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Routine: DVBCTBI3

DVBCTBI3.m

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  1. DVBCTBI3 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 2 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**125**;Apr 10, 1995;Build 9
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;C. Physical Examination (Objective Findings): 
  1.  ;;
  1.  ;;   Address each of the following and fully describe current findings:
  1.  ;;
  1.  ;;     1. Motor function.  Report the motor strength of the affected muscles
  1.  ;;        of all areas of weakness or paralysis using the standard muscle
  1.  ;;        grading scale, for example, weakness of flexion of left elbow
  1.  ;;        (3/5 strength for flexors), complete paralysis of left lower
  1.  ;;        extremity (0/5 for all muscle groups).  To the extent possible,
  1.  ;;        identify the peripheral nerves that innervate the weakened or
  1.  ;;        paralyzed muscles.
  1.  ;;
  1.  ;;          Standard muscle grading scale:
  1.  ;;
  1.  ;;          0=Absent  No muscle movement felt.
  1.  ;;          1=Trace  Muscle can be felt to tighten, but no movement produced.
  1.  ;;          2=Poor  Muscle movement produced only with gravity eliminated.
  1.  ;;          3=Fair  Muscle movement produced against gravity, but cannot
  1.  ;;          overcome any resistance.
  1.  ;;          4=Good  Muscle movement produced against some resistance, but
  1.  ;;          not against "normal" resistance.
  1.  ;;          5=Normal  Muscle movement can overcome "normal" resistance.
  1.  ;;
  1.  ;;     2. Muscle tone, reflexes.  Describe any muscle atrophy or loss of
  1.  ;;        muscle tone.  Examine and report deep tendon reflexes and any
  1.  ;;        pathological reflexes.
  1.  ;;     3. Sensory function.  Describe exact location of any area of abnormal
  1.  ;;        sensory function.  State which modalities of sensation were tested.
  1.  ;;     4. Gait, cerebellar signs.  Describe any gait abnormality, imbalance,
  1.  ;;        tremor or fasciculations, incoordination, or spasticity.  If there
  1.  ;;        is spasticity or rigidity, assess any limitation of motion of 
  1.  ;;        joint (including joint contracture) by following the Joints
  1.  ;;        examination protocol.  (A tandem gait assessment (walking in a
  1.  ;;        straight line with one foot directly in front of the other) is
  1.  ;;        recommended).
  1.  ;;     5. Autonomic nervous system.  Describe any other impairment of the
  1.  ;;        nervous system, such as orthostatic hypotension, hyperhidrosis.
  1.  ;;     6. Cranial nerves.  Conduct a screening exam for cranial nerve
  1.  ;;        impairment.  If positive, follow Cranial Nerves examination
  1.  ;;        protocol.
  1.  ;;     7. Cognitive impairment.  Conduct a screening examination (such as
  1.  ;;        Mini-mental State Examination) to assess cognitive impairment and
  1.  ;;        report results and their significance.  Does the screening show
  1.  ;;        problems with memory, concentration, attention, information
  1.  ;;        processing, aggressiveness, decreased spontaneity, etc.?  If yes,
  1.  ;;        have these been confirmed by prior special examinations, such as
  1.  ;;        neuropsychological testing?  If not, are these indicated?  If
  1.  ;;        cognitive abnormalities are found, claimed, or suspected, request
  1.  ;;        a Mental Disorder examination protocol by a mental disease
  1.  ;;        specialist.
  1.  ;;     8. Psychiatric manifestations.  Conduct a screening examination for
  1.  ;;        psychiatric manifestations, including emotional behavior.  If a
  1.  ;;        mental disorder is suggested, request a mental disorder exam or
  1.  ;;        PTSD exam, as appropriate, by a mental disease specialist.
  1.  ;;     9. Vision and hearing screening examinations (if abnormalities are
  1.  ;;        found, or there are symptoms or a claim of eye or ear impairment,
  1.  ;;        request an eye or audio exam by a specialist).
  1.  ;;    10. Skin.  Describe any areas of skin breakdown due to neurologic
  1.  ;;        problems.
  1.  ;;    11. Endocrine dysfunction.  Describe any evidence of endocrine
  1.  ;;        dysfunction due to TBI.
  1.  ;;    12. Oral and dental screening examination.  Describe jaw malalignment,
  1.  ;;        cracked or missing teeth, etc., and refer for special Dental and
  1.  ;;        Oral examination when indicated.
  1.  ;;    13. Other abnormal physical findings.
  1.  ;;
  1.  ;;D. Diagnostic and Clinical Tests:
  1.  ;;
  1.  ;;     1. Skull X-rays to measure bony defect, if any, due to surgery or
  1.  ;;        injury.
  1.  ;;     2. Include results of all diagnostic and clinical tests conducted in
  1.  ;;        the examination report.
  1.  ;;
  1.  ;;E. Diagnosis:
  1.  ;;
  1.  ;;     1. List each diagnosis.
  1.  ;;     2. Capacity to manage financial affairs.
  1.  ;;        Mental competency, for VA benefits purposes, refers only to the
  1.  ;;        ability of the veteran to manage VA benefit payments in his or her
  1.  ;;        own best interest, and not to any other subject.
  1.  ;;        Mental incompetency, for VA benefits purposes, means that the
  1.  ;;        veteran, because of injury or disease, is not capable of managing
  1.  ;;        benefit payments in his or her own best interest.  In order to
  1.  ;;        assist raters in making a legal determination as to competency,
  1.  ;;        please address the following:
  1.  ;;
  1.  ;;        a. What is the impact of injury or disease on the veteran's ability
  1.  ;;           to manage his or her financial affairs, including consideration
  1.  ;;           of such things as knowing the amount of his or her VA benefit
  1.  ;;           payment, knowing the amounts and types of bills owed monthly,
  1.  ;;           and handling the payment prudently?  Does the veteran handle
  1.  ;;           the money and pay the bills himself or herself?
  1.  ;;        b. Based on your examination, do you believe that the veteran is
  1.  ;;           capable of managing his or her financial affairs?  Please
  1.  ;;           provide examples to support your conclusion.
  1.  ;;        c. If you believe a Social Work Service assessment is needed
  1.  ;;           before you can give your opinion on the veteran's ability to
  1.  ;;           manage his or her financial affairs, please explain why.
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;Signature:                                     Date:
  1.  ;;END