the same mental conditions (Gotcha and tracking here!)  so they will need to break down the condition for TBI  B/C most if not all TBI Symptoms are evaluated from conditions that are in your Head  including vision and other conditions TBI can cause or be related to.

With your PTSD Rating I am not sure how they will rate your TBI?  IDK? (Gastone thought my PTSD C&P results (PTSD FORUM) would produce 70%)

Without a PTSD Rating here is how they rate the TBI.

The VA evaluates the residuals of traumatic brain injury and their effect on the veteran’s current level of cognitive function, emotional/behavioral function, and physical function in order to assign a disability impairment rating.  Cognitive functions are defined as memory, concentration, attention, and executive functions of the brain.  Executive functions include abilities for goal setting, speed of information, judgment, and decision making.  Emotional and behavioral functions are evaluated based on a diagnosis of a mental disorder.  These may include inability to control anger, impulsiveness, and lack of initiative, inappropriate sexual activity, poor social judgment, and changes in personality.  Physical functions are evaluated under the appropriate diagnosis, which may include a neurological disorder.  The severity of symptoms may fluctuate in severity from day to day and from person to person.  Because brain function is temporarily or permanently impaired following a TBI, and structural damage may or may not be detectable with current technology, the VA has the duty to evaluate subjective symptoms as well. (GO-TO-HERE)

It is noteworthy to mention that if you were originally diagnosed with mild, moderate, or severe TBI at, or close to, the time of injury, the VA will not rate your disability based on those classifications while you were in service.  Your disability rate is based on the current level of functioning at the time the claim is filed.

VA evaluates TBI at 0, 10, 40, 70, and 100 percent.  Recognizing that the schedule for rating brain disease due to trauma was outdated, the VA revised the rating schedule criteria which became effective October 23, 2008.  [Schedule for Rating Disabilities; Evaluation of Residuals of Traumatic Brain Injury (TBI), 73 Fed. Reg. 54693-54705 (Sept. 23, 2008)] A veteran whose residuals of TBI were rated under the old version of the code may request review under the new code irrespective of whether his or her disability has worsened since the last review.  VA will review that veteran’s disability rating to determine whether the veteran may be entitled to a higher disability rating under the new diagnostic code.  The claim will be treated as a claim for an increased rating.  The effective date, however, cannot be effective before October 23, 2008.

you will more likely be called up for a C&P for the TBI. this is when they will assign a rating.   jmo (SERIOUSLY??  But this C&P Exam Jan 2018 was for a TBI C&P Exam??  So they will schedule me for another one????)

I am not sure how they rate the PTSD AND TBI together? (Me either???)..but as I understand it they do....but I also understand they don't rate for the same condition twice  so I think they give certain conditions for the TBI And rate the severity of the TBI Symptoms.

Other Hadit elder members can help you better than I   because I am not up to date on TBI's (sorry)

No worries on what you could speculate to; I just appreciate any thoughts or input!!!

GB

 

[Buck52]

 if they can't make a decision on the TBI then yes you will be called in for another C&P..Correction I had assummed you were already S.C. and rated 100% for PTSD. So depends on what your rated for your other conditions like PTSD how high your rated will depend on  if your meet the criteria for SMC. 

I am only guessing here  we never know what the VA is going to do but if you get a 70% rating for PTSD and 40% for TBI that should give you a 100% schedular rating.

 to get SMC's You will need another separate condition at 60% to meet the criteria for SMC...With the exception of combined ratings all added in then you could possible meet the SMC Criteria.

  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?

it means the TBI is in your favor  as I understand it.

Edited February 6, 2018 by Buck52

[Grumpbox]

I really feel this opens up the door for TDIU for me.  However, I'm no expert on this.  I do know however, that when these headaches come on, they completely restrict what I can do.  I read about a lawyer named, Robert Friedman (Friedman Disability). Mr. Friedman stands firm behind his belief that while a 50% rating is the maximum the VA will provide Vets, it is an incapacitating illness, which qualifies for TDIU.  Again, I am lost on all this, but it makes sense why I haven't been able to work....