Historical TBI eval (not a C&P!)

[awgv001]

I thought this might interest you, for those of you familiar with my history of posts and claims questions.

Short note - this was the TBI eval I had done a few years ago - before I was denied in part for not having a "conclusive diagnosis" for TBI. --- Might this be why I never had a C&P ordered for me? Certain portions have been redacted for privacy, and to remove some "No" answers to shorten the read or when information doesn't contribute to the claim.

Thoughts???

4 How many serious OEF/OIF deployment related injuries have occurred?
One
6 Did you lose consciousness immediately after any of these experiences?
Yes, one episode
6-A If yes, estimate the duration of longest period of loss of consciousness.
Less than 6 hours
7 Did you have a period of disorientation or confusion immediately following the incident?
Yes, one episode
7-A If yes, estimate the duration of longest period of disorientation or
confusion.
Up to 1 month
8 Did you experience a period of memory loss immediately before or after the
incident?
Yes, one episode
8-A If yes, estimate the duration of longest period of memory loss (Post
Traumatic Amnesia (PTA)).
More than 3 months

10 Were you wearing a helmet at the time of most serious injury?
No
11 Were you evacuated from theatre?
No
12 Prior to this evaluation, had you received any professional treatment
(including medications) for your deployment related TBI symptoms?
No (Work in progress to correct this)
13 Since the time of your deployment related injury/injuries, has anyone told
you that you were acting differently?
Yes

Symptoms
16. Please rate the following symptoms with regard to how they have
affected
you over the last 30 days. Use the following scale (Neurobehavioral Symptom
Inventory):
None 0 - Rarely if ever present not a problem at all.
Mild 1 - Occasionally present but it does not disrupt activities, I can
usually
continue what I am doing; does not really concern me.
Moderate 2 - Often present, occasionally disrupts my activities; I can
usually
continue what I am doing with some effort; I am somewhat concerned.

Severe 3 - Frequently present and disrupts activities; I can only do
things
that are fairly simple or take little effort; I feel like I need help.
Very Severe 4 - Almost always present and I have been unable to perform
at
work, school, or home due to this problem; I probably cannot function without
help.
16-A Feeling dizzy: None
16-B Loss of balance: None
16-C Poor coordination, clumsy: None
16-D Headaches: Very Severe
16-E Nausea: Mild
16-F Vision problems, blurring, trouble seeing: Very Severe
16-G Sensitivity to light: Severe
16-H Hearing difficulty: Severe
16-I Sensitivity to noise: Mild
16-J Numbness or tingling in parts of my body: Severe
16-K Change in ability to taste and/or smell: None
16-L Loss of appetite or increase appetite: None
16-M Poor concentration, can't pay attention: Very Severe
16-N Forgetfulness, can't remember things: Very Severe
16-O Difficulty making decisions: Moderate
16-P Slowed thinking, difficulty getting organized, can't finish things:
Severe
16-Q Fatigue, loss of energy, getting tired easily: Moderate
16-R Difficulty falling or staying asleep: Very Severe
16-S Feeling anxious or tense: Very Severe
16-T Feeling depressed or sad: Severe
16-U Irritability, easily annoyed: Very Severe
16-V Poor frustration tolerance, feeling easily overwhelmed by things:

Very
Severe
17 Overall, in the last 30 days how much did these difficulties (symptoms)
interfere with your life?
Extremely
17-A In what areas of your life are you having difficulties because of these
symptoms?
work relationships, difficulty remembering tasks and many daily events
18 In the last 30 days, have you had any problems with pain?
Yes
18-A Location of pain: (Check all that apply)
Head/headaches
18-B In the last 30 days, how much did pain interfere with your life?
Extremely
18-C In what areas of your life are you having difficulties because of pain?
headaches that are incapacitating twice per week
19 Since the time of your deployment related injury/injuries, are your overall
symptoms:
Worse
20 Additional history of present illness, social history, functional history,
patient goals, and other relevant information.
---REDACTED---Notes that the back pain and headaches cause him difficulty at work. Has to stop and rest that
causes him trouble at work.
21 Current medications:
---REDACTED--- Total of 5
22 Physical Examination:
---REDACTED--- Straight leg raise positive
on the right with radiation ot the knee, and positive for pain in the left
without radiation. Negative SI maneuvers on the left but positive on the right.
Notes pins and needles in the feet bilaterally.
23 Psychiatric Symptoms:
Yes

23-A If yes or suspected/probable, symptoms of which disorders?
Depression
PTSD
Anxiety disorder (other than PTSD)
24 SCI: (Is this "Spinal Cord Injury"?)
No
25 Amputation:
None
26 Other significant medical conditions/problems:
Yes
27 Based on the history of the injury and the course of clinical symptoms, did
the Veteran sustain a TBI during OEF/OIF deployment?
Yes
28 In your clinical judgment the current clinical symptom presentation is most
consistent with:
A combination of OEF/OIF deployment related TBI and Behavioral Health
condition(s)

[CavScout19DRecon]

Same thing with me, I had a TBI exam done at the VA that was NOT a CP exam, I was told to go to this APT after a TBI screen from the VA dr office near my house.  I then applied for TBI compensation and they sent me to a DR that did not do a exam, only asked me about my childhood.  I have a PTSD exam this week and Ill let you know what the VA rates me because I believe they are trying to combine the two. 

 

EDIT-  Did you have nexus letters?  I had 2 old army buddies that were there write up about the vehicle explosion I was in, because the incident was never documented, just like a lot of the stuff we went through was never "documented".  

Edited February 3, 2020 by CavScout19DRecon

[awgv001]

19 hours ago, CavScout19DRecon said:

Same thing with me, I had a TBI exam done at the VA that was NOT a CP exam, I was told to go to this APT after a TBI screen from the VA dr office near my house.  I then applied for TBI compensation and they sent me to a DR that did not do a exam, only asked me about my childhood.  I have a PTSD exam this week and Ill let you know what the VA rates me because I believe they are trying to combine the two.

EDIT-  Did you have nexus letters?  I had 2 old army buddies that were there write up about the vehicle explosion I was in, because the incident was never documented, just like a lot of the stuff we went through was never "documented".  

I actually have TWO nexus letters, because the last time the VA denied me, I showed it to the doctor who referred me to the TBI clinic, and he got red in the face angry (not at me) because he believes it was utter BS that they denied on the basis of a not "conclusive diagnosis" when it was spelled out very plainly.

The doctor then wrote a concurring Nexus to back up the first doctor's Nexus even further. I think that's about as solid as a medical diagnosis can get when multiple doctor are now having to team up to convince a non-medical person (Rater) that such a diagnosis exists, despite whatever they think. I also have two buddy statements as well, but I could get more if I needed....my situation was rather embarrassing to me, however, fortunately my entire group (some 150+ people) were there at the time to witness my situation. I was documented when I left the service....but not for TBI ---- they only rated me for migraines, and "overlooked" but got onto record several other symptoms that should have made more sense to have me evaluated for TBI in the first place....but it didn't happen until just a few years ago.

Would this fit the criteria for 70-100% for TBI?

[blahsaysme2u]

@awgv001 go through the check list and see how you rate buddy. thats what i did just to verify for myself. its very helpful. 

http://www.militarydisabilitymadeeasy.com/tbi.html

[awgv001]

--OH--edit, and also because there's not a DBQ for TBI that I found, or I'd do it that way too.

There was one person I recently saw on the forums that got one even though the VA came back and said it wasn't warranted for them...?

I mean, I'm awaiting a bva hearing right now, but since I have the nexus, event of injury (statements included), and the chronic diagnosis........

VA obviously failed me on "duty to assist" by never issuing one after the initial claim, re-open, DRO, and then now the appeal.

Or.....just wait, cause the BVA should lay the smack-down on this claim once it hits the table.

In essence, I'm desperately trying to prevent an unnecessary REMAND.

I'm fortunate that I'm not suffering a financial crisis at the moment, but that could change overnight, thanks, Murphy's Law.

Some other important TBI info I found here that falls within the timeline that I was evaluated, and remarks on the shoddy performance in the initial review/diagnosis etc. of TBI

https://www.va.gov/oig/pubs/VAOIG-16-04558-249.pdf

Included is basically the same form that was used and I posted details of above...I'll pop into my local office and have my PCP (physiatrist) fill it out.

TBIdbq.pdf

Edited February 7, 2020 by awgv001

[Richard1954]

My personal experience concerning  TBi and the C/P for a TBI....  I suffered a TBI in 1975, I was thrown from a moving jeep injuring my back and hitting the left side of my head on the pavement.. I was unconscious for 3 days in the Hospital. When i woke up  I had severe pain in my back and headache with blurred vision and reduced hearing. Like an Idiot ( well maybe not since in 1974 Concussion  was not called a TBI)  I did not make a claim until 2018. I went to the C/P at the Local VA, I was shown some pictures that were hand drawn and asked to remember them, a minute later I was asked to draw the same pictures, I could not remember the pictures., I was asked specific questions about memory and I told the doctor, I do not remember names or groups of numbers like phone numbers ( I have to write my own phone number down). I also do not remember anything about the accident except what I was told after I woke up. I only remember what was going on before the accident, but I do not know how I ended up on the pavement or how I was injured. Later much later,  many years after my retirement I had head scans done due to headache and not being able to remember names or numbers.... I was found to have brain damage on the left frontal lobe.  Later still when I had to have eye surgery due to steroid use for my lung condition my left eye, was found to have been damaged , torn  zonules , which hold the eye lens in place. . The doctors determined that in all likely hood the zonules were damaged when I hit  my head on the pavement. And doctors also suspect that it was this same accident that caused my hearing loss.  Anyway.... after answering some questions, and trying to recall pictures or write things I had been shown.. I ended up with a 40% rating... and it was determined that I had had a serious TBI based on all the damage to my body, but more important the memory loss and being knocked out for 3 days.. I did have all active duty medical records that proved the injury.  It is important to know that the more serious the injury   may result in presumptive service connection down the road for things like Parkinson disease ... Anyway.. my point was that the C/P exam as easy... To this day I cannot remember my phone number or names of new people I meet..... 

[awgv001]

8 hours ago, Richard1954 said:

My personal experience concerning  TBi and the C/P for a TBI....  I suffered a TBI in 1975, I was thrown from a moving jeep injuring my back and hitting the left side of my head on the pavement.. I was unconscious for 3 days in the Hospital. When i woke up  I had severe pain in my back and headache with blurred vision and reduced hearing. Like an Idiot ( well maybe not since in 1974 Concussion  was not called a TBI)  I did not make a claim until 2018. I went to the C/P at the Local VA, I was shown some pictures that were hand drawn and asked to remember them, a minute later I was asked to draw the same pictures, I could not remember the pictures., I was asked specific questions about memory and I told the doctor, I do not remember names or groups of numbers like phone numbers ( I have to write my own phone number down). I also do not remember anything about the accident except what I was told after I woke up. I only remember what was going on before the accident, but I do not know how I ended up on the pavement or how I was injured. Later much later,  many years after my retirement I had head scans done due to headache and not being able to remember names or numbers.... I was found to have brain damage on the left frontal lobe.  Later still when I had to have eye surgery due to steroid use for my lung condition my left eye, was found to have been damaged , torn  zonules , which hold the eye lens in place. . The doctors determined that in all likely hood the zonules were damaged when I hit  my head on the pavement. And doctors also suspect that it was this same accident that caused my hearing loss.  Anyway.... after answering some questions, and trying to recall pictures or write things I had been shown.. I ended up with a 40% rating... and it was determined that I had had a serious TBI based on all the damage to my body, but more important the memory loss and being knocked out for 3 days.. I did have all active duty medical records that proved the injury.  It is important to know that the more serious the injury   may result in presumptive service connection down the road for things like Parkinson disease ... Anyway.. my point was that the C/P exam as easy... To this day I cannot remember my phone number or names of new people I meet..... 

Thanks Richard! Yeah, I just got another referral back out to neuro - thanks to my pcp - idk when yet, but anything that develops from this round will help bolster my claim i'm sure, cause otherwise I only have the workups done in 2016 to go with, and for whatever reason, the VA wrote in the denial that it was an "inconclusive diagnosis"....I asked the doctor about it and showed him the statement my (2016) neuro wrote, and he was just like....."It's spelled out right here" "Tbi due to trauma in service" -- so none of us know as to what the va is talking about, but its a claim sitting at the bva anyways so I'm not too concerned...once it gets up to that level with the information I have, I hope someone calls the rater and asks them what the hell they were thinking when they wrote their own opinion in the denial based on an older letter, and threw out the diagnosis from my most recent neuro without at LEAST giving benefit of the doubt since one neuro says yes, and the other says no. ---Note on this - it wasn't "actually" a "NO tbi" from the first neuro - what happened was that he wasn't actually evaluating me for a TBI, but for the migraines...so he recorded the episode of syncope, but not the fall. That one slip of details has cost me 8 years of headaches so far, at least until I reach bva.

That being said, when I did the workups with the neuro, they never had me do memory tests or anything of the sort, they just filled out an evaluation sheet and asked me several questions, and prescribed a med for my migraines that "takes the edge off" unlike standard ibuprofen.

I still have not had a C&P for TBI even since those workups over 4 years ago now, and after turning in statements and other evidence...they are planning on giving me a new MRI/CT....

I don't have the active duty records - all I have in regard to that is several witness statements from people who were serving with me and saw it happen ---- except for the things they consider secondary to the tbi, as I did not report the head trauma, but came out with tinnitus, visual changes (possibly diplopia), severe migraines, and memory loss.

Not sure how to tie those in, because when speaking to my doctor he was like "migraines and tinnitus have a wide variety of sources they could arise from" - in a way, I feel like he was helping me prepare my future arguments....I'm not a doctor, so it's up to them to opine that these other contentions are "more likely than not" secondary to the tbi in the first place....yikes.

I forget names, I recently picked up a high school yearbook, and there's people in there I can't remember for the life of me, birthdays, appointments....I totally understand, if I didn't keep a little pocket book or small diary, I would get lost on what I was doing today. I've made it a pretty regular routine of combing through Hadit in the mornings and it seems to have stuck over the years, and I hope that it has helped others with some of my guidance...I know it has certainly helped me! (SC'd for PTSD thanks to hadit!) It's been a while since my last "success" but the ball has been rolling on some claims for years now.

Again, thanks for the feedback @Richard1954 - I wonder if a veteran can request a C&P for tbi somehow??? Maybe I just haven't spoken to the right person yet.

Edited February 12, 2020 by awgv001