DVBCTBI2 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**125**;Apr 10, 1995;Build 9
;
;
TXT ;
;;Narrative: The potential residuals of traumatic brain injury necessitate
;;a comprehensive examination to document all disabling effects. Specialist
;;examinations, such as eye and audio examinations, mental disorder
;;examinations, and others, may also be needed in some cases, as indicated
;;below. If possible, conduct a thorough review of the service and post-
;;service medical records prior to the examination.
;;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; 1. Report date(s) and nature of injury.
;; 2. State severity rating of traumatic brain injury (TBI) at time of injury.
;; 3. State whether condition has stabilized. If not, provide estimate
;; of when stability may be expected (typically within 18-24 months of
;; initial injury).
;;
;; Inquire specifically about each symptom or area of symptoms below, since
;; individuals with TBI may have difficulty organizing and communicating
;; their symptoms without prompting. It is important to document all
;; problems, whether subtle or pronounced, so that the veteran can be
;; appropriately evaluated for all disabilities due to TBI.
;;
;; For each of the following symptoms that is present, answer specific
;; questions asked.
;;
;; a. headaches - frequency, severity, duration, and if they most
;; resemble migraine, tension-type, or cluster headaches
;; b. dizziness or vertigo - frequency
;; c. weakness or paralysis - location
;; d. sleep disturbance - type and frequency
;; e. fatigue - severity
;; f. malaise
;; g. mobility - state symptoms
;; h. balance - state any problems
;; i. if ambulatory, what device, if any, is needed to assist walking?
;; j. memory impairment - mild, moderate, severe
;; k. Other cognitive problems Y/N? If yes:
;; i. Slowness of thought
;; ii. Confusion
;; iii. Decreased attention
;; iv. Difficulty concentrating
;; v. Difficulty understanding directions
;; vi. Difficulty using written language or comprehending
;; written words
;; vii. Delayed reaction time
;; viii. Other - box to describe
;;
;; l. speech or swallowing difficulties - severity and specific type
;; of problem - expressive aphasia?, difficulty with articulation
;; because of injuries to mouth?, aspiration due to difficulty
;; swallowing?, etc.
;; m. pain - frequency, severity, duration, location, and likely cause
;; n. bowel problems - extent and frequency of any fecal leakage and
;; frequency of need for pads, if used; need for assistance in
;; evacuating bowel (manual evacuation, suppositories, rectal
;; stimulation, etc.) - report type and frequency of need for
;; assistance.
;; o. bladder problems - report the type of impairment (incontinence,
;; urgency, urinary retention, etc.) and the measures needed:
;; catheterization - constant or intermittent?, pads (must be
;; changed how often per day?), other - describe).
;; p. psychiatric symptoms
;; mood swings
;; anxiety
;; depression
;; other
;; q. sexual dysfunction - type, and, if erectile dysfunction, state
;; most likely cause and whether vaginal penetration is possible
;; r. sensory changes, such as numbness or paresthesias - location
;; and type
;; s. visual problems, such as blurred or double vision - describe
;; t. hearing problems, tinnitus - describe
;; u. decreased sense of taste or smell - if present, follow
;; examination protocol for Sense of Smell and Taste
;; v. seizures - type and frequency
;; w. hypersensitivity to sound or light - describe
;; x. behavioral changes
;; irritability
;; restlessness
;; other - describe
;; y. oral and dental problems, such as difficulty with jaw movement,
;; tooth loss or damage, etc. - describe
;; z. other symptoms - describe
;;
;; 4. Report course of symptoms - are they improving, worsening in severity
;; or frequency, or stable?
;; 5. List current treatments, condition for which each treatment is being
;; given, response to treatment, and side effects.
;;
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCTBI2 4843 printed Dec 13, 2024@01:48:50 Page 2
DVBCTBI2 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 1 ; 12 FEB 2007
+1 ;;2.7;AMIE;**125**;Apr 10, 1995;Build 9
+2 ;
+3 ;
TXT ;
+1 ;;Narrative: The potential residuals of traumatic brain injury necessitate
+2 ;;a comprehensive examination to document all disabling effects. Specialist
+3 ;;examinations, such as eye and audio examinations, mental disorder
+4 ;;examinations, and others, may also be needed in some cases, as indicated
+5 ;;below. If possible, conduct a thorough review of the service and post-
+6 ;;service medical records prior to the examination.
+7 ;;
+8 ;;A. Review of Medical Records:
+9 ;;
+10 ;;B. Medical History (Subjective Complaints):
+11 ;;
+12 ;; 1. Report date(s) and nature of injury.
+13 ;; 2. State severity rating of traumatic brain injury (TBI) at time of injury.
+14 ;; 3. State whether condition has stabilized. If not, provide estimate
+15 ;; of when stability may be expected (typically within 18-24 months of
+16 ;; initial injury).
+17 ;;
+18 ;; Inquire specifically about each symptom or area of symptoms below, since
+19 ;; individuals with TBI may have difficulty organizing and communicating
+20 ;; their symptoms without prompting. It is important to document all
+21 ;; problems, whether subtle or pronounced, so that the veteran can be
+22 ;; appropriately evaluated for all disabilities due to TBI.
+23 ;;
+24 ;; For each of the following symptoms that is present, answer specific
+25 ;; questions asked.
+26 ;;
+27 ;; a. headaches - frequency, severity, duration, and if they most
+28 ;; resemble migraine, tension-type, or cluster headaches
+29 ;; b. dizziness or vertigo - frequency
+30 ;; c. weakness or paralysis - location
+31 ;; d. sleep disturbance - type and frequency
+32 ;; e. fatigue - severity
+33 ;; f. malaise
+34 ;; g. mobility - state symptoms
+35 ;; h. balance - state any problems
+36 ;; i. if ambulatory, what device, if any, is needed to assist walking?
+37 ;; j. memory impairment - mild, moderate, severe
+38 ;; k. Other cognitive problems Y/N? If yes:
+39 ;; i. Slowness of thought
+40 ;; ii. Confusion
+41 ;; iii. Decreased attention
+42 ;; iv. Difficulty concentrating
+43 ;; v. Difficulty understanding directions
+44 ;; vi. Difficulty using written language or comprehending
+45 ;; written words
+46 ;; vii. Delayed reaction time
+47 ;; viii. Other - box to describe
+48 ;;
+49 ;; l. speech or swallowing difficulties - severity and specific type
+50 ;; of problem - expressive aphasia?, difficulty with articulation
+51 ;; because of injuries to mouth?, aspiration due to difficulty
+52 ;; swallowing?, etc.
+53 ;; m. pain - frequency, severity, duration, location, and likely cause
+54 ;; n. bowel problems - extent and frequency of any fecal leakage and
+55 ;; frequency of need for pads, if used; need for assistance in
+56 ;; evacuating bowel (manual evacuation, suppositories, rectal
+57 ;; stimulation, etc.) - report type and frequency of need for
+58 ;; assistance.
+59 ;; o. bladder problems - report the type of impairment (incontinence,
+60 ;; urgency, urinary retention, etc.) and the measures needed:
+61 ;; catheterization - constant or intermittent?, pads (must be
+62 ;; changed how often per day?), other - describe).
+63 ;; p. psychiatric symptoms
+64 ;; mood swings
+65 ;; anxiety
+66 ;; depression
+67 ;; other
+68 ;; q. sexual dysfunction - type, and, if erectile dysfunction, state
+69 ;; most likely cause and whether vaginal penetration is possible
+70 ;; r. sensory changes, such as numbness or paresthesias - location
+71 ;; and type
+72 ;; s. visual problems, such as blurred or double vision - describe
+73 ;; t. hearing problems, tinnitus - describe
+74 ;; u. decreased sense of taste or smell - if present, follow
+75 ;; examination protocol for Sense of Smell and Taste
+76 ;; v. seizures - type and frequency
+77 ;; w. hypersensitivity to sound or light - describe
+78 ;; x. behavioral changes
+79 ;; irritability
+80 ;; restlessness
+81 ;; other - describe
+82 ;; y. oral and dental problems, such as difficulty with jaw movement,
+83 ;; tooth loss or damage, etc. - describe
+84 ;; z. other symptoms - describe
+85 ;;
+86 ;; 4. Report course of symptoms - are they improving, worsening in severity
+87 ;; or frequency, or stable?
+88 ;; 5. List current treatments, condition for which each treatment is being
+89 ;; given, response to treatment, and side effects.
+90 ;;
