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]

I read through this a lot before applying.  Hopefully it helps, if you haven't already found this.

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

Also, my three C&P examinations for TBI seemed to cover this outline pretty closely.

https://benefits.va.gov/PREDISCHARGE/DOCS/disexm58.pdf

There are DBQ's for it.  Sounds like you have one.  

Here is one I had done from an outside MD.  This is what got the ball rolling.  See files.tbi redacted E0021.pdf

tbi redacted E0022.pdf

[blahsaysme2u]

any updates my friend?

[Oceanbound]

subscribed 

[awgv001]

On 3/25/2020 at 6:02 PM, blahsaysme2u said:

any updates my friend?

Yeah, I ditched the Neuro because he refused to complete a DBQ, quote, "Usually it's the VA that prescribes these kinds of forms" - Then proceeded to hand the packet back to me...Note - He also refused about my inquiry to having a sleepy study (never had one before)...he essentially said "No" that it's not a regular part of something something rather....It's like the guy didn't want anything to do with anything I had politely requested. At least I won't be wasting any more of my time around the guy, as that made my decision very quickly!

So I cancelled any new scans and tests etc. I do NOT want to move forward with this doctor. So instead, I sent a message to my PCP about getting referred back to Director of the TBI/Poly I had seen before, who was already familiar with my symptoms, and had entire workups completed in my favor. -- I had filed for review via RAMP back in 2018, but they tossed it out with a handful of bogus reasons for denial. I have all that I need for when I get to the BVA (Caluza elements, strong medical opinions, evidence, etc.) and get this show turned around without the possibility of remand for C&P.

I just wanted the DBQ done. smh...

[awgv001]

Update -

             So it was discovered that the original issue specifically kept being tossed around in "word play" and thus the VA had not added "TBI" specifically to my "problem list", therefore no ICD code (127295002, btw) or any data was a component of reviews/treatment for the last several years. It was originally listed as "headaches" and "syncope episode(s)" but everyone seemed both hesitant and reluctant to say TBI until it became irrefutable. I suppose, that may also be why even with all the evidence, that the issue was tossed even at the higher level - they didn't read the Nexus/diagnosis and IF they did, made it up that the opinion was "inconclusive" without explaining any further.

This has since been corrected, and now the VA acknowledges that I have had TBI for years - and it all starts with the headaches I reported in service.

Now - I'm unsure if when I go to the hearing that I can address it that way. I just want to state my case - explain that this all started in service with injuries, secondaries, and ultimately a conflicting difference of opinion between two different Neuro's who 1: the first diagnosed the headaches and visual changes - and DOCUMENTED my injury details - yet failed to remark TBI. 2: the 2nd Neuro gave a second opinion and concluded that his diagnosis and prior workups are all cause for my headaches etc.

 

I'm still awaiting a hearing at the BVA - I assume they aren't taking any claims cases yet other than a video-hearing....thing. I don't want to go it alone, from what I understand is that opting for video-hearing (at home) can leave you without a rep? IDK.

End point. Next comes the hearing - April 2019 docket. - No updates on my place in line, as it doesn't show the line on my page at all.

Edited December 18, 2020 by awgv001