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Routine: DVBCTBI5

DVBCTBI5.m

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DVBCTBI5 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 1 ; 12 FEB 2007
 ;;2.7;AMIE;**134**;Apr 10, 1995;Build 1
 ;
 ;
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.
 ;;
 ;;Health care providers who may conduct TBI examinations:
 ;;Physicians who are specialists in Physiatry, Neurology, Neurosurgery, and
 ;;Psychiatry and who have training and experience with Traumatic Brain Injury
 ;;may conduct TBI examinations.  The expectation is that the physician would
 ;;have demonstrated expertise, regardless of specialty, through baseline training
 ;;(residency) and/or subsequent training and demonstrated experience.  In
 ;;addition, a nurse practitioner, a clinical nurse specialist, or a physician
 ;;assistant, if they are clinically privileged to perform activities required
 ;;for C&P TBI examinations, and have evidence of expertise through training
 ;;and demonstrated experience, may conduct TBI examinations under close
 ;;supervision of a board-certified or board-eligible physiatrist, neurologist,
 ;;or psychiatrist.
 ;;
 ;;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).
 ;;    4. 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, which?:
 ;;
 ;;          i. Decreased attention
 ;;
 ;;         ii. Difficulty concentrating
 ;;
 ;;        iii. Difficulty with executive functions (speed of information
 ;;             processing, goal setting, planning, organizing, prioritizing,
 ;;             self-monitoring, problem solving, judgment, decision making,
 ;;             spontaneity, and flexibility in changing actions when they
 ;;             are not productive)
 ;;
 ;;         iv. Other - 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 - describe
 ;;       q. erectile dysfunction - if present, state most likely cause and
 ;;          whether vaginal penetration with ejaculation is possible.  State
 ;;          type of treatment and if it is effective in allowing intercourse
 ;;       r. sensory changes, such as numbness or paresthesias - location
 ;;          and type
 ;;       s. vision 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. neurobehavioral symptoms
 ;;            irritability
 ;;            restlessness
 ;;            other - describe
 ;;       y. symptoms of autonomic dysfunction, such as heat intolerance, excess
 ;;          or decreased sweating, etc.
 ;;       z. other symptoms, including symptoms of endocrine dysfunction or
 ;;          cranial nerve dysfunction - describe
 ;;
 ;;    5. Report course of symptoms - are they improving, worsening in severity
 ;;       or frequency, or stable?
 ;;    6. List current treatments, condition for which each treatment is being
 ;;       given, response to treatment, and side effects
 ;;    7. Describe any effects on routine daily activities or employment 
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;    Address each of the following and fully describe current findings:
 ;;
 ;;    1. Motor function.  Report the motor strength of the affected muscles of
 ;;       all areas of weakness or paralysis using the standard muscle grading
 ;;       scale, for example, weakness of flexion of left elbow (3/5 strength
 ;;       for flexors), complete paralysis of left lower extremity (0/5 for all
 ;;       muscle groups).  To the extent possible, identify the peripheral
 ;;       nerves that innervate the weakened or paralyzed muscles, even when
 ;;       the weakness or paralysis is of central origin.
 ;;
 ;;       Standard muscle grading scale:
 ;;
 ;;       0 = Absent  No muscle movement felt.
 ;;       1 = Trace  Muscle can be felt to tighten, but no movement produced.
 ;;       2 = Poor  Muscle movement produced only with gravity eliminated.
 ;;       3 = Fair  Muscle movement produced against gravity, but cannot
 ;;           overcome any resistance.
 ;;       4 = Good  Muscle movement produced against some resistance, but not
 ;;           against "normal" resistance.
 ;;       5 = Normal  Muscle movement can overcome "normal" resistance.
 ;;
 ;;    2. Muscle tone, reflexes.  Describe any muscle atrophy or loss of muscle
 ;;       tone.  Examine and report deep tendon reflexes and any pathological
 ;;       reflexes.
 ;;    3. Sensory function.  Describe exact location of any area of abnormal
 ;;       sensory function.  State which modalities of sensation were tested.
 ;;       Identify the peripheral nerve(s) that innervate the areas with
 ;;       abnormal sensation.
 ;;    4. Gait, spasticity, cerebellar signs.  Describe any gait abnormality,
 ;;       imbalance, tremor or fasciculations, incoordination, or spasticity.
 ;;       If there is spasticity or rigidity, assess any limitation of motion
 ;;       of joint (including joint contracture) by following the Joints
 ;;       examination protocol.  (A tandem gait assessment (walking in a
 ;;       straight line with one foot directly in front of the other) is
 ;;       recommended).
 ;;    5. Autonomic nervous system.  Describe any other impairment of the
 ;;       autonomic nervous system, such as orthostatic (postural) hypotension
 ;;       (if present, state if associated with dizziness or syncope on
 ;;       standing), hyperhidrosis, delayed gastric emptying, heat intolerance,
 ;;       etc.
 ;;    6. Cranial nerves.  Conduct a screening exam for cranial nerve impairment.
 ;;       If positive, follow Cranial Nerve examination protocol.
 ;;    7. Cognitive impairment.  Conduct a screening examination (such as the
 ;;       Montreal Cognitive Assessment (MOCA) or Mini-Mental State Examination
 ;;       (MMSE) to assess cognitive impairment and report results and their
 ;;       significance.  Does the screening show problems with memory,
 ;;       concentration, attention, executive functions, etc.?  If yes,
 ;;       neuropsychological testing to confirm the presence and extent of
 ;;       cognitive impairment is needed, unless already conducted and of
 ;;       record.  Include test results in the examination report.
 ;;    8. Psychiatric manifestations.  Conduct a screening examination for
 ;;       psychiatric manifestations, including neurobehavioral effects.  If a
 ;;       mental disorder is suggested, request a mental disorder exam or
 ;;       PTSD exam, as appropriate, by a mental disease specialist.
 ;;    9. Vision and hearing screening examinations (if abnormalities are
 ;;       found, or there are symptoms or a claim of eye or ear impairment,
 ;;       request an eye or audio exam by a specialist).
 ;;   10. Skin.  Describe any areas of skin breakdown due to neurologic problems.