source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCTBI2.m@ 628

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.
 ;;