Traumatic Brain Injury

Name:	SSN:
Date of Exam:	C-number:
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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.

1. headaches - frequency, severity, duration, and if they most resemble migraine, tension-type, or cluster headaches
2. dizziness or vertigo - frequency
3. weakness or paralysis - location
4. sleep disturbance - type and frequency
5. fatigue - severity
6. malaise
7. mobility - state symptoms
8. balance - state any problems
9. if ambulatory, what device, if any, is needed to assist walking?
10. memory impairment - mild, moderate, severe
11. Other cognitive problems Y/N? If yes:
    
    1. Slowness of thought
    2. Confusion
    3. Decreased attention
    4. Difficulty concentrating
    5. Difficulty understanding directions
    6. Difficulty using written language or comprehending written words
    7. Delayed reaction time
    8. Other - box to describe
12. 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.
13. pain - frequency, severity, duration, location, and likely cause
14. bowel problems - extent and frequency of any fecal leakage and frequency of need for pads, if used; need for assistance in evacuating bowel (manual evaluation, suppositories, rectal stimulation, etc.) - report type and frequency of need for assistance.
15. 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).
16. psychiatric symptoms
       mood swings
       anxiety
       depression
       other
17. sexual dysfunction - type, and, if erectile dysfunction, state most likely cause and whether vaginal penetration is possible
18. sensory changes, such as numbness or paresthesias - location and type
19. visual problems, such as blurred or double vision- describe
20. hearing problems, tinnitus - describe
21. decreased sense of taste or smell - if present, follow examination protocol for Sense of Smell and Taste
22. seizures - type and frequency
23. hypersensitivity to sound or light - describe
24. behavioral changes
       irritability
       restlessness
       other - describe
25. Oral and dental problems, such as difficulty with jaw movement, tooth loss or damage, etc.- describe
26. 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.

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.
   

   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.
4. Gait, 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 hypotension, hyperhidrosis.
6. Cranial nerves. Conduct a screening exam for cranial nerve impairment. If positive, follow Cranial Nerves examination protocol.
7. Cognitive impairment. Conduct a screening examination (such as Mini-mental State Examination) to assess cognitive impairment and report results and their significance. Does the screening show problems with memory, concentration, attention, information processing, aggressiveness, decreased spontaneity, etc.? If yes, have these been confirmed by prior special examinations, such as neuropsychological testing? If not, are these indicated? If cognitive abnormalities are found, claimed, or suspected, request a Mental Disorder examination protocol by a mental disease specialist.
8. Psychiatric manifestations. Conduct a screening examination for psychiatric manifestations, including emotional behavior. 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.
11. Endocrine dysfunction. Describe any evidence of endocrine dysfunction due to TBI.
12. Oral and dental screening examination. Describe jaw malalignment, cracked or missing teeth, etc., and refer for special Dental and Oral examination when indicated.
13. Other abnormal physical findings.

D. Diagnostic and Clinical Tests:

1. Skull X-rays to measure bony defect, if any, due to surgery or injury.
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. List each diagnosis:
2. Capacity to manage financial affairs
   Mental competency, for VA benefits purposes, refers only to the ability of the veteran to manage VA benefit payments in his or her own best interest, and not to any other subject. Mental incompetency, for VA benefits purposes, means that the veteran, because of injury or disease, is not capable of managing benefit payments in his or her best interest. In order to assist raters in making a legal determination as to competency, please address the following:

1. What is the impact of injury or disease on the veteran's ability to manage his or her financial affairs, including consideration of such things as knowing the amount of his or her VA benefit payment, knowing the amounts and types of bills owed monthly, and handling the payment prudently? Does the veteran handle the money and pay the bills himself or herself?
2. Based on your examination, do you believe that the veteran is capable of managing his or her financial affairs? Please provide examples to support your conclusion.
3. If you believe a Social Work Service assessment is needed before you can give your opinion on the veteran's ability to manage his or her financial affairs, please explain why.

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