I just went through a bunch of old notes. Trying to find any new evidence. Found 6 more notes from doctor visits while active duty regarding post concussion syndrome along with other issues. Notes from being referred to the mTBI clinic after seeing the doctor who raised concerns about the post concussion syndrome. Also found a DBQ for evaluation of residuals of TBI. A couple of concerns with it...
Section I:
3. Evidence Review
"Was medical evidence available for review as part of this examination?"
Yes is marked on the questionnaire. Next question is
"If yes, indicate evidence reviewed as part of this examination."
Out of 12 possible options to select, nothing was marked. "Other" is also left blank.
Section II:
Further into the questionnaire...
1. Memory, attention, concentration, executive functions
"No complaints of impairment" is marked. But notes from previous doctor visits with the VA and while on active duty showed concerns with memory and concentration.
Section III:
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)?"
"No" is checked for the question.
Out of 15 or 20 selections for residuals to be identified, nothing was marked. Reading through them I believe a few should have been. The three that I certainly have issues with is that I have a Tinnitus, Migraines, and PTSD w/MDD all diagnosed through the VA.
So why would they mark the "No" box to this question?
Preparing for another round with an appeal for TBI/Post Concussion Syndrome.
In retrospect, post concussion syndrome (PCS) is a common sequelae of traumatic brain injury (TBI), and it is a symptom complex that includes headache, dizziness, neuropsychiatric symptoms, and cognitive impairment. PCS is most often described in the setting of mild TBI, but it may also occur after moderate and severe TBI, and similar symptoms are described after whiplash injuries as well. Remember, the a loss of consciousness (LOC) event does
not have to occur for PCS to develop.
Moreover, PCS is very controversial, especially in its protracted form. The symptoms are vague, subjective, and common in the general population. The affected patient population is heterogeneous with varying degrees of injury to the head and brain. As such, individual patient characteristics may alter the expression of the injury while the underlying pathophysiology is undefined. To that extent, test results may or may not be abnormal; when present, test abnormalities do not follow a consistently defined pattern.
It's known that Mild TBI results after a blunt force, non-penetrating head trauma, and it is most often defined as mild by a Glasgow Coma Scale (GCS) score of 13 to 15, 30 minutes after head injury. So, a Concussion is a subset of a mild TBI (mTBI) , and it is a trauma-induced alteration in mental status that may or may not involve a LOC event.
With that all said, I have experienced very similar results with not receiving an official mTBI diagnosis while on active duty in the U.S. Army albeit it was well documented about my PCS diagnosis and its symptomatology.
Currently, I am appealing the VBA's decision to not military service connect my original VA claim for TBI albeit it will probably be denied again if they use the straight TBI criteria (e.g., an official TBI diagnosis) and not the mTBI criteria (e.g., a PCS official diagnosis).
As such, I have rebutted using the
DSM-V criteria for a "chronic" PCS medical condition as shown within my well-documented symptomatology. Hopefully, it shall be granted a military service-connection disability under VBA guidelines using the 38 CFR VASRD code 8045's facets of evaluation of cognitive impairment and other residuals of TBI not otherwise classified.
Indeed, please continue your fight for PCS to be granted as a military service-connection disability under VBA guidelines; I know that I definitely shall continue the fight
until the very end at this point in time!
Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer."
Best Wishes!