DVBCQPN3 ;;ALB-CIOFO/ECF - PERIPHERAL NERVES QUESTIONNAIRE (continued); 5/15/2011
;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
;
TXT ;
;;
;; Indicate affected nerves, side affected and severity of condition:
;;
;; a. Radial nerve (musculospiral nerve)
;; Note: Complete paralysis (hand and fingers drop, wrist and fingers
;; flexed; cannot extend hand at wrist, extend proximal phalanges
;; of fingers, extend thumb or make lateral movement of wrist;
;; supination of hand, elbow extension and flexion weak, hand grip
;; impaired)
;;
;; ___ Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;^TOF^
;; b. Median nerve
;; Note: Complete paralysis (hand inclined to the ulnar side, index and
;; middle fingers extended, atrophy of thenar eminence, cannot make
;; fist, defective opposition of thumb, cannot flex distal phalanx of
;; thumb; wrist flexion weak)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; c. Ulnar nerve
;; Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal
;; interspaces, thenar and hypothenar eminences; cannot extend ring and
;; little finger, cannot spread fingers, cannot adduct the thumb;
;; wrist flexion weakened)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;^TOF^
;; d. Musculocutaneous nerve
;; Note: Complete paralysis (weakened flexion of elbow and supination of
;; forearm)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; e. Circumflex nerve
;; Note: Complete paralysis (innervates deltoid and teres minor; cannot
;; abduct arm, outward rotation is weakened)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;^TOF^
;; f. Long thoracic nerve
;; Note: Complete paralysis (inability to raise arm above shoulder level,
;; winged scapula deformity)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; g. Upper radicular group (5th & 6th cervicals)
;; Note: Complete paralysis (all shoulder and elbow movements lost; hand
;; and wrist movements not affected)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;^TOF^
;; h. Middle radicular group
;; Note: Complete paralysis (adduction, abduction, rotation of arm,
;; flexion of elbow and extension of wrist lost)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; i. Lower radicular group
;; Note: Complete paralysis (intrinsic hand muscles, wrist and finger
;; flexors paralyzed; substantial loss of use of hand)
;; ___Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;^TOF^
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPN3 6344 printed Oct 16, 2024@17:48:38 Page 2
DVBCQPN3 ;;ALB-CIOFO/ECF - PERIPHERAL NERVES QUESTIONNAIRE (continued); 5/15/2011
+1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
+2 ;
TXT ;
+1 ;;
+2 ;; Indicate affected nerves, side affected and severity of condition:
+3 ;;
+4 ;; a. Radial nerve (musculospiral nerve)
+5 ;; Note: Complete paralysis (hand and fingers drop, wrist and fingers
+6 ;; flexed; cannot extend hand at wrist, extend proximal phalanges
+7 ;; of fingers, extend thumb or make lateral movement of wrist;
+8 ;; supination of hand, elbow extension and flexion weak, hand grip
+9 ;; impaired)
+10 ;;
+11 ;; ___ Right:
+12 ;; ___ Normal
+13 ;; ___ Incomplete paralysis
+14 ;; ___ Complete paralysis
+15 ;; If Incomplete paralysis is checked, indicate severity:
+16 ;; ___ Mild ___ Moderate ___ Severe
+17 ;;
+18 ;; ___ Left:
+19 ;; ___ Normal
+20 ;; ___ Incomplete paralysis
+21 ;; ___ Complete paralysis
+22 ;; If Incomplete paralysis is checked, indicate severity:
+23 ;; ___ Mild ___ Moderate ___ Severe
+24 ;;^TOF^
+25 ;; b. Median nerve
+26 ;; Note: Complete paralysis (hand inclined to the ulnar side, index and
+27 ;; middle fingers extended, atrophy of thenar eminence, cannot make
+28 ;; fist, defective opposition of thumb, cannot flex distal phalanx of
+29 ;; thumb; wrist flexion weak)
+30 ;; ___Right:
+31 ;; ___ Normal
+32 ;; ___ Incomplete paralysis
+33 ;; ___ Complete paralysis
+34 ;; If Incomplete paralysis is checked, indicate severity:
+35 ;; ___ Mild ___ Moderate ___ Severe
+36 ;;
+37 ;; ___ Left:
+38 ;; ___ Normal
+39 ;; ___ Incomplete paralysis
+40 ;; ___ Complete paralysis
+41 ;; If Incomplete paralysis is checked, indicate severity:
+42 ;; ___ Mild ___ Moderate ___ Severe
+43 ;;
+44 ;; c. Ulnar nerve
+45 ;; Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal
+46 ;; interspaces, thenar and hypothenar eminences; cannot extend ring and
+47 ;; little finger, cannot spread fingers, cannot adduct the thumb;
+48 ;; wrist flexion weakened)
+49 ;; ___Right:
+50 ;; ___ Normal
+51 ;; ___ Incomplete paralysis
+52 ;; ___ Complete paralysis
+53 ;; If Incomplete paralysis is checked, indicate severity:
+54 ;; ___ Mild ___ Moderate ___ Severe
+55 ;;
+56 ;; ___ Left:
+57 ;; ___ Normal
+58 ;; ___ Incomplete paralysis
+59 ;; ___ Complete paralysis
+60 ;; If Incomplete paralysis is checked, indicate severity:
+61 ;; ___ Mild ___ Moderate ___ Severe
+62 ;;^TOF^
+63 ;; d. Musculocutaneous nerve
+64 ;; Note: Complete paralysis (weakened flexion of elbow and supination of
+65 ;; forearm)
+66 ;; ___Right:
+67 ;; ___ Normal
+68 ;; ___ Incomplete paralysis
+69 ;; ___ Complete paralysis
+70 ;; If Incomplete paralysis is checked, indicate severity:
+71 ;; ___ Mild ___ Moderate ___ Severe
+72 ;;
+73 ;; ___ Left:
+74 ;; ___ Normal
+75 ;; ___ Incomplete paralysis
+76 ;; ___ Complete paralysis
+77 ;; If Incomplete paralysis is checked, indicate severity:
+78 ;; ___ Mild ___ Moderate ___ Severe
+79 ;;
+80 ;; e. Circumflex nerve
+81 ;; Note: Complete paralysis (innervates deltoid and teres minor; cannot
+82 ;; abduct arm, outward rotation is weakened)
+83 ;; ___Right:
+84 ;; ___ Normal
+85 ;; ___ Incomplete paralysis
+86 ;; ___ Complete paralysis
+87 ;; If Incomplete paralysis is checked, indicate severity:
+88 ;; ___ Mild ___ Moderate ___ Severe
+89 ;;
+90 ;; ___ Left:
+91 ;; ___ Normal
+92 ;; ___ Incomplete paralysis
+93 ;; ___ Complete paralysis
+94 ;; If Incomplete paralysis is checked, indicate severity:
+95 ;; ___ Mild ___ Moderate ___ Severe
+96 ;;^TOF^
+97 ;; f. Long thoracic nerve
+98 ;; Note: Complete paralysis (inability to raise arm above shoulder level,
+99 ;; winged scapula deformity)
+100 ;; ___Right:
+101 ;; ___ Normal
+102 ;; ___ Incomplete paralysis
+103 ;; ___ Complete paralysis
+104 ;; If Incomplete paralysis is checked, indicate severity:
+105 ;; ___ Mild ___ Moderate ___ Severe
+106 ;;
+107 ;; ___ Left:
+108 ;; ___ Normal
+109 ;; ___ Incomplete paralysis
+110 ;; ___ Complete paralysis
+111 ;; If Incomplete paralysis is checked, indicate severity:
+112 ;; ___ Mild ___ Moderate ___ Severe
+113 ;;
+114 ;; g. Upper radicular group (5th & 6th cervicals)
+115 ;; Note: Complete paralysis (all shoulder and elbow movements lost; hand
+116 ;; and wrist movements not affected)
+117 ;; ___Right:
+118 ;; ___ Normal
+119 ;; ___ Incomplete paralysis
+120 ;; ___ Complete paralysis
+121 ;; If Incomplete paralysis is checked, indicate severity:
+122 ;; ___ Mild ___ Moderate ___ Severe
+123 ;;
+124 ;; ___ Left:
+125 ;; ___ Normal
+126 ;; ___ Incomplete paralysis
+127 ;; ___ Complete paralysis
+128 ;; If Incomplete paralysis is checked, indicate severity:
+129 ;; ___ Mild ___ Moderate ___ Severe
+130 ;;^TOF^
+131 ;; h. Middle radicular group
+132 ;; Note: Complete paralysis (adduction, abduction, rotation of arm,
+133 ;; flexion of elbow and extension of wrist lost)
+134 ;; ___Right:
+135 ;; ___ Normal
+136 ;; ___ Incomplete paralysis
+137 ;; ___ Complete paralysis
+138 ;; If Incomplete paralysis is checked, indicate severity:
+139 ;; ___ Mild ___ Moderate ___ Severe
+140 ;;
+141 ;; ___ Left:
+142 ;; ___ Normal
+143 ;; ___ Incomplete paralysis
+144 ;; ___ Complete paralysis
+145 ;; If Incomplete paralysis is checked, indicate severity:
+146 ;; ___ Mild ___ Moderate ___ Severe
+147 ;;
+148 ;; i. Lower radicular group
+149 ;; Note: Complete paralysis (intrinsic hand muscles, wrist and finger
+150 ;; flexors paralyzed; substantial loss of use of hand)
+151 ;; ___Right:
+152 ;; ___ Normal
+153 ;; ___ Incomplete paralysis
+154 ;; ___ Complete paralysis
+155 ;; If Incomplete paralysis is checked, indicate severity:
+156 ;; ___ Mild ___ Moderate ___ Severe
+157 ;;
+158 ;; ___ Left:
+159 ;; ___ Normal
+160 ;; ___ Incomplete paralysis
+161 ;; ___ Complete paralysis
+162 ;; If Incomplete paralysis is checked, indicate severity:
+163 ;; ___ Mild ___ Moderate ___ Severe
+164 ;;^TOF^
+165 ;;
+166 QUIT
