TBI rating without a C&P?

[RMurr]

I have been reading this form for about two months now and I’m hoping you may be able to give me some insight. I submitted an application for compensation in January 2018 for injuries I received in a long time ago.

Here is a bit of the back ground. When I got out of the service in 1995 I thought I was applying for benefits, turns out it was only the Gulf war registry.  I’m not trying to make an excuse for why I didn’t apply earlier, just telling you what happened. I was in a head on car crash in panama, hit by a drunk driver.  I was out for 15-30 min, then spent 4 days in the hospital. The Va sent me for a C&P 3 weeks ago for adjustment disorder with anxiety, The DR. is the one who told me I was in the hospital for 4 days. I only knew what my ex-wife told me. After an hour doing the exam the DR. made a call to QTC and was requesting that I have a cognitive exam done, of course they said no, it wasn’t being asked for.

1.      Should I be getting another C&P for TBI? I did submit my neurologist reports that said all my condition i.e. short term memory problems, migraines and emotional problems were a direct result of the accident, and I have the LOD report. along with the list of my meds i'm on.

2.      Or will they just use what in my file and the C&P and render a decision?

 

I do have a few other items I’m claiming, but I will post them in the correct forum.

 

Thanks for any help you can give.

[jfrei]

Get a copy of the C and P what does The doctor say caused your adjustment disorder I was diagnosed with a chronic adjustment disorder due to my TBI. What does he explain caused it?

[RMurr]

The exam was done by QTC so I won't be able to get the report till after the decision is made.

I also don't think putting in a request for the c&p exam would help since it seams to take forever. I'm just getting a bit uneasy, and driving the wife nuts.  

I'm pretty sure he is going to say the accident caused it. he made a comment that I was a model soldier until accedent then I got two article 15. 

  

 

[Buck52]

RMurrr

QTC Did your exam, you should have a phone fax# from the QTC people that did your C&P  Request it from them and also any travel mileage  if you get travel pay.

If that don't seem to help check with your local VBA (Veterans Benefits Administration) after 2 weeks and see a VSO there .

sign a FOIA and request a copy of your QTC C&P Exam on date **/**/****

Your entitled one free copy.

  the VBA  VSO OR Counselor can look on the computer and bring up your QTC Exam & Print you out a copy of the exam   (if you can't get QTC to  do it.)

Actually this is considered a medical record and your entitled to those after 3 days from the VA and about 2 weeks from a contractor due to snail mail.

I did this about 3 1/2 years ago...not sure anything has changed?

You should not have to wait fro a decison...if they don't give you a copy of this exam  let them know your taking it up with the hospital Director  or the C&P Chief.

Edited August 27, 2018 by Buck52

[RMurr]

thanks Buck, I will give that a try.  

the only thing positive that I have learned is that they have 500 pages of documents from the hospital and medical files. Maybe now I will finaly learn what gave me disantary that caused a 2 month hospital stay. All they said to me was parasites.

I will give an update once I get the records. 

thank you guys again for the help.

 

[Buck52]

Roger that RMurr

THE VBA can just find the C&P EXAM if you can tell them the date it was on?..  & Also VA Release of medical records at your VAMC, you can give dates that you want ,like if your C&P Exam was recent  just tell them to go back to that date. this will prevent you from getting boo coo medical records.

[RMurr]

It's been a bit, but they finally gave me a C&P for my TBI. This is what they put in my DBQ. Any thoughts? Thanks in advance for all your help. 

 

Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI)

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:      History of concussion noted on C&P examination dated 6/17/1995. Motor vechicle accident in 1986 and hit with wooden board in 1991. Veteran      reported headaches in frontal area every 2-3 months throbbing, resolves      with aspirin in 45-60 minutes. Also once in a while feels dizzy and  dysequilibrium. No c/o memory problem, vertigo. No psychiatric      manifestations were described.

      Report of medical history 1/22/1990 noted head injury 87 in car accident.

      Statement of medical examination and duty status 10/19/1985 motor vehicle accident on Howard AFB, "was severely injured from striking the windshield with his head."

      Diagnosed with cervical strain following a motorcycle accident 10/18/1983

     

Headache Evaluation Dr. 11/29/2017: "these symptoms have been a stable impairment over the intervening years." Veteran reported a short fuse and depressed/anxious mood. Diagnosed postconcussional syndrome, migraine, obstructive sleep apnea, tinnitus, and unspecified anxiety      disorder. "cognitive symptoms are a product of his concussion to some  degree but I suspect that they are being exacerbated by mood symptoms and fatigue."

 

C&P psych mental disorders 7/31/2018 proffered diagnoses of generalized anxiety disorder and adjustment disorder with mixed disturbance of emotion  and conduct. Examiner indicated that Veteran's fatigue, irritability, and  difficulty concentrating are overlapping symptoms.     

   

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] N/A claimant diagnosed with TBI in-service         

Date of diagnosis: 10/19/1985

   

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)             Date of diagnosis:    10/19/1985

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

Other diagnosis #1:    Migraine headaches              Date of diagnosis:    11/29/2017

   

2. Medical history    -----------------    Describe the history (including onset and course) of the Veteran's TBI and    residuals attributable to TBI (brief summary):       Veteran reported limited independent recollection of the head injury event, stating that he is repeating what was told to him by his ex-wife       and other sources of information.  He said that when he was stationed in Panama he was in the driver's seat of a stopped car when another car struck it head on. He estimated the date as December 1985. He reported he was taken to a hospital for an unspecified amount of time. He did not receive followj-up treatment.      

Following his head injury, Veteran reported "having problems." He stated he couldn't sleep and was frequently late to work. He and his wife argued, sometimes escalating physically. He reported receiving 2 Article 15's during this time period and losing rank. Veteran reported decreased interest in previously enjoyed activities following the injury, and believed that these symptoms led to his divorce from his first wife. Veteran stated he sought a psychiatric evaluation but "he told me there was nothing wrong with me." He has not sought psychiatric treatment since. He reported, "I learned to deal with it." Veteran estimated that he had 2-3 other head injuries playing football or bumping into something, but did not lose consciousness. He reported he may have experienced an alteration of consciousness, "Nothing bad that I can remember."      

Veteran reported cognitive symptoms of memory impairment. He said that his       job position changed three years ago after he forgot to perform a task, resulting in great expense for the company. He said he had missed more minor things earlier which were easy to fix. Veteran reported easy irritability, such that he avoids the company of others. He attempts to cope with regular physical exercise. Veteran reported that he has been under the care of a non-VA neurologist for his headache condition for approximately one year. He said that his current medication has reduced the frequency of his headaches from 2-3       times per week to 3 times per month. Side effects of medication include weight gain. Veteran could not identify specific triggers for headache.  Duration is up to a day. Location is bifrontal. He reported vomiting with headache 1-2 times per year. Associated symptoms of photo- and phonosensitivity. Medication reduces headache pain but does not alleviate it. Prior to receiving treatment for the headaches, Veteran estimated       missing work due to headache 7-8 days per year. Veteran stated he did not experience headache pain prior to the head injury. There is no family history of a headache condition.          

 

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):  Veteran reported cognitive symptoms of memory impairment. He said that his job position changed three years ago after he forgot to perform a  task, resulting in great expense for the company. He said he had missed more minor things earlier which were easy to fix.                   

2. Judgment    ----------    [X] Normal       

3. Social interaction    -------------------    [X] Social interaction is routinely appropriate       

4. Orientation    -------------    [X] Always oriented to person, time, place, and situation       

5. Motor activity (with intact motor and sensory system)    -------------------------------------------------------    [X] Motor activity normal       

6. Visual spatial orientation    ----------------------------    [X] Normal       

7. Subjective symptoms    ---------------------    [X] Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light          

8. Neurobehavioral effects    -------------------------    [X] One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them           

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

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?      

[X] Yes   [ ] No              If yes, provide type of test or procedure, date and results (brief       summary):      

Montreal Cognitive Assessment (MOCA) performed 1/22/2019

Visuospatial/Executive: 4/5      

Naming: 3/3      

Attention: 5/6      

Language: 3/3      

Abstraction: 2/2      

Delayed recall: 3/5 (4/5 with cues)      

Orientation: 6/6

Total score: 26/30, which is within the normal range                

 

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: Veteran reported prostrating headaches require bedrest, which preclude economic activity. Veteran reported cognitive and mood symptoms have disrupted his work and relationships, but has been employed with the same company for over 20 years and has been married for 20 years.                   

5. Remarks, if any:    ------------------    Prior to starting the interview, the Veteran was identified via birth date    and Social Security number. I thanked the Veteran for serving our country and    introduced myself as a neutral examiner. I informed the Veteran of the    purpose of the assessment and its non-confidential and non-therapeutic    nature. I advised the Veteran regarding the voluntariness of participation    and conditions necessitating mandated reporting. I further notified the Veteran that any decision about the claim is solely determined by the    Veteran's Benefits Administration, and that any questions following the exam    should be directed to the Regional Office.  The Veteran expressed an    understanding of the advisory and agreed to proceed with the evaluation.

All opinions are rendered with a reasonable degree of psychiatric certainty.

Veteran sustained an in-service head injury in 1985, resulting in loss of consciousness and hospitalization. Subsequent to the head injury, he reported experiencing headaches, mood, and memory disturbance. Please see headache    DBQ. As noted in the 7/31/2018 mental disorders, Veteran has been diagnosed with anxiety disorder and adjustment disorder. The symptoms of fatigue, poor concentration, and irritability also overlap with TBI.