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)

[El Train]

Before I applied for TBI claim, I had two nexus (MD & Psyc) letters and one dbq (psyc) turned in.  Paid for out of pocket because I knew they would deny.  Got called in for 3 VA C&P TBI's.  First one took 2.5 hours with QTC.  It was at least as likely as not.  2nd C&P took 1.5 hrs, same thing, with additional symptoms (she wasn't amused VA sent me in again and was very helpful).  3rd C&P, the Dr. says he's the tie breaker.  Tie breaker for what Bro!.  It's four positive opinions already (one MD, one Psyc & two Neuropsycs).  Guess it went good.  I just got my rating approved for TBI at 70%.  They also increased my PTSD to 100%.  The combined both under the PTSD.  To many overlapping symptoms.

It's crazy what they put us through to get TBI approved.

[awgv001]

17 minutes ago, El Train said:

Before I applied for TBI claim, I had two nexus (MD & Psyc) letters and one dbq (psyc) turned in.  Paid for out of pocket because I knew they would deny.  Got called in for 3 VA C&P TBI's.  First one took 2.5 hours with QTC.  It was at least as likely as not.  2nd C&P took 1.5 hrs, same thing, with additional symptoms (she wasn't amused VA sent me in again and was very helpful).  3rd C&P, the Dr. says he's the tie breaker.  Tie breaker for what Bro!.  It's four positive opinions already (one MD, one Psyc & two Neuropsycs).  Guess it went good.  I just got my rating approved for TBI at 70%.  They also increased my PTSD to 100%.  The combined both under the PTSD.  To many overlapping symptoms.

It's crazy what they put us through to get TBI approved.

Yeah @El Train, and it makes no sense sometimes to me how I have been denied repeatedly, even though I have a majority of the "regular" symptoms, and in service event/trauma...(as well as all other caluza elements) they rubber stamped a denial saying "You did not have a conclusive diagnosis of TBI"...Bull hockey!!

Again, I'm just glad to be getting another referral to a new neuro---something so hopefully I have another shot at a better explanation and a more detailed exam ---

I'd be more than happy to attend a C&P exam if they would finally issue one for me...

Interestingly enough, the workups for TBI that I did sound nothing like what @Richard1954 has had, so now I'm really confused as to what they have had me doing this whole time.

I had CT/MRI - and a couple of questionnaires, and a test of touching fingertips to my nose, but no memory tests, or pictures or anything like that....wth????

When did I join the circus????

[El Train]

21 hours ago, awgv001 said:

Yeah @El Train, and it makes no sense sometimes to me how I have been denied repeatedly, even though I have a majority of the "regular" symptoms, and in service event/trauma...(as well as all other caluza elements) they rubber stamped a denial saying "You did not have a conclusive diagnosis of TBI"...Bull hockey!!

Again, I'm just glad to be getting another referral to a new neuro---something so hopefully I have another shot at a better explanation and a more detailed exam ---

I'd be more than happy to attend a C&P exam if they would finally issue one for me...

Interestingly enough, the workups for TBI that I did sound nothing like what @Richard1954 has had, so now I'm really confused as to what they have had me doing this whole time.

I had CT/MRI - and a couple of questionnaires, and a test of touching fingertips to my nose, but no memory tests, or pictures or anything like that....wth????

When did I join the circus????

Good deal.  If you need, I have a Psyc Dr. that will tear any of your past C&P's to shreds.  He does C&P's for the VA and will work on behalf of vets too (for a cost of course, which is worth it).  He will separate and diagnose as well as increases for TBI/PTSD.  I will warn you however, the VA may not like this approach.  But ultimately, they have to take this evidence into consideration.

[awgv001]

I wish it were that simple @El Train however, I never had a C&P to begin with for TBI - only referral (2016) to VA neuro who evaluated and diagnosed, and then the DRO rater shot it down as an "inconclusive diagnosis" but that's no longer important while my claim awaits the BVA as I will most likely get this new referral done and get further evaluation to help solidify my claim. I have evidence with a conclusive diagnosis, and a nexus for my back problems related to the TBI as well, or at least linked to service. The biggest hurdle has just been getting TBI SC'd, and no telling how long my wait will be for a hearing at BVA (April 2019 docket, does not qualify for expediting) so nearly at a year now. No big deal to me, like I said, I'm 100% certain that if they do their job right at the BVA there will be no issue moving forward. I'll be at the 100% mark, and potentially SMC (s) and/or CRSC as a future endeavor on dealing with the DoD side of things. Until then, we wait in line!

Has anyone ever had a back-dated diagnosis? I guess what I'm looking for is the diagnosis to be "when the injury occurred" since it is impact/trauma related, after all, that is precisely when the injury manifests, but not necessarily the symptoms. I think the new neuro referral may be able to shed more light on this...thankfully the M21-1 and correlation to secondary disabilities is a thing, or I believe there would be no chance to have my claim backdated as far as I believe it should go (When I claimed migraines, tinnitus, and visual changes that I was separated for) I'll have to bring that up at the appointment.

Unless something changes rather quickly I think I'll have it done before my hearing, and be able to get copies etc to come charging in with more substantial evidence.

Edited February 13, 2020 by awgv001

[awgv001]

@Berta @broncovet @Vync @El Train @CavScout19DRecon @blahsaysme2u @Richard1954 @Buck52

I'll try to keep these in order, have a few things I wanted to share to shed more light on my journey. The first two pictures are of the RAMP decision I got in 2019, and the 3rd image is the SOC (dated 2018?) Note - the claim is in docket at the BVA now. Also attached are the Nexus statements. Another note - (The one from Emory is the Nexus that was IN VA POSSESSION at the time of this RAMP decision, but not the 2 new ones.

As always, thank you guys for your time, patience, and consideration. Let me know if there's something more I can substantiate for my claim.

Biggest Note - I had lengthy complaints of the secondaries to TBI while in service, and had no issues getting SC'd for those (except the sciatic/back issues) and an initial low-ball rating on migraines.

Let me know your thoughts!

 

Ramp Decision Jan 2019 ~~~

 

In the fourth paragraph below they state I didn't complain of TBI - That's true, I didn't, but I didn't recognize at the time that the symptoms I faced were linked to it.

 

The page below this line is the SOC I received, dated Apr 2018.

 

 

NEXUS/IMO'S LISTED BELOW

Now, I'm not sure why in this particular nexus that the Dr. used the Emory letterhead and not the VA one, as there was a reference in the "reasons" citing about my "private IMO" (This Dr. works at BOTH VA and Emory on alternate days.)

 

These two were not in VA possession at the time of the RAMP decision.

 

Edited March 2, 2020 by awgv001

[awgv001]

Alright folks! I secured a new appt with Neuro THIS WEEK! I got a copy of a DBQ in hand, and I'm prepared to ask a lot of questions, hopefully I don't overload this guy with too much info. I'm surprised that they don't offer a TBI DQB specifically on the DBQ page of the VA - so I'm planning on getting "Review Evaluation of Residuals of TBI (R-TBI) DBQ" which has a lengthy host of questions and further investigation found on NCBI - link provided below as well. Aside from whatever the "normal" workups are for this...What else should/could I do/ask during these appt's?

https://www.ncbi.nlm.nih.gov/books/NBK542603/