source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCTBI2.m@ 1714

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.
        ;;