DVBCTBI3 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 2 ; 12 FEB 2007
;;2.7;AMIE;**125**;Apr 10, 1995;Build 9
;
;
TXT ;
;;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
;; 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 own best interest. In order to
;; assist raters in making a legal determination as to competency,
;; please address the following:
;;
;; a. 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?
;; b. 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.
;; c. 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.
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCTBI3 6039 printed Apr 09, 2024@20:51:01 Page 2
DVBCTBI3 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 2 ; 12 FEB 2007
+1 ;;2.7;AMIE;**125**;Apr 10, 1995;Build 9
+2 ;
+3 ;
TXT ;
+1 ;;C. Physical Examination (Objective Findings):
+2 ;;
+3 ;; Address each of the following and fully describe current findings:
+4 ;;
+5 ;; 1. Motor function. Report the motor strength of the affected muscles
+6 ;; of all areas of weakness or paralysis using the standard muscle
+7 ;; grading scale, for example, weakness of flexion of left elbow
+8 ;; (3/5 strength for flexors), complete paralysis of left lower
+9 ;; extremity (0/5 for all muscle groups). To the extent possible,
+10 ;; identify the peripheral nerves that innervate the weakened or
+11 ;; paralyzed muscles.
+12 ;;
+13 ;; Standard muscle grading scale:
+14 ;;
+15 ;; 0=Absent No muscle movement felt.
+16 ;; 1=Trace Muscle can be felt to tighten, but no movement produced.
+17 ;; 2=Poor Muscle movement produced only with gravity eliminated.
+18 ;; 3=Fair Muscle movement produced against gravity, but cannot
+19 ;; overcome any resistance.
+20 ;; 4=Good Muscle movement produced against some resistance, but
+21 ;; not against "normal" resistance.
+22 ;; 5=Normal Muscle movement can overcome "normal" resistance.
+23 ;;
+24 ;; 2. Muscle tone, reflexes. Describe any muscle atrophy or loss of
+25 ;; muscle tone. Examine and report deep tendon reflexes and any
+26 ;; pathological reflexes.
+27 ;; 3. Sensory function. Describe exact location of any area of abnormal
+28 ;; sensory function. State which modalities of sensation were tested.
+29 ;; 4. Gait, cerebellar signs. Describe any gait abnormality, imbalance,
+30 ;; tremor or fasciculations, incoordination, or spasticity. If there
+31 ;; is spasticity or rigidity, assess any limitation of motion of
+32 ;; joint (including joint contracture) by following the Joints
+33 ;; examination protocol. (A tandem gait assessment (walking in a
+34 ;; straight line with one foot directly in front of the other) is
+35 ;; recommended).
+36 ;; 5. Autonomic nervous system. Describe any other impairment of the
+37 ;; nervous system, such as orthostatic hypotension, hyperhidrosis.
+38 ;; 6. Cranial nerves. Conduct a screening exam for cranial nerve
+39 ;; impairment. If positive, follow Cranial Nerves examination
+40 ;; protocol.
+41 ;; 7. Cognitive impairment. Conduct a screening examination (such as
+42 ;; Mini-mental State Examination) to assess cognitive impairment and
+43 ;; report results and their significance. Does the screening show
+44 ;; problems with memory, concentration, attention, information
+45 ;; processing, aggressiveness, decreased spontaneity, etc.? If yes,
+46 ;; have these been confirmed by prior special examinations, such as
+47 ;; neuropsychological testing? If not, are these indicated? If
+48 ;; cognitive abnormalities are found, claimed, or suspected, request
+49 ;; a Mental Disorder examination protocol by a mental disease
+50 ;; specialist.
+51 ;; 8. Psychiatric manifestations. Conduct a screening examination for
+52 ;; psychiatric manifestations, including emotional behavior. If a
+53 ;; mental disorder is suggested, request a mental disorder exam or
+54 ;; PTSD exam, as appropriate, by a mental disease specialist.
+55 ;; 9. Vision and hearing screening examinations (if abnormalities are
+56 ;; found, or there are symptoms or a claim of eye or ear impairment,
+57 ;; request an eye or audio exam by a specialist).
+58 ;; 10. Skin. Describe any areas of skin breakdown due to neurologic
+59 ;; problems.
+60 ;; 11. Endocrine dysfunction. Describe any evidence of endocrine
+61 ;; dysfunction due to TBI.
+62 ;; 12. Oral and dental screening examination. Describe jaw malalignment,
+63 ;; cracked or missing teeth, etc., and refer for special Dental and
+64 ;; Oral examination when indicated.
+65 ;; 13. Other abnormal physical findings.
+66 ;;
+67 ;;D. Diagnostic and Clinical Tests:
+68 ;;
+69 ;; 1. Skull X-rays to measure bony defect, if any, due to surgery or
+70 ;; injury.
+71 ;; 2. Include results of all diagnostic and clinical tests conducted in
+72 ;; the examination report.
+73 ;;
+74 ;;E. Diagnosis:
+75 ;;
+76 ;; 1. List each diagnosis.
+77 ;; 2. Capacity to manage financial affairs.
+78 ;; Mental competency, for VA benefits purposes, refers only to the
+79 ;; ability of the veteran to manage VA benefit payments in his or her
+80 ;; own best interest, and not to any other subject.
+81 ;; Mental incompetency, for VA benefits purposes, means that the
+82 ;; veteran, because of injury or disease, is not capable of managing
+83 ;; benefit payments in his or her own best interest. In order to
+84 ;; assist raters in making a legal determination as to competency,
+85 ;; please address the following:
+86 ;;
+87 ;; a. What is the impact of injury or disease on the veteran's ability
+88 ;; to manage his or her financial affairs, including consideration
+89 ;; of such things as knowing the amount of his or her VA benefit
+90 ;; payment, knowing the amounts and types of bills owed monthly,
+91 ;; and handling the payment prudently? Does the veteran handle
+92 ;; the money and pay the bills himself or herself?
+93 ;; b. Based on your examination, do you believe that the veteran is
+94 ;; capable of managing his or her financial affairs? Please
+95 ;; provide examples to support your conclusion.
+96 ;; c. If you believe a Social Work Service assessment is needed
+97 ;; before you can give your opinion on the veteran's ability to
+98 ;; manage his or her financial affairs, please explain why.
+99 ;;
+100 ;;
+101 ;;
+102 ;;Signature: Date:
+103 ;;END
