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Question About Tbi Exam


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#1 Kim82

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Posted 28 January 2011 - 07:39 PM

So I went to the TBI clinic yesterday to be evaluated for TBI because I screened positive for it with my Primary Care Dr. So the Dr. asks me all these questions then he asks me if I lost conciousness I told him I don't think I did but everything was a blur at the time of the incident but anyhow so I go to the ROI today to get the results and he contradicts himself in the report so I don't know what to think. I will post what he said now:

Are the history of the injury and the course of clinical symptoms cosistent with a diagnosis of TBI sustained during OEF/OIF deployment: NO

In your clinical judgment the current clinical symptom presentation is most consistent with: A combination of TBI and behavioral health conditions

This is where I am confused he says yes I have TBI but then he says it wasn't sustained during OIF.....um how the hell else did I get it? He even states I did not have any other head trauma so I am so confused. When I showed it to my Pysch Dr. today she looked at it and said he probably checked no on accident, so how do I fix this?

also at the end of the report it lists Impressions and it says:

Concussion, no loss of consciousness, no post traumatic amnesia.
Head Aches
PTSD
Blurring
Hearing Loss
Intraabdominal Bleed, Treated Non Surgically


Should I take the report to the Patient Advocate and see if they can get the dr to fix it? Im not ready to put in a claim with the VA for it yet, because I am still waiting on my inital claim to finalize. I don't want to add to it to slow it down. But I could imagine that when I do file a claim this report is going to make it difficult.

Any help is appreciated. Thanks.

Kim


#2 halos2

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Posted 28 January 2011 - 11:13 PM

Seems as though he is going around the bush with this. Stating in part there may be...a combination of TBI and behavioral health conditions, but as you stated failed to acknowledge it in the question prior.
Also he did not write any diagnosis of TBI with his impressions. You can go to the patient advocate, some are helpful, some are not, but as far as getting the documentation change it may be possible if you call up to the C&P arena which did your exam, and ask to speak to the dr who completed it. Of if you could stop by for a few minutes to receive correct information that you could not objectively understand. Some C&P units do not like to see or talk to the claimant post exam, but a few years back my VAMC got a Gem of a C&P Director who goes out of her way to check the veterans status, and to make sure they get a more than adequate exam, but the examiner follow through all conditions claimed.
Perhaps the dr did check the wrong box, but no diagnosis might be why he didn't too.
You will have nothing to lose but a call or trip to see if it would/could be updated. They usually have the files 2 weeks or more prior to exam, and a week to 10 days post exam to place copies of their documentation in it. Remember one thing you never give up! No matter what they say, or what they award you have recourse you can use. The first thing is to receive a favorable rating/award...if over 30% you can claim your spouse and 3 children. Also to get therapy associated with your disabilities/and medication if needed too.
This process may take a long time so don't get discouraged. You will always find someone to write to here at hadit, and we are all on your side, and will try to lead you in the right direction. Welcome here, and glad you found us too.:rolleyes:





So I went to the TBI clinic yesterday to be evaluated for TBI because I screened positive for it with my Primary Care Dr. So the Dr. asks me all these questions then he asks me if I lost conciousness I told him I don't think I did but everything was a blur at the time of the incident but anyhow so I go to the ROI today to get the results and he contradicts himself in the report so I don't know what to think. I will post what he said now:

Are the history of the injury and the course of clinical symptoms cosistent with a diagnosis of TBI sustained during OEF/OIF deployment: NO

In your clinical judgment the current clinical symptom presentation is most consistent with: A combination of TBI and behavioral health conditions

This is where I am confused he says yes I have TBI but then he says it wasn't sustained during OIF.....um how the hell else did I get it? He even states I did not have any other head trauma so I am so confused. When I showed it to my Pysch Dr. today she looked at it and said he probably checked no on accident, so how do I fix this?

also at the end of the report it lists Impressions and it says:

Concussion, no loss of consciousness, no post traumatic amnesia.
Head Aches
PTSD
Blurring
Hearing Loss
Intraabdominal Bleed, Treated Non Surgically


Should I take the report to the Patient Advocate and see if they can get the dr to fix it? Im not ready to put in a claim with the VA for it yet, because I am still waiting on my inital claim to finalize. I don't want to add to it to slow it down. But I could imagine that when I do file a claim this report is going to make it difficult.

Any help is appreciated. Thanks.

Kim



#3 Kim82

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Posted 29 January 2011 - 11:48 AM

Halos,

This Exam wasn't a C&P exam this was a referal by my Primary care dr and the lady at the vet center because they said I screened pos for TBI so they sent me to him as a second level testing. When I talked to my mental health dr yesterday about it she had no doubt that I had TBI so I don't know. I have yet to file a claim for TBI, I was not going to file a claim for something I did not know for 100% I had it just wouldn't be right ya know. So until I can get a definitive answer and diagnosis I am not going to claim it. I am still in my 5 year window for health care so I can still go and see the dr whenever I need or want to. But I will be going for an MRI at some point they put in a request for it so now I just wait for an apt cause I guess they do that off site. Thank you for your input and time :)

#4 timetowinarace

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Posted 29 January 2011 - 10:09 PM

I would have to guess that your Phych Dr. is probably correct. The wrong box was checked.

Impressions listed Concussion and Concussion IS a TBI. Also, I believe referal for MRI is the next step in the evaluation. It appears that you are progressing through the screening process and that would not be the case if the answer was truly NO.

I think if it were me, I would attempt to have the answer corrected. In the future, a busy rating specialist may glance at that answer and deny a claim.

#5 Kim82

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Posted 29 January 2011 - 10:19 PM

Oh I am most deff going to get it changed no doubt about that I can't afford for a mistake like that to mess things up. I will address it on Monday with the patient advocate.

#6 Gulfvet45

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Posted 31 January 2011 - 09:59 AM

Get with the doctor and ask him if he he might have checked the wrong box first. Remind him of how you got your TBI in OIF.

If that does not work, then go to the rep.

Still file. Get statements from those in your units on your injuries.

Halos,

This Exam wasn't a C&P exam this was a referal by my Primary care dr and the lady at the vet center because they said I screened pos for TBI so they sent me to him as a second level testing. When I talked to my mental health dr yesterday about it she had no doubt that I had TBI so I don't know. I have yet to file a claim for TBI, I was not going to file a claim for something I did not know for 100% I had it just wouldn't be right ya know. So until I can get a definitive answer and diagnosis I am not going to claim it. I am still in my 5 year window for health care so I can still go and see the dr whenever I need or want to. But I will be going for an MRI at some point they put in a request for it so now I just wait for an apt cause I guess they do that off site. Thank you for your input and time :)



#7 Kim82

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Posted 31 January 2011 - 03:52 PM

Ugggghhhhh I am beyond aggrivated right now. I talked to my OIF case manager about the paperwork from the Dr. and she said because I did not lose conciousness and I did not have post traumatic amnesia and something else that I could not have suffered from A TBI....seriously wtf. since when do you have to have lost concisousness to have a TBI or not remember anything about the attack of course I am going to remember it I remember it like it was yesterday because it was by far the worst experience of my life, how could they expect me to forget that? Ugh I give up sometimes. Either way I have these stupid head aches that never go away even with meds and if they wont let me file for TBI I will at least file for the Migraines, the damn VA needs to take care of me! I didn't get this way because of anything I put myself into jeez! Yeah yeah I signed the dotted line no crap but did I know that it would come with all of this heck no! Had I known would I have signed? Probably not! VA GET IT TOGETHER AND TAKE CARE OF ME! AND EVERYONE ELSE SHEESH!

#8 carlie

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Posted 31 January 2011 - 04:25 PM

Kim,
Here's a link to the exam worksheets.
TBI is a very convoluted exam with many facets.

http://www.vba.va.go...exams/index.htm

#9 timetowinarace

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Posted 03 February 2011 - 02:49 AM

Ugggghhhhh I am beyond aggrivated right now. I talked to my OIF case manager about the paperwork from the Dr. and she said because I did not lose conciousness and I did not have post traumatic amnesia and something else that I could not have suffered from A TBI....seriously wtf. since when do you have to have lost concisousness to have a TBI or not remember anything about the attack of course I am going to remember it I remember it like it was yesterday because it was by far the worst experience of my life, how could they expect me to forget that? Ugh I give up sometimes. Either way I have these stupid head aches that never go away even with meds and if they wont let me file for TBI I will at least file for the Migraines, the damn VA needs to take care of me! I didn't get this way because of anything I put myself into jeez! Yeah yeah I signed the dotted line no crap but did I know that it would come with all of this heck no! Had I known would I have signed? Probably not! VA GET IT TOGETHER AND TAKE CARE OF ME! AND EVERYONE ELSE SHEESH!


If it makes you feel any better, I also did not lose conciousness nor do i have amnesia for the event. I was also told by VA I did not have a head injury. I'm rated 100% P&T for my tbi. In other words, don't give up.

You may not want to know my whole story though. I'm still learning the lengths the VA went to deny me. Last Nov(2010) I was seen by my neuro and he told me I have a brain lesion that showed on MRI. A concern for stroke due to location and all that. Problem is, my MRI was done in 2003. Was told no TBI cuz nothing on MRI at the time.

I suggest a different approach. I hadn't posted on Hadit in quite some time but I'll try to help you if you want.

#10 Gulfvet45

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Posted 03 February 2011 - 08:31 AM

get your doctor to send you to the WRIISC (risk)
http://www.warrelatedillness.va.gov/

you can call them now and try and get to get in.

Ugggghhhhh I am beyond aggrivated right now. I talked to my OIF case manager about the paperwork from the Dr. and she said because I did not lose conciousness and I did not have post traumatic amnesia and something else that I could not have suffered from A TBI....seriously wtf. since when do you have to have lost concisousness to have a TBI or not remember anything about the attack of course I am going to remember it I remember it like it was yesterday because it was by far the worst experience of my life, how could they expect me to forget that? Ugh I give up sometimes. Either way I have these stupid head aches that never go away even with meds and if they wont let me file for TBI I will at least file for the Migraines, the damn VA needs to take care of me! I didn't get this way because of anything I put myself into jeez! Yeah yeah I signed the dotted line no crap but did I know that it would come with all of this heck no! Had I known would I have signed? Probably not! VA GET IT TOGETHER AND TAKE CARE OF ME! AND EVERYONE ELSE SHEESH!