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Routine: DVBCTBI2

DVBCTBI2.m

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  1. DVBCTBI2 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 1 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**125**;Apr 10, 1995;Build 9
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;Narrative:  The potential residuals of traumatic brain injury necessitate
  1.  ;;a comprehensive examination to document all disabling effects.  Specialist
  1.  ;;examinations, such as eye and audio examinations, mental disorder
  1.  ;;examinations, and others, may also be needed in some cases, as indicated
  1.  ;;below.  If possible, conduct a thorough review of the service and post-
  1.  ;;service medical records prior to the examination.
  1.  ;;
  1.  ;;A. Review of Medical Records:
  1.  ;;
  1.  ;;B. Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;   1. Report date(s) and nature of injury.
  1.  ;;   2. State severity rating of traumatic brain injury (TBI) at time of injury.
  1.  ;;   3. State whether condition has stabilized.  If not, provide estimate
  1.  ;;      of when stability may be expected (typically within 18-24 months of
  1.  ;;      initial injury).
  1.  ;;
  1.  ;;   Inquire specifically about each symptom or area of symptoms below, since
  1.  ;;   individuals with TBI may have difficulty organizing and communicating
  1.  ;;   their symptoms without prompting.  It is important to document all
  1.  ;;   problems, whether subtle or pronounced, so that the veteran can be
  1.  ;;   appropriately evaluated for all disabilities due to TBI.
  1.  ;;
  1.  ;;      For each of the following symptoms that is present, answer specific
  1.  ;;      questions asked.
  1.  ;;
  1.  ;;        a. headaches - frequency, severity, duration, and if they most
  1.  ;;           resemble migraine, tension-type, or cluster headaches
  1.  ;;        b. dizziness or vertigo - frequency
  1.  ;;        c. weakness or paralysis - location
  1.  ;;        d. sleep disturbance - type and frequency
  1.  ;;        e. fatigue - severity
  1.  ;;        f. malaise
  1.  ;;        g. mobility - state symptoms
  1.  ;;        h. balance - state any problems
  1.  ;;        i. if ambulatory, what device, if any, is needed to assist walking?
  1.  ;;        j. memory impairment - mild, moderate, severe
  1.  ;;        k. Other cognitive problems Y/N?  If yes:
  1.  ;;               i. Slowness of thought
  1.  ;;              ii. Confusion
  1.  ;;             iii. Decreased attention
  1.  ;;              iv. Difficulty concentrating
  1.  ;;               v. Difficulty understanding directions
  1.  ;;              vi. Difficulty using written language or comprehending
  1.  ;;                  written words
  1.  ;;             vii. Delayed reaction time
  1.  ;;            viii. Other - box to describe
  1.  ;;
  1.  ;;         l. speech or swallowing difficulties - severity and specific type
  1.  ;;            of problem - expressive aphasia?, difficulty with articulation
  1.  ;;            because of injuries to mouth?, aspiration due to difficulty
  1.  ;;            swallowing?, etc.
  1.  ;;         m. pain - frequency, severity, duration, location, and likely cause
  1.  ;;         n. bowel problems - extent and frequency of any fecal leakage and
  1.  ;;            frequency of need for pads, if used; need for assistance in
  1.  ;;            evacuating bowel (manual evacuation, suppositories, rectal
  1.  ;;            stimulation, etc.) - report type and frequency of need for
  1.  ;;            assistance.
  1.  ;;         o. bladder problems - report the type of impairment (incontinence,
  1.  ;;            urgency, urinary retention, etc.) and the measures needed:
  1.  ;;            catheterization - constant or intermittent?, pads (must be
  1.  ;;            changed how often per day?), other - describe).
  1.  ;;         p. psychiatric symptoms
  1.  ;;              mood swings
  1.  ;;              anxiety
  1.  ;;              depression
  1.  ;;              other
  1.  ;;         q. sexual dysfunction - type, and, if erectile dysfunction, state
  1.  ;;            most likely cause and whether vaginal penetration is possible
  1.  ;;         r. sensory changes, such as numbness or paresthesias - location
  1.  ;;            and type
  1.  ;;         s. visual problems, such as blurred or double vision - describe
  1.  ;;         t. hearing problems, tinnitus - describe
  1.  ;;         u. decreased sense of taste or smell - if present, follow
  1.  ;;            examination protocol for Sense of Smell and Taste
  1.  ;;         v. seizures - type and frequency
  1.  ;;         w. hypersensitivity to sound or light - describe
  1.  ;;         x. behavioral changes
  1.  ;;              irritability
  1.  ;;              restlessness
  1.  ;;              other - describe
  1.  ;;         y. oral and dental problems, such as difficulty with jaw movement,
  1.  ;;            tooth loss or damage, etc. - describe
  1.  ;;         z. other symptoms - describe
  1.  ;;
  1.  ;;   4. Report course of symptoms - are they improving, worsening in severity
  1.  ;;      or frequency, or stable?
  1.  ;;   5. List current treatments, condition for which each treatment is being
  1.  ;;      given, response to treatment, and side effects.
  1.  ;;