DVBCWTB2 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
;
;
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:
;;
;;Generalist clinicians who successfully complete the Compensation and Pension
;;Service (C&P) TBI training module are permitted to perform TBI residual
;;disability examinations, subject to existing VBA/C&P guidance on examiner
;;qualification, including M21-1MR, III.iv.3.D.18.b.
;;
;;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. Also document all negative responses.
;;
;;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.
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWTB2 9330 printed Sep 23, 2025@19:30:21 Page 2
DVBCWTB2 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 1 ; 12 FEB 2007
+1 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
+2 ;
+3 ;
TXT ;
+1 ;;Narrative: The potential residuals of traumatic brain injury necessitate a
+2 ;;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-service
+6 ;;medical records prior to the examination.
+7 ;;
+8 ;;Health care providers who may conduct TBI examinations:
+9 ;;
+10 ;;Generalist clinicians who successfully complete the Compensation and Pension
+11 ;;Service (C&P) TBI training module are permitted to perform TBI residual
+12 ;;disability examinations, subject to existing VBA/C&P guidance on examiner
+13 ;;qualification, including M21-1MR, III.iv.3.D.18.b.
+14 ;;
+15 ;;A. Review of Medical Records:
+16 ;;
+17 ;;B. Medical History (Subjective Complaints):
+18 ;;
+19 ;; 1. Report date(s) and nature of injury.
+20 ;; 2. State severity rating of traumatic brain injury (TBI) at time of injury.
+21 ;; 3. State whether condition has stabilized. If not, provide estimate of
+22 ;; when stability may be expected (typically within 18-24 months of initial
+23 ;; injury).
+24 ;; 4. Inquire specifically about each symptom or area of symptoms below,
+25 ;; since individuals with TBI may have difficulty organizing and
+26 ;; communicating their symptoms without prompting. It is important to
+27 ;; document all problems, whether subtle or pronounced, so that the
+28 ;; veteran can be appropriately evaluated for all disabilities due to
+29 ;; TBI. Also document all negative responses.
+30 ;;
+31 ;;For each of the following symptoms that is present, answer specific questions
+32 ;;asked.
+33 ;;
+34 ;; a. headaches - frequency, severity, duration, and if they most
+35 ;; resemble migraine, tension-type, or cluster headaches
+36 ;; b. dizziness or vertigo - frequency
+37 ;; c. weakness or paralysis - location
+38 ;; d. sleep disturbance - type and frequency
+39 ;; e. fatigue - severity
+40 ;; f. malaise
+41 ;; g. mobility - state symptoms
+42 ;; h. balance - state any problems
+43 ;; i. if ambulatory, what device, if any, is needed to assist walking?
+44 ;; j. memory impairment - mild, moderate, severe
+45 ;; k. other cognitive problems Y/N? If yes, which?:
+46 ;;
+47 ;; i. Decreased attention
+48 ;;
+49 ;; ii. Difficulty concentrating
+50 ;;
+51 ;; iii. Difficulty with executive functions (speed of information
+52 ;; processing, goal setting, planning, organizing, prioritizing,
+53 ;; self-monitoring, problem solving, judgment, decision making,
+54 ;; spontaneity, and flexibility in changing actions when they
+55 ;; are not productive)
+56 ;;
+57 ;; iv. Other - describe
+58 ;;
+59 ;; l. speech or swallowing difficulties - severity and specific type of
+60 ;; problem - expressive aphasia?, difficulty with articulation
+61 ;; because of injuries to mouth?, aspiration due to difficulty
+62 ;; swallowing?, etc.
+63 ;; m. pain - frequency, severity, duration, location, and likely cause
+64 ;; n. bowel problems - extent and frequency of any fecal leakage and
+65 ;; frequency of need for pads, if used; need for assistance in
+66 ;; evacuating bowel (manual evacuation, suppositories, rectal
+67 ;; stimulation, etc.) - report type and frequency of need for
+68 ;; assistance
+69 ;; o. bladder problems - report the type of impairment (incontinence,
+70 ;; urgency, urinary retention, etc.) and the measures needed:
+71 ;; catheterization - constant or intermittent?, pads (must be changed
+72 ;; how often per day?), other - describe
+73 ;; p. psychiatric symptoms -
+74 ;; - mood swings.
+75 ;; - anxiety.
+76 ;; - depression, other (describe).
+77 ;; q. erectile dysfunction - if present, state most likely cause and
+78 ;; whether vaginal penetration with ejaculation is possible. State
+79 ;; type of treatment and if it is effective in allowing intercourse.
+80 ;; r. sensory changes, such as numbness or paresthesias - location
+81 ;; and type
+82 ;; s. vision problems, such as blurred or double vision - describe
+83 ;; t. hearing problems, tinnitus - describe
+84 ;; u. decreased sense of taste or smell - if present, follow examination
+85 ;; protocol for Sense of Smell and Taste
+86 ;; v. seizures - type and frequency
+87 ;; w. hypersensitivity to sound or light - describe
+88 ;; x. neurobehavioral symptoms -
+89 ;; - irritability.
+90 ;; - restlessness.
+91 ;; - other (describe).
+92 ;; y. symptoms of autonomic dysfunction, such as heat intolerance, excess
+93 ;; or decreased sweating, etc.
+94 ;; z. other symptoms, including symptoms of endocrine dysfunction or
+95 ;; cranial nerve dysfunction - describe
+96 ;;
+97 ;; 5. Report course of symptoms - are they improving, worsening in severity
+98 ;; or frequency, or stable?
+99 ;; 6. List current treatments, condition for which each treatment is being
+100 ;; given, response to treatment, and side effects.
+101 ;; 7. Describe any effects on routine daily activities or employment .
+102 ;;
+103 ;;C. Physical Examination (Objective Findings):
+104 ;; Address each of the following and fully describe current findings:
+105 ;;
+106 ;; 1. Motor function. Report the motor strength of the affected muscles of
+107 ;; all areas of weakness or paralysis using the standard muscle grading
+108 ;; scale, for example, weakness of flexion of left elbow (3/5 strength
+109 ;; for flexors), complete paralysis of left lower extremity (0/5 for all
+110 ;; muscle groups). To the extent possible, identify the peripheral
+111 ;; nerves that innervate the weakened or paralyzed muscles, even when
+112 ;; the weakness or paralysis is of central origin.
+113 ;;
+114 ;; Standard muscle grading scale:
+115 ;;
+116 ;; 0 = Absent No muscle movement felt.
+117 ;; 1 = Trace Muscle can be felt to tighten, but no movement produced.
+118 ;; 2 = Poor Muscle movement produced only with gravity eliminated.
+119 ;; 3 = Fair Muscle movement produced against gravity, but cannot
+120 ;; overcome any resistance.
+121 ;; 4 = Good Muscle movement produced against some resistance, but not
+122 ;; against "normal" resistance.
+123 ;; 5 = Normal Muscle movement can overcome "normal" resistance.
+124 ;;
+125 ;; 2. Muscle tone, reflexes. Describe any muscle atrophy or loss of muscle
+126 ;; tone. Examine and report deep tendon reflexes and any pathological
+127 ;; reflexes.
+128 ;; 3. Sensory function. Describe exact location of any area of abnormal
+129 ;; sensory function. State which modalities of sensation were tested.
+130 ;; Identify the peripheral nerve(s) that innervate the areas with
+131 ;; abnormal sensation.
+132 ;; 4. Gait, spasticity, cerebellar signs. Describe any gait abnormality,
+133 ;; imbalance, tremor or fasciculations, incoordination, or spasticity.
+134 ;; If there is spasticity or rigidity, assess any limitation of motion
+135 ;; of joint (including joint contracture) by following the Joints
+136 ;; examination protocol. (A tandem gait assessment (walking in a
+137 ;; straight line with one foot directly in front of the other) is
+138 ;; recommended).
+139 ;; 5. Autonomic nervous system. Describe any other impairment of the
+140 ;; autonomic nervous system, such as orthostatic (postural) hypotension
+141 ;; (if present, state if associated with dizziness or syncope on
+142 ;; standing), hyperhidrosis, delayed gastric emptying, heat intolerance,
+143 ;; etc.
+144 ;; 6. Cranial nerves. Conduct a screening exam for cranial nerve impairment.
+145 ;; If positive, follow Cranial Nerve examination protocol.
+146 ;; 7. Cognitive impairment. Conduct a screening examination (such as the
+147 ;; Montreal Cognitive Assessment (MOCA) or Mini-Mental State Examination
+148 ;; (MMSE) to assess cognitive impairment and report results and their
+149 ;; significance. Does the screening show problems with memory,
+150 ;; concentration, attention, executive functions, etc.? If yes,
+151 ;; neuropsychological testing to confirm the presence and extent of
+152 ;; cognitive impairment is needed, unless already conducted and of
+153 ;; record. Include test results in the examination report.
+154 ;; 8. Psychiatric manifestations. Conduct a screening examination for
+155 ;; psychiatric manifestations, including neurobehavioral effects. If a
+156 ;; mental disorder is suggested, request a mental disorder exam or
+157 ;; PTSD exam, as appropriate, by a mental disease specialist.
+158 ;; 9. Vision and hearing screening examinations (if abnormalities are
+159 ;; found, or there are symptoms or a claim of eye or ear impairment,
+160 ;; request an eye or audio exam by a specialist).
+161 ;; 10. Skin. Describe any areas of skin breakdown due to neurologic problems.
