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Routine: DVBCTBI5

DVBCTBI5.m

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  1. DVBCTBI5 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 1 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**134**;Apr 10, 1995;Build 1
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;Narrative: The potential residuals of traumatic brain injury necessitate a
  1.  ;;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-service
  1.  ;;medical records prior to the examination.
  1.  ;;
  1.  ;;Health care providers who may conduct TBI examinations:
  1.  ;;Physicians who are specialists in Physiatry, Neurology, Neurosurgery, and
  1.  ;;Psychiatry and who have training and experience with Traumatic Brain Injury
  1.  ;;may conduct TBI examinations.  The expectation is that the physician would
  1.  ;;have demonstrated expertise, regardless of specialty, through baseline training
  1.  ;;(residency) and/or subsequent training and demonstrated experience.  In
  1.  ;;addition, a nurse practitioner, a clinical nurse specialist, or a physician
  1.  ;;assistant, if they are clinically privileged to perform activities required
  1.  ;;for C&P TBI examinations, and have evidence of expertise through training
  1.  ;;and demonstrated experience, may conduct TBI examinations under close
  1.  ;;supervision of a board-certified or board-eligible physiatrist, neurologist,
  1.  ;;or psychiatrist.
  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 of
  1.  ;;       when stability may be expected (typically within 18-24 months of initial
  1.  ;;       injury).
  1.  ;;    4. Inquire specifically about each symptom or area of symptoms below,
  1.  ;;       since individuals with TBI may have difficulty organizing and
  1.  ;;       communicating their symptoms without prompting.  It is important to
  1.  ;;       document all problems, whether subtle or pronounced, so that the
  1.  ;;       veteran can be appropriately evaluated for all disabilities due to
  1.  ;;       TBI.
  1.  ;;
  1.  ;;For each of the following symptoms that is present, answer specific questions
  1.  ;;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, which?:
  1.  ;;
  1.  ;;          i. Decreased attention
  1.  ;;
  1.  ;;         ii. Difficulty concentrating
  1.  ;;
  1.  ;;        iii. Difficulty with executive functions (speed of information
  1.  ;;             processing, goal setting, planning, organizing, prioritizing,
  1.  ;;             self-monitoring, problem solving, judgment, decision making,
  1.  ;;             spontaneity, and flexibility in changing actions when they
  1.  ;;             are not productive)
  1.  ;;
  1.  ;;         iv. Other - describe
  1.  ;;
  1.  ;;       l. speech or swallowing difficulties - severity and specific type of
  1.  ;;          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 changed
  1.  ;;          how often per day?), other - describe
  1.  ;;       p. psychiatric symptoms
  1.  ;;            mood swings
  1.  ;;            anxiety
  1.  ;;            depression
  1.  ;;            other - describe
  1.  ;;       q. erectile dysfunction - if present, state most likely cause and
  1.  ;;          whether vaginal penetration with ejaculation is possible.  State
  1.  ;;          type of treatment and if it is effective in allowing intercourse
  1.  ;;       r. sensory changes, such as numbness or paresthesias - location
  1.  ;;          and type
  1.  ;;       s. vision 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 examination
  1.  ;;          protocol for Sense of Smell and Taste
  1.  ;;       v. seizures - type and frequency
  1.  ;;       w. hypersensitivity to sound or light - describe
  1.  ;;       x. neurobehavioral symptoms
  1.  ;;            irritability
  1.  ;;            restlessness
  1.  ;;            other - describe
  1.  ;;       y. symptoms of autonomic dysfunction, such as heat intolerance, excess
  1.  ;;          or decreased sweating, etc.
  1.  ;;       z. other symptoms, including symptoms of endocrine dysfunction or
  1.  ;;          cranial nerve dysfunction - describe
  1.  ;;
  1.  ;;    5. Report course of symptoms - are they improving, worsening in severity
  1.  ;;       or frequency, or stable?
  1.  ;;    6. List current treatments, condition for which each treatment is being
  1.  ;;       given, response to treatment, and side effects
  1.  ;;    7. Describe any effects on routine daily activities or employment 
  1.  ;;
  1.  ;;C.  Physical Examination (Objective Findings):
  1.  ;;    Address each of the following and fully describe current findings:
  1.  ;;
  1.  ;;    1. Motor function.  Report the motor strength of the affected muscles of
  1.  ;;       all areas of weakness or paralysis using the standard muscle grading
  1.  ;;       scale, for example, weakness of flexion of left elbow (3/5 strength
  1.  ;;       for flexors), complete paralysis of left lower extremity (0/5 for all
  1.  ;;       muscle groups).  To the extent possible, identify the peripheral
  1.  ;;       nerves that innervate the weakened or paralyzed muscles, even when
  1.  ;;       the weakness or paralysis is of central origin.
  1.  ;;
  1.  ;;       Standard muscle grading scale:
  1.  ;;
  1.  ;;       0 = Absent  No muscle movement felt.
  1.  ;;       1 = Trace  Muscle can be felt to tighten, but no movement produced.
  1.  ;;       2 = Poor  Muscle movement produced only with gravity eliminated.
  1.  ;;       3 = Fair  Muscle movement produced against gravity, but cannot
  1.  ;;           overcome any resistance.
  1.  ;;       4 = Good  Muscle movement produced against some resistance, but not
  1.  ;;           against "normal" resistance.
  1.  ;;       5 = Normal  Muscle movement can overcome "normal" resistance.
  1.  ;;
  1.  ;;    2. Muscle tone, reflexes.  Describe any muscle atrophy or loss of muscle
  1.  ;;       tone.  Examine and report deep tendon reflexes and any pathological
  1.  ;;       reflexes.
  1.  ;;    3. Sensory function.  Describe exact location of any area of abnormal
  1.  ;;       sensory function.  State which modalities of sensation were tested.
  1.  ;;       Identify the peripheral nerve(s) that innervate the areas with
  1.  ;;       abnormal sensation.
  1.  ;;    4. Gait, spasticity, cerebellar signs.  Describe any gait abnormality,
  1.  ;;       imbalance, tremor or fasciculations, incoordination, or spasticity.
  1.  ;;       If there is spasticity or rigidity, assess any limitation of motion
  1.  ;;       of joint (including joint contracture) by following the Joints
  1.  ;;       examination protocol.  (A tandem gait assessment (walking in a
  1.  ;;       straight line with one foot directly in front of the other) is
  1.  ;;       recommended).
  1.  ;;    5. Autonomic nervous system.  Describe any other impairment of the
  1.  ;;       autonomic nervous system, such as orthostatic (postural) hypotension
  1.  ;;       (if present, state if associated with dizziness or syncope on
  1.  ;;       standing), hyperhidrosis, delayed gastric emptying, heat intolerance,
  1.  ;;       etc.
  1.  ;;    6. Cranial nerves.  Conduct a screening exam for cranial nerve impairment.
  1.  ;;       If positive, follow Cranial Nerve examination protocol.
  1.  ;;    7. Cognitive impairment.  Conduct a screening examination (such as the
  1.  ;;       Montreal Cognitive Assessment (MOCA) or Mini-Mental State Examination
  1.  ;;       (MMSE) to assess cognitive impairment and report results and their
  1.  ;;       significance.  Does the screening show problems with memory,
  1.  ;;       concentration, attention, executive functions, etc.?  If yes,
  1.  ;;       neuropsychological testing to confirm the presence and extent of
  1.  ;;       cognitive impairment is needed, unless already conducted and of
  1.  ;;       record.  Include test results in the examination report.
  1.  ;;    8. Psychiatric manifestations.  Conduct a screening examination for
  1.  ;;       psychiatric manifestations, including neurobehavioral effects.  If a
  1.  ;;       mental disorder is suggested, request a mental disorder exam or
  1.  ;;       PTSD exam, as appropriate, by a mental disease specialist.
  1.  ;;    9. Vision and hearing screening examinations (if abnormalities are
  1.  ;;       found, or there are symptoms or a claim of eye or ear impairment,
  1.  ;;       request an eye or audio exam by a specialist).
  1.  ;;   10. Skin.  Describe any areas of skin breakdown due to neurologic problems.